A DIGEST OF TWENTY YEARS' EXPERIENCE IN THE TREATMENT OF UTERINE CANCER, INCLUDING 367 OPERATIONS BY GALVANO-CAUTERY. BY JOHN BYRNE, M.D., M.R.C.S.E., Surgeon-in-Ohief to St. Mary's Maternity; Chief of Gynecological Department, and President of the Faculty of St. Mary's Hospital, Brooklyn ; Fellow of the New York Academy of Medicine ; Member and Ex-President of the New York Obstetrical Society ; Fellow of the American Gynecological Society; Corresponding Member of the Gynecological Society of Boston; Permanent Member of the American Medical Association; Member of the Kings County Medical Society, and of the Pathological Society. REPRINTED FROM THE TRANSACTIONS OF THE AMERICAN GYNECOLOGICAL SOCIETY, VOL. XIV., 1889. A DIGEST OF TWENTY YEARS' EXPERIENCE IN THE TREATMENT OF UTERINE CANCER, INCLUDING 367 OPERATIONS BY GALVANO-CAUTERY. BY JOHN M.R.C.S.E., Surgeon-in-Chief to St. Mary's Maternity; Chief of Gynecological Oepartment, and President of the Faculty of St. Mary's Hospital, Brooklyn ; Fellow of the New York Academy of Medicine ; Member and Ex-President of the New York Obstetrical Society ; Fellow of the American Gynecological Society; Corresponding Member of the Gynecological Society of Boston; Permanent Member of the American Medical Association ; Member of the Kings County Medical Society, and of the Pathological Society. REPRINTED FROM THE TRANSACTIONS OF THE AMERICAN GYNECOLOGICAL SOCIETY, VOL. XIV., 1889. PHILADELPHIA: WM. J. DORNAN, PRINTER. 1889. A DIGEST OF TWENTY YEARS' EXPERIENCE IN THE TREATMENT OF UTERINE CANCER BY GALVANO-CAUTERY. By John Byrne. M.D., M.R S.C. Ed., Brooklyn. Lest the title affixed to this paper might mislead or give rise to misconception as to its scope and purport, I deem it proper to state at the outset, first, that, for obvious reasons, the introduction of voluminous details, such as my clinical record might supply, shall be purposely omitted. Secondly, that histories of cases must also be dispensed with, or at least confined to such as might serve to elucidate the method of treating cancer of the uterus which I have pursued for the last twenty years. Thirdly, that such numerical statistics only as may seem indispensable for grouping or classifying the whole will be utilized as a basis for determining results; and lastly, a due regard for the rules governing the author of a paper demands that in this instance the discussion of ques- tions touching etiology, diagnosis, or the pathological features peculiar to each group or class, will have to give way to the more practical inquiry as to the best means by which the victims of this dreadful malady may be benefited and their lives prolonged. It will thus be seen that what I propose to submit for consideration will be more in the way of facts and suggestions based solely on personal experience, together with such critical views and opinions as have been formed and strengthened by long and somewhat extensive clinical observation. Conse- 4 TREATMENT OF UTERINE CANCER. quently, though the subject to be cousidered will admit of no visionary theories, or the attractive glitter of surgical exploits, yet I trust an unembellished statement, such as I shall en- deavor to present, may be found worthy the thoughtful con- sideration of every conservative gynecologist. Furthermore, should my remarks prove to have any weight in checking the prevailing craze for pelvic evisceration, or, at least, so much thereof as hysterectomy for the cure of uterine cancer would imply, one aim of this paper will have been attained and the interests of humanity promoted. The history of galvano-cautery in this country presents but little worthy of special mention beyond what is already fa- miliar to every gynecologist, nor in the struggle for recognition does its record differ from that of other advances, whether in medicine, surgery, or the arts. By its introduction as a sur- gical measure actual cauterization received a fresh impetus, and, for the first time, we were thus put in possession of a means whereby the excision of diseased parts by heated knife or loop, and in a bloodless and otherwise safe manner, could be readily effected. The full import of these peculiar attributes was at once recoguized by gynecologists especially, and the manifest ad- vantages of electro-cautery over older, and, to a great extent, obsolete methods, being duly appreciated, its adoption in uterine surgery may be said to have become quite general for a few years. Soon, however, reports of failure became frequent, so much so, indeed, as almost to outweigh, in the mind of a superficial observer, all previous clinical data. Some there were who, though encountering much trouble, and having achieved but partial succeess at first, but full of hope and confidence, suc- ceeded by perseverance in overcoming the obstacles of inex- perience, while many, though satisfied as to its merits, but, it is to be presumed, attracted mainly by its novelty, were un- able to resist the counter-pressure of disappointment, and finally abandoned it. As to the latter class, though all were JOHN BYRNE. 