Bert quotes six cases of inversion complicated by fibroids. In two of these cases death occurred. In two simple cases reposition was resorted to, and in two instances reposition was performed after the removal of the tumor. In one case reposition failed.
Oldham, Desaulx and Herbiniaux report cases of inversion due to tumors and occurring after labor. (Demarquay, loc. cit.) If the pla centa is attached over the seat of the tumor, profuse hemorrhages take place after confinement. Lambert cites seven such cases. In four of these most violent hemorrhage occurred, and two of the cases terminated fatally. (R. Lee and Ashwell.) Macfarlane,' Aubinais s and Ramsbotham witnessed the simultaneous escape into the vagina of the tumor and the placenta which had been located upon it. These observers believed, at first, that they were dealitg with postpartum inversion of the uterus. In view of the fact that uterine atrophy often results from the growth of fibromata, and that the latter constitute absolute obstructions to delivery, one might expect that they would frequently produce rupture of the uterus. This is, however, not the case. Very few exact statements bearing on this point, aside from Fergusson's case, in which the rupture was produced by the operator, are found in literature. Nauss alludes to ten cases (beside that of Furgusson), but does not give their details. Among Susserott's cases I only find five cases of rupture, and in only one of these, that of Vollmer,' can the rupture be attributed solely to the tumor.
In Bezold's case a transverse presentation and a fibroma co-existed, and version was not performed until labor had continued for 13 hours. Abegg's* case does not belong to the class now occupying our attention. In his case there was a cancer of the portio vaginalis, with extensive car cinomatous infiltration of the uterine parenchyma, and a fibroma at the fundus. Rupture occurred in labor. It is doubtful to what extent the fibroma was responsible, in Shekleton's° case for the rupture, inasmuch as perforation and evisceration of the child, and amputation of its arm, were performed with a sharp hook after labor had continued seventeen hours! Lambert, moreover, mentions two cases in which women died of uterine rupture before delivery, the autopsy revealing fibromata of the uterus. Since, however, the presentations were transverse in each instance, the rupture was more probably due to that fact.
The case of R. Barnes' is unique. It was one of hard fibroid in the anterior inferior uterine wall, with rupture of the urinary bladder durhig labor. Including this case, thirteen women died undelivered, according to Sfisserott's statistics, which embrace the early observations of Voigtel, Hildanus, Kiwisch, Lee, Bartholin and Vollmer. In the other cases, cited by him, i.e., those of Hall Davis, Mintzer, Ostertag, and De Ha6n, the women died after the birth of the child, but before the expulsion of the placenta. Chaussier's case was one of transverse presentation, in which version was not undertaken. Lambert (loc. cit., p. 201) quotes a similar case from Boivin and Duge.
Intra-parietal fibromata of the uterine body, particularly if located in the posterior wall, as well as sub-serous ones situated at the fundus, may lead to incarceration during labor, by either accompanying or preceding the child's head in its descent into the pelvis. • These tumors, however, often spontaneously escape form the pelvis into the abdominal cavity; when the pains grow active, the head descends and the membranes rupture. The labor may then be easily accomplished. It is also often stated that these tumors may be displaced upward with surprising facility, by force applied to the vagina or the uterus. The case is quite different with another class of these tumors. They are lo cated in the pelvis from the very commencement of pregnancy, become incarcerated very early, and increase so rapidly in size, owing to congestion of their vessels, that they often produce, even during pregnancy, partial or complete occlusion of the pelvic canal.
When labor begins they are pressed, if possible, still deeper into the pelvic cavity, and do not permit the descent of the child's head into the latter. In other cases the head, or some other member of the child, en ters the pelvis simultaneously with a segment of the tumor, but the in carceration is thereby only rendered more complete, and delivery often becomes impossible. Cervical myomas, particularly if sub-serous, occa sion these unfortunate results. Such occurrences are very frequently mentioned in literature. The seat of the tumors is, however, not clearly described, the degree and significance of the incarceration are not rightly appreciated, and doubt is thereby engendered regarding the operative pro cedures adopted.