scope gives sufficiently early and positive evidence, so that we can go ahead and save a life.

DR. JOSEPH H. BRANHAM, of Baltimore.-I did not intend to say anything on this subject, but it is so important that it ought to be freely discussed by this Association. I think in the treatment of local cancer we are making advances that are going to be very important. You will doubtless remember that a year or so ago there appeared an excellent article by a German authority (Winter) on this subject, in which he claims that within a short time 75 per cent. of all cases of cancer would be curable. I think he is on the right track. I believe his statement is not an exaggeration. But if we discuss the subject in such an indefinite, haphazard manner as many of the Fellows have this morning, we will recede from that position. In the first place, malignant tumors of the uterus can be diagnosticated with absolute accuracy by the clinical evidence and the microscope. If the microscopist is furnished with tissue at the border-line between adenoma and normal subjacent tissue, he is perfectly competent to tell positively whether it is cancer or not. Of course, there are cases in which adenoma is present, but infiltration has not taken place, and then it is doubtful. Will the adenoma begin to infiltrate and become a distinctly malignant growth, or will it not? You cannot tell that. If the disease recurs repeatedly the uterus should be removed. We have certain indications of the nature of the disease in these cases. If we do not temporize, but make a thorough and careful examination, remove a certain part of the growth, have it examined, and if malignant make a radical operation at once, in a few years we will cure 75 per cent. of all of these cases instead of 12 or 20 per cent., as is the case now. The clinical picture of cancerous growth is typical. There is an infection of some kind or a change in the tissue, beginning locally and invading the tissue of the organ. In a large proportion of cases the uterine tissue becomes infiltrated, the glands become involved, and finally transmission of the infection through the blood takes place. All this shows that the disease begins locally, and then invades the body generally. If we can operate on these cases early, I feel confident we will cure nearly all of them after a while.

Our methods of diagnosis by the microscope are improving rapidly. It is only a few years since men have become skilful with the microscope, and microscopy has now been brought to such a state of perfection that microscopists can make accurate diagnoses if surgeons will furnish them with the right tissue.

Recently I had a case similar to those reported. Scrapings were given to the microscopist, who subsequently reported that the tissue I

gave him was adenoma; but there was no point in that tissue which showed infiltration, and therefore no malignancy. He could not say that it was malignant, but the disease recurred rapidly, and I removed the uterus. At the operation there was only slight infiltration in the lining membrane. It was very distinct, and there is no question but that it was the beginning of malignant adenoma. Other forms of cancer are more easily diagnosticated with the aid of a microscope than ordinary adenoma of the body of the uterus, which becomes malignant in many cases.

DR. JAMES F. W. Ross, of Toronto.-I would like to ask Dr. Branham one question. Did you ever see a true adenoma of the body of the uterus in which you did not consider it advisable to remove the whole organ? From my own experience, the cases of true adenoma of the body of the uterus I have seen have been malignant and have required removal of the entire organ, just as does the breast when the disease involves that part of the body.

DR. BRANHAM.-The disease differs at times. In some cases we may only have an ordinary papilloma of the uterus with a distinct glandular appearance. In cases of true adenoma of the body of the uterus I would certainly remove the entire organ. The border-line cases are very hard to differentiate in many instances.

DR. CHARLES G. CUMSTON, of Boston.-As a pathologist I have had a number of specimens presented to me from time to time from different sources, and I must say that, of all the specimens, scrapings from the uterus in cases of suspected carcinoma have been the most unsatisfactory. Of one hundred specimens given to a pathologist, he could come to a definite conclusion in about sixty; in the other forty it would remain very uncertain.

DR. BRANHAM.-If the pathologist got tissue taken from the point where the tumor impinges on the pelvic tissue, I believe he would be able to make a diagnosis in 60 per cent. of the cases.

DR. ROSENWASSER (closing the discussion).—I am afraid the scope of my paper has been misunderstood. It excluded entirely a discussion of the early diagnosis of cancer. It was limited to cases of apparently advanced cancer, which, on thorough examination, proved to be no cancer at all. Any one would presume from the pathognomonic symptoms in these cases that they were really cancer, and would overlook the necessity of a microscopic, or a further physical, examination. I call attention to these exceptional cases which simulate cancer, and which ought to be excluded before we give an opinion or decide upon the treatment. A decision can be arrived at usually inside of forty-eight hours. The woman whose case is my text came to me

after an Eastern specialist had pronounced her incurable, and had sent her home to die. Dr. Longyear's discussion indicates the object of this paper, namely, to emphasize the importance of the differential diagnosis between cases of apparently advanced cancer and other conditions.

