Wiener' amputated the cervix for cancer, and three days after the operation child birth followed.
C. Braun' advises the removal of all vaginal masses during pregnancy. If the cancer is confined to the uterus, he favors premature delivery, fol lowed by total extirpation of the uterus. Where this is not practicable it may be well to wait until full term and then perform Caesarean section, in order to save the child.
Spencer Wells • successfully performed Freund's operation in a woman six months pregnant. Bischoff ° did a similar operation in the eighth month of pregnancy. The mother died but the child was raved.
In another case of small cervical cancer Bischoff induced premature delivery. Eight days after the birth of a living child, he removed the diseased cervix by amputation. The woman recovered and 2i years later gave birth to a living child.
In view of the above facts it seems to me that it is the duty of the physician to remove as thoroughly as possible the diseased parts, even when gravidity is present, whenever there is a reasonable hope of being able to operate through sound tissues, and of either curing the disease radically, or of arresting its further progress for a lengthy period. If the area of the disease is so large as to render an operation of this kind no longer feasible, we are not justified in scraping or cauterizing the affected parts during the existence of pregnancy, unless the disease is making rapid progress and hemorrrhage and sloughing threaten the life of the patient. If this is not the case, and if the degeneration is not extending at all or but very slowly, all operative measures are contra-indicated as liable to endanger the existence of the foetus.
Whether delivery takes place before the normal end of pregnancy, or at full term, in cases of cancer of the lower segment of the uterus, its course depends altogether on the extent of the disease at the time. If only one lip of the os be affected, even a mature and fully developed infant may be easily and quickly born, either the diseased part participat ing in the dilatation of the os, or the sound lip alone stretching sufficiently to permit of the passage of the head. Cases of this kind have been recorded by Cazeau, Chantreuil, Spiegelberg and others. Judging from Cohnstein's series of cases it appears to make a difference whether it is the posterior or the anterior Iip that is affected. When the posterior lip alone
was diseased spontaneous delivery always terminated favorably for mother and child alike, but when the degeneration was confined to the anterior lip the result was favorable for the mother in 87.5 per cent. and for the child in 83.3 per cent. of the cases. If this difference is not a mere coinci dence, it may be attributed to the greater importance in general of the anterior lip of the os during childbirth.
When both lips of the os, or the greater part of the vaginal portion is diseased, the resistance offered to delivery is so great that the latter very rarely terminates spontaneously. The pains are very seldom capable of dilating the infiltrated and unyielding lower segment of the uterus; and when delivery occurs spontaneously it is usually only after severe and deep lacerations of the diseased parts, which may extend into the cavity of the peritoneum, or after the degenerated tissue has been squeezed and crushed to a pulp. Under these circumstances profuse hemorrhage with subsequent rapid decomposition of the crushed parts, peritonitis, and septicaemia quickly lead to the death of the mother. Almost all the infants perish in these cases from the tedious course of birth, which, moreover, usually requires artificial aid for its completion.
Depaul ' describes a case of cancerous tumor involving the whole of the cervix, in which a six months' foetus was born spontaneously, although delivery proceeded very slowly. Other cases have been reported, chiefly by Chantreuil, and also by Levret, Loenhardtt, d'Outrepont, Kilian, Nagele, and P6delaborde (loc. citat. pp. 25 to 28). Martel' also wit nessed the birth of a dead foetus after a labor lasting forty-five hours, the mother recovering. Cohnstein found that spontaneous delivery termi nated favorably for the mother in 37.5 per cent., and for the child in 33.3 per cent. of these cases. When the disease involved the entire cervix the .percentage of recoveries was only 34.7 for the mothers, and 25.0 for the children. In one hundred and twenty-eight cases of unassisted labor at the normal end of pregnancy there were twelve fatal cases of rupture of the uterus, and five instances of laceration of the cervix, in three of which the death of the patient resulted. Of Herman's (1. c.) 180 cases, fifty one were delivered normally at full term, and sixteen of the women diet.