hold the gland firmly to the chest walls. We must operate while the gland is free and before axillary involvement has occurred, with the hope that only the superficial and axillary set of lymphatics which are within reach of the knife are involved. Otherwise, being cut off from the parent tumor, they seem to take on new life and seek new fields to prey upon. In lecturing, I usually divide my cases into two sets-the medullary or soft variety and the scirrhous or hard. Other forms are rare. I have seen but one case of Paget's disease of the nipple and only two of colloid carcinoma. One was that of a young woman less than thirty years of age. The disease had progressed rapidly, the breast giving the appearance of being greatly distended; the superficial vessels were prominent. The patient was operated upon against my advice; in three weeks after the first operation the remaining breast became involved. This, too, was removed, and she finally died of cancer of the liver within a short time of the second operation. About 12 per cent. of my cases have been under 40 years of age, 52 per cent. from 40 to 50, and 14 per cent. from 60 to 65.

I have been much impressed by the lack of knowledge displayed by our Northern brothers in regard to the frequency of cancer of the breast in the colored race. They speak of it as extremely rare in the negro. Rodman is the only writer who seems to have taken the trouble to investigate this matter, and states that from statistics gathered from the hospitals of Louisville, the disease is as frequent in the negro as in the white race. As I have stated, of the seventy-eight cases treated by me, fifty-six were colored and were treated in my ward at the Charity Hospital within the past six years. In looking over the reports of the Charity Hospital from 1890 to 1900, inclusive, I find a total of 279 cases. Of these 111 are white, 117 colored, and in 51 color is not given. This seems to confirm Dr. Rodman's statement, which I believe is correct. Although we can not rely upon the hospital reports, as it is probable that more white than colored women are operated upon outside of the hospital, it is also true that more colored than whites with cancer of the breast are not operated upon at all. The increased mortality from these reports also proves that the colored patients postpone treatment until it is too late. In the 279 cases

referred to the mortality in the blacks was 25 per cent., in the whites only 9 per cent.

That traumatism is a large factor in the causation of cancer seems probable, as it is so frequent among the class of women who do manual labor, thereby subjecting the mammæ to constant friction, not even affording them the protection of a corset. That we are still in the dark as to the etiology of cancer, is certain; but with the good work going on under the direction of Roswell Park and other great scientists, let us hope that we may yet arrive at the truth and with it a means of cure.

The X-Ray is holding out a new hope, but the work done so far is too recent to be judged..

There is within our means one certain method of eradicating this disease, and it is now that I appeal to you, both as surgeons and physicians, to apply it, and apply it vigorously. That means is preventive, and not curative. The average physician, I am convinced, is lax in his methods of examination. Usually burdened with a large practice, he is satisfied to give his attention to such complaints as the patient may indicate, not knowing that a grave and threatening danger is hidden from view. When examining a female patient, why not add to the usual routine form of questions such as would direct attention to the breast? I have been so much impressed for the past two years with the importance of early operation that I make it a practice to ask the question, and twice have been rewarded for my pains.

One patient, a young married woman, in whom there was no suspicion of trouble at the time, returned six months later with a small fibroma, which was quite painful, and which I removed with local anesthetic, giving her instant and permanent relief, both mentally and physically.

Another case I have under observation at present, and unless the symptoms subside, within a reasonable time, I shall remove the growth.

For the cure of cancer, early operation is necessary; for the prevention of cancer, removal of the source of danger. Do not wait until it presents itself in a threatening form, but seek it in its harmless state and draw its fangs before they are fastened too deep into its victim to be eradicated.

The gynecologist has already so trained the feminine world that women flock to his consultations, not because they have

tumors, but because they fear them. Let us sound the danger signal with a note of warning, that though abdominal tumors are a menace to life, mammary tumors are a danger.

Clinical Reports.

A CASE OF PROLONGED GESTATION.

By B. A. COLOMB, M. D., Union, La.

Mrs. J. M., age 30, pregnant for the second time. Herself and husband of average size. First child 2% years old, delivered normally at term after a rather prolonged labor; weight 11%1⁄2 pounds.

Last menstrual period began September 13, 1902, lasting three days. No complications during pregnancy. Labor calculated for June 20. About that period the woman had uterine pains about three days after a rather profuse flow of milk from the breasts, lasting several days.

