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afforded the patient a quiet and comparatively painlessdeath, instead of the horrible suffering which an open cancertoo often entailed. With regard to the " complete opera-tion of Mr. Banks, Mr. Pick quite agreed with him that theremoval of the disease should be most thorough, and that, inorder that this might be so, no heed should be taken t6 pre-serve sufficient skin to form flaps to cover the gap left, butthat, if necessary, the sore should be left to granulate as anopen wound. But he was not prepared to agree withMr. Banks that clearing out of the axillary space was eithernecessary or judicious. The proceeding added very materiallyto the danger of the operation, as shown by Mr. Banks’tables; and in his (Mr. Pick’s) experience it was only in asmall percentage of cases that the disease recurred in theaxillary glands, the cicatrix remaining healthy. He there-fore regarded the proceeding as unnecessary, and it was alsoinjudicious as adding to the mortality. Mr. Pick was in-clined to attribute the success which Mr. Banks had obtainedrather to the very free removal of the breast and surround-ing tissues than to the extirpation of the axillary glands.Mr. BUTLIN said that in the discussion on Dr. Gross’s

paper, during the meeting of the International Congress inLondon, he had been inclined to take a similar view to Dr.Gross and Mr. Banks with regard to the removal of cancerof the breast. Since that time, however, he had made a verycareful study of the natural history and course of cancer ofthe breast, and of the cases published by the author of thispaper, and had come to the conclusion that the very freeremoval of the mamma and opening of the axilla, recom-mended by Mr. Banks in every or nearly every instance ofcancer of the breast, is an unsurgical and unscientific pro-ceeding. Besides several minor propositions, Mr. Banks hadput forward two main propositions: that the operationshould include the entire mamma with the overlying skinand parts beneath in all cases, and that the axilla should beopened, whether enlarged glands could be felt in it or not.Mr. Butlin dissented from both propositions. From the c

first, because the operation bore no direct relation to the ex- (

tent of the disease. The tumour was often of small size, andsituated in the inner or the lower segment of the breast, andthe incisions, instead of being carried equally far from it inevery direction, were perhaps three icnhes from it in onedirection, and less than one inch in other directions. Cancerof the breast must be treated in the same manner and on thesame principles as cancer of the lip and similar parts ; veryfree removal of the disease, the surrounding textures, theoverlying skin, and the fascia over the muscle, if need be;but not removal of parts which were not, and probablynever would be, affected. With regard to the second pro-position, most surgeons were agreed that the glands in theaxilla should be removed if they were enlarged and could betaken away. Mr. Butlin would go so far as to open the axillain cases in which an indefinite fulness could be felt. But hewould not open the axilla in other cases. He had collectednotes of 101 cases in which the axilla had not been opened,and 209 cases in which the glands had been removed. Themortality in the first set was 10 per cent., the proportion ofwomen alive and well at the end of three years, 18 per cent.The mortality in the second set was 20 per cent.; the numberof women remaining well at the end of three years about5 per cent. The cases in which there was no affection ofthe glands, and in which the axilla had consequently notbeen opened, were by far the best cases for operation, notonly on account of the less severity of the operation, butbecause the disease was less malignant.Mr. HARRISON CRIPPS thought the profession was much

indebted to the persevering manner in which Mr. Banks hadbrought the subject of the removal of the axillary glandsso prominently forward. Though he would not like to makean arbitrary rule that they should invariably be removed, heagreed that in the majority of leases such treatment wasindicated. The question to some extent turned on whetherorl not the opening of the axilla and removal of the glandsadded greatly to the danger of the operation. According tothe experience of St. Bartholomew’s Hospital this did notappear to be the case. In the five years from 1863 to 1867,at a period when it was the exception rather than therule to open the axilla, the mortality after amputation ofthe breast was as near as possible 11 per cent. Owing,however, to improved methods and better sanitary con-dition of the hospital, the rate of the mortality duringthe last five years only amounted to 5 per cent., and,moreover, during this latter period, in about half thecases the axillary glands had been removed. In the last

year’s reports it is especially noted that of thirty-eight casesof amputation of the breast for cancer, in nineteen theaxillary glands were also removed, but the rate of mortalitywas exactly the same-viz., one death in the nineteen casesin which the glands were untouched, and one death in thenineteen cases in which the glands were removed. The highrate of mortality in Mr. Banks’ cases appeared to be entirelydue to blood poisoning, the result of insanitary surroundings.Mr. Cripps considered that in operating for breast cancer thefree removal of skin over the tumour, although it mightappear to be supple and not complicated at the time of

operation, was of the utmost importance, for it frequentlyhappened that recurrence took the form of cancerous nodulesin the skin bordering on the cicatrix, and that this phe-nomenon showed how often the skin was really infected, andshould have been freely removed at the original operation.

