involve this region. Williams collected 25,196 cases of carcinoma from the mortality returns of England and Wales, finding that 9.6 percent in males and 5.3 percent in females were located in the rectum. The preponderance of male victims is shown also in the United States census of 1900, namely, 5.4 percent as against 3.5 percent. In this connection, Williams points out that the disporportion between the sexes has been steadily lessening ever since 1850. At this time it was 1 to 2.2, while for 1901-5 it was 1 to 1.3. He believes, if this disporportionate increase among males is not arrested, the affection will soon be equally prevalent in the sexes, or the comparative proportions even reversed, as is the case in Australia and New Zealand. As is well known, the preponderance of deaths in the female sex from cancer is due to the frequency with which the mammæ and uterus are involved. The corresponding organs in the male are rarely the seat of the disease, but for all other localities the male liability is the greater.

So much for statistics. With improved modes of living and sanitation, the blackdeath and the sweating-sickness have been extinguished, scurvy and leprosy have been practically stamped out in civilized communities, smallpox is robbed of all its terrors, the way to lessen malarial and yellow-fevers is pointed out, and some impression has been made upon the "great white plague"; yet cancer continues its fell ravages.

Is there anything that can be done to check this foe? Your speaker believes there is and that this Society may be made. a powerful factor for good in such a crusade. In Germany a similar crusade has been started against cancer of the uterus by Winter. Agitating the subject both among the profession and the laity, it is estimated that the number of cases of inoperable cancer of this organ has been reduced over 30 percent as a result of calling attention to the early symptoms.

Ignorance as to Cause; Imperfect Diagnostic

Methods

At the start we are confronted with the fact that the cause of cancer is still un

known. Cohnheim's embryonal theory, Ruffer's "cancer parasites," Russell's "fuchsin-bodies," Sanfelice's blastomyces, Doyen's micrococcus neoformans, not one of these meets all the requirements from an etiologic standpoint. At present, while a dispassionate review would lead one to conclude that the parasitic theory is the most probable, still, for the time being, we are compelled to bring in the Scotch verdict of "not proven."

But if there is any one thing known about cancer, it is the fact that in the beginning it is a local affection; later, after it has invaded the lymphatics, it may be said to be a general disease.

How necessary, then, to be able to attack the disease in its early stages, if we are to do so with any hope of success. Here, again, we meet with another difficulty, the fact, namely, that we have at present no means of diagnosis save microscopic examination of portions of the growth. While the technical part of our art has wellnigh reached perfection, the diagnostic part limps along far in the rear. The various refinements of serodiagnosis have been tested in cancer, with negative results, as well as the blood-picture and the hemolysis

test.

In the portion of the human economy with which we are especially occupied in this Society, the difficulties of diagnosis are increased by the fact of the disease commencing insidiously in a cavity of the body. It is well known, of course, that cancer per se gives rise to no distinctive symptoms. We are, however, better off in this respect than the internist 'who attempts to diagnose the presence of a gastric carcinoma or one in the small bowel; for in the rectum the disease is at least accessible to vision through the proctoscope.

Coming now to cancer of the rectum particularly-while Allingham recorded a case of columnar epithelioma at the age of 12, and various observers have seen the disease in other young patients, still, in general, it is a disease peculiar to middle and old age. Of 2914 cases of rectal cancer in the male referred to by Williams, 2592 patients were over 45, as well as 2180 of

carcinoma.

Responsibility of the Family Physician

Rectal and Uterine Carcinoma in the

Cancerous Age

This brings me at once to the crux of my argument: that every person who has reached the socalled "cancerous age" should be examined periodically for evidence of commencing carcinoma, not necessarily of the rectum alone, but, in the female for example, of the uterus also. However, confining ourselves to the former viscus, the necessity for this examination is shown by the figures set forth by our associate, Dr. Tuttle, in his book: Of 600 cases of rectal carcinoma, only 6.7 percent involved the anus; 26.3 percent were located in the infraperitoneal and 67 percent in the supraperitoneal region. In other words, the majority of the tumors were so situated that they would give rise to no early symptoms of the disease, and thus, by the time they caused phenomena marked enough to attract the patient's attention and lead him to consult the surgeon, the period for operation, with a reasonable expectation of permanent cure, has passed by. Neither the patient nor the practitioner should allow their interest in these periodic examinations to slacken.

