UTERUS. .
Until submucous fibromata have attained a certain size, about that of an apple, they can be recognized by the touch only when they have caused dilatation of the os uteri, sufficient to render their smooth inferior border accessible to the palpating finger. The diagnosis is, of course, still easier when the tumor has become completely extruded from the uterus and can be felt, together with its pedicle, in the vagina. The dilated os may so tightly clasp the pedicle, if the latter be slightly developed or if the base of the tumor be very broad, as to closely simulate inversion of the uterus. The position of the fundus may be determined by the sound, by con joined manipulation, and, if necessary, by rectal palpation, and errors in diagnosis may thus be prevented.
It is well known that the opposite and more serious mistake of considering an inverted uterus an extruded fibrous polypus has been much more frequently made. Fibromata.which had completely escaped from the uterine cavity have, also, been mistaken for prolapsus uteri.' Foster' met with a case in which the prolapsed uterus was regarded as a fibroma and accordingly removed. The patient survived. Such errors could certainly be prevented by careful examinations.
So long as small submucous fibromata are not accessible to direct pal pation, performed according to the method already described, they dilate the uterus to an extent commensurate with their size. The uterus is, almost always, symmetrically enlarged, since the tumors are situated in its cavity. It has also preserved its natural form, or is, at the most, more globular than normal.
Although the profuse hemorrhages and the uterine discharge may, in such cases, suggest the existence of chronic metritis, the uterine pains which are seldom absent, and which resemble those of labor, will direct attention to the possible presence of a foreign growth in the uterine cav ity. The tumor can, however, only be diagnosticated after the dilatation of the cervix by means of a sponge tent, or of several laminaria tents simultaneously introduced. Shortening of the vaginal portion of the cervix uteri specially points to the presence of such a neoplasm in the uterine cavity. Owing to their great mobility, submucous fibromata are
early forced against the os internum. Interstitial fibroids of small di mensions are, likewise, difficult to diagnosticate. The enlargement and increased consistency of the uterus are, in this instance, likely to lead to the diagnosis of chronic metritis, since that disease accompanies the de velopment of the neoplasm. In many cases the little fibroid may be dis covered on the anterior or posterior uterine wall by conjoined manipula tion. The sound furnishes more definite information, since the shape of the uterine cavity is of equal diagnostic importance with its enlargement. Anteflexion and retroflexion may, moreover, be excluded by the use of the sound. In many cases, however, it will be necessary to dilate the os uteri, and even this procedure will fail of establishing the diagnosis pro vided the tumefaction of the endometrium be slight.
If the interstitial fibromata be of large size they are easily accessible to palpation. The enlarged uterus is mobile as a rule, and has either descended lower into the pelvis than is normal or has risen above the superior strait. The nearer the tumor is located to the internal os the more is the vaginal portion of the cervix shortened. The only other cases in which a similar shortening is observed are those in which the tumor encroaches considerably upon the uterine cavity. The sound often reveals sinuosities and changes of direction in the uterine canal, and, usually, an enlargement of the uterus cprresponding to the size of the tumor. These signs sometimes fail, however, and it is not always possible to reach the fundus with the sound. The diagnosis is specially difficult if several fibroids are present. Whatever cannot be de tected in these cases by palpation, cannot, usually, be established by the sound. The depth of an interstitial fibroid beneath the uterine mucous membrane and the breadth of its base ordinarily, only be discovered after a thorough dilatation of the cervix.