CANCER OF THE WOMB. 155 



scribed knots pushing toward the surface. Even this form of can- 

 cer, however, must derive its origin from preexisting epithelium, 

 probably from isolated cervical glands, and from abnormally dis- 

 tributed vestiges of the primordial epithelial germ. Sometimes the 

 disease takes the form of a firm scirrhus, but more commonly it 

 assumes that of a soft medullary cancer, with a predominance of 

 epithelium and with scanty connective tissue. The infiltration and 

 ulceration travel upward to the internal os, and sometimes even in- 

 vade the body of the womb. Thus not the neck alone, but a large 

 part of the body of the organ, may disappear. An extension of the 

 disease to the vagina imparts to the latter a hard, puffed-up, brawny 

 quality, so that the finger can no longer recognize the os uteri. Still 

 later, the cancerous infiltration of the ureters often causes obstruc- 

 tion of the urine and hydronephrosis (even to the extent of fatal 

 uraemia), and, by invasion of the bladder and rectum, with conse- 

 quent destruction of the septa separating these cavities, large fistulas 

 are formed ; and it has even happened that all three cavities have 

 been blended into one horrible cloaca. The tubes, ovaries, and 

 other pelvic organs, and the muscles, areolar tissue, and even the 

 bones, are finally attacked, either by contiguity or by metastasis ; 

 so that at last the womb is, as it were, walled up by cancerous in- 

 filtration and peritoneal adhesions. More distant regions finally arc 

 invaded the inguinal and retroperitoneal glands, the peritonaeum, 

 omentum, mesentery, intestine, liver, and perhaps even the breast. 



SYMPTOMS AND COURSE. In the earliest stages of uterine can- 

 cer there is slight pain in the back and abdomen, the menstrual 

 flow is augmented, and there is leucorrhrea, which is not at first 

 profuse, except in a case of malignant papilloma. So little is pre- 

 sented to distinguish it from the more unimportant disorders of the 

 sexual organs, that in the beginning the malady is rarely recognized. 

 It would seem, indeed, that that form of it which commences by 

 deep-seated nodules presents no symptoms whatever so long as the 

 mucous membrane remains intact. In many cases no serious symp- 

 toms arise until the cancerous mass begins to ulcerate and break 

 down ; so that the period for operative interference has already 

 passed ere the nature of the malady has been recognized. Indeed, 

 even in the earlier stages, while the mucous membrane remains 

 sound, a local examination will not always reveal the existence of 

 cancer, and the most experienced gynecologists admit that the dis- 

 tinction between a cervix enlarged by cancerous infiltration and a 

 simple hypertrophy of the neck may at first be impossible. Schroe- 

 der describes a condition of the mucous membrane as characteristic 

 of cancer even before the period of ulceration. The membrane is 



