The typical, violent pains that have been designated as cancer-pains chiefly depend on the other hand on an extensive implication of the sur rounding tissues in the morbid process. Thus when cancerous infiltra tion spreads to the body of the uterus, pain results probably from lesions of the terminal nerve filaments in the substance of the uterus. In the same way, when the infiltration becomes diffused throughout the connec tive tissue of the pelvis, the coincident mechanical irritation and stretch ing of the numerous nerve ramifications of this region may excite constant pain of a tearing and lapcinating character, the large nerve trunks, however, being generally exempt. For the same reasons both the normal distension and the evacuation of the bladder and rectum become painful. The less widely cancerous infiltration extends into the sur rounding pelvic cellular tissue, the less complaint is there of pain This most readily explains a frequently observed fact, namely, that wide spread epitheliomatous destruction sometimes occasions no suffering worth mention, or at most, perhaps, only trivial pressure symptoms, rapid sloughing keeping pace with infiltration. Moreover, we often find that intense pain due to cancer of the connective tissue between the uterus, bladder and vagina ceases abruptly as soon as gangrene leads to the forma tion of a vesico-vaginal fistula.
Now while the so-called cancer pains are often mitigated when the can cerous masses are attacked by sloughing, the latter process not infrequently gives rise to pain of another kind, namely from irritation of the peri toneum in the vicinity of the cancerous ulceration. In addition to distinct attacks of peritonitis which not very rarely complicate the affection under consideration, a certain degree of pain or rather of sensitiveness on pressure of the pelvic peritoneum is always present. We sometimes find, also, an increased tension of the muscles of the abdominal parietes (Schroder).
While, then, hemorrhage. discharge, and the above-described varieties of pain are almost inseparable attendants of cancer of the uterus, at least from the time that the neoplasm begins to break down, there are in addi tion to these some other, more rare conditions, the dependence of which upon the disease in question is not quite so clear. This is particularly true of pruritus of the external genitals, which is by no means so frequent as some would lead us to believe, excluding of course that form dependent upon cutaneous affections of the external genitals due to the constant trickling away of urine through a fistulons opening.
Certain other so-called " consensual " phenomena, such as mastodynia, as portrayed by Simpson, West and others, are still more rarely observed.
On the other hand we quite often meet with gastric symptoms such as anorexia, nausea, and vomiting, which sometimes make their appearance in so early a stage that they must in truth be classified as "consensual " phenomena, while the gastric symptoms that occur during the later stages are caused by anemia, peri-uterine irritation, urwmia, etc.
All the remaining disorders of carcinoma uteri are dependent upon the further progress and course of the disease. Before I proceed to give a short description of the different forms of this course it is scarcely neces sary to mention that the various occurrences that I am about to portray, may manifest themselves simultaneously or in varying succession in the same patient. and that the picture of the disease is usually, therefore, much more diversified than would seem from the following. It has pre viously been stated that carcinomatous ulceration very quickly spreads to the corpus uteri, and that the lumen of the uterus, and sometimes even the whole organ, becomes converted into a cavity filled with a decompos ing, fetid, pulpy mass, into which the individual cancer nodules project. In this manner destruction may proceed until only a small remnant of the fundus is left; sometimes even this melts away, leaving no trace of the visous. These are the cases that have sometimes been strangely described' as expulsion of the diseased uterus These processes are almost invariably associated with adhesive inflam mation of the fold of the peritoneum lining the cul-de-sac of Douglas, and give rise to the ordinary signs of this condition, and to interference with the functions of the pelvic viscera. This perimetritis in rare instances leads to acute peritonitis, which is rapidly fatal; more often it is the starting-point of a chronic peritonitis. On the other hand I have encountered acute peritonitis following the rupture into the peritoneal cavity of a collection of decomposing detritus in the walls of the uterus, or of an abscess in the newly-formed adhesions, and sometimes also in consequence of the escape of broken-down masses through a Fallopian tube into the abdominal cavity.
Diffuse cancer of the peritoneum in the form of very numerous dis seminated, miliary deposits is a comparatively very rare occurrence.
Cancerous ulceration of the cervix very often also spreads to the vagina, and then gives rise to similar conditions as when the extension occurs upwards into the uterine cavity. We find wide-spread destruction of the vaginal walls, associated with active inflammation of the remaining rela tively healthy parts of the canal.