THE RETAINED UTERINE CERVIX MILDRED CARIKER, M.D., AND MALCOLM
B.
DocKERTY, M.D.,
RocHESTER, MINN.
(Fronz the SectioiZ of Pathology, 1.uuyu Fout'tdatiott/·: artd tbe Sectiotl of Surgifal Pathology, Mayo Clinic and Mayo Foundation)
N unknown number of retained uterine cervices remain normal. Others bleed, lose support, or produce malignant growths. It is with this latter group that the present study is concerned. From the year 1926 through 1951 the files of the Mayo Clinic contain the histories of 334 women who presented themselves for examination because of symptoms referable to such retained cervices which were subsequently removed or subjected to biopsy. Clinical histories were reviewed, as were the original microscopic slides. The surgical specimens were re-examined, and additional sections were made from four or more quadrants of the squamocolumnar junction of the cervix, the upper rnd of the cervical canal, and any grossly abnormal area. Biopsy material was recut if sufficient material was present. Paraffin embedding and hematoxylin and eosin staining were used. For presentation the cases have been separated into benign eervices and thosP containing a primary malignant growth. An interval of 2 years between the time of subtotal hysterectomy and appearance of the cervical malignant lesion was used as a measure of true pl'imary malignancy of the retained cervix. This is the criterion set up by several who have reported this lesion. 3 • 5 • 7 • 9 • 13 • 24 • 25
A
The Benign Group There were 256 patients whose cervices were histologically benign. Seventy per cent of the patients were in the 40 to 60-year age bracket, but more than 10 per cent were less than 30 years of age. Subtotal hysterectomy had been performed as early as 1914 or as late as 1947, with an average interval of 10 years between the two procedures. The most frequent symptoms were vaginal bleeding, in 91 cases, and those related to prolapse of the cervix with attendant cystocele and rectocele, in 100 cases. "Vaginal discharge," "recent biopsy of the cervix reported as benign," pelvic pain, fear of a malignant lesion of the cervix subsequent to a malignant lesion of the removed uterine fundus, and vesicovaginal fistula were less frequent causes for seeking medical advice. The cervical bleeding reported by the 91 patients began shortly after hysterectomy in some and appeared years later in others. Histologic examination of the cervical canal of those with bleeding disclosed the presence of endometrium in 40 instances (Fig. 1). The endometrium \vas atrophic in 25, proliferative irt 11, and secretory in 4. The bleeding appeared irregularly in 46 patients, continuously in 10, on contact in 9, and with cyclic rhythm in 26. Those with cyclic *The Mayo Foundation, Rochester, Minn., is a University of Minnesota.
379
part of the Graduate School of the
380
('ARIKER Al\ll llOCKER'l'Y
Arn. ]. Obst. & Grnec. August,
J<1~7
bleeding all had some ovarian tissue nresent, and all but 5 had regular intervals of 24 to 30 days with scant-to-normal blood. loss as compared with the preoperative menstrual flow. vVhere endometrial tissue lined the canal, it was equivalent to that found lining the uterine eavity and Pxtended from varying levels in the cervical canal to distances of as short as 1 em. to ~ mm. aboYe the squamocolumnar junctional zone. This last measur-ement was made in 10 spceimens. TherP was PIH1onl<'tt·ial tiss1w in tlw c·c·t·\-i(•al c·Htuli in ~4 wonwn who gan· no history of hlccding. Indications for surgieal intervention w0re given as follows: blPt>ding in 71 patients, prolapse in J 00, prcsenee of a pelvic mass in 46, and infiammator~ changes in 26. The presence of fistulas, endometriosis, a sm;pected malignant lesion, stenosis of the os, pelvic pain, and eradi<•ation of foci of inl'<•<·tion ead1 