twelve months later presented herself with a uterine cancer advanced far beyond the operative stage. Fibroid tumors of the uterus are no longer considered as harmless as they formerly were. During the last six weeks I have removed two uteri for fibroids which had undergone malignant degeneration. The specimen shown in Fig. 11 was removed from a maiden woman aged 40. The larger mass on the left was incarcerated within the pelvis and was rapidly strangulating the bowel. The smaller one on the right floated upward and rested beneath the spleen. Total abdominal hysterectomy was made with the patent in the Trendelenberg posture. The smaller tumor was studded with sar comatous nodules. The tumor and uterus weighed fifteen pounds. The specimen shown in Fig. 12 was removed from Mrs. S. aged 40, a widow and childless. Eighth months ago I amputated the breast for a scirrhus cancer. She has suffered for years from pelvic distress, dysmenorrhea and menorrhagia. The uterus distended the hypogastric region. The operation was made through the abdomen. The fibroid was of the sub-mucous variety and had assumed malignant degeneration. It is yet too early to determine in either of these cases whether or not a permanent cure has been accomplished. Senn (1) maintains that transformation of innocent into malignant growths is not uncommon. While I by no means believe that all, or even the majority, of fibro-myomas call for operative interference (1) Pathology and Surgical Treatment of Tumors, p. 61. I do believe that these growths should be carefully watched and if evidences of malignancy develop they should be removed at once. Women who are victims of badly lacerated cervices and who will not, or can not, undergo an operation, should submit to a local examination at least every six months. Therapeutics. Many vaunted specifics for cancer have been from time to time put forth, but as yet nothing reliable in the way of a "cure all' has been accomplished. Personally, I have pinned my faith to the homœopathic remedy and I believe that, when properly selected, it will do all that any form of internal medication known at the present time can do in the way of staying the progress of the disease. The remedies most useful are those capable of profoundly impressing the system when given to persons in health. Prominent among them is arsenic and its compounds. I have done more with Arsenicum Iodide that any other one remedy. Hydrastis, Lachesis, Conium, and the preparations of lime and potash are often serviceable. These remedies will do much in the way of palliation and in maintaining a favorable condition of the system. However, and I wish to emphasize this point, I do not believe that there is one single authentic case of cancer on record cured by internal medication. I mean by this where the disease has been proved malignant beyond all doubt by the microscope. On the other hand there is every reason to believe that the carefully selected homœopathic remedy will so favorably impress the system as to ward off many cancers. However (and I speak from the standpoint of a surgeon), this fact should not lead the prescriber to place too much faith in the efficacy of internal medication. Granting, for the sake of argument, that cancers have been cured by homœopathic medica-. tion, the per cent. of such cures is so small as to make it unsafe to rely on internal remedies in operable cases. Sixty-six per cent. of the uterine cancers which came to me in 1895 were inoperable. In a goodly number of these cases the gentlemen who had them in charge followed, instead of instituting a careful local examination, the lead of a blind symptomatology which proved disastrous to their patients. With our present knowledge of cancer of the uterus, and with the statistics of hysterectomy for the disease now accessible, there rests with the general profession a tremendous responsibility. It is the family physician to whom we must look for the early recognition of the disease. During the last two years the treatment of inoperable cancers and sarcomas with the toxins of erysipelas and bacillus prodigiosis has received much attention. Coley (1) summarizes the cases treated by him up to May 1, 1894, as follows: Twenty-five cases of inoperable sarcoma, eight of inoperable carcinoma, and three of carinoma or sarcoma were treated with the mixed toxins. Improvement followed the treatment in carcinoma in a number of cases but there were no cures. Six of the sarcomas were apparently cured. One was a case of recurrent sarcoma of the hand which had been removed surgically six times; the patient remained in perfect health two years after beginning the treatment. In another case a very large and presumably malignant tumor disappeared under the mixed treatment. In twenty-four additional cases treated since the above date, all of which were inoperable, the