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CLINICAL
GYNECOLOGIC
ONCOLOGY
NINTH EDITION

CLINICAL
GYNECOLOGIC
ONCOLOGY
PHILIP J. DISAIA, MD ROBERT S. MANNEL, MD
The Dorothy Marsh Chair in Reproductive Biology Professor
Professor, Department of Obstetrics and Gynecology Division of Gynecologic Oncology
University of California, Irvine College of Medicine Stephenson Cancer Center
Irvine, California University of Oklahoma Health Sciences Center
UCI Medical Center Oklahoma City, Oklahoma
Orange, California
D. SCOTT MCMEEKIN, MD (†)
WILLIAM T. CREASMAN, MD Presbyterian Foundation Presidential Professor
Distinguished University Professor University of Oklahoma Health Sciences Center
Department of Obstetrics and Gynecology Oklahoma City, Oklahoma
Medical University of South Carolina
Charleston, South Carolina DAVID G. MUTCH, MD
Ira C. and Judith Gall Professor of Obstetrics and
Gynecology
Department of Obstetrics and Gynecology
Vice Chair of Gynecology
Washington University School of Medicine
St. Louis, Missouri

†Deceased.
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

CLINICAL GYNECOLOGIC ONCOLOGY, NINTH EDITION ISBN: 978-0-323-40067-1

Copyright © 2018 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without permis-
sion in writing from the publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
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and contraindications. It is the responsibility of practitioners, relying on their own experience and
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To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
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contained in the material herein.

Previous editions copyrighted 2012, 2007, 2002, 1997, 1993, 1989, 1984, 1981.

Library of Congress Cataloging-in-Publication Data

Names: Di Saia, Philip J., 1937- editor. | Creasman, William T., 1934- editor. | Mannel, Robert S., editor. |
McMeekin, Scott, editor. | Mutch, David G., editor.
Title: Clinical gynecologic oncology / [edited by] Philip J. DiSaia, William T. Creasman, Robert S. Mannel,
Scott McMeekin, David G. Mutch.
Description: 9th edition. | Philadelphia, PA : Elsevier, [2018] | Includes bibliographical references and index.
Identifiers: LCCN 2016049213 | ISBN 9780323400671 (pbk. : alk. paper) | ISBN 9780323443166 (eBook)
Subjects: | MESH: Genital Neoplasms, Female
Classification: LCC RC280.G5 | NLM WP 145 | DDC 616.99/465–dc23 LC record available at https://lccn.loc
.gov/2016049213

Exectutive Content Strategist: Kate Dimock

Director, Content Development: Rebecca Gruliow
Publishing Services Manager: Deepthi Unni
Senior Project Manager: Beula Christopher
Designer: Julia Dummitt
Marketing Manager: Michele Milano

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 We dedicate this book in memory of our friend, colleague,
and co-editor, Dr. Scott McMeekin, who recently lost his own battle with
cancer at 51 years of age. Readers of this book are undoubtedly familiar with
his name because he authored more than 100 publications in the field of gynecologic
oncology, and his expertise in uterine cancer placed him at the forefront of defining
the standard of care for the management of this disease. His dedication to helping
women with gynecologic cancers was only surpassed by his dedication to his wife
Cathy; their children Charlotte, Jackson, and Remy; and his loving parents,
Donald and Charlene. Although we will benefit from his scientific
contributions for years to come, we will all miss his presence.
Contributors

Sheri A. Babb, MS, CGC David E. Cohn, MD Eric L. Eisenhauer, MD

Genetic Counselor, Department of Obstetrics Professor, Division of Gynecologic Oncology, Associate Professor, Department of
and Gynecology, Division of Gynecologic James Cancer Hospital, Ohio State Obstetrics and Gynecology, Director,
Oncology, Washington University School University Comprehensive Cancer Center, Division of Gynecologic Oncology,
of Medicine, St. Louis, Missouri Columbus, Ohio University of Cincinnati College of
Role of Minimally Invasive Surgery in Medicine, Cincinnati, Ohio
Floor J. Backes, MD Gynecologic Malignancies Epithelial Ovarian Cancer
Assistant Professor, Division of Gynecologic
Oncology, James Cancer Hospital, Ohio Robert L. Coleman, MD Jeffrey M. Fowler, MD
State University Comprehensive Cancer Professor, Department of Gynecologic Professor, Division of Gynecologic Oncology,
Center, Columbus, Ohio Oncology and Reproductive Medicine, James Cancer Hospital, Ohio State
Role of Minimally Invasive Surgery in University of Texas, MD Anderson Cancer University Comprehensive Cancer Center,
Gynecologic Malignancies Center, Houston, Texas Columbus, Ohio
Invasive Cancer of the Vagina; Targeted Role of Minimally Invasive Surgery in
Emma L. Barber, MD Therapy and Molecular Genetics Gynecologic Malignancies
Clinical Fellow, Department of Obstetrics
and Gynecology, Division of Gynecologic Larry J. Copeland, MD Mary L. Gemignani, MD
Oncology, University of North Carolina, Professor and William Greenville Pace III and Associate Attending Surgeon, Department of
Chapel Hill, North Carolina Joann Norris Collins-Pace Chair, Surgery/Breast Service, Memorial
Gestational Trophoblastic Disease Department of Obstetrics and Sloan-Kettering Cancer Center, New York,
Gynecology, James Cancer Hospital, The New York
Wendy R. Brewster, MD, PhD Ohio State University, Columbus, Ohio Breast Diseases
Director Center for Women’s Health Epithelial Ovarian Cancer
Research, Professor, Department of Camille C. Gunderson, MD
Obstetrics and Gynecology, Division of Patricia A. Cronin, MD Assistant Professor, Gynecologic Oncology,
Gynecologic Oncology University of Breast Service, Department of Surgery, Stephenson Cancer Center, University of
North Carolina, Chapel Hill, North Memorial Sloan Kettering Cancer Center, Oklahoma, Oklahoma City, Oklahoma
Carolina New York, New York The Adnexal Mass
Epidemiology and Commonly Used Statistical Breast Diseases
Terms and Analysis of Clinical Studies Chad A. Hamilton, MD
William T. Creasman, MD Director, Division of Gynecologic Oncology,
Dana M. Chase, MD Distinguished University Professor, Walter Reed National Military Medical
Assistant Professor, Creighton University Department of Obstetrics and Center, Bethesda, Maryland
School of Medicine, University of Arizona Gynecology, Medical University of South Germ Cell, Stromal, and Other Ovarian
College of Medicine at St. Joseph’s Carolina, Charleston, South Carolina Tumors, Fallopian Tube Cancer
Hospital and Medical Center, Phoenix, Adenocarcinoma of the Uterine Corpus;
Arizona Sarcoma of the Uterus Thomas J. Herzog, MD
Palliative Care and Quality of Life Deputy Director, University of Cincinnati
Philip J. Di Saia, MD Cancer Institute, Vice Chair of Quality
Christina S. Chu, MD The Dorothy J. Marsh Chair in Reproductive and Safety; Paul and Carolyn Flory
Associate Professor, Division of Gynecologic Biology; Director, Division of Gynecologic Professor, Department of Ob Gyn,
Oncology, Department of Surgical Oncology; Professor, Department of University of Cincinnati, Cincinnati, Ohio
Oncology, Fox Chase Cancer Center, Obstetrics and Gynecology, University of Invasive Cancer of the Vulva
Philadelphia, Pennsylvania California–Irvine College of Medicine,
Basic Principles of Chemotherapy Orange, California Erica R. Hope, MD
The Adnexal Mass; Genes and Cancer: Genetic Walter Reed National Military Medical
Daniel L. Clarke-Pearson, MD Counseling and Clinical Management Center, Division of Gynecologic
Robert A. Ross Professor of Obstetrics and Oncology, Bethesda, Maryland
Gynecology, University of North Carolina, Kemi M. Doll, MD, MSCR Fallopian Tube Cancer
Chapel Hill, North Carolina Assistant Professor, Department of Obstetrics
Complications of Disease and Therapy and Gynecology, University of Marilyn Huang, MD
Washington, Seattle, Washington Assistant Professor, Division of Gynecologic
Complications of Disease and Therapy Oncology, Sylvester Comprehensive
Cancer Center/University of Miami/Miller
School of Medicine, Miami, Florida
Invasive Cancer of the Vagina