acc>ounted for a Hinallnumlwr of rec:onmwwlat iom~ fol' snrgc'l',\'1'he abdominal approar·h was employesenee ot' a pc>h·ic·. twno1· or lweause of tht' need to repair fistulas (Jli'Psent in :3 patients). Fnilah·l·al ooplwreetomy in 58 patiPnts aw1 bilateral oophorectomy in ~:3 accompanied the n'moval of the cr•rvix. Cysti<· oophoritis, hemorrhagic and follicular e.vsts wen' present in 56 specimens, ewlotnctrim;i:-; in 4, fibromas in :2, and a dc•ntwid e,n;t in cmr,. ..Ylalignant tumors involn•nts wc'.l'<' benign. llistologic examination of the Cl'rvix :-;]wwed ~quamouR-c.ell metaplasia iu '27 instanees, uleeration with neerotie snrt'aeP and inftammator:v ehanges in tlw hase in ;{ speeimem;, and endometriosis in () (Fig. :.! ) . In om• of tlH•sc> the <'nrlnmetriosiH was superficial on the posterior surface of the eervix, but in the otlwr 5 the endometriosis was deep in the wall of the eervix (Fig. 1). Inftammatory l·.hangl'S, milcl to severc: and lWimarily s1ilwpithelial, wert: present in Hi t'et·viePs. A elinieal diagnosis of <:rrvic-iti~ mu l e'l'osion of t h<• e<'nix in 43 patients eoulcl not hP cn1lfi1·me\l histologi<'nll)'. hut in other· instmH•c's in whiPh this diagno:<:is was mad<> the mict·mwopic· finclinl!:s wc·tT of' papillat·y proliferation of tlw columnar epithelium at the· squatnoc·olnmnar <'pitlwlial junction with growth of th<' columnar epithr'lium O\'!'l' tlw squamous PpithPlium evere overweight was not known. Vaginal l'!'-
moval of the cervix with repair of the cystocele and rectocele was accomplished
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in all of these 100 women. Mechanical failure returned in 9 women as early as :2 years or as late as 15 years after the operation. An enterocele d eveloped in 5 women, complete prolapse of the vagina in 2, cystocele in one, and urinary ineontinenee in one. :B~ollow-up studies on the patients whose retained cervices showed no malignant tissue revealed that 5 had subsequently succumbed. In 2 the cause of Fig. 1.
Fig. 2. Fig, 1.-An endocervical gland contains both endometria l type of epithelium and usua l columnar mucous epithelium, suggesting a possible origin of endometrial elements found in the cervical wall In 5 patients. (Hematoxylin and eosin; X135.) Fig. ~.-Area of endometri osis deep in the wall of a retained cervix. Epithelium is endometrial in type, but stroma is somewhat more compact than normal. (Hematoxylin and eosin; X150.)
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& Gynec. August, 1957
J. Obst.
death was extension of ovarian cystadenocarcinoma, as previously described. In the third case, melanoma of the right great toe produced generalized metastasis and death 2 years after the cervix was removed. The fourth woman died of lymphoblastoma 8 years after operation. The cause of death of the remaining patient was not ascertained. No~ operative deaths occurred in these 256 patients. The Malignant Group
Carcinoma was present in the retained cervic1•s of 78 of the entire group of 334 women. Sixty-two of these were squamous epitheliomas, 13 were adenocarcinomas, one was an adenoacanthoma, and 2 cervices contained multiple tumors. The adenoacanthoma. exhibited the characteristic admixture of adenocarcinoma and squamous~cell carcinoma. ·we graded it 2 by the Broders method. Of the 2 cervices which contained multiple tumors, one contained both cell types, adenocarcinoma, grade 2, and squamous-cell epithelioma, grade 3, lint th1• failure of complete mixing suggested independent origins. The other cervix had two distinct tumors, an adenoe. ~When the cervical carcinoma was diagnos<:·
- - - - ---Ai1 • TI11E OF STJB'rO'J\t\_L
AGB
~ YKARS)
-10-19-~-
--~--lTYSTEI~gCTO}!Y
----~--A_T___ l'LME UF 11IAciN08lS -(W--~L~~~ll\OMA OF CllKVlX
:.!O-::m :10 :l9
40-MJ 50-59
3:3 33
60-6fl
liS
1
70-79 TABLE
If.