From this time she complained that the child was growing upwards, under the ribs, and was not like the other one. She stated to me that she would never deliver herself and requested an examination to determine that question. An examination made July 10, showed the head presenting, high up anteriorly, the uterine enlargement extending higher than normal. The opinion was expressed that the child was large, but in view of the fact that the first one weighed 111⁄2 pounds, no trouble was to be expected in the present instance.

July 12 labor came on, the presentation being L. O. A. After six hours of good pains there was but slight engagement of the head. Delivery was then attempted with forceps (Holt's). These advanced the head somewhat, but finally slipped. After several attempts and pushing the blades higher up so as to get them further back on the occiput, and by unusual compression of the handles, the child was finally extracted. The forceps were not able to grasp the head owing to its size, and held only when it had come down a little and could reach around the occiput. The head was very large and showed the tremendous

pressure to which it had been subjected. The child weighed 13%1⁄2 pounds and died a few moments after birth. Except for a partial paralysis of the right leg the woman had no complications.

The dystocia arose partly from the size of the child, but mainly from the mature cranium which failed to yield. A woman who could safely deliver a child of 11%1⁄2 pounds at one time should not have any great difficulty with a child weighing only two pounds more, unless some additional cause were present.

The determination of prolonged pregnancy is not an easy matter, since there are so many liabilities to error. In this case the fact that the child was evidently of unusual size, the effort at labor at the set time and subsequent flow of milk should have been evidence enough. The proper management of such a case resolves itself into two methods of procedure: (1) Termination of the pregnancy at the prescribed limit of time.

(2) Symphysiotomy, which would have saved the child, but increased the mother's risk. She had specially requested not to be cut under any circumstances, even had we been in a position to do the operation.

MULTIPLE URETHRAL

(PERINEAL) FISTULÆ OF EIGHT YEARS' DURATION-EXTERNAL URETHROTOMY, MODIFIED COCK'S PROCEDURE-ANAMNESIS-PRELIMINARY OBSERVATIONS.

By B. A. TERRETT, M. D., Natchitoches, La. White male of 35, single, a native of Louisiana, section foreman by occupation. Has always been healthy except for diseases incident to childhood. Has been somewhat dissipated at times, imbibing quite often to excess. During a pronounced spree he contracted a very obstinate case of gonorrhea in the fall of 1892. After partaking generously of several patent medicines and seeing no apparent change in the course of the disease, he eventually (two and a half weeks later) consulted a physician, who cured the purulent discharge after some three weeks. In the meantime he was unable to see the physician, owing to his work, which carried him some distance from home,

but he continued to faith fully carry out the instructions until a marked diminution in the discharge had occurred. Then he desisted from ulterior medication, imagining that the inflammatory process had entirely subsided. Some weeks later he began to experience some little difficulty in urinating, and for the first time witnessed a decided diminution in the calibre of the urinary flow. Preferring to defer further treatment until certain work had been completed, which necessitated his presence and which could not be finished for nearly two weeks longer, he allowed the condition to progressively grow worse, and, when forced to seek medical aid, an acutely painful swelling about the size of a hickory nut had occurred in the region of the perineum about a half centimetre to the left of the raphe, which finally ruptured and discharged a deciliter of semi-tenacious and yellowish pus. From this adventitious opening some urine soon began to escape during the act of micturition. In the meanwhile, the natural channel gradually became blocked by the stricture, which soon successfully defied the escape of any vestige of urinary output by the natural route, and the bladder could only be emptied by the artificial avenue created by the abscess. Attempts were made by the physician to enter the bladder by the normal route, but all efforts were futile, and, refusing a radical operation-external urethrotomy-he was dismissed from further treatment. For eight years he allowed himself to linger thus, was forced to wear a perineal cloth pad to protect himself from the discharge, both of pus and at times some urine from the fistulous tracts, and suffered also from a recurrence of three other perineal abscesses during this time, which, in turn, formed urinary fistula. On October 11, 1900, I was called in consultation with my friend, Dr. Z. T. Gallion, to see the patient, who was now suffering from a distressingly painful attack of cystitis.

PHYSICAL EXAMINATION.-Patient is restless and apparently in much distress; complains of severe pains in back, in trevesical region, and in perineum. Is compelled to void water every twenty or thirty minutes, and during the act of micturition suffers intensely. Pulse strong and regular but somewhat quick, 120; some pyrexia, 103 F. Examination of the heart and lungs shows these organs to be intact. Inspection of the perineum reveals three small orifices in this region, through which a seepage of pus and urine can be seen to take place. Internal