Schroder, Hofmeier, Staude, and his

own.

Of far more importance is the question of the ultimate result of hysterectomy for uterine carcinoma, and it is in this connection that statistics are most unreliable. I believe with Pozzi that it is better to use the term durable than final cure in connection with the question of recurrence after radical operation for cancer of the uterus, for an unprejudiced perusal of the exhaustive European statistics unquestionably proves that recurrence is to be feared long after it has been arbitrarily fixed as the limitation of danger or the line of cure. Take, for instance, the table of Krukenberg, which records an observation of 188 patients who recovered from the operation of vaginal hysterectomy for carcinoma; these patients were observed for a period of five years with the following results: At the end of one year 110, or 58 per cent, of the cases were found free from recurrence; at the end of two years 63 out of the remaining 141, or 44 per cent; at the end of three years 42 out of the 112 living, or 37 per cent; at the end of four years 26 out of the 88 living, or 29 per cent; at the end of five years 9 out of 51, or 17 per cent.

Pozzi says: "I believe one must mistrust the original diagnosis in patients who remain free from recurrence; to me hysterectomy is merely palliative treatment, whose results are of greater or less duration, the average being in my experience hardly more than one year, after which time the disease reappears and leads to death within a year at the latest. In young patients and those of the papillary or proliferating form recurrence is often extremely rapid. One is, however, none the less authorized to perform hysterectomy, as to amputate the breast and dissect the axilla, an operation whose prognosis is certainly more serious. Recurrence is always to be feared in either case, but a cure, though temporary, is still a cure."

While I think the views expressed by Pozzi are extremely pessimistic from the standpoint of recurrence, still they sound a timely key-note to the clamor and reckless promises that have been

made to these unfortunate victims by overzealous surgeons.

So prominent and successful a vaginal hysterectomist as Jacobs, of Brussels, is recently quoted by an American surgeon as saying that in 85 hysterectomies for uterine cancer occurring in his practice, there have been 84 recurrences of the disease. Admitting that the anatomical conditions of the uterus are probably more favorable for the rapid dissemination of carcinoma than. any organ of the body, we must still believe that the very early recognition of cancer, followed by removal of the organ, is entirely consistent with nonrecurrence. At the same time the percentage of such cases will ever be so small as to make the radical operation a very unpromising one. practice that has obtained in this country and elsewhere of performing hysterectomy in cases of cervical carcinoma, even though there be slight extensions to the vaginal mucous membrane and pelvic deposits, seems, in view of the bad statistics for even more favorable cases than these represent, little less than surgical experi

ments.

The

It is a well-known fact that the high amputation as advocated by Schroder held from a surgical standpoint an advantage over hysterectomy for a long time as an operation for cancer of the cervix.

While so little can be said for the treatment of carcinoma from a radical standpoint, much may be done to ameliorate this loathsome disease in a palliative way, and I know of no surgical procedure designed as a purely palliative measure that is attended with happier results than the operation of thorough removal of the cancerous disease by a sharp spoon, and subsequent applications of bismuth, chlorate of sodium, and if need be, antiseptic vaginal douches.

Advanced cases of cervical carcinoma, in other words, cases as they usually consult us for the first time, are certainly more advantageously treated by palliative than by so-called radical measures. I believe the patients live as long, with the palliative operation probably repeated two or three

times, they live in as much comfort, and their lives are not jeopardized by even a five per cent mortality. In addition to this, the surgery of carcinoma, so much more successful elsewhere in the body, is not brought into disrepute by having the gloomy statistics of radical operation for uterine carcinoma placed into contrast.

I think a safe rule for the selection of a line of treatment would be about as follows: Where the disease is distinctly limited to the cervix, or where from scrapings we have reason to believe that we have a primary and limited cancer of the body of the uterus or endometrium, the operation of hysterectomy should be performed. I think our present operative guide, viz., mobility of the uterus and absence of vaginal invasion, an unreliable one, for we do see cases of uterine cancer extending from the cervix to the body of the uterus where the uterus is nothing but a shell, and yet the vagina is not involved and the uterus may be nonadherent to the pelvic structures. Such cases, in my judgment, give little promise from radical operation; in fact, I have seen cases like the one depicted where the cancerous cachexia was well established. I would advocate, then, a restriction in the limit of operable cases from a radical standpoint.