[Kl>ICATIO:
~~~~--~~----
INDICATION
Fibromyoma Fil•romyoma with menorrhagia :Menorrhagia Postmenopausal bleeding Malignant lesion of uterus Malignant lesion of ovary Postirradiated ear(_~.lnoma of eerYix Pelvic inflammatory disease Cystic ovary Pelvic pain Hypertension Acute appendicitis Prolapse of uterus Unknown
l'ATJE!-I'l'S _____ ---28
11 6
1 l I
3
1
1
1 1 1 20
Fibromyoma, either with or without menorrhagia, was the most frequent indieation for the initial procedure of subtotal hysterectomy (Table II). Ji'ive of the 78 removed fundi contained an adenocarcinoma. One of these has been
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described earlier in this paper as having developed an adenoacanthoma in the retained cervix and 2 others multiple tumors of squamous and columnar epithelial cells. The intervals between operative procedures in these three Fig. 3.
Fig. 4. Fig. 3.-Inv.asive grade 3 squa1nous-cell epithelioma of the . . . . . . ~ u.n.. associated \vith in situ carcinoma of the overlying epithelium. Note the lymphatic channel plugged with carcinoma. (Hematoxylin and eosin; X 50.) Fig. 4.-Grade 3 squamous-cell epithelioma in a retainect cervix. (Hematoxylin and eosin; X150.)
were 16, 10, and 2 years. The remaining 2 cervices in this group of 5 cancerous fundi produced squamous-cell carcinoma. Of these 5, the patient with the adenoacanthoma died in 9 months from metastasis to the abdomen, lungs, and
384
..0 CD
ii:
CARIKER
A:t~D tJOCKERTY~
Am. J, Obst. & Gynec. August. 1957
""
'"
ii:
.,.;
,~
ciJ ~
-~ ;:.
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Number 2
RETAINED UTERINE CERVIX
385
sunraclavicular lvmnh nodes. the metastasis beine: adenocarcinoma; another who had one of the ~louble t~mors and a third patient who had squamous-cell epithelioma died in 3 years; the other patient with two separate tumors in the cenix was still living at 3 years and 7 months; the fifth patient could not be traced. Vaginal bleeding was the presenting symptom in 61 of the 78 women with ca1·cinoma of the cervix. The bleeding was sometimes continuous but on other occasions it was intermittent and irregular; it was usually scanty but occasionally profuse. Some patients had had bleeding for at least 5 years, others only for 4 clays, the average duration being 11.9 months, and many had the symptom for less than 6 months. Eight women asked for an evaluation of preYious treatment of carcinoma of the cervix; 12 had had a diagnosis of carcinoma by biopsy before presenting themselves for examination; 3 had had a In addition to a diagnosis of C' linieal diagnosis of cal'cinoma of the eervix. eal'einoma hy biopsy rJ patients had teceived ir1·adiation therapy. The treatnwnt had ]wen within a year before admission, exc<'pt for one patient. who hnd reeeivet1 such treatntent ~0 y(:!ars previou~1y. Physical examination showed almost uniformly a firm cervix with or without u](·eration awl with tumefaction involving only the cervix, extending to the vagim1l fornices, progressing to the broad ligaments or fixing the entire pelvis. Two lesions which proved to be in situ growths were described on examination as bleeding on manipulation and :3 others as "cervicitis," "lacerated cervix," and a "polypoid growth." The growths were classified by the eriteria of physical findings as set down by the r~eague of Nations for staging the extent of a tumor, and a biopsy was taken either in the office or in the operating room. In 69 cases, biopsy only was performed. In 5 the cervix was rrmovecl vaginally and in the remaining 4 the cervix was removed abdominally. Additional operative procedures included colostomy to relieve a stridure in one case and a radical -w ertheim dissection in another. ·Microscopically, the in situ lesions had the cellular picture of cervical malignancy, with inPrease in C<'ll size, enlarged hyperchromatic nuclei, alteratiotiS of polarity of eells. and the presence of mitotic figures; all changes were limit<'d to the squamous superficial layers. The infiltrative squamous-cell car(•inomas exhibited the same changes hut with extension to various depths in the wall of tlw cervix and even beyond the limits of the cervix (Figs. :1 and-+). The a
Fig. 5.-Gracle 2 adenociircinoma involving the lymphatics adjacent to its primary site in a retained cervix. (Hematoxylin and eosin; XlOO.) Fig. 6.-Grade 1 mucus-producing adenocarcinoma primary in retained cervix. (Hematoxylin and eosin; X200.) Fig. 7.-Same lesion as in Fig. 6, demonstrating papillary features and cellular detail. (Hematoxylin and eosin; X150.) Fig. 8.-Grade 2 adenocarcinoma primary in retained cervix, which produced excessive amounts of mucus with relatively scant numbers of malignant epithelial ceJJs. (Hematoxylin and eosin; X150.)
