Whenever the hemorrhage is profuse, styptic injections must be used, such as vinegar and water, dilute solution of sesquichloride of iron, 1 to 5, or tampons saturated in these solutions may be applied to the bleeding surface. Alum or tannin may be incorporated with cacao butter, or sprinkled upon cotton and placed in the vagina. A prompt effect is produced by pouring diluted solution of sesquichloride of iron through a speculum directly upon the bleeding surface. Permanganate of potash in concentrated solution is of service in correcting the offensive odor. Iodoform has been employed in powder, in gauze and in suppositories, for the same purpose, but it cannot be used continuously, as its odor becomes intolerable to the patient and her attendants. Chinoidine sprinkled upon the ulcerations through the speculum is less objectionable; it removes the odor and improves the appearance of the ulcer, but it causes violent pain when brought in contact with wounds upon the surface of the body, and it must be ascertained whether its action is the same when applied to carcinoma of the cervix.

The uremic symptoms, nausea, anorexia, vomiting, headache, and distress in the stomach are at first treated with tonics, such as tincture of ignatia amara or compound tincture of cinchona, with mustard-plaster to the epigastrium, and later with ice internally and also upon the head. In persistent uremic vomiting I have used with advantage one-drop doses of tincture of iodine in water. Again, temporary improvement may be occasionally observed without the administration of any remedies.

Warm baths are very acceptable to many patients, while others fear them on account of subsequent hemorrhage.

Obstinate constipation is relieved as long as possible by injections of from one to one and a half quarts of tepid water; but the temperature of the water may be varied to suit the conditions. When these prove ineffectual, drastics should not be at once employed, but rather mild cathartics, such as magnesia, rhubarb, laxative Indian fruit, etc., given. These remedies may be frequently changed and given in combination.

The strength of the patient must be sustained chiefly by vegetables and nutritious, well-spiced soups and broths. The majority of patients soon refuse meats of all kinds, though many are re

freshed and strengthened by game, bouillon, fresh meat-juice, oysters, sardines, caviar, ices and strong wines.

I will mention but two specifics, viz., condurango and Chian turpentine. The former is often of service in gastric and intestinal complications in the form of a decoction 15: 175; it lessens the pressure, nausea and anorexia, but it will never cure a cancer. Chian turpentine has been warmly recommended from time to time, but little or nothing has been so far accomplished by its use in Germany. It was only a few weeks ago that its action was highly commended to me by some of my colleagues in Odessa.

Cancer of the Body of the Uterus.

Pathological Anatomy.-Carcinoma of the body of the uterus, not involving the cervix, may be primary or secondary. Primary carcinoma begins either in the superficial epithelium or in the glands of the mucous membrane. In the first variety we find occasional isolated glands more or less involved, but it is chiefly the cells of epithelial carcinoma that infiltrate the uterine mucous membrane and muscular tissues in irregular strands; the cells may be found in various stages of development, as small as the interglandular cells, or in round or cone-shaped masses as large as decidua cells. When degeneration of the carcinomatous tissue takes place, the interior of these masses is composed of débris, fat corpuscles, granular matter, colonies of micrococci and isolated groups of cells; the vessels are obliterated, and pigment deposits occupy their place; but in the deep tissues the vessels are tolerably well preserved. The other variety of primary carcinoma of the body is that which is known as adeno-carcinoma, due to change of type in those polypoid neoplasms developed from the glandular endometrium. This variety grows toward the cavity and develops new glandular tubules which, while covered at the periphery by cylindrical cells, have, according to Breisky, pavement cells and cancroid masses in their interior.

I am unable to state with certainty whether the so-called parenchymatous variety of uterine carcinoma occurs primarily in the body as it does in the neck of the uterus. Klebs* states with

* II., 869.

reference to it: "The point of origin of this neoplasm cannot be determined with certainty. The probability is that it arises from the vicinity of the internal os, at which point a predisposition to the development of deep-seated carcinomatous neoplasms exists, on account of the great number of ovula Nabothi. This hypothesis explains the uniform development of nodules in the substance of the body of the uterus and of the cervix. Those carcinomata are probably very rare which originate in the body of the uterus, i.e., from the uterine glands." It seems to me that the region of the internal os is peculiarly liable to infiltrating carcinoma, because

Primary Cancer of the Body, with Retroflexion.-Origin from the posterior wall. Perforation into Douglas's cul-de-sac.

of the larger development of glands at this point. When the neoplasm has penetrated the wall of the uterus, it causes adhesions with the bladder or rectum (shown in fig. 58), tubes or ovaries, becomes encapsulated, and may finally form a large, offensive, suppurating cavity.

