Complication with pregnancy has.been noted once. Bailly saw a gravida with a voluminous, lobulated carcinoma of tbe recto-vaginal septum, which had developed in the fifth month of pregnancy, and proved an ob stacle to delivery. In the last three months of this pregnancy, the patient began to have a wat,ery, at times reddish discharge, which during the fourteen days preceding delivery became profuse, and since it had no odor it was considered to be liquor amnii. The patient had only suffered pain during coitus, after which act she had ordinarily lost a small quantity of blood. During the second stage of labor the posterior vaginal wall to gether with the tumor was driven down to the vulva by the advancing head, and they retreated during the intervals. The tumor was neither torn nor did it bleed, although the child was removed artificially. The puerperium was normal. month later the patient was very thin and anaemic, any exertion causing hemorrhage, and in the intervals there was a constant serous discharge. The speculum was carefully introduced, and the surface of the tumor was seen to be warty and white; it occupied the entire posterior vaginal wall. The tumor was much softer than at the time of delivery. On touch by the finger or instruments, there re sulted hemorrhage, and pain, with faintness. Five months after deliv ery the woman died of exhaustion. Kiister has recorded an instance of indu.ction of labor by means of an elastic catheter in case of extensive carcinomatous infiltration of the vagina in a woman of twenty-four, who had previously miscarried three times. During the third pregnancy she began to suffer from profuse leucorrhcea, and since the third puerperium, she had almost constant hemorrhages, and in the interval watery dis charges. During the fourth pregnancy, she bled almost continuously. The vaginal walls were covered with a large number of elevations and depressions, the lower inch of the canal alone being normal, smooth and soft. The external os was smooth and intact, and the cervix as well, although the canal was patulous. To the right and posteriorly the cervix was roughened. The masses were curetted, and the vagina irrigated with carbolic acid. Labor was induced eight days thereafter, delivery occur ring in two days. During labor the patient was feverish and complained of pain to the right of the uterus. Seven days after delivery she died of septic pyemia. A crescentic ulcer, 3f inches in diameter, was fogad in the vagina, with hard walls. The base of the ulcer was uneven, torn, covered with a yellowish-green deposit. It extended down to the mus cularis. It began a finger's breadth above the introitus and extended on to the cervix, more to the left than to the right. On the anterior wall the mucous membrane was not implicated longitudinally for about of an inch. In the diagnosis of carcinoma of the vagina, the well-known broad-based, nodular, immovable tumors are characteristic. They readily bleed on touch, and the serous or purulent discharges are always present. Papillary cancroids may appear as marked cauliflower-like exorescences, with great tendency to hemorrhage, and readily breaking down, and even microscopically they may thus be differentiated from large simple papil lary hypertrophies. It is important to determine as to whether the growth is primary or secondary. It is necessary to carefully examine the neighbor ing organs, in particular those of predilection. Only where the cervix is not implicated, or else only externally near the vaginal growth, only where the rectum and the vulva, the bladder and urethra, are free, and no traces are found in other organs whence metastasis might take place, can we assert that the growth is primary in the vagina. Differentiation
from sarcoma is to be made by the microscope. The cancroid and papil lary forms generally extend from neighboring organs, the flat and strati fied are usually primary, while the infiltrated nodules are most frequently metastatic from distant organs, such as the stomach.
The nugatory results from the treatment of carcinoma when primary in the vagina depend on the difficulty of removing the growth in its en tirety. Curetting with the sharp spoon, removal by the galvano-cautery and ligature, cauterization by various agents, and the hot iron, extirpation with the knife, these have all been tried without result. Nevertheless attempts should ever be made at extirpation. Where the tumor is still circumscribed in extent and in depth, so that its removal with the knife or scissors is possible, the procedure is to be recommended not only on account of the certainty of being able to work in non-infiltrated tissue, but also on account of the possibility of checking the hemorrhage by ligature or suture, since the movability of the vaginal walls allows of the approximation of quite large wounds by means of suture. According to Hegar and Kaltenbach we should not abstain from operation for fear of injuring the bladder or the rectum, for any incision into them, after the removal of diseased portions, may be closed by suture. Schroeder has recently performed the most radical operation in such cases. He operated in three cases of carcinoma of the posterior wall, where the disease reached the fornix. He first incised superficially the vaginal mucous membrane from the entire tumor. At the upper border he prolonged the incision through the entire thickness of the mucous membmne, and loosened the carcinoma from above downwards. In one of these cases the peritoneum in Douglas's fossa was torn, and brought together by suture. In the first two operations he simply united the edges of the MUCOUS membrane cross wise, and this left a depression in the posterior fornix, where the secre tions collected, and this led to suppumtion. In the last case he included the rectal wall by sutures which did not extend through it, and then fixed a drain tube in the posterior fornix. The first patient died of sepsis from suppuration of the wound; the second recovered and two and a half months thereafter there was no recurrence; the third patient recov ered from the operation, but it is too early to make any statement in regard to ultimate result.
It is very exceptionally, however, that cases suitable for operation are met with, and ordinarily our operative aim can only be palliative in order to control for awhile the hemorrhage and the suppuration, and this is done by the measures we have spoken of. The more deeply we are able t,o cauterize, the longer in duration the result. Exceptionally, however, this may couse profuse hemorrhage, as is proved by the following case recorded by Grilnewaldt: In a woman of thirty-two the cervix was am putated for carcinoma, and six months thereafter there was recurrence on the posterior vaginal wall which included the cicatrix left by the previ ous operation. In the attempt at removal of this recurrent growth, by the galvano-c,autery, a profuse parenchymatous hemorrhage occurred, which resisted treatment, the patient dying in about six minutes. At the autopsy it was found that the anterior branch of 'the hypogastric artery had been cut through in the incision. Spiegelberg records an instance of sarcoma, where an analogous operation was performed, and where ab scess occurred which quickly led to the death of the patient,