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All our patients with a recent thromboembolic occlusion of limb arteries treated with streptokinase have been reviewed retrospectively. Clearing of the main artery, as judged by arteriography or reappearance of arterial pulsations, occurred more often when treatment was started early. If only patients with an iliac, femoral, or popliteal artery occlusion are considered, those who received a lower initial dose had a significantly higher clearing rate and a significantly lower mortality than those who received a high initial dose (500,000 units of streptokinase or more). Therefore an initial standard dose of 1,200,000 units of streptokinase is no longer recommended in these conditions, and even an individually titrated initial dose of more than half a million units could be hazardous. If no neurological abnormalities were present on admission amputation was never necessary, even if clearing of the main artery did not occur. If there was sensory loss of at least part of a limb, amputation was avoided only if the pulsations returned in at least one artery of hand or foot.

A retrospective survey of all cases of osteosarcoma of the femur and tibia treated at the major centres in the United Kingdom during 1952-9 was carried out in an attempt to assess the respective value of treatment by surgery and radiotherapy and the feasibility of a larger prospective study. Of the 192 patients available for the comparison, those treated by radiotherapy alone did least well. A combination of the two treatments—radiotherapy followed by amputation—produced better results, in terms of survival, than amputation alone; however, the comparatively small numbers involved and the inadequacy of information about the factors dictating the choice of treatment make firm conclusions impossible. A controlled clinical trial on a larger scale might provide answers to the outstanding questions.

Eighty-five cases of clostridial infection, including 56 cases of gas gangrene, followed "clean" surgical operations performed in British hospitals in the course of two years. Nearly all the serious infections followed amputations of the leg for ischaemia or other operations on the leg in which a foreign body was implanted. All the infections were sporadic, and the evidence suggested that the infecting organism usually came from the bowel of the patient. Nearly half of the operations were performed in modern theatres with satisfactory ventilation and unexceptionable arrangements for the sterilization of instruments and dressings.Skin sterilization was often carried out perfunctorily or with agents with poor sporicidal activity. Total eradication of spores from the skin is, however, difficult to achieve, and recontamination may occur during the operation. Hence it is considered justifiable to give penicillin prophylactically to the small group of patients at serious risk from postoperative gas gangrene.

Subungual malignant melanoma developed on both great toes of a 61-year-old woman. The lesions had been diagnosed elsewhere as ingrowing toenails and had been treated as such for two years. The difficulty in clinical diagnosis is illustrated by the description of three other patients with subungual malignant melanoma. The tumour should be considered as a possible cause of any persistent abnormality of the nail bed or the nail itself, especially if it is pigmented.

Of four cases of postoperative gas gangrene in three hospitals three followed amputation of legs with gangrenous lesions, and one followed gastrectomy. Clostridium welchii was isolated from the wounds and the faeces of each patient; small numbers of Cl. welchii were found on the floors of the theatres where the operations had been performed.Two infections occurred in one hospital on successive days. Typing of strains of Cl. welchii from these patients showed that they were serologically distinct. Further studies suggested that in each of the four cases infection was probably acquired from the patients' intestinal flora, probably through faecal contamination of skin.In 76 patients sampling of the skin with surface contact plates showed occasional heavy contamination of the thighs, groins, and buttocks with Cl. welchii, most of which were present as spores or sporing bacilli; Cl. welchii was more commonly found in patients with incontinence of faeces. Compresses of povidone-iodine applied for 30 minutes were found greatly to reduce the numbers of Cl. welchii, and swabbing with 70% alcohol was effective in some cases; washing with soap and water had no effect on the numbers of Cl. welchii on the skin.

