ity that may cause the postponement of a thorough physical examination.

The usual symptoms of cancer of the cervix are hemorrhage, pain, and discharge.

Hemorrhage.-The first symptom that should direct our attention to this disease is bleeding from the vagina. Such hemorrhage often first appears as a menorrhagia— as an increase in the amount of blood lost at the normal menstrual periods. The loss of blood may be greater, and the duration of the period longer. Sometimes, if the woman keeps quiet during the period, the loss of blood and the duration are about as usual; but if she is upon her feet the loss is increased, and if she begins an active life immediately after the usual duration of the menstrual period has elapsed, bleeding may reappear for one or more days.

In other cases slight bleeding appears in the menstrual interval. A spot of blood may be discovered upon the clothing. The accustomed leucorrheal discharge may occasionally be streaked with blood. Such appearances are most frequent after long walking or standing or physical work, or after straining at stool, or very often after coitus.

If the woman has passed the menopause, the hemorrhage of cancer may appear as a re-establishment of menstruation-often to the satisfaction of the woman. This post-climacteric bleeding may occur with more or less regularity-every month or every three or four monthsor it may appear as an occasional loss of blood after unwonted effort.

All hemorrhage of this kind, in women over thirty years of age, demands immediate and careful physical examination. Any bleeding from the vagina in a woman who has passed the menopause should arouse the gravest suspicion. From the slight hemorrhages just described the bleeding increases in intensity and duration, until there is a continuous loss of blood that saps the strength of the woman and produces the profound anemia cha

racteristic of the last stages of cancer of the cervix, Sudden fatal hemorrhage in this disease is rare.

Pain is not a constant accompaniment of cancer of the cervix in the early stages, nor is it in any way characteristic. The intensity and character of the pain may depend upon the direction of the growth of the disease. In some cases pain is absent throughout. The pain may be dull and gnawing in character, or it may be sharp and lancinating. The pain may resemble that of uterine colic. It may be referred to the back in the region of the sacrum, or to one or both ovarian regions, or to some part of the pelvis remote from the uterus, as the crest or It may extend the anterior superior spine of the ilium. down the posterior or anterior aspects of the thighs or In most cases of cancer of the cervix into the rectum. pain is not a prominent symptom until the later stages. Discharge from the vagina may be present in cancer of the cervix before there are any symptoms of hemorrhage or pain. The discharge depends upon the position and character of the growth and the stage of the disease. It may first appear as an ordinary cervical leucorrhea in a woman previously free from such discharge; or the discharge of cancer may first appear as an increase of an In such cases it is due to hyperaccustomed leucorrhea.

secretion from the irritated cervical glands.

Later in the disease, when ulceration takes place or when the friable vascular vegetations appear, the leucorrhea becomes puriform in character and streaked with blood. It then becomes thinner, less mucous in consistency, and of a constant brownish color from the admixture of blood. The pus and débris from the breakingdown cancerous mass increase, and a horrible odor characteristic of the later stages of cancer of the cervix. appears. This odor is not peculiar to cancer. caused by the sloughing tissue, and is observed when such a process occurs in other conditions, as in sloughing fibroid polyp. The discharge is irritating in character, and the ostium vaginæ, the vulva, and the inner aspects

It is

of the thighs become excoriated in those who do not observe strict cleanliness.

Systemic absorption of the cancerous discharges produces a general septic condition, which, with the anemia from hemorrhage and the uremia from obstruction of the ureters, results in the so-called cancerous cachexia.

The symptoms that have just been described are those most usual in cases of cancer. It must always be remembered, however, that these symptoms vary very much in intensity or prominence and in the stage of the disease at which they appear. Sometimes acute pain, hemorrhage, and excessive discharge are present from the very beginning even before the presence of cancer can be demonstrated without the aid of the microscope. In other cases all these symptoms may be absent until the disease is very far advanced. None of the symptoms are absolutely pathognomonic of cancer. During the menstrual life of the woman hemorrhage from the womb. occurs as a symptom of a great variety of diseases; and even in the post-climacteric period, though hemorrhage should always excite alarm, yet it may be caused by a benign form of endometritis or intra-uterine growth. The pain of cancer may also characterize a variety of benign conditions; and the vaginal discharge, even when most offensive, may be simulated by that from a sloughing intra-uterine fibroid.

