Reprinted from The Atlanta Medical and Surgical Journal, July and August, 1896. ONE HUNDRED AND SIXTY-SIX CASES OF CANCER OF THE PREGNANT UTERUS OCCURRING SINCE 1886. GEORGE H. NOBLE, M.D., President of the Medical Association of Georgia; Secretary of the Section on Obstetrics and Diseases of Women, American Medical Association ; Gynecologist to the Grady Hospital, etc., Atlanta, Ga. Reprinted from The Atlanta Medical and Surgical Journal.] ONE HUNDRED AND SIXTY-SIX CASES OF CANCER OF THE PREGNANT UTERUS OCCURRING SINCE 1886 * GEORGE H. NOBLE, M.D., President of the Medical Association of Georgia; Secretary of the Section on Obstetrics and Diseases of Women, American Medical Association; Gynecologist to the Grady Hospital, etc., Atlanta, Ga. My attention was turned to this subject by four cases that came under my observation, one of which was the vaginal hysterectomy, post-partum, reported to this Association one year ago; the others, one of which was a vaginal hysterectomy for incipient cancer of the pregnant uterus, were reported to the Atlanta Obstetrical Society some time in the past. The success in these cases has encouraged me to look more care- fully into the treatment, etc., and as a result report one hundred and sixty-six cases of cancer of the pregnant uterus which have occurred since the year 1886, the time of the Bar thesis. I shall confine this report mainly to the statistics of the treat- ment and results, referring you to Bar, Cohnstein, and others for information concerning the age, the period of recurrence, the period of abortions, etc. There were twelve partial amputations of the cervix in the first seven months of pregnancy, averaging five and one-third months. Ninety-one and six-tenths per cent, of the mothers recovered from the operations; 8.3 per cent, died; 66.6 per cent, went to full term, one child dying subsequently; and 41.6 per cent, aborted (one conception of six months living, Case No. 11). Two of the mothers had subsequent operations for the removal of the cancer, but recurrence obtained in both cases. Another conceived a second time and died of peritonitis thirteen days after confinement. * Read before the Southern Surgical and Gynecological Association in November, 1895. A-.* «- V- A, A*, \ J. . 2 Of the three cases of intravaginal amputation of the cervix, two recovered from the operations, giving a mortality of 33.3 per cent.; the children the same. One mother died of peritonitis, one died suddenly six weeks after confinement, and the third had two subsequent operations for removal of the malignancy, making an ultimate mortality of 66.6 per cent.—possibly 100 per cent. The intra vaginal amputations give a combined mortality from operations, of mothers 19.3 per cent., of infants 40 per cent. The above fifteen cases were operated upon at an early stage of the disease (or at a time when the conditions were most favorable for any operative measure), with an ultimate maternal mortality of 60 per cent.; that of the babies 33.3 per cent. (See Table I.) Sixteen supravaginal amputations were done prior to the seventh mouth, with a mortality of 6.2 per cent.; six had recurrence of the disease, three had no return, and seven were not observed; there was, therefore, an ultimate mortality of 66.6 per cent, in the nine cases in which the records are complete; thirteen cases were lost, mortality 82.5 per cent. Of the remaining three, one went to full term, 6 per cent., and the other two were not mentioned. One case aborted thirty-five days after conception, aborted again in forty days; conceived a third time, was delivered normally, and was well five years afterward. These cases were also in the early stages of the disease when the portio vaginalis alone was involved, thus presenting a fair opportunity for testing the merits of the operation. (See Table II.) There were three cases of supravaginal amputation of the cervix in puerperal state, but the data are not sufficiently complete to give very satisfactory information. Two were operated upon immedi- ately after the confinement, one dying in seven days; the other was not