As regards the further progress, Schroeder distinguishes three modes of the spreading of the disease: first, upwards, into the body of the uterus; second, downwards, into the vagina; and, third, into the connective tissue of the pelvis. This last is the most important. It takes place either by a

Section of a flat cancroid (epithelioma) of the cervix. e, squamous epithelium; cc, carcinomatous cells; between these is seen some granulation tissue (Schroeder).

continuous infiltration of the adjacent connective tissue, or as a chain of nodules running in the direction of the utero-sacral ligaments; these nodules, probably, correspond to lymphatic glands.

In its further progress, the carcinomatous growth invades the surrounding organs. Pushing its way forwards in the cellular tissue between the bladder and the uterus, it involves the mucous membrane of the former; it first produces vesical catarrh, then sloughing of the walls, and finally vesico-vaginal fistula. The bladder is affected in a considerable proportion of cases; of 311 cases of carcinoma this occurred in 41 per cent., fistula resulting in 18 per cent. (Gusserow). From the position of the ureters, they are frequently involved. The carcinomatous growth may press upon the ureters near their point of entrance into the bladder, or it infiltrates their walls and the consequent thickening produces constriction at the part affected. Thus results dilatation of the ureter above, which produces hydronephrosis and finally atrophy of the kidney. The frequency of this condition will be apparent from the fact that Blau found it

present in 57 out of 93 post-mortem examinations. More rarely does the carcinomatous infiltration extend backwards into the rectum and

Carcinoma beginning in the cervix uteri, and ending in the production of recto-vesico-vaginal fistula (Farre).

produce recto-vaginal fistula; of 282 cases the rectum was affected in 18 per cent., fistula resulting in 8.5 per cent. (Gusserow). When both

Fig. 274.

Vertical mesial section of pelvis, from case of carcinoma uteri. a, perineum; b, symphysis pubis; c, rectum; d, body of uterus; e, small fibroid; f, urethro-vaginal septum; g, bladder. A small tube passes between bladder and excavated cervix through a fistula (Barbour).

bladder and rectum have been opened into, a common cloaca is produced as in Fig. 273.

Perforation into the peritoneal cavity is rare. The peritoneum is not simply pushed forward, but is taken up into the carcinomatous growth. As this process goes on, adhesions are constantly being formed between the walls of the peritoneum in front of the growth so that it does not project free into the cavity beyond. These adhesions further prevent the peritoneal cavity from being opened into when the carcinomatous mass breaks down.

The accompanying sections, made from post-mortem preparations, will serve to illustrate some of the points noted above.

Points to be noted in Fig. 274.

1. Seat of disease in the cervix;

2. Complete destruction of the cervix and lower segment of the uterus;

Vertical mesial section of pelvis, from case of carcinoma vaginæ et uteri. f, points to vagina eroded by disease; e is a malignant growth attached to uterus.

Other letters as in Fig. 274 (Barbour).

3. Production of an irregular cavity through the extension of the disease in three directions through the cellular tissue

(a) Behind the uterus,

(b) Between the uterus and the bladder,

(c) Between the vagina and the bladder.

4. The pouch of Douglas entirely obliterated and partially replaced by the carcinomatous excavation, the vesico-uterine pouch shortened by adhesions, perforation into the peritoneal cavity at one point;

5. Bladder small and contracted, carcinomatous fistula ;

6. Rectum intact.

Points to be noted in Fig. 275.

1. Vagina (as well as cervix) affected, the nymphæ had a cartilaginous consistence, inguinal glands enlarged—although not shown in figure;

2. Extension of the disease along the mucous membrane of the uterus, excavating it though not destroying the walls to the same extent as in Fig. 274;

3. Partial obliteration of the pouch of Douglas;

4. Bladder dilated through pressure on the urethra, its walls apparently not involved;

5. Rectum intact.

ETIOLOGY.

The female sex is more liable to carcinoma than the male. According to Sir J. Y. Simpson's statistics, the proportion is as 2 to 1. These statistics are drawn from the annual reports of the Registrar-General for England during the years 1847-1861. During that time there were 87,348 fatal cases of carcinoma, of which 61,715 were among women and 25,633 among men. For the year 1860, the deaths from carcinoma among men were .97 per cent. of the total male mortality, among women were 2.2 per cent. The cause of this greater relative frequency is connected with the development of the sexual organs in the female. Up to puberty, the mortality (from carcinoma) of the sexes is the same; afterwards, the relative proportion of female to male deaths gradually rises till it attains its maximum about the age of 50, after which it falls away again (Fig. 276).

The diagram on page 140 is based on the statistics of 91,058 deaths in Great Britain. It brings out three facts: the total number of deaths in each sex increases with age to a certain point; the increase among women is relatively the greater; it reaches its maximum at an earlier age with the female sex.

The most frequent seat is in the uterus, where fully one-third of the total cases occur; the next in frequency is the mamma.

Although the immediate etiology of carcinoma is unknown, there are certain causes, general and local, which favour its development.

1. The general predisposing causes are the following:

Heredity;
Age;

Depreciation of the vital powers.

Table and diagram of comparative fatality of carcinoma in male and female, according to age. In the diagram, the upper line indicates mortality in female, the lower that in the male.