EPITHELIOMA AND CARCINOMA OF THE CERVIX UTERI.
While it seemed likely for a long time that histological investigations would furnish us with exact ideas as to the causes of the malignancy of certain tumors that have for centuries been called cancer, almost the contrary has resulted; for our anatomical comprehension of this most important group of affections has been greatly obscured, on the one hand, by the multiplicity of observations, and on the other by the dispute as to the starting-point of cancerous develop ment. Although it is true that the epithelial character of cancerous neoplasms is almost universally acknowledged, by which remark I do not mean to assert that it has been decided whether it is the connective tissue or already existing epithelium of whatsoever variety that furnishes the matrix, yet the mystic formula of " atypic epithelial proliferation " no longer suffices to characterize carcinoma. As before, these neoplasms are still " malignant epitheliomata." It is not their morphological con stitution, but their biological history, their clinical course, the study of their conduct while still a part of the living organism, and their relations to the latter, which are decisive. For ages back it has been known that tumors often develop in the uterus, especially in its vaginal portion; that these tumors make their appearance as a rule in later life; that they often break down resistlessly, invading the surrounding tissues, causing hemor rhage and signs of gangrene, not infrequently giving rise to new deposits in distant organs unconnected with the original site of disease, and that finally they lead to the death of the individual, partly from the direct local effects of the disease and partly by its debilitating influence upon the whole organism (cachexia). These neoplasms constitute one of the most frequent sources of disease of the female genital tract and have always been termed cancer of the uterus.
Now, while the above purely clinical definition may sound very old fashioned, it still possesses the undeniable advantage of not overstepping the bounds of what we positively know. Although anatomico-histologi cal research has been unable as yet to give us a satisfactory explanation of the malignancy of cancer, and has yielded scarcely any definite infor mation regarding its etiology, yet we can by no means afford to neglect results gained in numerous painstaking investigations, if we desire to obtain any enlightenment as to the nature and course of this malady.
We may divide cancer of the cervix uteri into two great classes, which we will designate by their old appellations of epithelioma and carcinoma. If we employ Bleb's' classification, which, as far as my experience goes, conforms most closely with clinical observations, we may distinctly differ entiate the flat epithelioma of the cervix, the cancerous ulcer, from the papillary variety. We have, besides these, the parenchymatous or infil trated form of cancer of the uterus, which we might as well call carcinoma. Let us see how far this division corresponds with Billroth and Waldeyer's classification of epithelial and glandular carcinoma. In the first place let me give Kleb's description of the above-mentioned varieties in the words of their author: The " flat epithelioma " of the cervix originates from the internal surface of the os uteri, strictly speaking from that part which is provided with transitional epithelium. The deeper epithelial strata of this region penetrate, according to Klebs, into the stroma of the mucous membrane and into the muscular tissue. The more the circu lation is affected by the inward proliferation, the more rapidly do the epithelial masses on the surface break down, so that we not infrequently find a deeply excavated, crater-shaped ulcer extending up to, or even beyond, the internal os at a time when there is as yet no trace of disease on the external surface of the vaginal portion. Every experienced gynecologist will remember having met with one or more instances of limited epitheliomatous ulceration of the external os, the portio vaginalis seeming to be in other respects healthy: these cases will have appeared to have offered a good opportunity for amputation through sound tissues, but close examination will have disclosed but too often that the cancerous destruction had already extended high up into the cervix and beyond the fornix of the vagina. The deeper the ulceration and the more extensive the invasion of the submucous tissues the greater is the attendant necrosis. In this way very large cavities are often formed—the destruc tive process invading the bladder, the vagina, and the rectum.