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has ever Buy Cialis 20mg Australia been written concerning any disease. Mayo Robson, Kehr, and others who have had large ex- perience in the surgical treatment of gallstones, have also written voluminously on diseases of the gall- bladder and bile ducts. Of the making of books, reporting of cases, and writing of articles on this subject, there is no end. My reasons for writing on a subject on which others have already so ably written are as follows : A careful and painstaking examination of many sufferers has forced me to cer- tain conclusions not in accordance with those of Alayo Robson, Kehr, and other writers. So bril- liant have been the achievements of Buy Cialis 20mg Australia gallstone sur- geons, so much has been written on the surgical as- pect of the subject, that it seems to be forgotten that this is a disease specially amenable to medical treat- ment; and if medical and hygienic means adapted to the requirements of each individual were resorted to early enough in the course of the disease, in very few cases indeed need the question ever arise as to whether the patient should submit to the brilliant, yet often dangerous and even fatal remedies of the gallstone surgeon. In my experience nearly all who suffer from gallstones get relief sooner or later without operation. I learn also from the records of the surgeons themselves, viz., that operation by no means always procures permanent freedom from the symptoms of this disease. Before entering on a somewhat systematic discussion of the subject, I shall mention three considerations that I believe should be well weighed before any medical man ad- vises a patient to submit Buy Cialis 20mg Australia to operation. I. Winiwarter, a German surgeon, said tliat the diagiiosis of gallstones is sufificient indication for op- eration. This is exceptional. There are few medical men or surgeons Buy Cialis 20mg Australia who would suggest that ever)' in- dividual who has gallstones in the gallbladder or bileducts, ought to undergo operation to have them removed. Postmortem records abundantly show that the presence of gallstones is not inconsistent with long life, and Buy Cialis 20mg Australia they have been found in large numbers in the gallbladders of those who have never during life suffered any pain or discomfort that led even to a suspicion of their existence. In 1,150 postmortem examinations made at Strassburg, Schroeder found gallstones in the gallbladder and bileducts of 141, or 12.26 per cent. In 742 post- mortems made at Manchester, Brockbank found gallstones in 49, or 6.6 per cent. If ever)' individ- ual in whose gallbladder or bileducts are gallstones suffered the agonies of biliary colic, peace on earth would be impossible. So sudden and severe are the attacks that seldom would there be a gathering in church, theatre, or music hall undisturbed by the groans of the sufferers. Buy Cialis 20mg Australia Happily, when the stones do not migrate nor set up inflammation, there is no need for interference, and from this it follows that if by medical means the stones can be kept at rest May i8, 1918.] Buy Cialis 20mg Australia WEISS: GALLSTONES. 933 and inflammation (prevented, surgical treatment is unnecessary. 2. Medical and hygienic remedies can claim a vastly larger proportion of cures than surgical. What proportion of those who have gallstones ever actually suffer it is exceedingly difficult to estimate. Buy Cialis 20mg Australia Many of the patients seen in ordinary practice have only slight and transient attacks. Medical men in Carls- bad, to vk'hich many resort who suffer from the disease in an aggravated form, say they very seldom have a fatal case and send very few to the surgeon. Operation i certainly believe to be the best treat- ment in a limited number of cases, but a comparison of a number of patients who have not undergone operation with cases of a similar type on whom op- eration has been performed will jjrobably show that the mortality among those who have been left Buy Cialis 20mg Australia to vis medicatrix nature is considerably less than those who have undergone operation. 3. When in any individual case the f(Uestion of operation is discussed, the argument is generally ad- vanced in its favor that though the morlabty be comparatively high, the relief given is more rapid than by Buy Cialis 20mg Australia any other means and the cure more likely lo be comijlete. As regards relief being more quickly obtained by surgical than other means, it is true that many patients are able to leave the hospital in a few weeks, but I have not yet seen any one who has undergone a severe oi)eration restored to the average strength and energy within a few months while the effect on the Buy Cialis 20mg Australia constitution is generally felt for a life- time. To this, however, many patients who have suffered for a long period would readily submit, pro- vided they could be assured there would be an end to the frequently recurring attacks Buy Cialis 20mg Australia of agonizing pain. Unfortunately, however, operation provides no absolute safeguard against future attacks. No surgeon has had a larger experience than Kehr, of Halberstadt, nor jirobably can any one be regarded as his superior in diagnosis or technic. In his Aidritiiiig cur Erlcrnitng der Diagiwstik dcr cinzel- nni I'oniicii dcr GnUcnstcUikrankhcit, we find the following statement which summarizes a great part of his work: "I have \\\) to A]iril i, i8t)<), performed .409 ojierations on 35.^ patients suspected of having gallstones or in whom gallstones were actually found to be iircsent." Mere we find fifty-six operations more than liie number of patients. .Mlowing for the fact that some may have l)een operated on oftener than twice, we thus find that fifty in 353, or one in seven, had to undergo operation oftener than once. Some of these operations we find from tiie list of cases appended were due to the first operation not being conqilete ; others, to a return of the disease. When the gallbladder Buy Cialis 20mg Australia is merely opened — cholecysto- tomy — and its contents, gallstones, mucus, or pus, removed, if Ihc condition which led lo the fonna- tion of the gallstones persists, there seems to be no reason why they should not contimie to fonn. It is well known tiiat after o])erations of this kind, stones arc frequently passed. After the more severe operation of cholecystectomy, with a mortality in the hands of the best surgeons, of five to fifteen JHT cent., when not only the conteiUs but the entire gallbladder is removed, it is true that stones can no longer form in the gallbladder ; but this gives no