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is put on to keep the packing in position and to permit it to become firm, and the patient is not allowed to swallow, but is fed, if necessary, per rectum. On the third day the packing has become quite firm, and all the cases operated on by him and so treated were then able to swallow without difficulty. As displacement of the packing is not possible, thanks to the gauze on the one side and the bandage on the other, he was always able to leave the packing undisturbed for nine or ten days after the operation. On the seventh or eighth day the packing being soaked with secretion, permits fluids swallowed by the patient to come through, and it becomes necessary to use an oesophageal tube for feeding purposes. On the ninth or tenth day the packing is removed, first the strip and then the gauze,

and in all such cases one could then be sure that the cavity of the wound was perfectly granulated over. result of this the danger of septic pneumonia is much lessened. After removal of the first packing the wound is then re-packed in the same way, only of course the second packing does not close the cavity as accurately as the first, and it is therefore necessary to continue to nourish the patient artificially. The packing is changed every four or five days until the wound is healed. The wound diminishes gradually, and in spite of the fact that it has not been sutured, it looks as well as if it had been. In many cases it is necessary to close the fistula in the neck. This method has not failed in any of his cases, and not one has died of septic pneumonia. The only case of death that he has to recount was in his private practice, and as the history shows, it resulted on the sixth day after the operation in consequence of hæmorrhage from a thyroid vein.

On the basis of these results, this method can be recommended by Koschier in cases of total extirpation, as it has the inestimable benefit that, after healing has resulted, the patient is able to breathe and phonate through a Schornstein tracheotomy tube.

In conclusion, he discusses the indications for the various operations for the removal of cancer of the larynx. He opposes the method employed by some surgeons in Germany of endolaryngeal removal of cancer, on the ground that the

chance of a radical removal is minimal, for even if the case is seen early it is not possible to decide by the image in the laryngeal mirror how far the tumour has extended into the deeper tissues. An exception can be made only in those cases in which on other grounds a severe surgical operation is contra-indicated, if, for example, the age of the patient and his general condition render an anæsthetic, and prolonged after treatment inadmissable, and where the size of the carcinoma already occasions difficulty in breathing, which one could relieve by a simple and easily performed endolaryngeal operation.

Cancer grows much slower in old people than in the young; an example of this is seen in the case of a patient. aged seventy-three, with marked atheroma of the blood vessels and chronic bronchitis on which he operated. Under such circumstances the removal of the almost bean-sized tumour by endo-laryngeal means was justified.

Considering the unreliability of laryngoscopic examination in clearing up the probable extent of the carcinoma, one should open the larynx and make a closer inspection, and then decide if thyrotomy is sufficient, or if extirpation of the cartilage appears to be necessary. The thyroid cartilage does not become carcinomatous in the middle line at first, but about one cm. to the side of the middle line, corresponding to the favourite primary site of carcinoma of the vocal chord, at the junction of the anterior and middle third. When the cricoid is found to be involved at this point the necessity for hemisection of the larynx is determined, and according to the extent of the tumour either the aia of the thyroid cartilage with the arytenoid of the affected side, or also the affected part of the cricoid is removed. Since the carcinoma originates most frequently on the anterior part of the vocal chord, the anterior commissure and anterior part of the vocal chord on the other side is frequently also diseased. It is therefore very necessary always to remove a portion of the thyroid cartilage on the other side with the soft parts attached, so that one has more certainty of reaching healthy tissue.

In the more advanced cases in which the whole larynx is carcinomatous one must naturally perform a total extirpation with or without removal of the cricoid. In cancer of the epiglottis he has carried out subhyoid pharyngotomy. With the exception of the first six cases of cancer of the larynx on which he has operated, he always operates in two stages. Tracheotomy is done five or six days before the major operation, and is usually a high tracheotomy, which allows the patient to become accustomed to the changed breathing situation and permits any irritation to subside. At the principal operation the Trendelenburg cannula with the funnel for anæsthesia is used.