0 PERATIVE measures for the relief of leucorrhea aim to remove the infected endocervical mucosa, from which the discharge originates. This paper tabulates the results obtained by conical excision of the cervix in 130 patients operated upon at the Long Island College Hospital, between February, 1927, and May, 1930. Only proved cases of inflammatory cervicitis, and those followed for at least one year are included in this study. Trichomoniasis was excluded in cases of vaginal discharge recurring after operation. Viewed in the light of end-results, removal of the endocervix either by amputation, or the more conservative excision, has not proved entirely satisfactory. R. M. Rawls, in a series frpm the Woman’s Hospital, in which the technic of Emmett was employed, reported 60.7 per cent cured, 31.1 per cent improved, 7.1 per cent unimproved and 1.1 per cent as aggravated following operation. H. B. Matthews, employing the Sturmdorf technic in a series of 70 cases, recorded 70 per cent cured, 22.8 per cent improved, and 7.2 per cent unimproved. In a follow-up group of 75 patients from the Bellevue Clinic, operated upon by the Sturmdorf technic, F. W. Sovak tabulates 88 per cent cured, 4.7 per cent improved, and 5.3 per cent as unimproved. In this series of 130 cases, the Sturmdorf technic was used, although in the older patients and in those requiring extensive plastic operation, removal of the cervix was more radical. Catgut replaced silkworm for the inversion suture in restoration of the portio. Preoperative preparation consisted of thorough application of one-half strength tincture of iodine to the vulva, vagina, and cervix. Where curettage was performed, a quarter-inch iodine pack was placed in the cervical canal and retained during extirpation. In cases of prolapse, douches of bicarbonate of soda and boro-glyceride tamponade were employed for several days prior to operation. In this series of 130 cases, 103 or 79.2 per cent were cured, 23 or 17.7 per cent were improved, and 4 or 3.1 per cent received no benefit (Table I). In one of every five cases therefore the ultimate operative result was unsatisfactory. It is the purpose of this paper to analyze the causes of failure. Broadly speaking, leucorrhea, recurring after cervical operation may be immediate or late. In the latter instance, a symptom-free interval of several months is present and vaginal discharge results from reinfection