The PRESIDENT expressed surprise at the amount of op-position which the important paper, just read, had elicited.He was under the apprehension that surgical opinion wassteadily drifting in the direction of opening the axilla andenucleating all discoverable lymphatic glands, whether de-finitely implicated or not. Often it was impossible to saywhether there was axillary invasion or not until the armpithad been opened up. Clearing away the glands was adesirable measure, in that it diminished the risk of subse-quent pressure (from secondary malignant enlargement)upon the axillary vein and the cords of the brachial plexus,thus obviating, as he believed, the oedema and neuralgia ofthe arm so often met with when the glands were left un-touched. Probably, also, the removal of the glands mightbe the means of checking a general invasion of the lymphcurrents; the risk of remote infections was certainly lessif those centres of infection, the glands, were out of theway. The operation was a severe one, but it had thegreat recommendation of being thorough. He failed tosee how an operation for malignant tumour could becomplete which did not effect at the same time the can-cerous glands associated with that tumour.

Mr. BANKS briefly replied.

MANCHESTER PATHOLOGICAL SOCIETY.

A MEETING of this Society was held on Feb. 9th, Dr. J.Dreschfeld, President, in the chair.

Cystomct of the Ovary.—Mr. W. A. STOCKS showed apreparation of a cystoma about the size of an orange whichhad passed down Douglas’s pouch, and had been extrudedthrough the anus, pushing the anterior wall of the rectumbefore it. It had been successfully removed by operation.

Vesical Calculi.—Mr. W. A. STOCKS also showed thirty-seven calculi which had been removed from the bladder ofa man by lateral lithotomy. Each original calculus containeda minute millet-seed nucleus, around which had beendeposited some buff-coloured urates, showing a distinct con-centric arrangement, and having four or five lines of a muchlighter colour radiating from the centre to the circumference,after the manner of those seen in the transverse section ofan orange, each stone being about three-eighths of an inchin diameter. At this stage of their development many ofthese stones seemed to have undergone spontaneous divisionthrough the lines above mentioned, forming a second seriesof nuclei. Every stone had been covered with a thick layerof phosphates, those of the primary series forming stonesthree-quarters of an inch, and those of the latter series,stones of about half an inch in diameter, irregular in shapeand furnished with a varying number of facets.Mammary Tumours.—Dr. W. THORBURN exhibited a series

of sections of various breast tumours. He demonstratedthe varieties of cancer and their modes of growth, andshowed preparations illustrating every stage in the develop-ment of cysts and intra-cystic growths in non-canceroustumours. Among the rarer forms he showed a pure myxoma,an adenoma without overgrowth of the connective tissueelements, and a typical " villous cancer."

hatra-ocular Crowths.—Dr.HILL. GRIFFITH showed twelveglycerine jelly preparations demonstrative of intra-oculargrowths and cyclitis, and mentioned the diagnostic appear-ances of sarcoma of the choroid, glioma of the retina, andplastic cyclitis on the so-called pseudo-glioma.

Changes in the Spinal Cord and Peripheral Nerves afterAmputation.-Dr, E. S. REYNOLDS made some observationson the changes in the nervous system after the amputation

629

of limbs, showing a series of specimens from a case. Havingbriefly referred to the history of the subject, and especiallyto some recent observations made by Friedlander andKrause, he pointed out that the changes in the case whichhe had investigated consisted in a simple atrophy of themajority of the fibres in the nerve trunk of the amputatedleg, with increase of lymph spaces and connective tissue,and that this change could be traced up to the cord,principally in the posterior nerve root, but also in theanterior nerve root. In the cord the changes were limitedto the lumbar region, and consisted of a slight decrease ofthe posterior horns and columns, and a more marked decreaseof the anterior horns, affecting the number and structure ofthe cells in all the groups, but especially in the postero-lateral and central groups. Clarke’s column was notaffected.

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MIDLAND MEDICAL SOCIETY.

A MEETING of this Society was held on March 2nd,Mr. Lloyd Owen, F.R.C.S.I., President, in the chair.Locomotor Ataxia with Joint Disease. - Dr. SUCKLING

showed a man aged forty-eight, who was suffering fromlocomotor ataxia with disease of his knee-joints. He was

quite well up to twelve months ago, when he had attacksof vomiting with shooting pains in the legs. Soon after hecomplained of having girdle pains. The knee-joints beganto enlarge about nine months ago, there being pain only inthe left one. At the present time there is marked cracklingon movement of each joint, with enlargement especially ofthe internal condyle of the femur on both sides, and partialdislocation outwards of the patella and tibia on the leftside, on which side there is also some genu valgum ; thereis no excess of fluid in either joint. The knee-jerk is loston both sides, the pupils are unequal and respond to accom-modation, but not to light.Tumour of Bladder treated bryS’upoa-puhic Cystotomy.—

Mr. BENNETT MAY reported this case, and showed the partsremoved after death, which took place six months after theoperation. In comparing the two methods of operating-viz., by the median perineal and by supra-pubic cystotomy,—Mr. May observed that the former was undoubtedly thesimpler and possibly safer operation, and was an excellentmeans of exploring the bladder, whilst it was also quiteadequate for the removal of some tumours. For the majorityof cases of tumour of the bladder, however, it was far inferiorto the supra-pubic operation, which gave opportunity forinspection and more thorough manipulation within thebladder. From the point of view, also, of the patient’s sub-sequent condition, and for the purposes of permanentopening for micturition, when, as so often happens, thetumour cannot be removed, the supra-pubic operation wasinfinitely preferable. He had found the perineal opera-tion a complete failure in relieving the patient’s sufferingsfor any length of time; and for all cases of diagnosedtumour he should operate by the supra-pubic method,provided of course that the bladder could hold sufficientwater.

