The papillary epithelioma begins, according to Klebs, on the vaginal aspect of the cervix, as a papillary hypertrophy. The proliferating epithelial investment of these new structures invades the subjacent tissues and then breaks down. New papillary excrescences develop on the base of the resulting ulcer, these in their turn necrose, and thus the pro cess repeats itself until, finally, the most extensive destruction ensues, although perhaps its progress is somewhat less rapid than in the preceding variety.
Carcinoma proper begins in the deeper tissues of the uterus, and consists of more or less firm, nodulated deposits, covered by healthy mucous membrane, which, spreading towards the surface only after a time and by no means invariably, become gangrenous and break down, form ing cancerous ulcers which produce rapid necrotic disintegration of the tissues. It was formerly believed that this form of cancer originated in the connective-tissue framework of the uterine substance, but such opin ion is not accepted by modern investigators, who hold that this variety also commences in the mucous membrane. Klebs, for instance, is inclined to locate the starting-point of the disease in constricted cervical glands. He assumes that the ovula nabothi in the region of the internal os are to a certain degree disposed to undergo cancerous metamorphosis, and explains in this way how this form of carcinoma of the uterus tends to extend upwards into the body and fundus of the organ, as well as downward into the cervix. In either case spheroidal tumors develop, which project beyond the surface, or are distributed as isolated nodules in the muscular strata of the uterus and also as large nodes in the pelvic connective tissue. The individual masses are usually soft and succulent, and consist of irregularly shaped epithelial cells, often imbedded in a scanty interstitial tissue. Almost all authors recognize two forms of carcinoma of the uterus. FOrster describes a papillary and a parenchymatous epithelial cancer. Waldeyer' recognizes only epithelioma of the uterus. He has observed but one case of cancer develop from the glands of the cervical canal, and he believes that these cases are very rare. According to Waldeyer epitheliomata of the cervix originate from intra-papillary inward prolongations of the rete Malpighi of the lips of the os. If the papillae
of the mucous membrane participate to any great extent in the process, a papillo-villous growth results; otherwise the affection consists either of a circumscribed or a diffuse infiltration, occasioned by an ingrowth of the deeper layers of the epithelium into the connective-tissue substratum.
These views are on the whole nothing more nor less than the applica tion of the current hypotheses of carcinoma in general to carcinoma of the uterus. The researches of Ruge and Veit have led these investi gators to entirely different results, and have been widely accepted, especi ally since they allow a readier comprehension of the clinical history of the various forms of cancer. Even the treatment of cancer has been influenced by the results of their anatomical researches. Nevertheless we need further studies before we can decide upon the true value of their investigations. These authors, then, as well as Schroder, distinguish positively between cancer of the portio vaginalis and cancer of the cervix proper. They claim that cancer of the " vaginal portion " never orig inates in the pavement epithelium of the surface, but starts from the deeper connective tissue, or from the newly-formed glands found in erosions. Its boundary line would appear to be the external os, and it does not invade the cervix or body of the uterus. When it extends, the vagina and peri-uterine tissues become affected.
Cancer of the cervix, on the other hand, starts from the connective tissue of the walls of the cervix, from submucous nodules, or from the glands of the mucous membrane. The disease does not extend outward beyond the external os, but very readily passes beyond the internal os, and thus reaches the pelvic cellular tissue.
The simplicity of this description certainly has much in its favor, but we must not forget that daily practical experience shows that the above distinctions are not very easily ascertained. So that while these views may be welcomed as an attempt to elucidate a confused subject, they are not to be received as having finally settled it.
It has recently been demonstrated that carcinoma may develop from adenomata, that is from neoplastic utricnlar glands. Testimony to this fact is offered by cases reported by Breisky-Eppinger, J. Veit, and others.