operations which were unknown five years ago, and yet they are apparently ignorant of the possibilities of an operation for cancer rightly done. This is most unfortunate, for it encourages physicians to undervalue the importance of exactness in diagnosis when the growth is strictly local and, therefore, entirely amenable to operation. Moreover, it encourages the running after false gods, the chief of which is the treatment by x-rays, which are responsible for the loss of many valuable lives that might easily have been saved. It is almost inconceivable that relatively so few surgeons are doing a complete operation in mammary cancer. Yet it is eleven years since the publication of Halsted's epoch-making paper containing the most positive and convincing proof as to our duty when dealing with this pitiless enemy of womankind, and thirty-eight years since Moore advocated not so complete a procedure, it is true, but still a far more radical operation than is frequently seen at the present day. Operations for mammary cancer if performed, as they should be, in the first stage when the growth is small and strictly local, should furnish 75 per cent and upwards of cures. This is even less favorable than operations for cancer of the lip.

Cancers of the second degree, where the neoplasm has become adherent to adjacent tissues and there is moderate axillary involvement, the condition nearly always encountered at operation, are curable in 50 per cent of the cases.

In cancer of the third degree, where the entire breast is adherent to the chest wall beneath and the enlarged axillary nodes have coalesced into one large mass, possibly adherent to everything about them, but little can be promised. Still, operation should be undertaken, for now and then an unexpected cure is witnessed. I have had one such case myself, and recently while lunching with Prof. W. W. Keen he told me of a case of his where he at first declined to operate, the cancer was so far advanced; yet a complete operation gave perfect relief, and the woman died five years later of apoplexy entirely free from recurrence of the cancer.

The experience of another year has increased the conviction expressed in my paper before the British Medical Association at Oxford last July, that the supraclavicular glands should be explored and removed, if enlarged-in all cancers situated in the upper hemisphere of the gland. It has been shown by Poirier and Cuneo that a chain of superficial lymphatic vessels passes from the breast directly over the clavicle, and empties into the glands in the posterier triangle of the neck. Of three such cases treated in the past year all were explored. In one there was unmistakable involvement; in the other two absolutely normal glands and fat were found. Unless there is macroscopic involvement I do not make an elaborate dissection of the neck, for I believe it to be unnecessary and needlessly to prolong an already lengthy procedure.

Extensive as these operations seem, and really are, the operative mortality can almost be ignored, as it is less than one per cent.

It seems hardly necessary for me to say to you that I appreciate very highly this honor which you have conferred upon me in electing me to the presidency of the Minnesota Academy of Medicine, a position which has been so worthily filled by my official predecessors. Trusting that I may be able to keep up the high standard which has been set for me, and that I may have your individual help in making our meetings interesting and instructive, I thank you.

*President's Address before the Minnesota Academy of Medicine, November 1, 1905.

I have always prized my membership in the Minnesota Academy of Medicine very highly, indeed, and can look back through the past seventeen years of delightful fellowship to the first informal meeting in the West Hotel when the Academy was formed. Most of us are still "hale and hearty despite our forty years," as one of my ten-year old friends recently put it in her original composition. A few of our most valued members and esteemed friends have gone over to join the great majority. Drs. French,

anxious for operative relief, when they come to realize the true nature of their disease, and it is very difficult to refuse, if one thinks there is any hope of recovery. As you will notice, I have not included any cases operated upon during the past three years; for, although one cannot say that a three years' interval without a recurrence means that the case is cured, still I have never seen a case die from a malignant growth that has shown no recurrence three years after removal One case of carcinoma of the breast lived thirteen years after her first operation, eventually to die of pulmonary carcinoma. She had five separate operations, her recurrence always came within the three-year limit.

I have operated upon 96 malignant growths up to three years ago, 70 sarcomas, and 89 carcinomata. 55 were of the uterus; 15 of the breast; and 26 in other parts of the body. The operative mortality has been 12. I have not been able to follow 22 cases, leaving 62 cases for our further consideration as to ultimate results. Of the 22 unknown cases it is only fair to conclude that some of this number are alive and well, for when I started this study two weeks ago, I wrote letters in various directions regarding these and other unknown cases, and was amazed to find that three cases whom I supposed to be dead were alive and free from disease. On the other hand, there is the chance that some of the cases now alive and well were mistaken in microscopic diagnosis. One case of supposed carcinoma of the cervix I am now inclined to believe was not malignant, but that is only a clinical impression, not being a microscopist myself. Of the 43 known uterine cases, 10 are alive from four to sixteen years since operation. Of the 12 breast cases, all Halsted operations, one is living five years after operation, without a sign of recurrence. Of the mixed cases one lived five years to die of old age. Subtracting these 12 cases, which are probably cured, from the 62 which we are studying, we have 50 cases. Of this number 46 died from recurrences, and 4 died from other causes within the next few months after the operation. In these cases my records show that the time which each patient lived after operation to eventually die of recurrence was as follows:

One lived 13 years; 2 lived 5 years; I lived

4 years; 5 lived between 3 and 4 years; 9 lived between 2 and 3 years; 17 lived between 1 and 2 years; I lived less than 1 year.

