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. It is very
rare in women who have never conceived. Statistics 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, an area 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 first variety is called squamous-cell
carcinoma of the cervix. The second and third varieties are called
adeno-carcinoma of the cervix.
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 (squamous-cell carcinoma)
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 assume the polypoid or vegetating form, and become readily
recognized by the unaided senses.
[Illustration: FIG. 114.--Cancer of the vaginal aspect of the cervix.]
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 exuberant, 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
(adeno-carcinoma), extensive destruction of tissue may take place
before any appearance of the disease is observed 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.
[Illustration: FIG. 115.--Cancer of the cervical canal, with metastasis
to the vagina.]
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 ulceration 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
(adeno-carcinoma), 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, 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.
[Illustration: FIG. 116.--Nodular cancer of the neck of the uterus
(_a_) (Ruge and Veit).]
As has been said, when ulceration and destruction take place, in the
last stages of the disease, all the varieties of cancer present a
similar appearance and are accompanied by similar symptoms.
Cancer of the cervix uteri may extend to the vagina, to the body of
the uterus, to the broad ligaments, the bladder, rectum, ureters, and
the peritoneum, and it may be carried by the lymphatic vessels to the
pelvic and inguinal lymphatic glands.
In nearly all cases of long standing the upper part of the vagina is
involved. Sometimes the whole of the vaginal canal, from the cervix to
the vulva, is infiltrated with cancerous growths.
The body of the uterus always becomes involved sooner or later. This
is most apt to occur in those cases in which the disease begins in
the cervical canal. The endometrium is affected by direct extension,
the malignant disease being often preceded by some benign form of
endometritis.
Sometimes the cervix becomes hypertrophied by general infiltration to
three or four times its usual size.
The broad ligaments are very usually involved by direct extension of
the disease. They become thick, hard, and very rigid, holding the
uterus fixed in the pelvis. When only one ligament is affected, the
uterus is drawn to that side. The ureters become involved by extension
of the infiltration to their walls or by pressure upon them by the
thickened broad ligaments.
The bladder, on account of its close relationship to the cervix,
is always involved in the last stages. The disease may extend to
the vesical mucous membrane, and symptoms of cystitis will appear.
Sometimes the vesico-vaginal septum is destroyed and a urinary fistula
results. Extension to the rectum is not so common. As the disease
extends upward the peritoneum may be perforated, though this is an
unusual accident. In most cases peritoneal involvement is preceded by
local inflammation and by adhesions which prevent direct penetration of
the peritoneal cavity.
The pelvic and retroperitoneal lymphatic glands become affected in the
later stages of cancer of the cervix.
The inguinal glands are rarely involved in the last stages of the
disease. Metastasis to remote parts of the body is unusual. Cancer of
the cervix usually remains localized and does not become metastatic.
From this description it will be observed that in the early stages of
cancer of the cervix the disease presents a variety of appearances.
As cure of the disease depends upon its early recognition, it is of
the utmost importance that the physician should be familiar with these
early phenomena.
When cancer begins in an erosion of a laceration, we find that the
eroded surface bleeds more easily than in the non-malignant condition,
and is somewhat more elevated than the surrounding surface of the
cervix. We may by palpation detect around the erosion a more or less
indurated edge which is not felt around a benign erosion. The submucous
structures of the cervix may feel brawny and indurated. If the erosion
has become an ulcer, the indurated edges and the involvement of the
deeper structures of the cervix are more marked. It must always be
remembered that an ulcer of the cervix is very rare as a benign
condition.
In the vegetating form of cancer of the cervix we may find small warty
growths, or large cauliflower-like masses, or rounded or irregular
protuberances growing from the surface of the cervix. There is here
also felt an induration around the base of the growth and throughout
the cervix.
A very striking characteristic of cancerous growths of the cervix uteri
is their friability. The warty growths or cauliflower-like masses
break off readily upon even gentle palpation, and profuse bleeding
often results. There is no other disease of the cervix in which the
outgrowths are of such a friable and vascular character. Even in the
ulcerated form of cancer the edges of the ulcer are of this same
friable nature.
When the disease begins immediately within the external os, this
opening becomes enlarged, the cervical canal is destroyed, and there is
presented the appearance of a deep conical excavation, with ulcerated,
unhealthy edges, in the center of the vaginal cervix. When the disease
begins still higher up, the cervical canal may be the seat of extensive
destruction of tissue before any lesion is visible below the external
os. Usually, however, the os is sufficiently open to permit the
condition of the canal above to be seen.