vi
 CONTRIBUTORS vii

Lisa M. Landrum, MD, PhD David Scott Miller, MD, FACOG, FACS Brian M. Slomovitz, MD, MS, FACOG
Assistant Professor of Obstetrics and Amy and Vernon E. Faulconer Distinguished Sylvester Professor of Obstetrics and
Gynecology, University of Oklahoma Chair in Medical Science, Director and Gynecology and Human Genetics, Chief,
Health Sciences Center, Oklahoma City, Dallas Foundation Chair in Gynecologic Division of Gynecologic Oncology,
Oklahoma Oncology, Professor of Obstetrics and Sylvester Comprehensive Cancer Center,
Endometrial Hyperplasia, Estrogen Therapy, Gynecology, University of Texas Miller school of Medicine of the
and the Prevention of Endometrial Cancer Southwestern Medical Center, Dallas, University of Miami, Miami, Florida
Texas Invasive Cancer of the Vagina
Robert S. Mannel, MD Adenocarcinoma of the Uterine Corpus
Professor, Division of Gynecologic Anil K. Sood, MD
Oncology, Stephenson Cancer Center, Bradley J. Monk, MD Professor and Director, Ovarian Cancer
University of Oklahoma Health Sciences Professor, Creighton University School of Research, Department of Gynecologic
Center, Oklahoma City, Oklahoma Medicine, University of Arizona College Oncology and Reproductive Medicine,
The Adnexal Mass; Role of Minimally of Medicine at St. Joseph’s Hospital and The University of Texas, MD Anderson
Invasive Surgery in Gynecologic Medical Center, Phoenix, Arizona Cancer Center, Houston, Texas
Malignancies Invasive Cervical Cancer; Palliative Care and Targeted Therapy and Molecular Genetics
Quality of Life, Palliative Care and
Charlotte S. Marcus, MD Quality of Life John T. Soper, MD
Attending Physician, Division of Professor, Department of Obstetrics and
Gynecologic Oncology, Walter Reed David G. Mutch, MD Gynecology, Division of Gynecologic
National Military Medical Center, Judith and Ira Gall Professor of Gynecologic Oncology, University of North Carolina
Bethesda, Maryland Oncology; Vice Chair of Gynecology, School of Medicine, Chapel Hill, North
Germ Cell, Stromal, and Other Ovarian Washington University School of Carolina
Tumors Medicine, St. Louis, Missouri Gestational Trophoblastic Disease
Genes and Cancer: Genetic Counseling and
L. Stewart Massad, MD Clinical Management; Appendix A Krishnansu S. Tewari, MD
Division of Gynecologic Oncology, Staging; Appendix B Modified from Associate Professor, University of
Department of Obstetrics and Common Terminology Criteria for Adverse California–Irvine College of Medicine,
Gynecology, Washington University Events (Common Terminology Criteria for Division of Gynecologic Oncology,
School of Medicine, St. Louis, Missouri Adverse Events); Appendix C Blood Orange, California
Preinvasive Disease of the Cervix Component Therapy; Appendix D Cancer in Pregnancy; Invasive Cervical
Suggested Recommendations for Routine Cancer
Cara A. Mathews, MD Cancer Screening; Appendix E Nutritional
Assistant Professor, Gynecologic Oncology, Therapy Joan L. Walker, MD
Department of Obstetrics and Professor of Gynecologic Oncology,
Gynecology, Women and Infants’ Emily R. Penick, MD Department of Obstetrics and
Hospital, Warren Alpert Medical School Fellow, Division of Gynecologic Oncology, Gynecology, University of Oklahoma
of Brown University, Providence, Rhode Walter Reed National Military Medical Health Sciences Center, Oklahoma City,
Island Center, Bethesda, Maryland Oklahoma
Preinvasive Disease of the Vagina and Vulva Germ Cell, Stromal, and Other Ovarian Endometrial Hyperplasia, Estrogen Therapy,
and Related Disorders Tumors and the Prevention of Endometrial
Cancer; Preinvasive Disease of the Vagina
G. Larry Maxwell, MD Stephen C. Rubin, MD and Vulva and Related Disorders
Chairman, Department of Obstetrics and Professor and Chief, Division of
Gynecology, Inova Fairfax Hospital; Gynecologic Oncology, Department of Lari B. Wenzel, PhD
Assistant Director, Inova Schar Cancer Surgical Oncology, Fox Chase Cancer Professor, Department of Medicine and
Institute; Co-P.I., DOD Gynecologic Center, Philadelphia, Pennsylvania Public Health, Associate Director,
Cancer Translational Research Center of Basic Principles of Chemotherapy Population Science and Cancer Control,
Excellence; Professor, Virginia University of California, Irvine,
Commonwealth University School of Ritu Salani, MD California
Medicine, Falls Church, Virginia Associate Professor, Department of Palliative Care and Quality of Life
Fallopian Tube Cancer Obstetrics and Gynecology, James
Cancer Hospital, The Ohio State Shannon N. Westin, MD, MPH
D. Scott McMeekin, MD(†) University, Columbus, Ohio Associate Professor, Department of
Presbyterian Foundation Presidential Epithelial Ovarian Cancer Gynecologic Oncology and Reproductive
Professor, University of Oklahoma Medicine, University of Texas MD
Health Sciences Center, Oklahoma City, Anderson Cancer Center, Houston, Texas
Oklahoma Targeted Therapy and Molecular Genetics
The Adnexal Mass; Sarcoma of the Uterus

†Deceased.
viii CONTRIBUTORS

Siu-Fun Wong, PharmD, FASHP, FCSHP Catheryn M. Yashar, MD, FACR, FACRO Rosemary E. Zuna, MD
Associate Dean of Assessment and University of California, San Diego, Moores Associate Professor of Pathology, Pathology
Scholarship, Professor, Chapman Cancer Center, Radiation Oncology, La Department, University of Oklahoma
University School of Pharmacy, Irvine, Jolla, California Health Sciences Center, Oklahoma City,
California; Volunteer Clinical Professor Basic Principles in Gynecologic Radiotherapy Oklahoma
of Medicine, University of California- Endometrial Hyperplasia, Estrogen Therapy,
Irvine, Irvine, California and the Prevention of Endometrial Cancer
Palliative Care and Quality of Life
 P r e fa c e

The first eight editions of Clinical Gynecologic Oncology were development of diagnostic techniques that can identify precan-
stimulated by a recognized need for a readable text on gyneco- cerous conditions, the ability to apply highly effective therapeu-
logic cancer and related subjects addressed primarily to the tic modalities that are more restrictive elsewhere in the body, a
community physician, resident, and other students involved better understanding of the disease spread patterns, and the
with these patients. The practical aspects of the clinical presen- development of more sophisticated and effective treatment in
tation and management of these problems were heavily empha- cancers that previously had very poor prognoses. As a result,
sized in these editions, and we have continued that style in this today a patient with a gynecologic cancer may look toward
text. As in every other textbook, the authors interjected their more successful treatment and longer survival than at any other
own biases on many topics, especially in areas where more than time. This optimism should be realistically transferred to the
one approach to management has been used. On the other patient and her family. Patient denial must be tolerated until
hand, most major topics are treated in depth and supplemented the patient decides that a frank conversation is desired. When
with ample references to current literature so that the text can the prognosis is discussed, some element of hope should always
provide a comprehensive resource for study by the resident, be introduced within the limits of reality and possibility.
fellow, or student of gynecologic oncology and serve as a source The physician must be prepared to treat the malignancy in
for review material. light of today’s knowledge and to deal with the patient and her
We continued the practice of placing an outline on the first family in a compassionate and honest manner. Patients with
page of each chapter as a guide to the content for that section. gynecologic cancer need to feel that their physicians are confi-
We added “bullet” points to the chapters of this edition to dent and goal oriented. Although, unfortunately, gynecologic
emphasize important areas. Readers will notice that we have cancers will cause the demise of some individuals, it is hoped
included topics not discussed in the former editions and that the information collected in this book will help to increase
expanded areas previously introduced. Some of these areas the survival rate of these patients by bringing current practical
include new guidelines for managing dying patients; current knowledge to the attention of the primary care and specialized
management and reporting guidelines for cervical and vulvar physician.
cancer; current management and reporting guidelines for breast
Our ideas are only intellectual instruments which we use to
cancer; expanded discussion on the basic principles of genetic
break into phenomena; we must change them when they
alterations in cancer; techniques for laparoscopic surgery in
have served their purpose, as we change a blunt lancet that
treatment of gynecologic cancers; and new information on
we have used long enough.
breast, cervical, and colon cancer screenings and detection. The
—Claude Bernard (1813-1878)
seventh edition contained, for the first time, color photographs
of key gross and microscopic specimens for readers’ review; we
Some patients, though conscious that their condition is
have continued that in this edition. In addition, Drs. Di Saia
perilous, recover their health simply through their content-
and Creasman have handed the reigns over to the three associate
ment with the goodness of their physician.
editors. We have included several new authors. Much more
—Hippocrates (440-370 bc)
information is included to make the text as practical as possible
for the practicing gynecologist. In addition, key points are Philip J. Di Saia, MD
highlighted for easy review. William T. Creasman, MD
Fortunately, many of the gynecologic malignancies have a Robert S. Mannel, MD
high “cure” rate. This relatively impressive success rate with D. Scott McMeekin, MD
gynecologic cancers can be attributed in great part to the David G. Mutch, MD

ix
AC K N OW L E D G M E N T S

We wish to acknowledge the advice given and contributions made by several colleagues, including
Michael A. Bidus, Wendy R. Brewster, Dana Chase, Christina S. Chu, Daniel L. Clarke-Pearson,
Robert L. Coleman, Larry J. Copeland, Eric Eisenhauer, Jeffrey Fowler, Mary L. Gemignani, Emily
M. Ko, Robert S. Mannel, Cara Mathews, D. Scott McMeekin, David Miller, Bradley J. Monk,
David G. Mutch, G. Scott Rose, Stephen C. Rubin, Ritu Salani , Jeanne Schilder, Brian M. Slomo-
vitz, John T. Soper, Frederick B. Stehman, Krishnansu S. Tewari, Joan Walker, Lari B. Wenzel,
Siu-Fun Wong, Catheryn Yashar, and Rosemary E. Zuna. We give special thanks to Lucy DiGi-
useppe and, especially, Lisa Kozik for their diligent administrative support in preparing the
manuscript and to David F. Baker, Carol Beckerman, Richard Crippen, Susan Stokskopf, and
David Wyer for their excellent and creative contributions to many of the illustrations created for
this book.
We are grateful to the sincere and diligent efforts of Kate Dimock, Rebecca Gruliow, Teresa
McBryan, Ashley Miner, and Beula Christopher from Elsevier in bringing this book to fruition.
Through their deliberate illumination and clearing of our path, this material has traversed the
far distance from mere concept to a compelling reference book.
Drs. Mannel, McMeekin, and Mutch would like to acknowledge and thank Drs. DiSaia and
Creasman for their continuous and tireless mentorship throughout our careers. They have served
as role models in our professional and personal lives.

x
 1
Preinvasive Disease of the Cervix
L. Stewart Massad, MD

OUTLINE
Natural History Atypical Squamous Cells, Cannot Exclude HSIL
Epidemiology Low-Grade Squamous Intraepithelial Lesion
Human Papillomavirus Vaccination High-Grade Squamous Intraepithelial Lesion
Screening Atypical Glandular Cells
Core Principles for Managing Abnormal Screening Test Endometrial Cells in Older Women
Results Postcolposcopy Management
Managing Abnormal Cervical Cancer Screening Test Results Managing Women With No Lesion or CIN1 at Colposcopy
Managing Abnormal Results in Young Women Managing Women With CIN2 or CIN3
Unsatisfactory Cytology Treatment of Cervical Disease
Pap-Negative, Human Papillomavirus–Positive Women Managing Abnormal Results During Pregnancy
Atypical Squamous Cells of Undetermined Significance Future Directions
Cytology

KEY POINTS
1. Human papillomavirus (HPV) persistent expression is 4. mRNA expression is as sensitive but more specific than
required for progression to cancer. DNA testing.
2. HPV vaccination has the potential to eradicate cervical 5. Screening guidelines have changed dramatically with the
cancer. use of contesting and increased intervals between
3. Cervical cancer screening now relies heavily on HPV screenings.
testing.

