At first the surrounding pelvic connective tissue takes on a condition of simple inflammatory swelling and infiltration, but it soon becomes invaded by the disease proper, and before long the functions of the bladder and rectum are interfered with, and this too before these organs become dis eased. Deftwation becomes difficult and painful, and quite often large hemorrhoids develop. Micturition also becomes painful, and patients are tormented by an incessant desire to pass water. Vesical catarrh is very prone to occur. As a rule the destructive process sooner or later invades the bladder and rectum, especially the former. In 311 cases of cancer of the uterus, the bladder underwent cancerous infiltration in 128 instances., in 56 of which vesico-vaginal fistula resulted. The disease generally travels in a direct line from the vagina through the pelvic cellular tissue to the bladder, and therefore the posterior wall of this viscus and more especially the trigonum are the parts that are almost invariably attacked in the first instance. Isolate(' metastatic deposits in other portions of the bladder are extraordinarily rare. The above accidents are always com plicated with vesical catarrh, and not infrequently also with diphtheritic inflammation and ulceration of the mucous membrane. It is, therefore, not surprising that septic poisoning should now and then develop, as is illus trated by a case of Eppinger's.' Pyelonepbritis is a relatively more frequent, but still rather exceptional complication of the affection under consideration.
It was observed by Blau in ten out of the ninety-three cases recorded in the transactions of the Pathological Institute of Berlin. A participation of the ureters in the diseased process is a matter of great consequence. In his ninety-three cases of cancer of the uterus Blau noted fifty-seven instances of dilatation of one or both ureters with consecutive hydrone phrosis. While this complication is of but little moment when one 'ureter only is involved, the contrary is true when both tubes are occluded, as then bydronephrosis, with all the symptoms of acute or chronic uremia, rapidly develops. The constriction or the total obliteration of the lumina of the ureters is only exceptionally dependent upon cancerous infiltration in the walls of the duets; the latter are usually compressed at their points of entrance into the bladder. This pressure may be due either to dense cicatricial thickening or, what is more often the case, to cancerous infiltra tion of the pelvic cellular tissue. Again we not very infrequently find the cause of the obstruction to consist in cancerous infiltration of the vesical mucous membrane in the region of the trigonum. This explains how it is that patients who have suffered for a short time from almost absolute anuria, and who have already begun to manifest symptoms of uriemia, are quite suddenly relieved by the formation of a vesico-vaginal fistula.
Among the other changes that may affect the parenchyma of the kidneys we may mention parenchymatous nephritis (observed by Blau four times), atrophy of the kidney (seven times), and amyloid degenera tion (four times). In two of Blau's ninety-three cases there was " cloudy swelling of the epithelium of the urinary tubules; " metastatic deposits were found in three instances.
The rectum much more rarely participates directly in the cancerous degeneration than does the urinopoietic apparatus. In two hundred and eighty-two cases, the rectum was invaded fifty-three times, and in thirty-seven of these a recto-vesical fistula resulted. Moreover, as sociated inflammatory states of the mucous membrane of the rectum occur much less frequently than is the case with the vesical mucous membrane.
Another, and also not infrequent result of infiltration of the cellular tissue of the pelvis is a thrombosis from pressure of the large veins of the pelvis such as the internal iliac, the common iliac, etc., with consecutive tense oedema of one or both lower extremities. It need scarcely be stated that py-femia also may arise from this cause.
The various modifications and disturbances of function of the digestive tract have previously been cursorily alluded to. It is necessary, however, to again direct attention to them, because of the marked influence which they exert upon the whole course of the disease. Together with obstinate constipation there is almost invariably present, even from the beginning, loss of appetite, sometimes with disgust for all food, especially meat. In addition to this, more or less obstinate vomiting often sets in at quite an early period. This is very seldom due to cancer of the stomach, which affection rarely occurs simultaneously with cancer of the uterus. Somewhat oftener but still quite rarely it is attributable to cancer of the liver or peritoneum. Incessant vomiting may also be dependent on chronic perifonitis, that frequent complication of cancer of the uterus, or more often on uraemia. In most cases, however, the symptom is simply the result of an ordinary chronic gastric catarrh, such as usually develops quickly from habitual constipation or anaemia. Another factor is undoubtedly the atmosphere in which these patients live, in spite of the most rigid cleanliness.
Discharge, hemorrhages, vomiting and anorexia very soon induce marked emaciation, with anemia and hydrEemia. Various regions of the body become edematous, the skin assumes an anemic discolored hue; in short we very soon observe all those signs and symptoms which go to make up the alas ! too well known, and yet not easily described cancerous cachexia. The latter condition and the aspect of profound suffering are particularly aggravated when incessant pain allows not even momentary repose by day or night to the harassed and tormentei individual.