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Ligation of arteries has received a great deal of study since the time of Ambroise Paré. The healing of arteries after ligation in continuity was admirably described in 1886 by Warren.1 In 1922, Leriche2 of Lyons gave a very complete report of the remote results of ligations and resections of arteries from the functional point of view. The work of both these authors has been largely substantiated and confirmed in this study, which, however, is primarily concerned with a search for the best method of ligating a large artery so as to produce a permanent occlusion of the arterial channel.The problem suggested itself to me a few years ago on hearing a verbal report of a patient with an aneurysm of the innominate artery who bled to death at a second operation after the innominate artery had previously been ligated. An attempt to open the aneurysm led

As Hertzler has remarked, it seems strange that a viscus capable of such a wide range of locality as the appendix will, when inflamed, always have a point of greatest tenderness over the so-called McBurney's point, about midway between the right anterior superior spinous process of the ilium and the navel. He says the answer is that it does not. While the normally placed appendix gives pain at this point, the appendix abnormally situated shows maximum pain and tenderness elsewhere.The symptoms of a typical uncomplicated case of acute appendicitis permit little diagnostic doubt. The rather sudden pain beginning in the epigastrium or around the navel, and the general abdominal discomfort with pain and muscle spasm eventually settling in the right iliac fossa, are almost pathognomonic of appendicitis. The sequence of the pain in the epigastrium or around the navel and later in the right iliac fossa is important. These

An appreciation of the proper therapy for ulcer of the stomach and duodenum depends on a knowledge of the pathologic conditions present, and an acquaintance with the physiology of these viscera. It is of prime importance in surgical operations to remove or to correct the pathologic conditions, but it is also essential to restore physiologic function. Much of the physiology of the stomach remains undetermined. As Alvarez says, in observing the function of the stomach, we see more than we can understand. However, there are many established facts, especially from recent research work, which are very helpful in comprehending the pathogenesis of gastric and duodenal ulcers, and in adopting the proper treatment for these lesions. Consequently, I will review briefly the relevant physiology, concerning (1) the motility of the stomach, and (2) its secretion.PHYSIOLOGYThe stomach is divided by the insisura angularis into two main portions, the pyloric and

Cancer in readily observable regions, as the mouth, arises from a preexisting benign lesion, a papilloma, a small ulcer or a point of constant irritation. It seems probable that this holds good in the more inaccessible regions of the body, where early observation is difficult or impossible. In a patient of mine, Mrs. C. C. S., with advanced cancer of the transverse colon, there were several small adenomas near the cancer (figs. 1 and 2). The histologic structure of one of these adenomas showed that, while the growth was benign, there was a tendency to hyperplasia of the epithelial cells (fig. 3). It is a logical conclusion that the cancerous lesion of the colon originated in an adenoma like this. SYMPTOMS AND SIGNS Often the first symptom of carcinoma of the colon is obstruction. This is usual when there is a scirrhous cancerous stricture. A disturbance of the bowel movements

The etiologic relation of peptic ulcer to cancer of the stomach is acknowledged by all pathologists who have studied the subject. There is, however, a great difference of opinion as to the number of cases of cancer of the stomach due to peptic ulcer. The incidence varies from about 2 per cent, estimated by Ewing1 of New York, to more than 60 per cent by MacCarty2 of the Mayo Clinic. MacCarty says that, in about 70 per cent of the chronic gastric peptic ulcers, cells can be found that present the cytologic appearance of cancer. Though MacCarty does not state that this percentage of chronic gastric peptic ulcers would eventually become cancer, such a conclusion is suggestive. The opportunities at the Mayo Clinic for examining fresh tissue are great. According to W. J. Mayo,3 "von Eiselsberg of Vienna reported that 30 per cent of all ulcers of

