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The pathogenesis is not known. The treatment is the treatment of the hysteria.

The headache of epilepsy is, in my opinion, a pressure headache. A lumbar puncture in such cases invariably demonstrates a high fluid pressure, and the pain, dullness, and sense of fullness and oppression are relieved by withdrawal of fluid, in some cases a considerable amount of fluid.

Trauma to the head is usually followed by headache. If the skull and underlying dura are injured, adhesions may result, and the headache continue for years. If the shock produce a secondary neurasthenia, the headache is of the neurasthenic type. If the trauma but cause concussion of the brain, a generalized headache with brady cardia and vomiting may result. This doubtless results from vaso-motor disturbance secondary to injury of the vaso-motor centers in the medulla and over the cortex, the so-called vaso-motor symptom complex. The headache The headache is much more severe and lasting, and more obstinate to treatment if there be some pre-existing arterio-sclerotic changes. Trauma to the head stimulates the secretory activity of the choroid plexus and may retard the reabsorption of fluid, and after severe or slight trauma there is usually found an increased quantity of fluid with increased pressure. Withdrawal of fluid gives partial or, in some cases, complete relief.

Headache associated with disorders of the special senses.

The Eye: Errors of refraction or accomodation, weakness of the eye muscle or in short any disorder about the eye which irritates the ophthalmic division of the trigeminus may cause headache either frontal or occipital.

The nose is liberally supplied with branches of the first and second divisions of the trifacial and hyperaemia of the mucosa, acute or chronic rhinitis, anatomical defects which hinder free respiration, or any other condition, about the nose of an irritating nature may cause severe headaches.

Mouth infections by their local irritation and by the absorption of toxins from the mouth cause headaches. . The treatment of the above types of headaches would be the treatment of their causes.

Headache of great severity occurs in association with acute otitis media. Meniere's symptom complex is usually accompanied with diffuse headaches. Acute and chronic gastritis, gastric hypersecretion, and constipation cause headaches by irritation of the terminal branches of the vagus and by the irrative action of the absorbed toxins upon the dural nerves. The headache of cerebral arterisclerosis is increased in severity by straining at stool.

Headache in diseases of the kidneys are of frequent occurance. In all forms of nephritis

there is incomplete removal from the blood of the toxic products of metabolism and they irritate the dural nerves causing headaches. These toxins also stimulate the choroid plexus to hyperactivity and a pressure headache results. Another cause of pressure headache associated with these conditions is the increased intra-cranial circulation resulting from the high blood pressure. Removal of the toxins by stimulation of the skin and intestines and removal of the excess cerebro-spinal fluid by lumbar puncture will relieve the headache.

The headaches of general diseases are toxic and pressure in their etiology. The headaches which are so constant and severe in infectious diseases result from the irritation of the dural nerves by the circulating toxins, and from the increased intracranial tension due to the hyper-secretion of fluid by the choroid plexus. Lumbar puncture and withdrawal of fluid gives surprising relief of the pain and improves the mental condition. The toxins also cause a vaso-motor paresis with engorgement of the dural vessels, which irritates both the vaso-motor and dural nerves and thus contributes to the headaches. Cold to the head is beneficial.

Acute and chronic intoxications are responsible for much headache. The most common types of this class of headaches are those associated with lead, alcoholic, tobacco and gastrointestinal intoxications. Rest and elimination of the toxic agent is the appropriate treatment. In chronic alcoholism, there is usually an increased intra-cranial tension which can be relieved quickly by lumbar puncture.

During the course of such constitutional diseases as anaemia, chlorosis, and diabetes, headaches are very annoying symptoms. The treatment is the treatment of the underlying condition. 937 Rialto Building.

THE PERCY CAUTERY IN CARCINOMA
OF THE CERVIX*
CARYL POTTER, M. D.
St. Joseph, Missouri

The treatment of malignancy has been divided into (a) general, and (b) local.

All of the general therapy has depended upon empiricism for its basis and the best evidence. we have that we are far from a definite etiology is the fruitlessness of our general modes of attack. The application of Chian Turpentine by Clay; Atoxyl by Keith; scelenium and tellurium compounds of eosin by Wassermann; the serotherapy of Fischer, Levine, Babcock, Hodenpyl and I and the Coley vaccine have nearly or completely fallen by the wayside because they had no fundamental etiological basis for their

*Read before the Medical Society of the Missouri Valley at Keokuk, Iowa, March 21, 1917.

