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MY stand on the treatment of breast cancer has been widely misunderstood. Many surgeons believe that I advocate what the British call "lumpectomy" and irradiation. Nothing could be further from the truth. I do, however, stand firmly against the traditional radical mastectomy. I consider it to be archaic, and I believe that it has no place in the modern treatment of breast cancer.I strongly support modified radical mastectomy. It is primarily indicated for a patient who, at the time of operation, has palpable involvement of a few low or central axillary nodes. If the involvement is extensive, however, and particularly if the nodes at the apex are palpably involved, I agree with Haagenson that the axilla should not be dissected. It is better to rely on irradiation to control the cancer in the apical, supraclavicular, and internal mammary nodes.In patients who at the time of operation have no

Though signal advances have been made recently in many surgical problems, the treatment of cancer of the head and neck has, it would seem, neither received the attention nor kept the pace of progress in other fields. These unhappy cases are too often regarded as specters at the clinic. The operative treatment is hampered by tradition and conventionality, and the tragic ending of so large a proportion of these cases has held back lay and even professional confidence.In this paper it is intended to present an outline sketch of the conclusions regarding the surgical treatment of cancer of the head and neck in the curable stage. The etiology, the diagnosis and the pathology will not be considered. It is generally admitted that cancer is primarily a local disease. Each case, then, is presumably at some period curable by complete excision.The immediate extension from the primary focus is principally

The physiological basis for the use of vagotomy in the treatment of duodenal ulcer rests on two findings: (1) patients with duodenal ulcer have increased nocturnal gastric secretion of hydrochloric acid and (2) complete vagotomy abolishes the increased secretion.11 Excellent clinical results from the use of subdiaphragmatic vagotomy with gastroenterostomy in duodenal ulcer have been reported by Dragstedt, Crile, and others.2 An unpublished report of a nation-wide survey conducted by the vagotomy committee of the American Gastroenterological Association in 1950 cited excellent results from the operation in nearly 98% of the patients. Other reports have indicated an unsatisfactory experience with the operation, and the 1951 report of the committee mentioned above was less impressive than that of the preceding year, although there were still about 94% of patients satisfied with the results of the operation.3Because of these conflicting views, further studies on the long-term results of

The animals were all reduced to full surgical anesthesia by ether before the experiments were begun, and were killed before recovery therefrom. Respiratory tracings were obtained by means of a rubber tambour, attached to a canvas band, encirling three-fourths of the circumference of the animal's chest. This energized a writing style attached to an organ-key mechanism. Respiratory tracings were obtained very accurately. Blood-pressure was recorded by means of a mercury manometer. The drums were revolved by a mechanism so made as to be capable of a variety of movements, ranging from one revolution in thirty minutes to eighteen per minute, so that any phase of any given tracing might be duly recorded. The following is a part of a rather extended research, which enabled us to estimate the reliable reduction with comparatively few experiments.Surgeons have not infrequently encountered, in performing a laryngotomy, sudden collapse at the moment when the

In recent years the widespread publicity given to the subjects of cancer detection and prevention, the emphasis on periodic physical examinations and the development of cancer detection centers has resulted in an increased cancer consciousness in the population at large and in the medical profession. Therefore, physicians are being consulted oftener regarding the potential malignancy of benign lesions. Notable among these are nontoxic nodular goiters.Few physicians would deny that firm discrete adenomas of the thyroid should be removed. The controversial question is whether to advise removal of soft nontoxic nodular enlargements of the thyroid. Many of these goiters are not enlarging or causing symptoms, and the patients often are unaware of their presence until they are found on a routine physical examination. EXPLANATION OF THE HIGH REPORTED INCIDENCE OF CARCINOMA OF THE THYROID There

