on the parts of the body most accessible to inspection and examination. We must, therefore, look upon all abnormalities such as warts, moles, keratosis, chronic ulcers, etc., as potentially liable to malignant degeneration.

In cancer of the lip only one-fourth come for operation in the first six months. We should never let such an ulcer go over one month without cure, or excision, with microscopical examination. Above all things we should not treat it empirically as syphilis. If a so-called ulcer is allowed to go from three to six months, it regularly extends to the glands of the neck. Under those circumstances only onehalf can be cured by the most extensive operation-namely, the dissection and removal of all the glands from one or both sides of the neck with wide removal of the lower lip. If, however, the true character of the lesion can be determined early, a wide "V-shaped" excision is curative.

Nearly all epithelioma of the skin can be cured by the actual cautery under anaesthesia in the early stages, provided it has not extended to the neighboring lymph glands. While radium and the X-ray have achieved their most brilliant cures in superficial epitheliomata, we must not lose sight of the efficiency of the actual cautery in these cases. Properly used it is one of the most satisfactory agents at our command.

Illustrative of the role that chronic irritation plays is the established fact that cancer of the gall bladder rarely, if ever, occurs in the absence of gall stones. Three percent of all patients who are operated on for gall stones have cancer of the gall bladder. What does it profit a person, therefore, to carry around gall stones that can be removed under proper conditions with a mortality of less than one-half of one percent; whereas, the simple carrying of the stones subjects a patient to six times that risk from cancer alone.

Likewise it has been shown that one-half of all the epithelial neoplasms in the kidney are followed or associated with stone in the kidney.

Why should we teach women higher mathematics and

give her suffrage and neglect to teach her that any lump in the breast in a woman over forty is or will become cancerous in thirteen instances out of fourteen? Collectively in all ages only one-half of the tumors are benign, and as only one-third of the cancers of the breast were originally benign, why should we leave them? Who can tell which tumor is Why remove a fibroid or

or will become malignant? cystic tumor from other sites in the body and let the breast alone? We can tell if the tumor is frankly cancerous, but we can not tell if it is not. It is a stirring experience to find one out of every four cases of cancer of the breast, when first seen by the surgeon, is hopeless. One-half of the delay is from the patient's fear or ignorance. The other half is caused by the delay in our profession. "Observing" these growths is a dangerous pastime. The old advice to "not trouble the tumor until the tumor troubles you" is a murderous sophistry. We must not wait for pain in the tumor. It may be too late. Puckering of the nipple, axillary and cervical metastasis are often waited for to confirm the diagnosis, more is the pity. When the diagnosis is thus confirmed we have waited for the very symptoms which then well nigh contraindicate operation so far as the permanence of cure is concerned.

Women should be taught that lumps in the breast at the start, if removed properly, give 85 to 100% of cure, depending upon whether it is or is not cancer. If it is left alone it gives from 85 to 100% of deaths, depending upon whether or not it is cancer. No growth should be removed, however, that is not carefully studied by a competent pathologist.

Inasmuch as inadequate and meddlesome operations upon a genuine malignant neoplasm is prone to disseminate the growth, we must seriously consider the wisdom of the radical operation in suspected cases without the halfway measure of partial removal, to be followed even in a short time. by the so-called radical, or may be then too late removal. As a matter of fact the elaborate removal of the breast by

the Halstead or Rodman method has a mortality of only one-half of one percent in the hands of an expert with all of our delay; the ignorance of the laity and other handicaps, nearly one-third of the cancers of the breast operated on, good, bad and indifferent, are alive and well after five years. This can be doubled by early diagnosis and insistence of wise and effective surgery.

Considering that the stomach harbors two-thirds of all the cancers of the gastro-intestinal tract, should we not employ a searching scrutiny in all cases of chronic dyspepsia to the end that those which are suspicious should be studied unremittingly to show cause why it is not cancer. If after thirty-five one man in every seven dies of cancer, and if the stomach causes one-third, it means that one man in every twenty-seven who reaches and passes that age is going to die with it, and yet but seldom is a diagnosis made early. Even when a surgical diagnosis is made only onethird can after exploration have the radical operation done.

