This book is a digest of the literature of ophthalmology, with index of publications for the year 1903. The choice of the year on ophthalmology. The cuts are excellent and many of them entirely new and of special interest; for instance, those illustrating the new operations for cataract. As the busy oculist needs a reliable annual summary, the book fulfills this need most beautifully. Both author and publisher have done themselves credit in the production of this book, which has splendid paper, print, and binding. W. J. LEACH. BOOKS RECEIVED. The Universal Method of Clinical Writing by Means of Clinography.— By Prof. V. Pensuti, Chief Physician in the Hospitals of Rome; ex-Chief Assistant of Medical Clinic; Professor of Medical Pathology in the University of Rome. Reprinted from the Journal of the American Medical Association, May 20, 1905. Press of the American Medical Association, 103 Dearborn Avenue, Chicago. Personal Views on the Management of Typhoid Fever.-By Edw. C. Register, M. D., Charlotte, N. C.; President of the North Carolina Medical Society; President of the Councillors of the Medical Society of North Carolina; exPresident of the Board of Medical Examiners of North Carolina; ex-President of the Charlotte Medical Society; Editor of the Charlotte Medical Journal. Reprint from the Charlotte Medical Journal, June, 1905. Mouth-Breathing.-By W. H. Fitzgerald, M. D., Laryngologist to St. Francis Hospital, Hartfort, Conn.; Member Hartford Medical Society, Boston City Hospital Alumni Association; Associate Fellow New York Academy of Medicine, etc. Published by the author. Respiratory Affections; Symptoms and Their Treatment.-By Justin Herold, A. M., M. D., New York. Reprint from the American Therapist, May, 1904. A System for the Surgical Correction of Harelip and Cleft Palate. - Geo. V. I. Brown, A. B., D. D. S., M. D., C. M., Milwaukee, Wis. Reprinted from the Journal of the American Medical Association, March 18, 1905. Press of American Medical Association, 103 Dearborn Avenue, Chicago. How the General Practitioner Should Treat Gonorrhea. - By Ferd. C. Valen tine, M. D., and Terry M. Townsend, M. D., New York City. Reprinted from the Journal of the American Medical Association, October 29, 1904. Press of American Medical Association, 103 Dearborn Avenue, Chicago. Some Forensic Problems Concerning Venereal Diseases.-By Ferd. C. Valentine, M. D., and Terry M. Townsend, M. D., New York City. Reprinted from Albany Law Journal of April, 1905. The Argus Co., Albany. "Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downwright facts at present more than anything else." -RUSKIN. Original Communications. I SOME REMARKS ON THE TREATMENT OF CANCER.* BY J. SHELTON HORSLEY, M. D., Professor of Principles of Surgesy in the Medical College of Virginia; Surgeon to Memorial Hospital. N accepting the kind invitation to read a paper before the Southwest Virginia Medical Society, it has given me no little concern to select a subject that might be interesting and practical, both to the general practitioner as a medical man and to those who are particularly interested in surgery. The domains of medicine and surgery often meet on common ground, but in no instance can so much be gained by close association between practitioners of medicine and surgery as by their cooperation in the treatment of malignant growths, particularly those known under the general term of cancer, for here an early diagnosis is absolutely essential to successful treatment. It is true that, so far as the origin of cancer is concerned, we have but little more knowledge now than was in the possession of our forefathers. Still it cannot be said that no progress has been made in the study of cancer. No one can explain why a grain of corn sprouts and grows, and, in fact, all vital phenomena are surrounded by a cloud of impenetrable mystery. Though no one can explain the origin of life, a person who studies the habitat, the method of growth, and the conditions favorable to life of the grain of corn is certainly more fitted to cultivate this cereal successfully than one who is ignorant of such things, even though both are equally ignorant of the original cause of growth. So in cancer, one who studies the tumor as a whole, and the cells as units * Read before the Southwest Virginia Medical Society, at Pulaski, July 5, 1905. composing it, and notes the rapidity of growth, the various kinds of cancer, and the relative malignancy of some as compared with the almost benign course of others, is certainly much better fitted to deal with these neoplasms intelligently than is an individual who ignores such sources of knowledge. As is well known, cancer is supposed to be a tumor made of epithelial cells. The classification of the various forms is by no means a satisfactory one, for the term "epithelioma" can, strictly speaking, be applied to any form of cancer. For the purpose of these remarks, we may divide cancers generally into skin cancers, meaning those derived from the epithelium of the skin or adjacent mucous membrane, and another class including adenoid and alveola cancers, being forms that are derived from either columnar or secreting epithelium and whose origin is not. originally connected with the skin. Taking the skin cancers, which are commonly called "epitheliomas," we find they differ very greatly in malignancy. Some forms that are often about the upper portion of the face seem to remain the same for years, and are so slightly malignant that their progress may not be perceptible. It must be remembered, however, that not infrequently these forms take on vigorous growth, though the majority of them do not give serious trouble. They sometimes appear as an open sore, or ulcer, and sometimes as a wartlike process. The more benign forms are usually small ulcers with a hard margin and a shallow, indolent surface. This is the form that can be easily cured by paste. The ease with which these are cured is almost unfortunate, as it permits many sufferers to become the victims of unscrupulous charlatans. These patients, after being advised of the nature of the growth by some intelligent physician, and after exclaiming in no uncertain terms upon the horrors of the knife, at once repair to the advertising quack, who puts on a paste and often cures the patient. The patient at once becomes a walking advertisement for his saviour, and a monument of everlasting damnation to the physician who first told him of his trouble and advised him to have it removed with a knife. Sometimes, however, the paste does not cure, but merely incites a sleeping growth to greater activity. Some of the most difficult cases of cancer that I have ever had to operate upon were those that originated as small, almost harmless skin cancers that could have easily been cured by a slight