MASS.
Carcinomatous masses crumble away at the lightest touch, and present minute tissue fragments, while in degenerating myoma the connective tissue and the muscular elements are removable with much greater diffi culty, and show a fibrous structure both to the touch and to the naked eye. The nature of the disease is of course definitely settled by micro scopical examination. The same is true in distinguishing ulcerating polypi; indeed these could in any event only be confounded with the exceptional forms of epithelioma which are actually or only apparently attached by a pedicle to the portio vaginalis, and which in England and in France are designated respectively as " mushroom " and "champignon " epithelioma. It is more difficult to understand how Richet ' could have mistaken an epithelioma of the cervix for a piece of retained placenta. An error of this nature should, it seems to me, exclude itself, when we remember the seat of the disease, and would seem possible only in con nection with an isolated carcinoma of the corpus uteri, a subject which we have yet to discuss.
The diagnosis of cervical carcinoma may sometimes be rendered difficult by reason of reactive inflammation, at any point of the vagina below the focus of disease, with the subsequent formation of a stenosis, sufficiently close to permit only of the escape of small quantities of blood and putrid fluid. On the other hand, it must not be forgotten that similar stenoses are sometimes encountered in the vagina, especially in its upper third, of old individuals. who are free from any cancerous affection.
If catarrhal conditions are present in these cases, the secretions which escape through the aperture of the stricture may assume a foetid character in consequence of stagnation above the seat of constriction. If in such cases a positive diagnosis cannot be made by rectal examination, we must by some means open up the strictured portion of the vagina.
It has been stated on a previous occasion that Liebmann ' observed some cases of " flat epithelioma" commencing in the upper part of the mucous membrane of the cervix, the vaginal portion seeming externally to be perfectly healthy. In these cases the diagnosis wavered between simple cervical endometritis and epithelioma. What argued in favor of the lat ter was not only the foetid odor and sanious tinge of the discharge, circum stances which are certainly rare in endometritis, but above all, the fact that the discharge was entirely devoid of any slimy consistency. More
over, we can easily recognize an enlargement of the cervical canal through deep ulceration. We have here touched on a point which is at once the most difficult and the most important in the diagnosis of cancer of the uterus, namely, the recognition of the initial stage of the disease.
In the same measure as the diagnosis of an ulcerated carcinoma of the portio vaginalis is easy, so is it difficult to detect incipient epithelioma and cancerous infiltration of the cervix underneath the, as yet, healthy mucous membrane. And yet it would be, as we shall see, of really invaluable consequence to us from a therapeutic aspect, could we recognize the first stages of the disease at a period early enough to allow ufit to readily and radically extirpate the degenerated tissues.
Epithelioma of the os uteri always manifests itself at first in the form of the so-called erosion. It may sometimes be differentiated from the ordinary benign follicular erosion of the mucous membrane lining the cervix and that covering its vaginal surface, by the fact that the former is more deeply and evenly excavated and possesses more infiltrated bor ders. The papillae springing from the base of the ulcer are often markedly hypertrophic, bleed very readily, and often exude at any early period the previously described fluid resembling meat juice. which is rarely the case when we have to do with the so-called papillary erosions. Still. some writers regard these very papillary erosions as the initial stage of epithelioma, while others such as Rage and J. Veit' consider them to be the commencement of true carcinoma, so that even an anatomical differ entiation is not always easy, to say nothing of the differential diagnosis during life. The latter may sometimes be established by the observation that in simple erosions (ectropium of the os) the cervical mucous mem brane is swollen, relaxed and soft, while in incipient epithelioma it pres ents a distinct ulcer and seems more than ordinarily adherent to the sub jacent parenchyma. If in addition we notice on the floor of the ulcer large, scattered, hypertrophic excrescences, which bleed freely on the slightest manipulation, our suspicions of incipient epithelioma are strengthened, and if some of these excrescences admit of easy removal by simple scraping with a dull instrument or the finger-nail, the ill-omened diagnosis is established almost to a certainty.