There are two definite classes of lesions of the stomach in which gastrectomy may be indicated. One is malignancy, and the other is peptic ulcer with its complications or sequelae. The first indication, malignancy, admits of no discussion. Gastrectomy is the only known cure for cancer of the stomach. Unfortunately, many patients suffering from this disease come too late for a radical operation, and there is sometimes a tendency to wait too long under medical treatment while the cancer continues to develop. Just what proportion of benign gastric ulcers become cancerous it is difficult to state. The percentage of gastric cancers arising from a peptic ulcer base is estimated at from 10 to as high as 70, the latter being the figures given by the Mayo Clinic. That a certain proportion of gastric peptic ulcers do apparently develop into cancer is admitted by all pathologists interested in the study of

The biologic processes that take place during the healing of any wound are always interesting, but a knowledge of what goes on during the healing of a properly sutured intestinal incision is necessary in order to comprehend the reasons for the technic.The law of apposing peritoneal surfaces in suturing wounds of the bowel was the first great step in the progress of intestinal surgery, and was established by Antoine Lembert in 1826, nearly a hundred years ago. This principle followed observation of nature's method of closing perforations by peritoneal adhesions and a deposit of lymph.Hertzler 1 has demonstrated that the healing of the peritoneum of wounds is due to the direct transformation of the deposit of lymph into connective tissue without the intermediate stage of granulation tissue formation. This direct transformation, however, can occur only when there is no marked infection. Otherwise, healing is by granulation.Within a

Defects in the common bile duct may result from errors in operative technic, from strictures following ulceration or trauma, or from neoplasms. Since excision of the gallbladder has become a frequent practice, possibilities for injuring the common bile duct, particularly in inexperienced hands, have multiplied.In an effort to devise some method that would be satisfactory in reconstructing the common duct, various procedures have been devised. Sullivan1 described an operation in which a rubber tube is sutured into the stump of the hepatic or the remaining upper end of the common duct, carried into the duodenum, and surrounded with neighboring tissue and omentum. Molineus, according to Walton, has suggested the use of the appendix for reconstruction of the common duct. However, it is often difficult to secure a satisfactory appendix, the nutrition of the transplanted appendix would be very problematic, and it would carry bacteria it normally contains, which

The 16,000 deaths every year in the United States from appendicitis are quite unnecessary. Early diagnosis and prompt treatment for appendicitis, as for diphtheria, should make the mortality from either of these diseases almost negligible. In late cases, however, the analogy limps, because late in diphtheria treatment is of practically no avail, whereas in the late stages of appendicitis proper treatment is usually successful.In the early stages of appendicitis almost any kind of appendectomy will do, but in the late stages skilful technic and physiologic procedures frequently make the difference between life and death. Late and neglected cases result largely from lack of appreciation of the importance of early operation, but, though education may do much to lower the incidence of late cases, there will doubtless for various reasons always be a considerable number of them. A large percentage of patients with a ruptured or gangrenous appendix operated on

Suturing blood-vessels is an eminently practical field of surgery, and its chief usefulness will probably be found in repair of accidental wounds of the vessels, in restoring the continuity of an artery or a vein after removing a portion of it when it is involved in a malignant growth, and in transfusion of blood. Aneurysms arising from any form of arteritis can hardly be dealt with successfully by the method of suturing applicable in a trauma of a healthy vessel, because satisfactory union requires a healthy intima. Aside from aneurysms, however, there should be many cases in the service of every general surgeon, and particularly those who do emergency surgery, in which the operator can employ blood-vessel suturing to great advantage.The method of suturing blood-vessels generally used is that of Carrel. Transferring the guy sutures after suturing each third of the vessel, the likelihood of their becoming tangled, the

It is not the purpose of this paper even to touch on all of the various phases of intestinal obstruction, but merely to call attention to a few features of this interesting affection. The first is the abuse of purgatives in this condition. Every surgeon has seen deaths caused by the injudicious use of purgatives. There are few things that require more judgment or skill than the correct exhibition of a suitable purgative at the proper time. Certainly in acute infectious diseases or in any case in which a toxemia is primarily present, a purgative is not only advisable, but absolutely necessary It is different, however, with acute obstruction from any other cause than that which has just been mentioned. A sudden obstruction, not due to nervous affections, always means one of two things: either an inflammatory condition of the peritoneum or else some form of mechanical obstruction, as bands,