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application and, until the specific cause is definitely known, other empirical general measures will probably be doomed to the same fate. The writer well remembers the conscientious and convincing enthusiasm of Hodenpyl for his autoserotherapy. So sure was he of the virtue of his serum that pilgrimages were made by research workers and clinicians from widely known medical centers to New York to investigate his claims. After the original enthusiasm had subsided the facts showed that there was no merit to this treatment based on empiricism.

The local means of attack have been more fortunate because knowledge of the character of the growth and its method of metastisizing offer a scientific basis for attack. If we are able to remove the whole growth and its natural channels of distribution or penetrate it with something powerful enough to destroy both we have acquired a partial or complete victory, the success or failure depending of course upon (1) whether we have cut beyond its distribution, or (2) whether our destructive agent has penetrated the whole mass and the cells which have escaped from the local situation. The cold knife enthusiasts claim the most for their ability to cut beyond the growth, while the radio-therapist, cold-iron and X-Ray extremists lay greatest claim to penetration. Conservatists from both are combining the two methods, using the best in each, and today herein lies the most efficient treatment for malignant growths.

In the endeavor to destroy carcinoma of the cervix we have these two schools represented: the one, headed by Percy, who says that "the removal of the cancerous uterus by the knife is nothing less than legalized assassination," advocates the cold-iron or Percy cautery; the other, headed by Wertheim, claims most for the Ries-Wertheim operation in all operable and border-line cases. With these two from which to choose what must be the attitude of the unbiased mind?

Like many procedures each shows best results in the hands of the inventors and one must choose the best from each school after a careful and painstaking study of the work of the inventor and his associates; of men of experience and ability who have applied one method or the other; and of the results of one's own personal experience. In the enthusiasm over a particular method one must not lose sight of end results which are the most important evidence of the success of a combination of the best in many methods or of a particular one.

The whole basis of Percy's work is founded on the experiments of Hoaland, Jensen, Lambert and Vidal who place the death of cancer cells at about 116 to 122 F. and the normal tissue cells at a temperature 14 to 20 higher and maintain that if the heat can be controlled suf

ficiently the viability of cancer cells will cease while normal tissue cells will remain unaffected. The Percy cautery is applied with this end in view.

From a number of experiments Percy concluded that the penetration of heat depended upon (1) the density of the mass, (2) the compression of the mass on the cautery, (3) the degree of heat developed, (4) the type of entrance made for the cautery, and (5) that if a charcoal core is avoided the area of coagulation far exceeds in size that ensuing from the application of a higher degree of heat for a longer period of time.

By avoiding a too high grade of temperature he therefore seeks to avoid a carbon-core which if developed, is impenetrable to the heat and prevents the destruction of cancer cells beyond the immediate point of contact; and tends to shut off proper drainage, thereby causing an accumulation of broken down tissue behind the core-a condition which favors the growth of bacteria and the development of septicemia. On the other hand the slow heat penetration causes coagulation necrosis of the whole mass, penetrates and kills remote cancer cells and sterilizes the whole locality of the growth. It has no effect on distant metastases which he claims do not occur till late in carcinoma of the cervix.

This last statement of Percy should be accepted with caution because we know of cases, and I have personally seen two, in which the local growth was apparently insignificent but dissection along the ureter after the technic of Wertheim revealed several deep glands, microscopically cancerous.

Again if the cold iron is more effective in eradicating carcinoma than the knife it is hard to see why the treatment is advocated only for inoperable carcinoma of the cervix and Percy's writings invariably refer to heat treatment in inoperable carcinoma of the cervix. Why isn't a treatment that is used for the inoperable form more applicable to the operable where the growth is more localized, more easily penetrated, less liable to have local or distant metastases and a pyometra or a parametritis? Surely a growth in its infancy would be more easily controlled by the cold iron than one in its maturity. Why then, I repeat, does it not stand as the treatment for all carcinomas of the cervix, operable and inoperable, if it is the best curative agent? Perhaps the newness of the treatment and the insufficient lapse of time for reporting end results has made Percy conservative, although his earliest papers were written over five years ago, the time-limit after operations for cancer to report a cure. Perhaps he is not willing as yet to affirm that heat penetration in operable carcinoma is as effectual as surrounding it and removing it in toto, when

possible, which is attempted procedure in the Ries-Wertheim operation.

