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alcohol. In some cases this gives quick and en- normal, in either the primary or secondary type, tire relief. The average time of treatment by mas- gives the greatest degree of relief. If the prisage required is from three to six weeks. During mary type be due to over-activity of the choroid this period of time attention should be given plexus, administration of extract of thyroid to the general condition of the patient. If
gland usually lessens the secretion, and in this anemia, disturbances of nutrition, digestion, manner controls the headache. In pachymeningiand so forth, be manifest, they should be cor- tis interna hemorrhagica which is usually serected by proper treatment. The administration condary to alcoholism, headache is a very annoyof iodides in some cases, even though syphilis ing symptom. Headache, coma, transitory parbe not suspected or demonstrated, apparently alyses, which are the most common symptom of facilitates the removal of the nodules.
this condition, are due in great measure to in
creased intra-cranial pressure, and lumbar puncHeadache Associated with Diseases of Indi
ture gives most immediate and satisfactory relief vidual Organs—Of the various organs diseases of the headache in many cases. of which have headache as a symptom there are no diseases known that have headache so con- Intra-cranial Syphilis-Headache may be a stantly associated as the diseases of the brain.
very early symptom in paresis and other forms Headache is a most constant symptom of intra- of cerebro-spinal syphilis. It is most severe in cranial tumor, and every protracted case of head- gummatous basal meningitis, but is present in ache should arouse suspicion of an intracranial · meningitis of the convexity and in meningotumor. The pain is described as dull, boring, encephalitis associated with meningo-myelitis. or gnawing, and always referred to the interior It may be periodical with nocturnal aggravation. of the skull. Patients have a feeling as though It is the result of the action of the syphilitic the head was about to burst. It is not so intense toxins as well as an increased intra-cranial preswith children who have more elastic skulls. The
sure, and to pressure upon the dural nerves. pain begins moderately and increases as the intra- Lumbar puncture gives temporary relief, but incranial pressure increases. Some cases may be tensive and prompt anti-luetic treatment should intermittent and subside for a period of even be administered. In cerebral arterio-sclerosis several months. Pressure of a tumor or the we commonly expect headache as a symptom. displaced intracranial structures upon the nerves Pain is the result of the changes occuring in the of the trigemina, are responsible for the pain. vaso-motor nerves of the atheromatous arteries, Relief may be given the patient by doing lumbar and to irritation of the dural nerves by the dispuncture, withdrawing from ten to sixty c. c.'s tended arteries secondary to the frequently ocof cerebro-spinal fluid. Removal of this fluid curing associated cardiac hypertrophy. Relief helps to restore the proper ratio between the can be given by careful regulation of habits, size of the skull and the intra-cranial contents. diet, rest in the recumbent position, administraIn some cases the freedom from pain following tion of iodides, stimulation of the excretory puncture extends over a considerable period of organs, and such other measures as will tend time. When the tumor is growing rapidly or to reduce the usually increased blood pressure. the fluid reaccumulates quickly, the relief is of In many of these cases lumbar puncture done short duration. 1 decompression operation or once a week over a considerable period of time an attempt to remove the tumor gives relief of has proven very beneficial. In the headaches longer duration. Headache is an early symptom of the various types of meningitis other than in brain abscess, it is not so prolonged nor so syphilitic, most important of which are the cereobstinate as the headache of brain tumor, nor bro-spinal and the tubercular types, headache has is it so severe. If a positive diagnosis be made both a chemical and mechanical etiology, and and the abscess located, operation should be done most beneficial results are obtained by withat once, but if for any reason there is cause for drawal of cerebro-spinal fluid. Any disorder of delaying the cranial operation, temporary relief the thoracic organs leading to passive hypermay be had by lumbar puncture.
aemia of the brain may be a cause of headache.
Any constricting band about the neck, such as Hydrocephalus - In the congenital type of the too tight collar or neck band of the shirt hydrocephalus there is rarely complaint of head- may for the same reason produce the same conache. There are two reasons for this. First, dition. Treatment of this form of headache is the inability of children to express themselves; the treatment of the underlying cause. second, the capacity of the skull for distention The most characteristic type of headache of prevents the increased tension of the dura. In hysteria is the so-called clavus hystericus, or acquired hydrocephalus, either primary or se- hysterical nail. The patient describes the pain condary, headache is a most distressing and con- as similar to the driving of a nail into the skull. stant symptom. Lumbar puncture and withdraw- Pain is usually limited to the convexity of the al of fluid until the fluid pressure approximates skull, and but a small area seems to be affected.
