dies first, and if they failed, then to try electricity or surgical procedure.

Dr. Kortright: Will Dr. Shoop inform us of the indications for electricity?

Dr. Shoop: That must be determined by experience. I have not classified the cases in such a way as to form a workingguide.

Dr. Chase: I would like to raise one question, which perhaps the reader or Dr. McNaughton will answer. How much risk there is in the use of electricity in the treatment of these cases provided there are pus accumulations in the tube or pelvic cavity; whether they deem it safe and wise treatment unless they can, by bimanual palpation, or other methods, determine the absence of pus accumulations in the pelvic cavity. I would like to know how they regard the use of electricity under those conditions-whether it is safe or not?

Dr. Gordon: In answer to the question asked by Dr. Chase, I would state that I have never treated a patient with electricity that had pus in her tubes, to my knowledge, and I have never heard of any accident following the use of electricity in such

cases.

Dr. McNaughton: I should say you would rarely be called upon to treat a case of that class. They are not likely to have uterine dysmenorrhea in pyosalpinx; that the dysmenorrhea which might occur under those circumstances would be more ovarian, so called, and I do not believe electricity would do very much good. I do not know that it would do any harm.

There is one point, Mr. President; I should like to state that I believe if a young girl is suffering from dysmenorrhea, and it continues, that the physician should make a diagnosis of that case. If it is due to flexion it should be discovered early and corrected, if possible, and in that way save future trouble. I believe we make a mistake on account of the delicacy, etc., in not making a diagnosis of these cases. It should be made in some way. If it can be done through the rectum, well and good, but if not, an anesthetic should be given and a diagnosis made. It is not wise to allow her to go on years and years with an upset nervous system, interfering with the work she may be called upon to do. If she has got dysmenorrhea commencing, due to flexion, it is wrong to allow it to go on without attempting to correct it, and I believe an examination should be made.

Dr. L. G. Baldwin: I agree with what Dr. McNaughton has

said.

The danger of examining young girls or unmarried women is overdrawn and overestimated. If a girl is sick enough to go to a doctor, that doctor should have the privilege of finding out what is the matter with her, and he should not guess at it. I have never had trouble to get them to submit, for if they are suffering they will do anything to get relief. I find if you go

right about it, as you would examine the throat, or chest, or arm, or anything else, they do not think anything about it. But if you give them a lot of preparatory treatment and say, "I hate to examine you—you had better bring your mother," and so on, you get them thinking there is something improper about it; but if you go right at it and examine, as a matter of course, they are perfectly willing to submit to it.

In regard to the question he raised, if you find a flexion it should be cured

Dr. McNaughton: I said you could treat it.

Dr. Baldwin: You can treat them, certainly, but to give relief, I take it in this discussion, anteflexions are meant more than retroflexions, and in my experience they are hard to cure.

Dr. McNaughton: For the very reason that they are postponed too long. If we got them early enough we might do more for them.

The President: (Dr. Matheson) I would like to inquire if any. gentleman here has had much experience in making examinations through the rectum.

Dr. L. G. Baldwin: I can say for myself that I have never been able to make out anything except gross pathological conditions through the rectum. Only in one case, and that quite recently, in locating a collection of pus high up on the right side, have I ever been able to gain any positive knowledge by examination through the rectum. Sometimes I have been able to say there was no serious disease, but I seldom get any information that is of value to me in making a diagnosis that was not more easily obtained through the vagina.

Dr. McNaughton: My experience is different, Mr. President. With the patient under ether, your fingers in the rectum, the rectovaginal partition being so thin, I think you ought to make almost as correct a diagnosis in that way as in the vagina itself, particularly if you have your patient anesthetized. I can diagnose flexions through the rectum, and have done it.

Dr. Matheson: When this method is practicable it should be adopted in the examination of virgins. It seems to me unnecessary

in the majority of cases to use an anesthetic in examining for the cause or causes producing dysmenorrhea.