Cervical cancer was once the most common cancer in women. types: HPV-16, -18, -31, -33, -35, -39, -45, -51, -52, -56, -58, and
It is among the most preventable cancers, and it has become -59. As described by Halec and associates, another eight types
rare among women who engage in cervical cancer preven- have been designated as possibly or probably carcinogenic:
tion programs. Nevertheless, with some 100,000 preinvasive HPV–26, -53, -66, -67, -68, -70, -73, and -82. Almost 200 HPV
lesions diagnosed in the United States annually, it remains a types have been identified. A new genotype is based on DNA
substantial threat. After tremendous gains following introduc- sequencing. A new type must share less than 90% DNA homol-
tion of cytology screening half a century ago, cervical cancer ogy in the L1, E6, and E7 compared with known HPV types.
rates continue to fall by about 1% annually. Careful compliance HPV-16 is the most oncogenic, accounting for more than
with evidence-based guidelines remains critical to sustaining 50% of cervical cancers. HPV-18 is found in 10% of cervical
progress. Effective programs reflect organized public health cancers and plays a particularly important role in adenocar-
efforts encompassing patient and clinician education, vaccina- cinogenesis. Types 31, 33, and 45 each account for around 5%
tion against causative types of human papillomavirus (HPV), of cancers. The other types are less oncogenic but have been
cytology and HPV screening, colposcopy triage for abnormal reported in large typing studies of cervical cancers. HPV-18 and
screening test results, and destruction of the at-risk cervical related HPV-45 are linked to cancers found at a younger age.
transformation zone for women with cancer precursors. HPV infection leads to cancer through multiple pathways,
but interaction of the HPV E6 and E7 gene products with p53
and pRb are critical: By inactivating or activating degradation
NATURAL HISTORY of their targets, E6 and E7 eliminate genetic surveillance and
Essentially all cervical cancers arise from persistent genital allow unchecked cell cycling, leading to accumulation of muta-
HPV infections (Fig. 1.1). The International Agency for tions and eventual invasive cancer. HPV-16 E6 and E7 bind their
Research on Cancer has designated as carcinogenic 12 HPV targets with greater affinity than other HPV types; this may

1
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2 CHAPTER 1 Preinvasive Disease of the Cervix

B
FIGURE 1.2 A cervical intraepithelial neoplasia lesion with
FIGURE 1.1 A, Koilocytotic cells with intranuclear virions
multiple mitotic figures.
(×6900). B, Human papillomavirus particles. Note the intranuclear
crystalline array (“honeycomb”) arrangement of virions
(×20,500). See the insert (×80,000). (Courtesy of Alex Ferenczy,
MD, Montreal, Canada.) protects against genital HPV infection, nonpenetrative sexual
behaviors may transmit the virus, and male exposures modulate
female risk. For example, spouses of men who engaged in sex
partly explain its greater oncogenicity. Persistent infections lead with prostitutes were at higher risk for cervical cancer than
to cancer in steps: Initial infection into basal epithelial cells those of men who did not, and cervical cancer risk is higher
leads to establishment of a ring chromosome from which car- among women whose husbands had more sexual partners.
cinogenic proteins are elaborated while virion production Women who report recent sex only with women are also at risk,
occurs in maturing epithelium. Disruption of the ring, often at though their risk may be marginally lower than that of hetero-
the HPV E2 regulatory region, allows integration of E6 and E7 sexual women. Condom use is not fully protective against HPV
sequence into the host genome. The accumulation of mutations infection because condoms fail to cover wide areas of genital
leads to nuclear changes visible cytologically as a high-grade skin, though it speeds clearance of HPV infections. Male cir-
squamous intraepithelial lesion (HSIL) and histologically as cumcision also reduces but does not eliminate HPV and cancer
high-grade cervical intraepithelial neoplasia (CIN) (Fig. 1.2) is risks. For these reasons, all women with prior sexual experience,
apparent histologically. Selection for invasiveness and metastasis including those who have not been sexually active for years,
through additional mutation and through gene methylation remain at risk for cervical cancer and merit screening until they
results in evolution to cancer. Multitype infections do not have multiple negative test results.
appear to increase cancer risk, and when multitype infections Despite the high frequency of HPV infection, most women
include HPV-16, most lesions are caused by HPV-16. Extant infected with carcinogenic HPV, including those with HPV-16,
HPV infections do not appear to predispose to or protect from do not develop cervical cancer. Instead, most infections are
infection by unrelated types. cleared immunologically. HPV is an intraepithelial virus, and
Vertical transmission of HPV from mother to infant has clearance appears to require recognition of infection by cell-
been documented in the Finnish HPV Family Study but does mediated immune cells. Roughly half of new infections are
not appear to result in cervical infection, with genital HPV in cleared within 6 months, with half of the remainder cleared by
only 1.5% of infants after 2 years; fathers’ HPV infections did the end of the first year after infection. Clearance is associated
not increase infant HPV risk. Although lifetime abstinence with greater density of CD8+ cells and lower density of
 CHAPTER 1 Preinvasive Disease of the Cervix 3

T-regulatory cells in underlying stroma. Cervical treatment such low levels of viral expression that they become nondetect-
speeds clearance and reduces risk for posttreatment acquisition able even with sensitive assays, reactivation appears to occur.
of new HPV infections. The type distribution of HPV infection This is apparent in cohort studies as the reappearance of previ-
after hysterectomy shows that HPV-16 and HPV-18 have a ously cleared infections in women who deny sexual activity,
greater predilection for cervical rather than vaginal epithelium, often because of illness. Risks in other immunosuppressed
with HPV types of lesser oncogenicity dominating in the states appear to be similar.
posthysterectomy vagina. HPV infection predicts risk for subsequent high-grade
HPV persistence is required for progression of infection to CIN, even among cytologically normal women. In most cases,
cancer, and women who clear their infections are at low risk. persistent HPV infections result first in cytologically detect-
New infections in older women typically do not progress to able abnormalities and then in colposcopically visible lesions
preinvasive disease or cancer, and women who clear carcino- that grow laterally before developing into invasive cancers.
genic HPV infections have low risk for reappearance with The 10-year risk of high-grade CIN after a single detected
subsequent high-grade CIN. These findings have important HPV infection exceeds 10%.
implications for termination of screening. Nevertheless, aging As developed by Richart through observational studies of the
appears to result in immune senescence, with many HPV infec- cervix using cytology and colpomicroscopy, a diagnosis of CIN
tions in older women attributable to reactivation of previously was based on progressively severe nuclear aneuploidy, abnormal
acquired by latent infections. Oral contraceptive use reduces mitotic figures, and loss of epithelial maturation. Initially
clearance. considered a progressive lesion, CIN was thought to begin as a
Although determinants of HPV persistence and progression small lesion with atypia near the basement membrane of the
of HPV infection to invasive cancer are poorly understood, cervical transformation zone, gradually increasing in size and
several risk factors are known. HPV infection of a cervix under- becoming less differentiated with an increasing proportion of
going active metaplasia increases risk, as reflected by the epide- the epithelium taken up by atypical cells until a full-thickness
miologic observations that early onset of first intercourse is carcinoma in situ developed and then became invasive. Given
associated with cancer. Smoking is linked to both CIN and this concept of progression from low-grade to high-grade
cervical cancer. Benzopyrenes have been identified in cervical disease to cancer, lesions of all grades were treated. When pro-
mucus, and the interaction of tobacco carcinogens with carci- gression does occur, however, it appears to require years. The
nogenic HPV increases risk substantially. Smoking also reduces median age of sexual debut in the United States is around 17
immune-mediated HPV clearance. Cervical adenocarcinoma years of age, and HPV acquisition commonly follows, but the
and adenocarcinoma in situ (AIS) have been linked to oral peak age of cervical cancer diagnosis lags by some 3 decades.
contraceptive use. Deficiencies in nutrients such as folate have This long transition time allows for even moderately sensitive
been linked to cervical oncogenesis but are uncommon among screening tests to identify persistent lesions for treatment before
US women. Variants of common HPV types that segregate by invasive cancer develops (Table 1.1).
ethnicity and polymorphisms in genes related to HPV immune Gradually, the regressive nature of most low- and midgrade
recognition or HPV protein products also modulate HPV lesions became apparent. Low-grade lesions, including warts
persistence and carcinogenic progression. Perhaps most impor- and CIN1, are histologic expressions of HPV infection. Green-
tant, lack of screening is a high risk factor for progression of berg and associates found that of 163 women with CIN1 after
HPV infection to precancer and cancer: Whereas appropriately low-grade cytology followed for a median of 36 months, 49%
screened women with multiple risk factors are at relatively low regressed, 43% persisted, and only 8% progressed to CIN3. In
risk, women with few risk factors who are not screened are at the Atypical Squamous Cells of Undetermined Significance/
higher risk. Low Grade Squamous Intraepithelial Lesion Triage Study
Immune factors play a clear role in the clearance or persis- (ALTS), a large randomized trial of management options for
tence of HPV-related cervical lesions, but the nature of immune women with borderline cytology results conducted under the
defects is poorly understood. Fukuda and associates showed auspices of the US National Cancer Institute (NCI), 2-year risk
that lesions that persist have fewer Langerhans cells and helper for CIN3 were 10% among women with CIN1. As reported by
T cells than lesions that are cleared, and tobacco smoking also Castle and coworkers, after controlling for HPV genotype,
lowers Langerhans and helper T-cell numbers. In contrast, with HPV-16–associated CIN1 progressing to CIN3 in 19% of
Molling and associates showed that, although natural killer cells cases, biopsy-proven CIN1 was not a risk factor for progres-
are decreased, regulatory T-cell numbers are increased in sion. These risk estimates may be substantially higher for
women with persistent HPV-16. Immunosuppression related to women with prior high-grade cytology.
coinfection with the human immunodeficiency virus (HIV-1)
illustrates the importance of immunity in the typical control of TABLE 1.1 Transition Time of Cervical
HPV. Women with HIV have much higher rates of HPV infec- Intraepithelial Neoplasia
tion, including multitype infections. HPV clearance rates are
Stages Mean Years
lower, although most women do clear their HPV infections if
Normal to mild to moderate dysplasia 1.62
observed long enough, especially if immune reserve as measured
Normal to moderate to severe dysplasia 2.2
by CD4 lymphocyte count remains above 200/cmm. Although
Normal to carcinoma in situ 4.51
most HPV infections in HIV-seropositive women are cleared to
4 CHAPTER 1 Preinvasive Disease of the Cervix

