Whenever the pelvis is so completely filled by the tumor that none of the methods of delivery mentioned are practicable, and when neither re position nor removal of the fibroid is possible, Cesarean section is our last resort. The results of the operation are worse if it be long post poned than when it is undertaken early, as is the case with Caesarean sec tion in general.
The prognosis is, however, also materially clouded by the uterine dis ease. Almost all operators specially allude to the profuse hemorrhages re ferable to increased vascularity of the uterus and to deficient contractility of the organ, both of which conditions are due to the presence and'growth of the fibroids. I find, as does Cazin,' twenty-eight Caesarean sections performed on account of uterine fibromata. Fourteen of these are care fully analyzed by Lambert. Beside these, mention should be made of the following : Braxton-Hicks,' Duclos,' Bristowe,' Netzel,° Spiegelberg ° and Cazin (loc. cit. where references to the following cases may be found): Thomas, Shipman, Conway, Putegnat, (9 cases),Retzius, Laroche, Bird. Only 4 out of the 28 patients recovered. 15 of the children were born alive, 8 were dead, and nothing is stated concerning the remaining 5. Sanger has recently collected 43 cases, in which Caesarean section was performed on account of fibroids. Only seven women recovered, i.e., a mortality of 83.7 per cent.
Eight of these cases occurred after 1876; of this number 3 were in stances of Porro's operation, all three dying, and 5 Cesarean sections, with only one death. 55.2 per cent of the children were extracted alive.
In Storer's case " a uterine tumor undergoing softening rendered extir pation of the entire uterus with its neighboring organs necessary, after the dead child had been extracted by Csarean section. The patient died.
A few cases of uterine fibroids have been cited above, in which pecu liar injuries inflicted upon the child's head, during labor, must be attrib uted to the effect of the tumors.
Simpson,' Kiichenmeister," Lachapelle and Blot' saw compression and flattening of the child's skull. Chaussier (cited by Siisserott) and BoiTin and observed fractures of the cranium. E. Martin,' saw sponta neous rupture of the anterior fontanelle, and in another case laceration of the superior longitudinal sinus.
We present, in conclusion, some statistics which may have a valuable bearing on the prognosis in the complication of labor now under consider ation.
Tarnier found among seven cases of uterine fibroids, in which labor was normally accomplished, one which was fatal for the mother, and three which ended disastrously for the child. The fate of one child was un known. Forceps was applied in six cases, in four of which the mother died. The child ablo perished in four cases. Among six versions three resulted fatally for the mother, and three for the child. Five women died before their confinement. Artificial abortion was once produced and the mother recovered. One embryotomy was performed and the woman died. In one case of enucleation both mother and child died.
Among 228 labors complicated by fibroids, 123 women or 53.92 per cent. die.l. Out of 117 children whose fate is mentioned 67 or 57.2 per cent. died (Nauss, toe. cit.) In 147 cases collected by Siisserrot, 78 mothers or 53 per cent. died. The result upon the children is only stated in 138 in stances, 91 of whom, or 66 per cent., died.
Being unable to again enter into an extended consideration of the diagnosis of fibromyomata complicating labor, we shall now only briefly allude to the conditions for which they are most frequently mistaken. The fibroids have often been mistaken fOr a second child, or for some part of one. They have also given rise to the diagnosis of extra-uterine preg nancy. They have been taken for uterine malformations and for pelvic exostoses.
The fibromata are often confounded with ovarian tumors. This error is unfortunate, since it leads to puncture of the soft tumor from the vagina, which impairs the prognosis.
Our present allusions to the treatment of these tumors must also be brief. If it be possible to remove the tumor during labor without too great danger, this must not be omitted. If its removal be impracticable, labor must be terminated in various ways according to the position of the child, and to the pelvic obstruction present. Energetic attempts at reposition of the tumor through the vagina and rectum should always be made before more active measures of treatment are adopted.