operation under cocaine, but, having been treated by the advertising quack with paste, the growth took on greater activity and became very extensive. One patient that I recall had a small ulcer about the size of a pea near the outer corner of the eye. The paste was applied to this, and after recurrence set in another paste was applied. The eye being eventually involved, the patient finally consulted me. It was necessary to excise the whole eyeball with the adjacent portion of the temporal molar regions in order to effect a cure. I do not mean to be dogmatic in these matters, and I think that a surgeon who sticks to one method as being the only one practicable in all cases must necessarily sooner or later come to grief in some of these cases. I have sometimes used the paste called "Marsdens Paste" in growths of the character above alluded to. This consists of one part of arsenious acid and two parts of gum arabic. These are rubbed together and kept in a dry state. When about to be applied, a sufficient amount of the powder is mixed with a watery 10 per cent. solution of cocaine until it attains the consistency of cottage cheese. This is applied to the cancer and left on from three to eight hours. It is then taken off and the raw surface washed with some weak antiseptic solution. At first but little change can be seen, but in two or three days evidence of a slough formation will appear, which in ten days or two weeks will come off, leaving a comparatively healthy raw surface. I do not wish to recommend the routine use of such a paste, though in mild cases of skin cancer on the upper part of the face the employment of this is justifiable. This character' of growth is very much more easily cured by the use of the X-ray, and the scar left by such treatment is less conspicuous than that left by the paste. While mild cases of the upper part of the face may be subjected to the treatment by paste, or, better still, by the X-ray, that form which occurs on the mucous membrane or at the junction of the mucous membrane with the skin should never be submitted to any other treatment than excision by the knife. To cure cancer we try to get rid of all cancer cells, and in all forms the safest and surest method is the intelligent use of the knife, as compared with the unsatisfactory and dirty process which frequently follows the separating of the slough as a result of the paste. We know this much about the nature of cancer, that whatever may be its cause, whether it comes from a parasite or from an embryonal cell, it is always capable in the late stages of producing a similar form of cancer elsewhere in the body. This formation of metastases is characteristic of malignant growths, and means that the infective matter from the cancer lodges in a healthy portion of the patient's body and thrives, reproducing a tumor similar to that from which the infective matter originally came. This fact, which is so well known, is too frequently ignored in the practical treatment of cancer. Cancer extends in two ways. First, by continuity and contiguity of tissue, in which case the line of travel of cancer is infiltrated by the cancer cells, and, secondly, by the blood or lymph. In this latter instance, the infective cells are transported along the lymphatics or blood vessels, more frequently the former, until they strike a place of lodgThe lymphatics or the blood vessels which transport these cells may, however, be unaffected. In this way we may operate upon a cancer of the face and at the same time remove glands which have become involved beneath the jaw without necessarily making a continuous incision from the growth to the glands, as the lymphatics which have transported the cells have merely served as common carriers. When the cancerous process has extended by continuity or contiguity of tissue, the cancer cells are found at all intermediate points between the most recent outgrowth and the original tumor. The practical application of this point is that whenever a cancer is removed, the tissue involved should not be cut through if it is possible to avoid it, but removed in a mass, for, if the infected tissue is cut through, some of these cells are most liable to be spilled into the wound, and the surgeon will in this way implant cancer cells into the tissue that was previously healthy and reproduce the cancer as surely as if the infection had been carried by the lymphatics. In operating upon cancers of the breast, for instance, if it is the intention of the surgeon to remove the pectoral muscles and the contents of the axilla, it must be because he believes these tissues to be infected with cancer. If the pectoral muscles are infected, it is probably by contiguity of tissue; so if the breast is first cut off and then the pectoral muscles, the surgeon has cut through the cancerous tissue, even though it may be imperceptible to the naked eye, and has almost surely spilled some cancer cells in the wound that he himself has made. However, if the muscles and the mammary gland are taken out in one mass along with the axillary contents, there can be no chance of such autoinfection. In removing cancers at any other portion of the body, this principle should always be borne in mind and applied whenever it is possible. It is not in the scope of this paper to more than mention the internal forms of cancer. Unquestionably the prognosis of cancer of the stomach is rendered much better by early operation than it has ever been before. The early operation cannot be undertaken unless such cases are sent to the surgeon when they are merely suspected, for when a tumor has formed and the diagnosis is plain, it is usually too late for radical operative procedures. When cancers are located in such positions that the adjoining tissue can be extensively excised, even though they have progressed to an advanced stage, operation may be undertaken with some prospect of cure. Very few cancers of the breast may be considered inoperable, because of the anatomical possibility of removing all adjacent tissues. The most hopeless form for surgical treatment appears to be carcinoma of the cervix uteri. Although extensive operations have been planned and performed, I do not know of any large series of cases in which the eventual result of such procedures has been even approximately satisfactory. Such growths are of considerable malignancy, and it seems useless to make wide dissections of the lymphatics and the broad ligaments when the rectum and bladder, which actually impinge upon the growths, are left intact. As a matter of fact, the recurrence after such operations is, as a rule, not along the track of the lymphatics, but in the scar and vault or posterior wall of the vagina, immediately adjoining the area that has been operated upon. An operation that has |