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greater buy viagra gateshead certainty of cessation of menstrual functions. In cases sufficiently grave to warrant castration the operator should carefully weigh the reasons, if any online viagra cialis exist, why the uterus should not be included with the appendages. The choice between Battey's operation and complete removal of the uterus and its appen- dages covers debatable ground, and each will continue to have its advocates until larger experience decides which has the paramount claim to our confidence. In this as in many other conditions the results of indi- vidual experience will and should govern very largely the mode of individual practice. It must be acknowl- edged that the arguments against hysterectomy in bleeding fibromas of this class are more sentimental buy viagra gateshead than real. The seat of disease is in the uterine struc- ture, for which operation is proposed, and depriving the woman of her ovaries may at the best only influ- ence this abnormal state by the arrest of periodical functional activity of this organ, and this may or may 8oo MEDICAL RECORD. [June 6, 1896 not be sufficient to arrest the pathological condition. True, there may be some added risk in removing the uterus, but it would not of necessity outweigh the greater good which hysterectomy makes probable. The liability of these growths to undergo malignant degeneration or suppuration will have due weight in deciding the question. These are the questions which the operator can determine in each individual case. There is, however, a class of cases of online viagra cialis buy viagra gateshead large growths in which no such perplexing question perturbs the surgeon, and in which none but radical measures are admissible. The revolution in methods which has attended the surgery of uterine fibroids (and I might say of abdominal surgery as a whole) within the last dec- ade gives the subject of their management new and buy viagra gateshead far-reaching interest. It is not my purpose to follow the successive steps of the intra- and extra-abdominal methods of German teachers and others, which have been improved upon and superseded by the American methods of Eastman, Baer, Goffe, Kelly, and others; suffice it to say, the evolution has been so complete and radical as to approximate perfection and rob the procedure of much that was formidable and dangerous. It is one of the marvels of modern surgery to note with what ease and safety large fibroids can be re- moved. The simplicity of this method, whether by supravaginal amputation or by complete extirpation, must recommend its adoption; it is the same except in buy viagra gateshead the final steps, and does not vary in principle and but little in detail, whether the tumor is large or small. To those familiar with the Trendelenburg pos- ture no argument is needed to demonstrate its su- periority over the horizontal position. It gives a clear field for observation, except in adhesions or in great intestinal distentions, and great facility for rapid manipulation. The steps of the operation are briefly as follows: After opening the peritoneal cavity in the median line by the shortest incision by which the growth can be delivered and easy manipulation ac- complished, adhesions between the tumor and abdom- online viagra cialis online viagra cialis inal walls and intestines should be gently separated, the online viagra cialis intestines pushed buy viagra gateshead upward into the abdominal cav- ity and held in position by a large thick laparotomy gauze sponge. The growth is lifted out of the perito- neal cavitv by volsella. A double ligature is then passed through the broad ligament so as to include the ovarian artery and the intervening tissues are divided. A second double ligature again transfixes the broad ligament so as to include the uterine artery, which can usually be felt pulsating under the finger, care being taken to keep sufficiently near the uterine body so as not to include the ureter, and the intervening struc- tures are divided by scissors. The broad ligament and arteries on buy viagra gateshead the other side are to be similarly tied off. These four ligatures usually cut off the arterial supply from the uterus and tumor. Sometimes in large growths other arteries may require ligation, or the proximal side may be held by press ire fora ps to pre- vent reflux from the uterus. This method of applying pressure forceps may be used in ligating the ovarian and uieiine arteries, in which case two single ligatures online viagra cialis would be used on either side. The peritoneum cover- ing the uterus .u a point three-quarters of an inch or an inch above the junction of the cen i\ villi the body- is incised anteriorly and posteriorly. Anteriorly it is dissected or pushed d< with the handle of the scalpel, thereby separating the bladder from its attach- es to the uterus. The posterior flap is carried down a similar distance, the qervix is amputated, and all that is required to complete the operation is to stitch these peritoneal flaps together over the stump of the cervix and attend to the toilet of the perito- neum. Before putting in a running buy viagra gateshead catgut suture to approximate these peritoneal flaps, it is oftentimes easy to turn in the stumps of the broad ligaments in such a manner as to leave them extra- and post-peri- toneal. If deemed wise to remove the cervix with the corpus entire, it can be easily accomplished by keeping up traction and by the use of curved scissors, snip- ping the attachments little by little around the entire cervix, having previously sterilized the vagina. Considerable variation in the method of applying the ligatures will obtain buy viagra gateshead in different cases, from changes in the breadth and depth of the broad ligament owing to the increase in size of the uterine body or thickening due online viagra cialis to inflammatory exudates. In some cases it is better to secure the uterine artery after incising the broad ligament than by transfixion. In others Kelly's method is simplest and best. The complications at-