EFFECT ON PERIPHERAL NERVE TRUNKS. The injection of eucain or cocain into a nerve trunk so as to place all its structures in contact with the drug produces an effectual physiologic "block." By the word "block" is meant such condition of the nerve that neither afferent nor efferent impulses can pass, the conductivity being as completely interrupted as if the nerve were divided. While general anesthesia prevents the appreciation of pain and the production of voluntary motion, it does not prevent such other afferent impulses as those caused by mechanical, thermal or electrical stimulation of the nerve endings or trunks, which produce changes in the frequency and the amplitude of the respirations, in the frequency and force of the heart beats, and in vasomotor action. Either eucain or cocain injected into a nerve trunk as above described prevents the passing of such afferent impulses, thereby preventing effects upon the respiration,

Lateral aberrant thyroid tumors occur as the result of an anomaly in the development of the thyroid gland. Histologically these tumors are not composed of normal thyroid tissue but have a papillary structure indistinguishable from that of papillary tumors of the thyroid.In forty-five of the 136 reported cases of tumors arising in lateral aberrant thyroid tissue, as shown in the accompanying table, the growth has been classified as malignant. Yet only two of the forty-five patients have been reported to have died as a result of recurrence of the tumor following operation. In no case has either local or distant metastasis of the tumor been proved. The remarkable survival record of the patients cannot fail to raise the question of whether or not the tumors were true carcinomas.Many of the tumors in the collected series were described as showing extensive metastasis to the cervical lymph nodes. Similarly it

A syndrome of profuse watery diarrhea, hypokalemia, and hypercalcemia, without gastric hypersecretion or ulcer is associated with pancreatic adenoma. Excision of a parathyroid adenoma and then hyperplastic parathyroid tissue temporarily relieved symptoms and restored serum calcium and serum potassium values to normal. The profuse watery diarrhea, hypercalcemia, and hypokalemia were permanently relieved by excision of a large pancreatic adenoma after recognition of the syndrome. The genetic aspects of this syndrome were demonstrated in the case presented. Of 14 members on the patient's paternal side, three had pancreatic adenomas, six had renal stones, and five had intractable peptic ulcers. Endocrine adenomas, frequently multiple, were seen in the patient and in two relatives.

CLEVELAND INTRODUCTIONThe species of animal now dominating the earth more completely than any other is at this moment in a state of abnormal activity — the back-wash of the European war is seen in the quickened pulse everywhere even in this land. Not only in war, but in peace also, the complicated machinery of civilization created by man often drives him to his own destruction. Nowhere is this industrial and commercial driving more intense than in this city. It has occurred to me, therefore, that it might be interesting to attempt an analysis of the mechanism by which this speeding is accomplished, and relate it to the speeding which is due to other stimuli such as infections, autointoxication, physical injury, etc. Since the process of speeding is identical with that of the transformation of potential into kinetic energy, the state of increased energy transformation might fittingly be called

The basis for this paper is a critical study of 472 operations on the stomach performed by my associates, Drs. Bunts and Lower, and myself, and in the records of Lakeside Hospital. Of these, 132 were performed by Dr. Lower and myself in accordance with the principle of anociation, these cases including explorations in cases of inoperable cancer, resections, and gastro-enterostomies for cancer and ulcer. Among these 132 cases there have been three deaths, a reduction from the former mortality rate in like cases of not less than 3:1. In but one other field is anociation so strikingly beneficial — in the surgical treatment of exophthalmic goiter.Originating in the great school of Vienna, fostered in Germany, its progress accelerated by Mayo-Robson, given a classic status by Moynihan, mechanized by Murphy, and culminating in the Mayo Clinic, the great field of gastric surgery through trial and error, progress and extension

For purposes of this paper, I shall divide surgical operations into two general classes: first, operations Performed on patients in fair fair general health; second; injury or disease. Belonging to the first class are: laparotomies for benign tumors of the uterus and ovaries,simple gastro-enterostomies, appendectomies, unoperations on patients whose vitality is impaired by complicated operations on the gall-bladder, the kidneys and the urinary bladder, uncomplicated herniotomies, excision of cancer of the breast, excision of benign tumors of thethyroid and simple goiters; in these the operative mortality has all but disappeared. Among 10,723 surgical operations performed by me, 4,127 belonged to this class; among these there was one death in 375 operations. There is but little advantage, therefore in any discussion of this group of cases so far as the immediate risk is concerned; but while the immediate risk is slight, these operations still bear a certain stigma, viz., a temporary nervous