Higher grades of dysplasia appear to represent clonal lesions about 6.2 million people will acquire a new infection annually.
arising from single-type HPV infections. Although women may Prevalence rates are highest among women in their late teens
harbor multiple HPV types in the genital tract, most multitype and early 20s, declining with age. Risk factors for HPV acquisi-
infections are associated with multifocal lesions. Moscicki and tion include smoking, oral contraceptive use, and new male
her team showed that 63% of adolescents and young women partners.
with CIN2 resolved lesions without treatment within 2 years; Among high-risk HPV types, HPV-53 is most common,
subsequent clearance was minimal, rising only to 68% after an detected in 5.8% of US women ages 14 to 59 years screened
additional year. McAllum and colleagues showed a similar 62% in the National Health and Nutrition Examination Survey
regression after only 8 months of observation for women with (NHANES) in 2003 to 2006. This was followed by HPV-16
CIN2 younger than 25 years of age. No patients in either study (4.7%), HPV-51 (4.1%), HPV-52 (3.6%), and HPV-66 (3.4%).
progressed to cancer during observation. In both studies, iden- HP-V18 was present in only 1.8% of screened women. In
tified CIN2 likely represented recent HPV infections. Regression NHANES, demographic risk factors for prevalent HPV infec-
rates are lower in older women, at least in part because lesions tion included younger age, peaking at ages 20 to 24 years; non-
detected later may have been persistent for years, and lesions Hispanic black ethnicity; unmarried; never educated beyond
that have evolved mechanisms to evade host immune-mediated high school; and living below the poverty line. Behavioral risk
clearance are likely to continue to persist. Castle and coworkers factors included reporting ever having sex, first intercourse
compared CIN2 rates in the immediate colposcopy and cytol- before age 16 years, greater numbers of lifetime partners, and
ogy surveillance arms of the ALTS. They found that over 2 years, number of partners in the past year. HPV type distributions
some 40% of CIN2 regressed. Trimble and colleagues showed vary across continents.
that HPV-16–associated lesions are less likely to resolve. Their HPV infection determines subsequent risk for precancer.
finding of associations with human leukocyte antigen (HLA) Among women enrolled in a Portland health maintenance
alleles and regression support a role for HLA-restricted HPV- organization who had HPV-16, the 10-year risk for CIN3, AIS,
specific immune responses in determining clearance. or cancer was more than 15% after HPV-16 infection, almost
Untreated, CIN3 poses considerable risk of progression to 15% after HPV-18, less than 3% after other oncogenic HPV
invasive cancer. This was best shown in a study of New Zealand infections, and less than 1% after a negative HPV test result.
women with CIN3 who were diagnosed between 1955 and 1976 In the United States more than 400,000 cases of CIN are
and were observed. Among 143 women reported by McCredie identified annually, at a cost of approximately $570 million. Of
and coworkers, managed only by punch or wedge biopsy, 31 these, Flagg and colleagues estimate about 100,000 are true
progressed to cancer of the cervix or vagina after 30 years. Risk precancers. The annual incidence of high-grade CIN is some 6
rose to 59% in 92 women with persistent disease after 2 years to 10 times higher than cervical cancer incidence. Preinvasive
of observation. These findings show both that treatment of lesions begin to appear some 2 years after infection. Cancer risk
CIN3 is mandatory regardless of age or other factors but also is quite low soon after infection: Despite a high prevalence of
that not all CIN3 lesions will inevitably progress to cancer. HPV detection among sexually active teens, cervical cancer
Treated CIN3 continues to pose a risk of progression to incidence is only about 1 in 1,000,000 before 20 years of age.
cancer. Women in the New Zealand study whose treatment Among women who develop high-grade CIN, only 30% to 50%
appeared adequate by current standards faced only 0.7% cancer will develop cancer over years of observation.
risk after 30 years. Studies from Scandinavian countries with Although demographic and behavioral risk factors cannot
integrated health systems can link databases on procedures and be used to target evaluation or therapy, clear risks for CIN and
subsequent cancers and provide accurate long-term results with cervical cancer have been identified. The international Collabo-
minimal loss to follow-up. Strander and associates showed that ration of Epidemiological Studies of Cervical Cancer reviewed
risk for cervical cancer rose significantly in previously treated evidence for various risk factors for cervical cancer and carci-
women after age 50 years, with standardized incidence ratios noma in situ, although their studies were not linked to HPV
compared with untreated women ranging from 3 to 5. Vaginal data. They found that oral contraceptive use raised the risk for
cancer risks were elevated across all ages, although the absolute cervical disease by 1.9-fold for every 5 years of use. First inter-
risk of vaginal cancer was low. Kalliala and colleagues in Finland course before 15 years of age was associated with twice the risk
confirmed this long-term increased risk and also found an of cervical cancer found in women with first intercourse after
increased risk for nongenital smoking-related cancers. Jakobs­ 23 years of age, and having more than five lifetime sexual
son and coworkers found that in addition to cervical cancer, partners carried more than double the cervical cancer risk of
women treated for CIN faced higher mortality rates from cir- lifetime monogamy. Lesser but still significant increases in risk
culatory system, alcohol-related, and traumatic death, consistent were associated with number of pregnancies and earlier age at
with the demographic and behavioral factors linked to CIN. first term pregnancy. Both squamous cancers and adenocarci-
nomas share epidemiologic risk factors, except that smoking is
linked only to the former.
EPIDEMIOLOGY The role of family history in determining cervical cancer
More than 80% of sexually active individuals acquire genital risk. Dissociating genetic components of familial risk from
HPV infections. Some 20 million Americans and 630 million cultural ones is difficult, as sexual attitudes and behaviors,
persons worldwide are infected with HPV. In the United States, reproductive patterns, and smoking are often linked to family.
 CHAPTER 1 Preinvasive Disease of the Cervix 5

