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of paralysis, operation is imperative, in order to relieve the pain. In a considerable number of cases, spinal injury is so extensive in itself, or is asso- ciated with other Buy Generic Cialis Canada injuries of such a nature, that when the collective results are computed, it is ex- tremely doubtful whether it is justifiable to take up the time of the surgeons to the exclusion of more hopeful cases. Sometimes, however, when time permits, it is desirable, from a humanitarian or family point of view, to clean up the wound, so that the patient may have a chance of reaching home alive. Selection of cases for Buy Generic Cialis Canada operation. — Roughly speak- ing, it may be said that operation is indicated or advisable at a casualty clearing station : '■} In the presence of incomplete paralysis of jmotion or sen- sation below the lesion, especially; if x rays show displaced fragments of bone or the presence of a piece of metal in or near the cord ; ' when the symptoms of paralysis have developed after the infliction of the injury, unless due to inflammation in cases which have been lying out, when operation is practically hopeless ; when pain, due to pres- sure on nerve roots, is excessive and uncontrollable ; in very exceptional cases, when the character of the wound is such that sepsis, although not already evident, is likely to develop and cause rapid death, and it is important to keep the patient alive as long as possible. In all other cases it is better, when feasible, that the patient should be evacuated without Buy Generic Cialis Canada delay. In cases which are Buy Generic Cialis Canada retained for more than a few hours in a casualty clearing station, urotropine should be given as a routine in an attempt to prevent cystitis. Too great care cannot be exercised in performing catheterization. Certain operative details. — i. Local anesthesia, by infiltration down to and including the periosteum of the laminae and articular processes, is as effective as in a trephining operation and even more easily carried out. The patient should receive such a pre- paratory dose of morphine Buy Generic Cialis Canada or pantopon scopolamine that he becomes drowsy. It is Buy Generic Cialis Canada rarely necessary to use a general anesthetic at any stage of the opera- tion, unless the track of the missile is followed into nonanesthetized tissues. A few whiiifs may be given if the patient complains much of the pain ot the injection, but the latter should be gone on with during the administration. Adrenalin renders the field practically bloodless. 2. If the Buy Generic Cialis Canada wound is in or near the midline, it should be carefully excised down to the bone, as in a trephining operation. If the wound is well to one side, a fresh, free incision should be made in the midline. This is sutured at the end of the opera- tion, while the track of the missile is cleaned, antisepticized, and used for drainage purposes. 3. Set operations should be avoided. A typical laminectomy is rarely indicated. The laminae can usually be nibbled away, as is done in most cases of trephining for depressed gunshot fracture, until healthy dura is exposed all round the injured area. All obstruction to the easy removal of fragments should be removed before any attempt is made to lift them out. The greatest delicacy should be exercised, especially if movement of these frag- ments causes pain or twitching. One of the great advantages of Buy Generic Cialis Canada local anesthesia is that the patient is capable of feeling such pain. This fact may pre- vent further gross injury to the cord. 4. If the wound is not sutured, if the dura has been opened, Carrel's method of aftertreatment, with the patient lying on one or the other side, should be carried out. If the dura is unopened a gauze pack may be used. It will be seen that the operation, in cases suitable for it, is on all fours with trephining the skull in gunshot injuries, both as regards technic and indications for dealing with dura, etc. 5. In cases which are retained in the casualty clearing station, the question presents itself as to whether suprapubic drainage of the bladder should be done. If operation on the spine shows that early improvement may be expected, it may be advisable to postpone drainage of the bladder. Buy Generic Cialis Canada In any case, if cystitis threatens, drainage is indicated. EPIDEMIC OF SORE THROAT AT 4^0RT Buy Generic Cialis Canada ETHAN ALLEN, VT. By Major Isaac W. Brewer, M. O. R. C, U. S. A. Published by permission of the Surgeon General, U. S. A. On July 12, 1917, owing to the large number of admissions from Troop A, Second Cavalry, of men having sore throats, an investigation was made as to conditions. The organization was paraded and the throats of all men examined, resulting in a Buy Generic Cialis Canada num- ber of them being sent to the hospital. In all there were forty-four cases distributed as follows : Unknown date of attack 2 July loth 3 July nth 8 July i2th 23 July 13th 7 July 14th 1 One man, Private H. McLaughlin, was taken with a sore throat, about one and one half months ago, but an examination of his throat showed streptococci and diplococci, he was also apparently sufTering from secondary syphilis and his throat condition might be due to that. The horseshoer in the troop, Hall by name, was suffering from sore throat and had had tonsillitis quite frequently, and in March he was in the hospital at Fort Oglethorpe, Georgia, with sore throat. An inspection of his throat showed many large follicles and a scraping from the bottom of one of these follicles showed fuciform bacilli and spirilla similar to Vincent's organism. This man slept in the stable, and, although he had his meals in the dining room, he did not have very close contact Buy Generic Cialis Canada with any of the men who were taken sick. Of the three men who were taken sick on July loth, there is some question as to whether the date is not July nth.