SUMMARY. 1 The growth of the thoracic appendages of Asellus relative to body-length shows simple allometry, negative in anterior, and positive in posterior limbs. In both sexes there are two phases of growth, the first corresponding to a short prefunctional period. In the female there is, in addition, a change to a lower r.g.r. about the time of puberty. Sex-differences are throughout emphasized by the larger maximum body-size in the male. 2 There is a gradient along the body in g.r. of the series of thoracic limbs relative to body-length. In the female the gradient is simple with a growth-centre in thoracic 8 and a progressive decline forwards to thoracic 2. In the-male the specialized thoracic 5 limb breaks up the gradient into an anterior and a posterior “series growth-centre”. There is a “heterosexual vestige” of this in the female. The posterior s.g.c. is in thoracic 6 in early stages and later moves back to thoracic 8. The anterior s.g.c. is probably in thoracic 4, moving later to thoracic 3, and is therefore independent of the anterior centre for body-width (Paper I. of this series, 1937). 3 Within each thoracic limb there is simple allometry between the individual segments and total limb-length. There is little indication of a change in r.g.r. at the end of the prefunctional period. Again, sex-differences (in a typical limb) are limited to growth of total limb-length relative to body-length. In these and other respects growth within the limb differs from growth of total limb-length/body-length. Differences between the various limbs of the thoracic series, however, do involve differences in segmental proportions at any particular total limb-length. 4 The growth-gradient along the limb involves two “limb growth-centres,” a proximal and a distal. The latter is the more intense, especially in posterior limbs. The former is in the basipreischium, the latter in the carpus in anterior limbs, but in the propus in posterior limbs. The gradient has essentially the same form in the specialized limbs, thoracic 2, 5, but with quantitative differences and with sex-differences. The distal l.g.c. possibly moves proximally during growth. 5 The “limb segment-length profile” and the “series segment-length profile” provide convenient means of studying the limb and series growth -gradients. The limb segment-length profile bears a resemblance to the actual profile of the limb, perhaps not entirely fortuitous. There are “typical” and “peculiar” segments in the limb as well as typical and specialized limbs in the series. 6 These two profiles, at right angles to each other, may be combined in * segment-length contour-map, which suggests close interrelationship in growth between all limbs, typical and specialized, and their constituent segments. The graded effects of stimulation and inhibition by centres of growth and of inhibition are apparently not limited to any one limb but affect segments of neighbouring limbs as though the whole series of limbs formed a single structure with complete continuity. The c.n.s., a structure with complete continuity, may conceivably provide the basis for this. 7 In regeneration a thoracic limb does not “climb its ontogenetic tree”; the proximal segments are at first longer, the distal shorter, than in a normal limb of the same total length. Approximation to normal proportions is achieved on completion of regeneration. This suggests a relatively slow diffusion distally of an essential regeneration-factor. 8 The rate of regeneration is roughly proportional to the size of the limb removed. It is relatively more rapid in the male. Regenerative power neither decreases (? apart from the second regeneration) nor increases with repeated regeneration, under constant conditions of amputation, in an individual which has virtually reached maximum body-size, but the rate of regeneration shows minor variations which appear quite fortuitous and without correlation in different pairs of regenerates. 9 There is no positive evidence that a regenerating limb affects the growth of any other limb except its partner, whether regenerating or not. When both limbs of a pair are regenerating the right is longer than the left more often than the reverse, and this may be statistically significant. Regeneration of the distal segments, only, of a limb causes temporary hypertrophy of segments immediately proximal to them. 10 Antenna 1 shows positive allometry relative to body-length, antenna 2 approximate isometry so that its great length is probably due to the initial size of the rudiment in the embryo. The curves of r.g. suggest that growth may be by segment-number only in antenna 1, but in antenna 2 by segment-length also. The rami of the uropods grow with positive allometry relative to body-length, the value of a being approximately the same as that for thoracic 8 limb. 11 Relative growth between various internal organs of Asellus in general, shows simple allometry, which usually falls into two phases, the transition being around puberty. In some organs there are earlier changes in growth-rate. The data, combined with those on thoracic limbs and those of Paper I., point to three important periods when g.r. may change; the natal, the juvenile, and the pubertal periods. 12 The cross-sectional area of the hind-gut (“rectum”) grows isometrically with that of the body, whereas that of the midgut diverticula (“liver”) grows more slowly (α=0–8). Possible functional differences between liver and rectum are considered. Zenker's cells have a higher r.g.r. than any other internal organ studied. 13 After embryonic stage 4 growth of the internal organs, liver and rectum, is entirely by cell-size. There was not sufficient evidence to show whether or no this transition from histo- to auxano-differentiation corresponded to a radical change in growth, as is possible in the thoracic limbs, where it also marks the onset of the functional period. 14 Phases of growth of “metamorphic” rapidity occur in regeneration of thoracic limbs, and probably in normal growth of some internal organs, where they occur at the same organ size in all individuals. 15 The frequent form of the curve of r.g. as a curve rhythmically undulating about a mean straight line of simple allometry is considered in relation to the sigmoid curve of absolute growth, and an adaptational cause postulated for both. Many of the features of r.g. in Asellus may possibly be adaptive. There is evidence for a specific upper limit to growth in AseUus. The frequency of an a-value of 1–2 (or 0–8) is noteworthy. 16 Brooks's Law of Arthropod-growth applies in Asellus only where growth is maximal. 17 There is possibly a tendency for ecdysis to be synchronous among the individuals in a small vessel. 18 During early regeneration the large spine-setae of the limbs develop partially invaginated within the limb; on this criterion the terminal claw of the dactyl is a typical spine and not a true segment of the limb.

The purpose of this paper is to present facts of clinical importance in the prescription and fitting of the suction socket above knee artificial leg. The suction socket has been shown to be advantageous as a fittting method for most above knee amputees. The actual fitting and alignment of a section socket leg involves special problems of functional anatomy and gait. 1 Excellent historical, statistical and technical reviews are available on the suction socket method of fitting, and these aspects of the problem will not be discussed in this paper. 2 Four subjects of clinical importance will be discussed: (1) the time required for the fitting of the suction socket, (2) the types of stumps in which difficult fit may be expected, (3) the type of surgical technique in amputation which produces a stump most favorable for fitting the suction socket and (4) the postoperative care and preparation for the