A surgeon, like a practitioner of any branch of medicine, is in a sense a biologist, for he is dealing with living tissue. The mechanical features of surgery have often been too much glorified. They are, to be sure, important, but a knowledge of the physiologic processes in the human body is equally essential. A patient who dies because the surgeon transplanted the ureters into the small intestine, where absorption is rapid, instead of into the rectum or sigmoid, whose function is chiefly receptacular, is just as dead as one who succumbs because of a defective intestinal suture or a poorly tied blood vessel.Successful surgery does not mean just the skilful mechanical performance of an operation. It is something even more important than this. It involves the consciousness of the surgeon that the technical steps are not an end in themselves but are more or less important guides toward

Therapeutic measures for disorders of any organ of the human body should be based on a knowledge of the physiologic functions of that organ. It is undoubtedly true that there are valuable empiric remedies, but usually further observation has shown that they were originally fortunate guesses and happened to fit in with the correction of a disordered function not understood at that time. A comprehension of disordered function naturally presupposes a knowledge of normal function.PHYSIOLOGIC CONSIDERATIONSIn the gastro-intestinal tract there are three vital and more or less distinct functions. One is the function of digesting or preparing the food, another is absorption, and the third is the motor function. Grave and continued interference with any one of these functions will result fatally. To some extent the motor function overlaps the other two, because by mixing and churning the food both digestion and absorption are promoted. In the stomach

The biologic defenses of the body against disease, trauma and the wear of age are wonderful, but they are not perfect. If they were perfect, man would live forever. Particularly interesting is the manner in which the body protects itself against injurious foreign substances. The epithelial lined body cavities have more or less specialized methods of protection. The stomach, for instance, by vomiting emits food that is spoiled, and many drugs that are irritating or disagreeable to the taste, and sometimes even rejects substances that are thought to be nauseating or noxious even though they are not. The excessive salivation when nausea occurs probably tends to dilute the offensive material, or to protect the walls of the mucous membrane. Vomiting undoubtedly is a habit that was acquired in the early days of evolution. The more refined drugs or poisons that are a result of chemical manufacture have not created a

There is no excuse for a new operation if the old ones are satisfactory. The results of a surgical operation are the test of its efficiency, and they should be viewed from two standpoints: First, and most important, is the clinical result and, secondly, the restoration of tissues or organs to their normal physiologic condition. It seems probable that no important physiologic function of the body can be abolished or seriously altered without creating a disturbance of health in at least some of the individuals thus affected.The usual surgical treatment for duodenal or gastric ulcers is gastro-enterostomy, with or without excision of the ulcer. When done for gastric ulcer, the ulcer is either excised or cauterized with the actual cautery (Balfour). When the gastro-enterostomy is for a duodenal ulcer, the ulcer is usually not excised, but is often sutured over or folded in. Another type of operation employed is

It cannot be too often emphasized that surgery should be more a science than an art. A surgeon who is a dexterous operator and who skilfully amputates a leg that with patience and scientific application could be saved is merely a good artisan, and is distinctly inferior to the surgeon who could save the leg even though he should be a bungling operator. The ideal is to be thoroughly imbued with the principles of the biologic sciences, thoughtfully to apply these principles, and at the same time to be mechanically skilful.The science of anatomy is essential to the mechanics of surgery. He would be a poor locomotive mechanic who did not understand the construction of his engine; and in operations on the neck, for instance, a surgeon who is ignorant of anatomy would be like the proverbial bull in a china shop. A knowledge of anatomy is essential to

Carcinoma of the small bowel is often considered extremely rare. Though it is not common it is more frequent than is usually supposed. Sarcoma, however, is found more often in the lower part of the ileum than in the large bowel. Cancer of the ampulla of Vater and its adjoining tissue increases the incidence of carcinoma of the duodenum.Three types of carcinoma of the jejunum and of the ileum may be considered: (1) the most common, adenocarcinoma; (2) carcinoid, or argentaffin tumor, and (3) melanocarcinoma.The paper by Rankin and Mayo1 in 1930, a later paper by Rankin and Newell2 in 1933 and Raiford's3 articles on tumors of the small intestine in 1931 and 1932 were thorough and interesting. They included reports on tumors of the small bowel occurring almost to the time of publication of the reports. Few cases have been added to the literature