5 ready to attribute their difficulties to imperfect apparatus or some inexplicable but inherent uncertainty regarding the thermal effects of electro-chemical forces, yet few, if any, seemed willing to question their own ability to utilize or cope with a power, of the nature of which, or the fixed laws govern- ing it, they had little or no previous knowledge. Another, and perhaps the most potent of all causes which have combined to retard its progress, has been the introduction of a more recent but singularly unsuitable thermogenic con- trivance1 in no essential feature a proper substitute for the voltaic current, and yet not only very generally adopted by leading gynecologists at the present day, but authoritatively recommended in preference to the latter, which, indeed, they sometimes even ignore. In short, what with over-zeal with- out knowledge, on the one hand, and on the other a certain degree of scepticism regarding the utility of what seemed to some but a complicated innovation, and an unwillingness on the part of many to put up with and accept some little trouble and inconvenience in lieu of advantages not otherwise attain- able, gal va no-cautery has certainly failed to meet with that degree of practical recognition which its early advocates hoped for and predicted. Nevertheless, neither the apathy of pseudo-conservatism nor the doubts, difficulties, and misgivings engendered by faint approval, groundless objections, or futile attempts to ignore what had been and might be accomplished through its agency, can alter facts or render their final acceptance less certain. Thus, in 1872, having for several years previously devoted much time in experimental study of the principles of electro- physics and their application to the generation of heat by voltaic action, and having satisfactorily tested and proved its applicability to the treatment of many and various diseases in the field of uterine surgery, thus fully verifying the reports of 1 The " thermo-cautery." 6 TREATMENT OF UTERINE CANCER those who preceded me, I detailed the results of my investiga- tions in a series of papers then published.1 Up to that time my cases of uterine cancer treated by galvano-cautery numbered twenty-four, of which seven were of the cervix and seventeen involved the entire uterus. So, even then, though it seemed premature to offer anything like positive statements regarding recurrence, sufficient clinical data had been brought forward to render it more than proba- ble that for the treatment of carcinoma of the cervix uteri we possessed in the galvano-cautery an agent of great future promise. I stated, moreover, that, "judging from the appa- rently complete restoration to health in the great majority of patients so treated, though the condition of some was in the highest degree discouraging at the outset, I cannot hesitate to believe firmly that their ultimate history will warrant the most favorable conclusions in this regard." Again, "that the electric cautery, when properly employed, is attended with less danger, immediate or remote, and promises better results than can be claimed for any other method of surgical treatment yet devised for such ailments." There is another point to which I would here call special attention, and which would seem to have been overlooked, unintentionally, I presume, by authors of papers and in dis- cussions touching supravaginal or high amputation for cancer of the cervix. I refer again to my own views and practice, fully eighteen years ago, as to the importance of excising or otherwise destroying, by whatever means employed, and re- gardless of apparent limitations, as much of the affected organ as could be safely spared. In formulating a set of rules for operating, my first was as follows : " In all cases of induration, destructive ulceration, and out- growths of the cervix uteri of a malignant nature, or believed to be so, and, therefore, warranting their excision by galvano- cautery or other means, such operations should never be 1 New York Medical Record, December, 1872 and January, 1873 ; also American Journal of Obstetrics, vol. v. JOHN BYRNE. 7 limited to the apparent line of demarcation between diseased and healthy tissue, but must include the whole vaginal cervix at least, and even more if need be."1 It is proper to add that this appeal to retrospective facts is prompted more in the interest of impartial history than from any desire to assert or record personal claims to priority, how- ever just and reasonable. Besides, it is manifestly within the scope of this paper to rescue from accidental or threatened oblivion records which have an important and practical bear- ing on the subject under consideration. Previous to 1872, although the galvano-cautery was viewed with much favor by the profession generally, and a few gave practical evidence of their confidence in its utility, yet its adoption, even by gynecologists, had not been by any means so general as its singular merits appeared to warrant. Why an agent by which many grave and important operations could be performed without loss of blood and with immunity from sepsis, but which, as ordinarily conducted, were often attended by dangerous hemorrhage or subsequent blood-poisoning should have been slow of adoption, was then surprising, and, to me, is now inexplicable. It is true, at the period referred to, though the gain was paramount to almost every other con- sideration, yet the obstacles were great, and oftentimes insur- mountable. Not alone the cost, but the very objectionable character of such galvanic apparatus as it was possible to obtain, to say nothing of the great trouble in its manipulation and the apparently fitful and uncertain nature of the power invoked, combined to demand an expenditure of money, time, and patience which few were prepared to bestow. Indeed, the choice of a sufficiently powerful battery lay between one con- sisting of the compound porous cells of Grove or Bunsen, re- quiring strong nitric acid and large quantities of dilute sul- phuric acid as excitors, or the single-fluid pile manufactured by the late Charles Chester, of New York, and which needed 1 Clinical Notes on the Electric Cautery in Uterine Surgery, page 61. 