Since the inauguration of the aseptic era the mortalityrate in abdominal operations has been falling steadily and to-day there are practically no deaths from simple abdominal operations for conditions unaccompanied by organic disease or infections.This reduced mortality-rate is due in part to an improvement in technic, but very largely to the exercise of an increasingly critical judgment on the part of the surgeon in his selection of cases.The technic has become standardized for such routine operations as the removal of benign tumors of the pelvic organs and for operations for chronic pyosalpinx, procidentia, prolapsus uteri, etc. The rare fatalities which occur in these apparently favorable cases result from some unforeseen and as yet uncontrollable factors such as embolism.The results secured by the individual surgeon have cometherefore to depend on two factors: his mastery of general operative technic and his policy in the selection of cases for operation.

A just presentation of the status of surgery in any subject is as difficult as the honor of presenting it here is high, for the forward movement in research and investigation in the whole field of medicine is world-wide and aggressive, and singularly effective. Events follow each other so swiftly that the profession itself requires an almost daily readjustment. Is there within the past generation in any other department of human endeavor a record of so. many basic discoveries as in medicine? Who can read the triumphs of preventive medicine, of biochemistry, of physiology, of pathology, without pride?Surgery has all but conquered the infections and benign tumors of the pelvic organs, of the kidney, of the appendix, and of the gall bladder; it has mastered the complications of gastric ulcer, it has cured hernia, removed goiters and corrected deformities. All these are, or may be, serious operations, and yet

Nineteen patients with metastases from histologically proved papillary carcinomas of the thyroid were treated by daily feeding of 0.2 to 0.3 gm (3 to 5 grains) of desiccated thyroid. Twelve of these patients (11 with metastases in lungs and 1 with an inoperable cancer and metastases in cervical nodes) have shown either regression of metastases or arrest of their growth for periods varying from 5 to 16 years and averaging 11 years. The cancers of seven remaining patients failed to respond to the treatment with desiccated thyroid or to any other type of therapy and the patients died with progressive growth of their metastases. The incidence of favorable response to feeding of desiccated thyroid was much higher in patients less than 40 years old than in those more than 40, and control was also obtained more frequently in those patients whose cancers had developed after radiation therapy of the neck for benign disease.

Subacute thyroiditis can be defined as an acute or chronic self-limited inflammation of the thyroid gland, which is probably initiated by a virus infection and prolonged by a granulomatous reaction to displaced or perverted colloid.SYNONYMSMany names have been given to the various inflammatory lesions involving the thyroid gland. Subacute thyroiditis, for example, has also been called pseudotuberculous thyroiditis, tuberculous thyroiditis, sclerosing tuberculosis, struma granulomatosa, granulomatous thyroiditis, giant cell thyroiditis, pseudo-giant-cell thyroiditis of de Quervain, struma fibrosa-giant cell variant, acute simple, acute noninfectious and acute nonsuppurative thyroiditis. Other types of thyroiditis such as struma lymphomatosa (Hashimoto) and Riedel's struma are distinct entities unrelated to subacute thyroiditis and are not considered in this study.1CLINICAL ASPECTSThe clinical course of subacute thyroiditis is variable but two rough categories can be recognized: (1) the acute fulminating type with fever, pain, exquisite tenderness and severe systemic symptoms; and (2) the chronic

Though signal advances have been made recently in many surgical problems, the treatment of cancer of the head and neck has, it would seem, neither received the attention nor kept the pace of progress in other fields. These unhappy cases are too often regarded as specters at the clinic. The operative treatment is hampered by tradition and conventionality, and the tragic ending of so large a proportion of these cases has held back lay and even professional confidence.In this paper it is intended to present an outline sketch of the conclusions regarding the surgical treatment of cancer of the head and neck in the curable stage. The etiology, the diagnosis and the pathology will not be considered. It is generally admitted that cancer is primarily a local disease. Each case, then, is presumably at some period curable by complete excision.The immediate extension from the primary focus is principally