The pathogenesis is not known. The treatment there is incomplete removal from the blood of is the treatment of the hysteria.
the toxic products of metabolism and they irriThe headache of epilepsy is, in my opinion, tate the dural nerves causing headaches. These a pressure headache. A lumbar puncture in such toxins also stimulate the choroid plexus to hypercases invariably demonstrates a high fluid pres- activity and a pressure headache results. Ansure, and the pain, dullness, and sense of fullness other cause of pressure headache associated with and oppression are relieved by withdrawal of these conditions is the increased intra-cranial fluid, in some cases a considerable amount of circulation resulting from the high blood presfluid.
sure. Removal of the toxins by stimulation of Trauma to the head is usually followed by the skin and intestines and removal of the excess headache. If the skull and underlying dura are cerebro-spinal fluid by lumbar puncture will injured, adhesions may result, and the headache relieve the headache. continue for years. If the shock produce a
The headaches of general diseases are toxic secondary neurasthenia, the headache is of the and pressure in their etiology. The headaches neurasthenic type. If the trauma but cause con
which are so constant and severe in infectious cussion of the brain, a generalized headache with diseases result from the irritation of the dural brady cardia and vomiting may result. This nerves by the circulating toxins, and from the doubtless results from vaso-motor disturbance increased intracranial tension due to the hyper-secondary to injury of the vaso-motor centers secretion of fluid by the choroid plexus. Lumbar in the medulla and over the cortex, the so-called puncture and withdrawal of fluid gives surprisvaso-motor symptom complex. The headache ing relief of the pain and improves the mental is much more severe and lasting, and more ob- condition. The toxins also cause a vaso-motor stinate to treatment if there be some pre-existing paresis with engorgement of the dural vessels, arterio-sclerotic changes. Trauma to the head which irritates both the vaso-motor and ural stimulates the secretory activity of the choroid nerves and thus contributes to the headaches. plexus and may retard the reabsorption of fluid, Cold to the head is beneficial. and after severe or slight trauma there is usually
Acute and chronic intoxications are responfound an increased quantity of fluid with in- sible for much headache. The most common creased pressure.
Withdrawal of fluid gives types of this class of headaches are those assopartial or, in some cases, complete relief.
ciated with lead, alcoholic, tobacco and gastroHeadache associated with disorders of the intestinal intoxications. Rest and elimination of special senses.
the toxic agent is the appropriate treatment. In The Eye: Errors of refraction or accomoda- chronic alcoholism, there is usually an increased tion, weakness of the eye muscle or in short any
intra-cranial tension which can be relieved quickdisorder about the eye which irritates the oph- ly by lumbar puncture. thalmic division of the trigeminus may cause
During the course of such constitutional disheadache either frontal or occipital.
eases as anaemia, chlorosis, and diabetes, headThe nose is liberally supplied with branches aches are very annoying symptoms. The treatof the first and second divisions of the trifacial ment is the treatment of the underlying condition. and hyperaemia of the mucosa, acute or chronic
937 Rialto Building. rhinitis, anatomical defects which hinder free respiration, or any other condition about the THE PERCY CAUTERY IN CARCINOMA nose of an irritating nature may cause severe
OF THE CERVIX* headaches.
CARYL POTTER, M. D. Mouth infections by their local irritation and
St. Joseph, Missouri by the absorption of toxins from the mouth cause headaches. . The treatment of the above
The treatment of malignancy has been ditypes of headaches would be the treatment of
vided into (a) general, and (b) local.
All of the general therapy has depended upon Headache of great severity occurs in asso
empiricism for its basis and the best evidence ciation with acute otitis media. Meniere's symp
we have that we are far from a definite etiology tom complex is usually accompanied with diffuse
is the fruitlessness of our general modes of headaches. Acute and chronic gastritis, gastric attack. The application of Chian Turpentine by hypersecretion, and constipation cause headaches Clay; Atoxyl by Keith ; scelenium and tellurium by irritation of the terminal branches of the compounds of eosin by Wassermann; the serovagus and by the irrative action of the absorbed therapy of Fischer, Levine, Babcock, Hodenpyl toxins upon the dural nerves. The headache of
and ill and the Coley vaccine have nearly or cerebral arterisclerosis is increased in severity completely fallen by the wayside because they by straining at stool.
