vagina may be readily made. In elongation of the vaginal cervix the fundus uteri is at the normal level; there is no inversion of the vagina; the vaginal fornices are in the normal position.

Elongation of the vaginal cervix to a degree sufficient to be considered pathological is very rare.

The treatment consists in amputation of the cervix. Chancre of the Cervix.-Chancre of the cervix is a rare lesion. One observer, Rassennone, found 117 uterine chancres in a series of 1375 cases of venereal sores on the female genitals. The sore may occur on either lip of the cervix and may extend into the cervical canal. The appearance is that characteristic of similar sores in other parts of the body.

The diagnosis may be made from a history of coitus with a man having active syphilis, by microscopic examination if necessary, and by the later appearance of secondary syphilitic symptoms.

Tuberculosis of the Cervix.-Tuberculosis of the cervix is a very rare condition. The appearance of the cervix in such cases resembles that of cancer. In fact, hysterectomy has been performed for this condition under the mistaken diagnosis of malignant disease.

The diagnosis may be made by the microscopic examination of the discharge and of excised tissue.

Complete hysterectomy should be performed for tuberculosis of the cervix.

CHAPTER XVI.

CANCER OF THE CERVIX UTERI.

CANCER of the cervix uteri is a very common disease. About one-third of all cases of cancer in women affect the uterus. Like cancer in other parts of the body, the disease has been observed at almost every period of life except infancy. It occurs most frequently during the active mature life of the woman, between the ages of thirty and fifty. It is probable that more cases occur during the latter decade of this period than during the former.

Cancer of the cervix is a disease of the childbearing

woman.

ceived.

It is very rare in women who have never conStatistics show that women who develop cancer of the cervix have borne on an average five children. The stout, well-nourished mother of a large family is very prone to cancer of the cervix.

It is probable that the chief predisposing cause of cancer of the cervix is a fissure or laceration caused by miscarriage or labor. A focus of irritation, a point of diminished resistance, is thus developed, where cancer may start in a woman predisposed to this disease. In some of the cases of cancer of the cervix occurring in sterile. women it has been found that previous traumatism had been inflicted by dilatation or incision of the cervix.

Cancer of the cervix uteri originates in one of three structures: I. The squamous epithelium covering the vaginal aspect of the cervix; II. The cylindrical cells lining the cervical canal; III. The epithelial cells of the cervical glands.

The early appearance of the disease, the gross form assumed by the cancer, the direction of growth, and the

clinical course depend upon the place of origin. In the late stages of the disease, characterized by extensive destruction of tissue, all forms appear alike.

I. Cancer of the vaginal aspect of the cervix very often begins in a benign erosion of an old laceration. The early stages of transition from the benign to the malignant condition are not apparent to the unaided senses, and can be recognized only by the microscope. Later a superficial ulceration is developed, or the cancer may

FIG. 114.-Cancer of the vaginal aspect of the cervix.

assume the polypoid or vegetating form, and become. readily recognized by the unaided senses.

It will be remembered that true ulceration as a benign condition is very rare on the cervix uteri. The erosion of a laceration is in no sense an ulceration. An ulceration of the cervix, therefore, should always excite the gravest suspicion. The polypoid or vegetating growths vary very much in size. They are sometimes very exu

berant, forming large cauliflower-like masses filling the upper part of the vagina (Fig. 114). In other cases they are small warty growths or rounded protuberances about the size of a pea. The disease usually spreads to the mucous membrane of the vagina. Less often it extends to the cervical canal and to the body of the uterus.

II. When the cancer begins in the mucous membrane of the cervical canal, extensive destruction of tissue may take place before any appearance of the disease is ob

8

FIG. 115. Cancer of the cervical canal.

served at the external os (Fig. 115). This is most likely to occur in those cases in which there is not present a bilateral laceration of the cervix with eversion of the mucous membrane. In some cases the whole of the cervix is destroyed, leaving only a shell, the lower portion of which is the vaginal aspect of the cervix.

When the cervix is lacerated and the mucous membrane of the canal is exposed, the disease is more early apparent, and we may then observe the malignant ulcera

tion of the exposed mucous membrane or the presence on it of cancerous outgrowths. This form of cancer of the cervix uteri is more likely to extend upward to the endometrium than is the form first described.

III. When the cancer begins in the distal ends of the cervical glands, it may appear as a nodule in the body of the cervix. It will be remembered that sometimes these glands become so distended peripherally that they appear beneath the mucous membrane of the vaginal aspect of the cervix as Nabothian cysts. In a similar way, when the glands become seats of cancerous infection,

FIG. 116.-Nodular cancer of the neck of the uterus (a) (Ruge and Veit). hard nodules of various size may appear or be felt beneath the vaginal mucous membrane. In other cases the nodule is situated beneath the mucous membrane of the cervical canal. These nodules disintegrate and perforate the overlying mucous membrane, and in this way form a malignant ulcer which may appear either in the cervical canal or on the vaginal aspect of the cervix.

As has been said, when ulceration and destruction take