sight to witness, too, the disappearance of a growth recurring in the vaginal vault after operation. It is a question for the next three years to settle, whether we will continue to operate on any of the group of cases which melt down under our radium therapy.

Up to the present radium has been used repeatedly to shrink an inoperable growth down and then to operate radically. Finally, in concluding this brief résumé let me say that while radium manifestly ought to replace surgery in many instances, and while it does some of its best work in curing cases which surgery has not the remotest hope of touching, yet, on the whole, there remains a large place for radium combined with surgery, either by following the surgical operation with radiations to reach nests of cells which the surgeon has not been able to eradicate, or to immunize the tissues, or to remove a growth which shrinks, but does not disappear, or to treat recurrences. With such a brilliant present who can declare what the future for this new and most potent agent may be? May we not legitimately look forward to a development as great as that we have witnessed in so short a term of years in the field of x-ray therapy and emanations?

1418 Eutaw Place.

A Study of Seventy Cases of Carcinoma Uteri.

BY HARRY A. DUNCAN, M.D.

PHILADELPHIA, PA.

It is not with any idea of presenting anything new concerning this most baffling question of medicin and surgery that these cases of cancer are discussed here, but rather to emphasize the difficulties of the problem as it presents itself to the surgeon.

While waiting for some self-sacrificing research worker to discover some form of therapy that will improve the results in the treatment of cancer, the surgeon has endeavored to educate the general practician to make earlier diagnoses and to instruct the public in some of the early signs of this insidious disease, so that the only effective known agent-namely, the knife-might be applied early enough to offer some hope of cure.

A brief study of the last seventy cases of uterin cancer admitted to the gynecologic service of the Samaritan Hospital is most disappointing when viewed in the light of

these efforts to educate the public and the profession to an early recognition of the real condition.

Of these seventy cases, 64.3% were inoperable carcinoma of the cervix uteri. In many no operative prodecure was attempted. Where a large cauliflower growth was present producing a foul-smelling discharge and hemorrhage, the sharp, serrated curette and actual cautery were used and the patient returned to her home after only a few days in the hospital. The local use of acetone kept the discharge and bleeding under control, but the miserable existence of these patients was not prolonged to any appreciable degree and the majority died within from six months to one year.

Twenty per cent. of this series suffered with operable carcinoma of the cervix uteri. After radical operation even these cases showed a high percentage of recurrences after one year-just how high a percentage it has not been possible to determine.

Carcinoma of the corpus uteri occurred in 15.7%. Three of these eleven cases were discovered by the routine examination of the endometrial shreds following curetment. Early radical operation has undoubtedly cured many of these patients, but several recurrences have been noted where the operation was late.

The menopause and the age for the development of cancer have been associated too emphatically by teachers. The average practician and certainly the average woman do not readily suspect malignant disease before the "change of life." Thirty-five per cent. of these cases developed in women less than 40 years of age. A drop of blood or a hemorrhage some time after the menopause may constitute a most suspicious symptom, but what shall be the danger signal in these 35% and more cases? Bleeding in more than half the cases means a carcinoma so extensive that any surgical procedure can be only palliative. Carcinoma in these young women always develops rapidly, and not only is the diagnosis made too late, but the operation accomplishes less at this age than it does for the older patient. Bleeding is undoubtedly the earliest symptom, and yet one patient 37 years of age presented herself in the dispensary complaining of "falling of the womb and denying any irregular bleeding, with the vagina filled with a cauliflower growth of the cervix which caused her death five months later. Pain is like cachexia in that it occurs so late in the course of the

disease that it is more a sign of impending dissolution than of cancer.

The duration of symptoms averaged eight months. Some few gave a history of symptoms over a period as long as three years, but these were usually in patients more than 60 years old. Surely some of these patients might have been saved had they been submitted to operation before suffering eight months, and there can be no question but that in some instances the family doctor was guilty of neglect. Most often the patient herself was to blame either in not consulting a physician or in refusing to submit to a thoro examination.

Six patients denied having had children or miscarriages and one of the six suffering with operable carcinoma of the cervix denied any instrumental traumatism of the cervix. Very little reliance can be placed in the statement, found in these six histories, that no one of these patients had ever been pregnant.

Two of the cases were complicated by pregnancy, one aged 27 years and one aged

29 years.

Five were complicated by fibromyoma. Three of these, aged 45, 50 and 53 years, suffering with carcinoma of the body of the uterus, denied any pregnancy. I think it was Cullen who, some years ago, stated that in his opinion the presence of fibroids might predispose to carcinoma.