The main criticism one has to make of Percy's work is that enough complete case reports with subsequent courses, complications, end-results and autopsy findings are not given to substantiate his theories and experimental work.

What do the reports from other sources say?

Of all using the technic Balfour of the Mayo clinic is perhaps the most enthusiastic but here again he advocates it for inoperable cases and reports nine subsequent hysterectomies in five of which the pathologist could find no evidence of remaining carcinoma. Still he thinks that a subsequent hysterectomy should be done because a uterus once the seat of carcinoma should be considered potentially malignant. He also advocates it as a preliminary to a total hysterectomy in "border-line cases". In early cases he does the Wertheim operation with as good results as in early carcinoma in many other locations which refutes Percy's statement that the cold knife in carcinoma of the cervix is legalized assasination.

Balfour's cases are of too short standing to report subsequent courses so, from the standpoint of end-results, are valueless.

William J. Mayo states that so far as his experience goes this method is applicable to a large variety of carcinoma and forms a palliation with prospects of cure in a group of cases in which the knife has been inefficient.

Perhaps the most adverse reports come from the Johns Hopkins Hospital. In Leonard and Dayton's report of "Complications of Percy's Cold-iron Method" autopsy findings showed pulmonary edema, hemorrhagic serums effusions, extreme cloudy swelling of the viscera, renal epithelial necrosis and gastric ulcers corresponding to the findings of extensive superficial burns; also, that a mass of sloughing coagulated tissue offers an ideal medium for growth of microorganisms. The danger of septicemia, therefore was considerable. Sections of areas remote and proximal to the growth showed cancer cells unaffected in any way by the heat.

In reading their reports one is inclined to believe that the application of heat was too heroic for one application because it was my experience that sloughs in the rectum and bladder did not occur except in the case where the growth involved the base of the bladder and the rectum, and these cases are not only rare but the growth has as much to do with the perforation as the heat. It seems in their cases that these sloughs could have been avoided had one or two subsequent applications been used instead of one extensive cauterization.

The technic is described in Percy's writings so the giving of details here would only be un

necessary repetition. A few points however which have not been emphasized or which differ from Percy are as follows: In our work the operator does the final vaginal preparation, using soap and water, alcohol and 2 per cent iodine in the vagina and over the vulva. He then thoroughly dilates the vagina and inserts the water cooled speculum and makes the rubber connections to the water supply. The patient is left in the lithotomy position with the thighs flexed on the trunk at an angle of about 60 per cent, the buttocks raised and the head lowered. A nurse holds the speculum in position and the desired cautery tip is fitted to the uterine canal. The patient is draped and the abdomen prepared while the surgeon goes through a second scrub-up. The incision should be generous, extending from the umbilicus almost to the symphysis. A complete bilateral salpingo-oophotectomy should always be done. This not only relieves subsequent distressing menstrual symptoms in patients previous to the menopause but also permits a much better exposure for ligation of the internal iliacs. These should always be tied except in the presence of a complication, such as the pyosalpinx encountered in case IV, reported below, when the ligation of both uterines can be substituted.

In this type of case no iliac ligation should be attempted because of the possibility of injury to large veins or retroperitoneal infection which might cause thrombosis of the iliac veins or stasis with gangrene of the lower extremities or the lodgement of distant emboli. Here also the anatomical arrangements are so obscured or distorted and the inflammatory process causes such a great amount of additional venous and arterial oozing that the attempt is not justified.

The ligation of the internal iliacs not only prevents hemorrhage from subsequent sloughs but it may diminish the blood supply to the uterus and thereby lessen nourishment to the carcinoma.

All the work inside the abdomen should be completed before inserting the cautery tip. Then the uterus is grasped with the left hand and the cautery inserted with the right hand which never comes in contact with the abdominal field again until the vaginal work is completed and the surgeon has changed his gown and gloves. In this way the right hand of the surgeon can coordinate with the left which grasps the uterus. This gives a better penetration and application of the cautery than when the assistant and surgeon handle the two fields separately. The heat should be gradually increased until the gloved hand can no longer hold the mass. By this time the uterus is usually freely movable. The limits. of application in our cases were 40 to 70 min

utes.

