As regards the final result of the disease it may be stated that death is in most instances due to marasmus, to a gradual wasting away and exhaus tion. In these cases it cannot be at all accurately prognosticated when the end may occur; it may seem imminent and yet be postponed for days and weeks. In Blau's ninety-three cases this mode of death was observed forty-eight times. Venous thrombosis, dysentery, diphtheritic inflamma tion of the bladder or of the rectum, and bed-sores, frequently enough hasten the final issue. In a large proportion of other cases the immediate cause of death is, as has already been stated, peritonitis in its various forms (38 times in 155 cases); sometimes it is a general purulent peri tonitis (30 times), or it may result from perforation (8 times), or from direct extension (17 out of 155 cases).
Blau also gives as the causa mortis pneumonia eleven times, pleuritis three times, and as often embolism of the pulmonary artery; once each pyelonephritis, fatty degeneration of the heart, pulmonary gangrene. and pyelophlebitis from a putrid clot in the portal vein. In the sixty-two cases mentioned in Seyfert's ' Klinik the following causes of death are recorded: pyEemia, nine times, amyloid degeneration of the abdominal glands, five times, 'edema of the lungs, three times, dysentery, three times, and uraemia, twenty-eight times. The last-mentioned affection is in my experience also one of the most common causes of death; its mode of de velopment has previously been described.
The chronic is, perhaps, the somewhat more frequent form; still, very acute cases with profound sopor and general convulsions are not at all rare.
The rarity with which septicemia and pyemia occur in cases of car cinoma of the cervix uteri must always have attracted the attention of investigators. A priori one would imagine that in an affection in which local gangrene develops at so early a period, especially in a situation in which under other circumstances absorption goes on so rapidly, and that when, as is here the case, numerous vessels are directly and constantly bathed in putrid fluids, one would imagine, I repeat, that ander these conditions septic infection would very often be encountered.
As far as I remember, Barnes' is the only one who considers that the phenomena that constitute the cachexia which accompanies cancer of the uterus are but consequences of septic intoxication. Yet even this author concedes that genuine septicaemia or pytemia, as defined by their anatomi cal and clinical features, is very rarely observed. Eppinger (1. c.), whose investigations are based upon the abundant material collected in the Anatomical Institute of Prague, has recently substantiated this fact. He describes two cases of septicaemia dependent on cancer of the uterus, in one of which the infection was propagated from the broad ligament, just as happens in puerperal pymmia. The reason why septic infection is so seldom observed under conditions which would appear to be especially dis posed to its development is, in my opinion, one in which Eppinger concurs in the main, that the tissues in the vicinity of the cancerous ulceration are in such a condition of cancerous infiltration and reactive inflammation that absorption is all but suspended. My own experience coincides with this view, for the only two cases of fatal pyaemia which I have met with in a very large number of cases of cancer of the uterus, were observed after operative measures had been undertaken. I had scraped away some epitheliomatous masses, leaving relatively clean wounds behind, which were scarcely or not at all separated by a wall of infiltration from the adjoining healthy tissues; in this way the absorption of decomposing matter was facilitated.
It is very difficult, indeed well-nigh impossible, to determine the dura tion of cancer of the uterus, because, as I have already repeatedly stated, the malady has almost without exception existed quite a long time before symptoms of such gravity have manifested themselves as seem to require professional advice. We can, therefore, only state approximately the length of time that usually elapses between the onset of the first symptoms and the fatal issue. Now, while this may vary in individual cases, especially since appropriate therapeutic measures quite often retard the further progress of the disease, yet it may be stated in general that carcinoma of the uterus usually ends fatally after a duration of from one to one and a half years, reckoning from the appearance of the initial symptoms.
The average duration of the disease in West's cases was seventeen months, in Lever's twenty, and in Lebert's sixteen. Seyfert found the average duration to be from three to four years in " epithelial carcinoma," while it was only one and a half years in the " medullary " form. In twenty-four cases, in which positive statements could be made, Tanner found the shortest time to be six months, the longest four and a half years, while in twenty-four other cases, in which the information was less reliable, the duration varied between five weeks and twenty-one mon tbs.
In twenty-two of my own cases I found the duration of the disease to be once 36 months, twice 24 months, three times from 12 to 20 months, 12 times from 9 to 11 months, once 84. months, once 6 months, and twice 4 months, or an average of exactly twelve months.
Now while the gangrenous process in carcinoma of the uterus may be considered as a step in the direction of cure, in so far as cancerous masses are thereby being continually destroyed, yet we can by no means accept as reliable those few statements in the literature of the subject which claim that uterine cancer may undergo spontaneous cure. The evidence adduced up to the present time, in support of these assertions is not sufficiently convincing; the cases of Gallard and Barnes (1 c.) at any rate can lay no claim to be accepted as decisive.
A study of the symptoms of carcinoma of the portio vaginalis shows sufficiently clearly that the diagnosis of cancerous ulceration is compara tively easy. One readily recognizes, on digital exploration, the luxuriating and ulcerating masses, the destruction of the vaginal tissues, the infiltra tion of the pelvic connective tissue. The examination is generally fol lowed by more or less hemorrhage. The fcetid discharge, the general condition of the patient, all render the recognition of the disease an easy one. On examining with the speculum one sees proliferating masses sprouting from a deeply ulcerated base, and covered with black, necrotic shreds. In short I certainly do not assert too much when I say that it requires only an approximatively careful examination to diagnose a de generating cancer of the vaginal portion. It is true, as I have pointed out on a previous occasion, that ulcerating fibromata in this situation have been mistaken for the affection which we are discussing; our doubts will speedily and easily be dispelled by paying attention to the condi tion of the os extetnum, and by examining a piece of the decomposing