Heitzmann (I. c.) in many respects follows the teachings of Ruge and Veit. He describes, in addition, a variety of cancer resembling epithe lioma of the skin, and corresponding to the " rodent ulcer" of older observers.
Apart from these observations, next to nothing has been written con cerning the initial stages of carcinoma of the uterus Liebman' is of the opinion that epithelioma of the vaginal portion develops oftener than has heretofore been imagined from papillary excrescences of the mucous mem brane of the cervix above the external os, and that it is therefore hidden from direct observation for a long time. Ho reports three cases of this description. Kiwisch, Wagner and others describe a similar condition. Virchow ' in particular reports a case in which the cervical canal was in a state of cancerous degeneration as far up as the internal os, while the external os was perfectly healthy. Starting from this point the cancer ous infiltration had invaded not only the cellular tissue between the blad der and the vagina, but had also involved the lymphatic glands and the vessels of the uterine adnexa, and had given rise to metastatic deposit in the kidneys, the supra-renal capsules, and the cutis. Schrader' mentions a similar case.
}legal.' describes a case in which the vaginal portion had undergone cancerous degeneration, but which at the first glance seemed to differ in no respect from one affected by simple benignant hypertrophy. Micro scopical examination disclosed marked hypertrophy of the connective tissue, with an abundant cellular proliferation, in the meshes of which were scattered collections of epithelial cells having no alveolar boundaries. No papillary excrescences could be detected in the mucous membrane of the cervix, nor was there any evidence of the origin of the neoplasm from the glandular tissue.
Although the title of this chapter would imply that in the con sideration of cancer of the womb we have first to treat of the de velopment of the disease in the cervix, we have nevertheless already identified carcinoma of the uterus with that of the vaginal portion. This is justified by the fact that the disease in the great majority of cases is confined to the cervix. Pichot' believes that an isolated affec tion of the fundus occurs only six times in one hundred cases of carcinoma of the uterus. Blau' found about the same ratio—that is, six instances of isolated affection of the corpus uteri among ninety-three cases of cancer of the uterus. Courty,' indeed, found but one case of this kind
among four hundred and twenty-nine cases of carcinoma of the uterus. The statistics of Forster' yield almost the same result; of four hundred and twenty cases of cancer of the womb, observed in Vienna, but one of carcinoma of the fundus.
Goldschmidt ° observed only one instance among 900 cases of malignant degeneration.
These figures will suffice to show the rarity of isolated, primary cancer of the fundus uteri. Now although it is true, as will be shown later, that recent investigations have demonstrated a somewhat greater frequency of these cases, still it must not be forgotten that quite a number of these tumor formations belong to the group of sarcomata, while others have been merely instances of extension of the disease from other organs to the fundus uteri, and therefore have no bearing on this point.
Of the various forms of cancerous disease of the cervix which we indi cated above, both the fiat ulceration and the papilllary cancerous ulcer should be grouped together under the common name of epithelioma, while the term carcinoma may be restricted to that variety which is located in the deeper tissues of the portio vaginalis, beneath the unaffected mucous membrane. This distinction is not without importance from a symptomatical and therapeutical aspect, but it cannot be strictly main tained, since both forms become similar as soon as necrotic disintegration has set in. Moreover, they are undoubtedly met within combination, or, to speak more correctly, one may become converted into the other. Thus after removal of an epithelioma in the portio vaginalis, one not infre quently finds fresh cancerous nodules developing higher up in the uterus, although there is no recurrence of the epithelioma in loco. For these reasons it is also exceedingly difficult to determine, with any degree of accuracy, the frequency with which epithelioma and carcinoma of the portio vaginalis occur. In this connection I will mention only the results which I have tabulated in a previously published article,' according to which, among 203 cases in which an anatomical diagnosis was possible, there were but 17 in which carcinoma alone, without papillary excres cences, was observed.