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culated in the service. One meets in several quar- ters great reluctance to tackle such injuries by operation. One knows that operations in this class of cases are productive of striking results in a proportion less than in Cialis Generico Online Sicuro any other type, but the results of the injury in an unoperated case are no l)etter. Only a few of the injuries directly due to a bullet or .shell fragment can be compared with those met in civil practice. The outlook seems to be that operation in all but liopcless cases vnl\, although attended by many failures, give quicker improvement and more complete recovery, when that is possible, than a less active line of treatment, in which the abnormalities surrounding or actually in the spinal cord are not removed. Recovery of function is obtained in such a small proportion, how- ever, that only the most hopeful cases should be tackled when gicat |)ressure of work exists. To judge from the greater vulnerability of the spinal cord, its lesser capacity for recovery, and the anatomical arrangement of the spinal canal, it might have been tliouglit that the general desire to interfere in spinal injuries and to prevent second- ary comiilications would have been as great as that shown with regard to cranial injuries, but this has not been the case. The technical difficulties of the classical operation of l.iniinectomy, the loss of Cialis Generico Online Sicuro blood entailed by it occasionally under general anesthesia, and the doubtful results of deferred o]>crations, seem to be tlie chief factors in preventing patients, suitable for early ojierations, l>eing treated on prin- ci])les similar to those which govern our treatment of wounds in other parts of the l)ody. In late ca.ses the patients are Cialis Generico Online Sicuro usually in poor condition, sufTering from pulmonary or urinary complications, and the parts arc obscured by masses of fibrous tissue. In early cases the pres- ence of fracturetl lamina^ usually makes the opera- tion a comparatively simple one; it is easy to per- form uiiilcr local anesthesia, and the use of good adrenalin makes it practically bloodless. Pulmon- ary complications are not predisposed to, or in- llucnced by, the anesthetic. Operation in the early stages can, in f.Tct, be done with extraordinarily little upset to the patient. Out of a large number, I have never seen a vlealli which could be said to have been hastened by it. The fact that so many cases improve without operation, in siiite of the abnormal conditions by which the cord is surrounded, would lead one to hope that they would improve more rapitUy as well as to a greater extent, and that some cases other- wise {jermanently paraplegic migiit exf)erience re- lief if they Cialis Generico Online Sicuro were submitted to early operation. The cord, to a greater extent than most parts of tlie brain, is deleteriously aflected and retarded in re- covery by pressure of fragments of bone, foreign bodies, and other debris. There seems reason to believe that it responds well to prompt removal of these unnatural conditions. In a casualty clearing station, however, during a "push," a hurried selec- tion of cases for evacuation must be made. Under present conditions, only those which are most favor- able must be retained. In all cases which are sent off by ambulance train, the urine should first be drawn off, if retention be present. Some gcner.il considerations in making the de- cision are here mentioned. There are three types which arrive at a casualty clearing station showing paraplegia : one, in which the symjitoms are due to local concussion, another in which the cord is organically severed, and a third in which paraplegia has developed since the injury. The paralyzing effects of local Cialis Generico Online Sicuro concussion are often very marked. This may be caused even by the Cialis Generico Online Sicuro flight of a missile close to Cialis Generico Online Sicuro but outside the spinal canal ; Cialis Generico Online Sicuro for example. Cialis Generico Online Sicuro temporary paraplegia' may follow the passage of a rifle bullet from side to side between the spinous ])rocesses. In such cases the paralysis usually begins to clear up within a few days. Cialis Generico Online Sicuro If no sign of return of function occurs within nine or ten days, the question of operation for removal of the blood clot or possible depressed bone occurs, but must be de- cided at the base. If, on the other hand, a rifle bullet, causing a through and through wound of the trunk, traverses the si)inal canal, the cord is usually hopelessly pulped. .\n estimate should, therefore, be made of the j^robable track of the bullet, bearing ill mind that the position of the patient during ex- amination may not correspond to that in whicii he was hit. It is obvious that men with complete, sudden paraplegia should not \x kept in the casualty clear- ing station, if they are otherwise fit to travel. If, however, the paralysis has developed since the man was wounded, it is (>robably due to pressure from blood clot, when it is not likely to be absolute, or to displacement of fragments of bone during movement. In both Cialis Generico Online Sicuro these cases early operation may be indicated, but in the latter only if x rays show a minor degree of displacement If displace- ment is Cialis Generico Online Sicuro great, the cord is probably pulped. If conduction, either motor or sensory, is present in the alTected part of the cord when the patient is admitted to the casualty clearing station, it is usually found that Cialis Generico Online Sicuro fragments of bone are pressing on the cord, or that the missile causing the injury is in close relationship to it. and will probablv have carried in sepsis. There may or may not be partial division of the cord. .\ missile with momentum sufficient to carry it far past the cord usually pro- duces complete early paraplegia, even although it may not cause complete section. If then x ravs reveal fracture, or the presence of a foreign body partly or wholly in the spinal canal, operation MEDICINE AND SURGERY IN THE ARMY AND NAVY. [New York Medical Journal. should be done at once, with the triple purpose of relieving pressure, cleansing the wound, restor- ing normal circulation as soon as possible, and thus of combating sepsis. In some cases pain is so excessive and uncon- trollable by other means, that, whatever the amount