Periosteal Sarcoma.—Mr. JORDAN LLOYD showed a girlaged eighteen who had developed a large malignant tumourof the forearm, probably a periosteal round-celled sarcomaof the ulna, with large ascending growths in the upper arm,the axilla, and the subelavian triangle. The tumour in theforearm was the first to appear, only fourteen weeks ago.This was cut into for the purposes of diagnosis, and onmicroscopic examination was found to be a small round-celled sarcoma. There was no history of malignancy or ofinjury. At the time of first seeing the case the diseasehad progressed too far to admit of removal.Injury to Sloulder.—Mr. A. F. CLAY showed a man aged

seventy-seven who had fallen downstairs on this shoulder;he was told by his medical attendant that he had " brokenhis arm high up." Three weeks after this Mr. Clay saw him,and found his humerus and clavicle intact, but about aninch and a half above the lowest part of the anteriorboundary of the axilla a round hard prominence the size ofa marble was seen and easily felt. It was then slightlymovable, but more in the lateral than vertical direction. Itfollowed the movements of the humerus. Since then it hasbecome absolutely immovable and is smaller. The coracoidprocess on the injured side was not so prominent as itsfellow.

Reviews and Notices Books.Leltrbuclt der CHirurchen Krankcheiten des Ohres (Text-

book of the Surgical Diseases of the Ear). By Prof. Dr.HERMANN ScHWARTZE. Stuttgart: Ferdinand Enke. 1885.

PROFESSOR. SCHWARTZE’S text-boek of aural surgerydeserves the attention of all otologists, not only as comingfrom such a well-known writer, but also from the intrinsicvalue of the work. To the practitioner who is versed inotological subjects the book will derive its chief attractionfrom the parts devoted to the newer operations on thehearing organ, in which the author, besides collating themost recent views of others, gives his own extensive

experience. A few of these may be briefly noticed.Division of the tensor tympani is, he says, a procedure

devoid of all practical value when employed for the reliefof deafness, tinnitus, or giddiness. He has never seen it

give any permanent relief to these symptoms, and cases arerecorded in which it has provoked an aggravation of thesame. As a preliminary operation in excision of thehammer it is more likely to come into use.

Excision of the drumhead and ossicles forms the subjectof a very interesting chapter. Schwartze’s first attemptsat excising the drumhead and extraction of the entiremalleus in sclerosis date from the year 1873; these failedregularly, owing to rapid regeneration of the membranatympani. A method of preventing this regeneration was,however, devised by Kessel, which is adopted by the author.Schwartze’s method of operating is as follows: The membraneis divided close to its periphery, the "tendinous ring" beingalso removed at the back part, according to Kessel’s plan. The

tendon of the tensor.tympani and the joint between the stapesand incus are then divided. The membrane, together with the

malleus and incus, is now grasped with a Wilde’s snare andremoved by a few careful to-and-fro movements. Thechorda

tympani is necessarily stretched, but if it should be torn

across the loss of taste occasioned is usually only temporary.The cases in which the operation is recommended are mainlyof two kinds: (1) Chronic suppuration of the middle etr,with caries of the ossicles, and cases of cholesteatoma of thetympanum ; (2) Immobility of the malleus, caused either bytotal calcification of the membrana tympani or by ankylosisof the malleo-incudal joint, it having been previously care-fully ascertained that the labyrinth is unaffected, and (by. exploratory puncture of the drumhead, &c.) that the stapes ismovable. Six cases briefly described by the author show the1 practicability of the operation, and that in some cases it is, capable of relieving the tinnitus; the improvement in thehearing power gained, however, was not marked. On the

whole, the results of excision are more favourable in suppu-rative cases or when there has been previous suppuration,than in cases of sclerosis.

We have dwelt at some length on this operation on ac-count of its novelty, but there are many other parts of thebook which deserve mention, notably the chapter on diseaseof the mastoid, a subject with which the author’s name isinseparably connected. Without agreeing with all ProfessorSchwartze’s statements, it may be said that the wholevolume is replete with interest to the student and prac-titioner of aural surgery, and forms a valuable work ofreference. It is liberally illustrated ; some of the figures werecognise as coming from the author’s

" Pathological Ana-tomy of the Ear."

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Discases and their Commencement. Lectures to TrainedNurses. By DONALD HooD, M.D. London: J. and A.Y Churchill.

DR. HOOD has in this small but useful work broughtdunder the notice of nurses the fundamental facts con-

nected with the causes, prevention, pathology, symptoms,and nursing treatment of a variety of diseases. The five