We all agree that the more thorough the diagnostician the better for the patient in the end. He should use all the physical means at his disposal-the finger after dilatation, the scrapings from the diseased mass, and the microscope. He should advocate all these measures in order to make sure whether he is dealing with cancer or not. If the disease is not cancer, mild local treatment will be sufficient to effect a cure. An unnecessary hysterectomy will be avoided and a gloomy prognosis will remain unspoken.

CYSTS OF THE URACHUS.

BY RICHARD DOUGLAS, M.D.,

NASHVILLE.

SIMULTANEOUSLY with the development of the amnion is the appearance of the allantois. This structure takes its origin at the lower wall of the cloaca, is at first solid, later becomes spherical and hollow. As it advances forward toward the periphery of the ovum it becomes wider and longer, reaching that part of the endometrium where it takes part in the formation of the vascular layer of the chorion, conducting the two arteria umbilicales, establishing the fetal and maternal circulation.

That portion of the allantoic vesicle remaining within the body cavity is generally spoken of as the urachus, a portion of which is destined to form the urethra and bladder, which are the " permanent functional parts." The remainder forms generally an impervious cord stretching from the summit of the bladder to the umbilicus; this is the urachus proper. Luschka declares that in the majority of males the urachus is found to be partially open and lined with mucous membrane; and it is remarkable that it is covered with flattened epithelium, when we remember that primitively it coalesced with the intestinal canal, which has cylindrical epithelium. Luschka (quoted by Schullenbach) describes the minute anatomy of the urachus as follows: (a) A structureless basement membrane. This is a very delicate, transparent, structureless membrane not acted on by acetic acid. It can be separated into smaller fragments which have a tendency to arrange themselves into folds. (b) A fibrous layer. This is attached to the outer side of the basement membrane and distinctly separated from the neighboring cellular tissue. It is interspersed with various long nuclei, having a dark contour, irregularly scattered through the fibrillary interstitial substance. (c) Epithelium.

The epithelial layer is found on the inner side of the basement membrane, and consists of a variety of cells such as are found in the bladder, ureter, calices and pelvis of the kidney. They are either ovoid or polygonal nucleated lamellæ, and are of variable form and size.

Many interruptions are liable to befall this organ during its evolution and decline, and to a brief study of its pathology we address ourselves.

VESICO-UMBILICAL FISTULA. The name of Cabrol is inseparable from the history of urinary umbilical fistula. In 1530 he had occasion to study a case of the disease in a young girl, made a complete diagnosis of the affection, established its pathology, and suggested a treatment. Since then researches have multiplied; Petit, Dupuytren, Roux, Velpeau, Nélaton, and others have added to the literature of the subject.

As we have seen, the urachus is found to be more or less pervious should the canal remain patulous throughout its extent from bladder to umbilicus, and if urine escapes from the navel opening we have a true congenital vesico-umbilical fistula. Many instances of this abnormality have been observed in children. Mr. Jordan Lloyd, as quoted by Byron Robinson, has in several cases passed a sound from the umbilicus to the bladder. Urachal fistulæ are really, then, not so very uncommon in infancy and childhood. They frequently close spontaneously. It is remarkable, in a careful study of the history of the pathology of the urachus, how many have had fistula in childhood to reopen again in after-life. Vander Veer's case, recorded in volume lxi. of the Medical and Surgical Reporter, so behaved. It is more unusual to find this condition existing in adult life. A striking case is recorded by Freer, of Washington, in a married lady forty years An injection of starch solution through the umbilicus appeared in the urine, as proved by the iodine test to the evacuated fluid. Heinrich Schullenbach gives the history of a case operated upon by Trendelenburg, as follows: "Male, aged sixty-six years. Tumor as large as the head, directly over the symphysis pubis, extending to the umbilicus, not movable. A sound could be passed through the opening at navel, from which there exuded constantly a turbid fluid, and the urine could be withdrawn through this fistula by means of a catheter. On opening the abdomen the

of age.