TAHLE
III.
DEATH OR SuRVIVAL OF i8 PATIENTS V{ITH CARCINOMA OF THE RETAINED CERVIX ACCORDING TO THE STAGE OF THE MALIGNANT TUMOR SURVIVING
DIED STAGE
~FMBER
H
2-l
ITT
....
1 :1
q,_)
[l
lV
13 i5 2
s
7S
22
10
T
0 Total
MORE THAN 5 YEARS
LESS THAN 5 YEARS
•>
3
~
]
6 3
i
lr-:oT '!'RACED
7 •) ~
11 1
1
3
± 1 36
1 11
6
28
'l'ABLE IV.
I
MORE THAN 5 YEARH
LESS THA~ 5 YEARS
3
47
DEATH OR SURVIVAL OF 78 PATIENTS \VITH CARCINOMA OF THE RETAINED CERVIX ACCORDING TO THE TYPE AND GRADE OF THE MALIGNANT TUMOR
I TYPE AND KUMBER GRADE* -------
-~-·-
I
L~;ss
SURVIVING
THAN Dr:ORE THAN 5 YEARS 5 YEARS
--
LESS THAN I 5 YEARS
2 3
1 ]2
3 3 2
I MORE
THAN 5 YEARS
~0'1'
TRACED
1
s
24
3
4 4
3
2
1
1 --Total
(i
~:,?
28
47
=
adenocarcinoma.
squamous-cell epithelioma; Adca tOne adenoacanthoma included.
*SCE
'l'ABLE V.
DEATH OR SURVIVAL OF 78 PATIEN'l'S WITH CARCINOMA OF' THE RETAINED CERVIX AccORDING TO STAGE, TYPE, AND GRADE OF THE MALIGNANT TUMOR TYPE AND GRADE*
S'l'AGE
I. Total lOt
II.
Total 24j:
III. Total 25§
IV.
Total
12
SCE 3 Adca 1 Adca 2 SCE SCE SCE Adca Adca
2
3 4 1 2
SCE 2 SCE 3 RCE 4 Adca 2 Adca 3 Adca 4 i::i\JJ'j
2
SCE 3 SCE 4 Adca 1 0. Total
t
5
Total 2
SCE
3
TOTAL
DEAD
3
3 1
1
2 12
2
1
2
l
2
1
10
5
1
l
7
9
4 2
~
2 1 1
1
1
1
1 7 3
1
1
1
6 1
SCE 3 Adca 1
2
1 1
adenocarcinoma. *SCE = squamous-cell epithelioma; Adca tincludes one case with both SCE 3 and Adca 1. nncludes one case with both SCE 3 and Adca 2. §Inciudes one case with adenoacanthoma 2.
