the cases of cancer the so-called pre-cancerous lesion no argument is needed to make plain the importance of timely attention to whatever source of frequently repeated or prolonged irritation there may exist, be it proctitis, suppurative processes, pruritus or ulcerated piles. These and other simple ailments, easily relieved if proper medical or surgical treatment be employed at the proper time, may, through malignant transformation, if neglected, result disastrously.

When the neoplasm already definitely exists the question of its removal or palliative treatment is not always easy to decide. Broadly speaking it may be stated that when the growth is found to be, or after careful examination is believed to be, a purely local affection, immediate, but radical, excision should be done. If on the other hand, as is so frequently the case, the growth is found to be no longer a local lesion but that it has extended into contiguous structures, involving other pelvic organs, surrounding or even distant lymphatics, then obviously extirpation can do no good. If, because of the extent of the involvement, the condition of the patient as regards lack of strength due to digestive or other disturbances, his apparent lack of ability to resist infection, etc., it seems impossible to do a complete operation, that is the removal of the entire growth with a safe margin of contiguous tissue, together with all infected glands no matter how remote, no operation for the removal of the tumor should be attempted. Partial removal of a carcinoma not only does no good but certainly does positive harm to the patient.

Under such conditions, then, whatever measures offer relief from the extreme pain attending rectal cancer, especially in its later stages, and conduce to the prolongation of life, merit attention. Chief among these, aside from the ordinary simple principles of diet, the use of antiseptic and astringent irrigations, etc., and the proper use of opium, there stands out prominently the operation of colostomy.

The writer is not aware of the attitude of the profession in regard to colostomy-many holding that it is never justifiable. A little investigation however, promptly brings out the fact that this view is based entirely-and as has been many times demonstrated, erroneously on the assumption that a colostomy is little more than a fecal fistula, offering practically no control of bowel contents. It is admitted that the procedure as formerly executed was unsatisfactory to both surgeon and patient, as it merely consisted for the most part of making an opening into the intestine which permitted the discharge of feces, flatus, etc., at all times.

Since an opening above the neoplasm is im

perative in most advanced cases of rectal cancer, a colostomy which will afford the patient at least partial control of the intestinal contents is an important desideratum. The methods of procedure hitherto employed being unsatisfactory, the writer devised what has been called a "controllable valvular colostomy,' which he has repeatedly practiced during the last few years in the palliative treatment of inoperable rectal carcinoma. The procedure is executed in the following manner:

The site of the colostomy is determined by the location and extent of the neoplasm, and should naturally be well above the uppermost limits thereof. The abdominal wall and peritoneum having been incised, the colon is brought into the wound and examined. The portion in which the artificial anus is to be located having been decided upon a heavy cat-gut or kangaroo tendon ligature is placed around it at a point which, when the operation has been completed, will be immediately within and in contact with the abdominal wall. While this loop of intestine is still outside the abdominal cavity, the ligature having been drawn sufficiently tight so that the lumen of the bowel if opened at that point. would barely admit the index finger, is secured upon either side of the ligature and brought together by a series of Lembert sutures completely encircling its circumference, thus producing an infolding of the intestinal wall. This is followed by a second row of Lembert sutures covering the first which produces additional infolding of the intestinal wall, and results in an aggregation of the circular and longitudinal muscular fibres and brings the intestine together for a length of five or six inches. This aggregation of circular and longitudinal muscular fibres conduces to the formation of an "artificial sphincter muscle." This portion of the intestine is then replaced within the cavity and the part that passes through the incision in the abdominal wall is carefully sutured to its sides. in such a way that the newly-formed artificial sphincter will be just beneath and attached to the abdominal wall A glass rod, such as is commonly utilized in other forms of colostomy, is then placed under the intestinal loop remaining outside to support it while healing is taking place, and a sustaining suture of silkworm gut is inserted at either angle of the external incision extending entirely through the abdominal wall, thus providing adequate anchor for the intestinal loop.

