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Introduction: Endometrial Cancer is a common gynecologic malignancy primarily treated with complete surgical staging, which may include complete pelvic and para-aortic lymphadenectomy. The role of lymphadenectomy is controversial, especially the intraoperative indications for the procedure. Three factors are important in decision to proceed with lymphadenectomy: Myometrial invasion, maximum tumor dimension, and histology. Many institutions incorporate these criteria in varying degrees in the decision to proceed with lymphadenectomy. This investigation assesses the use of intraoperatively measured MTD with and without pre-operative histologic grade. Methods: This study compared retrospectively EEC patients with intraoperatively measured MTD ≤2 cm to those with MTD >2 cm from January 1, 2002 to August 31, 2017. This assessment compared those with MTD ≤ 2cm with endometrial biopsy (EB) grade 1-2 to patients with MTD > 2cm with EB grade 3. Lymph node metastasis (LNM), recurrence, and survival were compared in these groups. Results: This study reviewed 222 patient cases. In tumors > 2 cm, LNM occurred in 20% cases while in tumors ≤ 2 cm, LNM was found in 6% cases (p=0.04). Recurrence and mean survival based on last follow up visit in these two groups were not statistically different (p=0.78 and 0.36 respectively). Data demonstrated a trend that when combined with preoperative EB International Federation of Gynecology and Obstetrics (FIGO) grade, a higher proportion of patients with EB FIGO Grade 3 and MTD > 2 cm had LNM compared to those with EB FIGO Grade 1-2 and MTD ≤ 2 cm (43% vs, 11%, p=0.06). LNM was found in 15% of cases in which lymphadenectomy was performed based on current practices, whereas if the criteria of EB FIGO 3 and MTD > 2 cm were used the incidence of LNM would have been 44% cases. However, using this criterion, two patients would not have had their nodal metastases detected. Compared to the current practice, the sensitivity and specificity of the proposed criteria would be 60% and 81%, respectively. The PPV and NPV would be 43% and 90%, respectively. Conclusion: The results indicate that MTD combined with EB FIGO grade can detect LNM in a higher proportion of cases when compared to current practice. MTD combined with EB FIGO grade may eliminate the need of frozen section sampling in a substantial number of cases.

New York, Feb. 15, 1898. To the Editor: —In theJournalfor Feb. 12, 1898, I find a reply from Dr. Haughton to Dr. Carstens which seems to fail to comprehend the subject of appendicitis in just the proper way. Perhaps there is no subject in medicine more thoroughly understood than that of appendicitis. The pathology, etiology, symptomatology and anatomy are all so completely recorded by our authorities that it is only the men who are too busy to read the works of authorities who imagine that there is still much room for discussion upon the subject. It has been demonstrated and recorded that the operative death-rate in acute and in chronic appendicitis without abscess, is only a fraction of 1 per cent, at the hands of several of our American surgeons. It has been demonstrated and recorded that the men who represent diagnostic acumen of the highest order are

Many years ago I was impressed by the fact that common operations for perineal repair dealt with fascia only, although operators spoke of catching up muscles which were not actually seen. Examination of perineums repaired in classical ways seemed to indicate that permanently satisfactory results are often missed. The general surgeon likes really to see muscles which he brings together for purposes of repair. Dissections of ruptured perineums showed that atrophy of most of the muscles and fascia took place rather rapidly when they were thrown out of commission. One muscle, however, remains plump and full because it continues to act in a special function. This is the pubococcygeal portion of the levator ani muscle. If the full free margins of this muscle are exposed and brought together in the mid-line with three or four kangaroo tendon sutures, the most important contractile part of the perineum is strongly restored. A

New York, May 22,1906. To the Editor: —InThe Journal, May 19, 1906, Dr. J. E. Summers says, on page 1510: "I have done the McBurney incision in hundreds of patients, a few of these being pus cases, but it is a dangerous incision for this latter class, even in the hands of the most experienced." My own experience has been so directly at variance with this statement that it seems best to go on record in the matter. For some years I have employed the McBurney incision almost exclusively in all sorts of appendicitis work, pus cases, general septic peritonitis and all the complications that one commonly runs across. If one uses a short McBurney incision in his pus cases, working rapidly by touch instead of by sight, avoiding gauze packing and all drains except a small wick, avoiding counter-openings and other unnecessary procedure, "leaving his patient as nearly

