A tolerably large myoma of this kind is in the collection of the Stras burg Obstetrical Clinic, but no history of the case accompanies the speci men.
Spiegelberg' relates a typical case of a subserous fibroma of this sort growing from the posterior wall of the cervix. lie rightly emphasizes the fact that tumors of this sort may almost completely fill the pelvis, and be irreducibly wedged in there without having contracted any adhesions whatever with the neighboring parts. When we come to speak of partu rition in connection with uterine fibroids, we shall have occasion to relate more cases of this kind, which are, however, very rare. Small tumors may of course exist without any great inconvenience. Samson Gommel, of Glasgow, found accidentally at an autopsy a myoma the size of a child's head, which stretched out to the right of the uterus, growing between the folds of the broad ligament, and attached to tho neck of the womb by a slender pellicle containing very large vessels. The whole lay freely movable without adhesions in the true pelvis.' Mattei' has described a similar case.
The submucous myomata of the cervix seem to be somewhat more com mon than the subserous, though but few cases of the kind are found in the literature of the subject. They arise with a tolerably broad pellicle from the inner side of the cervical canal, and may, through their growth and their weight, drag the uterus or the cervix far down, even outside of the external genitals. In this way a very peculiar condition of the parts may be produced, the recognition of which during life is often difficult; and the larger the tumor, the greater the difficulty of diagnosis. The lips have so entirely disappeared and the os is so far displaced upwards, that in most cases the observers for a long time thought they had to do with an inversion of the womb. Since the pediculated submucons fibromata of this variety very readily sink downwards they are often mistaken for pro lapsus uteri; they may indeed produce this condition, which often dis appears again upon the removal of the tumor. Characteristic cases of this kind are described by Peter Muller.' He found a smooth doughy feeling tumor, the size of a child's head, lying outside of the vagina; from this a slender pedicle passed into the vagina where it widened out into a thicker, conical, fleshy mass which seemed to go directly into the vaginal wall at the fundus. More careful examination revealed to the left of this conical body a fold 4 mm. wide, through which the sound passed for two inches into the cavity of the uterus. There was in this case a polypus of the anterior lip of the os, which had stretched it out very considerably. An artery was found in the pedicle. A similar case is re corded by Han Davis,' in which the tumor arose from the posterior lip with a pedicle one inch thick, and had caused a prolapse of the womb. B. Schultze' removed two pediculated myomata, one of which measured 24 cm. in circumference and sprang from the posterior wall of the cervical canal with a pedicle 4 to 4i cm. thick; the other arose from the anterior cervical wall.
Finally, a case related by Barnes' is instructive: A patient, thirty-seven years of age, had a tumor composed of prolapsed vagina and uterus out side of the external genitals. There was, however, no os discoverable, and while the tumor above was evidently composed of uterine tissue, the lower part, which was pediculated, was harder. As in the other cases, the whole mass was taken for a prolapse of the inverted uterus, until an opening was found anteriorly, which was seen to be the os. After the polypoid tumor attached to the posterior lip had been removed by the snare, although the fundus could be felt in the inverted vagina, the pro lapse was reduced spontaneously.
Submucous myomata of the cervix are in general easily removed when they are pediculated. This also applies to the interstitial variety, when they are developed in one lip and grow downwards. The latter grow less readily outside of the vagina, and also draw the uterus less frequently downwards and outwards, but are more often than the submucous myomata of the cervix mistaken for inversion of the uterus. When a large tumor of this kind grows downwards from one lip, the examining finger naturally finds the orifice of the cervix above; and through the even growth of the two lips in width the os becomes strongly stretched laterally, the free lips be ing stretched closely against the tumor; in this way a narrow slit is formed, which may be easily overlooked or may be mistaken for the edge of the os of an inverted uterus. P. Muller describes such a tumor, larger than a goose egg, growing from the posterior lip, which seemed to have grown completely into the posterior wall of the vagina so that it could be pal pated easily only through the rectum. The anterior lip could not be felt at all, and only after considerable trouble was the os discovered, in the anterior surface of the tumor, feeling like a little dimple; into it a curved sound could be passed backwards for two inches. The tumor was readily removed. It measured 10 cm. in length, 7 cm. in width, and 6 cm. in depth, and was enveloped in a layer of muscular tissue (the capsule) from 2 to 3 mm. in thickness.' Hurray* saw a similar large interstitial myoma in the posterior wall of the cervix. (See Fig. 14.) Chian ' describes a fibroma growing in the anterior lip, which had caused a prolapse of the entire uterus, and had drawn out the anterior lip into a pedicle the thickness of a finger. After removal of the tumor the prolapse was spontaneously reduced.
Spiegelberg (loc. cit., see Fig. 13) saw a fibroma arising in the posterior wall of the cervix, which had become wedged into the vagina and had formed adhesions with its anterior wall. In attempting to excise the tumor an opening was made into Douglas's cul-de-sac, and the patient died from pymmia.
A very interesting case, belonging to this category, is described by Freund.' There was a tumor the size of two fists outside of the vulva, the lower third of which was divided from the rest by a shallow depres sion. This under part was whitish in color and not sensitive to a pin prick; the upper two-thirds was bluish red, gangrenou&and very sensi tive. The tumor seemed to pass directly into the fundus of the vagina. A small opening was at length discovered on the posterior surface, through which a sound passed to the left for 5 cm. into the atrophied uterus. There was in this case an interstitial fibroma, whose lower third had been uncovered by the bursting of the capsule, the upper two-thirds still being covered by it as by a cup.
We find in the literature of the subject other cases of cervical myomata related by Virchow, Schroeder, Bayle, Dupuytren and others. I myself once removed with ease a myoma the size of a man's fist, which occupied the anterior lip, and which gave at first the impression of an inversion of the uterus. Cystic myomata have also been observed in this situation by Lee and Consat. They will be described when we come to treat of cystic fibromata.
Virchow is of the opinion that fibromata of the cervix have more the nature of connective tissue, and therefore grow more slowly. A consid eration of the cases related above, that certainly constitute the most im portant ones mentioned in the literature of the subject, does not throw much light upon the point in question.