Secondary cancer of the body of the uterus is associated with carcinomatous disease of the bladder or rectum and, in all such cases, has extended beneath the peritoneum and throughout the pelvic connective tissue.* There are other cases where it is pos

* Freund, Virchow's Archiv, lxiv., 1.

sible the primary affection was ovarian cancer combined with cancer of the villi of the fundus of the uterus.* But much more frequently secondary cancer of the uterus is a cancer of Douglas's cul-de-sac, which thence extends to the posterior wall of the uterus, to the tubes and ovaries. In two instances only have I been able to study this variety on the cadaver.

In the first one examined the carcinomatous growth was found upon the peritoneum in the form of globular polypi attached to it by a very delicate pedicle. The stroma of these polypi was a striated, wavy connective tissue arranged in alveoli. The walls of the alveoli were of varying dimensions, and inclosed an almost amorphous transparent substance, in which carcinomatous cells of medium size and having a large nucleus were distributed either irregularly or in the form of gland-like tubes. The cancer cells were located about the middle of the alveoli, the walls of the latter being entirely without epithelial covering. At intervals larger cavities had been formed by the disappearance of the alveolar walls, and in these spaces the remnants of the walls could be seen. In the groups of cells were larger, shining bodies, degenerated cancer cells, and dotted lines, the result of the destructive process. The thin pedicle was formed of striated connective tissue, and was abundantly infiltrated with very small, transparent cells, together with isolated nests of perfectly developed cancer cells. The interspaces in the peritoneal connective tissue were also filled with masses of cancer cells.

In contradistinction to colloid cancer of the uterine peritoneum, which when recent has very much the same appearance as a vesicular mole, there is still another form in which the carcinomatous tissues appear as broad-based, flat tumors upon the peritoneum, each of them being filled with carcinoma cells. Small, irregular strands of connective tissue ascend from the peritoneum into the tumor forming in it an irregular mesh; these meshes are partly formed of clear, structureless connective tissue without cellular elements, and partly completely filled with cancer cells. In many places the appearance is precisely similar to that of globular crypts which are seen upon section of a large cervical gland; in

* Klob, p. 372.

others, they are more tubular or flask-shaped. This is the alveolar cancer of the uterus. In the patient in whom we found this affection which evidently originated in Douglas's cul-de-sac, the bladder was involved, and carcinomatous nodules were present at the orifice of each ureter.*

In addition to the neoplasms which have been mentioned, other and similar primary growths are met with on the peritoneum, and especially in Douglas's cul-de-sac; these have been described by R. Schulz as proliferations of the endothelium of the peritoneal lymph vessels, and also by Waldeyer, as plexiform angiosarcomata. They are usually associated with tumors of other organs, especially of the ovaries.

Etiology. That which has previously been said as to the ætiology of uterine cancer will apply to primary and secondary carcinoma of the body. They show, however, from this standpoint, some peculiarities: First, they are most common in very old persons, and, second, they are more frequent than cervical carcinoma in virgins and nulliparæ, and, finally, they are extremely rare, which is rather remarkable when we consider the great numbers of uterine glands, and their frequent changes from recurring pregnancies. There are but three or four cases of carcinomata of the body of the uterus reported to date, to one hundred of the cervix. Further statistics are of slight significance, for although the number of authentic cases has been increased by Freund's operation, still Gusserow was unable, only five years ago, to collect more than eighty, and this number is too small to warrant many definite conclusions in regard to the etiology of the disease.

Symptoms. The chief symptoms are hemorrhage, pain, offensive discharge and emaciation, as in carcinoma of the cervix, though they manifest themselves in a characteristic manner. In the first place, while the discharge of blood is very frequent, it is inconsiderable, and is only a mucus tinged with blood; profuse hemorrhages are rare, a fact which has an obvious explanation in the vascular arrangement of the inner layer of the uterus which has been described. The pains, too, are not very severe,

* Plate xxiii. c, and plate xix, fig. 4.