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The protruding portion of intestine is not incised at once unless the need of immediate opening be imperative. The protruding portion of intestine is then anointed with sterile vaseline, the dressing applied, and the patient returned to bed. In forty-eight hours, if there be no especial need for earlier atten

tion, an incision is made in the form of a "T" at the most prominent portion of the protruding intestinal loop. A transverse incision is first made extending through about two-thirds of the exposed surface leading toward the proposed artificial anus, then a longitudinal incision sufficiently long to establish a free opening. This procedure is accomplished without the use of an anesthetic, the patient suffering practically no discomfort. By the insertion of a finger it will now be easily demonstrated that the artificial sphincter muscle causes complete closure of the intestine, yet possesses sufficient elasticity to permit the passage of feces. A purgative may then be administered to induce thorough cleansing of the intestinal tract, after which daily evacuations will occur normally or may be secured by either laxatives or enemata. In the majority of instances the patient will thereafter have complete control over the intestinal contents, and in all cases there will result a fair degree of control.

The advantages of this method of treatment should be obvious: In addition to saving the patient the straining and pain incident to the passage of feces, which would otherwise necessarily have to be forced through the cancerous stricture, it affords an outlet from a healthy portion of the intestine, thus making possible regulation of the fecal evacuations; it also renders much less likely the occurrence of hemorrhage from the neoplasm due to pressure and friction, and likewise obviates the more or less constant desire of the patient to defecate.

The adoption of this method of palliative treatment in inoperable rectal carcinomata will almost certainly lengthen the lives of these poor sufferers from one to three years beyond what could otherwise be possible, and will make existence during this period comparatively comfortable. The rectum should be frequently irrigated from above, the fluid passing over the neoplasm to be finally discharged via the anus. The neoplasm may be thus kept clean and also medicated as may seem advisable or necessary. It is oftentimes possible to soothe the irritated or ulcerated. cancerous rectum by the introduction of olive oil from above, allowing it to pass slowly downward through the strictured zone.

BERNARD ASMAN.

J. H. Outland, Kansas City, Mo., (Journal A. M. A., March 27, 1915), publishes the details of a technic he has used in eighty-four cases of vaginal hysterectomy, with one death. It is admittedly largely a modification of other methods, but he feels that he has utilized their good points and produced a simplified and advantageous

method.

SOME FACTS THE PROFESSION AND PUBLIC SHOULD KNOW CONCERNING CANCER.*

The registered areas of the United States for 1914 show that cancer claimed 100,000 victims and this area only included about 75 per cent. of the population. This fact in connection with the known fact that undoubtedly a large number of deaths occur annually from cancer, that are incorrectly diagnosed, will place the mortality from this dread disease at a conservative estimate, well towards the one hundred and fifty thousand mark.

In adults beyond the prime of life, cancer is one of the most frequent causes of death given in the vital statistics, and now that we have better learned to handle tuberculosis, cancer is rapidly reaching the head of the list in mortality statistics.

Those who are best qualified to judge, are of the opinion that if the public can be properly educated in regard to cancer, the annual mortality could be reduced at least one half. No one conversant with the subject to date will deny that we have sufficient information about which there is no disagreement which can be given to the public, and that this informaton will bring thousands of cases to earlier treatment, thereby greatly increasing the probability of cure. At the same time authorative information can be given to the rank and file of the medical profession, through the Medical Journals, thereby enabling them in their role of family physician to give needful advice timely.

The evidence now to hand is, that the percentage of cures in cancer can be increased. We recall the fact that the time is not so far past when we were taught by the ablest teachers, that all cases of cancer were hopeless. The object of the present propaganda is to combat this feeling of pessimism, still all too prevalent among the laity; and unfortunately too large a proportion of the profession are imbued with a feeling of skepticism regarding its curability, and question the correctness of the diagnosis in cases that survive the five and ten year period.

