If little spots of blood are discovered on the clothing between the periods and this so-called "spotting" occurs from sweeping, stooping, defecation, etc., examination will often find an ulceration that is probably malignant. Our old time text book symptoms of pain, hemorrhage, and odor are not the diagnostic signs of early cancer, but often of late, far advanced, inoperable cancer with beginning cachexia.

We are confronted with more inoperable growths in this situation than perhaps any other, not only on account of its frequency, but on account of the misinformation of the laity. Herein lies a great opportunity for educative meas

ures.

We must not be unmindful of the possibility of cancer in other than elderly women. I once had the sad experience of three patients in adjoining rooms in the hospital at one time with inoperable cancer, all of whom were under twenty-seven years of age.

In the early stages of cancer of the cervix radical operation is very satisfactory. In common with other surgeons I have a number of cases alive and well eight, ten and twelve years after operation. This, of course, means that all cases thus fortuitously diagnosed could be rendered equally immune.

The bones are a favorite and really the most frequent location of sarcoma; moreover sarcoma is the most usual tumor of bones; carcinoma is usually metastatic. The former growths most often occur in the long bones. If a swelling of bone grows very rapidly in young persons after injury, with pain, the suspicion of sarcoma is strong. X-ray picture is helpful. Don't wait many weeks. In central sarcoma pain precedes deformity, the joint is not involved. and to move it is painless. Exercise does not cause pain, but it comes oftenest at night. Metastasis of bone tumors is very early. Amputation is, on account of delay and mistakes in diagnosis and from the horror of the deformity and disability, always a last resort. Few medical men rarely recommend it early when it could be of some value,

FIG. I. OSTEO-SARCOMA OF FEMUR IN BOY.

and fewer patients agree to it then. Unfortunately they are only too willing in the end when it is of temporary value. I recently amputated at the hip for a high osteosarcoma of the lower end of the femur (Fig. 1) that had been growing for four years, preceded by pain for two years and criminally treated for gonorrheal rheumatism at Hot Springs for sixteen months preceding the operation.

The crying urgency then is for the diagnosis of cancer in its very beginning. It will revolutionize the disheartened attitude now generally held. Formerly we did incomplete operations for advanced and hopless cancer with the result

on the professional and lay mind that is yet so dispiriting. At present we are doing extensive and complete work in delayed but yet operable cases. The results are wonderfully better, but far from being satisfactory. The technical perfection is very high. The surgery of the future will be enhanced in efficiency and beneficence as the prompt recognition of cancer in universal. Countless lives will then be preserved and mankind protected from its greatest Scourge.

CLINICAL LECTURE ON "CARCINOMA OF THE

BREAST"

IN SERVICE OF DUNCAN EVE, A.M., M.D., F.A.C.S. Professor of Surgery and Clinical Surgery, Medical Department of Vanderbilt University.

Gentlemen:

REPORTED BY DR. ROBERT R. BROWN.

We have for to-day a case of cancer of the breast, so while we are waiting for the anesthetic, we shall endeavor to place the cancer problem more clearly and forcibly before you. Especially let us consider the earlier signs presented, now commonly called pre-cancerous conditions.

First let us bear in mind that 80 to 81 per cent of all tumors of the female breast are cancerous. This leaves a larger per cent of benign neoplasms than formerly taught.

Of the benign tumors a condition of chronic cystic mastitis is foremost in occurrence and importance. Dr. Rodman speaks of this condition as abnormal involution. It is a condition of hyperplasia about the glandular structures with resultant pressure cysts. This condition is often accompanied by a clear watery straw-colored fluid exuding from the nipple. Not the bright red blood significant of capillary cystadenoma, another potential cancerous condition. Forty to sixty per cent of these cases of abnormal involution ultimately become malignant.

We would also mention "Paget's disease" here to emphasize its importance and impress upon you that we now be

lieve this condition to be primarily cancer-"Duct Cancer," and that the cutaneous involvement is secondary.

Now, what shall we do with these cases? Some say a twostage operation. In the first stage tissue is removed for microscopical diagnosis and the wound closed, at a second sitting the radical operation being done. Gentlemen, we believe this an un-surgical procedure and in the face of a possible malignancy is wantonly courting disaster. However, a modification of this procedure is now very commonly done, viz., making of frozen sections. This appeals to you, no doubt, as a sane measure, but still it is oftentimes misleading and besides can rarely be done because the pathologist cannot be had.

Operation for cancer of the breast was done as early as the third century, by grasping the breast with large pinchers and sweeping it off with a stroke of the knife, then searing raw surfaces with the cautery. In 1804 Benjamin Bell advised removal of the axillary nodes. Chas. Moore, however, in 1867 destroyed the old constitutional theory of cancer and is really the father of our present day operation. Thus the evolution of surgical advances for the removal of the breast with cancer until we have the radical operation of to-day.

The patient you notice, gentlemen, is a negro man 48 years of age, who came here six months ago with a large, freely movable tumor in his right breast. Malignancy was not suspicioned at that time and the breast proper was swiftly removed and wound closed. Microscopical examination later, however, revealed its danger, but by that time patient was about well apparently, and refused further surgery. To-day, however, he comes complaining of re

currence.

Due to length of time elapsed, other operations, etc., we are compelled at this sitting to do a radical operation. There are numerous modes or methods to pursue. In this case we shall follow the technique proposed by Prof. Rodman of Philadelphia.

The first incision starts one inch below the clavicle and one and one-quarter inches to the under side of the arm. It is five inches long and parallel with the arm. Cut down to the pectoralis major muscle, now pass the finger under muscle emerging between costal and clavicular portion. With retractors expose tendon of muscle at the same time avoiding injury to acromio-thoracic and long thoracic arteries, which run along the two pectoral muscles respectively. The tendons of both muscles being severed, we can now easily clean out the axilla. The costo-coracoid membrane is largely sacrificed, avoiding injury to the cephalic vein.

We now start dissecting from above downward and we do this you notice largely by gauze dissection, a sharp instrument being avoided in this neighborhood. The sheath and fat are removed from vessels, and the arteries and veins that supply the field are here severed between the two ligatures, thus avoiding subsequent trouble with hemorrhage. We now have the axilla clean, having worked from above downward and removed the tissues en masse. We now make a long incision from middle of first one, passing well over on to sternum and curving downward on to abdomen. A similar incision is made on lower or outer side of breast. Beginning below we remove fascia of upper portion of the right rectus muscle, then around, and as we undermine the skin we bear in mind that the cancer cells spread in a centrifugal manner from the primary focus, and through the lymphatics in fascia and sub-cutaneous connective tissue. As we complete this undermining you see we have all lymphatics blocked, thus preventing expression of cancer cells to set up secondary nodules. We now remove the breast by cutting the pectoral muscles at their origin. You will have noticed the small amount of hemorrhage during this operation, also how easily the skin flaps now come together following our extensive undermining. All oozing is arrested and the wound closed without draining, the skin being fixed firmly to chest wall by broad adhesive strips.