CANCER OF THE INTESTINE; ITS SURGICAL ASPECT, WITH REPORT OF CASES. THE danger of septic infection was one of the most important, if not the controlling factor in limiting the field within which surgical operations could be properly undertaken a generation ago. Its removal by the development of an aseptic technique marks the beginning of a new surgery, one of whose first impulses seems to have been to see how much mutilation and interference nature will permit. Life is found to be quite livable without many of the organs. that had hitherto been supposed to be essential to its exist ance. But now that the possibility of these radical excisions and resections is established, must come the second stage in the new surgery, viz.—a careful study of the remote, as well as the immediate results of these new operations. It seems quite certain that we shall discover that much that is possible, is attended with very grave dangers to life, and is followed by an impairment of comfort and health, that makes the life that is left hardly worth living. Already strong protests are being made by our medical brothers against many of the more radical operations-protests that must be heard and if possible answered, for after all our purpose must be, not to see what surgical feats can be successfully accomplished, but how they can be made to contribute to the prolongation of life, and the relief of suffering. One of the most notable protests that has been made recently, was contained in the Anniversary Discourse before the New York Academy of Medicine, delivered December 5, 1901, by Dr. Reginald H. Fitz of Boston. 10 cases It is an exceedingly temperate and judicial review of the ultimate results of surgical interferenee with diseased conditions, that had hitherto been regarded as incurable. Much of it is naturally taken up with a consideration of the surgery of internal cancer, and it is to one feature of this, that I wish to call your attention for a few moments. In the records of the Massachusetts General Hospital for the ten years from 1890 to 1900 he found, of intestinal resection for cancer, of which, 8 died within a month after the operation; the 9th patient was found to have a girdling ulcer without gross evidence of malignant disease, although from microscopical examination, regarded as an adeno-carcinoma. He was at work as janitor and enjoying fair health two and a half years after operation. The 10th patient was not heard from. Of the five cases of intestinal anastomosis (for cancer) two died within the fortnight following operation; one lived 6 months, and 2 have not been heard from." "Of the 77 cases of cancer of the alimentary canal two, or only 3%, were living at the end of three years after the operation." If we consider the question of relief of suffering in those whose history subsequent to the operation could be learned, the result is equally disappointing. I have thought it would be worth while therefore, to look very briefly at the results which have been obtained by others in the surgical treatment of intestinal cancer, and to add my own small, but to me, significant experience. In the first place, one finds it quite unsatisfactory to depend overmuch upon a general compilation of reported The immediate results are so much better than the full reports from the more important clinics, that one feels cases. at once that the tendency to report individual successes, makes the general table relatively unreliable as a true index of the general mortality, and further, most of the cases are reported too early to give any assurance of the success or failure of the operation. Lardennois collected 241 cases with 24 deaths, a mortality of 34.8% and Bovis 171 cases, with a mortality of 31.5%. Contrast this with the combined experience of such operators as Krönlein, Korte, Czerny, Billroth-Salzer and König, whose 58 cases resulted in 28 deaths, a mortality of 48.4%; of these Kortes' record of 19 cases with 7 deaths, or 36.8% is the best-all of the others having a mortality of 50% or over. At St. Thomas' Hospital between 1888 and 1897, there were 12 resections with 7 deaths, and Von Bramanns in 1897 reported 14 cases with 6 deaths. According to Korte, the cæcum is the most favorable locality for operative interference, he having resected for carcinoma 5 times, and sarcoma once, with no deaths. This view is further supported by Macewen, who reports 5 cases with one death; and by Goullioud who had 6 enterectomies for cancer of the cæcum, with but one deathKrönlein, however, had 6 cases, with 3 deaths. It follows that the general mortality in intestinal resection for malignant disease, is still very high-almost 50%-except possibly in the region of the ileo-cæcal valve. So much for the immediate, now let us look for a moment at the later results. Of Kortes' 12 successful cases, 5 were well from 3 to 83 years after operation : 3 of his cases of resection of cæcum being alive 8, 64 years respectively. Two of McEwen's cases were alive more, and two less than 3 years after operation. One of Goullioud's patients was alive 3 years, the others less than one year, while Kronlein had 5 cases in which there had been no recurrence at the end of from 5 months to 14 years. Of Von Bramanns' |