The symptoms, however slight, which we know may occur with cancer of the cervix should never be disregarded. Examination should be made immediately. There should be no postponement or expectant plan of treatment. If physical examination is not satisfactory in elucidating the condition, resort should be had to the microscope. If this is not conclusive, the case should be watched as long as the suspicious symptoms continue, and further frequent examinations should be made.

If this plan of treatment is followed, and if women are taught to view with distrust, and not with complacency, any irregularities of menstruation occurring near the time.

of the menopause, or any post-climacteric return of menstruation or of irregular bleeding, the surgeon will be able to save many women with cancer of the womb who are now doomed to horrible deaths.

Cancer of the cervix, like cancer in other parts of the body, is of variable duration. Usually from one to three years elapse between the time when the first symptoms of the disease appear and the time of death. The disease may run its course, in exceptional cases, in a few weeks; in other cases it may last as long as five years, especially if the progress is delayed by palliative treat

ment.

Treatment.-Complete removal of the uterus is the only curative treatment for cancer of the cervix. If the disease is seen in the earliest stages, amputation of the cervix beyond the limits of the growth seems, theoretically at least, to be a proper plan of treatment. Practically, however, the operator can never be certain that the excision is made in healthy tissue. The senses of touch and unaided sight are not capable of defining the limits of malignant infiltration. Moreover, it must be remembered that the endometrium is very often involved secondarily from a cancerous focus in the cervix. Complete removal of the uterus should therefore always be practised in all cases in which there is a possibility of removing all of the disease.

The manner of performing this operation will be described subsequently.

The cases that are not suitable for the operation of hysterectomy are those in which the disease has extended to structures that are surgically inaccessible. Such cases include those in which the bladder or the rectum are involved, those in which the vagina is extensively implicated, and those in which the disease has extended into the broad ligaments or the cellular tissue of the pelvis.

When the bladder is involved, there are dysuria, vesical pain, and tenderness on vaginal pressure upon the base of the bladder, while the urine is altered in character,

containing blood, pus, and, in the later stages, brokendown necrotic tissue. Involvement of the rectum is manifest by digital examination.

When the broad ligaments are involved the uterus is held rigidly in the pelvis or is drawn to one side, and the bases of the broad ligaments, palpated through the lateral vaginal fornices, are thick and hard. When the cellular tissue of the pelvis is generally involved the whole vaginal vault feels indurated and the uterus seems fixed in the unyielding matrix.

In examining with the view of determining the practicability of hysterectomy, it is important to distinguish between cancerous and simple inflammatory involvement of the broad ligaments. The uterus may be fixed in the pelvis by inflammatory adhesions resulting from old tubal disease, and yet the cancer of the cervix may be strictly local and in a stage suitable for hysterectomy. In the simple inflammatory cases the adhesions are more attenuated, are higher in the pelvis, and lie chiefly posterior to the uterus. They are not directly continuous with the cervix. Frequently the enlarged tube and the adherent ovary may be felt. When the uterus is fixed by cancerous involvement of the broad ligament, we readily feel that it is the base of the broad ligament that is involved. The induration is broad, it is directly continuous with the induration of the cervix, and it lies to the side of the uterus.

Involvement of the pelvic lymphatic glands may sometimes be determined by vaginal palpation, one or more such enlarged indurated glands being felt lying posterior to the uterus. In most cases, however, glandular involvement can be determined only after the abdomen has been opened.

In general, it may be said that the operation of hysterectomy should be performed in all cases in which there is no cancerous involvement of the bladder and rectum, in which the vaginal disease may all be removed, and in which the uterus is freely movable.