recorded. The cervix in the remaining case was removed three weeks after the confinement and died two months later. The child in this case is the only one recorded as living. The mortality is 66.6 per cent, for both mothers and children. (See Table III.) There were twenty-three vaginal hysterectomies. In two cases the results are not recorded, leaving twenty-one cases, all success- ful—mortality nil. 3 The statistics by Pfannenstiel * give a mortality of 8.3 per cent, in thirty-six cases since 1882. Of the ultimate results two had re- currence as follows: one in eighteen months, died; one in twenty- nine months, died. Seven others were well when examined, as follows: two in one year; two in one and one-half years ; one in two years; one in four years; one in four and one-third years. The period of gestation at which the operations were done was as follows: one to two months, eight cases; two and one-half to three mouths, seven cases; three and one-half to four and one-half months, three cases. The hysterectomies were done before any very rapid extension or growth of the disease had taken place, hence the favorable results; mortality 23.4 per cent, at the end of one year. On throwing out the two cases that were well at the end of one year we have (of the recorded results) five recoveries and two deaths, or a mortality of 40 per cent, in eighteen months. Again throwing out the two cases that were well at eighteen mouths, we find a mortality at the end of the second year of 66.6 per cent. In this estimate all the living cases that have had no recurrences and have not gone two years since the operation are thrown out. Doubtless some of these have been permanently cured, and would reduce the percentage if accessible. This is a very good showing for vaginal hysterectomy, which seems to be keeping pace with the advance of surgery; thus prior to 1882 the immediate mortality was, according to Gusserow,f Duncan,]; and others, 23 to 28 per cent. Later, Fritsch§ reported 16 per cent.; next, Pfannenstiel |[ estimated it at 8.3 per cent.; then Fabbri, ** Modena, made it 4.1 per cent.; and, finally, the writer reports twenty-one cases without a death. (See Table IV.) There were seven cases of vaginal hysterectomy in the puerperal period from fourteen to twenty days after abortion or delivery; all recovered. The cancers were in an incipient stage and the wombs small, so that in these respects the operations were under favorable * Bar thesis. t Gusserow, “ Die Neubildunaren des Uterus,” Stuttgart, 1886. I Obstetrical Transactions, 1885. § Bar thesis, Paris. || Ibid. ** American Journal of Obstetrics and Diseases of Women, No. 200, p. 288. 4 conditions. The chief objections to operating in the puerperal state are the increased vascularity of the tissues, the usually worn down condition of the patient, and the difficulty experienced in effectually sterilizing the vagina, constantly bathed in foul smelling, septic lochia, etc. (See Table V.) So far there is one case of vaginal hysterectomy post-partum (done seventy-two hours after confinement). This one made a very fortunate recovery, though desperate and apparently unfavora- ble (case No. 63) by the writer. These eight cases without a death demonstrate that we need not fear to operate during the puerperal period when there is a reasonable hope for success. (See Table VI.) The total number of abdominal hysterectomies is sixteen ; twelve of these were Freund’s operation, one after Mackeurodt’s method, and the remainder not described. Of eleven cases seven died from the operation, making the death-rate 43.7 per cent. One case had enchondroma of the pelvis; another had return of the cancer in one year ; and a third had a return in a few months and died seven days after an operation for ileus due to cancer of the intestines. These three are the only ones with complete records, therefore it is impossible to give an estimate of the ultimate recoveries. The products of conception were all lost. (See Table VII.) Ceesareau section was done forty-three times, as follows: conser- vative (or Sanger), twenty-six; Porro, nine ; Freund’s, eight times. Of the twenty-six conservative operations seventeen died, seven recovered; in two the results are not recorded, and one was dead before the operation was performed. Mortality in twenty-three cases, 43.7 per cent. The high death-rate is evidently due to the fact that these cases are usually exhausted from prolonged labor, sepsis, etc., which unfits them for operations of this magnitude, for in the cases that do recover the wound heals kindly. In addition to the causes just mentioned, the chances for complications to arise subsequent to the operations are very much increased ; thus the liability to secondary hemorrhage and sepsis is much greater than in the non-malignant. This is illustrated by the fact that of the sixteen deaths, three died of peritonitis, two from hemorrhage sub- sequent to the operations, one from anemia, and two from exhaus- tion. Excluding the three cases of peritonitis as a factor in the 5 death-rate of ail the abdominal operations, 25 per cent, of the deaths were caused by complications not common to the non-ma- lignant subject, and doubtless it would appear greater if the im- mediate cause was known in all the cases. All cases dying at the end of three weeks and under are recorded in the list of the dead. One that died at the end of two months is recorded as recovered, having safely passed the effects of the operation. Of the twenty- six cases, twenty-three babies were born alive, three dead, and two died respectively two weeks and two months afterward—mortality 11.5 per cent. (See Table YTII.) The number of recoveries in the Csesarean-Porro operations were four; deaths, five, or mortality of 55.5 per cent. One of the recoveries went insane, after fourteen days, from chronic alcohol- ism. These cases were more favorable than those upon which the conservative operation was done, five of the nine having the cer- vix only involved. Of the conceptions seven were saved (twins in one instance), three lost, and one not stated, giving a mortality of 30 per cent. (See Table IX.) In eight Caesarean sections by the Freund method there were three recoveries and five deaths, giving a mortality of 62.5 per cent. Out of this number five babies were saved, mortality 42.8 per cent.; six of these cases were complicated, four by extensive exudates in the pelvis, one dying the next day with peritonitis (pre-existing ?), with a temperature of 39.5 C., another had been in labor seven days, while still another was very weak and anemic. This is an unfair test for Freund’s operation, some of them be- ing unfit for any attempt at radical operation, especially the four with extensive exudates in the vaginal walls. If these were thrown out (with three deaths and one recovery) the mortality would be slightly reduced. Thirty-four chilrdren were born alive, eight died, and two were not recorded, making a total of forty- four, there being twins in one case. This gives an aggregate mor- tality of 22 per cent. Of the forty-three cases of Caesarean section many were done re- gardless of the kind of operation best suited to them ; for instance, 6 there were seven cases of the conservative operation when the portio vaginalis or cervix uteri alone was involved. Total hys- terectomy might have been done with hope of ultimate recovery in some of them. Again, Freund’s operation was done in four cases where the ex- udate or disease had extended to the surrounding parts, which in- creased the death-rate of the operations done by this method. They were better suited to the Porro or to the conservative opera- tions. In five of the Porro it is possible that total hysterectomy might have been effected, as the parauterine tissues were not in- volved. This perhaps is not an unjust criticism, for the operations were all done in recent years and at a time surgery was making rapid strides toward perfection ; especially is this applicable to those done in the last few years, as they should have profited by previous results. While total extirpation following Caesarean sec- tion may not give as small a mortality in the immediate results as the