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staff said that it has thus far caused them to look upon many cases of
cancer of the uterus, heretofore considered inoperable, as possibly oper-
able. "While there I was told that Dr. Percy was the only outsider ever
asked to operate in the Mayo clinic; which he did, demonstrating the
use of his cautery.



SUEGEBY. 165

The Percy Cautery Avas devised and introduced by Dr. G. F. Percy of
Galesburg, 111. In order for one to be justified in trying a new technique
we are safe in demanding that it fulfill the following requirements :

1. The object shall be to ameliorate human suffering.

2. It should have legitimate claims based on an established scientific
principle.

3. It should have assurance that the method gives hope of doing more
good than any thus far known ; at the same time does no harm nor ag-
gravate the condition.

!N^ow, gentlemen, with your permission I shall endeavor to show that
the Percy Cautery Technique fulfills the above requirements.

The older men among you will recall that before the development of
aseptic surgery it was a matter of comment that a case of carcinoma
of the uterus operated on, where part or all of the uterus was removed,
and the patient developed erysipelas during convalescence, if she survived
the erysipelas she was slower to have a return of the carcinoma than
those cases operated on which did not have erysipelas. It was further
observed that in excessive bleeding in inoperable cancer where the in-
ternal iliacs were ligated to check the hemorrhage, notwithstanding the
marked discoloration of the tissues of the areas supplied by these ves-
sels (which persisted for twenty-four hours), the growth often subsided
for many months, during which time the patient was almost in normal
health.

In the first instance cited above there were two factors working to
retard or inhibit the growth of the cancer. A general or constitutional
factor represented by the high temperature of the erysipelas, and the
local one, by the overgrowth of connective tissue in the scar. Por years
it has been a matter of observation that all tumorous growths are ar-
rested, temporarily at least, when for any cause the patient is subjected
to high temperature. In the second instance the growth was probably
retarded on account of the cancer cells being of such low vitality as to
be unable to undergo the starvation from the temporarily arrested blood
supply and were largely killed by the time the collateral circulation was
established at the end of twenty-four hours.

Again, the pathologist and biologist have established the fact that
cancer cells are of considerably lower vitality than normal tissue cells,
and are destroyed by means which do not apparently affect the normal
cells, to wit : It has been shown that cancer cells are destroyed in a com-
paratively short time (from ten to twenty minutes) by temperatures of
from 111 to 120 degrees P., whereas normal cells are apparently not
affected by this temperature.



166 NORTH CAROLINA MEDICAL SOCIETY.

It is generally admitted that cancer is primarily a local disease, and
is not a constitutional or blood disease. Metastasis takes place through
a direct entrance of cancer cells into the blood vessels and lymph chan-
nels. This fact can be demonstrated by making serial sections through
the cancerous material into the neighboring tissues. Now, when an
attempt is made to remove the growth by the scalpel, curette, or an
eschorotic, it necessarily follows that some cancer cells will be trans-
planted into the injured blood vessels and lymph vessels, thereby ag-
gravating instead of relieving this condition.

So far, the best treatment for uterine carcinoma has been the Wertheim
operation, removing the entire organ and adjacent pelvic lymphatics.
But only too often in a vast majority of the cases is there a return of.
metastasis due to the unavoidable implantation of the cancer cells into
the open-vessel mouths by means of the scalpel.

Consequently, the ideal treatment is one whereby the cancerous growth
can be inhibited or destroyed before the Wertheim is done; and herein
lies the efficiency of the Percy Technique.

The use of the actual cautery has been in vogue for many years, but
its main drawback has been the injury to the adjacent normal tissues,
limiting its action to the immediate area of its application. The heat,
being applied for a very short time, had very little penetration.

*"The basic idea of this treatment — and this cannot be too often
emphasized — is not cauterization, but the production and dissemination
of heat in the gross primary mass of cancer."

In brief, the idea is to destroy the cancer cell by means of heat. It
would, of course, be impracticable as well as dangerous to raise the en-
tire body temperature up to 104 or 105 ; consequently the heat is applied
locally in the uterus. The amount of heat is regulated by rheostat, and
you are able to get heat penetration into the tissues, and this penetration
is further augmented by the heated juices of the uterus. You thor-
oughly cook to well done the cancer cell, both in the growth and ad-
jacent tissues, which can be accomplished at a lower temperature than
will affect normal tissue cells.

