1 its base, the distal end being bulbous. A concretion was found in exactly half the cases. In theorizing as to how the gastric symptoms are produced, Patterson believes that they are due to intestinal stasis. "This theory" he says, "is supported by the frequency with which the duodenum is found markedly dilated at operation, and by the fact that in one of the cases the stomach was dilated also. Further, as a rule the quantity of gastric juice evacuated after a test meal is greater than in healthy individuals, the percentage of volatile acids is usually increased, and in addition flatulence and constipation are prominent symptoms." In another article entitled The Clinical Significance of Gastric Hypersecretion and its connection with Latent Disease of the Appendix, which appeared in the same number of the Proceedings of the Royal Society of Medicine, Dr. W. Soltau Fenwick says, "Until the year 1907 I had convinced myself from post-mortem evidence, as well as from the more limited data afforded by operation, that 88 per cent of all cases of chronic hypersecretion were associated with a demonstrable lesion of the digestive organs, while in the remaining 12 per cent no disease that appeared to have any immediate connection with the stomach could invariably be detected. I was, however, well acquainted with a peculiar type of hypersecretion in which death frequently occurred from appendicitis, and was in the habit of warning the subjects of this complaint of their especial liability to inflam*mation of the appendix; but it was not until an opportunity occurred in that year of discussing the subject with Dr. W. J. Mayo, that the cause of this appendicitis, and also an explanation of the 12 per cent of cases hitherto unexplained, at once became apparent." The following is an analysis of 112 consecutive cases of chronic hypersecretion reported by Fenwick. Chronic ulcer of the stomach existed alone in. Gall-stones existed alone in.... Disease of the appendix existed alone in. Gastric and duodenal ulcers coexisted in. Duodenal ulcer and gall-stones coexisted in.. .12 .46 .12 .22 3 3 5 4 4 Again, bearing upon the diagnosis of this subject, Christopher Graham, who is with the Mayos, under the caption of "Differential Diagnosis of Diseases causing Gastric Disturbance," says: "Chronic recurring appendicitis is a type that usually gives stomach symptoms. There is no appendiceal tenderness, no pain at McBurney's point, no fever, no tumor, no symptoms that usually mark appendicitis, except those referred to the stomach. There may be pain, gas, vomiting, sour stomach, and pyrosis, but when compared with peptic ulcer they are irregular, and when gall-stones are considered the attack is too prolonged. The whole train of symptoms is caused more often immediately by food but this meal gives one effect and the next meal another; there is no regularity, meal after meal, as in chronic ulcer, and rarely does food give ease. Pain is often a queer, rather continuous distress, which is epigastric or indefinitely abdominal, which the patient describes as epigastric. There is no clear-cut day by day repetition, as in ulcer, and no attacks like gallstones of definite location of pain. Nausea, distress, a gassy, bloated condition covers the bad feeling of more cases of chronic appendicitis than of chronic ulcer or gall-stones. Exertion is a factor in appendicitis and sufferers from it are seemingly often unable to work. Pain may be epigastric only, but often indefinitely of the epigastric and abdominal regions or low gall-bladder or high appendix areas. If we have dyspeptic attacks with epigastric pain and radiation to the umbilicus or lower abdomen, consider, first, appendical disturbance." I can do no better in concluding the remarks I am making thau to read to you my conclusions in the article referred to. 1. The most diverse views prevail at the present time regarding the causation, pathology, and treatment of gastrointestinal autointoxication and so-called entero-colitis. 2. The association of the two conditions is frequently observed. 3. A most common symptom of chronic appendicitis is the discharge of mucous per anum because of the enteritis excited and perpetuated by the inflamed appendix. 4. There is increasing evidence going to show that a casual relationship exists between chronic appendicitis, with or without mucous enterocolitis and gastrointestinal autointoxication. 5. Lesions of the female reproductive organs may also, either by interfering with intestinal persistalsis through direct pressure or reflexly, so interfere with digestion as to cause gastro-intestinal autointoxication. 6. In dealing with the symptom-complex of gastro-intestinal auto-intoxication and mucous enterocolitis it is usually necessary to have recourse to surgery before permanent relief is obtained. This statement presupposes that intelligent dietetic, hygienic, and medi cinal measures have been faithfully observed previously to operation. 7. Relief following surgical work, when indicated, is usually immediate. It may be necessary, however, to keep the patient, especially if neurotic, under observation and treatment for some months following the operation.* 816 Rose Building. CANCER OF THE UTERUS. NEWMAN T. B. NOBLES, M. D., PROFESSOR OF SURGERY, CLEVELAND-PULTE MEDICAL COLLEGE; ATTENDING SURGEON, CLEVELAND CITY HOSPITAL. Cancer of the Uterus is so prevalent that nearly all general practitioners see at least two or three cases yearly and it is upon the family physician that we must rely to recognize the early symptoms and to indicate to the patient the appropriate treatment. Without his assistance the gynecologist will almost invariably see the case only when the disease is too far advanced to permit of a complete removal of the morbid growth. We now know that in the beginning cancer is essentially a local process, and that the apparently independent growths occurring in other organs are really metastases from the primary tumor. This knowledge has undoubtedly given rise to the great demand for surgical measures in this condition. Up to this time an operation has done more for those afflicted with this condition than any other line of treatment. The results to be sure, have not always been all that we desire. Better results would be obtained if the cases were brought to us sooner. In other words, if the family doctor could have an earlier opportunity to see these cases and to make the proper diagnosis the surgical results would be better. Unfortunately, we find that diagnostic symptoms at best are meager, and in the early stages give little or no clue to the real nature of the disease. Right here I wish to emphasize the value of curettage when there is the slightest uterine hemorrhage that cannot be satisfactorily explained. If the scrapings are given to an expert microscopist he will be able to make the proper diagnosis while the disease is purely local. The uterus can then be removed and the disease eradicated. In many cases the patient, when first seen, looks perfectly well and one would not for an instant suspect any serious trouble, where Note-Feb. 10, 1912. Patient's convalescence ideal. Gastric symptoms entirely relieved.