When certain species of animals, like rabbits and lemmings, increase beyond the limit desired by Nature in any locality, epidemic diseases suddenly appear and stop this disturbance of natural balance. In the earlier days of history the human species was subjected to similar epidemics. It seems to have been Nature's plan to allow the medical profession to take charge of this subject up to a certain point, but there are limitations which we may not be allowed to pass, because there appears to be a plan to destroy by poison various species of plants and animals which have arrived at stages of increase or of development beyond Nature's liking. Concerning the stage of development which is to be allowed for man, we can no more anticipate the limit than we can state the reason for the presence of so many thousands of suns in space. We may simply observe the

Draw a line from the right anterior superior spine of the ilium to the navel. On this line, an inch and a half from the anterior superior spine, we find McBurney's point. Tenderness on deep pressure at this point gives presumptive evidence of an irritative process in the vicinity of the appendix vermiformis, but tenderness on superficial pressure at this point may mean irritation of sensory nerves of the abdominal wall, and the irritation may be due to causes ranging from hysteria to toxemia. McBurney's point is of great diagnostic value to physicians who possess a considerable degree of collateral knowledge, aside from their familiarity with the symptoms of appendicitis. Instead of going out on the line to a point an inch and a half from the anterior superior spine of the ilium, come back on the line to a point situated an inch and a half from the navel.

Previous to the days of anesthetics and of aseptic surgery, operators strove to complete their work in the shortest time possible, and the results of skill in this direction were appreciated. Under the influence of modern methods of protection for the patient, there came a tendency to devote more time to detail in operative technic, and this sometimes degenerated into "puttering." It is quite as important for the patient to retain his natural resistance after operation as it is for the surgeon to add artificial means for securing asepsis during operation. Mr. Tait was the first prominent exponent of this principle, but the special reasons for his success were not understood in his day. We now know that infections are met by the cell resistance of the individual, and the better the general resistance of the patient, the better his special cell resistance. A patient usually retains a great fund of natural resistance during

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New York, March 28, 1903. To the Editor: —It seems incredible that the osteopaths should have been enabled to gain favorable legislation in several states, and it makes one feel that the physicians have not properly presented the matter in discussions before legislative committees. On several occasions when I have been present it was painfully evident that regular physicians who were being depended on by members of the committee had not read any of the books or other literature of the osteopaths, and that they were not prepared to take a dignified position in discussions. It seems to me that the osteopaths could always be defeated without the necessity for any very elaborate argument if some physician would take the trouble to have properly-prepared specimens of spinal columns to show to members of the committee. I have chosen a longitudinal section of a child three or four years of age

It seems strange when accurate knowledge is so easily accessible on the subject of appendicitis, that bad methods in the management of the disease still persist. I will briefly review some of these, and approximately in the order of their importance. The worst method is that which treats the patients by various medical means. Many of these recover without further attacks, many die and a larger number have recurrent attacks and suffer more or less invalidism for months or for years. It is impossible to determine in advance which course will be followed by any one case. That is always determined afterward. Consequently the cases that are going to recover without further attacks, recover; the ones that are going to get into dangerous complications, get into dangerous complications; the ones that are going to have recurrent attacks, have recurrent attacks, under medical treatment. There is no way for determining in advance

To the Editor: —The editorial on "Peanuts as Food" (The Journal, March 23, 1918, p. 850) is in line with progress. More, however, may be said to advantage. It is a rule in economics that people do not make an effort toward filling a need until the need is felt. The American Indians used a large number of plants that have not as yet been cultivated systematically for the general food market. Eventually civilized man may employ most of the things that the Indians ate. Man began to cultivate the annual plants that bring prompt return for his labors, and this he is likely to continue to do by preference until he comes to understand that nut bearing trees give a larger yield per acre at lesser expenditure of time, care and expense than annual plant crops require, as a general rule. Nuts may be divided into two general classes

New York, Sept. 20, 1901. To the Editor: —On page 852 ofThe Journalfor Sept. 28, 1901, I find a report of a paper read by Dr. E. P. Hershey, Denver, dealing with the question of the function of the appendix. Dr. Hershey apparently believes that the secretions of the appendix are important in their influence on bowel contents, but we know that such secretions are trifling in amount and not different from those of the cecum. Most of the appendices upon which I have operated have had their function already destroyed by bacteria. Further than that, we know that during middle life the appendix is prone to undergo normal involution changes, so that in later life there is little if any secreting surface left. Dr. Hershey says of the cecum: "This cul-de-sac is the most inviting place for the accumulations of feces. The mass remains here and would