8 TREATMENT OF UTERINE CANCER. no less than three gallons of the strongest bichromate solution to operate it. Nor was this all, for, in the event of an operation being called for at the residence of a patient, it was usually found necessary to invoke the aid of a truckman, who too often managed by rough handling to derange the metallic connections, and thus render the apparatus inefficient, perhaps at a critical moment. It is hardly necessary to remark that a steady perseverance in the use of the galvano-cautery, in spite of such perplexing obstacles demanded on the part of its pioneers in this country, Drs. Jacobi, Noeggerath, Guleke, and a few others, a degree of patient enthusiasm which could only spring from an intelli- gent conviction as to its great merits. As might be expected, however, a keen appreciation ot these drawbacks only served to stimulate further research, so that during the succeeding few years improvements in appa- ratus of various kind and construction, and designed for electro-cautery, progressed steadily until 1876, when the first really portable and powerful battery was exhibited at the Centennial Exposition in Philadelphia. For over a year pre- viously, and up to the present time, I have employed it ex- clusively in every operation for uterine cancer. Indeed, since its introduction, all reasonable cause of complaint as regards trouble, inconvenience, and uncertainty of action may be said to have been eliminated from cautery operations. In its con- struction this little battery presents many novel features which need not be referred to in detail at present, but, for the information of those who may not have had an opportunity to examine or use it, I may state that the most important and radical departure from all previous or subsequent voltaic organizations consists in the use of a compound metallic plate of high electro-negative qualities, and possessing a conduc- tivity equal to copper, yet practically indestructible with reasonable care.1 By this device, bulky and otherwise objec- 1 These negative plates are made by soldering a sheet of compact platinum on one side of a copper plate, and protecting the back and edges by a sheet of JOHN BYRNE. 9 tionable carbon plates are dispensed with, what is known as internal resistance is almost annihilated, and the thermal force generated in the cells is thus set free to be utilized where needed. It will readily be seen by any one at all conversant with the subject and whose mind is not hopelessly warped by preconceived notions, that there is no similarity whatever, either in principle of construction or practical working be- tween such an apparatus, and which I have been in the habit of using for the past fifteen years, and any other galvanic battery in existence. To class it, therefore, with certain other apparatus, though equally small and portable, but too often constructed in direct violation of fundamental principles, and, of course, necessarily and seriously defective, as well as "unre- liable and inconvenient," is certainly worse than folly; because, whether intended or not, it misleads the uninitiated, retards the progress of true conservatism in a most important field, and tends to belittle one of the most beneficent gifts that physical science has bestowed upon uterine surgery. With regard to the selection of a battery, however, it may be well to state that, in spite of the advantages to be obtained by using a perfect apparatus such as I have described, a moderate knowledge of the principles of electro-physics ought to enable any one desirous of performing cautery operations to do so satisfactorily by the aid of any properly constructed battery of sufficient power. Hopes seem to be entertained by some that the day is not far distant when a really portable storage battery may be devised to take the place of all others heretofore in use. I cannot share in any such hope, however glad I might be to feel that I could do so. An accumulated power sufficient for uterine cautery can only be obtained from large surfaces, which means both bulk and weight, while a properly con- structed rheostat or resistance coil for currents so strong would lead similarly attached. In this manner the copper is made to serve the purpose of a conductor merely. 10 TREATMENT OF UTERINE CANCER. in itself be no small matter.1 Consequently, instead of per- sisting, regardless of scientific facts, to grope after a will-o'- the-wisp, while neglecting to utilize, or treating with flippant objections what has been over and over again proved to be an inestimable benefit to the afflicted, would it not be well to inquire what and how much is demanded of us in a con- scientious discharge of one of the most sacred duties and trusts ? As to the Paquelin cautery, the preference accorded it by some gynecologists, though difficult to understand, must be due, in part at least, to a want of this easily acquired knowl- edge. In addition to its limited range of utility, the injury to sound parts from intense radiated heat, which must inevit- ably attend its use, should render any such comparatively clumsy device unsuited for intra-vaginal cautery.2 It may be said to be an ingenious philosophical contrivance for demon- strating the thermal power of benzine vapor under certain conditions, but should be relegated to the armamentarium of the veterinary surgeon, where it has latterly been found to be not only useful but perfectly safe. However, in spite of these objections, many gynecologists, under the delusion that diseased uterine tissues can be as neatly, safely, and effectually removed or destroyed by such an instru- ment, will, doubtless, continue its use. But, whatever the means resorted to may be, or in whatever manner excisions or amputa- tions, high or low, may be effected, subsequent cauterization oj the entire surface and edges of all parts from which cancerous material may have been removed will be found to be the best safe- guard against a recurrence of the disease. This important 1 This conclusion is the result of repeated but most unsatisfactory trials with a very perfect "storage " battery. 