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Stations. Wilmot Herringham. 34 MEDICAL RECORD. [July 7, 1917 3. The Admin stration of Anesthetics at the Front. Geoffrey .Mill-shall. 4 buy viagra minneapolis The Color Changes Seen in Skin and Muscle in Gas Gan- grene. Cuthbert Wallace 5. The Method of Spread of Gas Gangrene into Living Muscle. buy viagra minneapolis J. W. McNee and J. Shaw Dunn. 6. The Successful Conservative Treatment of Early Gas Gan- grene in Limbs by the Resection of Infected Muscles. C. H. S. Frankau. Hamilton Drummond and G. B. Neligan. 5. The Method of Spread of Gas Gangrene into Liv- ing Muscle. — J. W. McNee and J. Shaw Dunn state that in their experience gas gangrene is essentially a muscle disease and they have never seen it commence where in- generic viagra 50 jury of muscle could be excluded, the generic viagra 50 primary focis in every instance being in damaged muscular tissue. No example of gas gangrene beginning in and remaining localized to the subcutaneous tissue has been met with, and a condition spreading below the skin which is met with in base hospitals would appear to merit some special investigation before a relationship to the gen- eral type of gas gangrene can be established. Clin- ically, the rapidity of spread of gas gangrene into living muscle, once the disease has begun, is so remark- able as to demand some definite explanation such as has been sought for by histological methods and here suggested. The earliest case of gas gangrene examined histologically showed the condition already established three and a half hours after the wound was received, and they have seen massive gas gangrene of a limb lead to a fatal issue twelve hours after a wound of the thigh. A point to be noticed is that death may occur quickly, following a comparatively slight wound, when examination postmortem shows gas gangrene involv- ing buy viagra minneapolis only a small bulk of actual buy viagra minneapolis muscle tissue. The material elaborated by the bacilli, whether it be a true toxin or not, is a powerful systemic poison. Anthony Bowlby has pointed out that cases of this kind may very readily be mistaken for death from shock alone. Wounds involving main blood vessels allow rapid de- velopment of gas gangrene in distal segments or parts. The spread of gas gangrene into healthy, living muscle, with an intact blood supply is a less easy problem. Two factors generic viagra 50 must be brought to mind: one is the clinical observation, now well established by the microscope, that gas gangrene tends to spread in the longitudinal axis of the muscles, so that single muscles are in- volved from end to end while neighboring ones are un- touched. Fresh material is generic viagra 50 absolutely essential for correct conclusive investigation as the organisms prolif- erate and produce gas rapidly in the warm body after death. Amputated limbs and stumps left after ampu- tation afford good material generic viagra 50 for examination as anaerobic organisms are found buy viagra minneapolis in the healthy muscle at a consid- erable distance from the actual seat of the gangrene, but their presence does not constitute gas gangrene. The Bacillus aerogenes capsulatns (B. perfringens) is the commonest and most abundant organism present in this condition. By the examination of serial sections of tissue, most of the information has been obtained by the method buy viagra minneapolis of spread. Macroscopic-ally this spread- ing margin is sometimes fairly sharp, at other times, somewhat irregular. The muscle fibers at the margin are paler and duller than the normal but the color change is little more than might be accounted for by total absence of blood in the part involved. The outer limit of the process while indefinite can be mapped out fairly closely buy viagra minneapolis if the healthy tissue beyond is still con- tractile, as this power is lost in the part becoming gan- grenous. At the advancing edge the muscle is firmer to the touch than the healthy fibers beyond and the firm- ness is found in the gangrenous part behind. Micro- scopically in a section taken from as near as possible the advancing edge, various changes are found. Vari- ous normal fibers are seen, while others exhibit a strik- ing change. The staining reaction is different, and dots indicate the individual fibrils lost. The fibers generic viagra 50 are swollen, but are well separated from the inter- stitial connective tissue, to leave what appears to be a clear space. The fiber still shows the uniform eosin tint indicative of degeneration. The sarcolemmal nuclei still stain brightly. What determines the ad- vancing buy viagra minneapolis death of the fibers? The writers, after thor- ough experimentation, have decided that the spaces be- tween the fibers and the interstitial connective tissue are filled with a toxic fluid which spreads along the in- terstitial tissue and the fibers, killing the latter as it advances. Once the fibers are killed the anaerobic bacilli live on them, breaking down the sugars and pro- ducing gas in abundance. With regard to the route followed by these organisms, these are, at the spreading edge, never found in the fibers themselves, but are practically confined to the reticulum. After the fibers are broken down the organisms invade them in num- bers. Fewer germs are found in this completely degen- erated tissue, only gas, and they travel to the spread- ing zone. In rapidly spreading gas gangrene leucocytes are generally absent in the involved muscular tissue. The rapidity of buy viagra minneapolis the spread may account for this as leucocytes take time for development. McNee and Dunn conclude that the rapidity of spread of gas gangrene into living voluntary muscle is so remarkable as to re- quire explanation by a different process from that which governs ordinary septic invasion of tissues. It is sug- gested that the facts are accounted for by the peculiar anatomical structure of muscular tissue; as the sheaths inclosing the long individual fibers are so easily detach- generic viagra 50