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chronic processes. If there were no gallstones and little change in the appearance of the gall-bladder the lymphatic glands on the cystic online viagra no prescription duct and along the hepatic and common ducts should be palpated. If they were found to be swollen without other adequate cause the gall-bladder should be removed. If the glands were not swollen and no stones were found, then search must be made for other source of s\'mptoms. Rose- now's theory of the cause of this inflammation online viagra no prescription seemed plausible. Bacterial invasion of the wall of the gall- bladder might cause changes in its circulation with edema, infiltration, exudation, swelling of tiger viagra the lymphatic glands, and local necrosis of the niucous membrane. Papillomas of the gall-bladder occurred in the same manner but instead of a primarv destructive eflFect there occurred locally an overgrowth which might later become necrotic. Papillomas were found in 107 of the 2.538 cases of cholecystectomy in the Mavo Clinic from tiger viagra Jan. 1, 1907, to June 1, 1915. From a surgical stand- point, it was important to tiger viagra note that the tiger viagra papillomas of the gall-bladder were not cured by temporary drain- age but that cholecystectomy .should be performed. Dr. S.^J. MlXTER of Boston, Mass., strongly advocated the performance of cholecystectomy in preference to cholecystostomy. He was among the first to advocate the more radical measure, which he online viagra no prescription had practised for many years, and he was convinced that the advantages of this method were not to be questioned. Dr. George W. Crile of Cleveland said that his end- results in cholecystectomy had not been uniformly favorable and cited two instances, one in his own prac- tice and one in the practice of a colleague, where very small stones later formed in a tiny bit of mucous mem- online viagra no prescription brane left at the bottom of the gall-bladder, producing a diminutive cholecystitis with blocking of the cystic duct. Both cases were finally operated upon a second time by the speaker with much difficulty. Dr. Joseph C. Bloopgood of Baltim'ore stated that in the last two years at the Johns Hopkins Hospital he had studied a group of a thousand cases of operation upon the gall-bladder. Cholecystostomy was the usual procedure; in these cases there were 60 cases of cancer, in only two of which was the disease removable. He suggested that the future treatment of gall-bladder con- ditions be instituted early in the disease, with the hope that interference would take place before the develop- ment online viagra no prescription of cancer. Cholecystectomy was a protection against the development of cancer. He stated that in online viagra no prescription the series mentioned there had developed no cases of cancer of the gall-bladder where drainage was insti- tuted in which at the time of operation careful exam- ination showed no evidence of malignant disease. Dr. W. D. Haggard tiger viagra of Nashville reported a case of cholecystostomy in which the patient developed car- cinoma within a year. Dr. tiger viagra Willy Meyer of New York reported another case in which cholecystostomy v.-as followed by the develop- ment of cancer at the site of the drainage tube eight months later. A second operation was refused and the patient died. Dr. Archibald Macl.4.ren of St. Paul reported a case of cholecystectomy followed in eight months bj' online viagra no prescription cancer of the stump of tiger viagra the gall-bladder. Dr. J. J. Buchanan of Pittsburgh stated that he had been able to follow ninety-four per cent, of his cases, and in none of these had carcinoma developed. tiger viagra Resection of the Cardia for Carcinoma. — Dr. WiLLY Meyer of New York read this paper. He stated that he offered his report with some hesitation, inasmuch as the tiger viagra two patients upon whose operations it was based did not pull through. However, he was so fully convinced not only of the feasibility of the work, but of the possi- bility of a more frequent recovery from operation than had hitherto been observed, that he felt impelled to write the paper. He first referred to five resections of the cardia followed by an operative recovery. They were the cases of Voelcker, Kiimmel, Sauerbruch, Zaaijer, and Ach, each done by a diff"erent method, which he illustrated by lantern slides. He then proceeded to tell of his own online viagra no prescription experience with tv.'o operations done in the course of the winter, one at the Post-Graduate, the other at the German Hospital. He emphasized the necessity of doing the operation in stages, the tiger viagra first to represent gastrostomy with careful palpation of the pathologic conditions at and around the cardia; the second to consist in attacking the tumor from the abdominal cavity, if the healthy portion of the esophagus above the tumor could be reached from below. He strongly advised following the method of Ach, accord- ing to which the proximal stump was extracted from the posterior mediastinum through an esophagotomy wound at the neck and transposed downward under the skin of the chest. Dr. Meyer carried online viagra no prescription out the extraction method in both instances, but was forced each time by adverse conditions found to add a thorac- otomy at the same sitting. However, abdominal section plus thoracotomy plus esophagotomy evidently was tiger viagra too much for these reduced patients to stand at one time. In his second case the intratracheal insufflation did not work satisfactorily and was seemingly the prin- cipal cause of the fatal issue. In both his online viagra no prescription cases the work had to be done in the presence of and with preservation of a previously established gastric fistula, a point which tiger viagra did not online viagra no prescription have to be considered by the oper- ators whose cases were reported. Dr. tiger viagra Meyer stated that .\ch carried out the extraction method by means of a wire loop, introduced to the stump of the esophagus, which loop was then pierced with needle and thread. The latter was knotted and served to withdraw the esophagus from the tiger viagra posterior mediastinum. However, this kind of procedure added an element of sepsis and Dr. Meyer therefore had constructed a new esophageal extractor which obviated this drawback. He tested it in the dog with entire satisfaction and stated that he saw no reason why it should not work equally well in the human subject. All the steps online viagra no prescription of the resection of the cardia as witnessed in his two cases, also of the new instrument and online viagra no prescription of Ach's extraction method were illus- trated by lantern slides. Dr. Arthur Dean Bevan of Chicago said that thoracic surgery, being accompanied by enormous risks and requiring expert and experienced workers with per-