Two years ago 1 I published a paper on sarcoma of the long bones based on seventy-one personal observations. In this paper I gave a brief summary of the results of modern methods of treatment of sarcoma of the long bones. These results were by far the most disappointing in the whole field of modern surgery. Taking the femur for example, Butlin found 68 cases of sarcoma of the femur (subperiosteal), in which amputation at the hip-joint or just below the trochanter had been performed, and only one patient remained well beyond three years, which is sufficient proof of the practical failure of surgery alone in this condition. In my former paper 1 I proposed a new method of treatment with the hope, not only of saving more lives, but, in a certain proportion of cases, of saving the limbs as well. The number of cases so treated up to that time

Dr. John A. Wyeth read a paper on a "Bloodless Method of Amputation at the Hip-joint," at the meeting of the American Medical Association in 1890. He had previously reported two cases successfully operated on by the method, to the Section of Surgery of the New York Academy of Medicine. He again described his method at the Pan American Medical Congress in Washington. These cases were sarcomatous tumors of the thigh. In addition to these two successful cases, he gives also in detail in the paper referred to, two cases operated on successfully by McBurney and Fluhrer, the first being an infiltrating sarcoma of thigh, the second an osteo sarcoma. As to bleeding in these four cases Wyeth reported that in his own two cases there was "no bleeding at all;" in Fluhrer's not more than four ounces of blood was lost during the whole operation, while in McBurney's perhaps

In the past quarter century, spanning the years 1919 to 1943, fracture of the neck of the astragalus has received but scant attention. The few reported end results have been discouraging. A search of the literature over this period reveals not more than seventy-five papers dealing with this injury. These contributions, for the most part, are in the foreign literature. Most of these reports record isolated instances of fracture of the astragalar neck because of its rarity. The commonly employed therapy has been total or partial astragalectomy. This form of treatment in the case of an adult is an admission of inadequacy surpassed only by amputation. In the English literature of these same years there have been twenty-one treatises on fracture involving the neck of the astragalus. Seventeen reports have been from the United States; four have been from Great Britain. Again, the majority of these papers have value only

A year and a half has elapsed since this tendoplastic amputation through the femur at the knee was introduced inThe Journal.1A sufficient number of additional cases are available to warrant a resurvey of the factors presented in the initial paper. Experience at the University of California Surgical Division of the San Francisco Hospital and that of co-workers and surgeons elsewhere have suggested some slight changes in technic. With data on operative indications, matters of technic and points of criticism, this paper brings the status of this amputation through the femur up to date. In the Surgical Section of the Exhibit Hall there was an exhibit of surgically planned dissections, mounted for permanent preservation by a method devised by two associates, Dr. J. M. Saunders and Dr. A. H. Rice of the University of California Medical School and executed by our technical assistant, Mr. Rudolph Skarda. This paper

This paper will include information about the surgical procedure and related factors which underly the general plan of treatment. While many of the decisions and procedures discussed are not the nurses' responsibilities, they are factors which influence, and sometimes determine, the nursing care that the patient needs. Nurses working in other hospitals and with various surgeons may find, of course, that practices differ somewhat from those described here.

