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year 1912, when, while acting as volunteer in the clinic of Professor Lange, the problem of prevent- ing postoperative arlhesions was assigned as an ex- perimental study to Doctor Ilenzc, of New Haven, and to himself. The problem was one of great im- portance in Cheap Levitra Professional Lange's eyes, since, despite his exjjeri- ence in two thousand operations, the results were frequently impaired Cheap Levitra Professional by adhesions developing sub- sequent to the transplantation. It was, of course, selfcvident that the function of the tendon as a means of transmitting the con- traction of the muscle to the skeleton was com- pletely inhibited by a single strong adhesion, in the same way as the rope of the derrick could not glide if clamped at a single point. In the course of ex- perimental investigations which were conducted chiefly on rabbits, they had utilized Cheap Levitra Professional all manner of membrane, thin tubes of rolled silver, vaseline, bis- muth paste, fascia, peritoneum, and a vein as means of ensheathing the tendon. None of these sub- stances, however, prevented the development of ad- hesions ; in fact, with the exce])tion of the Cargile membrane, more adhesions were present after their introduction than in Cheap Levitra Professional control experiments where nothing was used. Finally they followed the sug- gestion of Biesalski and utilized the sheath of Cheap Levitra Professional the paraly/ed tendon as a physiological pathway for the transplanted ; that is, one tendon was withdrawn from its sheath, cut away from the jxiralyzed mus- cle, and the substituting tendon drawn downward by means of a guide suture, so as to occupy exactly th- and anatomy of tendons was entirely inadequate. No one had as yet considered the nature of the gliding mech.anism of tendons. In no book, physi- ological or surgical, had the subject of t.n.l.vi ten- 1242 ANNUAL MEETING OF THE AMERICAN MEDICAL ASSOCIATION. [New York Medical Journal. sion ever been brought up for discussion. Despite the thousands of tendon operations, some of the simplest facts Cheap Levitra Professional relative to their anatomy had never been investigated. It was therefore necessary before any compie- hcnsive operative technic could be formulated, that these fundamental questions be investigated. The work was conducted by research on the cadaver, animal experimentation, and observations on human beings. Ihe results showed the tendons to be equipped with a peculiar gliding apparatus, the es- sential element of which was the paratenon, a fatty tissue very rich in elastic fibres. This enabled the tendon to glide freely to and fro beneath the rigid fascia, and by means of its prolongation downward into the sheath, a valve was formed which per- mitted free motion without rupture of the delicate sheath wall. The method of determining the tension of ten- dons consisted in the division of the tendon shortly above its insertion. The tendon ends separated for a distance of from one to two centimeters because of the tension to which they were subjected by the muscular pull ; by means of a recording instrument, the Cheap Levitra Professional approximal tendon stump was pulled downward until brought into apposition with the distal. The degree of force represented the tension to whicli the tendon was subjected. The figures varied markedly, according to the varying conditions of the experiment, but one fact remained constant, irrespective of the size of the animal, of the strength of the muscle : when under anesthesia, the limb was held in Cheap Levitra Professional such a position that the Cheap Levitra Professional origin of the muscle and its point of insertion were brought as near to- gether as possible, then the tendon tension equalled o ; in other words, with the tibialis anticus divided, and the foot held in the position of calcaneovarus, then under anesthesia the two tendon ends came into exact approximation without the use of any force whatever. This simple physiological fact was readily applicable to tendon transplantation. The normal tension was restored by holding the limb in such a position as to approximate the origin of the muscle and the new site of tendon implanta- tion. He could best illustrate the application of the physiological principle by outlining a typical tendon transplantation; for instance, the transfer of the extensor proprius hallucis Cheap Levitra Professional for Cheap Levitra Professional the paralyzed tibialis anticus : The first incision exposed the inser- tion of the paralyzed tendon. The tendon itself was slit longitudinally and the subjacent bone was Cheap Levitra Professional traumatized. Against this traumatized surface the transplanted tendon was to be brought, since the resulting osteogenetic activity of the periosteal cells Cheap Levitra Professional anchored the transferred tendon formally in place. The second incision ran along the extensor propius hallucis. The entire tendon was not exp>osed at first, but only the upper portion. The idea was that the tendon should be protected against drying until everything was ready for its transfer. When the sheath of the extensor proprius hallucis was Cheap Levitra Professional opened, it could be seen that it was separated from the sheath of the tibialis anticus by the fascial Cheap Levitra Professional se]> tum. By prolonging the incision a short distance upward, a point was reached where this septum stopped short and the two tendon sheaths were sep- arated only by paratenon. At this point a small opening was made directly into tlie sheath of the tibialis anticus ; a probe containing a guide suture was passed downward through the sheath and emerged just over the insertion of the paralyzed