The pedicle will yield to torsion with the forceps. This is the simplest method and should always be tried in the first instance; the

Fig. 268.

Forceps with catch, for removing mucous polypi.

forceps shown at fig. 252, or a pair of Nelaton's forceps (fig. 135), are most suitable. If this fail, divide the pedicle with curved scissors. Make traction with the forceps to render the pedicle tense; too forcible

traction might produce inversion. Guarding the uterine wall with the fingers, carry in the curved scissors. In cutting, make the scissors hug the surface of the tumour and thus keep clear of the uterine wall. To divide the pedicle Sir James Simpson introduced the polyptome (fig. 269). Strangulation by ligature, formerly widely practised, is now entirely abandoned; the sloughing stump was a fruitful source of septicemia.

Fig. 269.

Sir J. Y. Simpson's polyptome (Sir J. Y. Simpson).

When the pedicle is of considerable thickness, it may be divided with the ecraseur or with the galvano-caustic wire. The wire ecraseur is preferable to the chain ecraseur, as it is more easily applied. For the nature and method of use of the ecraseur, the student is referred to treatment of Carcinoma of the Cervix. The galvano-caustic wire has been used extensively by Byrne* of Brooklyn, whose paper on this subject should be consulted.

When the size of the tumour makes the pedicle inaccessible, it must be diminished. This is best effected by Hegar's method: traction is made on the tumour, which is at the same time incised in a spiral manner with scissors; the tumour is thus (as it were) unwound, till finally the pedicle is reached and divided.

Chloroform is not necessary for the removal of smaller polypi. The section of the pedicle is painless; if pain be present on tightening the ecraseur round the neck of a polypus, the operator should examine carefully again to make sure that the wire is not constricting the inverted fundus. Where the polypus is large and the operation tedious, it is better to have the patient anesthetised as the operator has then more freedom.

* Electro-cautery in Uterine Surgery: New York, 1873.

CARCINOMA UTERI (OF CERVIX): PATHOLOGY AND ETIOLOGY.

LITERATURE.

Barbour-Case of Carcinoma of the Female Pelvic Organs: Edin. Med. Jour., July 1880. Barnes-Op. cit., p. 821. Gusserow-Die Neubildungen des Uterus: Stuttgart 1878, S. 177; and Ueber Carcinoma Uteri, Volkmann's Samml. klin. Vor., N. 18. Ruge and Veit-Zur Pathologie der Vaginalportion, Erosion und beginnender Krebs: Stuttgart, 1878. Schrader-Op. cit., S. 264. Simpson, Sir J. Y.-Op. cit., p. 140. Tanner-On Cancer of Female Sexual Organs: London, 1863. Virchow-Ueber Cancroide und Papillargeschwülste, 1850. The student will find the fullest references to literature in Gusserow and in Ruge.

By Carcinoma Uteri is usually understood Carcinoma of the Cervix, because in by far the larger proportion of the cases (98 per cent) this is the seat of the disease. The rarer condition of Carcinoma of the Body will be described separately.

PATHOLOGY.

On no subject in pathology has more been written and a greater variety of opinion expressed than on carcinoma. We have endeavoured to arrange, in the table on the page following, the facts most important for the student to know.

CLASSIFICATION.

There are three varieties of carcinoma usually given in the English text-books. These are medullary (encephaloid) and scirrhous cancer, and epithelioma. Now the distinction between the first two is merely a question of degree; in the former the cellular element, in the latter the fibrous stroma is in excess. When we say that medullary cancer is frequent but scirrhus rare, we only mean that carcinoma runs a rapid course when it occurs in the uterus. The distinction between these two and epithelioma is more marked and is therefore given in the table, but it is very doubtful whether it rests on a pathological basis.

From the above it is evident that we are not yet in a position to make a scientific classification. The division according to clinical

When ulceration and breaking down have been produced, these forms are no longer distinguishable.

features into true carcinoma and cancroid (kapkivos and eldos, like cancer) is convenient: it expresses nothing more than that in some cases progress is more rapid than in others; and that the disease in the one case produces metastatic deposits, in the other remains local.

ORIGIN.

As regards the origin, there are two distinct views. That the disease arises from connective tissue cells alone, is the view maintained by Virchow and his followers; while Thiersch and Waldeyer hold that in all cases it originates in epithelial cells. In the cervix, as possible sources, there are two varieties of epithelium; the squamous on the vaginal aspect, the cubical lining the canal. In the flat cancroid of the cervical canal, it arises from the cubical epithelium which lines the latter; in the papillary form, it originates in the cells of the rete Malpighi on its outer aspect (Klebs). It will be seen that Waldeyer holds the view that, in all cases, it arises from the latter only.

The most recent investigations into the origin of carcinoma are by Ruge and Veit. According to them carcinoma arises, in the majority of cases, from a transformation of the connective tissue cells; even the papillary form which produces the so-called cauliflower excrescence, although it apparently springs from the epithelium, is developed from the connective tissue cells. The connective tissue stroma becomes vascular

and almost like granulation tissue. The young cells, which are apparently produced from the connective tissue corpuscles, take on an epithelial character. These observers never saw plugs of epithelium extending downwards into the connective tissue.

Carcinomatous nodule growing in one lip of the cervix and pushing the mucous membrane outwards The figure to the right is a section of the cervix made through the line x (Schroeder).

POSITION.

There are apparently three places in the cervix where carcinoma