When the disease begins in the racemose glands of the cervix, the
nodules may be felt beneath the mucous membrane of the vaginal aspect
of the cervix. The whole cervix is usually indurated and somewhat
enlarged. The mucous membrane overlying the nodule may appear
congested, and upon palpation it is found that the overlying mucous
membrane does not glide readily over the nodule, but seems to be more
than normally adherent to the underlying structures.
In all the forms of cancer of the cervix there is present to a greater
or less extent a general induration of the cervix. The elasticity or
resiliency of the cervix is diminished or lost; this is shown not only
by the sensation upon palpation, but by the fact that the cervix is not
capable of dilatation, by sponge tent or otherwise, as in the normal
condition.
In the last stages of the disease the gross appearance is the same
in all forms of cancer of the cervix. The cervix may fill the whole
vaginal vault, sometimes hypertrophied to the size of the adult fist.
The presenting mass is ulcerated, gangrenous, and covered with friable
vegetations bathed in thin fetid pus and blood. The vaginal vault
itself is usually involved by extension of the disease. The body of
the uterus is found to be enlarged, and the mass of the cervix is held
rigidly in the pelvis by the thickened cancerous broad ligaments.
In some other cases, instead of a protruding mass we discover an
immense crater in the vaginal vault--a crater with indurated edges and
sides, surmounted by the body of the uterus. The size of the crater
shows that the destruction of tissue has extended far beyond the normal
limits of the vaginal and supra-vaginal cervices. The interior of the
crater presents an ulcerated, sloughing surface.
There is no condition which should be mistaken for cancer of the cervix
in the last stages. A sloughing uterine polyp presents superficially a
similar appearance, but the gangrenous mass will be found surrounded
by a ring or collar, often very attenuated, of healthy cervical
tissue, and the presenting tumor is usually elastic to the touch, not
unyielding and friable like the cancerous mass.
In the early stages of cancer the appearance resembles closely the
erosion of a bilateral laceration of the cervix. In the simple
laceration, however, the erosion is soft, not indurated; there are no
palpable edges; the cervix is not brawny; and it will be found that the
simple erosion yields to local treatment, while the cancerous erosion
does not.
Syphilitic ulceration and the ulceration of lupus are very rare upon
the cervix. Syphilitic ulceration sometimes presents all the gross
appearances of cancer. The history, the microscopical examination, and
the therapeutic test will enable one to make a differential diagnosis.
Cystic degeneration of the cervix should not be mistaken for the
nodular form of cancer, for the cysts may be seen and punctured and
their character determined.
Benign fibroid tumors of the cervix are very rare, are usually single,
and are larger than the nodules of cancer.
In every case of doubt, in every case in which the physician has
the least cause to suspect malignancy, microscopic examination of
an excised portion of tissue should be made. Examination of tissue
scraped off should not be relied upon. The most suspicious portion of
tissue should be seized with a tenaculum and freely cut out. Pieces of
tissue may be thus excised from two or more situations. In the nodular
form of cancer a nodule should be seized and excised. It is perfectly
justifiable, in cases which cannot thus be elucidated, to amputate the
cervix and examine the whole structure.
The excision of small pieces of tissue may be done without an
anesthetic, as little or no pain is caused by the operation. Bleeding
is very slight, and may always be controlled by a light vaginal
compress of gauze or cotton. If the case is not malignant, healing is
rapid. The specimen removed should be placed in absolute alcohol and
submitted to microscopical examination by an experienced pathologist.
=Symptoms of Cancer of the Cervix.=--A study of the early symptoms of
cancer of the cervix is of the greatest importance. In the early stages
the disease may be eradicated with every probability of permanent cure.
Cancer of the uterus is more favorable for surgical attack than cancer
in most other parts of the body. Excision of the disease is not done in
the continuity of an organ or a structure, but the whole organ attached
by distinct structures may be removed.
The great majority of women with cancer of the cervix come to the
operator when the disease has extended too far to permit any radical
treatment. Hopeless palliation is the only course to be followed. This
unfortunate condition of things is due to the ignorance of the woman in
regard to the significance of the early symptoms of the disease, and to
the failure of the physician first consulted to insist upon a thorough
examination as soon as any suspicious symptoms appear.
There is no one symptom of cancer of the cervix present in all cases,
and all the common symptoms may be absent in exceptional cases until
the last stages of the disease--until the disease has extended so far
that cure is impossible. It is of great importance to remember this
fact, so that the absence of one or more of the classical symptoms of
cancer shall not engender a feeling of security that may cause the
postponement of a thorough physical examination.
