SECTION ON SURGERY. 1. Chairman's Address-The Early Routine Extirpation of all Neoplasms. Bacon Saunders, M. D., Fort Worth. Tuberculosis of the Shoulder Joint, with Radical Operation for Its Removal. W. L. Allison, M. D., San Antonio. 3. Reflex Conditions Complicating Movable Kidney, with Report of Unusual Case. J. M. Inge, M. D. Denton. 4. Exstrophy of the Bladder-Treatment of Successful CaseImplantation of Both Ureters in Rectum by the Method of Maydl. James E. Thompson, B. S., F. R. C. S., Galveston. 5. Traumatic Lumbago (Traumatic Dorsalis). S. C. Red, M. D., Houston. 6. Intestinal Anastomosis by a New and Simple MethodReport of Case. A. C. Scott, M. D. Temple. 7. Tumors on the Breast, with Special Reference to Their Early Recognition and Treatment. M. Smith, M. D., Sulphur Springs. 8. Anatomy of a Case of Cystic Adenoma of the Thyroid Gland. Wm. Keiller, F. R. C. S., Galveston. 9. Amputation of the Hip Joint, with Report of Successful Case. W. J. Mathews, M. D., Austin. 10. The Management of Club Foot. R. W. Knox, M. D., Houston. CHAIRMAN'S ADDRESS. THE EARLY ROUTINE EXTIRPATION OF ALL NEO PLASMS. BACON SAUNDERS, M. D., FORT WORTH. Until the etiology of tumors is more definitely settled, there must of necessity be considerable lack of unanimity in their treatment in accordance with the views of the surgeon as to their causation, morphology, clinical history, etc. There are so many things to modify the treatment under all the manifold circumstances of the growth and development of neoplasms that it is scarcely reasonable to hope that the time will ever come in the history of tumor surgery when a uniform and universally applicable rule of procedure can be laid down for all cases. While this must be recognized as almost a truism, it is, nevertheless, none the less desirable to formulate from time to time, as increased knowledge and experience seem to warrant, some generally accepted and practiced method of treatment that is as universally adaptable as possible. Modern surgical technique and increased opportunities for observing the end result after operative treatment in an ever-increasing number of cases have brought about a wonderful change in the last few years. This has brought within the field of operative cure neoplasms formerly thought to be out of the reach of the most heroic surgery. Unquestionably great as have been these strides of advancement both in method and results, is it not possible to make yet greater improvement, notwithstanding our lamentable ignorance of the real cause of the essential properties that tend to a fatal termination in a number of the different varieties of neoplasms? The gain hitherto made in the treatment of tumors from almost the very dawn of surgery has been due to two principal factors: the technique that permits union without suppuration; and the general belief in the probable fact that in the beginning all tumors, innocent and malignant, are local in origin, and the consequent early excision of those known to be malignant. It is susceptible of easy demonstration that just in the proportion that the surgeon has recognized these factors and made them his rule of "faith and practice," so has the ratio of his success in treating tumors increased. Owing to difficulties in differential diagnosis of benign and malignant growths, that all of our boasted methods of scientific precision have not yet enabled us to overcome, the perfect results that should follow treatment founded on the recognition of these two factors have not been obtained. In other words, it is but the statement of a common and well known truth to say that thousands of cases end fatally every year because the surgeon is not able to decide positively of their malignant nature until past the time for the successful application of even the most faultless and radical technique. Failure in such a case can not, in fairness, be chargeable either to the operator or his method, but rather to the rule that compels him to wait for signs of malignancy in the neoplasm before resorting to operation. There can be no safety in such a rule so long as the diagnosis between an innocent and a malignant growth can not be made absolute, and that, too, in the very beginning. That neither the science of surgery nor its allies, pathology and bacteriology, afford the means of such accurate and absolute diagnosis, the daily life of every surgeon shows only too plainly and sadly. None of us but what can recall numerous cases where the growth at first gave every indication both in situation, history, physical and even microscopical appearance of innocence, and was supposed to be harmful only by the "accident of its size. and situation" that afterwards proved most malignant and fatal. So prone are all neoplasms to undergo malignant degeneration, or to furnish favorable conditions for the development of malignancy that it seems a safe, practical generalization might be formulated that no tumor, no matter what its apparent nature, is safe from malignant changes until it is either removed from the body or the patient having it is dead. Great and even brilliant as have been the achievements of modern surgery,-and they are both great and brilliant,-it has given us no cure for any considerable number of malignant growths other or better than that handed down from the fathers: their early and complete removal. This proposition must be accepted as true and leaves no room for the discussion here of the possible cure of a very limited number of neoplasms by other agencies. This possibility does not in any way change the truth of the general proposition that the only known cure for malignant neoplasms is their early and entire removal by the knife, or their complete destruction by some other equally effective method. It is not the purpose now to discuss any of these methods other than the knife, valuable and effective as they are sometimes under proper circumstances and with the right kind of restrictions thrown around their use. Much less is it necessary to mention in this presence the changes and degenerations that are observed to take place in tumors, the early behavior of which indicated characters the most benign. There is hardly a variety of benign tumor that has not been known to present at some period of its history characteristics that have made it a menace either to the life, usefulness, or happiness of its possessor. This aside, too, entirely from the question of malignancy. Malignancy is not by any means the only condition that takes place in the life of a neoplasm that makes it a danger and an ever-increasing burden and torture. Nowhere in the whole constantly broadening domain of surgery is there greater opportunity for the formulation of a truly democratic rule of procedure that will indeed guarantee "the greatest good to the greatest number." From this point of view it is believed it would be wise, and more in accord with surgical teaching and practice in other conditions, to remove early and completely (preferably and generally by excision) every neoplasm without regard to its apparent nature. The experience of every surgeon will suggest so many good reasons for the adoption of this practice and so few real objections to it that it would seem that opposition to it is not to be looked for from that quarter. It is expected that those who cure tumors by "the laying on of hands," the exercise of faith, and other occult practices, will raise a great "hue and cry" against the adoption of such a rule. "Ephraim is joined to his idols! Let him alone!" Earnest, conscientious surgeons are too busy in their efforts to save human life and prevent suffering and disability to slap at every fanatical gnat that swarms in the atmosphere of scientific progress. The rule for the early and complete removal of all neoplasms, regardless of their apparent nature, it justified in many cases by esthetic reasons. They all grow and increase in size, and the earlier they are removed the less the deformity caused by their presence, and the less disfiguration consequent upon their removal. The operation now is a mere bagatelle, both from the standpoint of possible danger and the possibility of scar or disfigurement, as compared with a later time. Many of them can be excised under the different kinds of local anesthesia, and their removal scarcely amounts to the dignity of an operation. All this without taking into consideration those conditions that may come about in any neoplasm that will make it an unpleasant and unwelcome guest from other than esthetic reasons, not to mention those that make a cure problematical or certainly impossible. The infinitesimal dangers from the occasional removal by this rule of a tumor that might never give serious trouble from its size, situation, or untoward metaplasia are not to be compared to those that may happen, and are happening every day, from waiting for some signs of danger before operation is undertaken. It is indeed a question worthy of the most thoughtful and serious consideration whether it would not be advisable from every point of view, at least in the present state of our ability, to make an early and definite differential diagnosis between innocent and malignant growths, to suspect every tumor of malignancy and treat it accordingly rather than to presume on its innocence until malignancy is established. If this rule were rigidly applied to all |