erosion.

I have seen such cases and I am satisfied that they do occur.

DR. J. ROWAN MORRISON: Dr. Grant's paper has been very interesting to me, in view of the considerable number of cases that he has had and the honest way in which he has reported them. Probably many men, when they send these patients to the surgeon, consider that they are not very far advanced, but when they come to operation they are found to be very far advanced. This only goes to prove what the essayist tried to make very apparent in his paper, that is the necessity of using all the methods at our command to make early diagnosis. I know that in my work about the stomach and other abdominal organs, I have come to pay much more attention to any symptoms which may in any way indicate a carcinoma of the viscera. I believe that I have improved by taking more pains with the history. Vomiting, tenderness, the appearance of occult blood in the stools, etc., are all things that I pay much more attention to now than I formerly did.

I believe in this way I will be able to diagnose these cases much earlier than would have been possible several years ago. If all of us would pay more attention to minor details, that at one time would not have been considered very important, I believe it will bear fruit.

Another thing is that people are now more willing to submit to operation for a condition that is presumably cancerous than they were formerly. As Dr. Meyers has said, many persons are prone to hide these things. I recently saw a woman with a tumor of the breast which had existed for fifteen years, but had not undergone any change until the last four or five months, when it had begun to grow somewhat. I discovered the growth by chance, and advised its removal. She wanted to delay, but upon a thorough

exposition of the case to her, she very readily consented to operation, which proved that the growth was a scirrhous

cancer.

There is certainly a good deal about cancer that we do not know. However, I look for developments when any subject of this magnitude is brought before the general public as this subject is being brought before them to-day. I am rather inclined to believe that the outlook for the treatment of malignant disease is better than it has been in the past, and that by early diagnosis we will be able to eradicate the disease in many instances before the inoperable stage.

In looking up some statistics to-day, I found that the mortality rate from cancer is very markedly increasing. This is particularly true in certain classes of people. For instance, native Africans seldom have the disease, while it is frequent among negroes in this country. It is frequently found in Europe and is more prevalent in Denmark and Switzerland. Again, the characteristics of the different. races seem to play a part. In some the condition is more frequently found in the stomach, depending upon the food they eat, and in other organs of the body depending upon the various characteristics of the people.

I believe that turning the searchlight on this subject thoroughly will result in a great deal of good.

DR. GRANT (closing): In looking over my card index of work that I had done. two years ago, I was pleased to note the very low rate of mortality, but in following up the subject, I was astounded to learn the high rate of mortality among patients operated on for malignant disease who had apparently gotten well and left the hospital, and it showed me how unsatisfactory had been that part of my work. I was very much surprised to find

that, of twenty cases of malignant disease, operated on in 1909, three of four operated upon for visceral cancer, were dead and the other one is now in such condition that the end is not far off.

Among these was one case of carcinoma of the stomach, and in that case gastro-enterostomy was done because the patient had not been able to eat anything for two weeks. Of the others, two were sarcomata, and the rest were carcinomata, involving either the peritoneum or the uterus. Two of the four hysterectomy cases are living and well. Of the other two, one, which was apparently as hopeful a case as I ever operated upon, died within a year after operation; the other was in very bad condition and died within five months after operation.

I thought it would be well to report an experience which has been so disappointing to me as this one. I do not know whether anything any one else could have done in these cases would have been any better. One of the cases of carcinoma of the breast recurred in seven months, and a second operation was done. The patient is still living, but I have very little hope for her recovery. It may be that I made a mistake in the primary operation, not doing it as thoroughly as it should have been done. Six of the eight cases of breast tumor operated upon are still living, without recurrence.

What it means to me is that operation for visceral cancer, with the possible exception of cancer of the stomach, unless done very early, is practically hopeless. I do not mean that this applies in carcinoma of the uterus, but in all of the viscera of the abdomen with the exception of the stomach and uterus it seems to me that the only hope of effecting a cure is to operate while the disease is local, and

no one can tell when dissemination is going to begin.

I did not say in my paper, as Dr. Frank apparently understood me to say, that we are not doing any better work in carcinoma to-day, nor that we do not know any more about it, but that in spite of development, the condition is as hopeless to-day as it was fifty years ago. A determination to operate on every suspected case, without waiting to confirm our diagnosis, is, in my opinion, the only way in which the prognosis can be improved.