The usual symptoms of cancer of the cervix are hemorrhage, pain, and
discharge.
_Hemorrhage._--The first symptom that should direct our attention to
this disease is bleeding from the vagina. Such hemorrhage often first
appears as a menorrhagia--as an increase in the amount of blood lost
at the normal menstrual periods. The loss of blood may be greater,
and the duration of the period longer. Sometimes, if the woman keeps
quiet during the period, the loss of blood and the duration are about
as usual; but if she is upon her feet the loss is increased, and if
she begins an active life immediately after the usual duration of the
menstrual period has elapsed, bleeding may reappear for one or more
days.
In other cases slight bleeding appears in the menstrual interval. A
spot of blood may be discovered upon the clothing. The accustomed
leucorrheal discharge may occasionally be streaked with blood. Such
appearances are most frequent after long walking or standing or
physical work, or after straining at stool, or very often after coitus.
If the woman has passed the menopause, the hemorrhage of cancer may
appear as a re-establishment of menstruation--often to the satisfaction
of the woman. This post-climacteric bleeding may occur with more or
less regularity--every month or every three or four months--or it may
appear as an occasional loss of blood after unwonted effort.
All hemorrhage of this kind, in women over thirty years of age,
demands immediate and careful physical examination. Any bleeding from
the vagina in a woman who has passed the menopause should arouse
the gravest suspicion. From the slight hemorrhages just described
the bleeding increases in intensity and duration, until there is a
continuous loss of blood that saps the strength of the woman and
produces the profound anemia characteristic of the last stages of
cancer of the cervix, Sudden fatal hemorrhage in this disease is rare.
_Pain_ is not a constant accompaniment of cancer of the cervix in the
early stages, nor is it in any way characteristic. The intensity and
character of the pain may depend upon the direction of the growth of
the disease. In some cases pain is absent throughout. The pain may be
dull and gnawing in character, or it may be sharp and lancinating. The
pain may resemble that of uterine colic. It may be referred to the back
in the region of the sacrum, or to one or both ovarian regions, or to
some part of the pelvis remote from the uterus, as the crest or the
anterior superior spine of the ilium. It may extend down the posterior
or anterior aspects of the thighs or into the rectum. In most cases of
cancer of the cervix pain is not a prominent symptom until the later
stages.
_Discharge_ from the vagina may be present in cancer of the cervix
before there are any symptoms of hemorrhage or pain. The discharge
depends upon the position and character of the growth and the stage of
the disease. It may first appear as an ordinary cervical leucorrhea in
a woman previously free from such discharge; or the discharge of cancer
may first appear as an increase of an accustomed leucorrhea. In such
cases it is due to hypersecretion from the irritated cervical glands.
Later in the disease, when ulceration takes place or when the friable
vascular vegetations appear, the leucorrhea becomes puriform in
character and streaked with blood. It then becomes thinner, less mucous
in consistency, and of a constant brownish color from the admixture
of blood. The pus and débris from the breaking-down cancerous mass
increase, and a horrible odor characteristic of the later stages of
cancer of the cervix appears. This odor is not peculiar to cancer.
It is caused by the sloughing tissue, and is observed when such a
process occurs in other conditions, as in sloughing fibroid polyp. The
discharge is irritating in character, and the ostium vaginæ, the vulva,
and the inner aspects of the thighs become excoriated in those who do
not observe strict cleanliness.
Systemic absorption of the cancerous discharges produces a general
septic condition, which, with the anemia from hemorrhage and the uremia
from obstruction of the ureters, results in the so-called cancerous
cachexia.
The symptoms that have just been described are those most usual in
cases of cancer. It must always be remembered, however, that these
symptoms vary very much in intensity or prominence and in the stage of
the disease at which they appear. Sometimes acute pain, hemorrhage,
and excessive discharge are present from the very beginning--even
before the presence of cancer can be demonstrated without the aid of
the microscope. In other cases all these symptoms may be absent until
the disease is very far advanced. None of the symptoms are absolutely
pathognomonic of cancer. During the menstrual life of the woman
hemorrhage from the womb occurs as a symptom of a great variety of
diseases; and even in the post-climacteric period, though hemorrhage
should always excite alarm, yet it may be caused by a benign form of
endometritis or intra-uterine growth. The pain of cancer may also
characterize a variety of benign conditions; and the vaginal discharge,
even when most offensive, may be simulated by that from a sloughing
intra-uterine fibroid.
