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cancerous breast, the growth is checked, or at times disappears entirely. The discovery that erysipelas is caused by strepticoci, led Dr. Coley to experiment with pure cultures of these organisms. It was shortly found that the addition of Bacillus Prodigiosus increased both the beneficial and harmful effects of the injections, but after repeated efforts the proper proportion of each was determined. By the careful and gradual injection of the toxins the dangers have been largely overcome and it is definitely proven that the administration of the sterilized toxins has a deterrent, and, in some cases, curative effect in malignant tumors, especially sarcomata.

In the successful cases the effect is very prompt, and noticable changes appear in from two to three days. In accessible regions Dr. Coley advises the injection immediately into the tumor, while in the intra-abdominal cases the results have been very gratifying by injections into the general system.

The direct effect seems to be the breaking down of the tumor and the subsequent absorption of the necrotic material. Dr. Coley reports about a hundred cases successfully treated by himself and others, some of fourteen years health without re


In every case the diagnosis was established without shadow of doubt, both clinically and microscopically, by competent


This form of treatment is not considered a panacea by its originator, but is strongly advised as an adjunct to skillful surgery and to be used in otherwise inoperable and hopeless cases. The best results obtain in the spindle cell sarcomata, though "Coley's fluid" has been known to alleviate the sufferings in a few cases of carcinosis. In this connection a preliminary report by a prominent New York pathologist is most apropos. A woman whose breast had been amputated for carcinoma became reinfected in the scar and later showed metastatic nodules in the liver. Her condition was regarded as hopeless when the unexpected atrophy and disappearance of the cancerous areas began to take place; this continued until no trace of the former malignancy was apparent. The peritoneal cav

ity, however, began gradually to fill with fluid; this was repeatedly tapped.

This very interesting fluid was injected into cancerous mice, causing a disappearance of the lesions. Later, it was also introduced into the systems of nearly fifty inoperable cancer patients and with very satisfactory results.

The details of these cases are promised as soon as they are available.

The investigator calls attention to the fact that he is not advertising a "sure cure" for cancer, but merely hopes to arouse the interest of the profession that further investigation may be conducted.

Other methods.

Other methods of combatting cancer, such as the introduction of live steam into the cavity of the uterus, or the extirpation of the ovaries in cancer of the breast, hoping thereby to cause a retrogression of the growth, have now largely fallen into disuse.


We have seen, then, that the cautery unaided has not proved satisfactory; that the application of the X-ray is limited to superficial growths, that drugs are powerless; "Coley's fluid" is potent only in a small proportion of sarcoma cases, and the cancer serum being as yet in the experimental stage, and so rarely procurable, is not available for routine treatment.

A consensus of the opinion of the foremost investigators points to surgery as our most reliable method of combatting cancer. In the near future some vaccine or serum may eliminate cancer from among the dreaded unknown diseases, but with our present-day knowledge one must turn to surgery for relief. Already from 10 to 50 per cent. of cures have been effected by this means, and this in spite of the fact that such a large proportion of cases presenting themselves for treatment are already inoperable.

The blame for this hopeless condition of cancer patients is divided between the medical profession and the patients themselves. For is it not a well known fact that the busy practi

tioner passes by the early and vague premonitory symptoms of cancer as affairs of no consequence. The patients are, for the most part, ignorant of nature's first warnings, and if reassured by their medical attendants, without an examination, will continue on their way, with never a thought until pain announces the hopeless stage.

The eradication of cancer, then, will be accomplished by the education of the medical profession and also the public. By a dissemination of knowledge, the general public will learn to recognize the earliest suspicious symptom, and the family physician will thoroughly examine his patients, and either set their minds at rest where no cancer exists, or by consultation with the surgeon and pathologist advise the early and complete removal of the offending organs or parts. Early diagnosis and skillful surgery then go hand in hand, and to them we must turn for relief from this ever present menace.

READ APRIL 13, 1910.

The study upon which this paper is based was originally undertaken as a critical analysis of the results obtained by my associate, Dr. C. G. McMullen, and myself in the cases of acute intra peritoneal infection which have been treated by us during the past two years. Primarily, this has been a critical study, undertaken with the idea of discovering our mistakes in order that we may be able, as far as possible, to avoid the occurrence of similar errors in the future. Therefore, our failures and their causes, as far as we have been able to ascertain them, will receive more than the usual amount of attention in this paper.

During the period under consideration, we have handled all cases of acute intra peritoneal infection according to a definitely systematized plan of treatment, the fundamental objects of which may be summarized under the following heads: First-The removal of the infection.

Second-The removal of the source of the infection.
Third-The limitation of the spread of the infection.

Fourth-The reduction of the absorption of toxins from the area of infection.

Fifth-The preservation of the patient's natural powers of resistance.

Sixth-The removal of toxic material from the stomach by gastric lavage, when necessary.

First-The removal of the infection.

This is the ideal therapeutic measure, and were it possible to always effectually remove the infection by operative procedures, the treatment of intra peritoneal infections would resolve itself into a simple question of operative technique. There can be no question of the possibility of completely removing the infection in cases of appendicitis, seen while the infection is still confined to the appendix. Likewise, it is possible to accomplish this in many cases of pyosalpinx and empyema of the gall bladder. But experience has very definitely shown that in late appendix operations and in salpingitis and empyema of the gall bladder, the operator is usually compelled to leave behind an infected field, the management of which is of vital importance.

In our own work we have made it a rule to operate at once when we believed the infection to be still confined to an offending organ which could be removed. We have also operated at once in most cases when we have felt reasonably certain that complicating the peritoneal infection was less than from twenty-four to thirty-six hours old.

Second-The removal of the source of the infection.

This is absolutely essential in cases of gross perforation of the stomach or intestines, because in such lesions the constantly increasing mass of infective material escaping into the peritoneal cavity makes the limitation of the area of infection by natural processes practically impossible. Murphy and many others have shown how satisfactory the results may be in this class of cases, provided only that the leak be closed during the early stages of the peritoneal infection and a post operative

regime be adopted whereby the peritoneum is given the best possible chance to take care of the remaining infection. It is a fact, however, that even as regards the therapeutic possibilities to be derived from removing the source of the infection, we must recognize certain very definite limitations. Thus, after the full development of the peritoneal infection, the removal of an infected organ, or even the closure of an intestinal perforation does not in itself produce a cure, for here again the management of the secondarily infected peritoneum remains the most important factor in the treatment. In our own practice we have made it a rule to operate at once in all cases of intestinal perforation, and, as before stated, have made it a rule to remove the offending organ when we are reasonably certain that the peritoneal infection had not existed more than from twenty-four to thirty-six hours. For reasons which will be given later, the non perforative cases with peritoneal infection, which had existed more than thirty-six hours, were not, as a rule, operated on during the acute stages of the infection. Third-The limitation of the spread of the infection. Only a few years ago surgeons were wont to look upon the peritoneum as one vast, smooth surface, over which pyogenic organisms would almost invariably spread once they had gained access to the cavity, and there can be no questioning the fact that the peritoneum offers, under certain conditions, almost ideal opportunities for the very rapid distribution of infective material. However, as we have come to know more of the behavior of the peritoneum when invaded by microorganisms, we have learned that if only certain unfavorable conditions be eliminated, the peritoneum, with its ally, the omentum, is abundantly able to confine within narrow limits the vast majority of intra peritoneal infections.

What I want to especially emphasize in this connection is the fact that the distribution of an intra peritoneal infection is, for the most part, dependent upon purely mechanical factors, and that in the absence of peristaltic movements, such as are produced by giving food or cathartics by mouth, the tendency of a localized peritonitis to spread beyond its original boundar

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