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head of the pancreas itself. This was so in seven out of twenty-two cases examined. It is thus conceivable that any inflammation affecting the common bile duct can easily, at times, involve the pancreatic duct or the head of the gland itself by direct online viagra sites extension, causing probably an interstitial pancreatitis which is cheap viagra news of a harmless nature in itself, and clears up when its ex- citing cause cheap viagra news namely, a calculus in the common bile duct is removed. Occasionally, when a calculus is impacted at the duodenal end of the common duct, a more severe inflammatory process is set up in the head of the pancreas, which leads to the formation of a large tumor as hard as iron and situated in a criti- cal position namely, the junction of the common bile and'pancreatic ducts. Originally set up by direct ex- tension online viagra sites of the inflammation, this pancreatic enlarge- ment in time takes on, to a certain degree, a character peculiar to itself. It may last for months or years be- fore removal of its cause allows of its reabsorption, and unless the exciting cause be removed the patho- logical condition of the pancreas may of itself cause death. Its development is slow and the condition runs a protracted course. Micro-organisms probably have no part in its causation. As the inflammation involves the common orifice online viagra sites of the common bile and pancreatic ducts and obstructs the flow of the secre- tions from two very important glands, the new condi- tion can be of more clinical importance than its excit- ing cause is. This marked pancreatic enlargement is rare, for Riedel met with it only three times in one hundred and twenty-two cases of gall-stone sur- gery. Its predisposing causes are not known, as cal- culi frequently occur in the common duct and even in the ostium duodenale without setting up any pancreatic inflammation, while a stone in the gall bladder seems to be sufficient to excite cheap viagra news its development. In two of the three cases the patients had been the subjects of gall stones for several years, and in the third for at least one year and probably longer. The last patient died after operation, and a microscopical examination showed the tumor to consist of an interstitial pancre- atitis without any evidences of malignancy. RiedeTs notice was first attracted to the condition in a patient on whom he operated for gall stones. A single large stone was found irr the gall bladder, while the cystic and common ducts were widely dilated, but contained no stones, and the head of the pancreas was felt to be enlarged to the size of a small apple by a tumor as May online viagra sites 23, 1896] MEDICAL RECORD. 729 hard as iron and of a typically carcinomatous nature. The case was considered hopeless, but the patient im- proved rapidly after operation, and, from a cachectic condition, grew to be quite healthy looking and well nourished. Two and a online viagra sites quarter years after operation this patient is still quite well. The tumor in this case could not be felt either before or after the operation. In the second case the enlarged head of the pancreas was larger (the size of a list), as hard as iron again, and calculi were extracted from the common bile duct and cheap viagra news gall bladder. With the former case in mind, can- cer of the pancreas was not diagnosed here. The patient improved after operation; the tumor, which before the online viagra sites operation could be easily felt, gradually online viagra sites vanished until it could no longer be palpated, and in a year and a half the patient had put on thirty pounds online viagra sites in weight and was still quite well. In both the above cases the enlargement of the head of the pancreas was almost certainly of an inflammatory nature. Confir- mation of cheap viagra news this supposition by pathological examina- tion was fortunately impossible, but in cheap viagra news the third and last case, the patient, who was very far gone when op- erated upon, died. cheap viagra news At the operation no calculi could be felt in the biliary passages, which were, however, made out to be dilated, while a hard resistance in the situation of the head of the pancreas was considered to be an irregular enlargement of this organ, though it could hardly be called a tumor. Shortly after the operation the woman died. Post-mortem, the biliary passages were found to be widely dilated and their walls thin, while the gall bladder and the larger ducts contained many calculi of the size of pins' heads. The pancreatic duct was constricted near its orifice and dilated toward the body and tail of the gland. The pancreatic lobules felt firmer than normal, prob- ably from fibrous development. Microscopic exami- nation of the gland revealed interstitial pancreatitis. Malignant new growth could be definitely excluded. The last patient probably died from the effects of the pancreatitis, which cheap viagra news had evidently been present for some time. Karlier operation would have given her a very good chance of recovery. The knowledge cheap viagra news that a non-malignant pancreatitis occasionally occurs in the course of cholelithiasis is important as affect- ing the prognosis of cases in which this gland is felt to be enlarged either before or during operations on the biliary passages. There are no points by which the nature of this pancreatitis can be definitely recognized during life except a favorable progress of the case after operation and removal of its exciting cause. The conditions for which it may be mistaken, or vice versa, are carcinoma of the head of the pan- creas and of the duodenum. In the latter condition, new growths in the papilla around the common duodenal orifice of the bile and pancreatic ducts, occasionally occur, and the palpating finger may mistake such for enlargements of the head of the pan- creas. New Views on Jaundice. At a recent meeting of the Verein fiir innere Mfidicin, as reported in the Miin- chencr mcclicinische Wochenschrift, February 25, 1896, Dr. Renvers, of Berlin, spoke on this subject. He claimed that the most recent investigations had shown that the doctrine of hematogenous jaundice could not be upheld. According to him, all varieties of icterus were hepatogenous. Catarrhal jaundice was not to be regarded as a merely mechanical damming-up of the bile behind an obstructive plug of mucus or as due to an inflammatory swelling online viagra sites of the bile ducts. It was