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mortem showed diffuse purulent meningitis involving both the base and viagra pill take the convexity. There was no local- ized accumulation of pus. The infection in this case followed along the carotid canal. Dr. Rwsohoff, of Cincinnati, said that it having been stated that there was considerable hemorrhage in the case just reported, he would viagra pill take like to mention a method which he had employed to overcome this. We all know that under the older methods much blood was lost, and that very frequently in an operation for the removal of a brain tumor the dura and the cere- bral veins were divided, causing such a loss of blood that the operation could not be completed in one sit- ting. The Esmarch strap has been used considerably, but viagra pill take all know the difficulty of properly applying it. its entire viagra pill take object often being lost through the sinking of the scalp into the orbit. The method which the speaker employs is a very simple one, but he has never seen a description of it. He introduces about an inch from the surface of the tumor a continuous chain suture, which he draws tight around the entire line of the incision. He recently practised this method in a case of sarcoma of the dura mater, in which the tumor was as large as a small orange, and which had been operated on twice before on the sup- position that it was a wen. When this suture is drawn tight, which can lie done very rapidly, the en- tire area of the skull is made absolutely bloodless and the incision was made within the line of the chain. ( )ne has but to remember the size of incision that is necessary for trephining and the difficulty of grasping the vessels in the tense scalp to appreciate how much blood will be saved the patient by using this suture. The sutures can be clipped and removed at the etui of twenty-four hours in order to remove the gauze packing, and the vitality of the flap will be in no way interfered w ith. Cholelithiasis and Cholelithotomy. Dr. Charles II. DUNN, of Minneapolis, read a paper based upon a study of forty cases of gall stone and a viagra pill take review of the chief viagra pill take literature of the subject. He had been im- pressed, he said, with the highly viagra delivery systems overdrawn notion of biliary colic and the misinterpreted view of the symp- tomatology of cholelithiasis prevalent in the general professional mind, with the mistaken prominence given to jaundice as a symptom, and with the tenacity with which a childlike pathology explaining its presence or absence on the purely mechanical action viagra delivery systems of the stone is held. Jaundice is a comparatively infrequent symp- tom, at least in the earlier course of the average cho- lelithiasis, and cases not rarely run their whole course without icterus. The author reported a case of a young ami otherwise healthy woman who died as viagra pill take a result of six weeks' attack of biliary colic with nearly constant pain, tenderness, and vomiting. She had had but one previous attack, of short duration, nearly a year before. A trace of bile was present in the urine, but at no viagra pill take time had viagra pill take there been a trace of icterus observable by the friends, trained nurses, viagra delivery systems or physi- cians. At the autopsy five gall stones were found, three in the gall bladder and two in the common duct. The presence or absence of icterus must not have too strong an influence on one in locating the stone. The indications for viagra delivery systems cholelithiasis should be divided into relative and imperative. If the attacks be frequent, the calculi not passed, and the symptoms not viagra pill take relieved by a reasonable hygienic and medical course of a few- weeks' duration, so safe an operation as cholecys- totomy at this stage is doubly preferable to further delay, even though no very threatening symptoms have developed; first, as the cheapest escape from present suffering, and second, as a preventive measure against the ever-possible dangers of cholangitis, duct impac- tions, etc.. which may entail a much more dangerous and trying operation upon a patient. In time the proper treatment of cholelithiasis, with few exceptions, will be considered to be early surgical interference, although, so long as the patient is in no apparent dan- ger, a rational non-surgical management through one or several attacks, as good judgment may dictate, can- not be condemned, and is to be heartily advised unless circumstances offer very perfect surgical advantages. When, however, after several clays' duration only a partial peace is declared, the general health begins to fail, local tenderness, lesser paroxysms recur, jaun- viagra delivery systems dice and infection threaten, one is confronted with a far more serious situation and the indications for in- terference may be termed imperative. The practical distinction between relative and imperative indica- tions in surgery is of the greatest importance and too often overlooked, and it seems a very pertinent ques- tion whether or not viagra pill take operation should be advised in the midst of a recent attack of colic, etc. Kehr, hav- ing, as he believes, learned to distinguish between gall-bladder colic and gall-duct colic, advises waiting when the latter exists, lest the stone be left in the choledochus or a difficult choledochtomy need to be performed. Many will be quite unable to make this differentiation with any certainty, while to delay long \\ ith a calculus in this most dangerous locality will often jeopardize the patient. The diagnosis once positively made, it would appear less difficult for a surgeon to viagra pill take approximate reasonably the burdens and the dangers of the disease in a given case, and to dis- tinguish between when to advise waiting, when to rec- ommend operation, and when to insist upon it, than to formulate rules for others. One prominent authority seems to regard the size of the stone as having an im- portant bearing upon operative indications, but, in the viagra delivery systems first place, we can foretell absolutely nothing as to the size viagra delivery systems of the stones before they are removed or passed, and in the second place, however much the theory that a small stone ought to be passed and a large stone can- not be passed may appeal to rational simplicity, the case above mentioned of the young woman proves that the facts fail to follow mathematical fancy. All modern observations go to show that nine times out of ten the gall stones occupy the gall bladder alone, and ninety- live times out of a hundred they occupy the gall blad- der alone or it and the cystic duct alone. In the vast majority of cases, therefore, the indication appears to be to open the gall bladder, remove the stones and debris, and temporarily drain the diseased organ. In the author's opinion, cholecystotomy, with temporary fistula, is the operation of election in the average cho- lelithiasis, and the one to be chosen probably eight or nine times out of ten. Various conditions in con- nection with the remaining minority will demand a