but rather absorbs it, from which we must assume that the maintenance of the new-born is but one of the functions of the female mamma. In two instances of double amputation of the breast coming under my observation in young women for cystic disease, both later married, but neither ever conceived. The complete amputation of both breasts is well known to produce most profound psychological impression, and often when but one is totally removed. The advent of nearly every variety of organic lesion here is quite invariably ushered in by depression of spirits and spells of distressing melancholy. Beatson's operation has clearly demonstrated the intimate relations subsisting between the breast and the ovaries. In monorchids, in cryptorchids, or hermaphrodism-imperfect development of the external male genitals-gynecomastia, or very large development of the mammæ, is a most conspicuous figure. CONCLUSION. The mamma is a highly organized, and, structurally, a most complex organ. Its functions are manifold. It is an essential and integral part of the generative system. Intermittent in function, like the testes, total ablation, like double castration, makes its impress on the sensorium. Very frequently degenerative or pathological changes begin in a single isolated lobe, about twenty of which are in each breast. In all non-malignant affections, radical measures should be limited as far as possible to the affected area or lobe. It is only in malignant disease of a progressive type, and life is imperilled, that total sacrifice of the breast is justified. Inasmuch as the functions and purposes of the axillary lymph ganglia are yet imperfectly understood, and their removal quite invariably enhances the risks of operation, involves a wide mutilation of the chest walls, and always leaves more or less impediment in shoulder action, or even at times a painful tumefied limb, it is only as an extreme and exceptional measure that their complete extirpation should be practiced. CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL. A STATED meeting of the above society was held November 7th, 1904. The President, Dr. Daniel S. Dougherty, occupied the chair. The following interesting specimens and papers were presented: Specimen of Gangrenous Appendix.-Dr. J. A. Robertson showed an appendix which had been removed from a patient the previous week. During the afternoon he had severe gastric pains and vomiting. At ten o'clock the same evening a diagnosis of appendicitis was made, based on the tenderness at McBurney's point at the ventrix. Slight intestinal obstruction was also suspected, as the vomiting persisted, and toward morning became fecal in character. The temperature was 103.8 deg., followed by collapse the next morning, and during this collapse the operation was performed, the appendix being removed about 9 a.m. Examination of the appendix revealed the fact that it was gangrenous near the tip, and midway there was a stricture. Opposite the point of stricture were two gangrenous spots, just ready to break through. This specimen demonstrated the rapid development of the disease, and emphasized the need for early operation. The speaker had seen seven consecutive cases of gangrenous appendicitis within the past two years, and had operated on them, with but one fatal result, and in that case he had hesitated more than twenty-four hours after the appearance of symptoms before operation. In his opinion, operation should be performed during the first twenty-four hours, or not at all. Dr. A. Lyle opened the discussion. He said that the point he thought of greatest importance was the sudden drop of temperature. Gangrenous appendicitis can almost always be diag nosed by this sudden drop of temperature. Many physicians might interpret this as a sign that the patient was on the road to convalescence and postpone operation, and the case would probably result fatally. In the suppurative type of appendicitis, the temperature continues to rise slowly and does not drop as suddenly. Dr. B. H. Wells said that he had seen this patient in consultation with Dr. Robertson, and an important feature, not men tioned by the first speaker, was the sudden cessation of pain. The temperature in appendicitis cases he thought a very irregular guide, as is the pain, or, in fact, any single symptom. The patient may have normal or subnormal temperature and normal or very slow pulse, but if the pain is severe and then suddenly stops, it is well to proceed carefully. The speaker had examined many cases under these circumstances, and often found extensive gangrenous appendix and intestines. Dr. M. Packard said that in his opinion from the standpoint of diagnosis it was immaterial how the temperature stood, but the pulse was an important factor. If the patient has a rapid pulse, with a normal or subnormal temperature, and a pulse of 100 and a temperature of 98.6 or even 98, operation should be performed. Another point mentioned by Mannenberg, and substantiated by Nothnagel as important in the differential diagnosis of appendicitis, is that of the second pulmonary sound of the heart, which is usually accentuated in appendicitis. Mannenberg reports this symptom in 170 out of 200 cases of appendicitis which he examined. Dr. Robertson, in closing the discussion, said that at the operation it was found that the complication which had been suspected was found to be present. About eighteen inches from the appendix the small intestine was strangulated and twisted, and the mesentery was twisted throughout, and for a few minutes we debated whether it would be wise to resect this portion of the intestine, but Dr. Wells suggested that it be closed. Specimens of Tubal Pregnancy.