Threatened or slow gangrene of the foot follows a diminution of the caliber of the blood vessels supplying the foot. This results from a disease which may be clearly systemic or which may manifest itself chiefly in the blood vessels of the lower extremities. Sudden occlusions, as by emboli, with consequent rapid gangrene, do not come under the title of this paper.The diseases of the vessels which cause slow or threatened gangrene of the foot may be divided into four groups: 1. ARTERIOSCLEROSIS. —This condition is caused by toxic products which may come from deranged metabolism, as in nephritis; from infectious diseases, as syphilis, or from general wear and tear, as in old age. It is found chiefly in the arteries. There is excessive thickening of the media or intima or of both. 2. INTERMITTENT CLAUDICATION. — This disease was described by Charcot and occurs in the legs. It

Plastic operations on the face are usually not lifesaving procedures; but the curing of a facial deformity not only relieves the physical discomfort of the patient and assuages his mental anguish, but gives relief to the inhabitants of the community in which the patient lives. The necessity for seeing daily some one with a hole in the frontal sinus, a retracted lip, or a deformed nose, is by no means an agreeable prospect. So if a philanthropist be one who makes two blades of grass grow where one formerly grew, plastic surgery of the face may be considered a philanthropic field. Surely it is of more importance to the community than the placing of monuments or the beautifying of streets.Surgery of the neck and plastic surgery of the face probably demand more skill than any other kind of surgery. It is essential for one who operates on the neck

William Beaumont1 in 1833 made the first definite note on peristalsis of the stomach. His observations and experiments on Alexis St. Martin began in 1825. Beaumont had been treating this patient, who had a gastric fistula following a wound from a shotgun, for nearly three years before it occurred to him to use St. Martin as a laboratory animal and observe what occurred in the stomach during digestion. In the eight years between 1825 and 1833 he made 238 experiments. Among other things he noted that the time required for disposal by the stomach of a moderate meal is from three to three and a half hours. He showed that the agent of digestion in the stomach is the gastric juice, which acts as a solvent and contains "free muriatic acid and some other chemical principle." The other chemical principle was demonstrated a few years later by Eberle to

During the last few years F. L. Meleney1 has written interestingly on symbiotic infections, and this subject is attracting much attention. Symbiosis of bacteria occurs when two or more kinds of bacteria are closely associated and live together harmoniously. Synergism means that there is some result from this association of bacteria not apparent from the bacteria in pure culture. Thus, a synergism would be necessarily symbiotic, but a symbiotic relation is not necessarily a synergism. In bacterial parasitism, bacteria prey on the host to the disadvantage of the host. Parasitism may merge into a symbiotic relation.A. M. Shipley2 says that the whole subject of symbiosis and infection is going to be one of the new fields for surgeons and bacteriologists. He calls attention to the fact that in the World War it was noticed that streptococci when accompanied by anaerobes produced a clinical condition that had rarely

The Principles of nerve suture are so intimately connected with degeneration and regeneration of peripheral nerves that a brief review of the histologic process involved may not be inappropriate. The method of regeneration of a mixed nerve has been the subject of much discussion, and even now there is no view that receives the general sanction of neurologists. The Wallerian or continuous theory, which claims that regeneration of the axis cylinder occurs from the central stump only, is being somewhat discredited. Recent researches tend to confirm the discontinuous theory or some of its modifications. Huber and Howell, in 1892, and later Bethe of Strassburg, have shown quite definitely by numerous experiments that in young animals regeneration of an injured nerve may be practically complete without any connection with the central end. In older animals regeneration without connection with the central stump also occurs, but is imperfect. Schütte,1 after an