1
5
5
1
1 1
16
1
NOT TRACEll
6
6
6
ALIVE
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roentgen therapy alone for one patient. Five patients received no irradiation therapy; these included 2 who had in situ lesions, one who underwent a radical lymph node removal, one with a grade 1 adenocarcinoma, and one who had a stricture of the intestine. Two patients received treatment elsewhere. 'l'he carcinoma of the retained cervix was fatal in 28 (36 per cent) of the 78 women studied; 22 of these women died in less than 5 years after treatment had been given. Three women were alive but with recurrences of the tumor pl'esent in this same 5 year period. Thirty-six ( 46 per cent) were alive 5 years OJ' more after they received treatment; 11 patients were alive less than 5 years afte1· treatment. Three patients could not be traced. The highest death rate was in the stage II and III lesions, which proved fatal in 17 of 49 cases so diagnm;ed. Although only 14 patients had adenocarcinomas and 12 of these wet·e graded 1 or 2, nevertheless, 50 per cent of these patients succumbed. 'I'he one patient with adenoacanthoma died in 9 months from widespread metastasis. The larger group ( 62 patients) with squamous-cell carcinoma and 2 patients with coexisting squamous-cell carcinoma and adenocarcinoma had a death rate of :33 per cent. Forty-seven of these 62 squamous lesion:-: were graded 8. Tables III, IV, and V depict these results.
Comment For mot·e than 30 years gynecologic surgeons have advised. that total rather than subtotal removal of the uterus be ])erformed if hysterectomy i:-; the indicated operation. 1 • 2 • 6 For the patients in whom it is not possible to remove the cervix it has been recommended that thorough curettage of the cervical canal and conization of the external os be additionally performed to denude these zones of all epithelium. But Masson17 pointed out that thh; lloeK not eliminate the danger of the subsequent development of carcinoma from thf' squamous epithelium of the portio that remains. As early as 1927 he reported a mortality rate of 1.3 per cent for total hysterectomy performed in 229 instances during that year and 1.8 per cent for subtotal hysterectomy done in 217 cases over the same period. The present-day status of blood hanki11g. chemotherapy, and antibiotic therapy has helped to bring this mortality rate to well below 1 per cent for almost all gynecologic surgeons. All agree that skilled surgeons should be performing the operation. The present study of benign retained cervices emphasizes that the ce!'Vix which has lost its support or which bleeds is the one which leads to most discomfort, disability, and anxiety. 22 • 23 Surgical removal of such cervices made them available for a complete search for the presence of a malignant lesion and at the same time offered opportunity to carry out an oftentimes needed vaginal repair. The microscopic study of the cervical canal, which demonstrated endometrial tissue extending down the canal to within 2 mm. of the squamocolumnar junction in 10 cases, diminishes the expectancy of removing sources of bleeding by removal of the uterine fundus only. 'rhis endometrial tissue was probably the source of endometrial glands and stroma, which were found in 5 instances deep in the wall of the cervix in much the same manner as when internal endometriosis or adenomyosis is found in the wall of the uterine fundus. Endometrial tissue on the posterior or peritoneal st1rface of the cervix, on the other hand, suggested that it vtas of ectopic origin and part of a pelvic endometriosis.
388
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Prolapse of the cervix over a prolonged period, with the atttcndant increased trauma to the vaginal portio, apparently did not increase the ineidenee of carcinoma in the cervix, for 100 of the patiPuts in this series had nu·ious degrees of loss of support with no associated malignant changes. The p11iiPJJi.s who did have carcinoma of the cenix clill not exhibit prolapse and wen• found On examination to have Yery minor degrees of loss 0 f support. Vaginal removal of the cervix ga Vt' the best access for repair u [ the supports of the vagina, but when a pelvic· mass m· a fistula into the eE·rvix n·quired an abdominal approach a satisfadut·y l'epair o[ vag'inal suppol't could be made from ahove. Mechanical faihll'e oN~lllTPd in only !J of the woml:'n who were treated by removal of a lHmign (•eni~c All lwll a pt'!'opeJ•atiYP •·oJnplaint of cervical prolapse. 