I have had little experience with the use of caustics, believing that they are greatly inferior to repeated use of the sharp spoon and antiseptic gauze packing to control hemorrhage. As an application following curettment, some days later, I would urge a trial of bismuth subnitrate and chlorate of sodium, equal parts, to be dusted over the granulating surface. It is marvelous the extent that some of these cases will improve under this treatment. I have under observation at the present time patients who, by repeated curettment and the use of this application, are enjoying a fair degree of health, although they have been victims of the disease for from one to two years; one case where it is now more than two years since the first curettment. One of these cases I deemed inoperable at the time she first consulted me; in the other (of longest duration), an elderly

lady (62 years), I deemed operation inadvisable on account of grave cardiac complications.

I would like here to interpolate that uterine carcinoma, like carcinoma elsewhere in the body, is of much slower growth in the aged than in young or middle aged subjects.

During an observation of more than two hundred cases of cervical carcinoma, I have met with but eighteen that I considered suitable for hysterectomy. With my present views upon the subject, I would probably not deem more than ten of these proper cases for hysterectomy. Of the eighteen operated upon, one died as a result of the operation; two of the surviving seventeen have passed the three-year limit without recurrence; in one of these I have some doubt as to the correctness of the diagnosis. Recurrence was so rapid in most of the others that I am reluctant to conclude that they would have lived as long and as comfortably by operative measures of a palliative character.

To summarize: I believe that we are justified in doing hysterectomy only after satisfying ourselves that the disease is limited either to the cervix or to the endometrium.

That our present method of determining cases for radical interference is faulty.

That all other cases, even including those advanced to the third stage, of marked cachexia and infiltration of the pelvic glands, should be repeatedly scraped, packed with iodoform gauze, and subsequently treated with the antiseptic douche and the application of bismuth and chlorate of sodium.

That much of the so-called cancerous cachexia in these cases is due to absorbtion from infection of the brokendown mass of tissue by pyogenic bacteria.

That from our knowledge of the anatomy of the uterus with its unusual lymphatic development, we are constrained to believe that the aggressive application of surgical principles that have proved so successful in carcinoma in other situations of the body, notably the breast, promises little when applied to cancer of the uterus.

A Case of Appendicitis: Operation.*

BY JOHN YOUNG BROWN, M. D., President of the Mississippi Valley Medical Association, St. Louis, Mo.

I report the following case as clearly substantiating the assertion so frequently made by those surgeons who advocate early operation in all cases of appendicitis, namely, that we can not be accurately guided, either by pulse or temperature, as to the nature and extent of the pathological conditions going on in and about the appendix in any given case.

I was requested by Dr. Paul Paquin

to see in consultation with him Robert R., aged forty-two; occupation, fireman. Three days before I saw him he left work and came home suffering from what he termed a bilious attack. When seen by Dr. Paquin he was complaining of great nausea, intense abdominal pain, and general tenderness in right iliac region. Pulse 80, temperature 99°. Dr. Paquin prescribed for him, and as the patient grew no better he concluded that he had to deal with a case of appendicitis, and on the following morning I was called.

On examination I found the abdomen slightly tympanitic, considerable tenderness over seat of appendix, but no mass could be made out. Rectal examination was exquisitely painful, and considerable bogginess could be made out on right side. Pulse was 80 and temperature 98.8°. I concurred in the diagnosis of appendicitis and advised immediate operation. The patient was accordingly moved to the Deaconess Hospital and prepared for operation. Assisted by Dr. Llewelyn Williamson, and in the presence of Drs. Paquin, Straus, and William Williamson, I opened the abdomen. From date of attack until patient went on operating table his pulse had never been above 82, and his temperature never higher than 99.8°. The nausea, however, persisted, and he had the general appearance of being a sick man.

