When we consider the extraordinary frequency of primary carcinoma of the uterus, it is very striking how seldom metastases occur in the uterus, in general carcinosis, originating in other organs. Wagner found only five cases of the kind. Klebs substantiates the same fact, adding that when the uterus is secondarily affected the disease is usually situated in the peritoneal investment of the organ, very rarely in the mucous mem brane.
In cancer of the different organs of the pelvis the disease more often spreads by continuity to the uterus, a point to which we will again refer in discussing carcinoma of the fundus uteri.
Before discussing the causes of the local disposition of the uterus to cancerous disease, it is necessary to determine the frequency of cancer in general. Statistics show that carcinoma of the uterus is an exceedingly common affection, particularly in Europe.' According to the thirty-second annual report of the registrar-general of England (Tanner, 1. c.), the population of that country in 1860 was *mated at 19,902,918; the mortality in the same year was 422,721, 215,238 men and 207,433 women. Of these deaths 6827 were put down as due to " cancer," 2100 occurring in males and 4727 in females, the latter sex, therefore, showing a preponderance of 2627. Another table issued by Hirsch' yields similar results. Thus in the year 1855 the population of England was 18,737,000, 9,427,000 being males, and 9,360,000 females. Of this number 6016 died of cancer, 1825 being men and 4191 women, an excess of 2366 in favor of the latter. The mortality resulting from cancerous disease was 0.32 in 1000 people, 0.19 in 1000 males and 0.44 in 1000 females. On comparing still larger statistics it will be found that twice as many women as men die of cancer. Accord ing to the registrar-general ' 87,348 people died of cancer in England, between the years 1847 and 1861; of these 61,715 were women, 25,633 men. The intimate connection between the above great preponderance of mortality in the female sex,. and cancer of the genital apparatus (including malignant affections of the mamma), is ehown by the fact that cancer befalls boys and girls in about the same ratio up to the age of fif teen, while from this time on, that is coincidently with the commence ment of puberty, the percentage augments very rapidly to the detriment of the female sex. This is more clearly demonstrated by the following table of 91,058 deaths from cancer (England and Scotland) which I have copied from Simpson (I. c,) This disproportion is rendered still more conspicuous by the frequency of carcinomatous disease of the uterus and mamma, if we examine more closely the statistics relating to the development of malignant tumors of the various organs in both sexes.
Schroder gives a compilation according to which, of 19,6e6 women who died of cancer, 6548 succumbed to carcinoma of the uterus. The statis tics tabulated by M. d'Espine and Virchow,' show the relative fre quency of cancer in various organs still more precisely. In these cancer
of the uterus ranks second, constituting 15 per cent., while cancer of the stomach constitute 45 per cent, of all cases of the disease. Virchow sets the percentage of cancer of the stomach at 34.9, and that of cancer of the uterus at 18.5. The tables arranged by Picot (1. c., p. 1183) yield sub stantially the mine figures, as follows: That is, of every 100 cases of cancer observed in the hospitals of Paris, 51 were located in the uterus and mamma. The statistical examinations of Sibley and others show the same relation. The absolute frequency of cancer of the uterus is most strikingly demonstrated by the tables com piled by E. Wagner from the records of 5122 post-mortem examinations in Vienna, Prague and Leipsic. Cancer was the cause of death in 441 cases, the uterus being the seat of the disease in 113 instances. That is, of the total mortality 8.6 per cent. was due to cancer in general, and 2.2 per cent. to cancer of the uterus.
The explanation of this great prevalence of cancer is, however, very unsatisfactory. Before entering into the etiology of carcinoma of the uterus, it will be advisable to first refer to two factors which are always alluded to in the etiology of cancerous diseases in general. These are age and heredity. As regards the former, it may be stated that all in vestigators agree in the assertion that cancer is essentially a disease of mature years. Thus, out of a total of 3385 cases of carcinoma uteri col lected by Lever, Kiwisch, Chiari, Scanzoni, Saxinger (Seyfert's clinic), Tanner, Hough, Blau, Dittrich, Lothar Meyer, Lebert, Glatter, Beigel, Schroder, Schatz, Winckel, Champneys and myself, we find That is, with but two exceptions, cancer of the uterus scarcely ever occurs before the twentieth year of age, at any rate not before puberty, and not even in the first few years after this period. Between the ages of thirty and fifty the frequency of the affection increases with great rapidity, subsides slowly between fifty and sixty, and decreases quickly after this age. One might from this conclude that the period of mature sexual development is most disposed to the occurrence of cancerous dis ease of the uterus, but a closer inspection of the above table shows, on the contrary, that the greatest susceptibility exists between the ages of forty and fifty, and almost as great a one between fifty and sixty, that is, just in the climacteric years. This last conclusion is substantiated by the statistical investigations of Glatter,' who found that the proportion of living women rapidly diminished with each successive year after forty five years of age. For example, of every 1000 females living in Vienna in the year 1864, 193 were between forty-one and fifty years of age, 122 between fifty and sixty, while there were 336 between twenty-one and thirty, and 249 between thirty and forty years of age. The mortality from cancer of the uterus was, according to the same authority, of all deaths occurring in females: .