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Howard A. Kelly, of Baltimore, read the paper. viagra cost singapore He said viagra cost singapore it would be seen that he was going to carry conservatism into the most extreme domain of gyne- cological work. He would speak viagra cost singapore of treating extra- uterine generic viagra caps pregnancy viagra cost singapore by evacuation through vaginal in- cision and drainage. Thirteen cases so treated were reported, all of which resulted in recovery except one, that of a patient who was in uraemic coma at the time of the operation and died in that state se\eral days later, death being in no wise due to the operation. As to the lass of cases suitable for vaginal puncture, evacu- ation, and drainage, he said they are those of extra- uterine pregnancy with rupture in the early months, which include the vast majority of all cases, but not the recent ruptures, nor cases, whether recent or more remote, of advanced extra-uterine pregnancy. The opening is made into the sac between vagina and rectum, enlarging it in line with the axis generic viagra caps of the pelvis by dilatation, avoiding wounding the rectum; the sac is cleaned out with the linger, and washed out with normal salt solution; this is done again as a final step before putting in gauze drain. The advan- tages over laparotomy were mentioned. In one in- stance he had diagnosticated extra-uterine pregnane,, which he treated in this manner and found dermoid cyst; in another he found simple pelvic abscess. The chief danger is from hemorrhage, but this is little likely to take place, since at this period tendency to active hemorrhage in the sac has ceased. In one viagra cost singapore of his cases, however, there was such hemorrhage as to necessitate rapid opening of the abdomen and removal of the sac. He was viagra cost singapore unable to explain why there should have been hemorrhage in this case, since rup- ture had taken place some time before. Dr. Kelly's paper was discussed in connection with the next one. Early Rupture of Extra-Uterine Pregnancy and Its Treatment. Dr. Fernand Henrotin, of Chi- 1 ago, said the object of this paper was to call atten- tion to some of the peculiarities of early rupture prior to the second month and draw some deductions as to its management. There are two classes of cases: 1, what may be termed complete rupture, with free primary abdominal hemorrhage; 2, incom- plete rupture in the tube, in which there may be secondary hemorrhage. It is not claimed that these very early ruptures are invariably complete. There is reason to be- lieve that many rupture into the broad ligament and are absorbed. Failure to observe discharge of de- cidual membrane is of little significance, for it may occur simultaneously with rupture, or follow it very closely. The physical signs are those of intra- abdominal' hemorrhage. Failure to recognize tumor alongside the uterus is not important. At this point Dr. Henrotin related a case of early complete rupture with hemorrhage into the abdominal cavity. viagra cost singapore The patient was in marked collapse, was eold. and seemed in rigor generic viagra caps mortis, yet he operated, made use of saline solution, and she made an unevent- ful recovery. In like cases, in which hemorrhage is evidently going on, immediate generic viagra caps operation alone can save life. The question of leaving a considerable quantity of fresh viagra cost singapore blood in the peritoneal cavity will depend' upon the urgency of the case and freedom from septic contamination. If there is no sepsis, one needs only remove the larger clots, and the opera- tion being thus done hastily the woman will stand a better chance of recovery. The author then considered the differential diag- nosis between tubal rupture and tubal abortion, after 8i: MEDICAL RECORD. [June 6, 1896 which his paper was discussed in connection with Dr. Kelly's. Those taking part in the discussion were Drs. Boldt, generic viagra caps Mann, Noble, Baer, Janvrin, Gordon, Ashton, Wat'hens, Currier, and the authors. Sev- eral of the speakers thought Dr. Kelly was only carrying out a generally accepted procedure, that of opening ac- cessible haematoma through the vagina, for at this period the case had practically ceased to be one of extra-uterine pregnancy. Some of the speakers, however, expressed preference for the abdominal method even in these cases of rupture which had become quiescent, as well as in recent active cases, on account of danger from hemorrhage. Suspensio Uteri with Reference to Its Influence upon Pregnancy and Labor. Dr. Charles P. Noble, of generic viagra caps Philadelphia, had collected in this paper all the statistics as far as possible of operations for suspension of the uterus to the abdominal wall, both in this country and abroad, the number of patients who had subsequently become pregnant, and the influence of suspension upon the course of pregnancy and labor. The foreign and American statistics agree in the fact that when the uterus has been firmly fixed against the anterior abdominal wall there have not infrequently been symptoms during the course of pregnancy due to failure of the uterus to rise and develop in the normal manner, and causing at labor obstruction as if a tumor existed at the attached portion. In a considerable proportion of cases, greater in Europe than in America, the obstruction has been such as to require forceps, version, Porro's operation, or Cresarean section. It is to be noted that these generic viagra caps difficulties have viagra cost singapore not been ob- served in cases operated upon by the Kelly method in which the attachment of the uterus to the anterior wall has been only through the parietal peritoneum, fol- lowed by the formation of a pedicle or ligature com- posed of peritoneum, and allowing normal motion and growth to the uterus. Consequently Kelly's method is the one which he would recommend, though slightly modified, when on opening the abdomen it