In our own work the following reports are submitted: Mrs. G. S., age 49, complained of a foul smelling, sanguino-purulent vaginal discharge and general weakness. She had first noticed a profuse watery discharge ten months previous which in a month became sero-sanguineous and a few weeks later sanguineous. She consulted a physician and was curetted six months before consulting me. The discharge was less profuse for about three weeks but then returned more abundant than ever before. Except for a few remissions it was continuous and sanguino-purulent in type. The odor had become very offensive in the last few weeks. She had been pronounced incurable and inoperable.

Examination

General: There was no marked loss of weight but there was evidence of a definite intoxication which I judged to be the result of absorption from a septic process.

Locally there was a large cauliflower-like mass involving most of the cervix to within about 1-2 cm. of the cervico-vaginal junction. The vaginal and bladder walls and the rectum were not involved. On going around and beyond the protruding mass the free smooth vaginal wall could be easily felt and the uterus seemed slightly

movable. The uterine outlet was entirely closed.

From my examination I concluded this to be a very favorable case for the cautery and the loss of weight and strength the result of a pyometra and an absorption from a blocking of the

uterine outlet.

Procedure: Percy's technic with the variations described above was exactly followed.

On Oct. 30, 1916, the abdominal cavity was opened and explored. The viscera were entirely free from metastases. The uterus was freely movable, the fixation apparently being due to the growth in the cervix which had extended into the body of the uterus. There was no eyidence of extra-uterine involvement. The fundus. was soft and boggy, apparently the seat of pyogenic infection. Retroperitoneal dissection to explore the internal iliacs showed no glandular involvement. The cautery was applied for 70 minutes with slow heat until the whole mass became so hot that it could not be held with the gloved hand.

On withdrawal the cartridge-shaped cautery tip showed a soft white necrotic mass clinging to it.

Subsequent Course: The patient left the hospital in three weeks. All discharge from the vagina had ceased and there was no return of any discharge up to the time of her death. After leaving the hospital she gradually became

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weaker, lost weight and died from general carcinomatous metastases three months after operation.

Repeated vaginal examination showed that the mass had disappeared and the uterus had become movable.

Case II. S. F., age 52, showed a mass in the left broad ligament extending into the vaginal vault. This followed a complete hysterectomy four months previous.

On October 12, 1916, there was an application of the cautery for forty minutes. Death occurred February 12, 1917, from complete anuria. The urine was negative at the time of cauterization and as she subsequently developed total anuria with intense pain and tenderness in the region of both kideys we concluded that she had developed a complete bilateral ureteral block from involvement of the broad ligament

Case III. L. K., age 64, showed surprisingly little cachexia or any symptoms of general carcinosis in view of the fact that the cervical growth involved the base of the bladder, vaginal walls and the rectum. No encouragement was offered but she insisted on the use of the cautery after hearing of it.

The Percy technic was followed. The cautery applied for 65 minutes until the hand could no tip which was carried well into the fundus, was longer hold the fundus. She died in uremic coma three days later.

Case IV. Mrs. M., age 39, was admitted to the hospital Dec. 11, 1916. Seven months. previous she had been examined by her physician who found a suspiciously hard cervix but apparently no definite growth. This combined with a continual sanguineous discharge, made him suspicious and he snipped off a portion of the hard mucosa for microscopic examination.

The pathologist reported adeno-carcinoma of the cervix. Despite his statements that she had an early carcinoma and his advice that she have a complete operation she refused to believe either the pathologist or her physician until seven months later when she was told by another examiner that she had an advanced carcinoma.

She returned to the man who originally examined her who stated that she was beyond the help of a hysterectomy and referred her to me for the use of the cautery.

Her general appearance was that of many women with pelvic pathology but not of one suffering from a malignant process. She was anemic but well developed.

Vaginal examination showed a well advanced cervical carcinoma involving the canal and extending a slight distance over the vaginal portion of the cervix but no bladder, vaginal wall or rectal involvement. The puzzling feature was the absolute fixation of the uterus and a large

mass in each fornix continuous with the uterus. We made an additional diagnosis of extensive broad ligament metastases which we thought were probable on account of the youthfulness of the patient and her naturally healthy lymphatic channel for distribution of the local growth. Operation Dec. 12, 1916.