2 This danger from radiated heat has been fully realized by all who have used the apparatus, and Dr. Wilson, of Baltimore, several years ago devised an ingenious means of overcoming this, by passing currents of ice-water through the handle during an operation. Whether many have conferred on their patients the benefits derivable from this very much needed invention, I can- not say. JOHN BYRNE. 11 principle, which was fully recognized over fifteen years ago, is a matter of record, and was farther exemplified in an able paper by Dr. Baker in 1882, in which it was clearly proved that even supravaginal amputation after his proposed method offered little or no security against recurrence when subse- quent cauterization had been omitted. Indeed, if further proof of this clinical fact were needed, it is, in my opinion, amply furnished by the interesting and instructive paper of Dr. Reamy, read at the last meeting of this Society.1 In look- ing over his admirably arranged table of fifty-five operations, I cannot but believe that at least fifty per cent, of such of his patients as succumbed to a quick recurrence of the disease would be living to-day had he combined my method with his own. Because, this tabic comprises only those cases in which the disease was limited to the portio or to the cervical canal, and these are the cases in which, according to my expe- rience, a recurrence of the disease within two years after excision and thorough cauterization has been extremely rare. Indeed, another and striking proof is thus furnished of how little may be hoped for from amputation of a cancerous cervix in whatever manner, unless followed by actual cauterization. When the proper apparatus for carrying out this important step in all such operations cannot be procured, much benefit may possibly follow repeated applications of zinc chloride as used and recommended by Mr. Tyson, of London, over forty- five years ago, again adopted by the late Dr. Sims, and still more recently employed with satisfactory results by Dr. Van de Warker. Over twelve years ago I had the honor to present to this Society, at its meeting in this city, a paper entitled "Amputa- tions and Excisions of the Cervix Uteri by Galvano-cautery," in which, after five years' additional experience, I reiterated my preference for this method of operating in cancer of the cervix uteri especially.2 Though typical cases of the disease 1 Gynecological Transactions, vol. xiii. p. 171. 2 Ibid., vol. ii. p. 57. * 12 TREATMENT OF UTERINE CANCER. and the results of treatment by this means were detailed, as indicating a promising field for cautery, yet, in order to avoid the too frequent habit of offering premature and necessarily incomplete statistics, or clinical facts and occurrences though striking and suggestive, yet insufficiently numerous to warrant logical conclusions, much material, even then available, was purposely omitted. For like reasons, and in opposition to repeated suggestions on the part of my colleagues and others, I have preferred to forego all personal gratification by withholding from publica- tion many interesting cases which have occurred from time to time during the past thirteen years, in private as well as in hospital practice. In adopting this course, however, and with the hope of being able to construct numerical statistics suffi- ciently comprehensive to guard against hasty conclusions, especially as to post-operative results, a certain degree of incompleteness is found to be unavoidable. Thus, while the condition of patients operated upon in the more stable Euro- pean communities may be traced for a long period without much difficulty, it will be found to be no easy matter to do so in a country like ours. Diversity of tastes and interests, as well as a restless desire on the part of many to better their social condition through change of residence or wandering adventure, impart to our people a nomadic character, which must ever be a stumbling-block to the statistician. Indeed, so far as the ultimate fate of most hospital and many other patients is concerned, only a well-organized body of profes- sional detectives could supply any satisfactory information. In addition to all this, the natural aversion of some to period- ical inspection, and the unreliable promises of others to report in person for a similar purpose, are, I imagine, characteristics common to all, and peculiar to no particular class or country. Besides, it must be admitted that there are those of every class and station in whom a restoration to health would seem to obliterate the chastening influences of affliction. Such patients JOHN BYRNE. 