cancer-patients that the cancer was preceded by some traumatic or inflammatory condition, while he accepts without question any other statement that the patient may make. I began my medical career with the same prejudice. I did not believe that cancers or benign tumors were usually preceded by inflammatory changes. I was annoyed by the persistence with which patient after patient gave the history of a bruise or an abscess, then a knot or lump; then, perhaps, a period of quiescence, then a rapidly developing tumor. A case came under my observation of a bruise followed by an abscess. The abscess was evacuated and a brawny infiltration remained. In a year the brawny infiltration had disappeared, but a mass of

tumor may become malignant. It is acknowledged by nearly all authorities that this change does occasionally take place. Mr. Williams admits it, while he deprecates its importance and minimizes its frequency. We can readily understand how a fibrous growth may become sarcomatous when we remember that there is no sharp anatomical distinction between these two classes. An increase of irritation, a more rapid cellular infiltration, is all that is necessary to make the change.

With carcinoma the case is somewhat different. We must introduce a new element-the proliferating epithelial cell. In every fibrous tumor of the breast we have epithelial cells lining the glandular ducts.

connective tissue could be felt deep in the gland at the seat of abscess. A year later this tumor began to grow rapidly and became painful. In order to remove it I found it necessary to remove the whole breast, and I was much surprised to find the tumor a typical adeno-fibroma, with a typical nodule of scirrhous carcinoma in its centre. This case I reported in full in the Virginia Medical Monthly for December, 1891. There is no anatomical bar to such an occurrence. It is contraindicated by no known physiologic or pathologic law. On the contrary, it is just what we would expect to occur under the circumstances: at least, up to the point of formation of the fibrous tumor. Then why should we throw out the overwhelming mass of testimony to show that tumors, both benign and malignant, are usually preceded by inflammatory conditions?

Let us go a step further and see how a benign

Physiology teaches us that these epithelial cells are under the influence of nerves, presumably by contact with a minute axis-cylinder fibril. Golgi's method of staining has shown us that these minute nervous fibrillæ exist in great numbers where they were previously unsuspected, and that they come into close proximity, if not actual contact, with each cell. There is scarcely a doubt that we shall now be able to trace them to the epithelia contained in adenomata; but it is easy to conceive that the contraction of newly formed connective tissue or that inflammatory infiltration may destroy by pressure all such nervous connection with some of the glandular epithelial cells. We would have then a cell resembling an amoeba entirely severed from all connection with the central nervous system, free to revert to its ancestral type, free to multiply ad libitum, free to wander into new fields and infil

makes intelligible many facts that are otherwise mysterious or inexplicable. Each step in the process is known and admitted actually to occur in nature under similar circumstances. Microscopic sections apparently show these processes actually taking place. The accompanying microphotograph of an adeno-sarcoma, kindly given me by Dr. Gray, of the Army Medical Museum, seems to show an eruption of epithelial cells from a broken-down tubule that is surrounded by a mass of fibrous tissue and apparently deprived of nerve-influence.

In some cases the invaders may be few and scattered, and may be squeezed out of existence by the connective-tissue development without leaving behind a tangible trace. We may thus account for the source of continued irritation and growth in some apparently benign growths. Indeed, the possibilities are almost unlimited. Once get a few epithelial cells separated by inflammatory infiltration, or connective-tissue development, from the general nervous system, and the varying fortunes of war between them and the leucocytes, influenced as they are by the relative activities and numbers of cells on either side, by the vascular supply and consequent reinforcement of leucocytes, by the vigor and resistance of the fixed cells of the tissue, and by many other remote and direct conditions, give us data sufficient to account for all the phenomena observed in tumors of the breast. It would take up too much time and be out of place here to attempt to show all the many ways in which the scale may be turned in favor of one or the other of the opposing armies; but we can readily understand how, if the invading archiblasts increase and travel a little too fast for the leucocytes to surround and imprison them, we will have exactly the conditions necessary for the formation of scirrhus : acini here and there, filled with cells, and a continual escape of a few scattering invaders into surrounding tissue, there to repeat the process or to be taken up by lymphatics and carried to distant parts, to start a new focus of infection. On the other hand, if the leucocytes are of sufficient activity, they will succeed in either destroying the invaders or holding them in check, and the growth will appear benign, or may even remain stationary for long periods; but if such a condition of affairs exists, there will always be danger of an irruption.

The evidence in favor of such a theory is considerable. In the first place, there is in it no contradiction of any known anatomic condition or physiologic law. On the contrary, it is just what we would expect under the circumstances from our knowledge of biologic processes in general. It

Patients with malignant tumors almost invariably give a history of previous inflammatory affections, although this evidence has been persistently and systematically ignored. Malignant tumors are more frequent in organs most subject to inflammatory and traumatic irritation. Indeed, it would seem that they never occur in normal healthy tissue, but always in some previously infiltrated tissue.