conservative operation, I feel assured that in properly selected cases it is the ideal operation where the fetus can be born per vias naturales. It offers some hope to the mother. According to these figures the conservative Caesarean operation is unquestionably the safest of the three, so far as it concerns the mother. It ought, therefore, to be employed in all cases with ob- struction to the birth of the child by extensive exudates or where there is not a reasonable hope of eradicating the malignancy. Porro’s operation is supposed to diminish sepsis in the cavity of the uterus, but that is counterbalanced by a suppurating stump in. the abdominal wound. If, therefore, it is a question of election between the two latter operations, the feebleness or weakened physical forces of the pa- tient ought to decide in favor of the conservative Caesarean opera- tion. It might be said, however, that there are not a sufficient num- ber of Porro operations in these statistics to give a fair estimate of its value. I must confess that I was prejudiced against the conservative operation as done in the past, regarding it in some in- stances a reckless abandonment of the mother for the sake of an often undeveloped, ill-nourished offspring that may soon die or inherit 7 the malignancy. But such is not the case when the mother’s con- dition is hopeless ; the child’s interest must then be subserved. (See Table X.) There were three forceps deliveries with previous operations, two by incisions and one curetting. Severe bleeding occurred in the two cases of incisions, one mother dying in twelve hours, and in the other case the child was lost. The remaining case was suc- cessful, also an additional one without a previous operation. Esti- mated results in such a small collection are very uncertain, but, as far as they go, they bear out the claim that the use of the forceps is attended with some danger, chiefly from rupture of the diseased cervix and as a carrier of infection. They also support the claim of Baudelocque* that 75 per cent, of mothers and 50 per cent, of children recover. (See Table XI.) I have encountered but one instance of amputation of the an- terior lip during labor, resulting in the recovery of the mother and death of the child. At five different times tumors were removed intra-partum by scissors, curette, forceps, thermocautery, etc., with four immediate recoveries of both mother and child. The case that died was a tumor of the cervix and vagina, which was partially removed; mortality 20 per cent. (See Table XII.) Incision of the cervix is a subject that is likely to present itself for consideration in a great many cases at or near the end of ges- tation. It is therefore one of considerable importance to the child and also to the mother, as it may be the means of evacuating the uterus preparatory to a subsequent extirpation. Seven cases with five immediate recoveries (mortality 28.5 per cent.) are shown in this list. Hemorrhage is the great danger to be feared; the two deaths in the list are chargeable to it, dying respectively in two and twelve hours. Another case was forcibly dilated by the hand, and the uterus ruptured through into the bladder and peritoneal cavity. She lived for three and one-half months, and is therefore on the list of immediate recoveries. Two others died respectively in five weeks and in two years. The final results were death in all the cases fully recorded. Several had protracted confinements, as fol- * Taken from Charpentier’s “ Cyclopedia of Obstetrics and Gynecology,” vol. iii., p. 168. 