13 exemplify the aptness of a certain proverbial allusion to the instability of lofty aspirations under pressure, and are very proue to regard injunctions as to all precautionary measures more in the light of professional curiosity than a sincere con- cern for their bodily welfare. From these considerations, it need not excite surprise when I state that, of 367 patients operated upon for uterine cancer during the past twenty years, no less than 151, or forty-five per cent., were lost to observation before the expiration of one year, and it has been found impossible to follow them up or to ascertain anything reliable as to their subsequent history. Under such circumstances, it is hardly necessary to remark that much difficulty has often been found in obtaining trust- worthy information regarding the period of exemption from relapse. A very large proportion of all my cases, but more especially those whose deplorable condition rendered it impossible to ac- complish more than relief from hemorrhage, pain, and offen- sive discharges, were hospital patients from distant parts of the country, while many others passed from observation by change of residence to other States and cities. In this way many known to be comparatively, and some quite, well for one, two, or more years, and so recorded, may have been much longer free from a recurrence of the disease. For example : Mrs. H., aged thirty-two, married six years, and the mother of two children, had well-marked cancer of the cervix, which was removed by galvano-cautery in February, 1878. During the first year thereafter she returned at stated periods for examina- tion, but all at once ceased to report. Three months ago she made her appearance at my clinic in St. Mary's Hospital, stating that she had been a resident of Ohio for the last ten years, had given birth to four children during that time, and called to see me on account of certain symptoms which reminded her of her former illness, eleven years ago. On making a digital examina- tion, a central depression in the vaginal vault indicated the 14 TREATMENT ON UTERINE CANCER. cervical entrance to the uterus. The surrounding tissues were soft and otherwise normal to the touch, and no evidence of pelvic disease could be detected. She was simply passing through the menopause, and very naturally felt a little apprehensive. As a further example of the difficulty experienced in getting patients to realize the importance of submitting to repeated examinations for a year at least after operation, and how nearly impossible it is to follow up their histories, the follow- ing case is worthy of mention: A prominent obstetrician in Brooklyn, being called to at- tend a case of labor, displayed by his manner some confusion on making a vaginal examination; observing which, the patient explained that she had been the subject of an opera- tion over two years previously. On referring to the hospital records, it was found that this patient had been attacked with pelvic pains and hemorrhage five months after her third con- finement, in April, 1879, and was found to have a rapidly de- veloping carcinama, which I removed by galvano-cautery on January 11, 1880. Though still living, she has never re- ported. As already stated, the total number of cases operated upon up to July 1st has been 367, and may be classified as follows: r. n. in. IV. The disease was limited to the portio-vaginalis in . 59 cases. The entire cervix was affected in . . . . 81 " The disease originated and seemed to be confined to the corpus in 8 " Both cervix and corpus were involved in . .219 " Total 367 " The following tables will serve to show the period of ex- emption from recurrence in a large number of the first and second classes, and the extent of relief or respite gained in cases for which palliative results only were looked for. JOHN BYRNE. 15 Class I.-Period of Exemption. Over 18 years . . 1 case. " 16 " . 1 " " 15 " . . 5 cases. " 13 " . 4 " " 10 " . 4 " " 8 " . . . . ' . . 7 " " 5 " . 6 " " 3 " . 6 " " 2 " . 6 " 36 " Operated upon during the past year . 2 " Died from cardiac asthenia 48 hours after operation . 1 case. Died from tetanus caused by cold plunge bath on fourth day after operation . 1 " Had a recurrence within two years and were operated upon a second time only1 .... . . 3 cases. Cannot be traced . 16 " - Total . 59 " Average period of exemption in 36 cases, 8 years 7 months. If to the 36 cases 16 unknown and 2 operated on too re- cently to be considered be added, and an exemption of but two years be allowed to each of the 57 cases, even then we obtain an average of over six years for each. The ages in this class were as follows: Between 25 and 30 . . . . 7 cases. " 30 " 40 . . . . 31 " " 40 " 50 . . . . 16 " " 50 " 60 . . . . 6 " Total . 59 " 1 One of these patients was quite well for nearly eleven years after the second operation, and died finally from cancer of the corpus uteri and ovaries 16 TREATMENT OF UTERINE CANCER. Class II.-Period of Exemption. Over 17 years .... . . . 1 case. " 13 " .... . . . 1 " " 11 " . 2 cases. <■ 7 " . 6 " " 5 " . 8 " " 4 " . 6 " " 3 " . 11 " 35 " Operated upon within two years and not included . 5 " Known to have had a recurrence within two years . 10 " Disappeared and cannot be traced.... . 31 " Total . 81 " Average minimum period of exemption in 35 cases was 5 years and nearly 6 months. If to these, 31 unknown and 5 recently operated upon be added, and we allow three years to each of the latter, we still obtain an average of over four years for each of the entire number. The ages in this class were as follows : Between 25 and 30 9 cases. " 30 "40 • . 37 " " 40 "50 . 29 " " 60 "60 . 6 " Total • • . 81 " Class III.-Period of Relief. Over 3 years ..... .... 1 case. " 2 " . . . . 2 cases. " 1 " . . . . 1 case. Less than 1 year .... . . . . 2 cases. Unknown . 2 " Total . 8 " Average period of relief from hemorrhage, pain, and offen- sive discharges in 4 cases was 2 years. JOHN BYRNE. 