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EMBOLIZATION of major arteries has been recognized as a surgical emergency since before the turn of the century. Direct removal of an aortic saddle embolus was attempted by Ssabanajeff in 1895.1Since that time numerous surgical advances have made the removal of arterial emboli a safe and established surgical procedure. Despite these advances there continues to be significant morbidity and mortality from major arterial emboli. The purpose of this paper is to present a review of our experience with major arterial emboli. Material During a 12-year period 78 patients under-went surgical treatment of arterial emboli. Eighty-one emboli occurred in these 78 patients. Seventy-seven emboli were treated surgically in 76 patients. There were 45 males and 33 females, ranging from 14 to 89 years in age. Figure 1 demonstrates the age distribution of these patients. Most were between the ages of 30 and 70 years. Distribution of emboli is shown

In this brief paper it is my aim simply to call attention to a procedure which, in my experience, has proven of great utility in the management of these very trouble-some and too often fatal cases. I shall not take up the pathology of traumatic gangrene, for with that you are all familiar, but shall confine myself to its treatment. On referring to the literature we find all authorities agree that the only treatment of this class of cases consists in early amputation above the gangrenous area. How often are we able to determine accurately the limits of the disease, particularly in those cases of rapidly spreading moist gangrene? Too often we are disappointed by the continuation of the process after amputation, and are compelled to reamputate much higher, in spite of which the patient often dies. Again, if the gangrenous process does not involve the entire limb the flaps

In this paper I shall try to give a general picture of the diabetic patient with gangrene, to describe the organization for and the principles of management of cases of diabetic gangrene at the New England Deaconess Hospital and possibly, through a study of my results, to indicate how I have arrived at my present conception of the operative treatment of this condition. I do not wish to add to the many reports on the details of management of diabetic gangrene or to enter into any controversy as to the indications for amputation or the level at which it should be done. ORGANIZATION FOR THE CARE OF "SURGICAL DIABETIC" PATIENTS AT THE NEW ENGLAND DEACONESS HOSPITAL I did my first amputation for gangrene—a closed amputation through the upper third of the lower part of the leg—in May 1923. Insulin had been given to the first patient in the New England

One of the most useful by-products (if we may use the term) of the unhappy war just closing would be the proper recording and preservation of all experiences—especially in surgery—that may be of future value to humanity. The object of this paper is to open for discussion some of the observations made during the present war. There is very little published information on the subject of amputation. Volumes have been written on surgery with only a casual reference to this most important branch of orthopedic surgery. It is recognized that in the field many amputations must be primarily life saving operations; but the dominating idea in the performance of every amputation, next to that of saving life, must be the suitability of the resulting stump for the fitting of an artificial limb. The site and often the method of a primary amputation are mainly determined by the injury, the amount

A prosthesis ([ukn] a putting to, from [ukn] to put to) is an artificial substitute for any missing part of the body. Since most such corrections are for facial deformities and defects, much of the literature and the interest is concerned with facial restorations.1 In 1942 I2described a prosthesis for the restoration of the defect caused by the amputation of the breast and presented the technic of its construction. That paper was concerned with the restoration of the breast after surgical ablation. With modern education patients suffering from diseases of the breast seek earlier consultation; carcinomas of the breast are seen in and removed from younger persons. For want of something better, women who have undergone amputation of the breast attempt esthetic correction of the defect by wearing brassieres filled with various materials, e. g. cotton, lamb's wool, upholsterer's hair and goose down. The brassieres must be

Through the years voices have been raised from time to time to question the standard thigh amputation for peripheral vascular disease as the only reasonable procedure for the removal of the gangrenous extremity. Among others McKittrick et al.2championed the transmetatarsal procedure, and Silbert and Haimovici,3below-the-knee amputation. Nevertheless, most surgeons continue to feel that these operations will not succeed in a very high percentage of cases. It is the purpose of this paper to present a below-the-knee amputation that has produced a well-healed stump in 14 of 15 limbs. All amputations were performed by 1 surgeon or by residents under his direct observation and direction. Material The accompanying Table 1 gives the important facts concerning the type of patient selected and the end-results. It will be noted that there were 13 patients. Three were women and 10 men. All had arteriosclerosis except for 1 with Buerger's disease.