The operations on the cases reported are of too recent date for one to speak of permanent results. Only three are of a longer duration than three years, and of these two are free from recurrence and one has died of it. It is noteworthy that in all cases where the carcinoma originated in the epiglottis, or had attacked it during the further progress of the growth, there was a recurrence within a year in the original site of the carcinoma. Three recurred in the tongue and one in the tonsil.

Without doubt, carcinoma of the epiglottis has a worse prognosis than that of the vocal chords, due to the rich lymphatic supply of the epiglottis, while the supply of the vocal chords is very defective.

The only case of death that he has to record at the conclusion of the operation cannot, as he says, be placed to the account of the method of packing, as in this case the patient was able to swallow quite well. The acute broncho-pneumonia followed hæmorrhage from a vein of the thyroid gland, and the patient had inspired a good deal of blood.

WILFRID GLEGG.

REVIEWS.

The Elements of Mammalian Anatomy, with special reference

to the Cat. By ALVIN DAVISON, Ph D.; pp. 242; illustra

tions 108 London: Rebman, Limited. 7s. net. THE above book is the last of a number of monographs devoted to the anatomy of the cat; it is, however, one of the least exhaustive. The method chosen by the author of treating his subject is good. After an introduction, in which he gives a classification of the animal kingdom, we have a description of the various systems of the cat in eight chapters; at the close of each the more striking variations met with amongst other mammals are mentioned. The book is copiously and well illustrated, the lettering being, however, frequently indistinct and cumbersome. The text is accurate and lucid, although, as in so many other text books, it is implied that the rabbit is devoid of a vermiform appendix. Some unusual wording and phrasing are found, such as “mesai,” “caudad," "cephalic portion of the cranium,” and “caudal portion of the nasal fossæ,” but they are readily understood with the help of the context.

The book, without possessing any distinguished merit, should prove of use to those students who wish to obtain a superficial and general knowledge of mammalian anatomy.

“The Lymphatics." By P. POIRIER, B. CUNEO, and G.

DELAMERE. Translated and edited by CECIL H. LEAF. 117 illustrations. London: Archibald Constable and Co.

18s. net. This is a book for which we have the highest praise. The subject is one of great importance and interest to both the diagnostician and the operating surgeon; it is, further, treated

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in a most able and exhaustive manner. The great advance in our knowledge of the subject which it marks is attributed to the use of Gerota's method of Prussian blue injection, a full description of which is given in the text. The first half of the book is taken up with a consideration of the general anatomy of the lymphatics by Delamere, and we here find a useful summary of our knowledge of the leucocytes.

Perhaps the most interesting statement made is that the lymphatics in a given region pass through three distinct glandular stages during their course." "The knowledge of these relays of glands placed in succession one behind the other in the lymph stream, is interesting from a pathological point of view, for they constitute so many stages at which the spread of infections and cancers is temporarily arrested.”

The most valuable portion of the book deals with the regional lymphatics and lymphatic glands, which have been described in great detail. The text is very considerably aided by numerous well-chosen and excellent illustrations. We might instance the figures showing the distribution of the lymphatics of the tongue and breast as likely to prove of great use and benefit. The translation is in every way worthy of the work, and all concerned are to be heartily congratulated upon its production. The only fault we can find with it is the strange omission of an index.

By

A Practical Text-Book of the Diseases of Women

ARTHUR H. N. LEWERS. Sixth edition. H. K. Lewis, 136,

Gower Street, London, W.C. 1903. A TEXT-BOOK that has arrived at the sixth edition has abundantly justified its position. In the present edition the author has again thoroughly revised the book and brought it up to date. The extra-peritoneal method of abdominal hysterectomy is, very properly in our opinion, omitted. The introduction of illustrative cases, of which there are seventy-four, is one of the special features of this hand-book, and materially helps to increase the interest of the reader. For students and young practitioners it still retains its position as one of the best of the smaller gynæcological text-books in the language.

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