'l'he reported frequencies with whieh ean·inoma begins in the retained cervix have been based on the number that oeeur <·om]>ared with 1lll •·arcinomas of the cervix diagnosed during au identieal pel'ioll of tin~t• at the same diagnostic center. In ] 953 Y onng an(l ,J onm;"' ('ompiJr,(] t hPH<' t'<'port.s and found an average incidence of 4-.l pet· tl'llt. .Meigs" 0 hased hi;; iig·ure ur 0.73 per cent on the number of lesion;; that developed after sul>total hystet·ectomy as observed in his own series of c'ases. ]·'rom our own standpoint we were unable to make any satisfactOl'y statisti<•al analyNis reg·ar·ding: itl('idPtwe of cer·vical carcinoma complicating OJH'ration whi('h involve•l presernttion of a cet'Vical stump. \Ve do consider it signifieant aml very im pol'tm1t that 11o less than 2:1 per cent of cervical "stump;;" which Jn·oducell symptoitJs that brought the patients to the clinic fot· treatment wet·e in faet th<• ;;(cat of pr·imary malignant disease. Son1e aLlthors 10 · 14 • ~ 0 ~ 26 have accepted an c-u·bitt'clry interval of l year ft·oJn the time of a subtotal hysterectomy to the time of diagnosis of ('(ll'(•itWIIl cervical carcinomas that were diagnosed 2 years or· more after th(· subtotal hysterectomy had been perfonned. This intl:'nal was used with the knowledge that there is a growing literature on eervieal carcinomas known to havl' been in situ for much longer periods be fore clinical symptoms awl lesions •weurred. The average interval between operative pt·ocedures was 10 years for hoth benign and malignant lesions, with an average age at rliagnosis of <'('t·vieal carcinoma advanced approximately a decade from the age at diagnosis of those in the intact uterus. The nullipal'ity (:H per cent) of this group of women, all but one of whom were manied, is hig·her than the 22 and 9 }Wt' cent given by others. 10 · 24 Maliphant'" hasecl his ::17 per cent of s
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The 5 year survival rate of 46 per cent is better than the average of 35 per cent given :for all carcinomas of the cervix. 8 • 11 • 18 • 19 • 21 Both radium and deep roentgen therapy were given to 65 patients. Vaginal excision of the <'ervix was performed for :J of 5 patients with in situ carcinomas. The tumor in these 3 was grade 3 squamous-eell earcinoma; eombined radium and roentg·en therapy was given additionally to one of these patients. Three are living ancl well at 4.7 years, 6 years, and 12 years later, respectively. The other 2 patients had in situ carcinoma and received radium and roentgen therapy for gl'ade 3 squamous-eell epitheliomas; they were well after 7 and 10 years, respectively. These patients with in situ carcinoma were studied in the era prior to the institution of our current program of eytodetection, and the line of treatment employed does not reflect our present policy. Two early stage I eareinomas were treated by vaginal excision. One patient with a grade 3 squamous-cell epithelioma received radium therapy postoperatively and was well 5 yrars later. The other patient had both a grade 3 squamous-eell epithelioma in the portio of the cervix and a grade 1 adenocarcinoma of the upper portion of the cervical canal. This patient received both radium and roentgen therapy and was well 3 years and 7 months after operation. Abdominal exf
CARIKER AND DOCKERTY
390
Am.
J. Obst. & Gynec.
August, 1957
hysterectomy a 54-year-old woman was admitted complaining of vaginal bleeding for :3 months. She was found to have a stage IV, grade 3 Sl1Uamous-ce11 epithelioma which had invaded the bladder with obstruction to the right ureter anarcinoma of the cervix. However, their deaths could have been prevented by adequate surgical treatment which could have been performed at no added risk. Moreover, the saving of months and years of discomfort and anxiety for the women whose benign retained cervices gave symptoms could have been made possible by a complete initial operation. Summary 1. The case histories of 334 patients for whom the retained uterine cervix had been surgically removed or subjected to biopsy were reviewed and the surgical material was studied. 2. These cases represent the women who had a sign or symptom referable >. to 1ne re1a1neu cervix wu1cn causect tnem to asK ror examination. 3. Of this group 78 women (23 per cent) had a carcinoma of the cervix and 36 per cent of these carcinomas caused the death of the patient. 4. Carcinomas of stages III and IV and squamous-cell epitheliomas, grade 3, were responsible, percentage-wise, for the largest number of deaths. 5. Adenocarcinoma, even of grade 1, caused a proportionally high mortality -death in half (7) of the 14 patients so afflicted. J
J
1
.
