THE TREATMENT OF ULCERATIVE COLITIS

their nuclei-yet subsequent events prove the condition to be innocent. I have records of eighteen instances where highly comp.,tent pathologists have expressed difference of opinion regarding the malignancy or otherwise of debris removed from the uterine cavity following abortion, expulsion of a vesicular mole, or normal full-time pregnancy. It is clear that the chorionic epithelium has the power of invasion of the uterine wall even in normal pregnancy. In normal pregnancy this power of invasion is controlled, whereas in chorion epithelioma the invasion is uncontrolled. Recorded cases of chorion carcinoma show that this neoplasm is one of the most malignant epithelial tumours we have to deal with; in fact, the occurrences of metastases in the lungs, liver, or vagina seem to have been the first indication of trouble in most of the cases on record. Early diagnosis, therefore, is of the utmost importance, but, as I have said, the histological picture of curettings in suspicious cases is unreliable. Fortunately the discovery that the Zondek-Aschheim test for pregnancy persists in casts of chorion carcinomata adds to our diagnostic armamentarium. In all cases where the histological picture is suggestive of chononi carcinoma, particularly in cases of persistent uterine haemorrhage following the expulsion of a hydatidiform mole, the urine should be examined at fortnightly intervals for the Zondek-Aschheim pregnancy phenomena. Should the test be found positive at the end of four weeks following evacuation of the uterus, and the curettings be found suspicious, then I consider drastic surgery necessary if the woman's life is to be saved. Nothing short of an extensive panhysterectomy, together with removal of both tubes and ovaries, followed by intensive deep x-ray therapy, will prove of any value. Mr. Salisbury's point concerning the necessity of first closing the cervix with a mattress suture so as to eliminate the risk of implanting cancer cells in the pelvic tissues during the removal of the uterus is an essential point in the surgical technique. In the ordinary way, direct implantation of a carcinoma cell from the body of the uteruLs is rare, but the chorion carcinoma cell differs from the usual carcinomata in that it has the capacity of survival and growth in any tissue on which it may be accidentally implanted furthermore, chorion carcinoma does not spread by lymphatic permeation, but by the blood stream. Finally, I would like to say that the opinion passed by some authorities that " chorion carcinoma varies much in malignancy " is based upon the histological picture alone, but if this picture be associated with a persistence of the Zondek-Aschheim test then this variation is not found to exist.-I am, etc., JOHN H. HANNAN, M.D., Pathologist, Hospital for W'omen, London, \V.l, Nov. 19th. Soho Square.