results were en couraging. Fig 9. Thirteen of the cases were sarcoma and eleven carcinoma. Of this number three of the sarcoma cases were supposed to be cured. In none of the carcinomas did the tumor entirely disappear, though in nearly all the progress of the disease was favorably affected. Coley begins with a minimum dose of the toxin and gradually increases it until a reactionary temperature of 103° or 104° is produced. He believes that the action of the erysipelas toxin is greatly increased by the toxin of the bacillus prodigiosis. Beck (2) on the other hand, while admitting that accidental erysipelas, like many other infectious diseases, has an influence on (1) Am. Jour. Med. Sci., Jan. 19, 1895. (2) Chicago Med. Recorder, August, 1894. malignant lesions, claims that the same effects may be caused by injections of zinc chloride, arsenic, potassium iod., and many other substances. Wyeth (1) maintains that sarcoma may be cured by any form of septic infection, though admits that the sepsis of erysipelas exercises the most powerful curative influence. Bernhart (2) reports highly satisfactory results from parenchymatous injections of a solution composed of six parts of salicylic acid to sixty of alcohol. Valliet (3) has obtained almost equally good results from the use of absolute alcohol alone. Adamkiewicz (Warren), imitating Koch's method of treating tuberculosis, treats cancers with a serum which he terms "canceroin" and which he obtains by macerating minute fragments of cancer in water. His success has been indifferent. Pyoktanin has also been used subcutaneously in malignant tumors with alleged success. The once vaunted specifics, chian turpentine and condurango, have long been entirely discarded. While the results thus far obtained in the treatment of malignant neoplasms by toxins and other agents used subcutaneously is far from satisfactory, I do not think that they should be ignored. They at least suggest possibilities which should encourage all serious investigators in this field of research. Surgical. I have given this somewhat extended review of the literature of the therapeutics of cancer quite as much to show that at the present time our chief reliance in the treatment of this most formidable disease must be placed in surgery, as to call attention to the work that is being done along this line. The first complete vaginal hysterectomy for carcinoma was made in 1813 by C. J. M. Langenbeck, but Czerney, in 1878, was the first to successfully revive the operation. Abdominal hysterectomy, as performed by Freund, was practically discarded for the vaginal operation because of its high mortality. Few specialists longer advocate high amputation of the cervix as a curative measure. Total hysterectomy, either vaginal or abdominal, is the only radical procedure which should be thought of. Up to two years ago the percentage of immediate recoveries was so largely on the side of the vaginal method that few abdominal hysterectomies were made for cancer. During the last two years, however, particularly in America, there is a tendency to revert to the abdominal, or the combined abdomino-vaginal, method. (1) Jour. Am. Med. Assoc., June 30th, 1894. This practice is the outcome of the more favorable results following total ablation of the uterus for fibroids. The mortality attending abdominal hysterectomy is now but little greater than that attending ovariotomy. The "pedical problem" was solved by total extirpation which was immensely facilitated by the Trendelenberg posture. As long as the disparity in the results of the two methods was so great, operators were loath to abandon the vaginal for the abdominal route. The result was that there were devised almost as many different methods of performing vaginal hysterectomy as there were operators. However, the great difficulty of cutting "wide of the diseased area" while working through the vagina alone has been generally recognized; and, since the Trendelenberg posture has so simplified abdominal hysterectomy, many surgeons prefer to work close to the pelvis through the abdomen. One needs but study the lymphatics of the uterus to appreciate that the Pratt method of enucleation is entirely inapplicable to carcinoma. During the last eighteen months I have been doing the combined operation and am more than delighted with it. It is performed as follows: The patient is first placed in the lithotomy posture and the cul-de-sacs opened in the usual way, as large a cuff of vaginal tissue being removed as is possible. The uterine arteries are next secured in catgut or silk ligations, as the operator may elect, and the broad ligaments severed on either side for a distance corresponding to the tissues included in the ligatures. This frees the cervix from the bladder, rectum and the base of the broad ligaments. The patient is next placed in the |