One other patient, aged 47 years, never married and denying any pregnancy, suffered with squamous-celled carcinoma of the cervix and fibromyoma of the corpus uteri. The fifth case, aged 36 years, the mother of one child, had squamous-celled carcinoma of the cervix, fibromyoma of the corpus uteri, double pyosalpinx and an ovarian cyst.

In view of the recent evidence presented by Miss Slye, of the tendency to cancer to be an inherited trait, it is interesting to note that 14.2% of these cases stated that a father or mother had died of cancer. Case histories as concerns heredity are never very reliable, but Miss Slye has accumulated such a mass of evidence showing the inheritability of a tendency to cancer that the profession certainly is justified in speaking of precancerous conditions and in making every effort to eliminate all conditions, such as lacerations of the cervix, that are irritating and tend to provoke the development of cancer, especially in the patient having a cancer ancestry.

2721 W. Lehigh Avenue.

Malignancy of the Lower Bowel. BY COLLIER F. MARTIN, M.D.

AND

HARRY Z. HIBshman, M.D.

PHILADELPHIA.

The apparent increase of malignancy has prompted a campaign for public enlightenment in the past few years in matters regarding the early diagnosis and radical treatment of this type of disease. There seems to have been but little attention, even of the medical profession, drawn to the subject here presented, with the consequence that this class of cases reaches the surgeon too late for satisfactory and hopeful treatment.

Lack of Early Symptoms.

Malignancy in the lower bowel is very frequently undiagnosed until the lesion has progressed beyond the stage when operation can offer any hope for a cure. This is due to the fact that the process usually begins above the anorectal line, that portion of the bowel having no direct spinal innervation; hence, cancer in an advanced stage may be present without producing acute or painful symptoms. Only when the new growth is either so far advanced as to cause obstructive symptoms, or has grown so large as to encroach upon the sensory nerve distribution of the anus, does the patient feel the necessity for consulting his physician.

This paper is based on the findings in 50 cases of malignancy of the rectum and anus occurring in a series of 2,308 consecutive cases suffering with rectal disease.

The etiologic factors, whether due to direct inheritance, inherited predisposition, or to antecedent pathology, cannot be discussed in a paper of this length, as this would require an extended study to be of any value.

Age.

The age of the patient suffering with malignancy is always interesting. One case occurred in a boy of 16 years of age; 5 cases occurred between the 21st and 30th years of life; 9 cases between 31 and 40; 6 between 41 and 50; 14 between 51 and 60; 11 between 61 and 70, and 4 between 71 and 80 years of age. The occurrence of 15 cases in patients under 40 years of age is extremely interesting in view of the teaching that carcinoma is a disease of later adult life.

Two of the entire series of cases were sarcomata. One occurred in a man 36 years of age, and the other in a woman of 54

years. This latter case occurred at an age when sarcoma is not frequently noted. In a previous series of cases, one case of sarcoma was seen in a man 72 years of age. This is probably the oldest case of sarcoma of the rectum on record. The average age of this series of 50 cases was 50 9/10 years. these patients 35 were males and 15 females. This is probably not the true proportion in rectal cancers, as many women, attributing their ailment to uterin trouble, consult the gynecologist.

Of

It is hard to say whether malignancy is becoming more common in young people, or whether our methods of diagnosis and observation are more accurate. It is just possible that the entire absence of special symptoms may have caused some cases to reach a fatal termination without a local examination having been made.

Symptoms.

Symptoms complained of by these patients were rather vague, and accurate histories were difficult to obtain. The shortest period of the existing symptoms noted was 3 weeks, while the longest gave a history suggestive of a malignancy existing for about 2 years previous to examination. The average duration until diagnosis was made may be put at from 10 to 12 months. The principal symptoms complained of were morning diarrhea, constipation, tenesmus, hemorrhage, and loss of weight.

Pain was not a pronounced symptom, but occurred more as an aching or burning with a sense of weight and obstruction in the pelvis. Not until the growth either involved the anorectal line, or some inflammatory condition intervened, did the patients complain of acute pain.

Diarrhea was noted in 30 cases and constipation in 15. Some of these cases had 15 to 20 stools daily, or rather attempts at stool. No mention was made of either symptom in 5 cases. This diarrhea is not of the ordinary type; it is usually pronounced in the morning after the patient gets out of bed, and while there may be one or two copious movements, after this, there is simply an attempt at stool, which results in the passage of a small amount of mucus and blood, sometimes mixed with pus. Even where the patient complains of constipation this desire for stool seems to be a pronounced symptom. While we speak of diarrhea as being a diagnostic symptom, more accurately we should speak of it as a tenesmus, or a frequent desire for stool.