In view of these facts, it seems more than probable to me that malignant growths usually originate in some previous inflammatory condition or fibrous tumor. However this may be, when we come to deal practically with mammary neoplasms we must admit that in their incipiency it is impossible to say whether they are malignant or benign, and that, even when well developed, apparently benign tumors sometimes suddenly take on the characters of malignancy. We must also agree that it is only in the very early stages of carcinoma that we can expect a large percentage of cures from removal of the growth; but, of course, all inflammations do not necessarily produce tumors of any kind. To produce a malignant tumor we must have prolonged irritation, and finally a separation of some epithelia from central nervous influence, and not only so, but we need perhaps a certain amount of inactivity or debility of leucocytes. This may be hereditary and account for the hereditary tendencies to cancer, or may be acquired in a variety of ways. The majority of surgeons to-day agree with Heidenhain that carcinoma is at first a local disease, and that recurrences are due to incomplete ablation. complete ablation. I wish to emphasize the fact that it is only very early in its development that we can make a complete removal. The very moment that the usual signs of malignancy begin to show the chances for complete removal become greatly lessened. The fact that some cures result from late operations does not in any way invalidate this stateIt is the general belief, borne out by the experience of others and by my own, that operations properly done at a sufficiently early period will almost invariably prove successful. In 1890 and 1891, and the early part of 1892, I operated upon four cases at a very early period, before there was any fixation, enlargement of glands, or other

ment.

squeezing. All cases should be examined microscopically after removal and recorded for future statistics. I imagine that many surgeons would be greatly surprised if they could see sections from all the small tumors they have thrown away without examination. There would be a vastly greater per cent. of malignant growths among them than most of us suppose. I would also urge that these microscopic examinations be made with great care by a competent man, and that he be given the whole tumor to examine, for it often happens that tumors present very different appearances in different parts of the growth.

There is little or no difference of opinion as to what should be done for plainly malignant growths. Thorough removal is the only hope, and the present operation of removing the pectoral muscles and axillary fat and glands is perhaps the best that we can do; but there are two very distinctly different ways of performing this operation. I shall briefly describe what I believe to be the important points to be observed. Begin with the axilla, so as not to force any cancerous material or cells from the axilla into the deeper tissues while manipulating the breast. Cut down to the axillary vessels, and tie all branches passing into the tissue to be removed. Remove the axillary contents in one mass by clean cutting with a sharp knife and without picking or pulling. In this way the axilla can be thoroughly cleaned in one-tenth the time and with less danger and hemorrhage, and less danger of squeezing infecting cells into the tissues that are left. Extend the incisions down over the tumor so as to enclose and remove all diseased skin and a considerable margin, at least an inch, of healthy skin. Turn back the healthy skin on each side so as to expose all tissue to be removed, and then remove it in one piece by clean cutting.

The

I would like also to say a word against any operation after a well-marked cancerous cachexia has appeared or secondary growths have begun in internal organs, unless it be clearly understood by all concerned that it is only for palliative purposes. undertaking of hopeless operations, as a rule, only brings surgery into discredit, and deters others from undergoing proper operations at the proper time. Patients with tumors have inquiring dispositions and communicative friends. They hear of every failure in the city, and are often in this way persuaded to put off an operation until forced to it by suffering, when it is too late.

THE school census which was ordered to be taken by the police department in New York City has been completed in all but eighteen districts. The reports so far received show that 399,314 children have been enumerated.

CURETTAGE IN THE TREATMENT OF TRACHOMA.

BY A. N. STROUSE, M.D.,

OPHTHALMOLOGIST TO MT. SINAI HOSPITAL DISPENSARY; CONSULTING OPHTHALMOLOGIST TO BETH ISRAEL HOSPITAL; OCULIST AND

AURIST TO ORPHAN ASYLUM OF ST. VINCENT DE PAUL.

In view of the frequency and obstinacy of this affection, a large number of methods of treatment have been suggested from time to time, many of which, after a brief period of trial, have been relegated to obscurity. It is my intention here to discuss briefly those procedures which are most extensively employed at the present time, and then to describe a method which in my hands has proved superior to all others, and has practically taken their place in my practice. My remarks apply chiefly to the severer forms of trachoma, although

it must be remembered that even in the milder

varieties recourse must now and then be had to

radical measures.

Probably the method which still enjoys the widest popularity among ophthalmologists is the application of such caustics as the solid stick of sulphate of copper or pure alum. This serves a useful purpose in milder or more recent cases, but after it has been given a fair trial it is often found that, after a certain amount of apparent improvement has been effected, the disease remains stationary, and in that event more radical measures are demanded. At any rate, even in favorable cases, the treatment by caustics is usually protracted, and requires a considerable degree of perseverance on the part of the physician and his patient, while it is often quite painful, especially at the commencement.

