softness, while deeper pressure fails to detect the stony hardness of cancer. It also lacks the nodulated feel which characterizes cancer.

Retention cysts of the Nabothian glands may be mistaken for malignant nodules. However, these cysts impart to the examining finger a sensation of resistance, and they are evacuated on puncture. They are usually multiple, whereas carcinomatous nodules extend from a single center.

Syphilitic ulceration of the cervix, although a rare condition, has been mistaken for malignant ulceration. The constitutional manifestations of this disease are rarely absent. Usually there are present condylomata and the condition yields to proper systemic treatment.

I am always suspicious of a cervix whose everted mucous surface is elevated above the surrounding structures, which bleeds easily and which is not speedily improved by proper treatment. I do not believe that a uterus thus affected should be unceremoniously sacrificed, nor is this necessary. By means of cocaine a section can be painlessly removed and subjected to microscopic examination. Uncertainty existed in the uteri shown in Figs. 9 and 10. The patient from whom the specimen shown in Fig. 9 was taken was placed on the table prepared for a trachelorrhaphy. Upon exposing the cervix the tissues looked suspicious and I removed a section and submitted it to Dr. C. H. Thurston, the pathologist of the Cleveland Medical College. I also curetted and postponed operative interference until a later date. Both the curettings and the sections

removed from the cervix showed unmistakable evidences of malignancy. The uterus was removed some days later, when it was found that the entire endometrium was involved in the cancerous process. At least two of the bystanders who were present at the

preliminary operation thought me unduly cautious and advised me to go on with the trachelorrhaphy.

Figure 10 shows very nicely the malignant nodules projecting from a cervix which was lacerated and badly everted. This happens to be the only double uterus I have ever removed. The patient is

Carcinoma of the Uterus with Cystic Distentton of the Right Ovary. Cancerous Nodule in the left cornu. (From the Author's Text-book of Gynecology, p. 661.)

45 years of age and has had four children. The evidences of malignancy were unmistakable and, without perhaps as thorough an examination of the pelvic organs as I should have made, I presumed that the unnatural shape of the uterus was due to a projecting fibroid. There are two cervical canals and there is nothing to indi

cate in which cavity the pregnancies occurred. Two weeks from the date of the hysterectomy the right breast was amputated for

cancer.

There is more uncertainty in the diagnosis of cancer of the body of the uterus and its lining membrane. As we have seen, the disease is much more rarely located in the body than in the cervix, but I do not believe that the disparity is as great as the older writers teach. In the examination of curettings the microscope is not infailible, for the reason that the whole depth of the uterine glands are rarely obtained by the curette, and it is sometimes exceedingly difficult to distinguish a simple glandular hypertrophy attending endometritis from cancer. I have, therefore, formulated the following rule by which I am governed: In a given case of menorrhagia occurring in a woman over forty years of age, which cannot be accounted for by systemic or peri-uterine disease, and which is not controlled by one or more curettings, I do not hesitate to remove the uterus forthwith. In at least a dozen hysterectomies made by me upon these indications the microscope has proved beyond all doubt the wisdom of the course pursued. I believe that menorrhagia due to non-malignant endometritis, with absence of serious peri-uterine or systemic disease, is always benefited by the intelligent and thorough application of the curette. The rule which I have formulated is more emphatically applicable if the woman is approaching the so-called cancerous age, if there is a recurrence of hemorrhage or discharge after the menopause, or if she presents a family history of cancer. In sarcomatous disease of the fundus the curette will usually bring away enough tissue to make the diagnosis certain. (1)

TREATMENT.

Prophylaxis. I again repeat that I believe that a very large per cent. of uterine cancers could be prevented by the timely corrections of the diseases and injuries which have been studied as etiological factors. I believe that every woman who has a serious laceration of the cervix, with eversion and deposition of cicatricial tissue, should have it repaired. This is especially true if there be an hereditary predisposition to cancer. Trachelorrhaphy, in skilled hands, is a most simple operation, and the danger attending it is

(1) Sarcoma of the uterus is not of common occurrence, yet it is occasionally met with. Guserrow analized seventy-five cases of sarcoma uteri. Of these twenty-five were childless, four of the twenty-five being virgins. Numerous instances of sarcoma of the uterus have been met with in women under twenty-five years of age, which contrasts markedly with carcinoma. Practically, the two forms of malignancy differ from one another only in their histological conformation: The nature of this essay precludes a more extended reference to sarcoma.

practically nil. Usually, too, when the condition of the cervix which I have described exists, there are certain disturbances of the general system which in themselves call for a correction of the local lesion. I have in another place (NORTH AMERICAN JOURNAL OF HOMEOPATHY, July, 1895), made a plea for the removal of all lesions of the lower orifices of the body at one sitting. Diminished physiological resistance is the very foundation of cancer, whether the disease start from a matrix of embryonic tissue, whether it be due to parasites, or whether it has its origin in protoplasm unfavorably impressed by

Epithelioma of the Cervix, growing into vagina. (From the Author's Text-book, p. 630) heredity. This diminished physiological resistance is brought about by malnutrition; and malnutrition, especially in women, is oftener due to lesions of the lower orifices of the body than to other causes. Pratt, of Chicago, has created in America a school of surgeons known as "orificialists." While wild and exaggerated claims have been made by many of Dr. Pratt's followers, and much harm has been done by a class of men who are ill-fitted to assume the responsibilities of surgery, I am firmly convinced that many surgeons are ignoring certain principles emphasized by Pratt which, if intelligently applied,

would work untold good in the prevention and cure of many diseases. Space will not permit of entering into an extended discussion of the so-called orificial philosophy. From an experience which is not altogether small, I am led to believe that the nutrition of the body can be profoundly impressed for evil by certain lesions of the lower orifices of the body; and that by correcting such lesions the patient can many times be lifted from a state of invalidism to health. Orificial surgery not only removes the local irritation, which in itself predisposes to cancer, but it places the system, especially

A Uterus showing advanced stage of Cervical Cancer. (From the Author's Textbook, p. 636.)

when aided by intelligent internal medication, in shape better to resist disease and degeneration.

Lesions of the uterine appendages should receive attention, and in gonorrhoeal pyosalpinx, where the uterus is much enlarged and diseased, I believe that it should be removed with the appendages. Usually the results are more satisfactory when this is done, for a uterus thus affected remains a menace to its possessor and may take on malignancy. I now have under observation a woman, 36 years of age, from whom I removed, eighteen months ago, a pair of pus tubes. She returned to her home in the interior of the State and