The possibility and efficiency of the practical application of the administration of iodin for the prevention of goiter as a public health measure were definitely established by Marine and Kimball in their classical experiment in the public schools of Akron, Ohio, in 1917. As the result of that study, the application of this principle of goiter prevention has been extended to various endemic goiter districts in this country and abroad, so that today children in various parts of the world are being benefited by prophylactic treatment, and the incidence of goiter is by so much diminishing.For a practical consideration of the problems of goiter, we may consider three abnormal states of the thyroid gland—hypothyroidism, malignancy and hyperthyroidism.HYPOTHYROIDISM (SIMPLE GOITER)The problems presented by simple goiter are comparatively easy of solution.1. Prevention.—I have already referred to the possibility and duty of preventing the incidence of simple goiter

Ileostomy is the main cause of complications in the surgical treatment of chronic, nonspecific ulcerative colitis. The principal complication is ileostomy dysfunction (obstruction) in the immediate postoperative period. The importance of this complication cannot be overemphasized. In a review of 210 patients undergoing ileostomy, Warren and McKittrick1 reported that 62% of their patients had dysfunction. Of 37 deaths in that series, were attributed to dysfunction of the ileostomy and its sequelae and 3 others were thought to have been possibly related to ileostomy dysfunction. The number of deaths from ileostomy dysfunction was second only to the number of deaths from peritonitis. Today, with the decreasing incidence of fatal postoperative peritonitis, it would appear that the ileostomy itself constitutes the primary postoperative hazard.Our experiences with the ileac stoma have led us to believe that the construction of the conventional ileostomy violates a fundamental surgical principle, i. e., the vulnerable serosa of the ileostomy is left exposed. Inflammatory changes in the projecting ileostomy are

It is the purpose of this paper to restate the principle of anoci-association as applied to surgical operations, to describe its application, and to present the results of operations by this method as compared with an equal number of operations performed by other methods.My argument assumes that physical action and emotional activity are only expressions of motor stimulation; it assumes that there are in every active animal and in man stores of energy which when released are expressed in motion or emotion; that when these stores of energy are consumed fatigue or exhaustion is produced. The stored energy of the body may be discharged by physical injury of sensitive parts of the body, by emotional excitation or by physical exertion.It is of highest importance to know that inhalation anesthesia does not prevent injury impulses from reaching the brain-cells and making them discharge their nervous energy, thus causing exhaustion

For many years, surgeons have accepted the old maxim that the smaller the cancer, the bigger the operation should be. It has been said that the chances of cure are best when a small cancer, without apparent metastasis, is treated by wide removal of the primary tumor and the lymphatics and lymph nodes that drain it. On the other hand, many surgeons believe that patients with advanced cancers that have metastasized extensively to nodes often should be treated palliatively by relatively small operations.There is mounting evidence from the field of immunology that the old adages are false and their opposites may be true. It now seems that removal of uninvolved regional nodes that drain small tumors may lower the patient's immunologic resistance to the implantation and growth of distant metastases. On the other hand, radical removal of large cancers and the nodes to which they have metastasized may prolong

The experience in abdominal surgery in the great war may be discussed under the following headings: (a) comparison between the intestine of the average soldier and of the average civilian; (b) the factor of exhaustion—the effect of cold and wet; (c) the time factor; (d) the comparative effects of lesions of the solid and of the hollow viscera; (e) combined thoracic and abdominal wounds; (f) the phenomena and treatment of internal hemorrhage; (g) the prevention and treatment of shock, before, during and after operation; (h) the anesthetic factor; (i) the incidence of bronchopneumonia after abdominal operations; (j) retroperitoneal infections; (k) the treatment of peritonitis; (l) operative technic, and (m) comparison with civilian abdominal surgery. COMPARISON BETWEEN THE INTESTINE OF THE AVERAGE SOLDIER AND OF THE AVERAGE CIVILIAN Soldiers whose general condition had not been too greatly impaired by exhaustion from fighting, by wet and cold, or by shock or hemorrhage