The usual incision was made, and on opening the abdomen about a quart of stinking serum was found free in the pelvis. This was sponged out, and I

Read before the St. Louis Medical Society, March 12, 1898.

found presenting in the wound a loop of ileum tightly bound down by a bandlike adhesion. The presenting ileum was dark in color, and at first I thought would necessitate a resection. However, after the constriction was relieved, the circulation gradually returned. From the adhesions present about the cecum it was conclusive that the patient had had frequent attacks of appendiceal trouble. The cecum was tightly bound down by adhesion, and it was with some difficulty that the appendix was found. Appendix was densely adherent to cecum, strictured, and gangrenous at tip, with a perforation about the size of a pea. After freeing the appendix, I cut it out to the head of the cecum, and stitched up the opening with a double row of sutures. This was with difficulty done, owing to my inability to bring cecum up into the wound. The abdominal cavity was copiously irrigated with several gallons of hot salt solution, carefully sponged out, and after placing several strips of gauze in a different direction, for drainage, the wound was closed. The patient reacted nicely, the gauze was removed in thirtysix hours, and his recovery was uneventful. It will be six weeks to-morrow since date of operation, and he is now up and will shortly return to work.

The above case to me presents many interesting points. Here was a man with a temperature and pulse almost normal, with every clinical symptom pointing to a mild attack of appendicitis, and yet, on opening his abdomen, conditions were found which conclusively proved that had operative interference been delayed twenty-four hours, he would have been beyond the reach of surgery to save. Several months ago I saw in consultation with Dr. H. H. Grant, of Louisville, a patient presenting symptoms almost identical with the case above reported. A diagnosis of appendicitis was made, and on opening the abdomen an intussusception was found, necessitating the resection of ten. inches of gangrenous ileum.

I know there are those who contend that they can tell just which cases should be subjected to operation and just which should not, but the more I see of this condition the more I am

convinced that we should operate on all cases at the earliest possible moment; that the great danger in this disease is delay. On this point, Fowler speaks very emphatically: 'As soon as the diagnosis of progressive appendicitis is assured, the abdominal cavity should be opened and the appendix removed. If opium has been injudiciously administered and the progressive character of the case in hand is doubtful, it is better to err on the side of safety and remove the appendix at once. The conditions present are usually beyond the power of nature to remedy, while in the hands of a surgeon who pays strict attention to aseptic details, both preliminary to and in the course of the operation, the latter entails less risk to life than that which is involved in even a mild attack of appendicitis which remains stationary at the end of twenty-four hours, with all its possibilities of lymphangitis, infection of the peritoneal cavity, retained muco-pus within the tube, and rupture of the latter into an unprotected peritoneal cavity."

Robert T. Morris, of New York, who has perhaps done more to develop the pathology of this disease than any other man in this country, in speaking of the indications for operation in appendicitis, says, "There are no groups of symptoms which will allow us to make a rational prognosis as to the eventual outcome, or the prospective complications in any progressing case of appendicitis, and we must abandon the hope of having any such classification of symptoms for a guide in the future. Attempts will be made from time to time to classify symptoms for prognosis from small groups of cases, but they will fail because of the nature of the disease." I speak then unequivocally, knowing that some patients are to die and others are to suffer, unnecessarily, because their advisers will believe themselves to be upon a prognostic track. There is but one rule to be followed, and that is to isolate an infected appendix as promptly as we would we would isolate a case of diphtheria, and for practically the same reason, viz., the infected appendix will probably infect other structures, and the infected throat is likely to infect other throats.

An

infected appendix is isolated when it is out of the patient. All cases of appendicitis that are otherwise within surgical limitations, and that are in reach of competent surgical services, are cases for prompt isolation of the appendix. Various periods of waiting have been tried with the effect of proving that the question is wedge-shaped, with the greatest number of deaths at the broad, waiting end, and the smallest number of deaths at the point of isolating an infected appendix, while infection is limited to the confines of the appendix.

We are held to our rule by two cardinal principles, viz: (1) Every hour of progress of any acute attack of appendicitis means increased damage to viscera, and with no infected appendix the patient would have no complications of appendicitis, if we leave him with no infected appendix.

