When we have to do with a papillary epithelioma, however, or with the more deeply seated carcinoma, ulceration occurs only in consequence of superficial gangrene and decomposition, and the symptoms are 'therefore of a corresponding nature, irregular hemorrhages, and the discharge of fetid, purulent and sphacelous masses.
It will be seen from the foregoing that the most constant indication of a disintegrating cancerous mass is hemorrhage. This is usually also the first symptom, being preceded by a somewhat profuse discharge, or by pain in exceptional instances only. It was the first symptom in about fifty out of every sixty cases of far-advanced cancerous ulceration observed by myself.
This preponderance, of course, may be explained on the assumption, that a bloody discharge is far more likely to attract the attention of the patient and to be fixed in her memory than would other more obscure and indefinite symptoms.
The nature of the hemorrhage varies. In women who still menstruate the first thing that is generally noticed is a more or less profuse flooding at each menstrual epoch, which the patients as a rule attribute to impend ing change of life. It soon becomes evident, however, that the menstrual flow has lost its normally intermittent character and a more or less con tinuous discharge is established of a sanguineous fluid, which the patients liken to the juice of raw meat. Iii other cases severe hemorrhages often recur at irregular intervals, and this is usually the first symptom which attracts attention in women who have passed the menopause; it is then apt to be regarded merely as the reappearance of the menses.
While the destructive metamorphosis of cancerous masses, then, is gen erally ushered in and accompanied by free hemorrhage, there are not a few cases, especially flat epitheliomata, where there is only a constant discharge of fluid of a reddish tinge, now and then containing a few streaks of blood. In these cases genuine hemorrhage scarcely ever or very rarely occurs. In other cases, particularly in the incipient stages of papillary epithelioma, an insignificant hemorrhage takes place only after traumatism, most often at first after sexual intercourse, or as the result of physical over-exertion, violent straining at stool, and the like. The more rapidly the cancerous masses break down, with the correspondingly luxuriant reformation of the papillary excrescences, (these two processes go hand in hand, as is well known), the more frequently and profusely does hemorrhage recur. so that extreme anaemia is rapidly induced.
Later on, the more extensive the area of sloughing and gangrene, the more rapid is the destruction of the cancerous infiltration, and therefore the sooner do the profuse hemorrhages cease, to give way to a sero sanguinolent discharge. In this stage we see only now and then a rather free loss of blood, as when a large vessel is perforated.
This is the reason why in so many instances hemorrhages cease entirely towards the close of the malady. It is nevertheless remarkable that one scarcely ever hears of a death from hemorrhage in these cases.
Although, as we have just seen, hemorrhage is an occurrence seldom absent in cancerous ulceration, there is one symptom which is, if possible, still more constant, namely a discharge from the vagina. Like hemor rhage this sometimes manifests itself before the neoplasm begins to break down, and it then either closely resembles an ordinary leucorrhcea or is more watery (in epithelioma). As soon, however, as a proliferating epithelioma gives rise to hemorrhage, the discharge generally approaches more to the nature of blood-serum, and becomes quite free, without hav ing any particularly penetrating odor.
Flat ulcerating epitheliomata excite a somewhat similar, but more purulent and certainly less abundant sero-sanguinoleut discharge.
As soon, however, as gangrene attacks either of the various forms of cancer of the cervix, the discharge acquires a more or less pronounced and disgustingly fetid odor, and, while still possessing a very thin consist ence, becomes of a dirty brown color in consequence of the admixture of fragments of sphacelated tissue.
The two symptoms that have just been described comprise all that is characteristic of the cancerous ulcer. Although very few cases of cancer of the uterus run their course without occasioning pain, yet the latter is by no means an essential symptom, inseparable from the existence of the disease as such. On the contrary as long as a cancerous ulcer is restricted to the portio vaginalis it in most cases neither excites pain nor is it sensi tive on manipulation. In those cases in which at an early period pain is complained of in the pelvis, abdomen, or back, there certainly exists some inflammatory irritation in the vicinity of the original focus of disease.