If such a pediculated tumor be located higher in the uterus, labor may be obstructed owing to limitation of intrauterine space, so that perfora tion of the child's head may be called for. (Gueniot," Priestley.") These tumors are, however, usually not observed until after the birth of the child, at which time they occasion bleeding, and are extruded from the uterus by the after-pains. They are then ordinarily removed by one of the methods above described, or are spontaneously separated from their uterine attachments. (Conf. cases of this kind observed by Depaul, Gar. diner, Montgomery, Holyoke, Radford, Collins and Churchill.') If the tumor be interstitial and located in the lower uterine segment, thus partially belonging to the class of cervical myomata. it may lead to such a limitation of the intra-pelvic space as to seriously obstruct labor. These incarcerated myomata will be considered hereafter in connection with the sub-serous cervical tumors. Interstitial myomata frequently have no direct influence upon parturition. They sometimes precede the child's head in its descent into the pelvis, but often recede again into the abdominal cavity, particularly after the rupture of the membranes, or are gradually retracted over the head and trunk of the child by the uterine contractions. In other cases they are so soft as to be flattened out by Cie advancing foetus. (Tarnier.) It is more frequently arserted than directly proven that these tumors enfeeble the pains. This may be explained by the circumstance, pointed out by Nauss, that a large part of the fibroids consist chiefly of smooth muscular tissue, which perhaps participates in the uterine contractions. Serious and even fatal secondary hemorrhages have, however, often been observed in these cases, and are referable to uterine atony.
Fibroids may so protract labor as to imperil both mother and child. Treuer reports such a case, in which the labor was terminated by the for ceps, after it had lasted three days, and the mother died.
Balmer and Barnetsche report a case in which the woman's death oc curred forty-eight hours after the termination of a labor which had con tinued six days.' M'Clintock' saw death occur from exhaustion fifty hours after the beginning of labor, in a case of triple pregnancy. In none of these cases was there any obstruction due to the tumor, and en feeblement of the uterine contractions could, therefore, be properly as sumed as the cause of the protected labor.
Sub-serous myomata, when located in the cervix, complicate labor in the most dangerous manner. The nearer their location is to the fundus the less manifest is their influence upon the parturient act, although they may occasion weakening of the pains when occupying that position.
Chaussier and d'Outrepont describe cases of sub-peritoneal fibroids, in which uterine stony led to fatal hemorrhages. Puchelt and Simpson men tion cases in which " exhaustion " from the same source is cited as the cause of death (quoted by Magdeleine). When, however, these sub-serous tumors are pediculated, they may occasion, even when located near the fundus, very dangerous symptoms of incarceration. This is particularly
the case if they possess a long pedicle, and are thus enabled to sink down ward into Douglas's where they either become adherent or are incarcerated by the enlarging uterus. Blot' was obliged to undertake a difficult version which resulted in the death of both mother and child, because of a large, pediculated, sub-serous myoma of the posterior uter ine wall, which had become adherent to the pelvic parietes.
Madge' punctured an incarcerated myoma during labor, and was after ward able to force the tumor upward out of the pelvis. The woman died of peritonitis and a sub-serous, movable tumor was found attached, by a long pedicle, from the fundus uteri.
Before considering the serious disturbances of labor referable to incar ceration of fibromata in the pelvis, it seems appropriate to emphasize the other methods by which these tumors unfavorably influence the course of parturition.
First, in this connection, is the relation between these tumors and the position of the child. Nauss (Inaug. Dissert. Halle, 1872) found among 86 labors complicated by fibroids, 46 cranial presentations, i.e., 53.4 per cent.; 22 breech, or 25.5 per cent.; and 18 transverse presentations, i.e., 20.9 per cent. Siisserott (Inang. Dissert., Rostock, 1870) found, among 68 such cases, 40 cranial presentations, i.e., 59 per cent., 16 breech or 23.5 per cent., and 12 transverse presentations, i.e., 17.5 per cent. Toloczinow,' obtained similar results, finding among 48 labors compli cated with fibromata, 25 cranial presentations, i.e., 52 per cent, 13 breech or 27 per cent., and 10 transverse presentations, or 20.8 per cent. Tarnier ' encountered 9 breech presentations among 22 cases of this rs• riety. The striking predominance of transverse and pelvic presentations will not excite surprise if one considers, beside the configuration of the uterine cavity, the fact that the entrance of the head into the pelvis must be impeded by the presence of fibromata deep in the pelvic cavity.
I have already stated that these tumors do not affect the uterine con tractions to such an extent as might be expected or as has been assumed a priori. The frequency of hemorrhage, however, particularly of pla cental hemorrhage in the presence of sub-serous fibroids, may be, to a certain extent, dependent upon uterine atony. Nauss, nevertheless, found hemorrhage expressly attributed to atony of the uterus in only five cases. On the other hand Sfisserott found that death was produced ex clusively by hemorrhage in 9 out of 147 cases collected by himself. lie also cites 33 cases of serious bleeding.
Winckel,' Segdwick,' Henry Yeld,' Senderling,' Hecker' and Daly' re ported similar cases. (Jhaussier, Burlatour, Chailly and others (Dew quay and St. V el, loc. cit.) saw fatal hemorrhages as the result of placenta prmvia complicated with fibromyomata. This category farther includes hemorrhages in inversion of the uterus referable to the presence of my omata, which usually occur before the expulsion of the placenta.