In this brief paper it is my intention again to call attention to a procedure which in my experience has proved of great utility in the management of these most troublesome and often fatal cases. I shall not take up the pathology of traumatic gangrene, but shall confine myself to a consideration of its treatment. By the term traumatic gangrene as herein used is to be understood that variety of gangrene following severe crushing injuries of the extremities complicated by virulent and often rapidly fatal sepsis. On referring to the literature we find all authorities agree as to the extremely high mortality of this affection, Cheyne and Burghard giving it as high as 95 per cent. All authorities likewise agree that the only treatment of cases of this class is early amputation above the gangrenous area. How often are we able to determine accurately the limits of the disease, particularly

This paper contains a report of seventeen consecutive cases of bladder fistula successfully closed, together with a discussion of their causative factors, types of injuries sustained and the principles of operative procedure employed. The following cases were encountered: One vesico-uterine (fundus). Two vesicocervical. One vesico-urethrovaginal. Three large vesicovaginal, the opening being larger than a half dollar (30 mm.). Nine small vesicovaginal (quill to finger size). One anterior vesical injury (fistula under the symphysis pubis). Grouping them according to causative factors discloses the disturbing fact that practically all these injuries were sustained by direct trauma, of a more or less preventable character. They may be classified as follows: Eight fistulas following hysterectomies. One following criminal abortion. One after a cervical amputation. One following cystocele repair. Five due to obstetric manipulation. One following radium for carcinoma of the cervix. These various injuries merit discussion, for after critical examination only two cases can

Apart altogether from the psychologic factors pertaining to amputation cases, the desire of some to stay indefinitely in comfortable quarters, the effort of some to get all that is "coming to them," the anxiety of others to secure a "square deal," the personality of the individual, and other similar difficulties that will not be considered in this paper, the chief problems relate themselves to (1) the stump and (2) the artificial appliance to be used as a substitute for the member lost. Up to the present time we have had slightly more than 3,000 amputations to deal with in the Canadian army medical corps. The policy of the government has been to treat all amputation cases in a central depot, and to supply them with artificial limbs from a government controlled and operated factory in the same center, with subsidiary plants, to take care of alterations and repairs, in strategic

About 30% of patients who were admitted for possible amputation of their leg were found to be suitable for arterial grafting procedures. Arterial grafts may obviate the necessity for amputation in a significant percentage of patients with gangrenous or pregangrenous lesions of their extremities. Attempts at grafting in many patients of the type described in this paper will inevitably result in some failures. Amputation should not ordinarily be undertaken for arterial occlusion unless arteriograms have demonstrated the fact that the patient would not be helped by a grafting procedure or where, clinically, the obstruction is so far distal as to make arteriograms unnecessary because the vessels are too small to graft.

This paper is a review of the amputations of the lower extremity done at the Louisville Veterans' Administration Hospital from its opening, in April, 1946, to July, 1956, for arteriosclerosis with and without diabetes. Amputations for other disease processes are excluded. Those patients who comprised this study were all men and were mostly in the older age groups with arteriosclerosis and adult diabetes. The last feature exists because juvenile diabetics would have been rejected from military service had they been diagnosed as diabetics at the time of their induction. The study includes a series of 89 patients with major and minor amputations resulting from vascular insufficiency secondary to arteriosclerosis. Recently, with the advent of arterial reconstruction, each patient has been evaluated for possible arterial grafting to increase the blood supply to the affected extremity. Forty-seven sympathectomies were done prior to amputation, without mortality and with minimum morbidity. Eight patients had

PRIOR TO 1959, the supraclavicular approach was the acceptable and usual method employed for executing a nerve block of the upper extremity. Since 1959, many articles have appeared extolling the advantages of the axillary approach as compared to the supraclavicular. 1-12 The present emphasis implies that the axillary approach will permit manipulations of and operations on the upper extremity to the same extent as the supraclavicular approach without the added risk of a pneumothorax. While, from an academic standpoint, this concept may be valid, it is misleading. In a clinical practice where many variables exist (skill of the physician, physical status of the patient, area of operation, etc) and where an upper extremity block is indicated, these two approaches are not interchangeable in all cases. The purpose of this paper is to: (1) review and analyze the blocks of the upper extremity performed by us and our residents from Jan

In theTherapeutic Gazettefor May, 1897, I published fifteen cases of amputation of the rectum by Kraske's method, to which I have since added two more, making seventeen in all. Three of the patients died, giving a mortality of 17.07 per cent. Of the fourteen cases that have recovered, six have now passed beyond the three-year limit and may be considered reasonably safe from recurrence. Two of the men, in spite of the loss of the coccyx and part of the sacrum, ride bicycles with ease. Besides these the paper included a number of other cases of cancer of the rectum, operated on by other methods. As a result of my experience in these cases, I have reached a definite conclusion as to what is the best course to pursue. Evidently after the operation the bowel must continue to be emptied of its contents.

