failure to permanently control hemorrhage. Microscopical examination shows the uterine glands increased in number, tortuous, and dilated. The interglandular stroma is very vascular, and there is a marked absence of muscular tissue. The quantity of hyperplastic tissue removed from the uterus is sometimes very large, and this together with its appearance, which resembles decidual membrane, are highly suggestive of the pathology under discussion, and warn us that we are dangerously near the region of neoplasms, where only radical measures avail for a cure.

We have somewhat anticipated a consideration of the prognosis of chronic metritis and hyperplastic endometritis, all clinical data going to show the intractable character of the disease, and its essentially chronic nature, and while instances of spontaneous cure have been recorded, this result has been so infrequent, that it may well be questioned whether we are justified in regarding such a contingency in our treatment, or allowing it to influence our judgment of the disease.

We have, however, to consider not alone the curability of chronic metritis and hyperplastic endometritis, but to study also most carefully the pathology of the malady in the light of a possible, and very probable matrix for the development of a wider departure from the normal standard of tissue building, for the uterus, more especially the endometrium, in which the major part of malignant neoplasms originate, when persistently deranged in the discretion of structures, is placed under suspicion, and must be so regarded until proven to be innocent of pathological crime.

Actual proof is lacking that chronic metritis and hyperplastic endometritis have ever degenerated into malignancy. The disease, because of its accompanying hemorrhage, if unchecked, always causes such profound anaemia as to threaten life, and reduce the patient to a condition in which recuperation is impossible. But that the pathology of the endometrium which we have briefly outlined contains the potency of further degeneration, judging from what is known of this structure, we cannot doubt. Erratic cell proliferation once established tends invariably in the direction of further deviation from healthy function, and we cannot close our eyes to the fact that any organ as seriously diseased as the chronically inflamed uterus, having its history of malignancy, is a menace to health, and contains elements of positive danger to life itself.

The only treatment that offers the least prospect of cure is removal of the degenerated uterus. The question of consequent sterility should not enter into the discussion, weighed as it is against the proposition of malignancy. The balance between muscular and fibrous tissue cannot be readjusted, and the hyperplastic endometrium has so far departed from normal histogenesis, as to place its reconstruction and return to physiological activity outside of the realm of probability.

We are, however, confronted with the fact that cases of

chronic metritis and hyperplastic endometritis have recovered, and therefore we are not justified, as we would be upon the establishment of a diagnosis of cancer of the cervix, in resorting at once to a hysterectomy, but because of this occasional history, and the chronic course of the disease, are obligated to try a less radical treatment in the hope that it may prove curative. My experience, however, has been, that the cases finally require a major operation, and with this experience, I am forced to the conclusion that the time consumed in conservative methods of treatment has been lost, as far as the cure of the disease is concerned.

The following case illustrates my position regarding the treatment of chronic metritis and hyperplastic endometritis.

Mrs. B, forty-six years old, four children, the youngest fifteen years old. Menstruation regular, painless, but always profuse, began at the age of sixteen. Four years ago when travelling in Europe, there occurred between the menstrual periods a sudden gush of yellowish water. This continued in diminishing quantity for a few days, when it ceased, not to

return.

From that time menstruation began to be irregular, sometimes delayed, at others anticipated, but always lasting from ten days to two weeks, and occasionally it was so profuse as to constitute a hemorrhage, from which recovery was very slow. There were no other subjective symptoms, save increasing nervousness, and general unfitness.

An examination found a large, retroflexed uterus, with a deep-bilateral laceration of the cervix. There was considerable ectropion of the cervical endometrium, which was rugose, congested, and in spots hemorrhagic. A sharp line divided this from the healthy mucosa of the portie vaginalis. A sound passed into the uterus was followed by free bleeding. The examination was made at the conclusion of an unusually severe hemorrhage.

I curetted the uterus, and amputated the cervical lips, carrying my incision well in to the vaginal fornices. The quantity of the mass removed from the uterus astonished me. It was dark purple, and resembled decidual membrane, a diagnosis, however, that was disproved by the subsequent laboratory report.

The pathological findings were: "Uterine glands increased in number, but regular in shape, the epithelial lining showing no lawlessness in growth. Interglandular stroma dense, composed of spindle cells, connective tissue cells, and fibres. Small blood vessels very numerous. Glands actively growing in number. Cervix, loss of epithelium, glands increased in number and size."

This curettement, in November, 1903, was followed by temporary relief from the menorrhagia. But recurring menstruation gradually became more frequent, and at last the flow was continuous, until in January, 1905, I curetted again. The pathological report follows: "Uterine glands increased in number. tortuous, and dilated. Interglandular stroma very vascular. No

muscle tissue present." At this operation also the quantity of tissue removed was surprisingly large, and of the same general appearance as that from the first operation.

The improvement following gave hope that the disease had been eradicated. Menstruation became very irregular, and on more than one occasion was delayed six weeks. At times the flow was very scanty, at others it developed into a long lasting hemorrhage.

In the summer of 1905, during an automobile tour in Europe, there was an alarming hemorrhage, which was repeated soon after her return home in the fall, from which time nothing controlled the flooding. The indicated remedy, styptics, intrauterine injections, the galvanic current, were without effect, the bleeding finally becoming continuous, with rapidly developing, profound anaemia. The patient was practically confined to her bed, as the least movement, or standing on her feet would increase the flow to such an extent that syncope followed.