Another point suggested by this case is as to the proper method of disposing of the stump in appendectomy. This question has been very much discussed of late, and many valuable papers have been written on this subject. For quite a number of years Price, of Philadelphia, has been practicing a method which I believe to be ideal in the large majority of cases. The operation consists in cutting the appendix out of the head of the cecum and closing the wound with a double row of sutures. The two methods now most commonly in vogue, the method of Edebolds, which consists in the inversion of the entire appendix, and the method of Dawbarn, namely, the inversion and burying of the stump after amputating the distal two thirds, with their various modifications, possess many disadvantages. As pointed out by Fowler, it not infrequently happens that in gangrenous inflammation of the appendix the gangrene extends to the cecal wall. Any method which leaves behind appendiceal tissue thus becomes the seat of inflammation, and is faulty in technique just in proportion to the amount of appendiceal tissue thus allowed to remain. He reports several interesting cases where, after careful treatment of the stump by the inversion method, there was subsequent extension of the gangrenous process, perforation and death

from general peritonitis. The excision method, as practiced by Price and modified by Fowler, is ideal in its simplicity. After protecting the surrounding parts with gauze, the cecum is held between thumb and index finger of left hand; an assistant seizes the appendix with a forceps, and the operator with curved scissors cuts the entire organ out of the head of the cecum; the wound in the cecum is then closed with a double row of sutures; the dirty sinus is removed, and we get a perfect coaptation of healthy tissues.

Societies.

The Louisville Surgical Society.*

Stated Meeting June 1, 1898, the President, John G. Cecil, M. D., in the Chair.

OPERATION FOR FRACTURE OF THE

SKULL.

[Continued Report.]

BY J. GARLAND SHERRILL, A. M., M. D.

At the April meeting of this Society it will be remembered that I exhibited several pieces of bone removed from the skull of a man who had been struck a severe blow upon the right side of the head, and was brought into the hospital and operated upon a few hours afterward. The operation was performed on April 6th; the fracture was found to be two inches in width by three and a quarter inches in length, involving the lower part of the right parietal and upper part of the squamous portion of the temporal bone. Upon removing the fractured bones, a large extra-dural clot was discovered, evidently due to rupture of the posterior branch of the middle meningeal artery. In the disIn the discussion which followed my report one of the members said that he had seen quite a number of such cases, and his experience was that they nearly all died.

The man has done well since the operation, and the wound has now almost entirely healed. He is before you, and those who desire to do so can ex

*Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.

amine him. He now complains of pain along the right jaw, especially when he moves it in opening and closing his mouth. The only way I can account for that is there might be a line of fracture leading down to the base of the skull, although a careful examination did not reveal any evidence of it at the time of the operation. It appears that he is also slightly deaf in the right ear. There was considerable bleeding from both ears following the injury, most from the right. He does not complain of headache or any thing else at the present time, except slight pain about the right jaw.

DISCUSSION.

Dr. William Cheatham: The appearance of this patient's ears shows that both drum membranes have been ruptured, and there is enough middleear trouble to account for the slight deafness he has.

FIBROMA OF THE LARYNX.

BY WM. CHEATHAM, M. D.

This gentleman, aged thirty-nine years, was sent to me from Indiana. He has been having trouble with his throat for five years, which has been getting very much worse during the last year. Upon examination I found on the posterior wall of his larynx a growth as large as the end of my thumb. At first it looked like a papilloma; touching it with a probe, I found it very hard, more like cartilage, and I then supposed it was a fibroma, although the location of a fibroma of the larynx is usually about the cords, and this is on the posterior wall.

I had the growth examined by Dr. Henry H. Koehler, and he pronounced it a fibroma. I pinched off several pieces with forceps, which could only be done by using very long-bladed forceps; I have been trying to pinch off a piece every day, until it is now reduced about two thirds, that is, about one third its original size.

You can see the growth very easily by the use of properly adjusted mirrors. The peculiarity of the case is that