sponding to the ileum which had been removed; this was cut out and left a triangular space. The bloodvessels were secured, and the legs of this isosceles triangle, so to speak, were brought into apposition with silk sutures. A gauze drain was inserted and the abdominal incision closed. The patient, on her return to bed, received an enema of normal saline solution containing an ounce of brandy. Some suppuration occurred, but in the end the patient made an excellent recovery. CASE II.-Perforation of the uterus by dilators; prolapse of intestine into the vagina; abdominal hysterectomy; recovery. A married woman, thirty years of age, suffered so severely from painful menstruation that she submitted to dilatation of the cervical canal at the hands of her medical attendant. The metal dilators at first passed with difficulty and, according to the doctor's statements, suddenly the womb became so relaxed that even the biggest dilators passed with the greatest ease; but when the parts were examined by means of a Sims speculum coils of intestines were seen in the vagina. I was asked to see the patient at once. There was very little bleeding, and, on introducing my finger into the dilated cervix, I felt the intestines and a wide rent through the posterior wall of the cervix. The patient was very pale, but did not show very marked signs of shock. She was anesthetized again and the skin of her abdomen thoroughly washed with warm soap and water. On opening the abdomen there was about ten ounces of blood in the pelvis and a wide tear across the posterior wall of the cervix. I then performed subtotal hysterectomy, but left both ovaries and tubes; carefully washed out the pelvis with normal saline solution, and especially the coils of small intestine occupying the pelvis. The wound was closed, with drainage as a precaution. Some suppuration followed, and a sinus persisted for some weeks, but the patient made a satisfactory recovery. 47 BROOK STREET, GROSVENOR SQUARE W. PRIMARY SQUAMOUS-CELLED CARCINOMA OF THE BODY OF THE UTERUS.* WITH THE REPORT OF A CASE. BY C. C. NORRIS, Philadelphia. (With plate.) THAT carcinoma follows the type of epithelium from which it arises is a rule that holds throughout the entire realm of pathology. That is to say, an epithelioma invariably has its origin from squamous epithelium, while an adenocarcinoma just as surely springs from a glandular type of epithelium. It is for this reason that primary squamous-celled carcinoma of the fundus of the uterus is such a rare tumor. The endometrial cavity above the external os is normally lined with high ciliated, cylindrical epithelium, and carcinoma arising from it is almost invariably of the glandular type. The rarity of squamous-celled carcinoma of the fundus is well shown by the fact that Cullen, at the time of the publication of his book on carcinoma of the uterus was able to find but three authentic cases of this condition in literature, and had himself never seen a case. Since that time, however, the tumor has. attracted considerable attention, especially in Germany, and a number of cases have been reported. Care must be taken in examining cases of squamous-celled carcinoma of the fundus to exclude all those cases in which a continuity from a cervical cancer can be demonstrated. Thus Emmanuel has collected nine cases, at least three of which are doubtful. Gebhard in 1892 was the first to report a case of primary squamous-celled carcinoma of the fundus. Since then undoubted cases have been reported by Fraischlen, Kaufmann, Batchelor, Keith and others. A number of theories as to the origin of this tumor have been advanced. *Read before the Philadelphia Obstetrical Society, November 7, 1907. As has been shown by the work of Ruge and Veit the squamous epithelium of the portio vaginalis normally ends at the external os; above this point the canal is lined by high, ciliated columnar epithelium. We know, however, that the meeting point of these different types of epithelium is not an absolutely fixed point, but varies considerably in different cases, and it has been thought that a very high extension upwards of the squamous epithelium may in some cases account for an epithelioma of the fundus, and this indeed seems probable in those cases originating in the lower part of the body of the uterus, but can hardly account for a localized growth occurring at the fundus surrounded by normal endometrium. Another view is that a squamous or keratoid change takes place in the epithelium of the body of the uterus, such metaplasia occurring independently of a new growth. In 1896, Reis reported a case of hornifaction of the entire uterine mucosa and suggested the name of ichthyosis uteri for the condition. The uterus was inverted in his case, and this probably accounted for the change in the endometrium. Mainzer reported a somewhat similar condition occurring in four cases, two of which were suspicious of a malignant change, and in all of which local applications of formalin to the uterine mucosa or atmokausis had been applied. Hitschmann finds a metaplasia of columnar into squamous cells a common occurrence in adenocarcinoma of the endometrium. This, in a careful study of our series of twenty-eight cases of adenocarcinoma of the body of the uterus at the Gynecological Laboratories of the University of Pennsylvania, we have found to be a rare occurrence. A transition of columnar to squamous epithelium in the uterus is reported by Noble. His case occurred in conjunction with a submucous fibromyoma. The irritation produced by the latter tumor may account for the metaplasia. A special feature of interest in this case was that the metaplasia was of a malignant type, and the fibromyoma was actually invaded by the epithelioma. Cases of local substitution of squamous for columnar epithelium are not confined to the uterus, but have been reported in the mouth, the ureter, the kidney, and the rectum, but always as a result of an inflammatory stimulus, although Lockyer, who examined Batchelor's case of epithelioma of the fundus, was inclined to think that such a change might result from old age. Others have suggested that this tumor may be accounted for |