This may occur in benign stricture also, and is due to the obstruction and impaction. More or less hemorrhage occurred in 19 cases. Occasionally the bleeding was profuse. Loss of weight and strength seem to be fairly uniform in occurrence, but in only 23 histories has any specific mention been made of the fact. There is one condition which is not often mentioned, but which occurs frequently. This is a patulous condition of the anal orifice. It was noted in 23 cases, and in 27 cases either not noted or absent. It probably was absent in but a few. This patulous condition is also seen in cases of benign stricture, and is probably due to the obstruction above, and to some interference with the normal defecation reflex.

The normal defecation reflex shows itself at its maximum when feces descends into the rectal ampulla and presses upon the anal papillæ and the dentate border. It has been pointed out that irritation at one point in the bowel is followed by contraction above that point and relaxation below. This starts a wave of alternate contraction and relaxation, which constitutes the act of defecation; any inflammatory mass or new growth along this course tends to interfere with this wave, and, if near the anus, renders the anal orifice patulous.

Only two of these cases had any history of previous rectal trouble, aside from the usual history of hemorrhoids in early life. In one case a membranous colitis persisted for the preceding 10 years, and another had an attack of dysentery 5 years before the appearance of symptoms of malignancy.

Carcinoma, usually of the adenomatous variety, occurred in 47 cases, epithelioma in 1, and sarcoma in 2. As complications, the fact may be mentioned that 2 cases had associated a carcinoma of the splenic flexure of the colon; 4 had involvement of the prostate gland; in 2 cases the bladder was involved; 2 patients had recto-vaginal fistulæ, and one case had a general carcinomatosis.

The growths were found, as a rule, in the lower portion of the bowel. The lowest carcinoma occurred 1 inch above the anorectal line; the highest one noted was 61⁄2 inches above this point. The majority of them began from 12 to 21⁄2 inches above the anorectal line. Practically all of them completely encircled the bowel, causing more or less mechanical obstruction. The lower borders of the growth were usually sharply defined, with elevated edges, and as the

finger was passed into the canal, deep ulcerations were noted. When most of these cases reached us, the growths were immovable, firmly fixed in the pelvis, this fixation being due partly to extension of the growth and partly to inflammatory reaction. Lymphatic involvement seems to be late and extends first to the sacral, then the pelvic, and, if the anus is involved, to the inguinal lymphatic. As noted in the advanced cases, new growths elsewhere, the liver, splenic flexure, bladder, prostate, are found; and occasionally, as in one case, a general carcinomatosis may be the setting

scene.

In both cases of sarcoma the growth apparently proceeded from the hollow of the sacrum, leaving the anterior rectal wall clear. Obstructive symptoms were not pronounced. The case of epithelioma involved the skin of the posterior margin of the anus and the skin over the соссух.

Diagnosis.

In examining this class of cases, with the presence of a palpable tumor, the air dilating proctoscope was rarely used, because of the conviction that the distention of the bowel with air might result in the rupture of the diseased bowel wall, and was rarely necessary for a correct diagnosis. The presence of the general symptoms of obstruction, offensive discharge (the odor of which in the advanced case is almost pathognomonic), loss of weight and cachexia, with the presence of a palpable tumor, permits of a diagnosis without the use of such dangerous methods. It is surprising to note how little additional information can be obtained by ocular examination.

Treatment.

When the case of rectal cancer has reached the inoperable stage, colostomy, with or without irrigation, may at least render the patients more comfortable by clearing up in large part the tenesmus present. The x-ray and radium offer little help.

That 2% of a series of 2,300 consecutive cases of rectal disease should exhibit malignancy; that 30% of these cases occurred before the age of 40; that the average duration of symptoms prior to proper diagnosis was from 10 to 12 months; that the early symptomatology is vague; that the period of hopeful surgical intervention is frequently past when the true condition is noted, must impress us with the necessity for

more careful and thoro rectal examinations in these cases in the hands of the general practician; and that the public must be impressed with the necessity for proper treatment of rectal disease—that self-medication for "pile" trouble by the laity must be deplored and discountenanced-for the laity will term any condition of pain or discomfort in the region of the rectum and anus as "piles." Only when these cases, as with cancer anywhere, come early to the surgeon, can the mortality from this dread disease be reduced and the duration of life extended.

BY J. C. ATTIX, M.S., D.D.S., M.D., P.D. Professor of Chemistry and Toxicology in the Medical and Pharmaceutic Departments of Temple University. Chemist, Pathologist, and Bacteriologist to The National Stomach Hospital. Chemist to the Samaritan Hospital, formerly X-Rayist and Radiotherapeutist to the Samaritan and Garretson Hospitals, Philadelphia, Pa., etc.