An instance showing the necessity for long-continued inspections was recently narrated by Powers of Denver. In 1889 he assisted at an operation for removal of the breast in a woman of 42. The method used was the Volkmann excision and clearing out of the axillary contents. The growth was about the size of a small apple, and the nodes in the axilla were hyperplastic though not malignant. During the first year the patient was examined every three months, and in the second year every four months. After the second year careful examination of the scar was made every six months, yet there was no evidence of relapse until December, 1907, when a small hard mass was found and excised which

Here the responsibility of the family physician is great, for he is usually the first one to be consulted. We fear he, too, will need some instruction as well as the laity. He must not content himself (as in dozens of cases we can recall) with a perfunctory diagnosis of "piles," without even an inspection of the anal region, and an equally perfunctory prescription of gallic acid ointment or some similar agent. The bowel must be inspected through the proctoscope; and this involves the possession of an appropriate armamentarium, and in turn the ability to interpret the appearances seen through the instrument.

In cases of doubt, the patient's life is not to be jeoparded, but advantage taken of consultation with the specialist. There is no reason why the splendid record achieved in the past decade in the early recognition of appendicitis should not be repeated in the case of rectal carcinoma. The family physician no longer contents himself with a finding of "inflammation of the bowels" or "typhlitis," or the like, but forewarned, he appraises the symptoms at their true value and either operates himself or sends the patient to the surgeon in due time.

J. B. Murphy, in his paper on "Peritonitis-General, Free, Suppurative," writes as follows, which is pertinent to the phase under discussion: "The author wishes to thank the family physicians for reference of cases, and to congratulate them on their early diagnosis and for prompt demand for surgical relief in these cases; to them, he feels, belongs much of the credit for the good results secured," etc.

Once any suspicious appearance is detected during such a proctoscopic examination, effective measures are to be undertaken immediately. There must be no delayone of the banes of the surgeon at the present time is the procrastinating family physician who keeps a patient under observation for weeks or months while he is making up his mind whether a swellingin the breast, let us say-is malignant.

When finally he decides that it is and the patient is referred for operation, there frequently is, by this time, involvement of all the tributary lymph-nodes, general cachexia, and all the other developmentsin other words, the golden opportunity has been allowed to slip by.

Prevention and Education

The subject of prevention of disease is one close to the hearts of the populace, as witness the propaganda of the American Medical Association, the activities of the state and municipal boards of health, and the flood of books and magazine articles treating of healthful living, the lessening of disease, and cognate topics. And here, it seems to me, is a great field for the activities of our own Society. Lectures should be delivered in language "understanded of the people," calling their attention to the ravages of malignant disease, with special attention to the rectum, and the splendid results afforded by early and radical intervention. Moreover, tracts and articles should be written, in equally simple language, promulgating such data.

The laity must be warned of the dangerous popular custom which leads nearly everyone experiencing discomfort in the rectum to make his own diagnosis of "piles" and to apply his own therapeutics in the shape of one of the many socalled "pile cures" found on the market.

Nor are the people alone in this superficial view of the subject. In his paper describing the technic and results in 120 resections of the rectum for malignant disease, W. J. Mayo observes: "It is an unfortunate fact that, in the majority of cases, cancer of the rectum is not recognized in time to obtain a radical cure. When one considers that such tumors are, as a rule, within easy reach of the examining finger and may readily be inspected with the proctoscope, it indicates a lamentable carelessness on the part of the profession and gives point to the saying that most errors in diagnosis are due to careless examination rather than to lack of knowledge." Nearly 10 percent of the cases subjected at the Mayo hospital to resection had been recently operated on for piles or had been

subjected to a futile dilatation with bougies for supposed stricture.