1. In the present paper the planariansDendrocoelum lacteum and a related, polyploid speciesDendrocoelum infernale are compared using developmental, physiological, and histophysiological criteria. Regeneration of the suction groove, an organ located at the anterior end of the animal, was investigated. Also, respiration rates were determined, and the neoblasts stained using an RNA stain. Finally, I succeeded in obtaining heteroplastic chimeras. 2. The results of the regeneration experiments showed that the level of amputation determines whether and how fast the suction groove is regenerated. After amputation in the anterior half of the animal, the groove is regenerated the faster, the closer the level of amputation is with respect to the anterior end. This holds for both species. On an absolute level, the two species differ markedly from one another in their ability for regeneration:D. lacteum regenerates approximately 2.2 times faster than doesD. infernale.After amputations in the posterior half of the body, the groove cannot be regenerated anymore, as shown usingD. lacteum; no conclusions on these questions can as yet be drawn forD. infernale. In heteroplastic chimeras either species shows regeneration, althoughD. infernale is not stimulated, in heteroparabiosis, to regenerate the suction groove as frequently asD. lacteum. 3. Physiological and histophysiological studies revealed additional differences between these two species.D. lacteum consumes 1.75 times more oxygen than doesD. infernale. Neoblasts of the two species become stained differently by methylgreen pyronin-Y: the cytoplasm ofD. infernale neoblasts stains less strongly than that ofD. lacteum neoblasts. 4. Thirteen heteroplastic chimeras were analysed histologically. Because of the differences in nuclear size of the two species it is possible to determine the border betweenD. lacteum andD. infernale histologically. Except for local discontinuities in the epidermis, the interspecific contact of tissues shows no gaps. The heteroplastic parts grow together tissuespecifically: only homologous tissues of the two species become joined. Pyknotic nuclei or nekrotic tissue was not observed. There seems to be no incompatibility reaction between tissues of the two species, as indicated by the fact that heteroplastic tissue combinations lead to the formation of chimeras as frequently as do homoplastic combinations. However, heteroplastic chimeras by and large disintegrate somewhat sooner than homoplastic ones. 5. In 4 of 13 heteroplastic chimerasD. infernale-cells immigrated into tissues ofD. lacteum. This immigration involves 4 epidermis cells that are integrated close to the border betweenD. lacteum andD. infernale in the foreign epidermis. On the other hand in 2 heteroplastic chimeras, whoseD. lacteum part had been irradiated with a lethal dose of 8000 R prior to transplantation, noD. infernale-cell immigrated into the epidermis ofD. lacteum. As an unexplained consequence of heteroparabiosis, the heteroplastic parts of otherwise harmonious chimeras do not cooperate in locomotion. Equally unexplained is the observation of unexpected eye formation in certain heteroplastic chimeras. 6. The effects of heteroparabiosis and possible correlations between polyploidy, physiology, and evolution are discussed.

An attempt has been made to clarify the bacteriologic principles underlying this disease. These principles and the conclusions drawn from the study of a large peacetime series of gas gangrene cases form the basis of this paper. The signs and symptoms are explained from the point of view of altered physiology. Particular attention has been directed to the necessity of making an early diagnosis. The various forms of treatment have been enumerated and a useful amputation for this condition has been described.

The mechanisms underlying pathologic pain states such as phantom limb pain remain a mystery. Observations that 1) pain may persist indefinitely; 2) trigger zones may spread to healthy parts of the body; and 3) pain may be abolished by either decreasing or increasing the sensory input cannot be explained solely in terms of peripheral causes or abnormal activity restricted to the spinal cord. This paper proposes that a portion of the brainstem reticular formation exerts a tonic inhibitory effect on transmission at all levels of the somatic projection system. The loss of sensory input after amputation would decrease the tonic inhibition and increase the probability of self-sustaining neural activity. The self-sustaining activity, its capacity to recruit adjacent neurons, and its occurrence at several transmission levels would underlie prolonged pain and spread of trigger zones. Modulation of the sensory input by anesthetic blocks or intense stimulation would abolish the self-sustaining activity and produce pain relief.

It is the purpose of this paper to describe the development of the lumbar dorsal root ganglia after amputation of the leg. This operation can be performed at a very early stage before any connexions between the limb and the central nervous system are established. Alternatively, it can be performed at a number of later stages after the limb has been innervated. The extent of interaction can then be investigated for each stage by observing the subsequent development of the ganglia and comparing it with that of normal animals. Amputation of the limb-bud or the growing leg results in partial removal of the peripheral field for both sensory and motor neurones; the operation thus provides a means of investigating the mechanisms that control the processes of proliferation, maintenance, and degeneration of nerve cells. Detwiler and his colleagues (Detwiler, 1933) have shown that in Amblystoma loss of cells from the ganglia (hypoplasia) follows amputation, and that increase in number (hyperplasia) follows grafting of a supernumerary limb.

