INTRA-MURAL CALCAREOUS TUMOUR IMPEDING LABOUR.

By Dr. A. WYNN WILLIAMS.

ON April the 19th Dr. Kirby requested me to see a patient with him who had been in labour for some time. He believed there was a bony tumour of the pelvis preventing the passage of the child's head, and considered it would be necessary to perform craniotomy.

The patient was forty-five years of age, primipara. On making examination the finger came upon a hard bony mass, covered with mucous membrane and apparently firmly attached to the ilium and sacrum in the vicinity of the left sacro-iliac sychondrosis, stretching across the pelvis, dividing the cavity, as it were, into two halves, leaving a space between the bony tumour and the opposite side of the pelvis of about an inch, where could be felt the os uteri, not much dilated, but readily dilatable, through which could be felt the child's head, and which was prevented making the necessary pressure on the os by the bony obstruction on which the child's head rested. I agreed with Dr. Kirby that it was necessary to perforate the child's head, which I did, chloroform being administered by Dr. Kirby. After having done so, and scooped out much of the brains, and removed several pieces of the parietal bones, I found it quite impossible to draw down the head, and came to the conclusion that our only resource was to procure a cephalotribe and crush up the child. Knowing that my friend Dr. Murray possessed one of these formidable instruments, I called upon him and asked him to come along with me and bring it with him, which he kindly did. On my return, after making an examination, I found the state of things entirely altered; the hard mass was not now firmly attached to the pelvis, but was moveable, and on inserting my finger into the os I distinctly

felt a rounded bony mass in the cavity of the uterus, whilst the head of the child had receded, and, in fact, the presenting part was now the tumour. I came at once to the conclusion that this mass had been contained in a pouch of the uterus, that it had been intra-mural. As, however, there was a possibility of its proving to be attached to the

child's head, and as it was certainly within the cavity of the uterus, it was deemed prudent, before attempting further delivery, to introduce the cephalotribe and crush up what could be grasped by the blades. This was done by Dr. Murray, and a piece of the mass was broken off and was brought away in the blades of the instrument.

After this there seemed space enough for the child to pass, and it was pulled through tolerably easily by means of the hooks. There still seemed some impediment to the passage of the placenta, and on introducing my hand into the uterus I came upon this large mass of calcareous matter, which I withdrew with my hand, the placenta immediately following. When my hand was in the uterus I could feel a pouch like a watch-pocket in the lower segment of the uterus, in which the tumour had been ensconced, in all probability for years. It was this intramural calcareous tumour wedged against the pelvis by the pressure of the child's head, and on which the force through the child's head was expended instead of on the os, that gave the sensation of its being a bony tumour attached to the pelvic bones. The lessening of the child's head removed this pressure, and the contractions of the uterus during my absence forced the tumour out of its nest into the cavity of the uterus, it being also not at all improbable that it was a perfect intra-mural calcareous tumour, and that during my manipulations and endeavours to extract the head of the child I had torn its thin internal covering, and in this way caused the enucleation of the tumour.

I think there can be no doubt, although there is no very marked history of uterine disturbance, that the patient must have suffered from an intra-mural fibroid for very many years, and that calcareous deposit had taken place in it, the advanced age of the patient (forty-five) before pregnancy took place having favoured this deposit. The tumour is composed microscopically of fine granular matter and ordinary fibrous tissue, as described in Paget's 'Pathology.' That fibroid tumours have been converted into calcareous there can be no doubt, but I never yet heard of one impeding labour. I am happy to say the patient made a good recovery.

CASE OF EXTREME DROPSY, FATTY DEGENERATION, AND FRIABILITY OF THE PLACENTA.

By JOHN BRUNTON, M.A., M.D., L.F.P.S., L.M.,

COUNCILLOR OF THE MED. SOC. LOND.; F.O.S.; SURGEON TO ROY. MATERN. CHARITY, &c.

MR. PRESIDENT and GENTLEMEN,-I beg to show you a very rare form of placenta. Unfortunately the process of preservation (in spirit of wine) has very much altered its condition. It is one of the unfortunate preparations which Dr. Tilt said were spoiling or spoiled.

When it was born it was fully four times as large, but the fluid contained in its structure has been absorbed by the spirit. The nature of this placenta is one of extreme hypertrophy (big enough for three children or more), and fatty degeneration coupled with general dropsy.

I was called to a lady in an hotel adjoining my house on Easter Sunday morning. I found her in labour with her first child. She had not gone the full term, but was in the beginning of the eighth month of utero-gestation. On examination I found an abnormal presentation, hand and foot (right hand and left foot). There was scarcely any bag of membranes. The patient was rather obstreperous, and, she being fat with thick thighs, I had some difficulty in manipulating, but by dint of perseverance I altered the presentation by bringing down the foot. By-and-by I delivered the child, which just gave a gasp or two and died.

On proceeding to remove the placenta I just caught the cord sufficiently to enable me to ascertain if the placenta was on the vagina, when without traction it broke off.

Cooling my left hand in water, I pressed the uterus through the abdominal walls, and was surprised to find the uterus very large and doughy. There was a little hæmorrhage, then action came on and this large placenta was extruded; further pressure, applied to deliver clots, delivered instead another portion of placenta, separate, distinct, and without membrane, then a second, and finally a

third piece. I put on firm pressure and a tight bandage; little or no loss followed, and for the first time I discovered that my patient was in an advanced state of dropsy. Feet, legs, thighs, abdomen, face, &c., swollen and pitting on pressure. When I was called it was neither night nor day, and in the dimness of the morning light I did not notice her condition. I have examined her urine; it is highly albuminous. She has done extremely well.

I believe this condition of placenta (dropsical) to be rare, and its friability I think is also remarkable. It becomes a question of importance to ask, when did these pieces break off? If they broke off early, then one would have expected concealed accidental hæmorrhage. There was none of this, and it is probable that uterine action severed them. Had I not carefully extruded these pieces, or had I been content with the delivery of the first placenta, in all probability a condition of affairs would have been left such as would bring on an autogenetic case of that fever which has been the subject of discussion for several nights.

CASE OF MONSTROSITY.

By Dr. WALLACE.

THE fœtus exhibited was born on the 21st of April, the mother being a primipara. The presenting part was the tumour on the head, which, when full of fluid, quite filled the cavity of the pelvis, and thinking it a case of hydrocephalus I tapped it, and the labour was easily completed. It was then found that the tumour, which seemed separated from the head, communicated with the brain; that one eye was wanting, and the left eye only rudimentary; there is no tongue, and the lower jaw seems scarcely developed, and the lower part of the face is connected with the skin over the clavicles by cicatriciallooking bands; there are six fingers on each hand, and