The theory of shock so ably advocated by my gifted friend Professor Henderson and my theory may in many important respects be harmonized. It seems best, however, to leave that to the future and to proceed at once to the presentation of the summaries of a long series of experiments and clinical observations in support of the kinetic theory which I have proposed elsewhere. This theory is called the kinetic theory because it is based on the phenomena and the consequences of the transformation of latent energy into kinetic energy as an adaptive response to environmental stimuli.In this paper, therefore, I shall discuss the pathology of traumatic shock; of emotional shock; of toxic and foreign proteid shock; and of drug shock. These several forms of shock will be considered in their acute and in their chronic stages and certain probable relations will be indicated between the several forms of

Civilized man has many diseases and infirmities in common with primitive man and the lower animals— accidents of birth, irregularities of adolescence and nutrition, cancer, infections and infectious diseases. On the other hand, there are certain diseases such as hyperthyroidism, neurocirculatory asthenia, peptic ulcer, diabetes and other less clearly defined diseases that are peculiarly the lot of civilized man. One should expect to find, then, that the mechanism the disturbance of which produces these diseases would be the mechanism on which civilized man's characteristics depend. The one characteristically human organ is the brain; the rise of the brain and its dominance has won for man his place in nature. It is characteristic of civilized man that his life is projected on rational lines, that it is full of work and worry as compared with that of the lower races of man and the lower animals.One would expect, therefore, that

The literature of the work hitherto done to discover some blood test for cancer is presented by Richard Weil.1 The technic followed in our work at Lakeside Hospital is based on that in current use, modified to meet clinical requirements.I have heretofore reported for the American Society of Cancer Research our observations on hemolysis in malignant tumors. This is in the nature of a report of progress in our investigation. The technic has been greatly improved and now seems to be quite accurate. It is exacting, must be precisely done, and every step amply surrounded by checks and controls.Dr. D. A. Prendergast made the first series of observations, after which Miss Ora Lewis took all the responsibility of the technic for seven months and made many improvements during the period of her painstaking work. Dr. A. M. Tweedie has been carrying on the work since Miss Lewis'

INTRODUCTORY. During the past eleven years I have conducted and experimental laboratory, in which some of the problems suggested in surgical practice have been investigated. On some we failed to throw any light; in some our results were inconclusive; and in others therir solution seemed to have been found, or at least useful data obtained. These were published in four monographs, to wit: "Surgical Shock," 1897; "Research into the Surgery of the Respiratory System," 1899; "Problems Relating to Surgical Operations," 1901; "Blood Pressure in Surgery," 1903.On the clinical side during a corresponding period, we accumulated notes on 5,800 major operations in general surgical service, including every variety excepting certain operations on the eye and ear.The discussion of the various operations is only from the restricted viewpoint of the title of this paper. In the experimental as well as the clinical Work my associate, Dr. W. E. Lower, was actively engaged during this time and shares fully with me the responsibility for the results.

Among the total of 2,169 operations for goiter which have been performed by my associates and myself, 1,020 have been for exophthalmic goiter.This statement at once suggests the query, On what basis were the cases of exophthalmic goiter differentiated from the other forms of goiter? Our rule has been to class as exophthalmic goiter every case in which, at the time of operation, there are symptoms of increased basic metabolism not due to any current exciting cause, and in which these symptoms are relieved or cured by diminishing thyroid activity. THE RÔLE OF THE THYROID IN EXOPHTHALMIC GOITER Among our cases we have seen no normal thyroids, hyperplasia being present in about 70 per cent.; most of the remaining 30 per cent. being adenomas, with a few colloid goiters (Marine, Graham).That hyperplasia is not a cause but a concomitant effect of exophthalmic goiter is shown by the following

During the past year a series of seventy-four carefully conducted experiments on the direct transfusion of blood in the treatment of hemorrhage in animals was made by Dr. Dolley and myself, and from these experiments the following conclusions were drawn:Arteries and veins of varying sizes may be readily anastomosed by Carrel's method so as to be impervious to blood and free from clotting; the transference of blood from one animal to another is most definitely accomplished by anastomosing the proximal end of an artery of the donor into the proximal end of the vein of the donee; convenience need be the only consideration in the selection of the vessels to be anastomosed; the blood of one animal may be rapidly transfused to another; the blood of one dog is isontonic with that of another dog; if a dog be bled to the last drop of blood that will flow,

