quently, septicemia, phlebitis with venous thrombosis, embolism, and cancer in adjacent tissues and distant organs, the liver especially.

Death may result from simple exhaustion (cancerous marasmus), or from hæmorrhage when a large vessel is opened, or from rupture of the uterus (rare), or from any of the above-named complications.

Death is sometimes delayed and torturing, and in the face of its being inevitable it often seems as though it were a mercy to hasten it. Etiology. Until puberty the death-rate from cancer is the same in both sexes; from this period both frequency and death-rate steadily increase in the female up to, and a little after, the menopause, at which period the difference in rate between the sexes is most marked. After the age of fifty there is a tendency for cancer to appear equally often in both sexes.

There is no doubt but that there is such a condition as a predisposition to malignant disease; but to what extent this can be inherited or not, is not yet determined. It is well known, however, that certain peculiarities of organization predispose to malignant disease. Among these is the cardio-vascular hypoplasia (Virchow), where the pulmonary arteries are undersized, and which occurs often with the phlegmatic temperament, characterized by an abundant adipose-tissue and an appearance of health, which is an appearance and nothing else.

Great differences are met with in authorities as to the frequency of cancer; reliable statistics, however, tell us that the uterus was attacked in three thousand cases out of a total of sixty-one thousand seven hundred and fifteen cases of carcinoma (anywhere in the body) in females. The same also afford us proof that the uterus is cancerous three times as often as any other female organ.

Heredity has an undoubted influence; I have gathered the statistics of many thousand cases, and find that an inherited taint can be traced in thirteen per cent of all cases on an average.

Age is the most potent factor in the etiology. Before puberty, indeed before the age of twenty, cancer is unknown or phenomenal. I have seen two cases-both ending fatally-where the patients were in their twenty-seventh and twenty-eighth year, respectively; and the sister of the last named died of cancer of the uterus in her thirty-first year.

The ten years following the menopause (forty to fifty) is the period of carcinoma uteri; the decade following this is the next most eventful period, and third in order stand the ten years preceding the climacteric.

Race seems to have little or no influence. Perhaps it is peculiar to my practice, yet I have seen more cases of carcinoma uteri among Germans than in any other nationality.

There is more than an accidental agreement between cancer and the number of children born; for it will be found that patients with cancer of the uterus will average one third more children than women free from malignant disease of the womb; indeed every case of carcinoma uteri will average five children, a large family at the present time.

Prolonged lactation, anti-hygienic surroundings, poor or improper food, exhausting diseases, grief and anxiety, all are more apt to be accompanied by cancer than an opposite condition of affairs; nevertheless, seventy-five per cent of cases will give a history of good health up to the development of this neoplasm.

It is quite certain that laceration or erosion of the cervix has a causative influence upon cancroid; hence in suspected epithelioma the previous history must always be elicited. I do not mean that laceration will cause it; but with a latent tendency, an erosion or laceration will often determine the precise point of eruption of the disease.

Treatment. This may be divided into constitutional and local; and the local treatment consists in (a), topical applications, and (4), operative procedures.

Constitutional treatment is always in order, and is always beneficial, but operative treatment demands the highest judgment; used in season, surgical means may eradicate a growth that never reappears; used when any tissue or part other than the uterus has become infected, an operation is useless for cure, and may, indeed, hasten the fatal termination.

But, be it understood, there is only one means of actually treating a patient with cancer, and that is to operate surgically, not merely to nurse her.

Hæmorrhage demands prompt treatment on account of the exhaustion it induces. Astringent injections-hot better than coldplugging of the vagina with small pieces of ice, or, rarely, plugs soaked in perchloride of iron, may be used. Tannic acid, rhatany, catechu, perchloride of iron, or ergot by the mouth or ergotine hypodermically I consider as inefficient, and are only mentioned here to be condemned. They are too frequently employed in practice.

Rest, especially during menstruation, freedom from mental shock of any sort, and cessation of intercourse should be enjoined to prevent hæmorrhage.

Pain finally becomes intolerable. What shall be given? The easiest way to quell this symptom is by filling the patient with opium or morphine, the latter given hypodermically.

Hydrate of chloral, while producing a more natural sleep than opium, does not seem to control the pain so well. Cannabis Indica and hyoscyamus are highly thought of by the French; also vaginal pessaries of iodoform (fifteen grains). The hydrochlorate of cocaine is an efficient local and general remedy for pain.

The discharge is offensive, and the patients wish its fetor destroyed before demanding treatment for almost any other symptom.

Condy's fluid, Labarraque's solution, carbolic acid, and its allies (thymol, phenol, etc.), bromine, lead acetate, or iodine-any of these will act antiseptically, and will in part deodorize the discharge. At the same time the amount of the discharge can be diminished by any astringent injection, such as alum, iron, zinc, lead, or copper, but tannic acid seems to have a specially favorable action upon the flux from cauliflower excrescences.

The diet should be as simple as possible, yet composed of food in which there is a minimum of volume and a maximum of nutriment. A milk-diet is known to be so beneficial that the laity regard it as a cancer cure."