Zelmanowicz and associates assessed the role of family history women. The bivalent HPV vaccine protects against only HPV-16
in cohorts of women prospectively studied in Costa Rica and and -18 and is less commonly used in the United States. It may
the United States. A family history of cervical cancer in a first- have superior antigenicity and may have some cross-protection
degree relative tripled the risk for CIN3 or squamous cervical against HPV types related to HPV-16 and -18. Most recently, a
cancer. The effect persisted after controlling for HPV exposure. nonavalent vaccine has been introduced, which is effective
No effect of family history on adenocarcinoma risk was seen. against the same types as the quadrivalent vaccine and also
Although several genome-wide association studies (GWASs) includes coverage against HPV types 31, 33, 45, 52, and 58;
have identified a range of genetic variants in candidate pathways enhanced coverage should prevent 90% of all cervical cancers.
that might contribute to cervical oncogenesis, Chen and col- Because HPV vaccines are prophylactic, population-based
leagues in a large Chinese GWAS found that only HLA and vaccination should begin before first sexual intercourse. Because
major histocompatibility class I polypeptide-related sequence A some 5% of US 13-year-old girls are sexually active, the target
genes were identified as candidate risk genes across several age for HPV vaccination is the ages of 11 to 12 years. However,
populations. vaccination can be initiated at 9 years of age in populations in
Lower socioeconomic status (SES) and minority ethnicity which sexual debut may occur earlier. Three injections over 6
are also linked to CIN and cervical cancer risk in the United months are recommended for all vaccines, although schedules
States, although distinguishing cultural contributions to cervi- vary. Some data suggest that two injections or even one may
cal cancer risk, such as a sense of fatalism, distrust of the medical be sufficient, at least for adolescents, but shortened vaccina-
care system providing screening services, and lack of health tion schedules have not been approved by the US Food and
education about the benefits of screening, are difficult to dis- Drug Administration (FDA). Because teen sexual activity is
tinguish from biologic risks related to ethnicity and SES, such unpredictable, delaying vaccination until girls are more mature
as genetic predisposition, toxin exposure, and micronutrient risks missing the vaccination window for many. Nevertheless,
deficiencies. many sexually active young women show no evidence of infec-
tion by target HPV types, and “catch-up” vaccination should
be considered. Testing of cervicovaginal secretions and serum
HUMAN PAPILLOMAVIRUS VACCINATION antibody testing are both insensitive for detecting prior HPV
Because HPV is the cause of essentially all cervical cancer, vaccination and are not recommended before a decision about
HPV vaccination has the potential to eliminate cervical HPV vaccination.
cancer. However, the US experience with HPV vaccination Several countries have instituted organized vaccination
has shown that several barriers will limit achievement of programs, either mandatory or using a school-based opt-in
this goal. mechanism with high uptake. Countries that used quadrivalent
Intramuscular delivery of synthetic HPV L1 capsid antigens vaccine have documented a dramatic decrease in genital warts
results in humor immunity; current vaccines are created in among teens but not older women, and abnormal cytology rates
protein synthesis using cell culture systems; because no actual have also fallen in the youngest women.
live or killed virions are used, HPV vaccines cannot cause HPV- In the United States, vaccination rates are suboptimal, with
related cancer. Despite early concerns that humoral immunity barely one-third of girls in target populations having received
would be insufficient to prevent infection, vaccine efficacy all three injections. Regrettably, despite the potential for vacci-
appears to approach 100%. However, currently available vac- nation to eliminate the disparately high risk of cervical cancer
cines are prophylactic: They must be delivered before HPV among women of minority ethnicity and lower SES, uptake has
exposure and do not appear to reduce risk in untreated women been lowest in these groups, potentially widening cancer dis-
with established target-type HPV infections. This is reflected in parities in future years. Nevertheless, decreases in HPV-16 and
the epidemiology of vaccine effectiveness, which declines with -18 in the pool of sexually active young women have been docu-
age, number of prior sexual partners, and prior abnormal cytol- mented, suggesting that less than ideal vaccination rates may
ogy. These findings mean that, although vaccination is effective nevertheless eventually yield population effectiveness.
for type-specific HPV naïve women through 45 years of age, Vaccine risks appear tolerable. Common side effects include
population effectiveness is too low to justify widespread use fever, rash, injection site pain, nausea, headache, and dizziness.
of vaccines beyond the upper age limit in vaccine trials, Anaphylactic and vagal reactions may be fatal, so vaccination
which extended to 26 years of age. Within trials, effectiveness should only be administered in sites with ability to manage
declined with age, and the American Cancer Society has reiter- anaphylaxis and fainting. Despite initial concerns, HPV vacci-
ated its guidance that HPV vaccination extend only through nation status does not enter into young women’s decisions to
18 years of age. initiate sex. Vaccination is contraindicated for pregnant women,
Three HPV vaccines are available. US clinicians have favored although no congenital anomalies or adverse pregnancy out-
the quadrivalent HPV vaccine, which protects against HPV-16 comes have been linked to HPV vaccination; the vaccine series
and -18, which together account for almost 70% of all cervical may begin after delivery. Interruption of vaccination does not
cancers, as well as HPV-6 and -11, which are the most common appear to require reinitiation of the three-shot series.
causes of genital warts. The benefit of cervical cancer prevention, The duration of vaccine effectiveness is unclear, but anti-
which might take decades to become manifest, is augmented by body levels remain elevated for several years after vaccination.
its ability to prevent genital warts, a concern for many young Booster doses are not recommended at this time. However,
6 CHAPTER 1 Preinvasive Disease of the Cervix

revaccination with nonavalent vaccine may provide additional TABLE 1.2 Bethesda 2001 Classification
benefit and should be considered for women younger than 26
years of age who previously completed bivalent or quadrivalent 1. Negative for intraepithelial lesion or malignancy
vaccines, especially those who have not initiated sexual activity a. Organisms may be identified
b. Other nonneoplastic findings may be noted
and so are at low risk for having acquired HPV.
(1) Inflammation
A history of HPV vaccination does not alter screening rec- (2) Radiation changes
ommendations for US women. This is because many women (3) Atrophy
of screening age were not vaccinated before initiating inter- c. Glandular cells status after hysterectomy
course, so vaccine effectiveness is unclear. There is no central d. Atrophy
US vaccine registry, and identifying vaccinated women by self- 2. Epithelial cell abnormalities
report may be inaccurate. No HPV vaccine covers all carcino- a. Squamous cells
genic HPV types, so women vaccinated before first intercourse (1) Atypical squamous cells (ASC)
remain at risk for infection and cancer due to nonvaccine types. (2) Of undetermined significance (ASC-US)
However, for women known to have been vaccinated against (3) Cannot exclude high-grade squamous intraepithelial lesion (ASC-H)
HPV-16 and -18 before first intercourse, and so at much lower (4) Low-grade squamous intraepithelial lesions (LSIL)
(5) Human papillomavirus (HPV), cervical intraepithelial neoplasia
risk for disease, deferring screening initiation until age 25 years
(CIN) 1
and screening with HPV testing alone at 5-year intervals is (6) HSIL (CIN2, CIN3)
rational. (7) Squamous cell carcinoma
b. Glandular cell
SCREENING (1) Atypical glandular cells (AGC)—specify origin
(2) Atypical glandular cells favor neoplastic—specify origin
The goal of any cancer prevention program is the reduction of (3) Endocervical adenocarcinoma in situ (AIS)
morbidity and mortality through intervention before symptom (4) Adenocarcinoma
onset. The current mechanism to achieve this goal is the iden-
tification and destruction of high-grade CIN lesions that are
presumed precancers. Many novices and some experienced
clinicians mistake the mechanism for the goal. However, iden-
tification of apparent precancers in women with comorbidities nonneoplastic changes, and divides epithelial cell abnormalities
that will be fatal in the medium term, before progression to into squamous and glandular changes of varying degrees of
symptomatic cancer, is not helpful. High-grade CIN in young severity (Table 1.2). Distinguishing squamous from glandular
women may resolve spontaneously and in some cases may be abnormalities is critical because glandular abnormalities carry
observed to avoid the sequelae of treatment. On the other hand, much higher risk for high-grade CIN, including squamous
some women without identified high-grade CIN face cancer dysplasias, as well as endometrial cancer and cervical adenocar-
risks similar to those of women with high-grade CIN and merit cinoma and AIS. Squamous changes related to HPV are termed
destructive cervical therapy. “squamous intraepithelial lesions (SILs)” because some lesser
Classically, screening has relied on Papanicolaou cytology changes do not reflect dysplasia or neoplasia, only cytomorpho-
testing followed by colposcopic assessment of women with Pap logic changes of HPV infection. Indeterminate lesions are
abnormalities, directed biopsy of the worst colposcopic lesion, termed “atypical squamous cells (ASC),” and these are subdi-
and treatment of biopsy proven high-grade lesions. Papanico- vided into ASC “of undetermined significance (ASC-US),”
laou testing is relatively insensitive: A single Pap test may which carries a low risk of associated high-grade CIN, or
be negative in almost half of women with high-grade CIN. “cannot exclude high-grade SIL (ASC-H),” which is a more
However, progression from HPV infection to cancer usually ominous finding that requires immediate colposcopy (see later
requires several years, allowing for multiple rounds of screen- discussion). An online atlas allows pathologists to standardize
ing, with greater sensitivity than single tests. findings and interpretations against national norms (http://
Cytology is the interpretation of all the mutations, methyl- nih.techriver.net). The 2001 update provided the basis for
ations, and other genetic modifications that alter the nuclear subsequent consensus conferences that provided risk-based
and cytoplasmic appearance of cells. As such, it is infinitely management guidelines.
graded. To be clinically useful, these changes must be aggregated Traditional Pap smears were collected by smearing samples
into categories that reflect a common natural history. Papani- across a glass slide and applying fixative followed by staining
colaou developed a five-class grading system, from normal to with a Papanicolaou stain. Today most cytology tests in the
invasive cancer, with atypia, dysplasia, and carcinoma in situ United States are conducted using liquid-based assays. In these
between. Modified systems were developed, and alternatives tests, cells are collected and suspended in preservative solution
were proposed. To unify terminology, the NCI convened a and then transferred to a slide. Liquid-based cytology results in
consensus meeting that developed the 1988 terminology known an even dispersion of cells, and techniques are available that
as the Bethesda System for cervicovaginal cytologic diagnosis. allow for elimination of red and white blood cells, but the
With the most recent update in 2001, this classification system “tumor diathesis” of pus and necrosis that allowed identifica-
identifies cytology as satisfactory or unsatisfactory, includes tion of cancer is lost, as are the “microbiopsies” that allowed
Exploring the Variety of Random
Documents with Different Content
 Merry’s Adventures.

chapter xvii.

