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as 32.7 per cent., a difference most remarkably in favor of trephining. It has not been shown that' this ratio of lessened mortality is an overestimate. The subject has been frequently discussed before medical' societies. In the discussion before the Philadelphia Neurological Society in ^94, Drs. Taylor, Keen,. Laplace, Dercum, and Sinkler participated; three un- successful and several successful cases were reported. It was also discussed before the Suffolk District Med- ical Society several years ago, Drs. Elliot, Putnam, Warren, and Bradford taking part (Bos. Med. ami Surg, four., February 9, 1893). At this meeting, Dr. John W. Elliot reported two cases of intracranial hemorrhage in which the operation was successful; in both the hem- orrhage accompanied depressed fracture. Dr. Putnam alleged that "the most satisfactory of the operations done at the hospital have been in this class of cases." Dr. Warren pointed out that the point of election for trephining in cases of hemorrhage is the pterion or the part where the parietal bone joins the frontal and temporal bones. " If no clot is found there, trephine farther back on a line parallel with the roof of the orbit." He thinks it a point of buy viagra holland great importance " that we should not only relieve the pressure caused buy viagra holland by the hemorrhage, but that we should also undertake, by making an opening cheap viagra with into a cranial cavity, to remove all the fluid which remains there." The point of elec- tion for drainage " should be a lower point in the cav- ity of the skull than the one selected for searching for a clot or the vessel itself, that is, through the squa- mous portion of the temporal bone, just above and a little behind buy viagra holland the external auditory meatus." Dr. Griffin, of Lincoln, Neb., in the case of a man who was injured over the arm and leg centre in a brawl, used a bradawl and chisel for trephining, and found the operation surprisingly easy ! The middle menin- geal buy viagra holland artery was bleeding profusely and was buy viagra holland tied. The man got well. cheap viagra with 1 It has been remarked that in cases of intracranial hemorrhage without a compound fracture of the skull, it is not always easy to find the bleeding vessel or even the blood clot by trephining. During a period of three years, Kroenlein trephined four closed skulls for the purpose of arresting hemorrhage from the middle meningeal artery. Two of his cheap viagra with pa- tients recovered, while the remaining two died because the extravasation was located posteriorly to the tre- phine openings and could not be found and removed at the time of the operation. Kroenlein therefore rec- ommends that in cases where the surgeon is reason- ably certain that the symptoms of compression are due to hemorrhage, exploratory trephining be continued until the haematoma is found. Thiersch had to re- move three discs of bone before buy viagra holland the blood clot was found." Scudder and Lund ' in an analysis of forty- five cases of trephining for intracranial hemorrhage since 1886 found thirty-three recoveries and twelve deaths, a mortality of twenty-seven per cent., which is a considerable improvement on older statistics. This improvement has doubtless resulted from the more ac- curate diagnosis which a careful comparative study of the symptoms in numerous cases has made possible, and in part from improvement in the operative tech- nique. 1 Medical News, October 14, 1S93. s Sajous' Annual, 1S88. 3 American Journal of the Medical Sciences, April, 1S95. Sen MEDICAL RECORD. [June 6, 1896 Medical Record: A Weekly Journal of Medicine and Surgery. cheap viagra with GEORGE F. SHRADY, A.M., M.D., Editor. Publishers WM. WOOD &. CO., 43, cheap viagra with 45, & 47 East Tenth Street. New York, June 6, 1896. THE RANK AND FILE. In these commencement times, when the colleges pa- rade their graduating classes amid tingling music, fragrant roses, and impassioned oratory, the looker-on is apt to put the question to himself, How many of all the flushed anticipations of brilliant futures will be paled before the stern discipline of inevitable disap- pointment? When we match ordinary professional success against real fame, the proportion which gains the latter is exceedingly small. The higher the de- gree the less the chance. To attain a pinnacle means the success of one in ten thousand. The law of pro- portions is founded on a mathematical certainty. The lower grades buy viagra holland show more liberal chances, the sweep- stakes in the race are not so heavy, and are purposely open to ordinary competitors. Still the training to race develops becoming assurance, creates proper endu- rance, and cheap viagra with in the end makes the essence of actual capa- bilities. If not a spirited and sweeping record breaker, we get the good and serviceable burden bearer. There are many of these in every field of struggling effort. They are in the majority which is always re- spectable, always efficient, and which does the really necessary and valuable buy viagra holland work for any community. We speak for such of the aspirants for high places who, in spite of every laudable effort, must be contented eventually to find their actual places with this ma- jority. It may not be on account of any lack of merit on their part, but rather in the elucidation of the gen-