The principal resources at present for the treatment of hemorrhage may be included in the following:(a) The administration of various fluids, such as normal saline, Ringer's or Locke's solution; (b) posture; (c) bandaging or other means of compressing the extremities and the abdomen; (d) stimulants.The effect of stimulants diminishes with the increasing gravity of the hemorrhage, and in every progressive case a stage is finally reached in which the anemic centers no longer respond. The heart muscle, however, retains much of its susceptibility to such drugs as digitalis, and may be functionally seriously damaged by the injudicious administration of this drug. Posture and bandaging may be considered together, as their aim is that of throwing as much of the diminished quantity of blood to the heart and the brain as is possible to help tide over the crisis. It is at once obvious that such measures are strictly

In reviewing the records of 893 operations on the biliary tract and 331 operations on the stomach performed by my associates, Dr. Bunts and Dr. Lower, and myself, together with those performed by other surgeons at the Lakeside Hospital, we find that the clinical course of certain patients after gastric resections and after common-duct operations is similar in many respects. At the time of operation pulse and temperature are normal, but the patient is emaciated and sallow in appearance; his vitality is much reduced; his demeanor is melancholic and he is alternately possessed by hope and despair. After the operation his downward course and exit strikingly resemble the sinking and disappearance of the unwary traveler who has been trapped by quicksand.Statistics show that no clinic has ever reduced the mortality rate of any considerable series of resections of the stomach below 10 per cent., and the mortality rate of

IN THE field of cancer we have seen the emergence of many radical ideas about treatment. Most of them, like Lysenko's concepts of evolution, were soon forgotten. I refer to the routine use of radical total pneumonectomy for cancer of the lung, radical prostatectomy for stage I and II prostatic cancer, total gastrectomy for cancers of the distal part of the stomach, total thyroidectomy and classical radical neck dissection for all papillary carcinomas of the thyroid, and the extended radical mastectomy for medial quadrant cancers of the breast. I believe that the conventional radical mastectomy also will follow Lysenko's theory—on the path to oblivion.To me, the most disturbing part of Anglem's paper is his almost paranoid criticism of all who do not agree with him, especially his personal and bitter attack on Dr. Vera Peters. Fortunately, Peters' reputation can stand by itself, for it was she who first conceived

It is sometimes desirable to treat open wounds by application of penicillin solution. In cases when a penicillin saturated pack cannot be applied in such a way as to reach all the recesses or when the contour of the wound is such that it will not hold the solution, a device for sealing the entrance of the wound to retain the solution is of value.In patients with external biliary fistulas the constant saturation of the dressings with bile makes the patient wet and uncomfortable. The same is true in the case of fistulas of the small intestine, and in addition secretions digest the skin if it is not protected. There is often a need for a device which will collect the secretions and at the same time protect the skin.The need for some way to collect the fluid and protect the skin was quite urgent in the case of a

ELSEWHERE in this issue of Elsewhere Journal, page 405, is presented a reasonable plan of treatment for asymptomatic thyroid nodules. The line of thought therein contrasts sharply with the opinions of some who believe (and can prove by statistics) that nodules in the thyroid are of no consequence. It contrasts also with the opinions of others who believe (and can prove by statistics) that all thyroid nodules should be removed. The author of the plan believes (and can prove by statistics) that some thyroid nodules should be removed and that others should not.The confusion of opinions and statistics in medical teaching is not limited to nodules of the thyroid. The treatments for gallstones, gastric ulcers, and polyps of the colon also have been subjected to the "all-or-none" principle. Yet to these and to many other problems there may be reasonable clinical and statistical approaches.Although it is not known