So many names have been applied to these superficial growths by various investigators and attempts have been so frequently made to classify them that at times one is confused.

Most classifications have depended upon the position of the growths. The terms rodent ulcer and Jacob's ulcer are much more infrequently used than formerly, but were originally applied to chronic ulcers about the head and face occurring beyond the age of 40, with a tendency to increase steadily in size, destroy progressively all tissues in their path, even cartilage and bone, until the features were distorted beyond recognition. These ulcers begin as a small, crusted nodule, usually without pain, even after the ulcer formation becomes deep. They are sharply, tho often irregularly outlined, with little or almost no secretion; the edges and base being indurated. They show little tendency to involve glandular tissue or to spread thru that avenue. They occur anywhere on the head, face or neck, but are more common on the upper portion of the face and forehead. Irritation seems to be an exciting cause, as in cuts from a razor in shaving. One well-marked case was at the site of a clipping off of a small part of an ear accidentally done by a barber. Warts and moles, especially the markedly pigmented ones, are favorite seats for development and they have frequently been observed at the former site of a psoriasis patch on the

face or other portions of the body. Strong rays of light, tar products and other chemical substances certainly induce these growths.

Another form sometimes classified as deep-seated epithelioma whose histologic origin is from a deeper layer of the skin, does not differ materially from the superficial type, but does show a greater tendency to give metastasis thru the lymphatics. This type is more prone to occur at the junction of skin and mucous membrane, especially about the mouth and nose. The cases when both skin and mucous membrane are involved are decidedly more malignant, extend more rapidly and yield to treatment less satisfactorily even when radical surgical means are used. This is the type of cancer which is frequently seen at the seat of old varicosed (leg) ulcers, after long-standing or chronic eczemas, from burns and, in fact, any long-continued irritation, or scars resulting from these frequently form a basis for the form known as malignant degeneration or Marjolin's ulcer. Any interference with normal nutrition as well as irritation is undoubtedly a factor in these growths and consequently senility plays an important

rôle.

Diagnosis.

There should be comparatively little trouble in diagnosing these growths. Chronicity, age, position are, of course, to be taken into consideration. Syphilitic ulcers are probably the most apt to be confounded with them. The Wassermann reaction should clear up the diagnosis provided the patient has not been taking antisyphilitic treatment. If the individual has been on specific treatment it should be withdrawn for a month and another Wassermann made. Another way to determine the difference between epitheliomatous and syphilitic ulcers is to subject the growth to three or four x-ray exposures. If the former, the growth will tend to subside; if the latter, the inflammation increases and the growth, together with the surrounding tissues, markedly flare up.

We have had a number of these cases sent to us for x-ray treatment where the growth became quickly inflamed and the Wassermann reaction proved positive. These cases have yielded promptly to salvarsan injections. On the other hand, we have had patients who personally applied for x-ray treatment for ulcers evidently

thought to be epitheliomatous, and when operative measures had been advised, these have subsided quickly on salvarsan, while surgery probably would have made matters

worse.

Treatment.

There is not the slightest doubt that x-rays properly applied will cure practically all of these cases. We feel certain it will cure every case where the skin alone is involved, altho in our hands a few cases (3 or 4), where the mucous membrane and glands together with the skin were affected, did not yield to the rays. With ever-increasing superiority of technic, larger dosage and better control, it is not unlikely that practically all of these growths, even of the deeper variety and where glands are involved, may be cured. Sidney Lange reports a case recently in Lancet-Clinic of a man, 64, with involvement of nearly the entire lower lip and glands of the neck of two years' standing, which yielded to three treatments, using the Coolidge tube.

As stated in a previous article (see MEDICAL WORLD, October, 1911), many of these cases fall into the hands of the so-called laity demands paste treatment in many cancer specialists" or "quacks." The

instances, also, and since this is the case the demand should be supplied by regular medical practicians.

There are certain other advantages also in the use of the various pastes. The time and expense for x-ray treatment is very materially curtailed, probably one-half, and many physicians do not have access to an x-ray outfit. The great advantage of x-ray treatment is freedom from pain. If the growths are very large, 2 or 3 inches in diameter, of a cauliflower-like formation, as frequently seen on the shins from old, varicosed or eczematous conditions, from burns and other injuries, these pastes are certainly worthy of careful consideration.

It is asking too much of the rays to destroy these exuberant growths and stop the process too, so the rapid removal of the diseased tissue by pastes is of service. It seems also that these caustic agents block up avenues of metastasis in a much more satisfactory way than do excisions or curettements, a factor which should not be disregarded.

There are many caustics, of course, capable of destroying normal as well as diseased tissue, and all of them cause considerable pain.