I cannot easily make my readers, who have always lived in cities

or towns, understand the pleasure of sleeping in the woods, with no
roof but the sky. Perhaps most persons would think this a hardship,
and so it would be, if we had to do it always: but by way of adventure
now and then, and particularly when one is about seventeen, with
such a clever fellow as Mat Olmsted for a companion and a guide,
the thing is quite delightful.
The affair with the panther had excited my fancy, and filled my
bosom with a deep sense of my own importance. It seemed to me
that the famous exploits of Hercules, in Greece, which are told by the
old poets, were, after all, such things as I could myself achieve, if the
opportunity only should offer.
Occupied with these thoughts, I assisted Mat in collecting some
fagots for our night fire—but every moment kept looking around,
expecting to see some wild animal peeping his face between the
trunks of the gray old oaks. In one instance I mistook a stump for a
bear’s head, and in another I thought a bush at a little distance, was
some huge monster, crouching as if to spring upon us.
The night stole on apace, and soon we were surrounded with
darkness, which was rendered deeper by the fire we had kindled.
The scene was now, even more wild than before: the trees that stood
around, had the aspect of giants, lifting their arms to the sky;—and
their limbs often assumed the appearance of serpents, or demons,
goggling at us from the midnight darkness. Around us was a
seeming tent, curtained with blackness, through which not a ray of
light could penetrate.
 I amused myself for a long time, in looking at these objects, and I
remarked that they assumed different aspects at different times—a
thing which taught me a useful lesson, and which I will give, gratis, to
my young readers. It is this, that fancy, when indulged, has the
power to change objects to suit its own wayward humor. Whoever
wishes to be guided right, ought, therefore, to beware how he takes
fancy for a guide.
When our fire had been burning for about half an hour, Matthew
having unbuckled his pack, took out some dried deer’s flesh, upon
which we made a hearty supper: we then began to talk about one
thing and another, and, finally, I spoke of the Indians, expressing my
curiosity to know more about them. Upon this, Mat said he would tell
an Indian story, and accordingly, he proceeded nearly as follows:
These six nations, you must know, were not originally confined to
this small tract of country, but they were spread far and wide over the
land. Nor were they always united, but in former days they waged
fierce wars with one another. It was the custom among all the tribes
to put captives to death, by burning them, inflicting at the same time
the most fearful tortures upon the victims. Sometimes, however, they
adopted the captive, if he showed extraordinary fortitude, into the
tribe, and gave him all the privileges of the brotherhood.
An instance of this sort occurred with the Senecas. They had
been at war with the Chippewas, who lived to the north. Two small
bands of these rival tribes met, and every one of the Chippewas was
slain, save only a young chief named Hourka. He was taken, and
carried to the village of the victorious Senecas. Expecting nothing
but torture and death, he awaited his fate, without a question, or a
murmur. In a day or two, he saw the preparations making for his
sacrifice: a circular heap of dried fagots was erected, and near it a
stake was driven in the ground.
To this he was tied, and the fagots were set on fire. The scorching
blaze soon flashed near his limbs, but he shrunk not. An Indian then
took a sharp piece of stone, and cut a gash in Hourka’s side, and
inserted in it a blazing knot of pine. This burned down to the flesh,
but still the sufferer showed no signs of distress. The people of the
tribe, came around him, and jeered at him, calling him coward, and
every other offensive name: but they extorted not from him an
impatient word. The boys and the women seemed to be foremost in
taunting him; they caught up blazing pieces of the fagots, and thrust
them against his naked flesh; but yet, he stood unmoved, and his
face was serene, showing, however, a slight look of disdain. There
was something in his air which seemed to say, “I despise all your
arts—I am an Indian chief, and beyond your power.”
Now it chanced that a daughter of an old chief of the Senecas,
was there, and her heart was touched with the courage and manly
beauty of the youthful Chippewa; so she determined to save his life if
she could: and knowing that a crazy person is thought by the Indians
to be inspired, she immediately pretended to be insane. She took a
large fragment of the burning fagot in her hand, and circling around
Hourka, screamed in the most fearful manner. She ran among the
woman and boys, scattering the fire on all sides, and at the same
time exclaiming, “Set the captive free,—it is the will of Manitto, the
Great Spirit!”
This manoeuvre of the Indian maiden was so sudden, and her
manner was so striking, that the Indians around were taken by a
momentary impulse, and rushing to the captive, sundered the strings
of bark that tied him to the stake, and, having set him at liberty,
greeted him as a brother. From this time, Hourka became a member
of the tribe into which he was thus adopted, and none treated him
otherwise than as a chief, in whose veins the blood of the Senecas
was flowing, save only a huge chief, called Abomico.
This Indian was of gigantic size, and proportionate power. He had
taken more scalps in fight, than any other young chief, and was,
therefore, the proudest of all the Senecas. He was looked upon by
the girls of the tribe, very much as a young man is among us, who is
worth a hundred thousand dollars. When, therefore, he said to
Meena—the daughter of the chief who saved the life of Hourka—that
he wanted her for his wife, he was greatly amazed to find that she
did not fancy him. He went away wondering that he could be
refused, but determining to try again. Now the long, dangling
soaplocks, and filthy patches of beard, worn by our modern dandies,
who desire to dazzle the eyes of silly girls—were not in vogue
among the Senecas: but foppery is a thing known among savages
as well as civilized people.
Accordingly, Abomico, when he had determined to push his suit
with Meena, covered himself entirely over with a thick coat of bear’s
grease; he then painted one side of his face yellow, the other blue;
his arms he painted red; on his breast he drew the figure of a snake;
on one leg he painted a skunk; on the other a bear. Around his neck
he hung a necklace of bears’ claws, and on his arm he bore forty
bloody scalps, which he had taken from the heads of enemies slain
in battle; at his back was a quiver of arrows, and in his left hand was
a bow. In his hair was stuck a bunch of eagles’ feathers; from his
right ear swung the skin of a racoon; in his right hand he bore the
wing of a crow.
Thus attired, Abomico marched toward the tent, where Meena
dwelt with her father. Never was a beau of one of our cities, new
from the hands of the tailor, more delighted with his appearance,
than was this Indian dandy, as he drew near to the tent, and waited
at the door for the maiden to appear. “If she can resist my charms
now,”—thought Abomico,—“she must be bewitched indeed!”
Meena soon appeared—and the chief spoke to her again,
begging her to become his wife. “Come!” said he—“go with me, and
be the singing bird in my nest. I am a great warrior. I have slain forty
brave men in battle. I have feasted on the flesh, and drunk the warm
blood, of my enemies. I have the strongest arm, the truest hand, the
swiftest foot, the keenest eye, of any chief in the mighty tribe of the
Senecas.”
“It is not true!” said Meena.
“Not true?” said the chief, in great anger and astonishment. “Who
dares to match himself with Abomico? Who can vie with him in the
race? Who can shoot with him at the mark? Who can leap with him
at the bar?”
“Hourka!” said Meena.
 “It is a lie,” said Abomico; though I must say, that he meant no
offence—because, among the Indians, such a speech was not a
discourtesy.
“Nay—nay,” said Meena—“I speak the truth; you have come to
ask me to be your wife. Hourka has made the same request. You
shall both try your power in the race and the leap, and at the bow. He
who shall be the master in the trial, may claim Meena for his slave.”
This proposition was gladly accepted, and Hourka being informed
of it, a time for the trial was appointed. The people of the village soon
heard what was going on; and, as the Indians are always fond of
shows and holidays, they rejoiced to hear of the promised sport.
The day of the trial arrived. In a grassy lawn, the sport was to be
held; and here the throng assembled. It was decreed by the chiefs
that the first trial should be with the bow. A large leaf was spread out
upon a forked branch of a tree, and this was set in the ground, at the
distance of about fifty yards. Abomico shot first, and his arrow
pierced the leaf, within half an inch of the centre. Hourka followed,
and his arrow flew wide from the mark, not even touching the leaf.
He seemed indeed careless, and reckless. But, as he turned his eye
upon Meena, he saw a shade of sorrow come over her face.
In an instant the manner of the young chief changed. He said to
himself,—“I have been mistaken: I thought the maiden slighted me
and preferred my rival: but now I know that she loves me, and I can
now beat Abomico.”
There were to be three trials of the bow. In the two which followed
the first, which we have described, Hourka had the advantage and
was pronounced the victor. And now came the leap. A pole was set
horizontally upon stakes, to the height of about five feet, and Hourka,
running a little distance, cleared it easily. Abomico followed, and he
also leaped over it with facility. It was then raised about a foot, and
Hourka, bounding like a deer of the wood, sprang over the pole,
amid the admiring shouts of the multitude. Abomico made a great
effort, and he too went over, but his foot grazed the piece of wood,
and the victory here again was awarded to Hourka.
 The face of the haughty Abomico, now grew dark as the thunder-
cloud. He could bear to be rejected by Meena; but to be thus
vanquished before the whole tribe, and that too by one who had not
the real blood of a Seneca, was more than his pride could bear. He
was, therefore, plotting some scheme of revenge, when the race was
marked out by the chiefs. It was decreed that they should run side by
side to a broad river which was near; that they should swim across;
ascend on the opposite bank to a place above a lofty cataract in the
river, and recrossing the river there, return to the point of their
departure.
The place occupied by the spectators, was so elevated as to
command a fine view of the entire race-ground; and the interest was
intense, as the two chiefs departed, bounding along, side by side,
like two coursers. The race was long nearly equal. They came to the
river, and at the same moment both plunged into the water. They
swam across, and at the same moment clambered up the rocky
bank on the other shore. Side by side they ran, straining every
muscle. They ascended to the spot above the roaring cataract, and
plunged into the river; then drew near the place where the water
broke over the rocks in a mighty sheet, making the earth tremble
with the shock of their fall. Still the brave swimmers heeded not the
swift current that drew them toward the precipice. Onward they
pressed, cutting the element like ducks, and still side by side.
Intense was the interest of the spectators, as they witnessed the
strife. But what was their amazement, when they saw Abomico rise
above the wave, grapple Hourka and drag him directly toward the
edge of the cataract. There was a shout of horror, through the tribe,
and then a deathlike silence. The struggle of the two rivals was
fearful, but in a short space, clinging to each other, they rolled over
the precipice, and disappeared among the mass of foam, far and
deep below!
Killed, by falling on the rocks, and gashed by many a ghastly
wound, the huge form of Abomico was soon seen drifting down the
stream; while Hourka swam to the shore, and claimed his willing
bride, amid the applauses of men, women and children.
 The Zodiac.