8 lows: one was in labor thirty-six hours; one in labor one and one- half days; one in labor six days; one in labor eight days. To this is ascribed in a very large measure the death of three babies. The infantile mortality was 35 per cent. After incisions the babies were delivered as follows: four by turning, with one death; one by extraction, with one death; one by forceps, with one death; two spontaneously, with one death. Of the seven cases, four were dead within three and one-half months after labor. It appears that after the cutting the hemorrhage is so great that there is a demand for immediate delivery or plugging of the womb with the extremities of the child for the purpose of controlling it. (See Table XIII.) Five induced abortions have been encountered, with a mortality of 20 per cent., the death in this case being due to puerperal fever. One case had a carcinoma the size of a hazelnut, successfully re- moved on the seventh day of childbed. The woman conceived again, and was delivered three years later at full term. One uterus had a deep rupture of the cervix, to which the curette and cautery were applied, resulting in normal childbed. The ultimate results are unknown, except in the one case which was cured by removal of the tumor and was well at the end of three years. As abortion destroys the child and does not materially benefit the mother, it becomes a question of doubtful utility, especially in cases that are amenable to other methods of treatment. (See Table XIY.) Lewis,* of Xew Orleans, states that about 40 per cent, of all cases abort spontaneously. Gusserow on Cobnstein says it is about 35 per cent., only 32 per cent, of the children being born alive, and hardly 20 per cent, lived until their mothers left the bed. “Here we have 20 per cent, of living children, and one-half of them without mothers.” The expectant plan of treatment presents a very good showing —that is, twenty-one cases with nineteen recoveries, two deaths, making a mortality of 10.5 per cent., including five cases under seven months of gestation, or 14.2 per cent, by excluding the five latter eases. Of the twenty-one cases the disease was confined to the cervix or a portion of the same, only two of which were ex- tensive, leaving fifteen cases limited in extent; three of the re- *Charpentier’s “ Cyclopedia of Obstetrics and Gynecology,” vol. iii., p. 166. 9 maining had invaded the neighboring tissues, and one was not stated. Thus the comparatively low mortality is explained, for a like number of advanced cases would have shown a much more woful set of figures. Charpentier* states that in forty-seven cases twelve died of rup- ture of the uterus and three of laceration of the cervix, or 31.9 per cent. Chautreuil places the maternal mortality at 36.7 per cent., and the writer at 24.3 per cent, the average of which is 30.4 per cent, childbed mortality. After confinement 35 per cent died within three months of can- cer, 28.5 per cent, of others had recurrences, while the remainder were not observed; thus 64.4 per cent, were either dead or in a helpless condition soon after childbed. Of the sixteen recoveries among the cases advanced to seven months of gestation, nine succumbed to the disease, one died of an operation, and six are not reported; thus no final cures are to be found in the list of those treated by the expectant plan. (See Table XY.) The very good showing has changed into a very poor one. Chautreuil places the infantile mortality at 60 per cent., Cohn- stein at 57 per cent., Hermann at 40 per cent., the writer at 50 per cent,, making an aggreate mortality of 51.8 per cent. Cohnstein (Bar thesis) states that 68 per cent, go to full term, and Hermann puts it at 28.3 per cent., which gives an average of 48.1 per cent. Then if only 48,1 per cent, of pregnancies go on to full term and 51.8 per cent, of these die, the estimate of success- ful issue is 24.8 per cent, of all the pregnancies in the cancerous uterus. The best way to arrive at a conclusion as to the most satisfactory method of conducting a case of this sort is first to exclude all the operative measures that have resulted in high death-rate and ac- complish but little good. Artificial abortion secures to the mother very little reduction in the childbed mortality, and defers death only for a limited time. When it is done with a view to subse- quent extirpation the advantages gained in the reduction of the size of the womb are counterbalanced by loss of valuable time and * Charpenlier’s “ Encyclopedia of Obstetrics and Gynecology,” vol. iii., p. 167. 