, ILL. THE OPERABILITY and prognosis in patients with carcinoma of the rectum depend on the presence and extent of lymphatic metastases as well as on the degree of local extension of the tumor and the absence of blood-borne metastases to the liver, lungs, bones, brain, etc. The present study was undertaken in an effort to determine the incidence, extent and location of lymph node metastases and the extent of radical removal necessary to insure eradication of all involved nodes.At first, this was done by a very careful dissection of the fresh, surgically removed specimen of carcinoma of the rectum. A full scale drawing was made, and the location of all lymph nodes was carefully noted on it. Between eight and 48 lymph nodes were found in each of 22 specimens examined by gross dissection. Nodes which were thought to be involved with carcinoma were labeled and circled with black ink on the drawing. All nodes were then sectioned and examined microscopically.Recognition of involved nodes by palpation is difficult or impossible when they are small. Four hundred ninety-six nodes from these specimens were examined grossly to determine the presence of metastases. Of the I I I lymph nodes containing carcinoma, only 48 showed any gross change, even in crosssection of the gland. Gabriel, Dukes and Bussey' tried to determine the presence of lymph node metastases in I,242 nodes found in operative specimens of carcinoma of the rectum. Of 337 nodes considered by them to have carcinoma grossly, only I32 were found to be involved when examined microscopically; and of 905 nodes considered to be free of carcinoma, I8 contained carcinoma when examined microscopically.Technic of Examination.-Later, in order to more accurately study all of the lymph nodes, we developed the following technic for examination of surgically removed specimens of carcinoma of the rectum. The ligature on the superior hemorrhoidal artery of the fresh specimen is removed and a small cannula is tied into the artery. The specimen is then perfused with a warm I per cent citrate solution under a pressure of about IOO cm. of water. Ligatures on the smaller vessels are removed so that the blood can be washed out, and as soon as there is a free flow of clear fluid from any open vessel, it is ligated. After one to three hours of perfusion, the specimen is white except for the extrinsic muscles surrounding the anal orifice, and for any small areas where there may have been an extravasation of blood. Such areas can be cleared by very gentle manipulation. After the specimen has become almost entirely white, the artery is injected with red lead. This is done under moderate pressure, using a syringe. The vessel is then tied and the specimen is (Fig. i).A full scale drawing of the bowel, arterial tree and tumor is then made. A section of the tumor is taken and placed in methyl salicylate. The lymph nodes can now be removed, each one can be labeled separately and its position charted exactly in its relation to the artery. These nodes are then placed in methyl salicylate ...

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AT the base hospitals it was possible to keep for treatment, for a period varying from one to three months, patients who by necessity were evacuated from the evacuation hospitals in a few hours after their operation. The results of certain operative procedures, complications arising in special types of injuries as well as the probable functional results in these injuries, could therefore be observed at the base hospital. In this paper, gunshot wounds of the knee-joint will be so considered.The primary operations in injured knee-joints were usually done at the evacuation hospitals where the policy of operative interference was fairly uniform. Through and through machine-gun bullet wounds of the knee without marked destruction of the articular surfaces were not usually operated upon. Haemarthrosis or marked effusion into the joint in such cases was usually aspirated. Practically all penetrating and perforating wounds from high explosives were operated as soon as possible, the wounds of the soft parts debrided, foreign bodies and loose bone fragments removed from the joint, and the capsule of the joint closed if possible. If infection had already manifested itself or was probable, the joint was left open. Long oblique fractures into the joint were usually subjected to a d6bridement of the wound over the fracture and the joint was not opened. It was, as a rule, not possible to hold these cases at the front more than forty-eight hours, and they were evacuated with the joint immobilized in a Thomas splint to the base hospital, where they were held until complications were cared for and a definite convalescence established.A group of such injuries in Base Hospital No. I3 will be considered from the standpoint of the original lesion, the type of operation performed at the front, the subsequent complications and their treatment as related to the function of the joint. Fifty-five cases had sufficiently good records for study. Forty-nine were operated at the front on an average of I.8 days after their injury and of these forty-two were operated within twenty-four hours after injury. Of the whole group thirty-one or fiftysix per cent. remained uninfected after operation, and twenty-four or forty-four per cent. became infected. The influence of early operation in prevention of infection is instanced in the seven joints operated later than twenty-four hours after injury. Five became infected, the average time of operation being eight days after injury.Infection is the most important factor in decreasing the ultimate usefulness of the joint. The type of injury to the joint, the post-oper-290

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