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masses of clot added to the degenerative changes char- acteristic of those processes. Progressively high tem- peratures common to fatal cases, however (though every care prescribed by aseptic rules be followed ), and their similarity in other respects to those treated without asepsis, make it doubtful, to say the least, if sepsis has been completely eliminated from them. The reduction of this mortality is a problem that now confronts the surgeon, and, as an entering wedge toward its solution, buy viagra digg the importance of a series of ob- servations that will buy viagra digg establish beyond doubt the rela- tion of sepsis to the fatal cases cannot be overesti- mated. Much maybe accomplished by the systematic and accurate observation of all cases of jelly viagra price fractured jelly viagra price skull in which there buy viagra digg is an open surface requiring dressing or in which jelly viagra price any discharge exists, by making bacteriologi- cal cultures at intervals during life and at the autopsy. Briefly, freedom from sepsis should be definitely and unmistakably proved in any fatal case by the unassail- able evidence supplied by bacteriological tests, to clear it from the suspicion of putrefactive infection. In searching for the source of infection, one is im- pressed with the invariable freedom with which the immediate seat of injury is now inspected, cleaned, and dressed, relieving in a measure the region of direct violence from the suspicion of contamination. Of the more remote sources, the common association of bloody and serous discharges from the ear and nasal passages suggests possibilities of bacterial infection through the extension of a fracture by Assuring to the internal ear; which, in addition, may supply jelly viagra price abundant material through the retained products of chronic disease. By laceration of the membrana tympani, direct connection is made with the outer air on one side, and on the other communication is opened through the Eustachian tube with the cavity of the naso-pharynx, which Paul Rauge terms " the storehouse from which the infective elements passing through the tube into the tympanum are derived." Fissures communicating directly with the nasal cavity are of necessity open to the buy viagra digg same in- fective influences. A large percentage jelly viagra price of those who die from skull frac- tures have these bloody or serous discharges; also those who survive for more jelly viagra price than five or six days jelly viagra price and then die. On the other hand, a good proportion of those who recover have the same history ; from which it is proper to infer that such discharges are not in themselves necessarily fatal nor the bony fissures asso- ciated with them. Another explanation for fatal cases must be found either in the character of the injury to the brain and its vessels, or that of the fissures through which they escape. A fissure extending through loosely fractured bone would be more likely to supply an avenue for in- fective material to reach the skull cavity than one that could be barely detected and closely resembled a crack in glass or porcelain. The variations between these extremes are common jelly viagra price to all fractures, and may explain a part at least of the differences of results in cases presenting similar symptoms. Should Assuring ex- tend in the direction of the internal ear, the difficulty of making that region aseptic and free from the possi- bility of dangerously contaminating an opening com- municating with the brain jelly viagra price is a serious one; especially so in old cases of otorrhoea. The cavity of the skull is not second to that of the peritoneum in the importance of maintaining perfect aseptic defences. The septic area, after careful disin- fection, should be approached from the wound at the vertex by widening connecting fissures with the ron- geur to half an inch, until the base can easily be 738 MEDICAL RECORD. [May 23, 1896 reached and packed with gauze above and below the fissure extending along the base. The brain can be lifted with a retractor and the auricle dissected up and displaced forward should it buy viagra digg become necessary. This packing of gauze limits hemorrhage without undue pressure upon the brain, and provides an excellent drainage apparatus from the vertex to the base of the skull. As possibilities of infection cannot be estimated before the development of unfavorable symptoms, when too late to institute antiseptic measures, however radical, conservative treatment should include at the first inspection of the wound a most rigid asepsis, the exploration of fissures with the utmost jelly viagra price precision, uncovering the whole circumference of the perfora* tion in the skull for that purpose, and providing un- limited drainage by widening the fissures into loosely connected bone that extend in the direction of the base. When nearly fifty per cent, of brain abscesses originate in suppurative ear diseases, the isolation of this region from the brain and its attachments during the repairs of a fractured skull demands the serious consideration of the jelly viagra price surgeon. It also suggests the question of a more radical clearing and asepsis of the ear cavities than can be obtained without anaesthesia in cases in which the temperature steadily rises, notwith- standing our precautions. The danger associated w ith such a plan lies in the possibility of forcing, by wash- ing under pressure, septic material through a wide fissure into the skull cavity, and emphasizes the im- portance of a competent primary asepsis of the ears in all fractures connected with them. Reports of cases were given illustrating the practice advocated. Dr. W. L. Estes, in discussing Dr. Beach's paper, said that the questions involved in this paper, which set forth very clearly the necessity of disinfection, the production of a septic state, and the employ- ment of proper drainage, are important ones and should not pass unnoticed. Too frequently these frac-