10 puerperal fever; and as the uterus can be extirpated as safely during pregnancy as at other times, artificial abortion is worse than useless. So also should amputations and partial amputations of the cervix be discarded if any hope for the mother remains. It is true that a few cases have been cured by this means, but the number is so small that it will not pay for the chance it has thrown away for saving the mother’s life. In like manner all “ dilly-dally ” methods, such as curetting and cutting off the exuberant growths, should be eschewed as dangerous despoilers of time and opportunity. The next con- sideration is whether we should act in the interest of the mother or the child, or both. In the incipiency of the disease, when the mother’s chances are good, give her the benefit of it. Late in the disease, when the mother’s case is hopeless, look to the interest of the child. Between these will be found cases of doubt in which there will be room for the exercise of judgment. Careful perusal of the statistics will show that vaginal hysterectomy is the most satisfactory means of securing permanent relief in the early period of gestation. Next to it is abdominal hysterectomy in suitable cases. The former gives an immediate mortality of 4 per cent, and an ultimate recovery of 33.3 per cent, at the end of two years, but the conceptions are all destroyed. So we have here a compari- son, upon the one hand, of 33.3 per cent, of ultimate recoveries of the mothers under vaginal hysterectomy, and, upon the other hand, 20 per cent, of ultimate recoveries of the children under the ex- pectant treatment, which proves the former decidedly preferable. At the close of gestation, when the mother’s case is hopeless, she should be delivered by such means as will best serve the child’s in- terest, though her immediate safety and comfort should not be dis- regarded. In instances of partial obstruction of the cervix inci- sion may answer; when the obstruction is complete, Caesarean sec- tion is indicated. Of the three methods, the conservative gives the best results, the infantile mortality being 11.5 per cent., against 50 per cent, of the expectant treatment. Or, out of sixty mixed operations forty-four children were born alive (70.3 per cent.), showing that any of the operative measures for delivering the fetus is superior to the expectant treatment. In the doubtful cases the fetus may be near the period of viability 11 and the mother’s chance hopeful. In that case gestation might be continued until the child is viable, when the uterus should be evac- uated and afterwards removed. This opinion is sustained by the success attained in operations done in the puerperal state, all the hysterectomies recovering. Thus, a short summary shows that vaginal hysterectomy should be safe in the early months of pregnancy and the puerperal state, when there is a reasonable hope for the mother. The abdominal hysterectomy should be done under the above conditions when the uterus is too large to be rapidly and safely re- moved through the vagina. That at or near the end of pregnancy Ceesarean section (conserva- tive) should be resorted to when the child’s interest is to be con- sidered. That Ceesarean section with Freund’s operation is permissible when the disease is confined to the uterus and the child viable. That in doubtful cases cutting of the cervix and rapid delivery may be judicious when the incision can be made in unulcerated or non-infiltrated tissue. That as there are four chances to one against the life of the fetus, and as an equal or greater number of mothers may be ultimately cured in the early stages of the disease, the safety of the fetus should not be allowed to hazard the life of the mother. And that, upon the other hand, the futile efforts directed to the interest of the mother when her case is hopeless should not jeop- ardize the safety of the fetus in the latter months of pregnancy. 186 South Pryor Street. 12 No. Operator. Bibliography. Location of cancer. Operation. Result, mother Result, foetus. Recur- rence, Time of gesta- tion. Diagnosis. Remarks. 