T HE purpose of this paper is threefoId: first, to present a case of traumatic appendectomy secondary to non-penetrating abdomina1 trauma; second, to caII attention again to the reIationship of trauma to appendicitis; and finaIly, to present a second case ihustrating the diffrcuIty in diagnosing appendicitis, traumatic or otherwise, in the presence of acute trauma. We have always questioned, as most surgeons undoubtedIy do, that trauma causes acute appendicitis. We have, in fact, believed that the ruling of the Works Progress Administration Commission’ in Washington in the earIy thirties was correct in hoIding that “. . . there is no such entity as traumatic appendicitis.” However, the senior author, on putting his hand into an abdomen, found a detached appendix and its attached mesentery. This finding proves that if trauma can cause an amputation of the appendix it can also initiate inflammation of that viscus. The case in point fohows

The experiments reported in this paper demonstrate that ependymal cells can stimulate a regenerative outgrowth when implanted into the limb of a lizard. Simple limb amputation, amputation followed by a sham operation, and amputation followed by the implantation of a cartilage tube from a tail regenerate were ineffective in causing the hind limbs of Xantusia vigilis to regenerate. However, amputation followed by the implantation of a cartilage tube containing ependyma caused regenerative outgrowths in 82% of the treated limbs. These results show that ependymal cells, in addition to initiating tail regeneration in their normal location, can when transplanted to the limb, initiate limb regeneration.

The number of persons with diabetes seen in the Mason Clinic has gradually increased throughout the years. 1 At the same time, the number of major amputations performed on these patients has steadily decreased. The lowering of the incidence of major amputation has been brought about by better management of the diabetes, instruction of the diabetic patient in care of the feet, and early control of infectious lesions by the use of chemotherapy and antibiotics, adequate drainage, and amputation of digits when necessary. 2 Prophylactic surgery on the static deformities has also played an important role in the lowered morbidity. It is the purpose of this paper to point out a few of the lesions of the feet in the diabetic patient in whom minor surgery is indicated. The management of these lesions will be discussed briefly. The proper handling of the concomitant diabetes is assumed, being of extreme importance.

SINCE the first successful replantation of a human arm in 19621 reports of similar cases have appeared.2 3 4 5 6 7 Success after replantation near the shoulder has been limited by varying degrees of neurologic deficit. The patient described in this paper, considerably younger than those in previous reports, demonstrated some of the hazards of replantation of extremities. However, her remarkable degree of reinnervation confirms a clinical impression that the indications for replantation should be more liberal in children than in adults. Case Report A 21-month-old, 9.8-kg. girl was admitted to the hospital on April 10, 1965, approximately 20 minutes after amputation of the . . .

INFECTION developing in an arterial graft is recognized as a major complication of catastrophic proportions as attested by several reports. 1,5,7-10 The present paper is based upon an experience in 12 such cases encountered on the General Surgical and Vascular Services of the Montefiore Hospital, since 1956. Material Between 1955 and 1962, a total of 201 arterial grafts were performed at the Montefiore Hospital by 11 attending surgeons. Table 1 lists the locations of the grafts. The occurrence of 12 cases of suppuration in this series represents, therefore, an incidence of 6%. Five attending surgeons scrubbed on the 12 cases of infection. The location and type of the grafts in the infected group are shown in Table 2. (One of these patients had the graft inserted originally at another institution, decreasing the incidence of suppuration in the cases originally done at this institution to just below 6%.) There were 11

In briefly discussing the subject of the prophylaxis of infection in operative surgery, it is my intention to speak also of the measures necessary to prevent unnatural union between tissues under the title given to this paper, and I shall first speak of the operation of amputation as it relates to the prophylaxis of infection and, in connection therewith, the prevention of the amalgamation of heterologous structures in the reparative processes of the wound. But before entering upon the subject I may be permitted to preface the discussion with the observation that there is but one author in the world, so far as I am aware, who holds and advocates the theory that the apposition of peritoneum to peritoneum is a surgical error, although I am clearly cognizant of the fact that thousands of operations terminate in the unnatural union of tissues; that is, the union of tissues of a