The Zodiac consists of a broad belt in the heavens, among which

the sun appears to make his annual circuit. The stars are arranged in
groups, and the ancients, who were fond of astronomy, called these
groups or constellations, by particular names. One group they called
ursa major, or great bear; one they called orion; another, the crown;
another, the dog; another Hercules, &c.
In the month of March, the sun is said to enter aries, that is the
group or constellation called aries, or the ram; in April it enters
taurus, or the bull; in May, gemini, the twins; in June, cancer, the
crab; in July, leo, the lion; in August, virgo, the virgin; in September,
libra, the scales; in October, scorpio, the scorpion; in November,
sagittarius, the archer; in December, capricorn, the goat; in January,
aquarius, the water bearer; in February, pisces, the fishes.
 The Voyages, Travels, and Experiences of
Thomas Trotter.

chapter xvi.
The grotto of Pausilippo.—​A dying man.—​The Lazzaroni.—​Weather
at Naples.—​The grotta del cane.—​Inhuman sport.—​Subterranean
fires.—​A Funeral.—​Characteristics of the Neapolitans.

I had heard a great deal of the grotto of Pausilippo, which is a

great tunnel through a mountain at one end of the city, and I took a
walk toward that quarter, for the purpose of visiting it.
This is certainly one of the most surprising works of art in the
world, considering its age. It was executed two or three thousand
years ago, and is probably the most permanent artificial work on the
face of the earth. Even the Egyptian pyramids will not last so long as
this. To have some idea of it, you must understand that Naples is
separated from the towns on the northern coast by the hill of
Pausilippo, which is a ridge of solid rock.
Through this rock an immense tunnel is cut, three quarters of a
mile long, and nearly a hundred feet high. It is broad enough for two
carriages to pass, and lighted by lamps. Several air-holes, at proper
distances, serve to ventilate it and keep the air pure. A great deal of
travel is constantly passing through it: and during the heat of
summer, the grotto, has a most refreshing coolness. The rumbling of
the carriages is echoed from the rocky vault overhead in a very
remarkable manner. Altogether, the place struck me with surprise
and astonishment; and when I thought of our railroad tunnels, which
we boast of as modern inventions, I could not help repeating the
observation of king Solomon, that “there is no new thing under the
sun.”
 While I sat at supper in the evening, I was startled by hearing a
bell tinkling violently under my window. I ran to the balcony and
found the whole street in a blaze of light. A religious procession was
going down the street bearing lighted tapers. I was told that it was a
priest going to administer extreme unction to a dying man.
At the sound of the bell, which was carried by one of the
procession, all the neighbors ran to the windows and balconies with
lamps and candles, and fell upon their knees; for this is the custom
on such occasions. In an instant the whole street was in a blaze of
light, and the prospect of this illumination, with the long procession of
persons dressed in white, chanting a mournful dirge, and the crowds
in the balconies in solemn and devout attitudes, struck me very
forcibly. As the procession passed by each house, the spectators
crossed themselves and uttered a prayer for the soul of the dying
man. So sudden are the transitions of these people from the gayety
and merriment of their daily occupations to the solemnity of their
religious observances.
Everybody who has been at Naples, has something to say about
the Lazzaroni, which is the name given to the idle fellows and
ragamuffins of this city. Many people imagine them to be a distinct
race of men, like the gipseys in other parts of Europe; but this is an
error. Every city in Europe has its proportion of lazy and ragged
fellows: but in Naples their number is so great that they have
obtained this peculiar name. By some, their numbers are stated at
twenty thousand. I will not vouch for the full number, but they exist in
swarms. Nowhere else did I ever see such comical raggedness as
among these people. The scarecrows, which Yankee farmers set in
their cornfields to frighten away the birds, are genteel figures
compared to these fellows. One has half a pair of trowsers; another
half a jacket, and no trowsers at all; another wears the leg of an old
stocking for a cap; another has a ragged pair of breeches the wrong
side upwards for a shirt. As to the patches and tatters, they surpass
all power of language to describe. How they get their living, one is
puzzled to guess, for they seem to spend all the day basking in the
sun; and in spite of their rags and dirt, they appear to be as happy as
lords. They are constantly in good humor, singing, chattering,
grimacing, and cutting capers from morning to night. In fact,
notwithstanding their want of almost all those things which we call
necessaries of life, they appear to be troubled with very little
suffering. Their rags and nakedness give them little concern, for the
climate is so mild that they hardly feel the want of a covering. Their
food is chiefly macaroni, which is very cheap here: two or three cents
worth will suffice a man for a day. Their manner of eating it makes a
stranger laugh; they hold it up in long strings, at arm’s length, and
swallow it by the yard at a time. As for their homes, the most of them
have none: they sleep in the open air, on the steps of the churches,
and wherever they can find a convenient spot to lie.
It was about the middle of March, which is the most disagreeable
month of the whole year in this country; yet I found the weather very
mild and pleasant. Light showers of rain happened almost every day;
but these lasted commonly but a few minutes and were succeeded
by warm sun-shine. I could discern the Appenines at a distance,
covered with snow, while the hills around the city were decked with
green olive trees. Oranges and lemons were plenty and very cheap:
three or four for a cent.
I set out on a walk to visit the famous grotta del cane, or “dog’s
cavern,” which is only a few miles from Naples. The road lay through
the grotto of Pausilippo, and I could not avoid again admiring this
wonderful cavern, the work of men who lived in what we have
supposed to be an age of barbarism. At the further end I emerged
into the open air and found a region of fields and vineyards,
separated by walls of clay. Little children ran along by my side,
tumbling head over heels, clacking their chops, making queer noises
and antic gestures by way of begging for coppers. All along the road
were poplar trees, to which the vines were trained, but they were not
in leaf. After a walk of three or four miles I came to lake Agnaro, a
piece of water about the size of Fresh Pond in Cambridge. On the
shore of this lake is the grotta del cane. It is a rocky cavern which
enters horizontally a little above the water, and emits from its mouth
a sulphureous steam or vapor, which will kill a dog if he is put into
the cavern. People who live in the neighborhood keep dogs for the
purpose of exhibiting this phenomenon to strangers. The dogs know
the fatal properties of this cave, and refuse to go in. While I was
there, some of these fellows came to me and offered to exhibit the
experiment; but I declined, not wishing to see an animal treated with
cruelty for mere curiosity. They assured me that the dog need not be
killed—that they would only keep him in the cave long enough to
throw him into a swoon, and then bring him to life again by plunging
him into the water. I told them this was as bad as killing him outright:
for the animal could suffer no more by actually dying. They were very
unwilling to lose their expected fee, and answered me that there was
no suffering in the case, but, on the contrary, the dogs were very
fond of the sport! I laughed at this impudent falsehood, and refused
to have anything to do with the exhibition.
A few minutes after, a party of visiters arrived who had no such
humane scruples: they were resolved to see the experiment tried.
Accordingly, a dog was brought forward; and I now had a chance to
see how much truth there was in the assertion that these animals
were fond of being choked to death. The poor dog no sooner
perceived his visiters than he became as perfectly aware of what
was going forward as if he had heard and understood every syllable
that had been said. It showed the utmost unwillingness to proceed
towards the cavern, but his master seized him by the neck and
dragged him with main force along till he reached the mouth of the
cave, into which he thrust him howling and making the most piteous
cries. In a few minutes he fell upon the ground motionless, and lay
without any signs of life. The spectators declared that they had seen
enough to satisfy them; on which the fellow took the dog up by the
ears and plunged him into the lake. After two or three dips, the poor
animal began to agitate his limbs and at length came to himself and
ran scampering off. These inhuman exhibitions ought not to be
encouraged by travellers.
Every part of the neighborhood of the city abounds with evidence
of the existence of volcanic fire, under ground. As I walked along the
road I found the smoke issuing from holes and clefts in the ground:
and on placing my hands in these fissures, I found them so hot that
one might roast eggs in them. Yet people build houses and pass
their lives upon these spots, without troubling themselves with the
reflection that they live on a thin crust of soil hanging over a yawning
gulf of fire! In my walk homeward I passed by a hill, about the size of
Bunker Hill, which some time ago rose up suddenly, in a single night,
from a level plain. It is now all overgrown with weeds and bushes. If
it were not for Mount Vesuvius, which affords a breathing-place for
these subterranean fires, it is highly probable that the whole face of
the country would be rent into fragments by earthquakes and
volcanic explosions. Vesuvius may be called the safety valve of the
country.
On my way home, I was stopped on the road by an immense
crowd. It was a funeral. A long train of monks and priests attended
the hearse, each one clad in a dress which resembled a loose white
sheet thrown over the head and falling down to the feet, with little
round holes cut for the eyes. They looked like a congregation of
spectres from the other world. The corpse was that of an army
officer. He lay not in a coffin, but exposed in full uniform upon a
crimson pall edged with gold. Everything accompanying the hearse
was pompous, showy and dazzling.
This indeed is the characteristic of the people; almost everything
in their manners and mode of life is calculated to strike the senses
and produce effect by dazzling and external display. Nothing can
surpass the splendor of their religious processions, the rich and
imposing decoration of their churches, and the pomp and parade
and showy display which attend the solemnization of all their public
festivals. The population of these countries are exceedingly sensitive
to the effect of all these exhibitions, and their lively and acute
feelings bring them under the influence of whatever is addressed
strongly to their outward senses. They are little guided by sound
reason and sober reflection, but are at the mercy of all the impulses
that arise from a keen sensibility and an excitable imagination.
 Story of Philip Brusque.

chapter xi.
The meeting.—​Discussion.—​A government adopted.—​Conclusion
for the present.