Dr. Chase: I am quite in sympathy with what Dr. McNaughton says regarding the method of making examination. Now, in so far as the facts may be obtained concerning the condition of a woman's pelvis, without instruments-and certainly if one must confine himself to one or the other, he will always use the finger in preference to instrument-there are two conditions which cause trouble. One is the voluntary or involuntary resistance of the patient, and the other is the thickness of the abdominal walls. Now, if you can overcome this resistance, whether it is intentional or otherwise, you put your patient under the most favorable condition for ascertaining in what state the abdominal organs are, and if the woman is not fleshy or the abdominal walls are not thick, I think, with the finger in the rectum, and the abdominal walls thoroughly relaxed and bladder empty, you can ascertain a great deal, but if you attempt that without an anesthetic, unless it is a woman who has control of herself in a way that she thoroughly realizes, the results will be thoroughly unsatisfactory. There is no reason in the nature of things why there should be so much difference between the rectum and vagina, because, as Dr. McNaughton has stated, there is only the thickness of the posterior vaginal wall, and when the muscular structures are relaxed you can tell pretty well what is between the ends of your finger and the hand outside.

Dr. Maddren: I take it, Mr. President, that your question applied to those who are not given an anesthetic. I think we may also presume that it may be a first examination, and you would meet with the resistance the gentlemen have spoken of. It is difficult to find out very much without an anesthetic, because of the resistance.

I would like to ask Dr. McNaughton if generally he is satisfied with his rectal examination, and does not make a vaginal examination? That, I think, would be a test of the efficacy of the procedure.

Dr. McNaughton: I do not know, doctor; I prefer the vaginal route. I did make such an examination the other day. I made out an anteflexed uterus. Of course it is easy enough to make out a retroflexion. The anteflexion was outlined without an anesthetic, but it was a favorable case, with very little tissue between my fingers. I could almost have done it without a rectal examination.

Dr. Maddren: I have tried to do without an anesthetic, and generally ended in making a vaginal examination or resorting to the anesthetic in order to make a diagnosis.

Dr. Gordon: There is very little to be said in closing except to thank the gentlemen who have discussed the paper.

In regard to the treatment of young girls I believe that local treatment should be the last resort. One case I had under obser

vation three years. She married and then I began the electrical treatment. But still I believe that if a young girl is suffering so that she requires opiates, and opiates are the only thing that will give relief, we are justified in using electricity to save her from becoming an opium fiend.

In regard to rectal examinations, I do not know what the experience of others has been, but without an anesthetic I find greater reluctance on the part of the patient, and more disgust from the rectal examination than from the vaginal.

CARCINOMA OF THE BREAST.

BY GEORGE RYERSON FOWLER, M. D.,

Professor of Surgery in the New York Polyclinic, Surgeon to the Methodist Episcopal Hospital, and to the Brooklyn Hospital, Brooklyn, N. Y.

A Clinical Lecture delivered at the New York Polyclinic.

The subject of our lecture this morning will be illustrated by a woman aged forty-four, who comes to us with the following history: Her family history relating to the occurrence of neoplasms is negative. Her personal history states that she is married, has born five children, all of whom suckled both breasts alike. She has suffered from acute articular rheumatism. She is not sure concerning the occurrence of cracked or fissured nipple in this breast. She had a "broken breast" (acute suppurative mastitis) upon the right side while nursing one of her earlier children. The history obtained from her concerning her present trouble includes a statement that for a number of years she had thought that the breast affected, the right, was somewhat larger than the left, and that two years ago she received a blow upon this same breast. It was within two months of the reception of the blow that she first noticed a tumor of the breast. This has increased rapidly in size until it has assumed its present proportions. More or less pain has accompanied the development of the growth, the pain

being radiating and stabbing in character.

She has not decreased markedly in weight, but has lost strength during the past few months.

Inspection.-Examination reveals the following: The breast is half again as large as that of the other side. The nipple is retracted and the skin is thickened so as to present a peculiar goose-flesh appearance. All the structures of the skin of the affected breast

FIG 1.-Lines of incision. The dotted line shows the vertical incision occasionally employed.

have undergone hypertrophic changes, and the latter appear to the naked eye very much as the skin of the sound side would appear under a magnifying-glass of low power.

Palpation. The breast is infiltrated to a moderate extent in all its structures. In the upper and outer quadrant there is a distinct mass, easily distinguished from the remainder of the gland. The breast moves readily upon the chest wall. Beneath the axillary