Upon opening the abdomen an enormous double pyosalpinx was encountered long before the discovery of the carcinoma. A double salpingo-oophorectomy, was done and both uterine arteries instead of the internal iliacs were ligated for reasons explained before. The cautery was pushed well into the fundus and applied for 60 minutes until the fundus could no longer be held.

The recovery was uneventful. She gained very rapidly in weight and strength and showed marked improvement for two and a half months. A report in the past week stated she has commenced to lose ground again and that her decline for the past three weeks has been as marked as her improvement immediately following the use of the cautery. She does not complain of vaginal discharge or bleeding.

Except for number four the above cases have been followed to the end. From our own cases alone we are permitted to draw the following conclusions:

(1) The Percy cautery alone is not sufficient for the destruction of carcinoma of the cervix either operable or inoperable.

(2) In operable cases it: (a) Prevents general disability and autointoxication from the absorption of infectious material behind the mass. (b) Destroys the foul-smelling vaginal discharge. (c) Overcomes bleeding and the secondary anemia.

(3) In operable cases it should never be used as the only weapon against the disease but should be followed subsequently in two or three months by a hysterectomy. In these cases it is doubtful if the preliminary use of the cautery owing to the fact that one must wait two or three months for the subsequent operation which gives a good chance for the growth to progress is as safe as thorough preliminary cauterization of the cervix and immediate hysterectomy according to the technic of Wertheim.

in inoperable cases with the hope that we may attain results which more nearly approach the results reported indefinitely by Percy. In suitable cases we may use it as a preliminary to complete hysterectomy but until the reports justify its substitution, the Ries-Wertheim operation, although a more formidable procedure attended by a higher immediate mortality will be used in early cases because of its better endresults.

DISCUSSION

JEROME MORLEY LYNCH, New York: Although entirely outside of my province, I think we are very much indebted to Dr. Potter for a paper like this, because it is a very fair exposition of what can be accomplished with cauterization. The same principles apply to carcinoma that is situated in the rectum, i. e., early diagnosis, radical operation, and in inoperable cases one is justified in using any means that will prolong the life of the patient.

F. B. DORSEY, Keokuk: The few cases that we have been able to observe that have been treated by the Percy cautery method have been extremely unsatisfactory. I do not see that the patient has derived any greater benefit than was derived from the curettement of the cancerous mass in the oldfashioned way and by the use of the Paqulin cautery. We have this advantage with the Paqulin cautery over the method proposed by Percy: that we have none of the ill effects of long continued burning; we do not have those pronounced symptoms in some of the cases that we have seen and as described by Dr. Potter, following the older method. I do not see that it is one iota in advance; or that it causes the patient to live any longer; and for the mere fact that it does away with the discharge does not justify us in resorting to such radical measures. If the patient is in a condition that she can withstand the application of a cautery of this kind, preceded by the operative measures that are necessary, it occurs to me that a radical hysterectomy-I don't care whose method you follow-your own or a modification of some one's else should be done. You may have a high mortality rate, but you have a higher percentage of recovery. Of course the earlier you operate the higher your rate of recovery and the less your mortality. Mortality rests a good deal, in radical operations, on the dexterity of the operator. If a man is skilled and knows what he is doing, his patient has a better chance. The Percy operation subjects the patient to all the manifestations of extensive burns on the surface of the body.

C. E. RUTH, Des Moines: Eighteen years ago, in attempting to deal with extensive carcinomas, one case particularly comes to my mind now. It was a patient in whom the growth was very extensive, and I refused to operate. She begged to have me attempt relief and, without making any promises, I used the cautery very thoroughly. But in that case I followed the plan that I believe is best today, of rapid destruction of the carcinoma, for the reason that it was not then possible to operate on that case and do a complete hysterectomy. by any other method and not disseminate the carcinomatous material in

(4) In borderline cases it has its greatest field of usefulness and here in all cases it should be thoroughly used and followed in three to four months by a complete abdominal hysterectomy. Whether the abdominal operation is to be a complete hysterectomy alone or a complete hys- freshly opened tissue. The patient lived for five terectomy after the technic of Wertheim can be determined at the time.

years, and the result encouraged me to utilize the method and to extend it; and now in every case of carcinoma, wherever situated, I use the cautery

In closing it may be added that although when possible. we cannot at present lay any claim to its advisability for the cure we shall use it heroically

My mortality in following the early plan advocated by Percy, was so heavy that I abandoned it as

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