1 Schauta. Zeitschrift fur Heilkund Anterior Amputat’n Recov- Full term. In poste- 6 mcs. Carcinoma Cancer returned sixteen days Brag., 1887. lip. ant. lip. ered. ribr lip. after confinement; vaginal hysterectomy five months Bileted, A. after recovery. 2 Centralblatt fur Gyoa- kologie, 1884, No, 8, 44. Polypus in cerv. canal; ti Full term, died subse- cautery. health rela- and cautery, and extended to collutn in- quently. lively good the vagina. filtrated. nine mos. Kaltenbach. afterward. 3 Geburtshilflishrs Lehr- Anterior Excision •• Full term. In 4 years on posteri’r lip. In 4 years. 5 raos. Carcinoma Posterior lip removed, with re- buch, 1893. lip. ant. lip. cover y. 4 Schribe. Inaugural Dissertation, Halle- Wittenberg,1893. ti Full term. First excision in 1888, while preg- nant ; recovered. Cancer re- turned in 1892; again removed by excision ; recovered. Nor- mal delivery at full term. inalis. cancer. 5 Savory. Cervix. Scraping. « Pregnancy undisturb’d Recurred. Carcinoma Conceived again; spontaneous delivery at seventh month; xvii., 2. Godson. died thirteen days after. c Zeitschrift fdr Geburt- Cervix. Scraping. «* Lived. 7 mos. shilfe uud Gynakolo (cauli- gie, 1875, vol. i., No. 2. llower). 7 Fclsenreich, Amputat’n post. lip. Died. Lived. 4 mos. Carcinoma Mother died thirteen days after of peritonitis; carcinoma of Presse, 1883, 34. lip. lymphatic glands. 8 Helbig, Greifswald, 1889. Amputat’n post. lip. Abortion. 5 mos. lip. ered. size pig- eon’s egg. 9 Helbig. Greifswald, 1889. Amputat’n ant. lip. tt Abortion. Foetus size of finger. lip. size apple. 10 Olbrich. Greifswald, 18S7. Anterior Amputat’n ant. lip. it Dead. lip. size apple, OPERATIONS UPON THE CERVIX UTERI. TAEL’S I.—INTRA VAGINAL—PARTIAL AMPUTATION OR REMOVAL. 13 11 Schroeder. Taken from Ann.de Gyn. et d’Obstet.,Paris, 1891, xli.,p,187 (C.H.Strata). Zeitschrift fur Geburt- shilfe und Gynakolo gie, vol. xii., No. 1. Anterior lip. Anterior lip and cervix. Amputat’n' ant. lip. Recov- ered. II Abortion 3 wks. after, after living conception Abortion in 3 weeks. 6 mos. Anterior lip amputated above vagina. ant. lip (supra- vaginal). 11 operators 12 cases. 11 R. 4 abortions 5 returned. 8 carci- 1 D. 1 dead. 7 lived. 7 unknown. noma. 4 unknown. INTRA VAGINAL AMPUTATIONS OP PORTIO VAGINALIS. N(f>. Operator. Bibliography. Location of cancer. Operation. Result, mother Result, foetus. Recur- rence. Time of gesta- tion. Diagnosis. Remarks. 13 14 15 Thesis de Paris, 1886. Lehrbueh, 5th edition. Cervix. Cervix. Posterior lip. Amputat’n (galvano- caustic) of portio. Ainputat’n of portio. Amputat’n of portio. Died. Recov. from opor’tn Recov- ered. Died. Full term. Full term. Death of mother caused by Schroeder. Died in six weeks. Returned. 5 mos. 4 mos. Carcinoma peritonitis. Mother died suddenly after six weeks. Subsequently two operations to remove remaining portions of cancer. Forceps delivery. 3 operators. 3 cases. 2 R. 2 full term. 2 returned. 1 carci- 1 D. 1 died. 1 died. noma. 2 unknown. 14 No. Operator. Bibliography. Location of cancer. Operation. Result, mother Result, foetus. Recur- rence. Time of gesta- tion. Diagnosis. Remarks. 16 17 Schroeder. Schroedor. Taken from Ann.de Gyn. et d’Obst., Vans, 1894, xli., p.187 (C.H. Strata). Ibid. Os uteri. Os uteri. Supravagi nal ampu- tation. Recov- ered. <1 Lithope- dion. Abortion in No recur- rence. No recur- 4 mos. Carcinoma II 18 19 Strata. Strata. Zeitschrift f. Geburt- shilfe und Gynakolo- gie, vol. xii, No. 1. Ibid. Portio vag- inalis. Portio vag- “ “ it it 4 days. Abortion rence. 4 mos. II 20 Drude. Erlanger, 1889. (This i« inalis. Portio vag- U <1 4th day. Abortion in 4 mos. 21 Hoftneier. duplicate Case 11 of Wendrim’s 61 cases.) Zeitschrift f. Geburt- inalis size of fist. Ant. and a a 17 days. Abortion. Recurr’nce 7 mos. II 22 Hofmeier. shilfe und Gynakolo- gie, 1886, vol. xiii. Ibid. post, lips, size of a dollar. Portio vag- Abortion. in 7 months Early re- 23 Ilofmeier. Ibid. inalis. Portio vag- « Abortion. currence. Recurr’nce 24 Hofmeier. Ibid. inalis. Portio vag- « Abortion. in 13 mos 12 months 5 mos. „ 25 26 Hofmeier. Schroeder. Ibid. Zeitschrift f. Geburt inalis. Portio vag- inalis. Portio vag- .. .. Died from opera- tion. Rerov- Aborted recurrence in pelvic connective tissue. No recur- 2 mos. II Aborted again in forty days. 27 Drude. shilfe und Gyniikolo- gie, 1889, vol. xvi., and 1891. Erlanger, 1889. inalis. Right side, u nrpi 2 died. 4 unkn. TABLE XIII.