In regard to the duration of the disease from the time of the first recognizable symptoms we can approximately add six months to the above figures. In only a few cases were symptoms present one year before operation, although in one case a tumor of the parotid had been present six years before she was operated upon. Of this case I will speak again later, because it was of more than ordinary interest.

I was much surprised when I tabulated these cases to find such a iarge number of uterine cases (i. e. 10) alive and well, and such a small number (2) of the breast and mixed cases. This is particularly surprising when we come to consider that in the breast cases, which were to all clinical appearance favorable ones, we were able to remove the tumor and the healthy surrounding tissue, keeping some distance from the disease. This was also true in the osteo-sarcomata of the extremities; while on the other hand, it was necessary to go very close to the diseased tissue in removing the uterus through the vagina. The second case-history in my list, an amputation of the breast, was done within a few months of the publication of Halsted's first paper in 1891. I was immediately impressed with the conclusions which he drew, and have always followed his line of procedure. In spite of this fact, only one of the 12 cases which I have been able to follow, was alive and well five years after the operation. Two died from other causes in the next 12 months.

There was only one regional recurrence; all of the others died from either general or pulmonary carcinoma. carcinoma. Of this number I lived thirteen years from the time of her first operation; 2 lived three years; 2 between two and three years; 3 between one and two years; and three less than one year. Of the uterine cases, 55 in number, 9 were only palliative operations, the curette and cautery being thoroughly used. Most of these cases were operated upon, following the method of John Byrne, of Brooklyn.

It was thirteen years ago that Dr. Byrne reported 80 cases of carcinoma of the uterus where he had simply cauterized the diseased tissue with the galvano-cautery. Of this number 50 were

alive and well at the time of the report, and 24 of this number were alive and well from four to seventeen years after operation, without recurrence. Dr. Byrne's idea was that the cancer cells were destroyed deeper in the tissue than they could be if removed by any other method. There is no question about Dr. Byrne's honesty nor about his great clinical experience. There may have been doubt in the pathological findings. One of the cases operated upon by this method lived three and one-half years from the time of her first symptoms, and one, in which the cervix was practically destroyed, and the vaginal wall invaded, was known to be alive and well nine years after her operation of galvano-cauterization. The rest of these uterine cases, 46 in number, were vaginal hysterectomies, the earlier ones being done with the clamp, and the last 35 and more with catgut ligatures. Of the 55 cases there were 6 operative deaths; the youngest case was 24, the oldest 70. The ages were as follows:

Four between 20 and 30; 8 between 30 and 40; 24 between 40 and 50; 12 between 50 and 60; 6 between 60 and 70; I was over 70.

There were ten cases living as follows:

One at the end of 16 years; I at the end of 13 years; I at the end of 11 years; 2 over 9 years; I at the end of 8 years; I at the end of 61⁄2 years; I at the end of 5 years and ten months; 2 at the end of 4 years.

My histories give the location of the recurrence in only 16 cases; 13 of these were regional, and 3 central.

If the disease had broken through the uterine or cervical wall and invaded the base of the broad ligament or extensively involved the vaginal wall vaginal hysterectomy proved of little or no value. Some of the diseased tissue is usually left in my experience, the course of the disease is hastened rather than delayed, and the patient does not get enough respite from pelvic pain to make the operation justifiable.

The radical operation for cancer of the uterus which has been has been very strongly recommended by some operators in the past few years, is still of necessity an unproved agent. All agree that it is accompanied by a

higher primary mortality, and that there is more danger of urethral fistulæ. But these objections are unimportant if it can be proven that the number of ultimate cures is greater. Olshausen's experience in 671 hysterectomies for cancer leads him to favor the vaginal route, using the combined operation for cases in which the parametrium is invaded.