Of course, you can bring the iron to a higher heat at first and remove
the cauliflower masses, or so sear the outer parts as to check hemorrhage,
then lower the heat in the iron and proceed to cook the remote cancer
cells.

Now, as for the technique proper for the use of the Percy Cautery
in the treatment of carcinoma of the uterus :

1. The patient is prepared for an abdominal section.

2. Anesthetized, placed in an exaggerated Trendelenberg, with the
thighs flexed so as to get all the intestines out of the pelvis.



SURGERY. 167

3. The vagina is dilated and a water-cooled speculum introduced.

4. An abdominal incision is made sufficiently large to admit tlie hand.
The hand not only explores the pelvis to determine the amount of in-
volvement, but acts as an index to the temperature in the pelvis, and
guides the cautery to the different parts. The average gloved hand
being able to stand the temperature of from 111 to 120 degrees for ten
or fifteen minutes, there is sufficient temperature and time to destroy
the cancer cell and not injure normal tissue.

The cautery, previously heated, is introduced into the cervix, first
burning off the exuberant masses if present, then introduced into the
body of the uterus and maintained at the proper temperature. The
cautery is moved from place to place in the uterus as the abdominal hand
directs.

'•'"The important thing is not to convert the pathology into charcoal.
The charcoal or carbon thus formed inhibits the further dissemination
of heat, not only through the cancer mass, but beyond. More than this,
when the pathology is converted into charcoal, drainage is prevented for
a number of days. This permits of the absoi'ption of a larger quantity
of broken-down cancer cells than the average of the patients can tolerate,
and many of them die as a result of this mistaken method of applying
heat. Carbonization is produced in a few minutes by a cautery heated
to a bright cherry-red color. Carbon inhibits the dissemination of heat.
To overcome this, still greater degrees of heat are required, which are
extremely difficult to control, endangering the rectum, the bladder, and
the ureters. The heating iron, when used through the water-cooled
speculum, should not be hot enough to scorch a pledget of white cotton if
laid on the heating iron even for half an hour. No smoke or smell of
burning tissues should issue from the speculum as would occur if they
were being carbonized. The ear placed near to the speculum should
hear only a gentle simmer or bubbling while the heating head is in
the diseased mass."

It is desired that about forty minutes be consumed in this treatment,
when the abdominal incision is closed, cautery removed, patient put to
bed, and if considered an operable case at the end of four weeks, the
Wertheim operation is done.

When this Percy Technique is decided upon —

'•"T would strongly advise against the use of the curette or other
operative measures, for the reason that the heat is distributed through
the medium of the pathological overgrowth which we wish to destroy.
Heat does not encourage the extension of metastasis, while the curette



*"The Treatment of Inoperable Carcinoma of the Uterus bv the Application of Heat,"
by G. F. Percy, M.D. Reprinted from The Lancet, Aug. 1, 1914.



168 NORTH CAROLINA MEDICAL SOCIETY.

and knife do. Again, scar tissue is not formed after the use of the
curette, but is the usual sequel after the application of heat, and I have
yet to observe the redevelopment of cancer in cicatricial tissue. In a
personal case where this treatment was applied to an active, stinking,
bleeding, vegetative-like mass, springing from the craterous edges of a
practically destroyed cervix uteri, no evidence of carcinoma was found
on serial section eight months afterwards, when the uterus and cervix
were removed through the abdomen."

Now, let us see if the Percy Cautery Technique fulfills the three re-
quirements mentioned above :

1. The object should be to ameliorate human suffering. Yes, for it
removes the exuberant growth, checks hemorrhage, checks the discharge
and irritation therefrom, lessens or removes the odor from the slough-
ings from this mass, and last, but not least, relieves the pain.

2. It should have legitimate claims based on established scientific
principles. As mentioned above, the cancer cells are destroyed at a
lower heat than that required to injure normal cells. The temperature
is maintained for any length of time in the Percy Cautery by means of a
rheostat.

