1. As a fibroid polypus still intra-uterine or presenting through a naturally dilated and thinned-out cervix (submucous pedunculated).
2. As sessile growths presenting by their lower segments at the os uteri, which may be closed, or may be in varying degrees of dilatation (submucous sessile).
3. As tumours incorporated in the uterine wall (interstitial).
Fig. 66. Pedunculated Fibroid Polypi in various Stages of Extrusion. (From drawings made at time of operation.)
Operations for pedunculated tumours. If a fibroid polypus be still intra-uterine (Fig. 66) the proper treatment is to dilate the cervix (see [p. 156]), and, if the pedicle be sufficiently thin, to seize the growth with a pair of stout polypus forceps and twist it off by a slow rotary movement of the handles. Should the pedicle be thicker than the finger, the use of the wire écraseur is advisable. This is a scientific snare, with a loop of pianoforte wire and a handle or wheel by which it can gradually be tightened, causing the wire to slowly cut through the stalk of the growth (Fig. 67).
Fig. 67. Wire Écraseur.
The cervix is steadied with a volsella and the loop of the écraseur is shaped and bent to the size and position of the fibroid. The instrument is then passed into the uterine cavity and the noose pushed over the tumour up along the pedicle. The wire loop is then tightened up by means of the handle or wheel, and the wire cuts its way through and separates the growth from the uterine wall. It is somewhat dangerous to put any traction on the tumour before its separation, as is recommended by some writers, as the uterine wall itself may become somewhat inverted and the wire loop may cut through into the peritoneal cavity.
If the fibroid polypus has passed through the external os uteri, treatment is more simple. Slight traction may be made upon it by means of forceps, and the pedicle severed with scissors; no hæmorrhage takes place, owing to the retraction of the stump.