There is no indication in Mr. Symonds's paper that any part of any specimen removed has been microscopically examined. Even in the case where "a gland was enclosed in a ligature and part had to be left " we are led to believe that the gland was malignant with out being referred to the testimony of the microscope. At the present time there is comparatively little information as to the extent of gland invasion in cases which, from other points of view, are operable, and it is a matter for regret when the record of a case affords no information on the microscopic characters of the glands removed. It is most misleading to look upon the size or even the hardness of a gland as proof of malignancy. Glands as large as a bean at the upper end of the ileo-colic chain are not infrequently observed in cases where there is no suspicion of malignant or other disease of the bowel. It is well that " experience shows that the presence of such glands need not weigh against excision."Wehave shown 2 that the whole of the ileo-colic chain of glands must be regarded as being primary to the casoum and appendix, glands at the extreme upper end of the chain receiving direct vessels from the bowel and standing in the same relation to it as those in contact with it. Assuming that by "a gland close to the spine," one of the uppermost members of this chain is meant and bearing in mind the anatomy of the chain, it does not seem to us that an obvious enlargement of such a gland, even if thought to be definitely malignant, should disturb the operator's intention or give rise to more apprehension than a diseased gland of the anterior or posterior ileo-colic groups which would certainly deter no one from proceeding to excision. Gland disease limited to the ileo-colic chain and not involving the great glands around the superior mesenteric trunk should not forbid excision, other conditions being favourable, nor should the presence or absence of diseased glands determine the extent of the operation. In cases where there is no obvious change in the glands the whole of the chain should be removed, otherwise there is no reasonable certainty of complete removal of possibly infected glands. In cases where the glands are enlarged and possibly malignant there may be less certainty of complete removal. Shortly, we may say that this operation is the least and the most that may be done in carcinoma of the casoum and ascending colon.-We are, Sir, yours faithfully,
Jaques rubber catheter in the urethra continuously for three weeks, by the end of which time the perineal incision had considerably closed. The occasional passage of a No. 20-24 Clutton steel sound completed the treatment. After operation recovery was uneventful. Rigors were entirely absent, and the presence of the catheter did not even cause discomfort. At the present time-that is, 243 years after operationthe patient is well, and, as a precautionary measure, easily passes on himself a 20-24 steel sound once a month. The accompanying diagram shows a Jaques rubber catheter fixed in the urethra from the perineum after Wheelhouse's external urethrotomy by what I have termed a "perineal
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