The symptoms, however slight, which we know may occur with cancer of
the cervix should never be disregarded. Examination should be made
immediately. There should be no postponement or expectant plan of
treatment. If physical examination is not satisfactory in elucidating
the condition, resort should be had to the microscope. If this is
not conclusive, the case should be watched as long as the suspicious
symptoms continue, and further frequent examinations should be made.
If this plan of treatment is followed, and if women are taught to
view with distrust, and not with complacency, any irregularities
of menstruation occurring near the time of the menopause, or any
post-climacteric return of menstruation or of irregular bleeding, the
surgeon will be able to save many women with cancer of the womb who are
now doomed to horrible deaths.
Cancer of the cervix, like cancer in other parts of the body, is of
variable duration. Usually from one to three years elapse between the
time when the first symptoms of the disease appear and the time of
death. The disease may run its course, in exceptional cases, in a few
weeks; in other cases it may last as long as five years, especially if
the progress is delayed by palliative treatment.
=Treatment.=--Complete removal of the uterus is the only curative
treatment for cancer of the cervix. If the disease is seen in the
earliest stages, amputation of the cervix beyond the limits of the
growth seems, theoretically at least, to be a proper plan of treatment.
Practically, however, the operator can never be certain that the
excision is made in healthy tissue. The senses of touch and unaided
sight are not capable of defining the limits of malignant infiltration.
Moreover, it must be remembered that the endometrium is very often
involved secondarily from a cancerous focus in the cervix. Complete
removal of the uterus should therefore always be practised in all cases
in which there is a possibility of removing all of the disease.
The manner of performing this operation will be described subsequently.
The cases that are not suitable for the operation of hysterectomy
are those in which the disease has extended to structures that are
surgically inaccessible. Such cases include those in which the bladder
or the rectum are involved, those in which the vagina is extensively
implicated, and those in which the disease has extended into the broad
ligaments or the cellular tissue of the pelvis.
When the bladder is involved, there are dysuria, vesical pain, and
tenderness on vaginal pressure upon the base of the bladder, while the
urine is altered in character, containing blood, pus, and, in the
later stages, broken-down necrotic tissue. Involvement of the rectum is
manifest by digital examination.
When the broad ligaments are involved the uterus is held rigidly in the
pelvis or is drawn to one side, and the bases of the broad ligaments,
palpated through the lateral vaginal fornices, are thick and hard.
When the cellular tissue of the pelvis is generally involved the
whole vaginal vault feels indurated and the uterus seems fixed in the
unyielding matrix.
In examining with the view of determining the practicability of
hysterectomy, it is important to distinguish between cancerous and
simple inflammatory involvement of the broad ligaments. The uterus may
be fixed in the pelvis by inflammatory adhesions resulting from old
tubal disease, and yet the cancer of the cervix may be strictly local
and in a stage suitable for hysterectomy. In the simple inflammatory
cases the adhesions are more attenuated, are higher in the pelvis, and
lie chiefly posterior to the uterus. They are not directly continuous
with the cervix. Frequently the enlarged tube and the adherent ovary
may be felt. When the uterus is fixed by cancerous involvement of
the broad ligament, we readily feel that it is the base of the broad
ligament that is involved. The induration is broad, it is directly
continuous with the induration of the cervix, and it lies to the side
of the uterus.
Involvement of the pelvic lymphatic glands may sometimes be determined
by vaginal palpation, one or more such enlarged indurated glands being
felt lying posterior to the uterus. In most cases, however, glandular
involvement can be determined only after the abdomen has been opened.
In general, it may be said that the operation of hysterectomy should
be performed in all cases in which there is no cancerous involvement
of the bladder and rectum, in which the vaginal disease may all be
removed, and in which the uterus is freely movable.
In those cases in which complete removal of the disease is impossible
the operation of hysterectomy should not be performed, because, cure
being out of the question, the symptoms of hemorrhage, pain, and
discharge may be as well relieved by less dangerous forms of palliative
treatment. When the disease extends beyond the limits of the uterus,
hysterectomy is much more difficult and dangerous than when the uterus
is freely movable.
The remote results of hysterectomy for cancer of the cervix are
poor. In the very great majority of all cases submitted to operation
recurrence has taken place. It seems very probable that a few of the
cases of recurrence are due to transplantation of cancer-cells into
healthy tissue during the operation; but the vast majority die because
all of the diseased tissues have not been or can not be removed. The
hope for better results from the surgical treatment of cancer of the
cervix depends, not upon improvement in the surgical technique, but
upon the ability of the general practitioner to recognize the disease
in its earliest stages, before inaccessible structures have been
involved.