Since Sir Arbuthnot Lane brought intestinal stasis into prominence, the literature about it has been prolific. It has been approached from many points of view—surgical, medical and pathologic. It is, of course, an old condition masquerading under a new name. Smithies has called attention to the fact that the typical symptoms of intestinal stasis as described by Lane, such as muddy skin, headache, mental depression, lack of appetite, malodorous sweating, and abdominal aches and pains, are often absent in most pronounced cases of constipation, and that marked displacement of the large bowel, as demonstrated by the Roentgen ray, does not always cause constipation. Pathologists generally have not sustained the extreme views of Lane. That the symptoms as described by him do often exist, however, is common experience, but that they are caused by such marked changes in the colon as to demand its entire removal remains to be proved.Patients

The operation for reversal of the circulation in the lower extremity, or arteriovenous anastomosis, began to receive attention soon after blood-vessel suturing was put on a stable basis by the work of Carrel and others a little more than a decade ago. Certain cases of gangrene of the foot and leg are caused by gradual occlusion of the arteries in the lower extremities. This is due to some form of arteritis in which the intima plays the most prominent part and the artery walls become so thick that complete occlusion may occur. As a rule, the veins are but slightly affected. The arterial current has been switched to the veins with the idea that the arterial blood pressure would force the valves in the veins, and arterial blood would reach the ultimate capillaries of the foot, so conveying nutrition to the tissues.Complete reversal of circulation in the lower extremity,

Surgical operations are usually designed to save life or to increase function. Even plastic operations on other parts of the body than the face have as their chief object the restoration of function. Operations on the vaginal outlet are performed for the purpose of correcting malpositions. of the uterus or of returning the bladder and rectum to their proper position and so rendering these organs better able to functionate normally. Plastic operations on the hands or feet for deformities, on the bowel or bladder for fistulous openings, or on the throat or mouth for congenital defects, are intended to restore to usefulness the parts affected. Plastic operations on the face, however, are done chiefly for their cosmetic effect, as the function of no organ is materially altered by the facial deformities which such operations are designed to correct.While the correction of facial deformities cannot be classed as life-saving, such

In order to approach the treatment of congenital hydrocephalus more intelligently, it may be well to review, briefly, some of the views of its pathology. Congenital hydrocephalus is a term applied to that affection occurring in infants characterized by an abnormal accumulation of serous fluid within the ventricles of the brain. This tends to increase and usually gives rise to pressure symptoms on the brain, except in those rare cases occasionally seen in which the disease is arrested and the patient recovers without cerebral symptoms. The synonyms are chronic hydrocephalus, internal hydrocephalus, and hydrops ventriculorum cerebri. The so-called external hydrocephalus is quite different both in symptoms and pathology. It denotes an abnormal accumulation of serous fluid in the subarachnoid space1 and is very rare. It is usually secondary to cerebral hemorrhage or pachymeningitis, or else it is found with some congenital defect of the brain. Such an effusion is

The various ingenious methods used at present to unite the divided ends of the intestinal tract are prima facie evidence that no one method is satisfactory in all cases. The trend of surgical opinion seems in the direction of suture, as against mechanical appliances, and this results from the fact that an operative procedure requiring for its performance special apparatus is thereby handicapped. When the appliance is one that must be left in the intestinal canal till healing has been completed, additional disadvantages, such as gangrene and obstruction, at once suggest themselves. Undoubtedly, mechanical contrivances are sometimes indicated, but such instances should constitute the exception and not the rule.In a previous paper1 I have given results of experimental work in intestinal suturing and attempted to demonstrate the great advantages that the continuous suture penetrating all the intestinal coats has over the interrupted.