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A moderate amount of alcohol should be taken daily with the meals.

Next in importance to diet is the mental condition. The surroundings should be as pleasant as possible. The prognosis and diagnosis need only be known to the immediate friends.

Finally, certain symptoms, such as peritonitis, ulcerations, and erosions of the genitals, may call for treatment, which in no respect differs from that in non-cancerous cases.

In the local treatment of carcinoma of the cervix the application of caustics is one of the first things tried by the inexperienced; and it is the use of caustics for cancer anywhere that has become the pre-eminent means in the hands of the unprincipled.

Pure nitric acid removes by a slough extensive portions of the diseased tissue, and simultaneously stops hæmorrhage. The cervix should be washed and dried immediately before, and washed again immediately after the operation.

Chromic acid, bromine solutions, acetic acid, perchloride of iron, and even gastric juice have been employed as caustics, and of this group I prefer the first named.

Among the many remedies from which special benefits are said to accrue in the treatment of cancer is the milk of aveloz. In the

"New York Medical Record," of July 11, 1887, is a report on this drug, made by Dr. James B. Hunter, from which I make the following abstract:

"The milk of aveloz is the product of a plant growing in Brazil, one of the Euphorbiacea, many varieties of which are well known for their irritant and acrid juices. Dr. Hunter had not been able, from any botanical works at his disposal, to ascertain exactly the position of the plant furnishing the juice known as the milk of aveloz, but it appeared to be closely allied to the Hura crepitans, the milk of which is described by the older botanists as possessing extraordinary properties as an irritant.

Boussingault made an examination of some of the juice, and was attacked, he says, with a severe form of erysipelas. The courier who brought the juice, as well as the inhabitants of the house in which he spent the night on his way, were also attacked with severe inflammation of the skin. Another species of the same family growing in Brazil is the Hippomane mancinella, or manchineel tree, about which there are fabulous accounts, as that it is fatal to life to sleep beneath its shade. It is true, however, that a drop of the juice of that tree applied to the skin will quickly raise a blister full of serum. It is not surprising, therefore, that the milk of one of the Euphorbia family should be possessed of very active properties.

"Several years ago a small quantity of the milk of aveloz was sent from Brazil to the authorities at Washington, and distributed for trial. Then for a time none could be obtained. Later it was to be purchased of a gentlemen in this city-John T. Kirby, 16 Beaver Street. The depot for its sale is in Pernambuco, the juice being collected chiefly in the province of that name. The preparation is said to be patented by the Government of Brazil, and its use is indorsed by the Central Board of Health of Rio de Janeiro.

"Two preparations are furnished, one of which is recommended for open ulcers, and the other for cases of cancer in its early stages. The principal or only appreciable difference appears to be in the degree of inspissation.

"The method of using the drug advised is, that the affected surface be thoroughly cleaned with a carbolic lotion, and dried. The juice is then applied freely with a soft brush, retained in place by lint or cotton, and covered with light rubber or gutta-percha tissue. The purpose of the application is to produce the effect of a caustic. Special care is necessary to prevent contact with sound tissues, as it is extremely irritating. The application is repeated every three or six days, according to the condition. Dr. Hunter's experience

had been confined to cases of epithelioma of the cervix. He first alluded briefly to the experience of others. Its application to disease of the breast is said to be very painful. There is not usually much pain in its use on the cervix uteri."

During the past three years Dr. Hunter has applied the milk of aveloz in many cases of epithelioma of the cervix, and, though its effect had often been negative, in a certain number it had produced results that he had not obtained by any other means. In cases of spongy, easily disintegrated crevices, it had left a better surface than nitric or chromic acids, or than the actual cautery. It had also seemed to him that the recurrence was delayed longer than after the ordinary caustics. He had confined its use to cases where the knife was not applicable, or where operation was not allowed. In some cases he had been surprised at the comparatively healthy condition of the surface remaining after the eschar came away, and surprised also at the long interval that elapsed before there was fresh breaking down.

One of the effects of a free application of the juice to a diseased surface is to promote a copious serous discharge, thus depleting the congested vessels. In some cases a marked difference has been effected in the character of the discharge, which has become and remained for a long time almost inoffensive.

Cases which the doctor related illustrated the treatment and its results, which he described as follows: "All that could be said was, that they were in some respects better, as to the arrest of the disease and as to the comfort of the patients during its progress, than those afforded by many of the usual methods. As far as he could judge at present, he should not use the aveloz with any expectation of effecting a cure; but it seems probable that it may do more than some other remedies toward arresting the progress of the disease, and perhaps prolonging the period during which surgical treatment may be employed with some hope or promise of success.

"He had not lost sight of the fact that some cases of cancer of the uterus undergo changes in their progress that might erroneously be attributed to the remedies used; but, after making due allowance for that source of error, there still remains something to be said in favor of the drug in question.'

I have myself had no experience with aveloz, nor should I mention it here did it not have the indorsement of so good an authority as Dr. Hunter.

Caustics seem to have a temporary good effect, but I think the activity they excite may produce an extension of the neoplasm itself.