Even when we adopt the newer classification, as given above, the same difficulties present themselves. Thus Ilofmeier has collected 812 cases of cancer of the uterus observed at Schroder's clinic. Of this number 236 cases involved the portio vaginalis, 181 the cervix, and 28 the body of the uterus. 367 cases could not be classified.
This corresponds with what nas been recognized from time immemorial by all close observers, namely, that cancer of the uterus in the great majority of cases, not only commences as a localized affection of the cervix, but also retains its local character up to the very end; the rarity with which epithelioma, in any part of the body, becomes generalized, has long since been recognized. Instances of epithelioma of the portio vaginalis. with disseminated deposits in distant organs, so-called metastases, un doubtedly occur, but they are exceedingly rare. Those cases of cancer of the uterus which have been found associated with metastases elsewhere, were in all probability cases of carcinoma of the body of the uterus, in the above-defined sense of the term. Both forms of cancer extend by simple continuity to the neighboring tissues and organs. Beginning at the portio vaginalis, the affection very soon passes the internal os and attacks the body of the uterus. (In 93 cases Blau, 1. c., found that in 87 the disease unquestionably began in the cervix uteri, being confined to this situation in 48, and extending beyond the internal os in 31 cases.) While then in epithelioma the invasion of the neighboring organs occurs in the guise of an ulcerative process, in carcinoma the affection advances as a more or less continuous series of deposits in the pelvic connective tissue, transforming this rapidly into a firm, rigid and nodulated mass.
Epitheliomatous ulceration and cancerous infiltration almost alwaysex tend to the vagina, whenever the destruction of the vaginal portion has progressed to any considerable extent. Wagner (I. c.), whose observations were based almost exclusively on post-mortem examinations, found that this was almost invariably the case. Blau (L c.) states that this occur rence was noted in 75 out of 93 cases recorded in the journal of the Pa thological Institute of Berlin.
Infiltration of the peri-uterine cellular tissue within the pelvis leads cancerous involvement of the pelvic lymphatic glands (in 30 out of 92, according to Blau) and of the ureters. Epitheliomatous destruction in particular very often attacks the bladder. Thus, in a total of 218 cases, Wagner observed cancer of the bladder in 83 instances, that is in 38 per cent.; in 28 of these fistula' were present. Blau met with cancer of the bladder in 43 out of his 93 patients. Similar figures hold good as regards the extension of the disease to the rectum. This complication was ob served by Blau and Wagner in fifty-three out of two hundred and eighty two cases, fistulas having been produced in twenty-four cases.
The affection also generally spreads directly to the ovaries; this was noted forty-nine times in the above total of two hundred and eighty-three cases. In Blau's ninety-three cases the lumbar glands were involved in twenty-four, the soft tissues of the pelvis in twenty-three, and the retro peritoneal lymphatic glands in fifteen cases.
Direct extension of cancer to the peritoneum is decidedly more rare, probably because the growth becomes encapsulated and separated from the peritoneal cavity by newly formed connective-tissue, usually at a very early date. This complication was observed in only eighteen out of 2C4 cases. It is still more rare to find cancer of the uterus extending directly to the pelvic muscles and bones, or to the urethra and external genitals.
The following figures will serve to convey an idea of the frequency with which metastases occur. In 283 cases of cancer of the uterus, metastatic deposits were found 22 times in the liver and as often in the lungs. In 166 cases collected by Kiwisch (73) and Blau (93) secondary deposits were found six times each in the bones and pleura; five times each in the in guinal glands, stomach, bronchial glands and kidneys; three times each in the thyroid gland, mediastinal lymphatic glands and heart; twice each in the brain, supra-renal capsules, mesenteric glands, jejunum, lumbar verte brm and cutis; once each in the gall-bladder, duramater, external genital organs, muscular system and mamma.