This subject was suggested to me by a case that came under my care about five years ago. The patient was a colored man, a deaf mute, who had been suffering from obstruction of the bowels for several days before admission to the hospital. He was enormously distended and his condition was desperate. Operation was done under cocain and a volvulus of the sigmoid found. The sigmoid was twisted and so distended that it resembled a large cyst. The volvulus was excised and after removing the diseased bowel it was impossible to approximate the lower end of the large intestine to the small portion of the descending colon that was left. An artificial anus was formed. The patient recovered and left the hospital about four weeks after the operation. He was very ignorant and could not properly take care of himself. His condition was pitiful in the extreme.The necessity

Any experimental work dealing with intestinal obstruction as one of its chief features requires a preliminary statement of the presentstatus of obstruction. The exact cause of death in obstruction of the bowel has never been definitely determined. The three theories advanced are: (1) the nervous theory, which holds that the nervous system is affected in somewhat the same way as in shock; (2) the bacterial theory, which holds that death is due to the bacteria contained in the obstructed intestine; (3) the toxemia theory, which holds that death in obstruction is due to some perversion of intestinal metabolism. Metabolic toxins may be formed in the epithelium of the intestine, or the mucosa may permit the direct absorption of peptones and products from the intestine that are normally changed by the epithelium before being discharged into the circulation. The nervous theory has few advocates, but the bacterial theory and the theory

In no part of the body is the onset of cancer more insidious than in the bowel. As it is a local disease at first and becomes disseminated later on, an essential for successful treatment is early diagnosis, and anything tending to aid in this respect is of great practical advantage to the surgeon. It was formerly thought that carcinoma of all structures occurred in middle or later life, and a strong point in the differential diagnosis between carcinoma and an inflammatory mass, or a benign growth, has been the age of the patient. If the age were 40 years or more the chances seemed to favor cancer; under 40 years the likelihood of carcinoma apparently decreased with decreasing years, till its occurrence in childhood has been looked on as a pathologic curiosity.Recent reports, however, seem to show that carcinoma of the bowel, and particularly of the appendix, is

Occasionally defects of the cheek, caused by accidents, or as a result of operation for malignant disease, or from gangrene, are so extensive that plastic correction is exceedingly difficult. The margins of the defect are frequently fixed to the bone and do not permit much stretching. If the flaps are taken from the arm, the character and texture of the skin is so different from the skin of the face that the contrast is very noticeable. Then, too, it is frequently necessary to have an epithelial lining on the inside of the mouth, and though a mucous membrane lining is preferable to one of skin, it is often impossible to secure mucous membrane.Flaps from the forehead are used to remedy these defects, and are taken with the pedicle either from the temporal region or from the middle of the forehead. This, of course, necessitates cutting the pedicle later and

A fracture which has been apparently. properly reduced and treated according to the orthodox manner is supposed to go on to successful healing. Fortunately, this is usually the case. Occasionally, however, without any apparent cause, union fails to occur, and such an outcome is both distressing to the patient and embarrassing to the surgeon. Theoretically, bone should repair perfectly, as it belongs to the connective tissue group of tissues that are simple in construction and consequently easy of repair. We know that simple tissues repair readily, whereas the more complicated tissues, such as brain and epithelial and glandular structures, either do not repair at all, or else very imperfectly after a prolonged time. This is a simple, common-sense, biologic law that we would naturally expect. The exception in the case of bone is more apparent than real. The general connective tissueframe-work of the bone is built up even where no

These three cases are typical of a certain group seen at St. Elizabeth's Hospital during the summer and early fall months of each year.REPORT OF CASESCase 1.—W. F. S., a man, aged 28, physician, admitted, Sept. 5, 1922, had always lived in South Carolina. He complained of attacks of gnawing epigastric pain accompanied by nausea and weakness, coming from one to two hours after meals, and relieved by food and soda. These attacks had lasted for six years. One year, and again two weeks, before admission to the hospital he passed large, tarry stools for several days, and on the last occasion he spat up some fresh blood. The family history and past history were irrelevant, except for "malaria" during childhood.The patient was tall and fairly well nourished, with marked pallor and a "washed-out" appearance; the physical examination was otherwise essentially negative. Routine urine, feces, phenolsulphonephthalein