17 The ages in this class were as follows : Under 30 years .... " 40 " .... 2 cases. . 3 " " 50 . 2 " " 60 .... . . . . 1 case. Total 8 cases. The two patients whose ages were 26 and 28 respectively are now living. One has been operated on over two years ago, is now apparently in good health, and, so far as she knows, well. The other has been operated upon by curette and cautery twice within a year, and now looks and feels well, but, doubtless, will not long remain so. Class IV.-Period of Relief. Over 6 years 1 case. " 5 " . 7 cases. " 4 " . 10 " " 3 " . 41 " " 2 " . 10 " " 1 " . 9 " .1 78 Operated upon within one year .... . 4 " Known to have had a recurrence within one year . 26 " Lost sight of . Ill ' ■ 1 '■III Total . 219 " Average respite from pain, hemorrhage, and offensive dis- charges in 78 cases within a fraction of three years. The ages in this class were as follows : Between 25 and 30 ... . . . . 7 cases. " 30 " 50 . 109 " " 40 " 50 . 82 " " 50 " 60 . 14 " " 60 " 70 . 7 " Total . 219 " Of the 26 cases known to have had a recurrence within one year, 15 were under 40, and 11 under 50, while of the 9 who were made comparatively comfortable for nearly two years, 5 were over 50 and 4 over 60. 18 TREATMENT OE UTERINE CANCER. With regard to the period of exemption from recurrence of the disease in the first and second classes, it is proper to remark that only the time at which patients were known to be well and free from all symptoms of relapse, has been taken into account. Consequently, as several of my cases are known to have died from diseases other than cancer, and, as already stated, quite a large number have disappeared and cannot be traced, the period of respite is probably much understated. The methods of operating in both classes of cervical cancer have differed but little except in degree. Where the portio only has been the seat of disease and the cervical canal but little if at all involved, amputation by the heated loop or knife at or above the vaginal insertion, and recauterization oj the stump have been deemed sufficient. When the ulcerative destruction within and around the os has been extensive, or preceding this stage of the disease, the portio has been en- larged and indurated, and the cervical mucosa in all proba- bility involved, the following case will illustrate my usual mode of proceeding: Cancer of Entire Cervix. Mrs. M., aged forty-three, the mother of five children, the youngest four years old, had always enjoyed good health until about two years after her last confinement, when menstruation began to be excessive and prolonged. During the past twelve months severe and almost continuous backache, pelvic pains, and hemorrhage after slight exertion, combined to render her life very miserable. The hope and belief that " change of life " might account for her condition now gave way to the gravest apprehension, and she applied to me at the request of her family physician, in the early part of March, 1878. Though somewhat ansemic, there was in her .looks and general expression, an entire absence of that ashy pallor so suggestive of constitutional taint, but she stated that she had been steadily losing flesh for six months previously. On examination, much of the cervix, particularly on the left side and extending nearly up to the vaginal junction, was found JOHN BYRNE. 19 to be destroyed, but the vagina proper seemed to be intact, and the entire uterus was movable. The pouting, swollen, and irregular margins of the excavation bled freely on the slightest touch, and from the bottom of this cavity to the fundus measured a little over two and a half inches. Operation.-The patient having been anaesthetized, and the entire cervical canal thoroughly cleared out by a sharp curette, the uterus was drawn down by means of an expanding double tenaculum passed into its cavity, and the vaginal attachment in its entire circumference was severed by the heated knife carried obliquely upward in the direction of the os internum. The gal- vanic loop having been now adjusted, the intra-uterine double tenaculum removed, and increased traction being made by a vul- sellum applied below the loop, the latter was slowly contracted and the part removed. Lest any portion of the cervical canal might have been left, or escaped the action of the cautery, a suitable electrode was now passed up toward the uterine cavity to the extent of half an inch at least, the circuit closed, and this part thoroughly seared. Finally, the whole surface from which the cervix had been removed was gone over and over until the stump was charred and black. The recovery of this patient, like all others similarly treated, was rapid and uninterrupted, and she enjoyed excellent health up to the beginning of the present year, when she succumbed to an attack of broncho-pneumonia. With regard to such patients as' may not have reached the menopause, my rule has been to insist on their submitting to examination once a month for a year at least, if for no other object, to insure a free outlet for the menstrual flow; and, in the event of their home being at a great distance, strict injunc- tions in this regard have always accompanied their discharge. On this point what I wish to state distinctly is, that where this rule has been observed no serious trouble has ever occurred and none need be anticipated. As to the third class, though the disease was hopelessly advanced in four, there were at least two in which fixation being but partial, kolpo-hysterectomy might have been prac- 20 TREATMENT OF UTERINE CANCER. ticable, and would probably