Very large sub-serous fibromata, which greatly distend the abdominal cavity, may also exert sufficient downward pressure to give rise to irredu cible prolapsus of the uterus and vagina. A comparatively more frequent occurrence is inversion of the uterus dependent on sub-mucous fibroma.
If such a tumor be situated at the fundus, its very weight may drag the latter downwards, but inversion of the uterus cannot take place until the tumor has passed the neck of the uterus. After this has been accomplished, either, as is usually the case, in consequence of powerful uterine contractions, or very slowly by gradual dilatation of the os uteri, the facility with which the fundus is extruded through the os, or even beyond the external genitals (as I have once observed it), will vary accord ing to the closeness and breadth of its connections with the tumor. It is evident that pediculated myomata, so-called fibrous polypi, will much more rarely, or scarcely ever, give rise to inversion, as their distinct pedicle permits them to prolapse beyond the os uteri without at the same time dragging the fund us after them.' Cases of this kind have been described with sufficient exactness by Higgins, Oldham, Valenta, Velpeau, San tesson,' Langenbeck,' Copeman,' and Betschler.' Martin' observed inversion of the uterus in a nullipara from a pedicu lated, dense fibroma. McClintock' met with one instance of inversion of the uterus with prolapse of the organ, after violent emesis, in a patient affected with a tumor scarcely as large as an egg (compare illustration of case, Fig. 23). The same author describes a similar case (Fig. 24) in which a very small tumor of this kind also occasioned inversion. (This is prob ably the same case which is quoted in West's text-book, p. 282, from Crosse.) Pozzi' collected twenty-one cases from the literature, where fibromata attached to the fundus of the womb led to inversion and later to ampu tation of that organ. It is questionable whether sub-serous fibromata may under certain conditions, such as perimetritic fixation of the inferior seg ment of the uterus, cause inversion.
Still Louis Mayer describes a case which may perhaps be an instance in kind. Enough has been said to show that inversion of the uterus is very rarely occasioned by broadly attached fibromata.
Among four hundred cases of inversion collected by Crosse (cited by West, 1. c. p. 282), there were only forty which had developed in this manner, and even this small number includes numerous doubtful cases from older literature. Now although we must assume that there exists in these cases a certain amount of relaxation of the uterine substance ad joining the growth, or an atrophy of that part of the fundus correspond ing to the seat of the growth, yet in the only case which I have encoun tered" nothing of the kind could be found. Neither was there any fixa tion of the lower segment of the uterus, which, if present, would have favored the extrusion of the base of the uterus by labor-like pains. I have, moreover, not been able to find in the literature of the subject any statements bearing upon these points.
Other and sometimes very peculiar displacements and distorsions of the uterus are particularly liable to be induced by all myomata, that in any way fill out the pelvis. They are usually large sub-serous tumors growing from a broad base and which, starting generally from the posterior wall, develop in a downward direction so as to become retro-uterine, or even actu ally retro-vaginal, pushing the cul-de-eac of Douglas before them. In consequence of their location and size, these tumors are immovably fixed in the pelvis, although they need not always have become adherent to the walls of this cavity. They constitute the wedged-in, the incarcerated, fibro mata previously alluded to.
Similar conditions may obtain in cases of large sub-serous tumors, ori ginating on the lateral borders of the uterus, and growing between the folds'of the broad ligament, so-called intra-ligamentous fibromata. Sub serous tumors growing from the superior parts of the uterus, and large sub-mucous growths completely filling up the uterus, can only become in carcerated in the pelvis in case either the uterus or the tumors have pre viously contracted adhesions as the result of perimetritic processes. In either of these events the most varied symptoms of pressure with refer ence to the pelvic viscera may be developed.