slight difference of opinion. This may be explained by the variable period in the course of the disease at which the symptoms appear. Sir J. Y. Simpson gives the probable duration of life after the detection of the disease as from 2 to 2 years; Gusserow and Schroder give it as from 1 to 1; while, according to Fordyce Barker, it is as long as 3 years and 8 months. The statistics of H. Arnott, drawn from 57 carefully observed cases, give the duration, after the first symptom (usually a flooding), of true cancer as 53.8 weeks; of epithelioma, 82.7 weeks. We may say therefore to the patient's friends that the disease will run a course of from one to two years. It is better not to tell the patient herself what her trouble is, though its serious nature should not be disguised.

CAUSES OF DEATH.

The causes of death, arranged in the order of importance, are the following:

Exhaustion,

Uraemia,

Peritonitis,

Septicemia,

Hæmorrhage,

Venous thrombosis.

Exhaustion, under which we include marasmus, is the result partly of the drain on the system and partly of the inability to take food.

The importance of uræmia as a frequent cause of death has only recently been pointed out. According to Seyfert,* in the majority of cases death results from it. It is due to the compression of the ureters, as already described under pathology. It may be acute, accompanied by coma and convulsions; more generally it is chronic, and shows itself in the dullness of the patient, occasional headache, and decreasing sensibility to pain-which diminishes suffering as the disease approaches its termination.

Peritonitis is sometimes the cause of death, but not so frequently as one would suppose; the disease is prevented from extending generally to the peritoneum by the adhesions which are formed. When peritonitis occurs, it is localised and chronic; in some cases, however, a general peritonitis is set up which proves fatal. Perforation may take place from the sudden giving way of adhesions; the escape of the carcinomatous debris into the peritoneal cavity produces death from shock or septic peritonitis. The preparation shown at fig. 280 was taken Säxinger, Prager med. Vierteljahrsschrift, Bd. I., S. 103.

*

from a patient in whom the immediate cause of death was rupture of the uterus. The case is reported and the preparation described by

Carcinoma of the cervix leading to occlusion of os uteri, dilatation of uterus and perforation (A. R. Simpson). Uterus and vagina laid open; a bristle is passed through the perforation. A. R. Simpson (op. cit., p. 276). There was carcinoma of the cervix which had contracted the lumen of the canal; the cavity of the uterus was expanded, the walls being thinned out; at the fundus was a small perforation about the size of a pea, with thin edges,' through which fluid had escaped and set up peritonitis which rapidly proved fatal.

Septicamia suggests itself as a likely cause of death. We are familiar with it as produced in the puerperal condition: it is explained by the fact that, at that time, there is abundant means for absorption in the numerous lymphatics and the large veins which have been recently lacerated; hence, whenever septic matter is present, there is great risk of septicemia. Similar conditions exist in carcinoma, during the progress of which the blood-vessels are eroded and their extremities bathed in putrid matter. Barnes has drawn special attention to this as a source

*

of blood-poisoning; according to Eppinger's observations its occurrence is rare, and this he ascribes to the diminution of the absorptive power of the eroded vessels.

Hæmorrhage is in very rare instances immediately fatal. As already pointed out, though it is important as an early symptom, it occurs less frequently and is less abundant as the disease advances. If a large vessel be suddenly opened into, a fatal hæmorrhage may follow.

Venous thrombosis, due to mechanical compression of the veins, sometimes occurs; and a clot may be detached producing embolism in the lungs. Fatty degeneration of the heart is, sometimes, also present.

* Prager med. Wochenschrift 1876. S. 210.

CHAPTER X L.

CARCINOMA UTERI (OF CERVIX): TREATMENT.

LITERATURE.

Barnes-Op. cit., p. 856. Freund-Samm. klin. Vorträge, Nr. 133; and Centralbl. f. Gyn., N. 12, 1878. Gusserow-Die Neubildungen etc., S. 203. Hegar und Kaltenbach-Die Operative Gynäkologie, S. 391. Schroeder-Charité Annalen: V. Jahrgang, S. 343. Zeitschrift für Geburtshülfe und Gynäkologie: B. III., S. 419; B. VI., Heft II., S. 218. Simpson, A. R.-Op. cit., p. 261. Simpson, Sir J. Y.-Op. cit., p. 170. Sims, Marion-The Treatment of Epithelioma of the cervix uteri : American Journ. of Obst., July 1879. Thomas-Op. cit., p. 591.

THE treatment of carcinoma ought to be regarded in two aspects: first, as treatment of the symptoms; second, as treatment of the disease. Again, the treatment of the disease may be either palliative or radical.

We need not discuss here the vexed question whether carcinoma is a constitutional or a local disease. It cannot be too strongly impressed on the student that, as far as our present experience goes, in attacking the disease itself he must rely upon surgical and not on medical treatment. Our aim ought to be the removal of the disease and not merely the alleviation of the symptoms. To remove it completely we must recognise it early. Up to the present time successful treatment has been a rare occurrence, because we have failed to recognise carcinoma in its commencing stages. The possibility of treating it successfully in the future will depend on the possibility of our recognising it in its commencement. Not less important than early recognition is complete removal and that without delay. In the uterus, more readily than in the mamma, does the carcinoma get beyond the reach of the operator. In carcinoma mammæ, we can excise not only the breast but also the axillary glands if these should be already implicated. But, in carcinoma uteri, as soon as the pelvic glands are involved the case is hopeless as regards a radical cure.

We shall consider, first, the treatment of the symptoms; because, in the majority of cases, when the patient comes under our notice, the disease itself has already got beyond our remedies.

TREATMENT OF SYMPTOMS.

These are hæmorrhage, offensive discharge, pain.

HÆMORRHAGE.

In the treatment of hæmorrhage, there are two points to be considered; first, the instructions to be given to the patient; and, second, the means which we can ourselves employ.

(1.) The patient is instructed to take the liquid extract of ergot in large doses whenever there is much hemorrhage either during the menstrual period or independent of it. If she is subject to floodings, a friend might be taught how to give the ergotin solution hypodermically. Ice applied to the vagina and injections of cold water check hæmorrhage; a small piece of sponge or tampon of wadding, soaked in perchloride of iron, might be passed into the vagina if cold is not sufficient. The patient is recommended to avoid sexual intercourse, as this favours active congestion and in some cases is the cause of hæmorrhage. (2.) The means at our own command are the following

Simple pressure, effected by complete and thorough plugging of the vagina;

The use of styptics, caustics, or the actual cautery;

The removal of diseased tissue by the curette or other means. The plugging of the vagina should be done whenever we are called in on account of profuse hæmorrhage. The packing is carefully done with pledgets of lint or cotton wadding (with string attached) soaked in carbolic oil; the speculum is introduced carefully and not carried high up.

Of styptics, the best are the perchloride and the pernitrate of iron. Sir J. Y. Simpson recommended a saturated solution of the perchloride in glycerine. A pledget soaked in either of these is introduced, and placed so as to be in contact with the bleeding surface; and the rest of the vagina is packed, as above described, with the pledgets steeped in carbolic oil. The perchloride should be used with great caution in cases of advanced ulceration, as we have seen it corrode into the tissue so as reach the peritoneum and produce peritonitis. The use of caustics, cautery, and curette, will be considered under operative treatment.

OFFENSIVE DISCHARGE.

This is best treated by astringent and antiseptic injections. These should be used frequently, as it is important to keep down the unpleasant odour and make the patient's surroundings as comfortable as possible. If the discharge be plentiful and not very offensive, as in the