_Palliative Treatment of Cancer of the Cervix._--The palliative
treatment consists in removing as thoroughly as possible, with the
sharp spoon-curette, scissors, or knife, all the cancerous cervix, and
the maintenance of the surfaces thus exposed, as far as possible, free
from septic infection.
The woman should be placed in the lithotomy position; the cervix should
be exposed with the Sims speculum and, if necessary, with the lateral
vaginal retractors. All vegetations and all of the degenerated cervix
should then be cut away. It is usually necessary to carry the excision
of tissue as high as the internal os. Bleeding during this procedure is
sometimes very profuse. It diminishes, however, as the more degenerated
portions of the cervix are cut away and the healthier uterine tissue
is reached, and therefore it is always best to complete the operation,
notwithstanding hemorrhage.
The bleeding may be controlled by packing the cavity with gauze or
cotton, plain or saturated with Monsel’s solution. Moderate bleeding
may be checked by packing with cotton saturated with a 5 per cent.
solution of antipyrine.
In rare cases, in which the excision of tissue has been carried high
up in the lateral vaginal fornices, it may be necessary to ligate the
uterine arteries in order to control the hemorrhage. This may be done
by passing around the vessel, close to the cervix, a curved needle
carrying a heavy ligature. Bleeding from the circular artery may
readily be controlled in a similar way, the ligature being passed like
the first suture in trachelorrhaphy.
If the operation has been thoroughly performed, there will be left a
large crater or conical cavity in the vaginal vault. This cavity may
then be packed with sterile gauze, or, if there is much bleeding, with
gauze saturated with Monsel’s solution. Some surgeons sew together the
walls of the cavity to diminish as much as possible the raw surface.
Others char the walls with the actual cautery, in order to carry the
destruction of tissue still farther than has been done with the knife.
If the removal with the curette and knife has been thorough, it is
not necessary to make a caustic application. If, however, the cavity
is walled by obviously cancerous tissue, the use of the caustic is
advisable. This is usually the case.
Chloride of zinc is a valuable caustic in cancer of the cervix. It
should be applied as follows: After the cancerous tissue has been
removed as thoroughly as possible with the knife, the scissors, and
the curette, bleeding from the walls of the cavity should be checked
by packing with gauze, dry or saturated with a 5 per cent. solution of
antipyrine. The bleeding may very often be checked in this way in a few
minutes, and in this case the caustic may be immediately applied. In
case, however, the bleeding is not so quickly controlled, the packing
must be left in the cavity for twenty-four hours, at the end of which
time it may be removed, without anesthesia, and the caustic application
may be made.
Before introducing the caustic the vagina and the vulva should be
protected by thorough greasing with an ointment composed of 1 part of
bicarbonate of soda to 3 parts of vaseline.
The strength of the caustic should depend somewhat upon the thickness
of the tissue that separates the cavity from the peritoneum or other
important structures. The thickness may be approximately determined by
palpation. Usually a 100 per cent. solution of chloride of zinc may
be safely employed. If the walls of the cavity appear very thin--less
than a quarter of an inch--the caustic may be reduced to a 50 per cent.
solution. Small balls of cotton, about half an inch in diameter, should
be saturated with the caustic and carefully packed in the cavity. The
operator should be careful to remove quickly with the sponge any excess
of caustic that may be expressed from the cotton. Much unnecessary pain
may be experienced if the caustic comes in contact with the vagina or
the vulva.
When the cavity has been filled with the cotton balls carrying the
chloride of zinc, a large vaginal tampon of cotton well greased
with the alkaline ointment should be placed in the vaginal vault.
The packing should be removed from the vagina in forty-eight hours,
and vaginal douches of bichloride of mercury, 1:4000, should be
administered.
If this operation is carefully performed, the subsequent pain is
usually slight. In some cases, however, the action of the caustic may
be so painful that morphine is required.
The slough from the caustic may be discharged in one piece or in
shreds. It is usually separated in from five to ten days.
The subsequent treatment of the woman consists in the frequent use of
cleansing vaginal douches, such as a solution of bichloride of mercury
(1:4000), carbolic acid (3 per cent. solution), permanganate of
potash (10 grains to the ounce of water), and peroxide of hydrogen (1
part of the commercial peroxide to 3 or 4 parts of water).
The palliative treatment of cancer relieves the pain, the hemorrhage,
and the discharge. The relief is usually immediate, and may continue
throughout the disease. The hemorrhage is usually arrested for several
weeks, or even for months, and the discharge is much diminished with
the destruction of the necrotic cancerous mass. The progress of the
disease is delayed, and life is somewhat prolonged.