Background: In Indonesia, a country with Muslim population as a majority, circumcision is the most common operation performed in males. However, since circumcisions are also commonly performed by inexperienced individuals and during communal circumcision event, we frequently come across complications. One of the most severe complications is amputation of the penile glans. There are several techniques that can be used to treat this complication. In this paper we present some which have been used in our division and the result. Patient and Methods: We report three cases of traumatic penile glans amputation as a complication of circumcision that has been admitted to Cipto Mangunkusumo Hospital during January 2011 – January 2012. In first case we performed full thickness skin graft, in the second one we performed groin flap, and scrotal flap to reconstruct the third case. We evaluate the result for several months. Results: The three techniques showed no complication, good result in function and also aesthetically acceptable for patient and the family. Choice of technique that has been used to repair the amputated penis depended on the patient condition, and surgeon’s choice.Summary: The three techniques each has advantages and disadvantages, but all of them are acceptable, functionally and aesthetically.

Murphy and Best,1in 1957, reviewed the literature concerning partial nephrectomy. In their concise and useful paper they recommended simple guillotine amputation and presented convincing evidence that the least damage is done to the kidney with this technique. They described hemostasis as secured during the resection by placement of a Crafoord clamp on the vascular pedicle. One of us (W. E. G.) has previously reported use of a small bulldog clamp placed on the renal artery alone during biopsy or partial nephrectomy.2Recently, we have had occasion to use a different technique for hemostasis during partial resection and have found it simple and effective. The kidney is well mobilized, allowing access to all of its surfaces. The area to be resected is identified, and the renal capsule is stripped from the area which is to be removed. At a point on the normal kidney, below the area of

Wherefore you shall cut off as little of that which is sound as you possibly can; yet so that you rather cut away that which is quicke; than leave behind anything that is perished, according to the advice of Celsus. 1 It is precisely this philosophy expressed by Pare in the 16th century and its extension by recent advances in surgery that forms the basis for this paper. Pare continued, "Yet oft-times the commodity of the action of the rest of the part changes this counsell." 1 This wise advice forms a basis for the still valid rule that salvage of a part which is useless either in its original role or as a contributor to restoration of another part is unsound judgment. Specific sites of election for amputation in both the upper and lower limbs have been established as valid through four centuries of surgery. Decisions on appropriate treatment

In this paper I use the word "surgery" in its abstract sense, not concretely or connected with sensible objects or in its specific relation to definite things, as the amputation of a limb, the incision of an abscess or removal of a tumor, but rather the impression made on the mind, nervous system and emotions by the immaterial concomitants of the surgical act, as well as the act itself—the combination of hope, fear, expectancy, dread—the impressions and experiences connected with anesthesia, the sinking thought of passing through it into annihilation and nothingness, and all the other feelings of depression and momentary exhilaration known to us who have had personal operative experience. These things, these mostly emotional things, I believe are the cause at times of recovery from epilepsy, and may thus be regarded therapeutically because they cure just as drugs cure other diseases. My purpose, then, is to point out

IT is generally accepted that the speed and extent of learning are directly related to the amount and type of experience undergone by the student. In medicine, in which most experience is necessarily vicarious, areas do exist in which disease simulation can be effected, providing the student with a more direct experience of the disorder under consideration. These include conditions of sensory deprivation, respiratory insufficiency, neurologic and musculoskeletal abnormality and drug effect. This paper describes the use of disease-simulation technics in introducing small groups of third-year medical students to certain aspects of hemiplegia, lower-extremity amputation and rheumatoid arthritis, three conditions . . .

Denver Col., August 25, 1893. To the Editor: —In the last issue of theJournalI notice that in reporting the discussion upon Dr. Manley's paper on "Tarsal Amputations," Dr. Quimby is quoted as describing a modification of Pirogoff's amputation, and that other participants in the discussion are then quoted as calling this modified Pirogoff's procedure, "Quimby's operation." While it may be that the operation was original with Dr. Quimby, it was not necessarily originated by him, as it is described with brevity and clearness by Agnew in the second volume of his "Surgery." page 361, in the following words: "Instead of sawing off the malleoli and the articular surface of the tibia, I allowed them to remain, and placed the calcaneum in the mortise between the two; the union was complete and was followed by a remarkably useful stump. In other instances I have done this and with satisfactory