-Dr. L. J. Ladinski reported three cases of tubal pregnancy occurring in his practice during an interval of twelve days, and showed the specimens removed from these patients. The first patient had been bleeding from the uterus for four or five days, but the discharge had disappeared the day before the speaker saw the patient. Temperature was normal, pulse 110. Examination revealed a somewhat enlarged uterus, a characteristically enlarged tube, tender and sensitive to the touch. No bleeding from the uterus, however. A diag nosis of tubal pregnancy was made and operation advised. The following day the uterus was curetted and abdomen opened. There was free blood in the peritoneal cavity. The enlarged tube, with the fimbriated extremity very much dilated, and presenting a large blood clot, from which hemorrhage took place, was removed. This was a case, therefore, of tubal abortion. The tube might have been saved, but as the attachment of the sac was close to the uterine end, it was not deemed wise to do it. The patient left the hospital nineteen days after operation. The second patient was twenty-three years old. On the dav previous to her admission to the hospital she had been taken with a sudden, sharp, stabbing pain in the lower abdomen on the right side. With the onset of the attack she had a hemorrhage from the uterus. It was not time for her menstrual period, as she claimed to have menstruated only three weeks before. She felt dizzy, cold and extremely weak. Patient denied any possibility of pregnancy. Operation was performed under ether, the uterus being curetted. Upon incising into the peritoneal cavity, free blood welled out. The right tube was found very much elongated, and the gravid sac, with the amniotic sac unruptured, was found attached to the fimbriated extremity and external to it, and was removed. The left ovary presented a cyst the size of a hen's egg, to which the gravid sac and distal end of the right tube had evidently been attached, and was separated on manipulation before opening the peritoneal cavity. This ovary was removed. The distal end of the tube, which was found closed, was opened and everted. The appendix was removed and the wound closed without drainage. The patient made a good recovery. The third patient complained of a sudden, sharp onset of pain, with bleeding from the uterus which lasted for about twenty days. Examination revealed a tense, tender, elastic mass bulging into the left lateral fornix of the vagina. Uterus slightly to the right of the median line. Patient absolutely denies any possibility of pregnancy. A diagnosis of tubal pregnancy was made, the uterus was curetted and the abdomen opened. Free blood was found upon opening the peritoneal cavity. The left tube was much distended, with clots, and ruptured. The left tube was removed, including the left ovary, and the abdominal wound was closed in four layers, without drainage. The patient. made an excellent convalescence. Dr. Wells opened the discussion of these cases. He said that in extra-uterine pregnancy hemorrhage is usually attributed to rupture, while in reality it often occurs previous to rupture, and is not necessarily accompanied by this latter symptom. The ovum is expanded inside the tube, and the villi grow into the walls of the tube, and after a time grow straight through. The blood pressure causes the tube to sweat blood from the little ends of the villi. The same process makes the wall of the tube very weak, and the ovum is growing inside, and when it comes. across a naturally large blood-vessel, hemorrhage is apt to follow. A Case for Diagnosis.-Dr. M. Packard reported the case of a man who presented himself at the clinic about four weeks ago with the following history: Family history and previous history good. His present history began about nine months ago, with gradual difficulty in swallowing. The dysphagia became so extreme that it was impossible to take solid food of any kind. On several occasions he vomited blood, which was always of a bright red and never of a chocolate nature. He lost in weight as much as thirty pounds. Naturally, with this history, we suspected a neoplasm of the esophagus or cardiac end of the stomach. We passed an esophageal sound, which was not restricted at any portion of the esophagus, but on removal brought up about three drams of pure blood. The stomach was normal in size, but on account of the bleeding a test examination was valueless. Liver and abdomen were normal. The heart sounds were all feeble, but there was a relative accentuation of the second aortic sound. There was no burring or thrill. His blood examination showed 5,200,000 red, 100 per cent. hemoglobin, 7,600 whites, showing the blood absolutely normal, and ruling out with a positive degree of certainty malignancy, and especially of the stomach. His arteries were athermetic, and with this history the diagnosis pointed either to varicose veins of the esophagus or ulceration of the esophagus, due to arterio-sclerosis. Dr. Burtenshaw stated that Dr. Packard, in connection with the blood examination, said that the normal condition of the blood proved conclusively that there was no carcinoma. In the speaker's opinion, the blood examination alone was not conclusive proof that no malignancy or inflammatory condition was to be antici pated. Dr. Packard, in closing the discussion, said that he agreed with the last speaker that a normal blood examination alone was not conclusive proof of the absence of malignancy, but when a patient's blood gave a red blood cell count of over five million blood cells, and 100 per cent. hemoglobin, it is safe to assume that carcinoma is not present. In carcinoma there is usually a secondary anemia, and the hemoglobin of the red blood cells becomes polluted. Epithelioma of Vulva.-Dr. Brooks H. Wells reported two cases of epithelioma of the vulva which had come under his observation, and presented drawings and photographs to illustrate them. He said that primary epithelioma of the vulva is rare, occurring in only about three per cent. of the cases of cancer of the genital tract. Not much is known definitely of the predisposing causes. Long-continued irritation undoubtedly increases the chance of its appearance. Cancer may invade any portion of the skin of the vulva and spread outward in the direction of the lymph streams. Histologically, it usually gives the picture of a squamous-celled epithelioma, except when it invades the vulvovaginal gland, when we find the cylindrical-celled or adeno carcinoma. The treatment of cancer of the vulva should be early and radical excision, together with excision of the superficial inguinal glands on both sides. Prognosis as to permanence of relief is bad, |