[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.