had no fundamental etiological basis for their Headache in diseases of the kidneys are of
*Read before the Medical Society of the Missouri Valfrequent occurance. In all forms of nephritis ley at Keokuk, Iowa, March 21, 1917.
application and, until the specific cause is defi- ficiently the viability of cancer cells will cease nitely known, other empirical general measures while normal tissue cells will remain unaffected. will probably be doomed to the same fate. The The Percy cautery is applied with this end in writer well remembers the conscientious and con- view. vincing enthusiasm of Hodenpyl for his auto- From a number of experiments Percy conserotherapy. So sure was he of the virtue of cluded that the penetration of heat depended his serum that pilgrimages were made by re- upon (1) the density of the mass, (2) the comsearch workers and clinicians from widely known pression of the mass on the cautery, (3) the medical centers to New York to investigate his degree of heat developed, (4) the type of enclaims. After the original enthusiasm had sub- trance made for the cautery, and (5) that if a sided the facts showed that there was no merit charcoal core is avoided the area of coagulato this treatment based on empiricism.
tion far exceeds in size that ensuing from the The local means of attack have been more application of a higher degree of heat for a fortunate because knowledge of the character longer period of time. of the growth and its method of metastisizing By avoiding a too high grade of temperature offer a scientific basis for attack. If we are he therefore seeks to avoid a carbon-core which able to remove the whole growth and its natural if developed, is impenetrable to the heat and channels of distribution or penetrate it with prevents the destruction of cancer cells beyond something powerful enough to destroy both we the immediate point of contact; and tends to have acquired a partial or complete victory, the shut off proper drainage, thereby causing an success or failure depending of course upon (1) accumulation of broken down tissue behind the whether we have cut beyond its distribution, or core--a condition which favors the growth of (2) whether our destructive agent has penetrated bacteria and the development of septicemia. On the whole mass and the cells which have escaped the other hand the slow heat penetration causes from the local situation. The cold knife en- coagulation necrosis of the whole mass, penethusiasts claim the most for their ability to cut trates and kills remote cancer cells and sterilizes beyond the growth, while the radio-therapist, the whole locality of the growth. It has no cold-iron and X-Ray extremists lay greatest effect on distant metastases which he claims do claim to penetration. Conservatists from both not occur till late in carcinoma of the cervix. are combining the two methods, using the best This last statement of Percy should be acin each, and today herein lies the most efficient cepted with caution because we know of cases, treatment for malignant growths.
and I have personally seen two, in which the In the endeavor to destroy carcinoma of the local growth was apparently insignificent but cervix we have these two schools represented: dissection along the ureter after the technic of
one, headed by Percy, who says that "the Wertheim revealed several deep glands, microremoval of the cancerous uterus by the knife scopically cancerous. is nothing less than legalized assassination," Again if the cold iron is more effective in advocates the cold-iron or Percy cautery; the eradicating carcinoma than the knife it is other, headed by Wertheim, claims most for hard to see why the treatment is advocated the Ries-Wertheim operation in all operable and only for inoperable carcinoma of the cervix and border-line cases. With these two from which Percy's writings invariably refer to heat treatto choose what must be the attitude of the un- ment in inoperable carcinoma of the cervix. biased mind?
Why isn't a treatment that is used for the inLike many procedures each shows best results operable form more applicable to the operable in the hands of the inventors and one must
where the growth is more localized, more easily choose the best from each school after a careful penetrated, less liable to have local or distant and painstaking study of the work of the in- metastases and a pyometra or a parametritis ? ventor and his associates; of men of experience Surely a growth in its infancy would be more and ability who have applied one method or the easily controlled by the cold iron than one in other; and of the results of one's own personal its maturity. Why then, I repeat, does it not experience. In the enthusiasm over a particular stand as the treatment for all carcinomas of method one must not lose sight of end results the cervix, operable and inoperable, if it is the which are the most important evidence of the best curative agent? Perhaps the newness of success of a combination of the best in many the treatment and the insufficient lapse of time methods or of a particular one.