have been resorted to had I been able to reconcile such a questiouable proceeding with my sense of duty and responsibility. The fourth class consists of cases which are ordinarily either abandoned to their fate or treated by curette and subsequent applications of zinc chloride or other caustic substances. For the wretched condition of most of these patients, tem- porary relief and a brief prolongation of life are all that can be hoped for from any interference. Nevertheless, I am fully convinced that for a large proportion of these deplorable cases much can be accomplished by proper management, and I feel that I cannot urge too strongly a reconsideration of the sweeping verdict as to the inutility of all treatment, so com- monly pronounced and practically carried out in dealing with these unhappy sufferers. Than extensive cancerous destruction of the womb there is not, I believe, in the whole range of female afflictions, another malady the victims of which appeal so forcibly to our sym- pathies, nor is there one which demands more self-sacrifice and untiring efforts for its amelioration. So, I hold that it is a violation of every principle of ethics, both moral and pro- fessional, and something from which the promptings of humanity should recoil, to withhold from anyone, doomed to die from an incurable disease, any means, however trouble- some, through whose agency suffering may be lessened and life prolonged. Did the scope of this paper permit, many illustrative ex- amples of the appositeuess of this principle could be given; cases in which, by the unsparing application of a Simon spoon or other suitable instrument, the trimming off of all loose and ragged parts as preparatory steps, and a very thorough aud fearless cauterization, either at the time or within a few days thereafter, results almost incredible have been obtained, and that, too, without a single grave symptom following. In many cases the cachectic anaemia so characteristic of this class of sufferers, and the sad and anxious expression of JOHN BYRNE. 21 hopeless despair so often pictured in their emaciated counte- nance, have been noticed, after a few months, to give place to a buoyant and cheerful manner, and even a facial tinge of restored health. Indeed, it is not unusual to find patients, who have been operated upon in the manner described, quickly realize a remarkable improvement in their feelings, and in their looks and general condition, to present so great a change for the better that they, as well as anxious friends, are apt to cherish the vain hope that, after all, a more encouraging prognosis might have been ventured. Though this heaven- born solace in affliction, the boon of a beneficent Creator, is seldom, if ever, realized, but destined sooner or later to be withdrawn, it is gratifying to be able to state that in a very large number of patients who have been under observation up to and after the period of recurrence, this second and final attack differs in many important respects from the primary invasion. The hemorrhage is never severe and the odorous discharges are comparatively little, though inguinal and pubic pains and vesical difficulties are sometimes considerable, re- quiring for their amelioration the frequent use of anodynes. But, so far as the eye or touch could determine, I have rarely known the disease to recur in the vagina or in the cervical region where cauterization has been most thorough, but usually in the ovaries, or upper lymphatics, and less fre- quently in the fundus. If results, such as I have referred to in this general way, are to be hoped for, I cannot too strongly emphasize what has already been said regarding the manner in which cauterization should be conducted, and the extent to which it must be carried, especially in dealing with most cases of cancer in- volving both cervix and body. If ordinary cutting instruments, such as scissors or scalpel, be first used to remove diseased parts, it will rarely be possible to proceed with the final, and by far the most essential part of the operation-i. e., cauterization, as it ought to be done, without subjecting the patient to a second ordeal for this 22 TREATMENT OF UTERINE CANCER. special purpose. Plunging any actual cautery instrument into a mass of bleeding or otherwise wet tissue, will certainly fall far short of the desired object. Therefore, even after the application of a sharp or serrated curette, all bleeding must be allowed to cease and the cavity must be repeatedly sponged with some styptic solution until quite dry, or, open and bleed- ing vessels may be sealed by the cautery. In the latter event, however, the thermal agent should be credited with a haemo- static contribution to the operation only, and in no way influ- ences subsequent cauterization. Every part of the cavity should be gone over repeatedly, and each time as blood oozes from the searing tissues the cavity is to be sponged until finally charred, when all moisture will be found to have dis- appeared. The ragged borders of the excavation should next receive attention, and care should be taken that no raw spot be permitted to escape the cautery. A firmly rolled tampon of proper size, saturated with glycero-tannin containing five per cent, of carbolic acid, should now be inserted within the charred cavity, and a larger dry one placed in the vagina, both being allowed to remain for at least forty-eight hours. Should the patient complain of much pain, which is excep- tional, an opiate suppository may be given; but, as a rule, no medication, local or otherwise, will be needed. After the third or fourth day the bowels should be moved by enema, and the vagina douched night and morning with warm carbolized water. Such is the manner in which a very large proportion of my cases of cancer involving the body, or suspiciously high in the cervix, have been treated. The full extent to which cauterization may be carried with impunity, and short of devitalizing peritoneal or other adjacent structures, I am not prepared to say, but that it is marvellously great has been often remarked by all who have witnessed my method of dealing with these cases. There can hardly be any doubt, however, that the developmental activity of cancer cells or germs, in certain stages and under certain conditions, may be JOHN BYRNE. 