Gynecologists tell us that from 65 to 80 percent of all cases of carcinoma of the uterus are inoperable when first seen by them, because the patients looked upon the leucorrhea and hemorrhage as "delayed change of life," irregular menstruation or something of the sort.

In the same way, the public must be warned of the insidious onset of rectal carcinoma, that passage of blood and mucus in an elderly individual means, in many instances, something infinitely more serious than hemorrhoids. People must be warned also of the necessity for adequate bowel movements, avoiding constipation with its attendant evil of irritation from retained feces.

Some of the Obstacles in the Way

Lord Bacon says there are four chief obstacles in the way of truth: "The plea of an authority that does not deserve the name, long-standing habit, popular prejudice, and an ingrained ignorance that masquerades as so much knowledge."

In the proposed crusade we shall probably have to deal largely with the third of these hindrances-popular prejudice. The average layman has had relatives or friends die of cancer and looks upon the disease as the equivalent of a deathwarrant. If told he has cancer, he is prone to seek aid from various types of charlatans or nostrums. Many of these nostrums have been exposed lately in The Journal of the American Medical Association, and their composition shows that their use would be ludicrous, were it not for the pitiful aspect of the situation. As a last resort the surgeon is consulted, unfortunately too late for anything but palliative measures.

It is a most distressing characteristic of human nature that the very individuals one would least suspect-the leaders in their respective communities-are the ones to be led astray by the false gods of Eddyism, Dowieism, and the like. The keen business man, the clergyman, the lawyer or the judge are the ones carrying buckeyes, rheumatism rings or otherridiculous preventives.

The aversion to the knife so commonly seen is another strange failing. Before the days of anesthetics, when the struggling patient was held down by strong men and his shrieks unnerved the operator and alarmed the spectators, so only surgeons of iron will and determination could carry out operative treatment, one could understand this distrust of radical measures. But, with the refinements of anesthesia by modern methods (the drop-method of administering ether, and so on), when the subject loses consciousness, to awake with the diseased area ablated and nothing to testify to the operation save some pain and slight smarting during the period of wound repair, the fear of the knife in otherwise. intelligent people is strange indeed.

All of us have seen instances of women with a tumor in the breast (sometimes no doubt of a benign nature), who have consulted some charlatan advertising that "no knife is used," and who have suffered the tortures of the damned for weeks and weeks after the use of Vienna paste or plasters or caustic "arrows" until at last the mammary gland sloughed away, leaving an enormous, ragged, stinking cavity. No knife, forsooth! Better the knife, I say, than every moment of existence, day and night, made hideous by such infernal procedures.

So the problem, as may be seen, is no small one. I said a moment ago that cancer in the beginning is a local disease. This granted, then early and thorough removal must lead to a cure. If success attends a good proportion of early removals for cancer in other portions of the body, then an equally gratifying success will attend intervention for rectal cancer carried out correspondingly early. In his paper already referred to, Mayo reports cases in which the operated individuals are alive and well now, five, nearly eight, and nearly nine years after operation.

The Role of Cicatrices and of Inflammatory Processes

This leads me to allude to another phase of the subject. It has been shown of late that a large proportion of malignant growths originate in scar-tissue. We owe to the

Mayo clinic the demonstration of this as well as many other invaluable facts. In cancer of the stomach, for example, these operators found, from microscopic examination, that no less than 62 percent of the victims showed evidence of a previous ulcer. In rectal cancer, patients frequently give a history of previous operations on the part. Does the cancer occur in the scar left from an operation for hemorrhoids done by one of the commoner methods-ligature, clamp and cautery, or some other technic leaving much scar-tissue and sometimes. stricture? May it not occasionally be engrafted on the scar following the usual incision method of operating for fistula? All of us have seen large and ugly scars, from time to time, following this method.