for reporting end results has made Percy conThe whole basis of Percy's work is founded servative, although his earliest papers were writon the experiments of Hoaland, Jensen, Lambert ten over five years ago, the time-limit after operand Vidal who place the death of cancer cells ations for cancer to report a cure. Perhaps at about 116 to 122 F. and the normal tissue he is not willing as yet to affirm that heat cells at a temperature 14 to 20 higher and penetration in operable carcinoma is as effectual maintain that if the heat can be controlled suf- as surrounding it and removing it in toto, when
possible, which is attempted procedure in the necessary repetition. A few points however Ries-Wertheim operation.
which have not been emphasized or, which difThe main criticism one has to make of Percy's fer from Percy are as follows: In our work work is that enough complete case reports with the operator does the final vaginal preparation, subsequent courses, complications, end-results using soap and water, alcohol and 2 per cent and autopsy findings are not given to substan- iodine in the vagina and over the vulva. He tiate his theories and experimental work. then thoroughly dilates the vagina and inserts
What do the reports from other sources the water cooled speculum and makes the rubber say?
connections to the water supply. The patient Of all using the technic Balfour of the Mayo is left in the lithotomy position with the thighs clinic is perhaps the most enthusiastic but here flexed on the trunk at an angle of about 60 per again he advocates it for inoperable cases and cent, the buttocks raised and the head lowered. reports nine subsequent hysterectomies in five. A nurse holds the speculum in position and the of which the pathologist could find no evidence desired cautery tip is fitted to the uterine canal. of remaining carcinoma. Still he thinks that The patient is draped and the abdomen pre-, a subsequent hysterectomy should be done be- pared while the surgeon goes through a second cause a uterus once the seat of carcinoma should scrub-up. The incision should be generous, exbe considered potentially malignant. He also tending from the umbilicus almost to the symadvocates it as a preliminary to a total hysterec- physis. A complete bilateral salpingo-oophotomy in "border-line cases”. In early cases tectomy should always be done. This not only he does the Wertheim operation with as good relieves subsequent distressing menstrual sympresults as in early carcinoma in
toms in patients previous to the menopause but locations which refutes Percy's statement that also permits a much better exposure for ligation the cold knife in carcinoma of the cervix is of the internal iliacs. These should always be legalized assasination.
tied except in the presence of a complication, Balfour's cases are of too short standing such as the pyosalpinx encountered in case IV, to report subsequent courses so, from the stand- reported below, when the ligation of both uterpoint of end-results, are valueless.
ines can be substituted. William J. Mayo states that so far as his
In this type of case no iliac ligation should experience goes this method is applicable to a
be attempted because of the possibility of injury large variety of carcinoma and forms a pallia
to large veins or retroperitoneal infection which tion with prospects of cure in a group of cases in
might cause thrombosis of the iliac veins or which the knife has been inefficient.
stasis with gangrene of the lower extremities Perhaps the most adverse reports come from
or the lodgement of distant emboli. Here also the Johns Hopkins Hospital. In Leonard and
the anatomical arrangements are so obscured Dayton's report of "Complications of Percy's
or distorted and the inflammatory process causes Cold-iron Method” autopsy findings showed pulmonary edema, hemorrhagic serums effusions, arterial oozing that the attempt is not justified.
such a great amount of additional venous and extreme cloudy swelling of the viscera, renal epithelial necrosis and gastric ulcers correspond
The ligation of the internal iliacs not only ing to the findings of extensive superficial burns ;
prevents hemorrhage from subsequent sloughs also, that a mass of sloughing coagulated tissue but it may diminish the blood supply to the offers an ideal medium for growth of micro
uterus and thereby lessen nourishment to the organisms. The danger of septicemia, there
carcinoma. fore was considerable. Sections of areas remote All the work inside the abdomen should be and proximal to the growth showed cancer cells completed before inserting the cautery tip. Then unaffected in any way by the heat.
the uterus is grasped with the left hand and the In reading their reports one is inclined to cautery inserted with the right hand which never believe that the application of heat was too comes in contact with the abdominal field again heroic for one application because it was my until the vaginal work is completed and the experience that sloughs in the rectum and blad- surgeon has changed his gown and gloves. In der did not occur except in the case where the this way the right hand of the surgeon can cogrowth involved the base of the bladder and ordinate with the left which grasps the uterus. the rectum, and these cases are not only rare This gives a better penetration and application but the growth has as much to do with the of the cautery than when the assistant and surperforation as the heat. It seems in their cases geon handle the two fields separately. The heat that these sloughs could have been avoided had should be gradually increased until the gloved one or two subsequent applications been used hand can no longer hold the mass. By this time instead of one extensive cauterization.
the uterus is usually freely movable. The limits The technic is described in Percy's writings of application in our cases were 40 to 70 minso the giving of details here would only be un- utes.