It has been shown that 72% of cancer of the stomach that have been removed developed upon a chronic ulcer. Why "cure" a chronic ulcer over and over again. Should it not be excised like an indolent ulcer elsewhere? When they come to operation they have a history on an average of twelve years of soreness, and stomach trouble with many so-called cures. When a man past middle life has pain after eating that comes with considerable regularity at a rather definite time after food, that is associated with belching and occasional vomiting, investigate him closely. If it occurs in spells and finally he has a spell that is more prolonged than the others and is not relieved by the usual remedies, especially if he is losing weight and has a low percent of acid in the stomach, suspect cancer. If a man previously well should suddenly develop gastric symptoms without apparent cause, unrelieved in a reasonable time, suspect cancer. Stomach tests are helpful. The most important is whether or not there is retention of food. Obstruction with retention of food from eight to ten hours

is usually surgical and probably cancer. This test is very simple and should not be neglected any more than we would neglect to catheterize a man with residual urine in suspected prostatic obstruction. X-ray examinations are also of benefit. Do not wait for coffee ground vomit, glands at the root of the neck, on the left side, and cachexia. Tumor with obstruction and resulting vomit often tells its tale. When in doubt we would do well to make an exploratory incision. Curiously enough when the facts are presented to the patient they are usually willing to it, but we as medical men are prone to wait until all the returns are in before we can get our consent. If there is a hard metastatic mass in the plevis or a button-like protrusion of the umbilicus and especially if there is ascites, the time for surgical cure has departed. When the tumor is in the left side and fixed, the prognosis is bad, but a movable tumor in the pyloric end of the stomach should make the diagnosis. While only one-half of the cases at best can be diagnosed sufficiently early to do anything for them, let us diagnose that half. Of those who have the radical operation one-fourth live without recurrence for five years. That is an exceptional showing. One of my own cases is alive and well at the end of six years, after the removal of threefourths of the stomach. The mortality in resection of the stomach is only 10% on the average and 5% in the hands of the very expert.

It is interesting that although ulcer occurs more frequently in the duodenum, cancerous degeneration there is rare. It is said the pancreatic secretion is inimical to cancer. At any rate it is extremely rare in the small intestine. Mayo only had fourteen cases in fifteen years of which but five were operated on. I have reported a case of resection of forty-two inches of the small intestine for sarcoma in a boy of nine, who is alive and well at the end of three years.

In the last year I have had three cases of intestinal obstruction from a napkin ring carcinoma of the descend

ing colon. They all occured in women. One had very competent medical examination three months before the complete obstruction, but she was fleshy, the growth was very small and was too high for proctoscopic detection. A skigraph of a bismuth enema might have shown the constriction and operation would probably have resulted in cure. We were able to remove the growth by the Mikulicz method and colostomy at the time of the obstruction, but unfortunately there was already metastasis in the liver at that time.

Cancer of the rectum, that is so frequent, is probably overlooked more than in any other situation, because of the various minor rectal symptoms. Blood which elsewhere is always a serious indication is carelessly dismissed as probably coming from piles. In fact, fifteen percent of my cases of cancer of the rectum coming for operation have not only been diagnosed, but previously operated upon erroneously for piles. Failure to examine thoroughly in this situation is the cause of most of our mistakes. In one of my cases the patient had received treatment for over two years, but had never been examined. Ulceration of the rectum should be assiduously watched, but never treated without the suspicion of malignancy.

In spite of the anatomical and physiological drawbacks, as well as the reasons for delayed diagnosis of cancer in this region, the radical operation has yielded 20% of recoveries at the end of four years.

The uterus is the organ most neglected in the early recognition of cancer. The irregular, atypical bleedings are mistaken for the change of life. Patients think that this is regular and neglect to consult the physician. More women die of cancer of the uterus each year than men were killed in the Franco-Prussian war. If it were possible to have every woman under competent medical supervision during the climateric, more lives would be saved by discovering the existence of cancer and the institution of radical treatment than is saved by quarantine or vaccination.