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 uterus, as already described under pathology. It may be acute, accompanied by coma and convulsions; more generally it is chronic, and shows itself in the dulness 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 from a patient in whom the immediate cause of death was rupture of the uterus. The case is reported and the preparation described by 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. Septicemia 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 septicæmia. Similar conditions exist in carcinoma, during the progress of which the bloodvessels 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. 1 Säxinger, Prager med. Vierteljahrsschrift, Bd. I., S. 103. Hemorrhage is in very rare instances immediately fatal. As already pointed out, though it is important as an early system, it occurs less frequently and is less abundant as the disease advances. If a large vessel be suddenly opened into, a fatal hemorrhage may follow. 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. 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. CHAPTER XL. CARCINOMA UTERI (OF CERVIX); TREATMENT. Barnes-Op. cit, p. 856. LITERATURE. 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 hemorrhage, offensive discharge, pain. HEMORRHAGE In the treatment of hemorrhage, 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 hemorrhage; 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 hemorrhage. (2) The means at our own command are the following : : Simple pressure, affected 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 hemorrhage. 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 to 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 cauliflower excrescence, the indication is more for the use of astringents like sulphate of alumina and iron (4 grains to the oz.). Tannin or sulphate of zinc can also be used, and it is well to change the astringent occasionally. If there is much necrosis of tissue with very offensive discharge, carbolized water (1 to 50) is required. Acetate of lead (31 to 320) is recommended by Barnes. Solution of bromine (1 of the B. P. solution to 3 of water) is a good disinfectant, but its odour is disagreeable. Condy's fluid is largely used, but it is only deodorant, not disinfectant. The skin round the external genitals should in all cases be protected from the acrid discharges, as the irritation is a source of discomfort. A lotion of equal parts of olive oil and glycerine, or of olive oil and lime water, applied after each vaginal injection, serves this purpose well. PAIN. This can only be effectually relieved by some preparation of opium; it is well to delay the habitual use of this remedy as long as possible, as it interferes with digestion and nutrition. It may be given as a morphia suppository (of a grain in each) per rectum, or as the liquor morphi hydrochloratis by the mouth. We obtain its action most surely and quickly and with the least disturbance of the digestive system by giving it hypodermically. It is desirable to change the narcotic, as even opium gradually loses its effect; the hydrate of chloral, in 20-grain doses, may be used as a substitute. Various local anodynes have been suggested but are of little use. Attention to the general condition of the patient is very important. The three main points are to give a sufficient quantity of nutritious and easily digestible food, to keep the bowels regular, and to have the atmosphere healthy and the surroundings cheerful. Food should be given in small quantities and frequently; milk, eggs and beef-tea should be substituted for more solid food as soon as digestion fails. In the latter stages, the |