3rd. That the diagnosis of the existence of an obstruction is usually not difficult.

4th. That the diagnosis of the nature and the seat of the obstruction is, in most cases, most uncertain and unsatisfactory.

5th. That beyond the general history of the case, the most probable means of ascertaining the seat of the obstacle is, to follow carefully the distended intestine up to the point of obstruction.

6th. That under ordinary treatment these cases are fatal in the proportion of, probably, seven out of nine.

7th. That although no reliance can be placed on purgatives, on mercury, on opium, or any variety of injection, and that although in many cases they seem to aggravate the suffering, yet as it is unquestionable that in some cases they have been administered with relief, we cannot advise that they should be discarded, but we doubt the prudence of continuing to use them beyond two or three days.

8th. That the interference by surgical operation is justifiable when three or four days have passed without any relief from ordinary means (provided the constipation be complete and vomiting of fæcal matter continue), because it affords a greater chance for the preservation of life than ordinary

means.

9th. That if the indications as to the seat of the obstruction be sufficient to satisfy the surgeon, it is at or near that point that the incision should be made; but if there be much doubt, it is most prudent to make the incision on the median line.

10th. That if it be found impracticable to remove the cause of the obstruction, or imprudent to make any extended search for it, relief may be obtained by forming an artificial anus as near as may be prudent to the seat of the obstruction; and that if it be, as it frequently is, near the termination of the ilium, an incision on the median line admits of its accomplishment as near as may be to the termination of that intestine.

CASE

OF

MALIGNANT TUMOUR OF THE OS UTERI,

EXCISED DURING LABOUR.

BY JAMES MONCRIEFF ARNOTT, PRES.,

SURGEON TO THE MIDDLESEX HOSPITAL.

Received Nov. 15th-Read Nov. 23rd, 1847.

THE practitioner in midwifery is aware that the presence of malignant disease in the uterus is not an absolute bar to pregnancy, but he is also instructed that, seated in the os and cervix uteri, it may form a serious and even fatal obstacle to delivery.

Instances of this combination are happily not of frequent occurrence, yet Puchelt, in his work entitled "Commentatio de Tumoribus in Pelvi Partum impedientibus," published at Heidelberg in 1840, has collected thirty cases of scirrhus and cancer with pregnancy, and to these we may add seven others classed under the head of cauliflower excrescence, with pregnancy. Labour under these circumstances, always attended with difficulty and delay, presents very unfavourable results : of thirty-seven women, five died undelivered, four of them with ruptured uterus of thirty-two in whom delivery was effected by the efforts of nature alone or aided by art, sixteen were lost during labour; thirteen lived over their confinement, and of three the fate is not noted. Of the children, seventeen were born dead, in addition to the five undelivered, and of five no account is given.

The assistance rendered by art was in some of these cases by operations purely obstetrical, as turning, and the applica

tion of the forceps; but in two instances, incisions of the diseased parts were made, and in one they were excised.

It is with reference to the last-mentioned mode of relief that I am induced to bring the present case under the notice of the Society, partly on account of its rarity, partly because excision may have been overlooked as inapplicable, or has been too absolutely condemned.

In the authorised published abstract of the proceedings of the Obstetric Society of Edinburgh for the present year, it appears that at the meeting on the 10th of February last, Dr. Simpson stated that he had met with two cases of carcinoma uteri with pregnancy, in which the women had gone to the full time. In one the neck of the uterus was affected; it burst during the progress of labour, the child was still-born, and the woman died immediately. In the other the woman had been ill for three days; she was very much exhausted, and her pulse very rapid. The cervix was indurated at one side, and did not seem at all inclined to yield. Two or three small incisions were made through the indurated portion. This allowed the head to pass, and the delivery was completed after five pains. It was too late, however; the patient's pulse never rose, and she sank in two or three days afterwards.

Having alluded to a case of the same nature, which had occurred at some distance from Edinburgh, and in which delivery was effected by craniotomy, Dr. Simpson expressed his doubts as to the propriety of the operation, and argued that if in any instance we are justified in trying to save the child, at the expense of some additional immediate risk to the mother, it is in the case in question, where the mother's life is, from existing disease, not worth more than a few weeks' or, at most, a few months' purchase. He would recommend that the diseased and obstructing part be freely incised before the patient's strength is exhausted, for Nature generally at last effected this very operation by her own efforts; that is, the parts at last became torn and lacerated, but often when it was too late.

In a recent and esteemed English work on the diseases of the uterus, after incisions have been advised, it is stated that the practice of excision is one not adopted in this country, and one which, in the author's opinion, is not at all practicable, much less advisable.

It will, I think, be felt, after the perusal of the following account, that there may be cases in which it is both advisable and safe.

On the 4th November 1844, a lady applied to me, at my house, to have an excrescence, as she termed it, removed from her womb. On examination, I found the anterior lip of the os uteri enlarged and indurated, its surface smooth generally, but rugged and granular round the os itself, which was represented by a mere chink, and was with difficulty made out. The cervix above the enlargement seemed to be in a natural state. Examination gave no pain, but under it the parts bled.

The patient, a fine healthy-looking woman, 38 years of age, married, and the mother of several children, had not menstruated regularly for five months; but during that period she had had several momentary gushes, which stopped as suddenly. She was larger than natural, and had been sick.

I explained to her, that what she had, was not a mere wart or excrescence to be snipt off before she left my room, as she had expected; still that it might be removed; but before doing this, as there was a suspicion of pregnancy, and for other reasons, I desired a consultation. Accordingly Dr. Ferguson and I met, and then associated Dr. Locock with us.

In consultation, it was agreed that the disease was one not to be remedied but by its removal. It was also agreed that the state of the cervix uteri above, authorised this being done. But it was decided that the patient was at the fifth month of pregnancy; and it was determined that nothing. in the way of operation should be attempted until after the patient's confinement, when excision of the cervix uteri