There are, undoubtedly, cases in which delivery is normally accom plished without the displacement of a tumor, partially filling the pelvis. Such cases are reported by Ingleby, Hecker, and by Spiegelberg,' in which latter case maceration of the foetus facilitated its expulsion. Similar cases are cited by Lachapelle,' Simpson,' Habit,' and by E. Dlartin." In one of Martin's cases the expulsion of the child was rendered possible by rupture of the anterior fontanelle, and in the other by maceration of the dead child. These phenomena are rare, but those cases are still less fre quent in which a tumor located in the of Douglas, or in the superior strait, has spontaneously ascended under the influence of the pains, and has thus rendered delivery of the child possible. The tumors have, in these cases, probably been either usually or invariably interstitial, or sub-serous fibroids of the posterior wall, and not cervical tumors of large size.
Gueniot,' Blot,' Lehnerdt,' Spiegelberg' and Hecker ° report such cases. Only such cases of fibroid are, of course, included in this category as seemed partially or completely incarcerated in the pelvis, so that in some instances the propriety of a resort to Caesarean section had been considered.
Far more numerous and important, in their practical bearings, are those cases in which the tumor is deeply incarcerated in the pelvis at the be ginning of labor, but is at a later period displaced upward by force ap plied in the vagina, thus enabling labor to be spontaneously or artificially accomplished. The reposition of the tumor seems to be most easily ef fected after the rupture of the membranes, because the uterus is then smaller and more movable. Reposition naturally fails if the presenting part of the child be at the same time firmly impacted in the pelvis. In one series of cases the tumor had been punctured before reposition was attempted, most frequently because it had been considered ovarian, ow ing to its soft consistency.
In other cases the puncture was made for the purpose of reducing the size of the tumor as much as possible, and rendering it more movable. The object of the puncture was attained in only a few cases, since only a little bloody fluid was evacuated in most instances. The very dangerous nature of this operation must not be forgotten. It often produces gan grene of the tumor or peritonitis. Spath,' Madge' and Spiegelberg (lee. cit., p. 110) describe such cases, in which reposition of the tumor was ef fected, after its puncture, and delivery thus accomplished. In the two
former cases the mother died. In Spiegelberg's she lived. Cases are more numerous in which simple reposition succeeded, and in these the women recovered with one exception, that of Pillore's " patient, who died after delivery. The other cases, fourteen in number, were observed by Ashwell, C. Mayer,' Wegscheider,' Siebold, Hecker,' Hoogeweg,' Beatty, Depaul,' Barry,' Rankin,' Thirion,' Playfair,' and Winkel. Reposi tion thus succeeded in eighteen such cases, in three of which the patients died.
There are, finally, some cases reported in which the tumor could be removed before the child, and delivery thus effected. These were, of course, cases of sub-mucous or interstitial tumors of the cervix or of the lower uterine segments. Danyan " succeeded in enucleating a large fi• broma of the posterior cervical wall, which almost filled the pelvis. The child was macerated. The mother recovered. Heck's case (quoted by Siisserott, p. 34) terminated in a similar way, but both mother and child recovered.
Wynn Williams" met with a large calcified myoma, which was firmly pressed against the pelvic wall by the child's head. He could only ex tract the child after perforating its head, and crushing the myoma with the cephalotribe. Portions of the tumor were then removed and the child delivered. Heim (Siisserott, loc. p. 21), Diintzer, Keating and Langenbeck " have described cases in which the tumor was removed before the child's extraction, but the mothers died.
When the tumors do not completely fill the pelvis, the method of de livery will depend upon the circumstances of the case, i.e., upon the limi tation of intra-pelvic space, the position of the child, the character of the pains and the condition of the child. In short, the most varied con siderations which determine the nature of operative measures must be taken into account. Since this is not the place to explain those consid rations we merely quote some statistics from Susserott's carefully compiled tables.
Among 147 cases of labor complicated by fibroids, collected by him, the forceps were applied 20 times; 12 mothers and 7 children lived. Ver sion was performed 20 times: 8 mothers and 3 children were saved. The placenta was removed by artificial means 21 times, and only 8 mothers recovered! After the induction of artificial abortion 3 mothers died and 5 lived. Death of the women resulted in 2 out of 6 cases in which the child was perforated. Delivery was effected with the blunt hook in 3 cases. In one of these the mother died.