The time for the meeting of the people to take measures for the
establishment of a government for the island of Fredonia, was fixed
for the day which followed the events narrated in the last chapter.
This meeting was looked forward to with intense interest, by all
parties. The men, who knew that there could be no peace or safety
in society, without government, regarded the event as likely to decide
whether the inhabitants of the island were to be happy or miserable.
The women, who were perhaps not apt to reflect upon these
things, had also learned from their experience that a government,
establishing and enforcing laws, was indispensable to the quiet and
security of society: they saw that their own lives, their freedom, their
homes, were not secure, without the protection of law. Even the
children had found that government was necessary, and these as
well as the women, were now rejoicing at the prospect of having this
great blessing bestowed upon the little community of Fredonia.
The day for the meeting arrived, and the men of the island
assembled, agreeably to the appointment. First came the men of the
tent party, and then, those from the Outcast’s cave. The latter were
greeted by a shout of welcome, and mingling with the rest, a kind
shaking of hands took place between those, who so lately were
arrayed against each other in deadly conflict.
After a short time, Mr. Bonfils, being the oldest man of the
company, called the assembly to order, and he being chosen
chairman, went on to state the objects of the assembly, in the
following words:
“My dear friends; it has been the will of Providence to cast us
together upon this lonely, but beautiful island. It would seem that so
small a community, regulated by mutual respect and mutual good
will, might dwell together in peace and amity, without the restraints of
law, or the requisitions of government. But history has told us, that in
all lands, and in all ages, peace, order, justice, are only to be
secured by established laws, and the means of carrying them into
effect. There must be government, even in a family; there must be
some power to check error, to punish crime, to command obedience
to the rule of right. Where there is no government, there the violent,
the unjust, the selfish, have sway, and become tyrants over the rest
of the community. Our own unhappy experience teaches us this.
“Now we have met together, with a knowledge, a conviction of
these truths. We know, we feel, we see that law is necessary, and
that there must be a government to enforce it. Without this, there is
no peace, no security, no quiet fireside, no happy home, no pleasant
society. Without this, all is fear, anxiety, and anarchy.
“Let us then enter upon the duties of this occasion, with a proper
sense of the obligation that rests upon us; of the serious duty which
is imposed on every man present. We are about to decide questions
which are of vital interest, not only to each actor in this scene, but to
these wives and sisters and children, whom we see gathered at a
little distance, watching our proceedings, as if their very lives were at
stake.”
This speech was followed by a burst of applause; but soon a man
by the name of Maurice arose—one who had been a leading
supporter of Rogere—and addressed the assembly as follows:
“Mr. Chairman; it is well known that I am one of the persons who
have followed the opinions of that leader who lost his life in the battle
of the tents. I followed him from a conviction that his views were
right. The fact is, that I have seen so much selfishness in the officers
of the law, that I have learned to despise the law itself. Perhaps,
however, I have been wrong. I wish to ask two questions—the first is
this: Is not liberty a good thing? You will answer that it is. It is
admitted, all the world over, that liberty is one of the greatest
enjoyments of life. My second question then is—Why restrain liberty
by laws? Every law is a cord put around the limbs of liberty. If you
pass a law that I shall not steal, it is restraint of my freedom; it limits
my liberty; it takes away a part of that, which all agree is one of the
greatest benefits of life. And thus, as you proceed to pass one law
after another, do you not at last bind every member of society by
such a multiplied web of restraints, as to make him the slave of law?
And is not a member of a society where you have a system of laws,
like a fly in the hands of the spider, wound round and round by a
bondage that he cannot burst, and which only renders him a slave of
that power which has thus entangled him?”
When Maurice had done, Brusque arose, and spoke as follows:
“Mr. Chairman; I am happy that Mr. Maurice has thus stated a
difficulty which has arisen in my own mind: he has stated it fairly, and
it ought to be fairly answered. Liberty is certainly a good thing;
without it, man cannot enjoy the highest happiness of which he is
capable. All useless restraints of liberty are therefore wrong; all
unnecessary restraints of liberty are wrong. But the true state of the
case is this: we can enjoy no liberty, but by submitting to certain
restraints. It is true that every law is an abridgment of liberty; but it is
better to have some abridgment of it, than to lose it all.
“I wish to possess my life in safety; accordingly I submit to a law
which forbids murder: I wish to possess my property in security; and
therefore I submit to a law which forbids theft and violence: I wish to
possess my house without intrusion; I therefore submit to a law
which forbids one man to trespass upon the premises of another: I
wish to go and come, without hindrance, and without fear; I therefore
submit to a law which forbids highway robbery, and all interference
with a man’s pursuit of his lawful business.
“Now, if we reflect a little, we shall readily see that by submitting
to certain restraints, we do actually increase the amount of practical,
available, useful liberty. By submitting to laws, therefore, we get
more freedom than we lose. That this is the fact, may be easily
tested by observation. Go to any civilized country, where there is a
settled government and a complete system of laws, and you will find,
in general, that a man enjoys his house, his home, his lands, his
time, his thoughts, his property, without fear: whereas, if you go to a
savage land, where there is no government and no law, there you
will find your life, property, and liberty, exposed every moment to
destruction. Who, then, can fail to see that the very laws which
abridge liberty in some respects, actually increase the amount of
liberty enjoyed by the community.”
Maurice professed himself satisfied with this solution of his
difficulties; and the meeting proceeded to appoint a committee, to go
out and prepare some plan, to be submitted to the meeting. This
committee returned, and after a short space, brought in a resolution,
that Mr. Bonfils be for one year placed at the head of the little
community, with absolute power; and that, at the end of that period,
such plan of government as the people might decree, should be
established.
This resolution was adopted unanimously. The men threw up their
hats in joy, and the air rang with acclamations. The women and
children heard the cheerful sounds, and ran toward the men, who
met them half way. It was a scene of unmixed joy. Brusque and
Emilie met, and the tears of satisfaction fell down their cheeks.
François went to his aged mother, and even her dimmed eye was
lighted with pleasure at the joyful issue of the meeting.
We must now take leave of the island of Fredonia—at least for a
time—and whether we ever return to it, must depend upon the
wishes of our young readers. If they are anxious to see how the
people flourished under the reign of their aged old chief, and how
they proceeded in after years, perchance we may lift the curtain and
show them the scene that lies behind it. But I hope that our readers
have learnt, that not only men and women, but children, have an
interest in government, and therefore that it is a thing they should try
to understand.
 The Tanrec.

This creature resembles the hedgehog, but is larger than that

animal, and is destitute of a tail. It does not roll itself into a ball, for
defence, like the former animal. It passes three of the warmest
months of the year in a state of torpor, differing in this respect from
other animals, which become torpid from extreme cold. Its legs are
very short, and it moves very slowly. It is fond of the water, and loves
to wallow in the mud. It moves about only by night. There are three
species, all found in the island of Madagascar.

Letter from a Correspondent.

Little Readers of the Museum:
I sometimes read Mr. Robert Merry’s Museum, and I like it
very much, as I presume all his little “blue-eyed and black-
eyed readers” do. He talks very much like good old Peter
Parley. I should think he had heard him tell many a story while
he rested his wooden leg on a chair, with a parcel of little
laughing girls and boys around him. Oh, how many times I
have longed to see him, and crawl up in his lap and hear his
stories! But Mr. Merry says he is dead, and I never can see
him. I am very—very sorry, for I hoped I should sometime visit
him, for I loved him very much, and I guess he would have
loved me some, for I like old people, and always mean to treat
them with respect. How cruel it was for others to write books
and pretend that Peter Parley wrote them!—for it seems that
this shortened his life. I am glad, however, that Mr. Merry has
his writings, for I think he loves his little friends so well that he
will frequently publish some of them. I said that I loved Peter
Parley, and I guess you will not think it strange that I should,
when I tell you what a useful little book he once published,
and how much pleasure I took in reading it. He wrote a great
many interesting pieces which I read and studied, and they
did me much good, I think. I hope that the little readers of the
Museum will learn a good deal from what they read.
Peter Parley wrote a piece which told us how to make
pens. I read it over, and over again, and, finally, I thought I
would see if I could not make one. So I went to my little desk
and took out a quill, got my aunt’s knife and laid the book
before me and tried to do just as Peter Parley told me I must.
I succeeded very well, and my friends were quite pleased.
This encouraged me very much, and soon I made them so
well that my teachers made me no more pens. By-and-by my
little associates got me to make and mend theirs, and I loved
the business very much.
Well, a few years since, I went to a beautiful village to
attend school, where a splendid academy stands, around
which, are large green trees, under whose shade my little
readers would love to sit. There I staid two or three years.
Often did I walk out with the teachers, whom I loved, to
botanize, or ramble, with nimble step, over the beautiful hills
of that sweet place, and listen to the constant murmur of its
waterfalls, or gather the delicate flowers that grew so
plentifully there. But to my story. My teachers saw that I made
my own pens, and occasionally, when they were busy, would
bring me one to make for them. The students soon found it
out, and I had plenty of business. One day the principal of the
school came to me and offered to compensate me by giving
me my tuition one term, which was six dollars, if I would make
 and mend pens. I did not accept the money of course, though
I cheerfully and gladly performed the small service.
So you see, Peter Parley’s instruction has done me a great
deal of good, for how many persons there are who cannot
make a good pen, because they never learned how.
My little readers, I am now almost twenty years old, but I
still remember many other things which I read in Peter
Parley’s books when I was a little girl. Mr. Robert Merry talks
and writes just like him, almost, and I hope you will love to
read and study attentively Merry’s Museum, for it is a good
little work, and a pleasant one. Be assured, my young friends,
you can learn a great deal from it, if you read it carefully. I
should like to say much more to you, but I cannot now. I have
been sitting by the fire, in a rocking-chair, writing this on a
large book, with a pussy under it for a desk, but she has just
jumped from my lap, and refuses to be made a table of any
longer. So farewell.
Your young friend,
Laura.
Springfield, Jan. 6, 1842

Cookery Book.—“Has that cookery book any pictures?” said

Miss C. to a bookseller. “No, miss, none,” was the answer. “Why,”
exclaimed the witty young lady, “what is the use of telling us how to
make a good dinner, if they give us no plates?”