Aneurysms of neither traumatic nor syphilitic origin are unusual. The case here reported is an aneurysm originating from an infected embolus. Reports of such cases are seldom encountered in current medical literature.REPORT OF CASEMiss B. W., aged 23, entered St. Elizabeth's Hospital, March 25, 1924, complaining of a "tumor under the right arm." Her family history and past history were irrelevant. Seven weeks before admission to the hospital, an aching pain began in the right arm. A few days later, the fingers began to feel numb. The numbness gradually spread up the arm. Accompanying this was a paralysis of the fingers of the right hand, and a weakness of the entire right forearm and arm. Four weeks previous to admission, the patient's mother first noticed a round tumor in the right axilla. This mass was about the size of a hickory nut, and was tender on pressure. It

The etiologic relation of puerperal sepsis to perinephritic abscess has long been known, but the occurrence in my practice of three cases due to this cause, within two years, and the fact that the symptoms and course of the disease in each instance were quite similar, prompted me to report these cases. CASE 1. —Mrs. G., aged 32, white, was admitted to the hospital Oct. 27, 1904. Family history was of no significance, except that her mother had had consumption. There was no other history of tuberculosis, and no history of cancer. The patient's health was very good until four months before she came under my charge, when she had been delivered of a healthy baby. The confinement was uneventful, and her recovery apparently satisfactory. She had borne three children previously, and there was no history of sepsis or difficult labor in any of these births.About six weeks after

Transfusion of blood has been brought into prominence in the last few years as an emergency life-saving measure. This operation has been developed by Carrel, Guthrie, Crile and others to such a point as to render its performance quite satisfactory in the hands of an average surgeon who has done enough experimental work on the lower animals to perfect his operative technic. Its advantages have been so well demonstrated by clinical use that its position among surgical procedures is assured. In two kinds of cases it is particularly appropriate. The class of cases exsanguinated to such an extent that even when the volume of blood is increased by salt solution life cannot be maintained, can be saved only by transfusion of blood. The other group consists of patients who have been so enfeebled by disease that they cannot stand the operation necessary to cure them. Here transfusion of blood increases

To the Editor:—In an editorial (The Journal, September 29, p. 114) you comment on the present status of blood transfusion. After reviewing some of the work showing the disadvantages of the citrate method of transfusion, you commend very heartily whole blood transfusion. This commendation appears to be in keeping with results of physiologic and clinical investigations, but it is difficult to understand your position with regard to direct transfusion, in which the blood is directly conveyed from the artery of the donor to the vein of the recipient. The obvious objections to blood vascular suturing in transfusion are the technical difficulties and the rather prolonged incisions necessary to expose the vessels. These objections do not obtain when a short jointed cannula, such as the Bernheim cannula, is used. In a communication in the Archives of Surgery (September, 1923, pp. 466-468) I have reported fifty-four consecutive cases, in which this

The method of suturing blood-vessels which I described recently in The Journal1 consists in the use of a new instrument together with the application of a continuous mattress suture. The mattress suture apposes the intima more satisfactorily than the overhand stitch. I have found, however, that it is sometimes difficult to prevent leakage with the continuous mattress stitch, as the points between the sutures have but little compression by the suture and no raw surface, For this reason, if a leakage occurs, it is sometimes difficult to stop. This is particularly true when suturing vessels of different caliber, as in transplanting a segment of vein between the cut ends of an artery, and has been the chief objection to this method.In order to overcome this objection, I have recently used a double mattress stitch, or cobbler's stitch, which has been so successfully employed by Dr. Crile in intestinal

TO THE EDITOR: —My attention has just been called to the fact that Dr. George H. Monks of Boston has transplanted the anterior temporal artery with the flap attached to repair a defect made by excision of the lower eyelid for carcinoma. The description of his operation was published in the Boston Medical and Surgical Journal, Oct. 20, 1898. While there is considerable difference in some of the details of the operation, the principle is identical with that mentioned in my article on "Transplantation of the Anterior Temporal Artery" (The Journal, Jan. 30, 1915, p. 408). Of course, Dr. Monks is entitled to priority. I did not know of Dr. Monks' work when my paper was written.