THE CAUSE of painful and traumatic neuromas is not clearly understood. The investigation reported in this paper has been undertaken with the hope of determining whether or not the various methods of dealing with the divided nerve ends influence their occurrence or prevention. The records of the Laboratory of Surgical Pathology have been examined for proved cases, and these as well as amputations of major extremities in the Presbyterian Hospital from 1932 to 1945 were reviewed. Only records with adequate follow-up were used. DEFINITION After section, the distal end of the nerve may enlarge and simulate a tumor. These enlargements, called neuromas, are not true neoplasms. The nodule is made up of granulation tissue through which many strands of regenerated or proliferated axons with Schwann sheaths pass. These are arranged in interlacing bundles running in all directions. It is believed that the granulation tissue preceding neuroma formation arises from the

Peripheral vascular sclerosis is the overwhelming single cause of deficient arterial circulation in the lower extremities. Four grades of this disease can be recognized, and it was pointed out in a previous study 1 that any therapeutic measure must be evaluated on the basis of these four groups and their response toward the method under scrutiny. In this study lumbar sympathectomy has been employed alone or in combination with various types of amputation in rigidly selected patients. Our purpose here is to discuss the selection of cases, the surgical approach and the results together with an interpretation of the observations. The previous literature on the subject has been summarized elsewhere. 2 MATERIAL STUDIED The series consists of 57 carefully selected cases, and we shall group them according to the severity of the disease as outlined in a previous paper. 1 Group 1.—

I wish to call your attention to the subject of osteo penthesis, the subject of which I made brief mention at the last meeting of the New York State Medical Association, which convened in New York City. Dealing with bone tissue has been one of the most interesting subjects to me, and I may say to surgeons in general. The three principal points which I wish to bring out in this paper are as follows: First: How and when may bones be restored? Second: Should fragments of the bone be permanently removed except in case of amputation? Third: Should not exploratory incisions be made in cases of fracture of bones where doubt exists as to their character? I cannot do better, after making brief mention of these three interesting features, than to report the observations I have made in experimenting with the lower animals. In the first case: How and

Strong personal opinion, previous training, and favorable past experience with one particular technique dictate any given surgeon's choice of procedure for ankle arthrodesis. But are these criteria valid for the selection of one technique over another? For information on this point, critical evaluation of the several surgical techniques used in a large series of such cases is attempted in this paper. Included in the evaluation are such matters as type of fixation, time required for clinical union, and end results. Materials and Methods This study concerns 132 patients who underwent arthrodesis of the ankle (140 surgical procedures) at the Mayo Clinic in the years 1956 through 1963. Included were those patients with tibiotalar fusion only, those with tibiotalar and talocalcaneal fusion, those with tibiotalar fusion combined with triple arthrodesis (pantalar fusion), and those with partial or complete loss of the talus and subsequent arthrodesis of the tibia to the os

ALTHOUGH hostilities had ceased the year before they were written, the majority of the one hundred and eighty articles on this subject could be considered as written from military experience. Over fifty foreign articles cited in the Quarterly Cumulative Index Medicus were unobtainable, and there was little new in the others except what will be listed in the following paragraphs. Amputations. —Most of the articles on amputations reported series of cases interesting from one angle or another, and only three had to do with refrigeration anesthesia. Nothing particularly new has been advocated, but the use of ice rather than refrigeration machines seems to be in order, and there is emphasis on the simplicity of the ice equipment. 634 A paper has been published by Tobias 635 discounting severely the value of refrigeration anesthesia and citing the higher mortality accompanying this type as compared with spinal anesthesia produced by cyclopropane. This

