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and lips healed about three weeks after the sloughs separated. The author first saw the patient in Janu- ary, 1896. Several months previous to this an in- creased difficulty in swallowing was appreciated, but at that time this symptom w-as considerably worse and the feeling existed that small particles of food w-ere stopped before reaching the stomach, apparently low down in the (esophagus. Liquids could be swallowed slowly and with difficulty, but half an hour was occu- pied in drinking a glass of milk. For two or three days at a time swallowing was impossible, and then relaxation occurred. When first seen, the pulse and tem- perature were normal, the tongue was clean, the appe- tite good, and the pulse regular. Examination of the stomach revealed three strictures, seven and one-half and eight inches from the edge of the incisor teeth. No more were discovered until the instrument had passed thirteen and one-half inches down the oesopha- gus, when an obstruction was met which would not allow any instrument to pass. The largest instrument that would pass the stricture seven inches from the teeth was of the size of a No. 22 French urethral bougie, and nothing would pass lower than thirteen and one-half inches. Gastrostomy was decided upon, and the Sbani jew-Frank method was selected, which the author briefly described as follows: An incision is made about tesco viagra price a finger's breadth be- low the costal cartilages on the left side over the stomach. The first incision, three and one-half inches in length, goes down to the muscles, and the muscles are then divided in the direction of their fibres by blunt dissection. The peritoneum is opened in a line parallel with the edge of the costal cartilages. The stomach, having been with- drawn from the wound, is drawn strongly outward by a ligature passed through its walls, and traction is then made on this ligature by an assistant until a cone of the stomach three tesco viagra price or four inches long is drawn out of the abdominal incision. While the assis- tant holds this tesco viagra price cone in position by means of the liga- ture, the base of the cone is sutured to the parietal generic viagra questions peritoneum all the way around. The next step con- sists in making an incision through the skin, superfi- cial fascia, and areolar tissue down to the deep fascia. This incision is placed one inch above the margin of the costal cartilages, and its direction is parallel to that of the primary incision. By blunt dissection communication is made underneath the skin and su- perficial tissues between this incision and the primary incision, and through this communication the apex of the cone formed by the stomach is drawn. The wall of the stomach is then sutured to the skin and the stomach is opened. The primary wound is closed, the muscles being sutured seriatim and the skin inci- ison sutured last. The advantage of this plan is that it brings the stomach through the abdominal wall in an oblique direction, and a part of the stomach is includ- ed between the edge of the costal cartilage and the skin, forming as it were a valve. This device pre- vents leakage of the contents of the stomach during digestion, and is a great advantage over the old meth- od of making a direct communication between the stomach generic viagra questions and the abdominal incision. The subsequent history of the tesco viagra price case is unevent- ful, the patient gaining in flesh and strength and being perfectly nourished by means of feeding through the artificial opening. Since the operation a small bougie has been passed eighteen inches from the edge of the teeth, No. 15 on the French urethral scale was passed twenty inches, and No. 22 of this scale has been passed through the strictures at seven and seven and one-half and eight inches from the edge of the teeth. On account of the large amount of cicatricial tissue present, it is doubtful whether it will be possible to thoroughly divide it so that recontraction will not take place. The valve does its work very well and there is practically no leakage. A little gastric juice exudes from the opening, but none of the stomach contents. Dr. Rosenthal, generic viagra questions of Philadelphia, said he had tesco viagra price seen this operation performed by Dr. Thomas S. K. Mor- ton, and the only point about it upon which Dr. Mor- ton laid great stress was the advisability of getting the patient up as quickly as possible. Dr. Thomas, tesco viagra price of Pennsylvania, said that, in employ- ing the Abbe ligature in this operation, there might be the danger that the stricture will tesco viagra price recontract and ne- cessitate a repetition of the operation. tesco viagra price Dr. Cooper said that he agreed with Dr. tesco viagra price Morton as to the necessity of getting tesco viagra price the patients up as early as possible. Dr. Ferdinand C. Valentine said that he had had considerable experience in dealing with strictures of the urethra, but not of the oesophagus. He thought that somewhat the same methods would apply in generic viagra questions each case, and he believed that the method suggested by the author is a good one. Dr. W. J. Mayo, of Rochester, Minn., said he was of the opinion that Fenger's operation is the best for this particular class of cases, although it causes great annoyance generic viagra questions from leakage. He thought Dr. May : j> [896] MEDICAL RECORD. 745