In our own work the following reports are weaker, lost weight and died from general carsubmitted: Mrs. G. S., age 49, complained of cinomatous metastases three months after operaa foul smelling, sanguino-purulent vaginal dis
tion. charge and general weakness. She had first
Repeated vaginal examination showed that noticed a profuse watery discharge ten months the mass had disappeared and the uterus had previous which in a month became sero-sanguin- become movable. eous and a few weeks later sanguineous. She Case II. S. F., age 52, showed a mass in the consulted a physician and was curetted six left broad ligament extending into the vaginal months before consulting me. The discharge vault. This followed a complete hysterectomy was less profuse for about three weeks but then four months previous. returned more abundant than ever before. Ex- On October 12, 1916, there was an applicacept for a few remissions it was continuous and tion of the cautery for forty minutes. Death sanguino-purulent in type. The odor had be- occurred February 12, 1917, from complete come very offensive in the last few weeks. She anuria. The urine was negative at the time oi had been pronounced incurable and inoperable. cauterization and as she subsequently developed
total anuria with intense pain and tenderness Examination
in the region of both kideys we concluded that General: There was no marked loss of
she had developed a complete bilateral ureteral
block from involvement of the broad ligament weight but there was evidence of a definite intoxication which I judged to be the result of ab
Case III. L. K., age 64, showed surprisingly sorption from a septic process.
little cachexia or any symptoms of general car
cinosis in view of the fact that the cervical Locally there was a large cauliflower-like
growth involved the base of the bladder, vaginal mass involving most of the cervix to within
in walls and the rectum. No encouragement was about 1-2 cm. of the cervico-vaginal junction. offered but she insisted on the use of the cautery The vaginal and bladder walls and the rectum
after hearing of it. were not involved. On going around and beyond
The Percy technic was followed. The cautery the protruding mass the free smooth vaginal wall could be easily felt and the uterus seemed slightly applied for 65 minutes until the hand could no
tip which was carried well into the fundus, was movable. The uterine outlet was entirely closed. longer hold the fundus. She died in uremic
From my examination I concluded this to be coma three days later. a very favorable case for the cautery and the
Case IV. Mrs. M., age 39, was admitted loss of weight and strength the result of a pyo- to the hospital Dec. 11, 1916. Seven months metra and an absorption from a blocking of the previous she had been examined by her physiuterine outlet.
cian who found a suspiciously hard cervix but Procedure: Percy's technic with the varia- apparently no definite growth. This combined tions described above was exactly followed. with a continual sanguineous discharge, made On Oct. 30, 1916, the abdominal cavity was
him suspicious and he snipped off a portion of opened and explored. The viscera were entirely
the hard mucosa for microscopic examination. free from metastases. The uterus was freely The pathologist reported adeno-carcinoma of movable, the fixation apparently being due to the cervix. Despite his statements that she had the growth in the cervix which had extended an early carcinoma and his advice that she have into the body of the uterus. There was no eyi- a complete operation she refused to believe either dence of extra-uterine involvement. The fundus the pathologist or her physician until seven was soft and boggy, apparently the seat of pyo- months later when she was told by another genic infection. Retroperitoneal dissection to examiner that she had an advanced carcinoma. explore the internal iliacs showed no glandular
She returned to the man who originally exinvolvement. The cautery was applied for 70 amined her who stated that she was beyond the minutes with slow heat until the whole mass help of a hysterectomy and referred her to me became so hot that it could not be held with the
for the use of the cautery. gloved hand.
Her general appearance was that of many On withdrawal the cartridge-shaped cautery women with pelvic pathology but not of one tip showed a soft white necrotic mass clinging suffering from a malignant process. She was to it.
anemic but well developed.
Vaginal examination showed a well advanced Subsequent Course: The patient left the cervical carcinoma involving the canal and exhospital in three weeks. All discharge from tending a slight distance over the vaginal porthe vagina had ceased and there was no return tion of the cervix but no bladder, vaginal wall of any discharge up to the time of her death. or rectal involvement. The puzzling feature was After leaving the hospital she gradually became the absolute fixation of the uterus and a large