If I were to draw any conclusions from this small and imperfect list of cases, it would be that the operations which demand wide dissections and removal of neighboring glands are are not necessarily proven, and that they need further neighboring tissues and glands, as in the breast, study and prolonged observation. When they can be easily and safely removed without increasing the mortality of the operation, this should be the course to pursue, but I am not convinced as yet that this rule holds for removal of the uterus and rectum.

Several years ago my partner, Dr. Dewitt, returned from New York very enthusiastic over the possibilities of Cooley's erysipelas toxins, in the treatment of inoperable malignant tumors. We tried them in a considerable number of cases (about 15). There was absolutely no effect that we could see except in one case, this was a spindle-celled sarcoma of the parotid, which returned soon after removal. A course of erysipelas and prodigiosus toxins, prepared under Dr. Cooley's direction, caused a complete dissipation of the swelling in the neck. on two different occasions. She lived four years after the operation eventually to die of general sarcomatosis. It seemed to us in this case that the course of the disease was remarkedly affected and the woman's life prolonged by the use of the toxins. A few inoperable malignant growths which have been exposed to the effects. of the x-ray have also seemed to be delayed in their progress. But the only cure today, as in the past, lies in the early and thorough removal of the growth at the earliest possible moment.

Because of the difficulty of diagnosis in many cases and because others are too long neglected, the end-results in cancer will always be the saddest and most unsatisfactory page in surgery.

Surgery was founded on empiricism, and for centuries its theories and practices would make the present-day charlatan blush with envy. By the discovery of the circulation of the blood, the mysteries of the body began to be unlocked, and the study of anatomy was added. The surgeon became an anatomist and a skilled operator, but sepsis and shock held sway. Bacteriology and pathology banished the dread of sepsis, and the art of surgery became a science. Surgery was then found to be interwoven with every other department of medical science; and it was through the department of physiology that shock, the last impediment to successful surgery, was to be solved. A few years ago Crile and Cushing, in this country, and Lockhart, Sherrington and others, abroad, began to study shock physiologically. It was produced in animals fully anesthetized, and all the phenomena carefully recorded. It was thus determined that shock was caused by the fall in blood pressure due to the exhaustion of its vasomotor centers, and that collapse was caused by a sudden fall in blood pressure, due to a paralysis of the vasomotor centers. Hemorrhage and cholera cause collapse by the sudden withdrawal of the circulating fluid.

The causes of shock may be divided into two main classes: the effect of injury or operation on the important nerve paths of the body, and the effect of exposure and injury of the abdominal viscera. All the main nerve paths have a depressor nerve, which, when stimulated, lowers blood pressure, and also a pressor nerve, which, when stimulated, raises the blood pressure. Cold will inhibit the action of the pressor nerve only.

Cutting the skin, and dilating the sphincter and the os uteri will increase blood pressure. Burns of the second and third degrees will cause more shock than burns of the fourth and fifth degrees, because their terminal nerve filaments are still able to register the condition of the tis

*Read before the Minnesota State Medical Association, June 1, 1905.

sues in the central nervous system, while in burns of the fourth and fifth degrees the terminal nerve filaments are entirely destroyed, rendering them incapable of sending any message to the central nervous system. In amputations of the extremities, it will often be noticed that when the main nerves are severed the pulse will run up twenty to thirty beats a minute. By severing these nerves a fall of blood pressure is produced. Pulling on the brachial plexus in amputations of the breast has lowered the blood pressure one-third. In shock the arterial pressure is lowered and the venous raised; the blood in the latter is a bright arterial hue, due to the dilatation of the arterioles and the paralysis of the metabolic processes in the tissues. Shock is caused by the exposure and handling of the abdominal contents. Evisceration, pulling on the intestines, sponging, irrigating, and exposure will all cause shock. In abdominal shock we have marked congestion of the splanchnic blood vessels and an irritation of the sympathetic nerves. Operations in the upper part of the abdomen cause more shock than operations in the pelvis.

In cases of shock the following sequence of events tends to take place. There is at first a lowering of blood pressure, or a tendency to lower blood pressure. The vasomotor centers establish the former tension, or it may for a time be increased. There comes a time when the vasomotor centers fail to keep up the blood pressure and the heart is called on through the cardio-accelerator center for an increased speed, and in time this also fails to maintain the proper presThe blood remains a bright red, metabolism ceases, which in turn increases the vasomotor exhaustion, and the end is soon reached. When the blood pressure begins to lower in shock the portal pressure increases. During an operation the specific gravity of the blood increases, and is lowered with difficulty by intravenous injections. In shock the temperature is lowered, because the heat of the body is dissipated and is not produced. Ether increases the

sure.