SURGERY OF CONGENITAL HEART DISEASE BJxoRsH 671 congenital heart disease there were almost equal numbers in each year up to 7, three-fifths of this number in each year from 8 to 11, and one-fifth of this number in each year from 12 to 22, after which there were only scattered cases. The figures suggest that those surviving infancy have no great 'risks until they reach the age of 7, though clinical experience hardly bears this out. After 7 the chances of surviving become less, and increasingly so after the age of 12.If these figures can be taken as giving a true crosssection they mean that only one patient in ten reaches the age of 24 and only two in ten the age of 12. Many parents have been told that their children will not live to 7 or to 14 or to 21, and there seems some rough truth in these three round numbers as representing periods of increasing danger beyond which survival becomes less likely. During the last few months there have been some deaths after operation, but there have been many more among the other patients I have seen. These considerations seem ample justification for advising operation in spite of the relatively high mortality. The operation is essentially an anastomosis between a systemic artery and the pulmonary artery, most commonly an end-to-side subclavian-pulmonary anastomosis, though under special circumstances the innominate or carotid artery may be used or the anastomosis may be end-to-end. In onequarter of these cases the aortic arch will be right-sided instead of curving back as usual to the left and this will of course change the position of the innominate artery. The operation should be performed on the side opposite to the aortic arch because this gives a greater choice of systemic vessels that can be used and the subclavian artery can generally be turned down to the pulmonary artery with a less acute angle.In infants the small size of the vessels produces a surgical problem of the greatest difficulty, and the operation is much more dangerous and sometimes less lasting in its good effect because the anastomosis is too small as the child grows larger. For Results of OperationThe operation is not of course curative in the same way as in the other two groups because the underlying abnormality remains, but the improvement may be so great that the child appears normal to the parents. The immediate upset caused by the operation is less than might be expected, and intravenous fluid is often not required; when it is used only small amounts are needed. Many have a pleural effusion that often needs aspiration, but generally only once; other complications are not common. Of the first 38 cases operated on at Guy's Hospital 6 died, 7 could not have an anastomosis done or did not benefit much, and the remaining 25 were enormously improved almost at once, and this has been maintained.The immediate results of the operation are excellent, and the improvement seems to be maintained over the period of two to three years for which it has been possible to follow up Blalock's patients. The colo...

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We know the main facts abouit cancer. We know it is the chief cause of death in men and women in the years after 40-the time when they have established a place in life, a home, a reputation, when they are most useful to their profession and their country and most necessary to their families. We know that at first it is not a tumour but an insensible transformation of the cells in some part of the body to a structure that is a caricature of the normal rather than something new or different; that this new tissue has no nerve supply, and that it produces no inflammatory reaction in the normal parts surrounding it-in other words, that it is entirely painless, and in most cases entirely symptomless. We know that, for purposes of recording, cancers can be sorted into three stages, based on their gross naked-eye pathology: Stage I, in which there is a local growth only; Stage II, in which as well as the local growth there are early metastases in the nearest lymphatic glands or in tissues immediately adjacent; and Stage III, in which the primary growth or the metastases are fixed, or more distant organs are involved. We know also that in those parts of the body which can be effectively irradiated, or where a radical operation that satisfies pathological criteria can be performed-the breast, the colon, the rectum, and most parts of the skin-the five-year cures in Stage I are 80 to 90%, in Stage II about 50%, and in Stage III not more than 10%.Radiation will improve, but it is doubtful whether that improvement will be dramatic. Radical surgery can hardly get more radical, for the limitations now set are not the result of timidity or lack of enterprise but are rather due to Charles-Mayo's stipulation that among the results of successful surgery should be a live patient. If, therefore, we are to get more cures it can only be by finding more patients in Stage I, the stage of silence.Two of the most malignant of all growths are those of the oesophagus and the stomach. Cure of oesophageal cancer is almost unknown. Cure of gastric cancer is sometimes seen, but in not more than 5% of those cases that come to a surgical clinic; yet it is the commonest of all malignant growths, and the chief cause of cancer deaths in all civilized countries in which records are kept. There are no signs or symptoms by which we can diagnose these diseases in their early stages, but are there any which should raise our suspicions and allow us to start those investigations that will give the answer in time? It is those early signs that are the hardest to discover, and many of you may have observed some warning sign that the rest of us have not noticed. If you have I hope that you will share it Those who were in the first World War will remember the " stand to " in the front trenches an hour before dawn, the hour when mists and half-shadows conceal familiar objects, the hour when the enemy may creep unseen, when a suspicious alertness is the only way to safety. We should all " stand to " over our patients who have passed the forty mark, suspicious of t...

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