23 arrested or permanently destroyed by a degree ot heat much below that which would be detrimental, if not destructive to normal tissues. But, be the explanation what it may, certain it is that the thermal agent exerts some modifying influence on pathological processes much beyond and deeper than the surface actually cauterized ; hence the importance of repeated applications, so that every spot suspected of contamination may be thoroughly charred. It is needless to say that treatment of this kind can only be conducted in a satisfactory manner by the aid of proper in- struments, and that even the most delicately constructed elec- trodes should be wrapped with a thin strip of flannel behind the platinum coil or other device so as to guard against injury to the vaginal walls. On introducing and withdrawing the instrument also, especially when the large dome-shaped cauter- izer is attached, great care and a steady hand will be needed, and, in order to avoid hemorrhage, the knife should never be heated until first laid on the proposed line of incision. The most trifling injury by the heat, if near the vaginal outlet, will inflict more suffering and subsequent annoyance on a patient than the entire excavation and cauterization of her uterus. Consequently, cautery operations for uterine cancer demand not only thoroughness but great care in manipulation, and should never be half done nor hurried. I have thus tried to outline briefly the means by which I claim to have obtained better results, and without the sacrifice of a single life, than have yet been shown to follow any of the thousand and one vaunted remedies for uterine cancer. And, were it not that this unavoidably digressive and otherwise imperfect resume has already exceeded its proposed limits, to say nothing of your patience, a comparative analysis of the exploits of hysterectomists might be profitably supplemented. However, as all are already familiar with the ghastly record of lives sacrificed on the altar of reckless surgery by advocates of a measure for the cure (?) of uterine cancer which one of the most distinguished, intrepid, and phenomenally successful 24 TREATMENT OF UTERINE CANCER. British surgeons of the day1 does not hesitate to pronounce "a murderous operation," this lack of time and space may not, after all, be deemed a matter for regret. The leaders in this Quixotic crusade, in blazoning forth their equivocal triumphs, would fain have us believe that such patients as are fortunate enough to escape the perils of hysterectomy, and, through the interposition of Divine Providence are permitted to live apparently free from relapse for two or three years, are to be considered cured I The very statement of a claim so absurd is its own refutation. I have known many patients, three at least now living and in the enjoyment of apparently good health, one five years and two over four years after operation, and yet I have reason also to know that they are by no means cured ; consequently, in the statistics of uterine cancer, numerical contributions to the "cure" column should be carefully and not too lavishly doled out. In conclusion, I am fully conscious of the many omissions and defects in this effort to compress within the limits of a short paper the clinical work of twenty years. Nevertheless, in this epoch of aggressive surgical gynecology, when text-books on the diseases of women devote so much space to the tech- nique of hysterectomy and other more or less hazardous oper- tions, when, in the proceedings of societies ostensibly gotten up to promote the physical welfare of women, blood-curdling- assaults on their defenceless wombs and ovaries comprise the main and often the only subjects of discussion, when the scrip- tural mandate to pluck out offending organs no longer admits of a metaphorical interpretation, and when aspirants for popu- lar fame or gynecological recognition act as if the measure of true merit must be in direct proportion to the number and variety of their sexual trophies, any departure in a conserva- tive direction, however insignificant or devoid of merit, may, possibly, prove acceptable. 1 Mr. Lawson Tait. JOHN BYRNE. 25 Therefore, while fully alive to the marvellous achievements of abdominal surgery in the past decade, and conceding to hysterectomy a possible, but limited field, I confidently trust that the prevalent, and I believe waning, craze for indiscrimi- nate mutilation as a panacea for ailments many of which we know to be curable by more rational measures, will soon cease to be either fashionable or tolerated. Thus may the fair fame of American gynecology hope to escape the odium of reckless and criminal surgery.1 1 Vide a report of no less than seventy-five eases of laparotomy within a period of one year in a remote country district, and in the practice of one gentleman alone! American Journal of Obstetrics for July, 1889.