3. Should have assurance that the method gives hope of doing more
good than other means thus far known. At the same time does no harm,
and does not aggravate the condition. The regulated heat kills the
cancer cell without injuring the normal cell, this being thus far the only
means known which will effect this change in the deeper tissues. So
enabling one to subsequently do the Wertheim, working through either
scar or normal tissue. It does no harm, because the heat is not high
enough to actually burn, thereby producing the various fistulse. It does
not aggravate the condition, because the cells are killed before the ves-
sels are opened.

Finally, gentlemen, so great is my confidence in this technique being
used by such men as above mentioned, that I feel that I am at present
justified in saying that the Percy Cautery Technique is clearly indicated
in all cases of carcinoma of the uterus, whether inoperable or not, and
have no hesitancy in using it as the occasion arises.



SURGERY. 169



SAECOMA OF BOXE, WITH CASE REPORTS.



J. F. High SMITH, M.D.. F.A.C.S.
R. L. PiTTMAX. M.D.



The purpose of this paper is not to develop anything new in this
disease, its pathology, diagnosis, or treatment, but, on the contrary, will
deal most especially with the primary cause of the malady. In the
South, where there is comparatively little manufacturing as compared
with that in the JSTorth and all large manufacturing centers, exposure
to trauma is slight as compared with the greater frequency of bone in-
jury where this industry is more abundant. W. B. Coley of iN'ew York
City, of whom every one knows, from the importance of his serum in
this disease, has within the past thirty-five years treated between eleven
thousand and tAvelve thousand cases of sarcoma, while the average
surgeon in this country does not see so many cases. We have treated
within the past three years six cases, all giving a history of some trivial
injury, and for this reason are giving a brief synopsis, that we may
thereby impress upon every one the importance of thorough investiga-
tion in every case of bone injury, with especial reference to a previous
iiijury, be it even of trivial character, with the hope that an early diag-
nosis may be arrived at, upon which the nature of the treatment will
depend and the prognosis based.

Sarcoma is a connective tissue growth always taking origin from con-
nective tissue cells. It is a disease prevalent during early adult life, its
most common cause being that of trauma, extending by way of the blood
sti"eam and continuity of tissue.

Many different forms are recognized. The one with which Ave are
most fl-equently confronted is the giant cell variety. The other forms
occurring are composed of one particular form of cells or a combination
of types, such as the small and large round-cell combination, the small
round spindle cell, or a combination of the spindle and round cells. The
small round cell is regarded as the most malignant form of sarcoma,
the giant cell form being the least malignant of all forms, and is con-
sidered by Bloodgood of Baltimore to be very benign in nature. He
speaks of it as giant cell tumor, and not a cancer. On the contrary,
Coley of New York, who has had a vaM experience in dealing with this
variety of diseases, contends that the giant cell form may at times prove
to be one of the most fulminating forms of sarcoma.



170 NORTH CAROLINA MEDICAL SOCIETY.

DIAGNOSIS.

I do not think that making a diagnosis of the presence of sarcoma
with a reasonable degree of certainty is such a difficult problem, provided
one will make a thorough investigation into the patient's previous
history, when a history of trauma to the affected part can be elicited.

Surgically speaking, there are two great forms recognized, the central
or medullary and the subperiosteal. The central variety most frequently
involves the shafts of the long bones beginning near the epiphyseal line.
The growth is rather slow as compared with the subperiosteal form,
causes uniform destruction of the medullary portion of the bone, leaving
nothing but a shell of bone, which is filled with a dark brown, highly
offensive material composed of organized blood clot in which can be
found sarcomatous cells forming a network of bands. The subperiosteal
form appears between the bone and its enveloping periosteum, grows
very rapidly, frequent metastasis. 1 think that an impprtant sign of
diagnosis in the central form is the abruptness with which the diseased
bone ends and the healthy bone begins, slowness of growth, absence of
pain, or very little pain, little or no fever, no tendency to sinus formation
except in advanced cases, enlargement of the blood vessels over the af-
fected part, and the rapid loss of weight. The subperiosteal form is
more irregular in contour of its enlargement; growth is more rapid.
It is difficult to say where the diseased bone begins and the healthy bone
ends. The only means whereby a differential diagnosis of the forms,
can be made is by use of the X-rays. Murphy of Chicago states that
he relies more upon the diagnosis made by the rontgenologist than that
of the pathologist. This, I am sure, is true, and do not doubt but that
those who have had experience with the X-ray in the diagnosis of thi&
disease will readily agree with Dr. Murphy in his statement.