J
'f
,
•
1 .•
1
.
,
I
1
I
'1
{\
•
•one grade 2 adenoa.canthoma included in this group for statistical reasons.
Voiume 74 Number 2
RETAINED UTERINE CERVIX
391
G. Adenoaeanthoma vms the tumor type encountered in one cervix, and ') c·eJ·yices eontaiued hoth a squamous-cell carcinoma and an adenocarcinoma. I. Prolapst' of the rervix and vag-inal walls constituted the complaints and t1nc1ings present in 100 patients. 8. Cervical bleeding was the most frequent presenting symptom in both henign and malignant cervices. 9. Endometrium was found lining the cervical canal in 64 specimens, and there had been some type of bleeding associated with 40 of these. This endometrial tissue was found to extend as far distal as 1 em. to 2 mm. above the squamocolumnar junction. 10. Although abdominal removal of the cervix was done when pelvic masses and fistulas were present, the vaginal approach was considered to be of advantage in that more adequate repair of the vaginal wall could be done. This was of particular advantage in the 100 cases of prolapse of the cervix with aceompanying cystocele and rectocele. 11. Except in rare cases of very difficult procedures, the results of the present study indicate that, when hysterectomy is the choice of treatment, a total removal of the uterus is advisable.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
Cantril, S. T., and Buschke, Franz: \Vest. J. Surg. 50: 454, 1942. Carter, B., Thomas, W. L., and Parker, R. T.: AM. J. 0BST. & GYNEC. 57: 37, Hl49. Caulk, R. M.: Am. J. Roentgenol. 72: 469, 1954. Cosbie, W. G.: AM. J. 0BST. & GYNEC. 51: 751, 1946. Costolow, W. E.: Radiology 52: 41, 1949. Dodds, J. R., and Latour, J.P. A.: AM. J. 0BST. & GYNEC. 69: 252, 1955. Donnelly, Grace C., and Bauld, W. A. G.: J. Obst. & Gynaec. Brit. Emp. 56: 971, 104!). Fricke, R. E.: Proc. Staff Meet., Mayo Clin. 14: 705, 1939. Fricke, R. E., and Bowing, H. H.: Am. J. Roentgenol. 43: 544, 1940. Healy, W. P., and Arneson, A. N.: AM. J. 0BST. & GYNEC. 29: 370, 1935. Healy, W. P., and Frazell, E. L.: AM. J. OBST. & GYNEC. 34: 593, 1937. Hendricks, C. H.: J. A.M. A. 14.6: 100, 1951. Irwin, R. W.: Canad. M.A. J. 70: 561, 1954. Kelley, A. J., and Brawner, D. L.: AM ..T. 0BST. & GYNF.C. 66: 711, 1953. Lambright, 1\f. H., Jr., and Clement, K. W.: Ohio M. J. 47: 733, 1!)51. Maliphant, R. G.: J. Obst. & Gynaec. Brit. Emp. 62: 367, 1955. Masson, J. C.: AM .•T. 0BST. & GYNEC. 14: 486, 1927. Masson, J. C.: New Orleans M. & S ..J. 92: 235, 1939. 1\fayo, C. H., and Mayo, Charles: Ann. Surg. 93: 1215, 1931. Meigs, J. V.: AM. J. 0BST. & GYNEC. 31: 358, 1936. Phaneuf, L. E.: Am. J. Surg. 29: 479, 1935. Phaneuf, L. E.: AM. J. 0BST. & GYNEC. 64: 739, 1952. Phaneuf, L. E.: Am. J. Surg. 85: 711, 1953. Redman, T. F.: Proe. Roy. Soc. Med. 45: 331, 1952. Tice, G. M.: J. Kansas l\I. Soc. 54: 98, 1953. '?t>. Ward, G. G.: AM. J. 0BST. & GYKEC. 41: 660, 1941. 27. Young, H. A., and Jonas, A. F.: Surg., Gynec. & Obst. 96: 288, 1953.