The most common seat of these sub-serous fibromata is the posterior wall of the uterus; they are found but seldom at the side in the broad ligaments. Usually the tumors are multiple, though some may be intra• muscular or sub-mucous.
The influence of these tumors upon the shape of the uterus has been spoken of above. The change of form, when it occurs, consists in an atrophy and a lengthening of the organ. Atrophy, without at the same time a considerable lengthening of the organ, has nothing to do with the existence of a tumor, but is commonly due to senile changes. E. Kits ter has observed a very peculiar case of this nature. By reason of the growth of a myoma, the size of a man's bead, at the fundus, the uterus was greatly lengthened, the cervix especially being four inches long and with very thin walls. This elongated neck had become a cord the size of a finger, through a twisting of the womb two and a half times around - its axis; the round ligaments were wound spirally around this cord, look ing like two strings of the thickness of a goose-quill. The twisting had probably been caused by intestinal movements, as the anterior wall of the uterus was attached by ligamentous masses to the descending colon.
As sub-mucous fibroids only those tumors are to be designated which hang by a pedicle within the uterine cavity. They are entirely covered with uterine mucous membrane, as is also the pedicle. The latter is sometimes formed of mucous membrane alone. These so-called fibrous polypi differ greatly from the tumors with broad base which pro ject into the cavity of the uterus. The difference lies in the fact that they have a pedicle (varying in size, but usually rather short and thick), us well as in the symptoms and therapeutical indications.
Every fibroma of the uterus which is not pediculated must be classed among the intra-parietal tumors. These sub-mucous tumors resemble the sub-serous, except that they are apt to approach more nearly the myomata, or soft fibroids (V irchow, Rokitansky). There is but a scanty growth of intramuscular connective tissue, so that it is easy to separate the bundles of muscular fibres from each other. Sometimes there are considerable spaces between them filled with a loose connective tissue. These in
terstices often become actual cavities, which may perhaps be regarded as lymph spaces. The tumors are covered with uterine mucous membrane, beneath which there is usually a thin layer of muscular tissue. This smooth " capsule" is often cm. or less in thickness.' Although this is the usual formation of sub-mucous fibroids, yet some are met'with which are without a muscular coat or even without a covering of mucous mem bran. In those cases the pedicle consists entirely of connective tissue. Such tumors are really nothing but spontaneously enucleated whose coats (mucous membrane and muscular tissue) have disappeared (Mannel, Matthews Duncan).' Usually the mucous covering is greatly swollen, more or less in a condition of chronic catarrh, leading to bloody and muco-purulent discharges. When the tumor, however, has attained considerable size, the mucous membrane covering it is often greatly stretched and atrophied. By reason of this stretching of the mucous coat and the circulatory disturbances thereby induced, there is often vicarious congestion and swelling of the remaining portion of the uterine mucous membrane.
Klob has observed in the membrane thus stretched, spaces which he says are produced by the falling out of the utricular glands. According to him, therefore, there is a complete disappearance of the investing mucous coat, the remains constituting merely a large-meshed net-work. It must remain undetermined how deeply the utricular glands grow into the tumor, or whether the dropping out of such glands can give rise to the formation of cavities. Probably tumors of this kind do not belong at all to the class under consideration, but find their proper place under dis eases of the mucous membrane. Rokitansky (Klob) regards such new growths as adenoid sarcomata of the uterus, but even simple muscular tumors of the uterus he includes in general under sarcomata. Klebs found the mucous covering of fibroids lying in the vagina or external to it (the latter is a very' rare condition) to be thick and rugous, and covered with flat epithelium, thus presenting the appearance of the vaginal mucous membrane. lie stated that the portio vaginalis had on this account been mistaken for a fibroid.