Surgeons are bending all their efforts of late toward securing healing per primam, with linear cicatrices if possible. Here is a suggestion for us in our own work; secure smooth healing by resorting only to such procedures as leave the minimum of cicatricial tissue, hence the least-possible nidus for mischief in the future.

Along a similar line, J. B. Murphy, in the preface to his "Yearbook of Surgery,” states that chronic infection of the tonsils, urinary apparatus, intestinal catarrhs, etc., are not sufficiently appreciated for their destructive, chronic, poisoning effects. Endarteritis, endo- and myocarditis, nephritis, etc., are the direct consequences of such infections. Heretofore we have been satisfied with diagnosing the secondary disease, failing to look for or to locate the etiologic factor, as well as neglecting to remove it. Dr. Murphy goes on to say that chronic infections must be eradicated, thus avoiding the baneful and incurable secondary disease. We must act on such advice by attacking the cancer in its precancerous stage-to use a Hibernicism.

With the cooperation of the public, it seems to me, we should learn much about cancer in its early stages; diagnostic methods can be put to the crucial test; the technic will be improved; possibly the cause of the disease unearthed. To educate the public, we must-as has been well said— "organize, systematize, deputize, energize, supervise, and economize."

LCER of either the stomach or the duodenum is nearly always curable without surgery when treated early, properly, and persistently for a sufficient time. When neglected till it becomes old and chronic, it is often fatal by hemorrhage, perforation or carcinomatous degeneration, despite medical and surgical endeavor.

In no disease is it more important to make the diagnosis early or at least to begin the proper treatment promptly, even on the mere suspicion of the presence of an ulcer. It is better, of course, to make a reasonably sure diagnosis, with or without the help of a specialist, before instituting treatment, as this enables the physician to persevere with the right measures without doubt or wavering until the cure has been well established.

But it is a striking fact that, while to treat ulcer for something else may easily prove a fatal mistake, to treat for ulcer a disease which later proves to be something else (such as simple dyspepsia, gallstones, crises of tabes, or even cancer) is not likely to do any permanent harm; and to treat hyperchlorhydria for ulcer is the very surest way to cure it speedily. Whenever there is acute pain in the abdomen coming on regularly either immediately or one to four hours after eating solid food, whether there is vomiting or not, or whether there is or is not tenderness on pressure, it is safe to try the ulcer treatment.

The most common mistake is the prescribing of hydrochloric acid, pepsin, or the like, or of some hot stimulating mixture for supposed ordinary indigestion; and it may be said that this always aggravates all the symptoms of ulcer so markedly that

patients generally refuse to continue it, even if not ordered stopped.

The correct treatment for ulcer, on the other hand, namely, rest in bed, with exclusive rectal feeding for at least one week, followed by a diet of milk, with a very gradual return to the ordinary meals; and, for medication, 30- to 40-grain doses of bismuth subcarbonate with 50- to 60-grain doses of bicarbonate of sodium or other equivalent alkali, in a tumbler of water, three or four times a day, will almost invariablly bring immediate relief. And this relief generally is very positive and decided, except in some of the old chronic cases, and these may not yield to anything short of an operation. It is safer, then, to continue the milk diet a month or two and never let the patient return to the irrational habits which brought on the trouble originally, including eating too much meat—the meat extracts especially-and food highly seasoned with hot condiments.

It is proper to mention that in my own fairly large experience this line of treatment has almost never failed to bring gratifying results, still, Lenhartz, of Germany, has lately lauded a different diet in these cases, one which calls for a much larger amount of rich, stimulating proteids, including eggs and some meat. The value of such a variation of the dietetic treatment in some cases has been confirmed by careful observers in this country. The cases in which this method succeeded, after the other one failed, were probably some of the more chronic ones which had continued so long that the patients had become seriously reduced and debilitated, so that recuperation was possible only after a course of