After exhaustion or shock due to the condition for which operation is performed; after starvation from cancer or obstruction; after hemorrhage from perforating ulcers, etc., or following the physiologic disturbance produced by an operation itself—for instance, resection of the stomach, of the gallbladder, of the intestine, etc.—the most common danger incident to abdominal operations is infection. In civilian surgery, the principal sources of abdominal infection are the appendix, the gallbladder, the tubes, ulcers, or the operation itself; while in military surgery, infection may be due to missiles, clothing, or the contents of the hollow viscera—especially the last.It follows that a consideration of methods of prevention and treatment of abdominal infection has a direct bearing on every type of abdominal operation. The scheme of treatment to be presented is based on a total experience in all types of operations of my colleagues Dr. F. E. Bunts, Dr. W. E. Lower

If we view man and the lower animals as adaptive mechanisms, governed by the universal laws of physics and chemistry, then we must believe that every phase of human or animal behavior is occasioned by and in turn occasions physical and chemical changes in the body. Therefore an understanding of the vast alterations in the behavior of the anesthetized organism— changes which may range from the slightest depression of mental power through progressively deeper stages of unconsciousness to death, necessitates a search for the physical and chemical changes caused by the anesthetic. Accordingly, in this study we shall consider (a) the gross behavior of the anesthetized individual in a consideration of the relation of anesthesia to normal sleep; (b) the influence of ether and of nitrous oxid on the histologic structure of certain organs; (c) the relation of ether and of nitrous oxid to the hydrogen-ion concentration of the blood

Drainage of the common duct presents three dangers: much bile is lost, cicatricial contraction occasionally occurs, and should the drain-tube be occluded, or even if it be not occluded, bile may escape into and infect the peritoneal cavity beyond the field of operation.Owing to an interesting physiologic fact, the loss of bile may become a serious danger—a danger which is usually overlooked—as normally the bile passes through the intestinal tract, and the bile-salts are reabsorbed, return to the liver, again become a constituent of fluid bile, and thus continue their circuit. The continuous loss of bile by drainage in a good-risk patient may cause no apparent damage, but in elderly subjects and in poor risks from any cause, the steady loss of bile-salts and of fluid may prove fatal. In gallbladder drainage the bile can be collected and, as Yates has suggested, may be returned to the bowel; but

When the vasomotor center is exhausted stimulants such as strychnin are either valueless or harmful, because if the center is wholly exhausted it can have no effect, and if partially exhausted the stimulation will be followed by a deeper depression. Shock may be as readily induced by vasomotor stimulants as by injuries or operations; the former belong to the class of internal stimulants, the latter to that of external stimulants. Neither can be employed with advantage in the treatment of a shock produced by the other. Alcohol should be classed as a depressant. Nitroglycerin is of advantage only in certain diseases of the arteries. In digitalis the vasomotor factor in its effect is objectionable on the same grounds as that of strychnin. As to the cardiac factor in the action of digitalis, an increase in the heart's action, per se, has but a limited effect on the

To the Editor.—I have read with interest Dr Laforet's scholarly communication on informed consent, and I agree that it is possible to carry its principle to absurd lengths. However, I do stand firmly behind the lines he quoted from my article on "Breast Cancer and Informed Consent."There is a vast difference between not informing a patient of all possible complications that could occur after a standard operation, eg, repair of a hernia, and not informing a patient about the various alternatives for treating a clinical stage I cancer of the breast. Since there is no agreement among authorities in the field of breast cancer, I think it is imperative that the patient be so informed. Only if she knows this can she participate in the making of the decision.The same principles apply to the treatment of small, low-lying rectal cancers. The patient should be informed that many

Spontaneous rupture of a visceral vessel into the peritoneum or between the leaves of the mesentery has occasionally been reported in the literature, but it has usually been associated with trauma, intra-abdominal disease or malignant growth. Spontaneous rupture of a visceral vessel due to arteriosclerosis and hypertension is an extremely rare occurrence as judged by the reports in the literature, although most of the authors express their surprise that this phenomenon does not occur more frequently. The case presented here apparently belongs to the latter group of rare cases of abdominal apoplexy caused by marked arteriosclerosis and hypertension. We use the word "apparently" because in this case the exact site of rupture was not located.In reviewing the literature we found that ten previous cases of abdominal apoplexy associated with arteriosclerosis and hypertension have been reported: (1) Hilliard's1 case in 1918, (2) Starcke's2 case in 1923, (3) Green