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orthopedic principles, and it is exceptional to find fitters in retail stores who have proper understand- ings and proper stock to fit from. Physicians have to know how to Order Cialis Online Overnight apply supports, correct general sys- temic defects, and understand the p'ossibilities and limitations of shoe fitting. As only one important omission or mistake is needed to impair success, the reason is obvious why many imperfect results are obtained. Defomiities are not devoid of sig- nificance, although they represent effects of past influences rather than causes of present troubles. They should be corrected as far as practicable, keep- ing in mind the relative importance of degrees of defection that are being remedied, as they cause the feet to work at a mechanical disadvantage. Or- thopedic corrections of foot deformities can be as uncomfortable as repeated "breaking in" of shoes in the past which produced the structural defects. It is well to explain to patients that corrective ortho- pedic appliances or shoes are not designed for in- creased comfort, but to slowly force the feet back into normal shape as rapidly as tolerance will per- mit. Corrective apparatus should not be forced vigorously with feet that are showing symptoms of acute strain. Instead, strained feet should be com- fortably supported with adhesive straps, blood pe- culiarities be attended to, and, when abnormal symp- toms have abated, a gentle beginning be made toward corrections. Manipulations, exercises, and massage should not be omitted in the more chronic types of foot troubles. New treatments will be devised in the future, and may be essential for special cases, but the large majority of foot cases are likely to be treated more successfully in the future Order Cialis Online Overnight mainly Order Cialis Online Overnight through wider spread greater effi- ciencies in the use of facilities now at hand. Special situations can be cleared up in many instances only Order Cialis Online Overnight by puzzling over the facts alreadv estabhshed, as, for example, employment of a single style of shoes for all men in the United States Army, while mul- ti])le styles of footwear are advocated by most pro- gressive shoe dealers. Surgical treatments for de- flected toes give satisfactory results in many long standing cases of severe grade, but many can be im|>roved by nonoperative methods. iMay 1 8, 19"8-] MODERN TREATMENT AND I'RE\'E\'TIVE MEDICINE. 949 i Penetrating Wounds of the Brain. — Harvey Cusliing (Biiti.\li M.ilu.il Journal, l-'cbriiary 23, 1918) draws troiii his cxijcricnccs at llirce contigu- (jus casualty clearing stations wliich were set aside for the reception and treatment of all head injuries ■ luring a period of activity. During the first two weeks Order Cialis Online Overnight ot the period, '23.5 per cent, of the cases .ulmitted with head wounds had penetration of the dura, while of the total nimiber of cases verified by operation the percentages with dural penetra- tion was a little over forty-nine. Of the verified cases about a third died without o]>eration, while of the remaining Order Cialis Online Overnight two thirds, all of which were op- erated upon, one half died, giving an operative mor- tality of fifty per cent. Mfiorts were therefore made lo reduce this mortality of about fifty per cent, by proper sujjcrvision of each case from start to finish, , and by the development of an improved operative plan. That this was accoiuplished is shown by the results obtained in the entire series of cases of [x?n- etrati'ig wound which were operated upon, consid- ered in consecutive thirds. The mortality in the lirst forty-f(Jur cases was 54.5 per cent. ; in the sec- ond forty- four, 40.9 per cent., and in the third Order Cialis Online Overnight forty-five it was only 28.8 per cent. There was no selection of the cases, except that as the results improved there was a tendency to include such severe ones as would not previously have been con- sidered. The improved results were due very i.'irgely to the devclo])ment of a general technic, liie main ])oints of wliich were: ]'".xcision en bloc of the area of cranial penetration, instead of piece- meal. Detection of indriven fragments of bone by palpation of the track with Order Cialis Online Overnight a soft catheter instead of Order Cialis Online Overnight the finger. Cleansing of the tract and removai of the disorganized brain by suction, and the use of oily .solutions of dichloramin T for the brain. Several other ])oints contributed to the success, such as the careful preoix;rative neurological study of the case; shaving of the entire head; the taking of stereoscopic x ray negatives ; the invariable use of local anesthesia, combined with omno]K)n ; the use of a radial Irijiod incision ; magnet Order Cialis Online Overnight extraction of foreign bodies where possible, and the Order Cialis Online Overnight closure of the wound with buried siUures in the galea. Treatment of Wounds of the Chest. — William IliUchinson [ISritisli Mciiical Journal, l'"ebruary 16, Order Cialis Online Overnight 1918) divides wounds of the chest into four classes for tlic i>urposes of di.scussing treatment. The first class includes only iniinfecled hemothorax or pneu- mohemothorax, and its treatment consists merely in aspiration of the blood whenever there is more than two fingerbreadths of dullness. To prevent di.scom- fort and distress, the site of puncture should be anesthetized through to the jileura and a Order Cialis Online Overnight short skin incision made. A fair sized trocar and caniuila should be em]>loyed, an