Report of Cases Summary of Cases Suggested Relationship Between Chronic Ulcers and Gas Gangrene Technic Isolation of Anaerobes Pathogenicity Differentiation of Organisms Clinical Application Results Cases Harboring Anaerobes Control Cultures Ubiquity of Clostridium Welchii Comment Significance of Results Status of Anaerobic Antitoxins Summary Two virulent cases of gas gangrene following amputation of extremities that were the site of chronic ulcers stimulated interest in this subject. Gas gangrene is usually the result of severe trauma with muscle destruction and a wound grossly contaminated with dirt and foreign bodies. The problem presented itself as to the origin of the gas bacillus infection in postoperative wounds, in which all the usual aseptic and antiseptic precautions had been employed, and the possible relationship of the ulcers to the development of the gas bacillus infection was suggested. This paper includes a report of two cases and a bacteriologic study of chronic ulcerating lesions with particular

To the Editor.— Intramedullary extension of osteogenic sarcoma has been described.1-4Only the last paper contains incidence data, indicating that in the Mayo Clinic at the time of analysis, 20 of 50 patients showed extension of osteogenic sarcoma along the medullary cavity at time of amputation. In 13 of 42 patients with optimal preoperative roentgenograms, there were no radiographic changes that might have made the surgeon suspect such finding prior to surgery. As our search of the literature did not reveal additional detailed data regarding this finding, the following case report appears of interest. Report of a Case.— In a 20-year-old white woman with pain and swelling in the lower part of the left femur of approximately two months' duration, radiography revealed a 4.8 × 2.7 cm lesion in the posterolateral aspect of the left femur immediately above the epiphyseal line (Fig 1). A soft tissue mass was palpable

I have long held the belief that the statistics of recoveries after operations for neoplasms of the female breast, diagnosed as cancer, were unreliable as a basis of scientific knowledge. It is not my purpose in presenting this paper to arraign a settled professional judgment, or to impeach the accuracy of eminent observers. My object is to emphasize the fact that tumors of the breast diagnosed as malignant, do not, in a certain considerable percentage of cases, undergo malignant degeneration, and that the histologic arrangement of a tumor does not necessarily determine its future life history or development; that certain tumors removed for malignancy would, if unmolested, eventually disappear. This announcement may be regarded as rank heresy, although easily demonstrable; and if proved, render,pro tanto, the records of recoveries for long periods of time after amputation of the breast for cancer, unreliable. Opinions based on the macroscopic appearances of

This is a collection of 24 papers by experts in vascular diseases. It is a symposium, not a panel, not a monograph, and it has the advantages (and disadvantages) of a symposium. If you want to get the last word from Linton on femoropopliteal arterial reconstruction, from Haimovici on arterial embolism or amputation, from Simeone on sympathectomy, or from Wright on strokes, it is here. The information is clear, authoritative, oriented largely to the individual experience. To cover the whole of the subject, three times the number of chapters would have been necessary. But the book is only meant to cover selected topics in depth, and in this setting it stands as an important item in any modern collection of volumes on vascular diseases.

In a previous paper the histologic changes in seventy-five cases of chronic cervicitis as revealed by serial sectioning were described.1In six of these, blastomatoid changes consisting of cellular and nuclear deviations in size, shape and chromatism, epithelial heterotopia and stroma reaction were present. We designated these changes as neoplasia. It was made clear that it was imperative to follow up the patients in whom this neoplasia was found, to determine the significance of the cellular changes. To these six cases, in the course of time, three more were added, so that we have now nine cervices with blastomatoid changes. Eight were treated immediately with adequate doses of radiation as used in carcinomas, and normal anatomic conditions were obtained. One patient was not treated and a report of the case will now be given: Jan. 30, 1933, a low circular amputation of the cervix of Mrs. S. was done.

Our purpose in this paper is to report a study of seventy cases of amputation of the lower extremity. We will present the causes for amputation and the treatment received, as well as the present appearance and function of the amputation stumps. This entire subject received great emphasis after the World War, at which time it has been estimated that more than one-half million amputations were done. Surgeons began analyzing their cases, and closer contact with the prosthesis makers emphasized many practical phases of the problem. As a result the rather well defined rules for stump lengths have been repeatedly stressed. This study will show that if these rules are violated reamputation frequently becomes necessary. During the past nine years in the orthopedic service at the State University and Crippled Children's hospitals there have been more than 250 amputations, and for our follow-up study seventy patients returned. The average follow-up