Among the operative procedures the one most in vogue is expression. The cruder way of practising this procedure consists in squeezing out the contents of the follicles by means of the finger-nail, or the copper stick when applying it. This, however, the various forms of forceps devised for this puris less thorough and effective than the use of one of pose, among which the roller-forceps of Prof. Knapp is the most applicable. Expression has certain tract from its value, chief among which are the foldisadvantages which, in my opinion, greatly defollicles produces extensive laceration of the delilowing: The forcible expulsion of the trachomacate conjunctival tissues. The deeper-seated follicles to eradicate the disease thoroughly, especially if, as are evacuated with difficulty. The pressure required frequently happens, the roller of the instrument does not rotate, but glides over the surface, is so considerable that the underlying tissues are subthe affected part. In consequence of this the rejected to severe contusion, which retards healing of production of normal epithelium, after expression, is impaired, and an excessive amount of cicatricial tissue produced; moreover, certain parts of the con

junctival sac cannot readily be reached with the roller-forceps. Aside from these objectionable features, the pain attending this method is so marked as to necessitate the employment of general anæsthesia.

Among operative procedures in the treatment of trachoma, grattage, next to expression, is probably most often resorted to at the present day. As commonly practised, this operation consists essentially of scarification of the conjunctiva with an instrument provided with a number of sharp blades, followed by rubbing with a stiff brush moistened with a strong solution of bichloride of mercury (usually of the strength of 1 : 500). The brushings are repeated once daily for a week, at the end of which time a cure is sometimes effected. An extensive trial of

this method has led the majority of ophthalmic surgeons to discard its use, as it has been demonstrated that its disadvantages more than counterbalance whatever benefits may be derived from it. Extensive cicatrization is apt to result in consequence of the numerous and necessarily deep incisions, producing contraction of the conjunctiva of the lid, and entropion. Very little of the normal conjunctival membrane is visible after the operation, its place being taken by a cicatricial mass. Equally common sequelæ are cicatricial bands between opposing surfaces of the ocular and palpebral conjunctiva. This method, like expression, requires general anæsthesia, as it is attended with so much pain that the local application of cocaine is unavailable.

Excision of the retrotarsal fold may be dismissed with a few words, as it is an incomplete and unsat

isfactory method, and is but rarely employed. The same objections apply to puncture of the trachomafollicles with the galvanocautery-point, as well as to abscission and evacuation of the follicles with the needle, and similar procedures.

Recognizing the uncertain results derived from the methods above described, I was led about five years ago to devise a plan of procedure which in my hands has proved its superiority over all others with which I am acquainted.

This method consists essentially in curettage of the trachomatous tissue with a sharp curette shaped like a cataract-spoon. The cutting-edge of the instrument measures about 1.5 mm. in width, and is ground sharp in its entire circumference, while the back of the curette is flat and smooth. The shank should be elastic and yet sufficiently firm to withstand ordinary pressure, and is attached to a metal handle, so that the instrument can be properly sterilized. (See illustration.)

1 It was suggested to me that the spoon be fenestrated, but this is not advisable, for if the back of the instrument should come in contact with the cornea it would undoubtedly do more or less damage. The curette is made for me by F. G. Schmidt, N. Y.

After thoroughly cocainizing the conjunctiva the lower lid is everted and rapidly scraped over its entire extent. Then the upper lid is everted and held between the thumb and finger of one hand, while the curette is passed up into the fornix, and this part of the conjunctival sac scraped, care being taken to penetrate all the folds. The everted portion of the lid is treated last. During the entire procedure, which occupies but a few minutes, an assistant mops the lids with absorbent cotton dipped in an antiseptic solution (a saturated solution of boric acid or a bichloride solution 1 : 10,000).

When the hemorrhage, which is only slight, has ceased, we see a surface which is smooth except for a number of depressions or small cavities. These are deep or shallow, according to the seat of the trachoma-bodies contained therein. The surfaces are now thoroughly washed and touched with a 2 per cent. solution of nitrate of silver. This is really the only part of the operation that elicits any pain, and by the instillation of a few additional drops of cocaine even this may be entirely avoided.

The after-treatment consists in the application of iced pads for one-half to one hour, and by the end of this time any reaction will be found to have subsided. That the reaction, however, is inconsiderable is shown by the fact that ignorant dispensary patients, who frequently neglect to obey instructions, rarely complain of any inconvenience following the operation. The patients are ordered to return every other day, when they are again treated with the silver solution. The latter has given me better results than the 1 : 500 bichloride solution, which I first employed when it was recommended by the advocates of grattage. After the eighth to tenth day, when the epithelium is completely regenerated, and the cavities left by the trachoma-follicles have completely granulated and are flush with the surface of the conjunctiva, I sometimes discontinue the silver application and resort to the copper stick. This treatment is continued for the following week or two, at which time the patients are usually completely cured. palpebral conjunctiva is now smooth, the thickening and induration of the lids have markedly subsided, and pannus, if it has existed, shows a tendency to subside without further treatment, or even may have disappeared completely.

The

If at the end of four weeks the cure is not complete, the curetting should be repeated. The second operation is even of a more simple character than the first, as it is not necessary to curette so deeply and extensively, and naturally the reaction is even slighter than before.