In the control of cancer, we have to combat this skepticism, both in the profession and among the people. We possess the proof that cancer can be cured, taken in due time, and we must present our proof in such a convincing way that it will be believed. The most urgent need in the control of cancer is as stated above, in arousing the people to the necessity of seeking competent advice earlier and training the profession to the fact that the number of cures can be greatly increased by earlier intervention and better surgery.

The percentage of cures in fully developed cancer is relatively small. By fully developed

cases, I mean those in which there can be no question from the clinical signs alone of its malignancy. Where we do not need to study the gross or microscopical appearance of the cut tumor, the clinical picture of retracted and adherent skin, enlarged glands, cachexia and other unmistakable evidence, alas! makes the diagnosis only too easy.

This condition is what we term clinically malignant in contra-distinction to pathologically malignant, meaning by this latter term, a condition of malignancy that has not sufficiently advanced to enable us to make the diagnosis without the aid of the pathologist. When cancer is clinically malignant, the probability of cure is much smaller than when it is only histologically malignant, or in other words a case that falls into the hands of a competent surgeon before it reaches the stage where it can be diagnosed from the clinical signs alone has 80 per cent. chances for complete recovery as against 25 per cent. in the latter. The old method of waiting for the signs of malignancy simply means a vast decrease in chances of cure. The evidence now to hand is convincing that when the disease is treated before it becomes clinically malignant, the number of cures can be greatly increased.

In all parts of the body where we meet cancer, we also encounter lesions which histologically are not cancer, as for instance hairy and pigmented moles, warts, and other skin blemishes, and while histologically not cancer, experience and observation teaches us that a fair proportion of them ultimately become so. Anyone skeptical of this statement need only to question his patient carefully and he will be surprised at the frequency in the history of some skin defect previous to the developments of the malignant condition.

While we have no statistics to prove that the routine practice of advising the removal of all these so-called pre-cancerous lesions will lessen the deaths from cancer. Experience and observation points to the early acceptance of these statements as truths, and when that time arrives, no one need fear external cancer if he is educated to look upon these precancerous lesions as the possible earlier stage of the more formidable lesion, and at once seek competent advice. Fewer operations will be performed for the clinically malignant type with its small percentage of cures, and fewer cases of the inoperable type will be

Econ.

It has been found very difficult to educate not only the people, but the rank and file of the profession as to the potential dangers of a lump in the breast, small defects of the skin, and mucous membrane, and irregular bleeding from the uterus, notwithstanding these evidences or danger signals, usually

visible, and always palpable. One has only to visit any large surgical clinic to find that these evidences are only too often disregarded until too late.

The clinical symptoms of the external type of cancer are usually so distinct, and the diagnosis so readily made, that it should not be difficult to educate the public to seek early and competent advice, but even with this type our educational efforts have been far from satisfactory. When we turn to the other type, the internal cancer of stomach, gall bladder, pancreas, colon, etc., the picture is a dark one indeed, and the educational problem a far more difficult one. The beginning, so slow and insiduous, and the symptoms so closely allied to the minor gastro-intestinal disorders to which we are all heir; and so often, the symptoms not sufficiently distressing to cause the victim to seek advice, and if he should, the positive signs so few and elusive, that even a capable internist, can, in the majority of cases, only suspect but not diagnose, and has to fall back on the unsatisfactory advice to the patient, of having an exploratory laporotomy. Therefore, the inoperable groups of internal cancer will remain large until we either vastly either vastly improve our diagnostic acumen or educate ourselves and patients to understand, that in suspected cases an exploratory laporotomy is attended with far less danger than overlooking cancer in the operable stage, where it could be thoroughly removed at that time with every prospect of permanent cure.

The

In conclusion, I feel that evidence we now have to hand warrants these deductions: The control of cancer is a matter of education and the chief object of the present cancer propaganda is to hasten on this education that the percentage of cures may be increased. number of cases of cancer are rapidly increasing and soon will rival tuberculosis as a cause of death. The resources at our command in controlling this dread disease have not kept pace with developments along other lines and what little progress has been made by the scientists in this field has not, through lack of proper educational facilities been impressed upon the rank and file of the profession, to say nothing of the public at large.

