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from the bed of the tumor, Can You Take 40mg Of Levitra and the efforts to check the h»inor- rhage by ligation, the cautery, and sutures prolonged the opera- tion. Death occurred on the beginning of the third day, appar- ently from septic jieritonitis ; no autopsy was conceded. I presume the infection may have started from the place where the necrotic fibroma was imbedded. Here, perhaps, infectious germs existed, which, though made harmless for the time by the adherent peritonsBum, were set free by the operation, and found outside of their Can You Take 40mg Of Levitra prison very favorable opportunity for their deleterious action. The torsion of the pedicle illustrated very beautifully the way in which such tumors may be deprived of their blood-supply, and finally undergo retrogressive meta- morpliosis. With reference to supra- vaginal amputation of the uterus, I should like to mention in a few words the difl:erent ways in which the uterine stump is secured and treated. Here, as previously in ovariotomy, the Can You Take 40mg Of Levitra extra- and intra-peri- toneal methods stand against each other, and on both sides equal- ly good results are obtained. Schroeder and Martin, in their very extensive practices, trust to tight suture of the stump after funnel-like excision, Schroeder first advising the etaye suture. They do not use the permanent elastic ligature, and are strong advocates of the intra-peritoneal treatment. So are Olshausen, who uses the elastic ligature. Rose, and others, while the extra- peritoneal treatment is given the preference by Hegar, Kalten- bach, P6an, and others, as involving less risk of septic poison- ing, and leaving the stump accessible in case of secondary hsem- orrhage. Tliere exists, perhaps, no more striking illustration of the safety of aseptic procedures than the fact that such large masses of tissue as the ligated stump of the fibromatous uterus may be left in the abdominal cavity, deprived of blood-supply without undergoing decomposition and giving rise to infection. On the other hand, it can not be doubted that a certain amount of risk will always be attached to this way of acting; and that those Can You Take 40mg Of Levitra methods which secure nutrition to the stump with intra- peritoneal treatment will have to be regarded as the most per- fect ones. That good results can be achieved by the extraperi- toneal method nobody will doubt, and successful cases of it have repeatedly been reported in this society. I am, however, convinced that by and by, just as it has been with ovariotomy, the intra-peritoneal treatment will be more and more adopted. I should certainly give preference to Schroeder's metliod of securing the stump by tight etage sutures above all others if, with reference to haemorrhage, I conld regard it as free from all danger. It may be safe in the hands of operators who are working on such a large scale as Schroeder and Martin. I myself must confess that heretofore only the apprehension of a possible haemorrhage has prevented me from following them. In order to combine the advantages Can You Take 40mg Of Levitra which the elastic ligature offers in regard to hemorrhage with those offered by sutur- ing the stump, I tried in one of the aforementioned cases to apply the ligature beneath the peritoniBum, so that a certain amount of blood could be furnished to the stump through its peritoneal covering, which of course must be detached as little as possible above the ligature. Further observations will have Can You Take 40mg Of Levitra to be made in order to ascertain whether this procedure will always yield as good results as it has in my case. One mechanical contrivance I would mention, and of which I like to make use in all abdominal operations where practica- ble, is Thiersch's ligature spindles, with or without a holder, which I presented at a former meeting of this society. They are indeed very handy, and allow of securing pedicles and fleshy adhesions with more constricting force than can be exerted in the ordinary way of tying. The abdominal incision ought to be long enough to allow of an easy access to the operating field; I certainly prefer too large an incision to one which obliges the operator to work in the dark, or to do uncertain manipulations : for this latter reason often one of the principal dangers in these operations is incurred — namely, unnecessary and abundant loss of blood, simply be- cause the operator does not in Can You Take 40mg Of Levitra time and with ease get at the bleeding point. Whoever has seen those enormously dilated veins in the tumors would be convinced that bleeding from such a vessel for a very short time must be sufficient to endanger life. July 3, 1886. PROCEEDINOS OF SOCIETIES. 23 For this reason also every undue tearing force ought to be avoid- ed, and it is safer and wiser to work slowly and cautiously than to hurry at unnecessary hazard. The length of the abdominal incision adds nothing to the danger and gravity of the operation, and incisions of fifteen or more inches will heal without diffi- culty. To obviate loss of warmth from extensive denudation of the intestines, the use of large Hat sponges dipped in a weak aseptic fluid seems to me the most commendable. Dr. Mabkoe asked if the ovaries and Fallopian tubes were perfectly healthy in the first specimen. Dr. Lange replied that they were. On the presentation of the second specimen Dr. Lange drew attention to the fact that the tumors had grown between the broad ligaments Can You Take 40mg Of Levitra and overlapped the uterus, as it were, so that only a small portion of the cervix was visible. Dr. Markoe asked if Dr. Lange had ever tried Schroeder's method of closing the stump and removing the elastic ligature. Dr. Lange replied that he had not done so yet. Dr. Markoe then asked what kind of suture was used. Dr. Lange replied that it was a coarse silk suture, but that he had not seen any danger arise Can You Take 40mg Of Levitra from the elastic ligature. Dr. Markoe thought very favorably of this new method, and remarked that to leave the elastic ligature in the abdominal cavity was a serious matter. Dr. Gerster stated that from the published reports of Dr. Hofmeier, an assistant of Schroeder's in these operations for fibro-myomata, a serious objection was the frequent oozing caused by the stitches used to close the stump. Although the gentleman who published the report seemed to belittle this oc- currence, the speaker thought it quite a serious objection, and he did not think the elastic ligature was objectionable when passed under the peritonaeum, any more than the silk ligature; and, be- sides, it gave a safer closure of the vessels. It should be re- membered that when the elastic ligature was applied it became very thin by tension, and, as far as the mass itself was con-