We have ourselves seen extension of a cancroid, and found in the re moved tumor all the microscopic appearances of the disease. These ob servations are of the greatest interest, while they speak in favor of the local nature of the cancroid, although this very important fact has not been with certainty established. It is noteworthy, however, that cancroid of the external genitals seldom extends to the vagina, and that primary carcinoma of the vagina only rarely invades the vulva. (Mayer.) Infiltration of the glands begins late in case of cancroid. This form of cancer remains local for a relatively long time. If the first chain of glands is affected, the changes in them react unfavorably on the ulcera tion of the labia. The labia swell more and the disease extends rapidly. The progress of the disease varies much. In certain cases the infiltration and ulceration spread from its starting-point on to the perineum and the thigh, in others the lymph-glands are speedily invaded, and infiltra tion and ulceration in the inguinal folds result.
Symptoms and Progress.—In the early stage the nodules may remain stationary without symptoms, and even without attracting attention. Generally for a long time the only symptom is pruritus. When ulceration occurs a new stage begins, characterized by rapid increase, and usually death follows within two years. When the ulcerative stage has set in, the course of the disease cannot be checked. Death occurs after long grad ual sinking of the vital forces, the result of the pain, loss of sleep, lack of appetite from the disagreeable odors. Generally profuse hemorrhages, such as accompany cancroid of the uterus and the other carcinoma forms of the vulva, are here absent. The patients die of cachexia and of chronic septic infection.
As for the etiology of cancroid, we know very little of a certain nature. The only fact known is that its development in the later years of life is greater than is the case with cancer of other organs. But relatively few cases are met with in earlier life. According to L. Mayer's statistics, in 13 observations 7 women were between fifty and sixty years, 3 between thirty and forty, 2 between forty and fifty, and one between sixty and seventy. Hildebrandt's 3 cases were respectively fifty-three, fifty-six and sixty-two years of age.
Winckel's statistics are: West constitutes the only exception in regard to the influence of old age, in that he saw a case of cancroid of the vulva in a woman of thirty one. In one of Winckel's cases cancroid developed from a wart of the clitoris, at the age of sixty-four. Heredity, for long believed to be influ ential as a factor, may be ruled out. Ordinarily the cancerous tumor is
primary on one labium, and thence spreads. L. Mayer, however, has reported an instance where the disease existed concomitantly on both labia. As regards the influence of traumatism, in West's case, aged thirty-one, the cause was laid to a fall, five months previously, against a chair, followed by contusion and profuse hemorrhage. When West first saw the young woman the tumor was already deep enough to allow the placing of a nut in its cavity. It must be considered improbable that the disease may result from scratching of the genitals. That pruritus is ordinarily a concomitant of the disease, is proved by instances where the women have been examined at this stage, and a cancroidal nodule was detected.
Immediate excision of the nodules in an early stage not only leads to amelioration, but even to radical cure. The knife must be used, and the removal must be complete, the excision extending into sound tissue. Rokitansky uses the thermo-cautery. We do not think that this has any advantage over the knife, in.rogard to lessened hemorrhage, or, better, re moval of all the diseased tissue, and therefore we do not favor it. Ilemor rhage at the best is never so profuse that it cannot be checked, and there fore we favor the knife and consecutive suture of the wound. The patients, however, are usually seen too late. When the glands are affected, even though not suppurating, there is little ground for hope of ridical cure, for even careful removal of each affected gland does not guarantee against recurrence.
On the labia, where it is possible to remove all of the tissue, this should be carefully done. After the excision of the cancroid with the knife, thermo-cautery or galvano-wire, the cancroid should be touched with fuming nitric acid. Two years ago I operated on a woman of seventy five years of age, from whom nine years previously Schroeder had extir pated a cancroid of the right labium. In the spring of 1881 she noticed a nodule on the other labium, which had acquired considerable size be fore she was operated upon. In November, 1:381, the disease had spread to the clitoris, and notwithstanding careful removal, she died three years thereafter of recurrence.
Medullary carcinoma (glandular cancer), scIrrhus and sarcoma are seen less frequently on the vulva than cancroid. Louis Mayer only saw four cases in his extensive practice, Hildebrandt three, Schroeder two, West one, and we have seen one. Of Mayer's four cases, two were scirrhns, two sarcomata, and Hildebrandt had two scirrhus and one sarcoma. Blob, Baily, and Prescot report instances of melanotic carcinoma of the vulva.