Winckel' has more particularly laid stress on the difference existing in this respect between primiparous and multiparous women.
In 130 cases of cancer he found Nevertheless it is an open question whether these facts stand in any causal relation with the development of (lancer in the cervix uteri. As suming the existence of such relation, we may safely leave it to the scien tific convictions of each individual to decide whether he will accept it as evidence of the truth of the theory, concerning the origin of cancer from local irritation, or of the more recent doctrine of the development of ma lignant disease from pre-existing, embryonal disease germs. For my own part I do not see that the assertion of the greater fertility of cancerous individuals lends weight to either theory.
Many investigators believe that the disease not infrequently developer immediately after delivery. West observed this in 11.3 per cent. of his cases. Of 48 cases of cancer recently seen by me there were 9 in which the first symptoms of the malady were observed within one year after the last childbirth, the interval varying from a few weeks to eleven months, and two in which exactly one year had elapsed. H. Chiari' describes these cases of cancer of the fundus uteri, in which the disease developed immediately following the lying-in period, and ended fatally in from three to six months. The patients were between twenty-three and twenty-four years of age. The cancers had originated at the placental site.
W. A. Freund' has described several cases of the propagation of can cerous growths, from the rectum or bladder to the uterus, through the pelvic cellular tissues.
Now since it is well established that secondary cancer of the womb is very rare, and since, in the cases of such an occurrence cited by Freund, the idea of local irritation from sexual intercourse or parturition, was with tolerable certainly excluded (the majority of them being virgins), the author sees therein an indirect proof that primary cancer of the portio vaginalis uteri usually does arise from local irritation.
As long as cancer of the uterus is restricted to the portio vaginalis, and s s long as disintegration has not occurred to the extent of causing ulcera tion, so long may all symptoms of the disease remain totally in abeyance.
'This dictum is a necessary preliminary to a thorough comprehension of Vie course of cancer of the uterus in each and every instance. Perhaps one or more of those symptoms, the description of which will shortly follow, may have been present for but a few weeks or months, while the general condition of the affected individual may be excellent, and yet when we proceed to make an examination, we are often astonished to find wide spread cancerous destruction of the cervix and fornix vagina. This ex plains how it is that the malady runs so rapid a course, once subjective symptoms have declared themselves, and also shows why an affection, so pre-eminently local as cancer of the cervix is, should so seldom be amens, ble to local treatment.
Cancerous degeneration gives rise to no symptoms until ulceration has set in—none of the previously described forms and varieties of cancer of the cervix are exceptions to this rule. At most it may now and then happen that the deeply seated form, that which we have agreed to call carcinoma, may spread to the pelvic connective tissue and form nodular masses in Douglas's cul-de-sac, which may excite pain from pressure some time before the primary infiltration disintegrates. But this is not the rule.
On the w..ole it may be asserted that all or at least the chief symptoms of cancer of the uterus are coincidental in their appearance with ulcera tion in the vaginal portion. Before the development of these ulcers even obscure symptoms will but rarely have been present. The clinical features usually vary distinctly with the anatomical characters of the ulcers, as previously described. Thus, the symptoms accompanying the " flat epithelioma" (Blebs) are rather those of a simple ulceration of the vaginal portion, penetrating more deeply than is ordinarily the case; they consist in a moderately profuse, sero-purulent, inodorous discharge, pro fuse menstruation, and, exceptionally, irregular hemorrhages.