What I said about implantation was intended to mean that we should not fear it enough to make us hesitate to do any operation which will insure the thorough extirpation of the carcinoma. Some men seem to fear that transplantation may take place as the result of manipulation in the removal of the tumor. This idea should not prevail. The very rare instances in which carcinomatous pieces may be cut off and left upon a fresh surface are not sufficient to justify operating through a narrow area, or through the orifice of the vagina in order to avoid the possibility of infection of the peritoneum. The surgeon, not infrequently, will hurry his patient off the table, fearing that if more operative work is done he will lose his patient. In my opinion, the fear of additional shock or danger to the patient by holding him under the anesthetic a little longer in order to complete the operation should not deter a surgeon from going on with it. These are the points. which I meant to make with respect to the risk of implantation.

The use of cautery is of practically no service in a case that is hopeful. I believe the cases that are really hopeful do better under widespread excision, without attempting to heal it by cautery. Those

in which it is certain that all the infiltrations cannot be gotten away will be bene

fitted by the use of cautery, by delaying the reproduction of the condition. I have used it in two apparently hopeless cases. The application of acetone, in full strength, upon absorbent cotton, and pressed upon the ulcerating surface, seemed to me to have a beneficial effect in the way of retarding recurrence of the carcinomatous condition. In none of the cases reported did I employ this, but I have used it in cases operated upon earlier, and also since then, and it appears to me that it is only of value in cases where the carcinoma cannot be completely extirpated. It will retard the recurrence for a much longer time than I think can be obtained by other methods.

Selected Articles

THE FIELD INVESTIGATION OF EPIDEMIC POLIOMYELITIS 1 2

(What the Health Officer Can Do Toward Solving a National Problem) BY W. H. FROST,

Passed Assistant Surgeon, United States Public Health and Marine-Hospital Service. PREVALENCE AND SERIOUSNESS.

Epidemic poliomyelitis, which has for many years been recognized at intervals. in circumscribed localities as a serious

problem for the guardians of the public health, has in the present year become in the United States one of our national public health problems. It has become. so chiefly by reason of its enormously increased prevalence-an increase both in the total number of persons affected and in the area of epidemic prevalence.

Lovett (1), in a compilation prepared for the Massachusetts State Board of Health, gives the number of cases of poliomyelitis reported in the literature of

1Read at the Tenth Annual Conference of Sanitary Officers of New York, Buffalo, N .Y., November 18, 1910.

"Reprint from Public Health Reports, Vol. XXV, No 46, November 18, 1910. "For references see end of article.

1

After making all due allowance for the increase due to greater accuracy of diagnosis, it is still clearly evident that there. has been an actual, progressive and rapid increase in the occurrence of epidemics of this disease. And, what is of more vital importance to us, of the 8,000 cases reported from 1905 to 1909, approximately 5,000 have occurred in the United States, practically all within the three years, 1907-1909. The cases in 1907 were confined definitely to New York City and its vicinity. Epidemics were reported in 1908 from several States, in 1909 from at least 4, and in 1910 from at least 17 States.

The Surgeon-General of the Public Health and Marine-Hospital Service is endeavoring to collect from the health. officials of all the States reports of the prevalence of the disease in 1910. These reports (2), known to be fragmentary as yet, indicate approximately 2,500 cases

reported from 23 States; and additional reports, unofficially received, make it quite certain that 3,000 is a minimum estimate of the cases occurring in the United States during 1910.

These figures, to be sure, are not alarming when compared with the statistics of other infectious diseases; but there are, in the prevalence of epidemic poliomyelitis, certain features which add to the seriousness of the problem. First, its rapidly progressive increase, indicating, so far as predictions are justifiable, that the situation for the ensuing year will be more serious than at present. Again,

while the mortality of the disease, averaging perhaps 10 to 15 per cent., is not greater than that of other more widespread infections, the mortality in this case represents but a small part of the suffering and economic loss entailed. A very large percentage of those who escape with their lives are left with a permanent disability of greater or less degree, which often results in a life time dependence on the part of the victim and of distress on the part of his family. Epidemics of other diseases come, go and are forgotten; but epidemics of poliomyelitis leave in their wake cripples who will remain as objects of sympathy, often as objects of charity, to the next generation. Another most serious feature of epidemic poliomyelitis is the mystery which still surrounds its origin and means of dissemination, resulting in a lack of confidence in preventive measures and a magnification in the popular mind of the terrors of the disease.

PREVENTABILITY.

It is not, however, the seriousness of epidemic poliomyelitis, but its preventability, which fastens upon the health officer his responsibility in the matter; the seriousness of the disease only increases the gravity of this responsibility. So long as a disease is known to be irremediable the health officer may stand by and commiserate; if there is reason to suspect that it is preventable it is his duty to investigate; if it is known to be preventable, he must prevent.