CASE REPORTS.

The series of cases to report are six in number, all treated in High-
smith Hospital, Tayetteville, W. C. :

Case 1. Male. Age 38 years. Street car conductor. Was hit on left tem-
poral region by weight of bell cord unconsciously but repeatedly over three
years. Large spindle-cell sarcoma developed in the area. Within six mouths
after the first appearance was size of a cocoanut. Patient could not wear hat
and consented to operation when officials notified him that he must have
tumor removed or give up position, from the deformity it caused.

Operation: Left external carotid artery ligated to control hemorrhage.
Attempt at removal was made, but found to be too extensive. Wound closed
and patient died 18 hours later from cerebral thrombus.



SURGERY. 171

Case 2. Woman. Age 28 years. Three years previous to entering hospital
had right upper last molar tooth extracted with great difficulty to dentist.
Followed by much soreness and pain to patient. Six months previous to
operation noticed a lump in upper jaw in region of extracted" tooth. Gradually
increased in size until it was the size of a large lemon when she entered the
hospital.

Operation: Right sui^erior maxillary bone removed. Microscopic examina-
tion showed large giant cell sarcoma. This oi^eration was performed three
years ago. Up to twelve months after operation had no signs of recurrence,
Since then have lost sight of patient.

Case 3. 2Ialc. Age 19 years. Entered the hospital February 1, 1915, com-
plaining of rheumatism in right shoulder. History of case developed fact that
four months previous to entering hospital, while cranking automobile, crank
was thrown backward by motor, causing severe jar to arm and shoulder with
a twist of shoulder joint. Two months after time of accident noticed some
loss of power of right arm. Immediately patient noticed anterior portion of
head of humerus was enlarged. There soon appeared second enlargement on
inner side of the head of the humerus, filling up axillary space. When he
came to the hospital the entire upper one-third of humerus and head were
considerably enlarged, very hard and slightly painful. Shoulder joint fixed.

X-ray diagnosis. Subi>eriosteal sarcoma. Removal of arm and shoulder
girdle recommended. Patient, much surprised at diagnosis, went home, to re-
turn for operation, but did not return to Highsmith Hospital, but went to Johns
Hopkins Hospital. Baltimore, where operation was performed. Report re-
ceived was that growth was a mixed cell sarcoma involving head of the
humerus, scapula, clavicle, and two upper ribs. Had a recurrence within two
weeks after operation at site of incision. Wound never healed and patient
died five weeks after oiieration from metastasis into chest wall, right lung
and pleura.

Case 4. Girl. Age 11 years. Three years previous to admittance to the
hospital right upper last molar tooth was extracted. Twelve months after
removal had enlargement in this region. Was carried to nose and throat man,
who removed her tonsils. Six months after this operation came to hospital
with growth in the upper posterior part of jaw the size of a walnut. Right
upper maxillary bone removed. Examination proved it to be a giant cell
sarcoma. Three months after operation had a recurrence ; second oiwration
was performed. Four other operations were performed at intervals of about
every three months, making a total of six operations within fifteen mouths.
Last operation eight months ago. Had X-ray treatment from time to time
since first operation, giving frequent exposures until therapeutic limit was
reached, at intervals of every six weeks or two months. This patient has
been constantly under observation and at the present time has no signs of
recurrence.

Case 5. Girl. Age 15 years. Three years ago noticed enlarged condition
of the giuu of the right lower jaw. Consulted dentist, who extracted one
of her lower molar teeth. Growth continued to enlarge until at the time
of admittance to the hospital was size of closed fist. Operation was per-
formed April 24, 1915. Right lower jaw removed from epiphyseal line to



172 NORTH CAROLINA MEDICAL SOCIETY.

and including ramus. Growth was tlaat of a large giant cell sarcoma. Pa-
tient discharged May 26, 1915, in good condition. Wound healed nicely.