My advice to remove the uterus, which had been urged upon the recognition of the disease, finally prevailed, and I did a vaginal hysterectomy in April, 1906. The operation was an unusually difficult one owing to the size of the uterus, the shortness of the suspending ligaments, and the adhesions to the bladder and the rectum. In passing I will say that I have always found adhesions dense and troublesome after galvanism has been used, and I have learned to anticipate such complications when a hysterectomy follows electrical treatment. The recovery was entirely satisfactory. The patient is now absolutely well, and is able to walk six and eight miles without fatigue. As I did not remove the ovaries, or tubes, there are no indications of the climacteric.

The pathologist reported the following: "Proliferation of interstitial fibrous tissue of both the cervix and uterine body. Extensive atrophy of mucous glands. Proliferation of glands. in to the deeper layer-the effect of inflammatory stimulation. In the mucose there are many new formed blood vessels, containing an excess of leucocytes, serum, and red blood cells. An entire absence of muscular tissue."

Comparing these three pathological findings, we observe a progressive degeneration of structure, and though not reaching the construction that characterizes malignancy, still one sufficiently near that line to serve as a warning, and to impress upon us the wisdom of thorough eradication.

There is nothing in the least unusual in this case, but it is one of the most typical from beginning to termination, of chronic metritis and hyperplastic endometritis that I find among my clinical records.

42 West 48th street.

GASTRIC SURGERY AND THE GENERAL PRACTITIONER.*

WILLIAM F. HONAN, M.D., NEW YORK, N. Y.

During the past two or three years it has been my privilege to present before our societies several papers on "Surgery of the Stomach" in which operations and their technique were largely considered. As this subject is of comparatively recent date it has been my good fortune to see its growth and elaboration into the present-day methods. It is my present purpose, now that the experimental stage has been passed in this field of surgical endeavor, to urge recognition and prompt intervention in those cases which by common consent have been placed without the domain of expectant treatment. The internist is looking with but little favor and perhaps some dismay at the gradual encroachment of the surgeon upon those organs and regions which from time immemorial have been at the mercy of his therapeutic activity. Gradually the clinician has yielded in some quarters, but not without some hard-fought battles, but when the surgeon proposes to treat indigestion by operative measures, to invade that precinct so essential to the prescriber of herbs and simples, it is not only carrying the war into the enemy's country but spiking his guns as a preliminary feature. It is a pretty well established fact in the minds of the laity and parts of the medical profession that a surgeon must cut, that no matter what your ailment may be, consultation with him means preparation for operation. And it is largely true, for the patient and the physician can take no chances until they are well assured of the necessity of the cutting before they ever consult the surgeon. Invasion of the stomach seemed, therefore, a large proposition, and for that reason the early cases were largely those patients suffering from advanced malignant disease for which no hope could be entertained and surgery was tried as a last and forlorn hope. At the present time relief from the disturbances of function and distress, occasioned by pyloric stenosis, introgastric hemorrhage and the removal of pathological new growths are principal reasons of operative invasion of the stomach. For the most part the indications for and the technique of operations for these conditions are largely agreed upon. Gastro-enterostomy posterior or Finney's operation for pyloric stenosis due to stricture, Gastro-enterostomy for hemorrhage with resection of ulcer should there be one, and Pylorectomy or partial Gastrectomy for malignancy are the procedures mostly in vogue. To those might be added operation for infantile pyloric stenosis and cardio-spasm. It has been suggested as a principle fairly constant for safe practice that a patient with marked gastric symptoms whose condition is not markedly improved after two years of medical treatment should be sent to the surgeon and the necessity for *Read before the Worcester County Homeopathic Medical Society.

operation, exploratory or radical, seriously considered. At this juncture the value of methods of diagnosis might be considered very briefly. In many works on practice of medicine and in all on diseases of the stomach elaborate methods for the chemical examination of gastric contents which have been withdrawn at varying periods after the exhibition of some form of test meal are given with full detail. Then there is the use of certain effervescing substances to show the size of the stomach and facilitate percussion. The use of the splash sound after a test meal, the introduction of the gastro-diaphone, a fluorescent medium having been previously introduced, will give the size and outline of the stomach very satisfactorily. The employment of X-Ray after a diet of broth and bismuth has been extremely useful in the study of the organ during digestion. These and many other methods are taught and much space is always given to them in works on diseases of the stomach. Several surgeons whose names have been prominently identified with gastric surgery have stated that they placed little or no credence upon the chemical examination of gastric contents, and the point is well taken. As was formerly supposed by the pathologists a man should sit in his laboratory and make a diagnosis of the stomach lesion from the contents alone without having made a careful physical examination of the patient. Of course this is absurd; any method or form of technique that will develop a single bit of positive information is of value and worth the doing, but it should be taken in connection with and in relation to the other and qualifying conditions which go to complete the case. All the methods have a value to that extent. For example, in carcinoma the withdrawal of the stomach contents after a test meal will show diminished or absent H C1, increased lactic acid of fermentation, diminished or absent pepsin or milk-curdling ferments and occasionally bits of carcinomatous tissue. These are all evidences of cancer of the stomach when found, but if the diagnosis is only reached after all those data are present the patient is usually beyond the help of surgery. To be of the slightest benefit operation must be done somewhere in the precancerous stage before the cancer cell has burst through his basement membrane and carried infection to the nearest lymphatic gland. From the surgeon's standpoint he knows that with a two-inch incision in the epigastric region he can by manipulation get practically naked-eye evidences of the exact lesion of the stomach, and if the case is inoperable or the stomach be not the organ at fault, closure of the wound and convalescence is usually a matter of about one week. This of course makes the diagnosis almost certain and an operable lesion by this method is recognized long before the examination of the gastric contents would show anything very characteristic. Careful clinical examinations should, however, be made in every case, for as before stated, any fact however trifling it may seem, may prove of great importance, and personally I have had much help from such forms of exam