To define the status of the health officer in regard to epidemic poliomyelitis, it will be necessary first to give a brief summary of facts bearing on its preventability.

Laboratory studies, a large and valuable part of which has been contributed by Flexner and Lewis from the Rockefeller Institute, have demonstrated that

the disease is transmissible from human beings to monkeys and from monkey to monkey; animals other than the monkey have been found insusceptible, except by a few observers who report successful inoculations of rabbits (3, 4, 5).

It has been demonstrated that the specific causative organism is of minute size, being able to pass through a Berkefeld filter; that it is easily killed by heat and by comparatively weak disinfectants; that it is very resistant to cold and to drying. In the bodies of infected animals the virus (germ) of the disease has been demonstrated not only in the spinal cord and brain, but in the nasal mucous membrane, the salivary glands, mesenteric glands, and, after subcutaneous inoculation, at the site of inoculation and in the lymph glands receiving the drainage from that area. The cerebro-spinal fluid and blood have been found infectious in the early stages of the disease. It appears, however, that the virus is present in the blood only in the early stages of infection and then in small amounts.

The most uniformly successful method of inoculating monkeys is by injection of the virus into the central nervous system, but successful inoculations have been made into the peripheral nerves, intravenously, intraperitoneally and subcutaneously; also, which is of great importance, by introducing the virus into the stomach or intestines, by rubbing it into the scarified mucous membrane of the nose, and, as reported by one observer, by bathing the uninjured nasal mucosa with an emulsion of the virus (6).

Immunity after an attack of the disease is manifested in monkeys by insusceptibility to inoculation. In the blood of both persons and monkeys after recovery from the disease specific anti-bodies have been demonstrated, capable of neutralizing in vitro certain amounts of the virus. The

efforts to produce an antitoxin of therapeutic value have so far been unseccessful, as have also the efforts to devise a safe means of protective inoculation or vaccination.

Reviewing briefly the results of laboratory experiments, it is shown that epidemic poliomyelitis is an acute infection. due to a specific micro-organism. The demonstrations that the secretions of the nose and mouth are infectious even in monkeys inoculated intracranially, and the successful inoculation of monkeys through the respiratory and digestive tracts, form a convincing chain of evidence that the disease is transmissible by direct contagion.

Epidemiological studies have, to some extent, confirmed the inference drawn from experimental work, that epidemic poliomyelitis is transferred from person to person by direct contact, and have further indicated the probability of conveyance of the disease by healthy persons. Widely divergent inferences have, however, been drawn from the study of epidemics in different localities.

Wickman (7) stands as the pioneer in the epidemiology of poliomyelitis, having convinced himself, by extensive field studies in Sweden, that the disease is spread by direct contact. Other observers, reporting epidemics, have emphatically stated that there was no evidence of contagion. Such divergencies of opinion may be partly explained by differences in the thoroughness of investigation and in the personal equation of the observers. It must be evident, however to any one studying the reports that epidemics of poliomyelitis vary greatly in their degree of infectivity and in their apparent relation to contact.

Clinical studies have taught that the disease is Protean in its manifestations, often diverging widely from the classical

descriptions generally given in text-books. This fact is important from an epidemiological standpoint, as it raises, at the very outset, an obstacle alike to investigation and prevention, namely, the difficulty of recognizing the disease. Of extreme importance in this connection is the occurrence of abortive forms of poliomyelitiscases in which there is no paralysis. The absolute diagnosis of such cases has, in the past, often been impossible. There is, however, reason to hope that diagnostic methods worked out within the last year will aid greatly in their future recognition.

As regards the preventability of poliomyelitis, then, the disease is certainly due to a specific micro-organism which can be quite readily destroyed by the usual methods of disinfection. It is, therefore, preventable, provided that we can locate the organism accurately and apply the germicides thoroughly. The first problem is to locate the organism in that part of its cycle where it can be most readily destroyed. Our present knowledge indicates that man is the essential host, the breeding place of the organism, and that prevention should consist in the destruction of the organism as it is excreted from the body of the patient. The efficiency of such preventive measures mains, however, to be demonstrated. While it is, therefore, the duty of every health officer for the present to put into effect the preventive measures already indicated, it is highly important that he should at the same time make diligent investigation to ascertain whatever deficiencies there may be in such methods and to point out the means of supplementing or supplanting them.

FIELD INVESTIGATIONS.

re

Invaluable as laboratory studies have been and will continue to be in formulat