The public, and the profession as well, need to be taught that the number of cures can be greatly increased by earlier intervention and better surgery. All cancers are local in the

beginning. All cancers are histologically malignant, before hecoming so clinically, and there is a great difference in the prognosis between the two types, the percentage of cures being much greater in the former. In other words, if they wait until a very cursory examination will enable one with but little experience to make the diagnosis, then it is what is

known as clinically malignant, and chances for cure far less than in earlier stage.

Last but most important is to teach both public and profession that the greater hope for the eradication of cancer rests on the recognition and care of the pre-cancerous lesion whatever or wherever it may be.

ROBT. L. Bone.

SUPERFICIAL EPITHELIOMA

Since we are more interested in the treatment of disease whereby the patient is mostly benefited, my remarks upon superficial epi

thelioma will lead to the treatment for the following reasons:

First: In the majority of instances epitheliomata upon the surface is rarely mistaken for any other condition. Second, should there be any doubt as to an accurate diag nosis it is a very simple matter to remove a small section of the tumor and submit it to a pathologist for a laboratory diagnosis.

Do no cutting for diagnosis until other methods have failed as by cutting into a tumor may act as a stimulant to more rapid growth, dissemination of carcinomatous cells to adjacent tissue and into the lymphatic system causing metastasis.

For the purpose of study, skin cancers or epitheliomas have been divided into many classes or degrees.

In a clinical way the best division is seemingly into two forms, i.e., the first being of a very superficial nature that tends more towards superficial spreading, does not involve the underlying surfaces and the skin is not adherent to deeper tissues This form is seen quite often around the angles of the orbit possibly the more frequent location being the inner angle. These are very chronic in nature, of slow growth, after beng present several years the tumor having attained only a small size without glandular involvement and may be cured by X-ray, excision or caustics.

The second type is symptomatically an entirely different disease. Usually a few months after first noticed it involves the adjacent lymphatics, is a destroyer of life and is rarely cured by X-ray, excision or caustics, although in the majority of cases improvement is noted or the growth is held in check so long as treatment is persistent. This is the intractable form quite often occurring upon the lip and is microscopically the same as the less malignant. It is very rapid in growth, showing early lymphatic involvement with or without operative interference.

In the true skin-cancers (the first type) X-ray therapy is almost sure of success, the

cosmetic effect being better than from any other method of treatment.

For practical purposes the divisions of malignant lesions may be easily placed into three groups, i.e., those in the first, second or third degree of malignancy.

(1). The first degree or incipient surface cancers can be cured by physical methods, if deep by the same methods and surgery.

(2). The second degree of malignancy may be cured, and are usually benefited by either surgery On irradiation vigorously. Many inoperable cases under massive X-ray therapy may become operable, a permanent cure resulting by removal and post operative radiotherapy. In this way the lymph-channels are sclerosed, being virtually closed off and a much safer procedure than surgery primarily. In surgery all the immediate lymph channels near the tumor are opened giving an opportunity for transplantation to occur in

some other structures.

(3). The third degree of malignancy includes the superficial and deep inoperable growths which cannot be cured under any treatment, are very undesirable subjects as the prognosis can only be 100 per cent bad. Many of these cases are made more comfortable by treatment, all show improvement and later respond to no treatment.

What we believe to be the better points in technic of many of the early operators is at present being combined and in the hands of efficient, conscientious, tireless workers better results are being obtained throughout the country.

It is not my purpose to decry surgery in the least, but to present to you the best methods at present in vogue, by the most experienced workers in the larger clinics.

In the second and third degrees of malig nancy, numerous symptomatic cures are being reported where all visible and palpable malignant disease is first removed by electrothermic coagulation by the d'Arsonval current, followed, or sometimes preceded by massive doses of X-rav, by the cross-fire method in order to get Rays from as many fields of entrance as is possible.