—INCISIONS OF CERVIX. 27 No. Operator. ' Bibliography. Location of cancer. Operation. Result, mother. Result, foetus. Recur- rence, Period of ges- tation. Diagnosis. Remarks. 141 Gonuer. Cervix. 4% mos Carcinoma undGyn.,vol.x., No.l. and deliv- hazelnut, seventh day of ered again 3 years later; full term. childbed. 142 Clauss. Tubingen, 1890. Vagina and uterus. Recovered. 6 mos. Birth spontaneous seventh day; deep rupture of cer- vix; childbed normal; cu- reti e and cautery. 143 Clauss. Ibid. Cervix. Recovered. 5 mos. Childbed normal. T TT T foetus. 144 Floel. Centralblatt f. Gyn,, ’91, duplicate 32, Wend- riner’s 61 cases. Cervix (in- cipient). Recovered. Dead. Vaginal hysterectomy in puerperal period. dead child on account of exhaustion. 145 Heilbrunn. Inaugural Dissertation, Wurzburg, 1884. Dead. Fever. Vagina dead child. weeks of puerperal fever. 4 operators. 5 cases. • 1 died. 1 lived. 2 unkn, 4 unknown. TABLE XIV.—MISCARRIAGE, ARTIFICIAL OR INIUCED. 28 No. Attendant. Bibliography. Location of cancer. Accidents or compli- cations. Kesult, mother Result, child. Recur- rence. Period of ges- tation. Diagnosis. Time in labor. Remarks. 146 Correspond, du Schwei- zer Aerzte, 1890,vol.xx. Post, lip & right side. Deep rup- ture of cervix. Recov- ered. In 1 mo Carcinoma 2% dys. Spontaneous birth; cuie'te and cautery; childbed fever. 147 Schroeder. (I 8 mos. ( t Recurrent cancer; ant. lip amputated 4 years before. shilfe und Gyu , 1892, nective 3 mos. vol. xxiii. tissue. 148 Ibid. ( ( None. (( Died of peritonitis from sub- sequent vaginal hysterec- tomy. inalis. 149 Salzmann. 4 days. neighbori’g tissue pos- teriorly.!! (mu1 i- ,ated). served. 150 Brandt. Berlin, 1881, Cervix. Cervix rup- tured in six parts by traction on foot. Lived, None. 151 Bileted. Centraiblatt f.Gyn., 1884, No. 8. Cervix. (( (( Futile attempt to use for- ceps; turning. worse 2 mslat’r 152 Floel. Cervix. I i K Escape of waters five days without labor pains; turn- Gyn71896, No. 32. previa. ing futile; perforation; subsequent amputation and hysterectomy. 153 Dohlein. Dent. med. Wochen- schrift. Cervix. Fever. ( i None. < ( Subsequent vaginal hyster- ectomy eighteen days. 154 Jena, 1893. Cervix. Subsequent vaginal hyster- ectomy; recovery. 18 mos. 155 Heinricius. Anterior lip (extensive) Amputation portio vagi- nalis, 2% months later. icht, 1888, p. 126, 18 mos. 156 Perschin. Ibid, 1890. Anterior lip Amputation anterior lip; re- currence on posterior lip; lip. vaginal hysterectomy; re- covery. EXPECTANT PLAN OF TREATMENT. TABLE XV.—SPONTANEOUS EVACUATION OF UTERUS. 29 157 Stratz. Zeitschrift f. Geburtsh. u. Gyn., vol. ix., No. 11. Cervix. Lived. Carcinoma Supra-vaginal amputation of portio vaginalis. ered. 2 mos. 15S Hooper,J.W.D. Australian Med. Journ., 1889, N. S. xi., 417-426. Cervix. Died next dy Died. None. Husband positively forbade any interference. 159 Stephens, L.P. Atlanta, Ga. Seen by the writer. Cervix. Deep rup- ture of Died. Died. None. C i cervix. Version and extraction. 160 Schroeder. Ann. de Gyn, et d’Obst., Paris, 1894, xli., p. 187. Cervix. ered. (mace- 1 mo. rated). Papilloma. 161 Coe. Amer. Journ.Obst.,N.Y., 1893, xxvii., 515. Cervix, Lived, Vaginal hysterectomy; re- covered.” rence. hrs Tubingen, 189C. Cervix de- Sev’rehem- Living stroyed. orrhages. foetus. Amputation, fifth week af- terward, of portio vagi- 163 Felsenreich. Weiner medicin. Presse, 1883, p. 34. 4 mos. Carcinoma size small 3 years. (cauliflowr) apple. Cervix. 4 mos. nalis. 164 Schroeder. Ann. de Gyn. et d’Obst., Paris, 1894, xli., p. 187. Curette and cautery. Died Metas- 165 Mackenrodt. Ibid., 1894, pp. 81-97-187- 202. 7 mos. 3 mos. some tatic. days later. 166 Macken rodt. Ibid. (Hernandez, E.) Cervix (ex- Died in Died. Died in 6 mos. tensive. 2 mos. 2 mos. 18 reporters. 21 cases. 16 carcino- 2 died. 5deaths 11 unkn mas. 1 papil- loma. 4 unknown.