-J. C. W. as, on examination the disease may be far advanced or even inoperable. On the other hand, thin anemic, and cachectic women may supply some of the early and favorable cases. In brief it may be said, while it is often possible to form a fairly good idea from the general condition, external appearances are not infrequently very deceptive. Hemorrhage, as has been noted, is one of the most frequent symptoms; as a rule, it occurs early in the disease, but occasionally is absent throughout the entire course. A watery or purulent discharge is noted in practically all of the cases in the late stages. The uterine discharge is usually very offensive, and so characteristic that in the latter months one can almost make a diagnosis by the odor. It causes much irritation of the external genitals. Pain is a variable quantity in the early stages; some patients, indeed, throughout the entire illness complain of no pain whatever. Others, even at an early period, suffer with cramp-like pains in the uterus or have frequent backaches. As the process passes beyond the uterus and the growth presses on the nerve trunks, the pain is no longer limited to the pelvis and back, but often extends to the thighs, knees and often to the calves of the legs. So excruciating is the suffering in the late stages that many patients have to be kept constantly under the influence of morphine. As the disease progresses, the patient usually loses weight, but, as appears from some of our cases, the body autopsy may still be well nourished. The loss of flesh is to some extent due to the absence of appetite which invariably belongs to the late stages. Cachexia and emaciation usually go hand in hand, and it is no rare occurrence to find marked cachexia, even though the patient may be still well supplied with adipose tissue. There are several factors which doubtless are concerned in the production of the yellowish, waxy condition. In the first place, the hemorrhages are frequent, and consequently an anemia is present. This is still further increased due to the increasing loss of appetite. The continuous discharge also has its effect. So does the absorption of the products of decomposition from the growth. The statistics of operations for carcinoma of the uterus offer many uncertainties. In some instances the surgeons have run but little risks as they have operated on selected cases only. So they have been able to report a good percentage of recoveries. On the other hand there are those who disregard the question of statistics. altogether and operate on every patient who presents the slightest possibility of saving the patient. With the latter group we are in sympathy though the records show more failures. It is clearly the duty of every surgeon to take advantage of every reasonable chance of saving his patient. And it is clearly the duty of every physician to send his patient to a surgeon whenever she presents any of the symptoms of this troublesome pest. A very grave responsibility lies at the doors of the medical profession for the small progress made in the early diagnosis of uterine cancer and its successful treatment. How constantly is the consultant told: "I mentioned it to my doctor weeks or months ago, but he said, 'Oh, it is nothing; I will send you a little medicine or a little injection,' and never suggested any internal examination, so I did not like to trouble him again until the pain became so bad or the discharge so troublesome and then he examined me and said. I must have special advice at once." Invaluable weeks or months gone, and then the verdict of the consultant: "It is not a case for operation," which means "you have come too late," but cannot be so candidly expressed because he must guard the reputation of his professional brother. I admit that the false modesty of the patient, especially, in some cases of society makes the position a difficult one, especially for the young family doctor. But we must all be awake to what is at stake and to be firm in our demand for an examination, and if we have any doubt after such an examination, to urge that the patient should at once seek the advice of some one who has had larger opportunities for forming a sound opinion. I will go onestep further, and ask you, if there should be any to whom such a temptation comes, never to go on treating a case in which there is the shadow of doubt, either because you doubt or want practice. If the case is susceptible of treatment at all, it is only surgical which can avail, and that of so severe a kind that it requires the knowledge of the specialist if ever any disease did or does require special skill in operative treatment. It is easily apparent to us all then that the proper treatment of uterine cancer includes first of all a proper diagnosis. This made surgical measures must be advised at once. Given a uterus freely movable with no extension of the disease to the rectum or bladder and a not too great involvement of the surrounding tissues, the results from an operation will usually be good. Time lost at the start will never be regained. Unfortunately there are almost innumerable cases of uterine cancer that will not be cured by a surgical operation. I see many of these cases. Much can be done for these patients in the way of prolonging their lives and making them comfortable as long as life lasts. I find much relief is given if the organ is curetted and the cautery |