It remains to investigate what connection there is, if any, between tne ordinary functions of the uterus and cancerous metamorphosis. In indi viduals affected with cancer of the womb, the derangements of menstrua tion that may have been present in previous years have usually been of so trifling a nature that they cannot be said to stand in any causal relation to the existing affection. The statements that have been advanced upon this subject, are so contradictory, and are based upon so small a number of cases, that they do not deserve especial mention.' It has previously been pointed out that there seems to be a peculiar predisposition to the development of cancer in the climacteric period. Additional weight is lent to this observation by the statements of Rocque,' who among fifty cases found but eight in which the affection manifested itself before the advent of the menopause.
The current opinion that local mechanical or chemical irritation (trau matism) is the chief exciting cause of the development of local tumors, has also been strenuously advocated in explanation of the occurrence of cancerous degeneration of the cervix uteri. Particular stress has been laid upon two points, on the one hand the frequency, or according to others (Witllier and Scanzoni) the intensity with which sexual intercourse has been practised, together with the emotional excitement accompanying this act, and on the other hand the number of confinements. Without wishing to closely scrutinize here the value of the so-called " irritation theory," it may suffice to state with reference to the above-mentioned causes, that as far as the first is concerned, the local irritation of the os uteri during intercourse is not a very intense one, and with reference to the second, that the severer forms of injury caused by the parturient act, occur relatively but very seldom, and even then are separated by long in tervals.
Furthermore, when it is asserted that excessive emotional excitement is causally connected with the presence of malignant disease of the uterus, it is rather more probable that the former is but a symptom of the early stage of the latter. It is well known that pruritus of the external geni tals is not infrequently dependent upon carcinoma of the uterus. If the opinions entertained by Wernich and others were correct, namely, that the portio vaginalis undergoes peculiar changes of configuration, a kind of erection witn increased downward protrusion into the vagina, in indi viduals who possess hyper-sensitive sexual organizations, we could not deny that excessive sexual excitement is capable of inducing anatomical changes, and yet this would not in any manner serve to explain the im portance of this influence upon the malady now under consideration.
In estimating the significance of sexual intercourse, nothing of moment, for evident reasons, is to be gained by determining whether cancer of the cervix occurs more frequently among the married than among the un married. It has, therefore, been proposed to ascertain whether the affec
tion is especially frequent in prostitutes. As far as my knowledge goes, the attempt has not been made, and I doubt whether it can ever be car ried out with the required precision. For the malady, as we have already seen, usually manifests itself at an age when prostitutes have already long withdrawn themselves from official supervision. Parent Duchatelet ' states that he has observed carcinoma of the uterus in prostitutes much more rarely than he had expected; this statement is corroborated by T5allier, Collineal!, Cullivier and Behrendt. Of 365 females who died in Vienna of cancer of the womb, Glatter (1. c.) found that 91, or almost 25 per cent. were classed as seamstresses (Handarbeiterinnen), and as it is cus tomary for the majority of the Viennese prostitutes to designate themselves by this term, he concludes that this class of women furnish a relatively large contingent of cases of uterine cancer.
The relations existing between cancerous disease and frequent confine ments are more easily determined. In the first place it is remarkable that the disease rarely attacks sterile women. Thus but 121 out of 1540 cases collected by Tanner, West, Scanzoni, Seyfert, Beigel, SchrOder, Winckel and myself had not had any offspring.
It is more difficult to decide what influence the number of births exerts upon the development of carcinoma, since precise and accurate statements as to the number of premature births can but rarely be obtained, and yet these are of just as much consequence as full term deliveries, if one in clines to the opinion that the processes of pregnancy and the expulsion of the ovum are factors of moment in the production of cancer of the uterus.
West computes that every patient affected with this malady has had on an average 5.6 deliveries at full term, and 1.2 premature births, or a total of 6.8 births in all. Scanzoni's estimate is 7.01, Tanner's 6.5, Sibley's Lebeck's 3.9, Beigel's 5.9, Lever's 5.75, Lothar Meyer's 5.5, kers 5.6, SchrOder's 5.02, and my own 4.5. It has been found that in Prussia every married woman has on an average 4.6 children, in England 4.2, and in France 3.4. Assuming the correctness of these figures it is undeniable that those women who become at some future date the sub jests of carcinoma, are more fruitful than other women. We arrive at the same conclusion when we compare statistics on a larger scale than those given singly by the above-mentioned authors. Thus, the grand total of children brought into the world by 580 patients (of West, Tan ner, Scanzoni, Lever, Seigel, Lothar Meyer, and myself) was 3025, an average of 5.1 children to each woman, which certainly exceeds that of the average married women as estimated above.