Scanzoni,' on the other hand, mistook such a tumor for the portio vaginalis, a fold in the soft mucous membrane seeming to the finger to be the os. A. Martin' saw a very similar case in which a polypus was supposed to be the prolapsed uterus, on account of a similar depression existing on its under surface. The pedicle uniting these tumors to the uterine wall is composed of the same elements as the fibroid itself; its thickness and length, however, are very variable. The larger the tumor and the greater its circumference, the shorter and thicker usually is the pedicle. If the latter be long, the tumor hangs down low in the cavity of the uterus, or may even come outside of it. The large sub-mucous my omata of the uterus are, however, usually of such broad base that it is difficult to distinguish them from the intra-parietal variety. Clinically we may say that all tumors that can be cut off, i.e., whose base may be cut through, belong to the pediculated, the sub-mucous variety; while those whose enucleation can be accomplished only through division of the cap sule belong to the intra-parietal class. Cullingworth ' describes a fibrous tumor five and a quarter inches long by three and three-quarter inches in diameter, which had descended through the external genitals, and was attached to the uterus by two pedicles. Between the two was a space an inch and a half wide. The anterior pedicle was one-half inch long and three-quarter inches wide;and was attached to the left side of the uterus; the other, situated posteriorly and to the right, measuring one. quarter inch in length by one and a half inches in thickness, contained two good-sized vessels. Unfortunately no exact anatomical examination was made of this very peculiar case, the explanation of which anatomically seems so difficult. It is probably to be explained either by the formation of adhesions, or by suppuration causing a loss of substance in the tumor, for the report mentions the occurrence of suppuration.
While the tumors are often quite vascular, especially containing large venous branches, the pedicle seldom contains large vessels, and very rarely large arteries. In a tumor of this kind the size of a small apple, attached to the portio vaginalis, I once found an artery the size of a crow's quill in the pedicle, but that was an exceptional case. In the wall of the uterus, in the neighborhood of the pedicle, there are often very large veins. Indeed Blebs speaks of varices in this situation.
The more these tumors grow out into the cavity of the uterus, the more readily do they excite contractions of the muscular tissue, and Lre thereby forced down through the internal os, and not seldom even through the external os into the vagina. This process, which gives rise to a num ber of the most constant symptoms of sub-mucous fibroids, we shall con. Bider more fully later on. We will only remark here that the descent of the tumor is most evident during the menstrual enlargement of the uterus, and it occurs most frequently in the case of the softer variety, the fleshy mvoma. The rapidity with which this extrusion, which has been aptly called the birth of the polypus, takes place, depends in general upon the rapidity of growth of the tumor, then upon the thickness of the pedicle, the condition of the uterine walls, the rigidity of the os, and other condi tions which will be spoken of later. This process usually ceases when
the tumor has passed through the os, although here and there cases occur in which the uterine contractions continue, and, especially in relaxed con ditions of the womb, cause inversion. Such an occurrence takes place the more readily, the nearer the point of origin of the new growth is to the fundus.
The form of a pediculated uterine myoma is usually roundish, though a more oval shape is often caused by the shape of the cavity of the womb. In rare cases the tumor has an hour-glass shape, occasioned usually by constriction by the internal or external os, the part below the constriction becoming swollen from impeded circulation. Very rarely is the growth flat or doubled upon itself, as in a case described by L Mayer.' The changes in the uterus itself occasioned by the sub-mucous pedicu lated fibroids are tolerably constant. There is hypertrophy of the same form as in pregnancy. In the case of a large growth, the walls of the uterus are thick, and the mucous membrane is hypertrophied and contains large dilated vessels; so that one really might speak of a " grotseue fibreuse." The mucous coat of the tumor itself can take part in these changes only when the growth is small; but it may become ulcerated through move ments of the tumor. These ulcers, which however are caused most fre quently by injuries from without (from the examining finger, etc.), exert a very great influence upon the nutrition of the tumor, an influence which we shall study more carefully further on. They may also lead to the formation of adhesions with the neighboring mucous membrane of the uterus or even of the vagina. Such adhesions to the opposing surfaces of the uterine mucous membrane, with partial occlusion of the uterine cavity, have been mentioned by glob. Barnes also describes a similar specimen in the St. George's Hospital Museum. Demarquay' observed a case in which close connective-tissue adhesions of a polypus to the va matter of rendered the diagnosis, as well as the removal of the tumor, a ginal wall some difficulty.
The intra-parietal (intra-mural, interstitial) fibroids of the uterus are those which have arisen deep within the muscular wall of the womb, and then by their growth stretched out the surrounding muscular layers equally on all sides. Very small growths of this kind may not be discovered ex cept by a section through the wall of the uterus. But the larger ones push the peritoneum outwards and the mucous membrane inwards, so that in a certain sense they may be regarded as at the same time sub-serous and sub-mucous tumors. In this way it may often be difficult, anatomically as well as clinically, to recognize this variety. It has been already pointed out above that in such cases the distinction must rest upon the presence of the so-called "capsule." Every intra-parietal myoma is surrounded on all sides by a muscular layer of nearly equal thickness, from which it is separated by loose connective tissue. Upon section of this muscular layer, the tumor can ordinarily be shelled out with the greatest ease.