Efforts at determining the firmness of its attachment by traction upon the tumor are fraught with danger, if the removal of the fibroid be im possible, because suppuration of the neoplasm may orginate in the lacer ated wounds thus induced. The active and frequently repeated employ ment of sponge-tents must also be avoided, lest we produce gangrene of soft myomata situated immediately beneath the mucous membrane.
The direction of the cervix uteri often serves to indicate the seat of the tumor. If it be notably inclined toward one side, the assumption that the tumor is located on the other side is justifiable. If the position of the cervix ke unchanged, the fibroma is usually pediculated, submucous and small.
The question whether an interstitial fibroma be located in the anterior or in the posterior uterine wall may be settled by feeling the extremity of the sound, on bi-manual exploration, either before or behind the tumor.
The diagnosis of subserous fibromata will be easy, in proportion to the facility with which their connection with the uterus can be determined. This connection may often be discovered, in obscure cases, by imparting simultaneous movements to the tumor and the uterus by means of the sound. The looser the connection between the uterus and the tumor, the less marked is the enlargement of the former. The broader the base of the sub-serous fibroid, the more difficult is it to decide whether the tumor belongs to the uterus or only adjoins it. This is particularly true if the fibroma be of large size. The difficulties of diagnosis increase if the neoplasm has become retro-vaginal and incarcerated, or if adhesions attach it in the pelvis or to other abdominal organs. This point will re ceive special consideration in our remarks on differential diagnosis. On the other hand easily movable subserous fibromata with thin pedicles may likewise present difficulties in the way of diagnosis.
The statement that cervical myomata are easily diagnosticated is, indeed, true of those tumors which may be easily felt because located in the lips of the os, or attached to them by a pedicle. When, however, small subserous or interstitial tumors are developed in the supra-vaginal portion of the cervix, their diagnosis is often very difficult, especially if they be encapsulated. When a fibroma, developed in one of the lips of the os,
has attained a certain size, experience and authority confirm the fact that the difficulties of diagnosis are very great. Owing to the downward growth of such a tumor, which often completely fills the vagina, the os escapes upward. The free lip of the os is subjected to severe traction by the lateral growth of the tumor, and is transformed into a thin fold, lying in close apposition to the fibroid. An inversion of the uterus is thus simulated. A correct diagnosis is, however, easily made if the fundus be readily recognized by palpation. Breisky (1. c.) very pointedly calls attention to the fact that this is not always an easy matter. Fie says that the fundus is recognizable, however, by palpation of the round ligaments, the ovaries and the points of tubal attachment, either on one side or the other. If this cannot be easily effected rectal palpation may afford the desired information, although this is impracticable when the vagina is distended with large fibromata. Persistence in the investigation usually succeeds in the utilization of the sound, but the discovery of the os often demands much time and skill.
If the neoplasm is located in the anterior lip of the os, an examina tion in the lateral position with Sims's speculum is recommended. This method of examination is also adapted to cases in which the tumor develops in the posterior lip. If the os be discovered, the thorough introduction of the sound proves the absence of inversion. Such cases have been described by Freund,' Barnes,' Leon Le fort' and others. I myself encountered in two similar cases consider able difficulties in making a diagnosis, and overcame them in one in stance only by rectal palpation, and in the other by means of the sound.
Simpson' likewise emphasizes the diagnostic difficulties presented by such cases.
. It has been asserted that the sensitiveness of the uterine mucous membrane, as contrasted with the insensibility of the fibroid tumor, may assist the physician. I once had occasion to enucleate a fibroma from the fundus of an inverted uterus, but could not discover any difference be ,tween the sensibility of the mucous membrane and that of the tumor. Inflammation had, however, resulted from the inversion.