By massive dosage we mean as much as the skin will permit, without presenting an X-ray burn, an X-ray dermatitis being permissable to get the desired results. Very few patients object to a bronzing of the skin not more marked than a sunburn in order to secure a permanent benefit, when suffering from a malignancy. By the cross-fire method the tumor is attacked from as many skin surfaces as possibly the remaining surfaces being protected by sheets of lead. In this way the central portion of the tumor receives as many times the skin area as there are different fields of entrance.

In lesions treated by electro-thermic coagulation and massive irradiation a great deal of sloughing is expected for several days following their removal. Local or general anesthesia is required according to the location, extent of involvement and the temperament of the patient to be treated.

All palpable and visible malignant diseases must be destroyed, if possible, to prevent a recurrence, in and near the margins of removal unless it is possible to prevent this recurrent tendency by heavy Roentgen therapy.

The electrode under this technic sears or closes the vessels and lymph-spaces. Where a knife or cutting instrument is used directly the opposite is true, the vessels and lymph space being opened up giving a good opportunity for marginal and metastatic recurrences to present themselves in a short time.

Reversal of the Circulation.-J. S. Horsley, Richmond, Va., and R. H. Whitehead, University Va., (Journal A. M. A., March 13, 1915), have experimentad on dogs with the operation for reversing the circulation in the lower extremity that is, attaching the cardiac end of the artery to the distal end of the vein, and the distal end of the artery to the cardiac end of the vein, which had been reported as possible in dogs by Carrel and Guthrie, but which had been considered as of little actual value by Halstead and Vaughan. They had not themselves been convinced of its therapeutic value or its justifiability, since in order to prove that it is such by giving more nutrition it must be established that the arterial blood in the reversed vein reaches the ultimate capillaries of the foot. In case it does, how is the arterial blood returned to the heart? They conclude that the operation has no legitimate piace in clinical surgery except possibly in Raynaud's disease.

THE PRESENT STATUS OF THE CANCER PROBLEM; HAVE WE THE HOPE OF A CURE?

Have you ever asked yourself, possessing the full knowledge of medical lore that you do, what way you prefer to die? Have you ever in philosophical vein reflected upon what death would possess the least terror, the least suffering, the most complete euthanasia and tried to balance upon the scales of medical knowledge, which particular blade to the scythe of Father Time you would prefer to mow you down, as the last grain of sand fell through the hour glass of Time? Perhaps not. But certainly from time to time as your experience has ripened, the prayer has been spoken audibly or inaudibly, "From a Cancer Death, Good Lord Deliver Me." Have you not dreaded the ordeal that as physician, more in the sense of Christ than medical, you were compelled by duty and that heroic purpose of medicine to watch and wait by the cancer bedside, through travail and suffering, through agony and torture, until tired Nature, as God's Command, gave way to the inevitable, to that peace at last, that "passeth all understanding?" Have you felt the slightest regret when this took place? I cannot feel that the true physician would ever deny his patient the privilege of an early demise. We may rail and condemn the use of morphine, and improperly used, this is right to do, but when face to face with that terrible Demon, who, burying his talons in the soft, tender flesh of his victim, slowly tears and tortures; then, if in your nature, kindness and sympathy prevail, on bended knee, you thank the day that gave you opium and its derivatives. Te deum Laudanum.

But this care and suffering for humanity's sake, in the line of your professional duty, is as nothing, when the grim hand and terrible talon is placed upon you or those who are near and dear to you. To wake to the terrible consequences, no matter which way you turn is something a tender soul can hardly endure. Operative work and 80 per cent. death by cancer on one side and certain, sure cancer death on the other. It is indeed the choice of the martyr. These are silent and noble heroes, who meet death in its most horrible form, not in the full possession of health, in the gallant charge with fife and drum playing, but after weeks and weeks of agony and patience. To them the World holds no brief, their greatest blessing lies in Death and to them, this cold kiss is as that of a loving bridegroom to his newly wedded bride. What refined terror, what mental agony frequently is found in people, who bring to your consulting room. the legend "cancer in my family.' Does it? Whether it does or does not, does

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