Case 6. Female. Age 40 years. Two years ago, while cutting wood, axe
glanced, the back' of it striking her on the inner side of right knee. Three
months later joint became swollen, slightly painful, and patient gradually lost
in weight. Knee continued to enlarge. Entered the hospital March 6, 1915,
with the lower end of the femur very much enlarged and hard, with a peculiar
leathery feeling. Swelling extended five inches above the knee joint, ending
very abruptly. Skin white, vessels enlarged and tortuous. On asperation re-
moved small quantity of sterile bloody fluid. X-ray examination showed
absolute destruction of lower four inches of femur. Diagnosis of sarcoma
was made.

Operation: Limb amputated at junction of upper middle and thirds. Wound
healed nicely and patient went home two weeks after operation. Pathological
diagnosis : Large giant-cell sarcoma.

From a synopsis of these cases it is made evident that the least trauma
to a bony part is capable of producing sarcoma in the most fulminating
form, and from the history of these cases one might conclude that even
indirect trauma in the form of a twist, jerk, or jar is liable to produce
sarcoma. Just how this change is produced no one has been able to
prove. However, the consensus of opinion is that it is a result of the
reversion of the adult connective tissue cell to that of the embryonic'
form, vv^hich undergoes rapid multiplication, with destruction of the
adjacent tissues, the liability to metastasis depending somewhat upon
the character of the cell present. Prognosis likewise depends upon early
operation, character of the cell present, age, and general condition of
the patient.

TREATMENT.

Owing to the great scope of the field opened by a discussion of sarcoma
in all of its phases, I do not wish to enter into the treatment as minutely
as I have its etiology and diagnosis. As is the case with all malignant
conditions, there is but one treatment that offers any results, i. e., sur-
gical. Upon the variety of the sarcomatous cell present depends some-
what the surgical method employed. I do not feel that I can better
present this subject to you than to quote some of its greatest exponents.
Though working on the same subject and to the same end, their methods
differ somewhat in detail.

Bloodgood of Baltimore says :

"It is a question whether the so-called giant-cell sarcoma should be included
among sarcomas. I prefer the term 'giant-cell tumor.' Up to the present time
I have been unable to find an authentic case in which this giant-cell tumor
produced death by metastasis. The evidence so far demonstrates that ampu-



SUEGERY, 173

tation and, in many instances, resection in continuity, are unnecessary, or
avoidable surgery. Curetting should be the operation of choice in the first
instance. It should be performed under the Esmarch Bandage, the bone cav-
ity disinfected with pure phenol (carbolic acid), followed by alcohol; if the
resulting cavity is large, healing will be accelerated by filling the cavity with
a piece of transplanted bone. After resection the wound should also be dis-
infected as after curetting; if possible, the defect should be filled by a piece
of bone taken from the shaft of the bone involved by splitting longitudinally
the remaining uninvolved bone. If this is not feasible, the tibia is the best
bone from which to take the transplant. The diagnosis of a medullary giant-
cell tumor cannot be made positively until the tumor is explored with the
knife. The only hope for increasing the number of cures in the more malig-
nant forms of sarcoma of the bone is in the early and systematic diagnostic
employment of the X-rays."

On tlie other hand, Coley of 'New York contends that there are cases
where metastasis occur and that at times "even the most radical treat-
ment, amputation of the proximal joint, offers little or no chance of a
cure."

In a recent article of John B. Murphy, he makes the following state-
ment :

''In judging of the malignancy of a giant-cell sarcoma I rely more on the
X-ray picture than on the microscopical examination ; the disease in malignant
cases is found to cross the epiphyseal line, while in the more benign forms it
does not do so. I approve of resection rather than of curettement in these
cases, following the resection by transplantation of another piece of bone for
the maintenance of support."

After hearing the difference of opinion as expressed by the eminent
authorities as quoted above, one can readily understand why there is no
fixed and definite treatment to pursue in these cases. It depends entirely
upon the individual surgeon's experience w^ith these cases, the extension
of the growth, and character of the cell present. I believe that in all
forms of sarcoma early and thorough removal of the diseased tissue is
indicated, and that amputation far beyond the diseased area is the
safest and surest treatment to pursue.



174 NORTH CAROLINA MEDICAL SOCIETY.



THE CAI^CEE PEOBLEM.



John Wesley Long, M.D., F.A.C.S., Greensboro, N. C.

(Member Board of Directors of American Society- for tlie Control of Cancer.)



The cancer problem may profitably be discussed under two heads :
first, the strictly professional phase of the question ; second, that larger



Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 20 of 58)