The relative amount of muscular tissue and of connective tissue com posing the myofibroma has some bearing upon treatment. Pure myomata have, in my experience, been characterized by severe paroxysmal pains, resembling those of labor, which could be induced by touching the tumor with the sound. Similar pains, of great severity, accompanied each menstruation, and at that time the tumors, which had been of a soft con sistency, seemed to become harder and smaller, owing, probably, to their own contraction. In other cases pure fibromata seemed, rather, to be come soft and large from congestion. The remark may be made, in passing, that these soft myomata are well adapted to treatment with ergot, but that they readily become gangrenous if any intrauterine treatment is adopted.
Only a few other morbid conditions simulate uterine fibromata. In the first place the symptoms, and even the pathological processes, msy point to chronic metritis. This is the more likely to occur since, in many cases of uterine fibroid, the uterus is, actually, in a condition of chronic venous hyperemia. The differentiation of fibromata from chronic metritis is only difficult when the former are small sub-mucous or inter stitial ones. Larger tumors always occasion changes in the form of the uterus, and are, therefore, directly accessible to palpation.
Even small fibroids usually produce decided uterine pains, which are rarely so well marked in chronic metritis. A uterus containing sub mucous neoplasms is, moreover, of a globular form, and the vaginal portion of its cervix is often notably short, while the reverse conditions obtain in chronic inflammatory diseases of the uterus. Symptoms of uterine catarrh, particularly ulcerations of the cervix. accompany the latter, while such morbid phenomena less constantly accompany uterine fibroids.
Fibromata are readily distinguished from uterine displacements, partic ularly ante-flexion and retro-flexion, by the condition of the uterine cavity. The direction of the uterine canal is, however, only to be determined' by the sound. The reposition of the uterus by conjoined manipulation is by no means sufficient for the differential diagnosis of these conditions, for, on the one hand, the uterus may become fixed in an abnormal posi tion, and, on the other hand, tumors, (those which have sunken low into the cul-de-sac of Douglas for instance,) may be displaced upward, together with the uterus. Evacuation of the bladder, by means of the catheter, must always precede the above-mentioned diagnostic manipulations. Even a moderately full bladder often interferes with examination.
• In the case of %din ' a small fibroma having sunken into Douglas's cul-de-sac, and occasioned partial retention, the condition of affairs was not appreciated, and the bladder, consequently, punctured. Such cases
are, fortunately, rare.
Barnes' discoverel, by means of the catheter, that a fibroma, which seemed to be located in the anterior uterine wall, really belonged to the posterior wall of the bladder.
Interstitial fibromata often produce an abnormal prominence of the opposite uterine wall, a condition usually only discovered during sounding.
Fibroids must, farther, be differentiated from epithelioma. An epithelioma of the vaginal portion of the cervix, or carcinoma of the body, is not likely to be mistaken for a fibroma, but the reverse has occurred on several occasions. When a fibro-myoma has escaped from the external es and become gangrenous, the general condition of the patient is not only so bad that she presents a marked " c,achectic " appearance, but the local condition may closely resemble epithelioma of the porta) raginalis, as I have myself once observed. The palpating finger penetrates a soft, pulpy mass which seems to distend the fornix vagina., while gangrenous shreds adhere to the finger. The discharge is exceedingly copious, offen sive and often bloody. If the other hand discovers, on abdominal palpa tion, that the enlarged uterus is globular in form, an error is, however, readily prevented. If this be impracticable on account of the small size of the tumor, the relation of the gangrenous mass to the vaginal parietes must be discovered. Gangrenous epitheliomata always involve the vaginal walls, to a greater or less extent, while a gangrenous myoma leaves them intact. The healthy smooth lips of the dilated os uteri can always be discovered if the case be one of fibroma. It is also not so easy to remove parts of a gangrenous fibroma with the finger, as it is in cancer, and the shreds of the latter are soft and friable, while those of a fibroid are firm and fibrillated. A microscopical examination will clear up all doubts. (Coif. Braun, Chiari, and Spith, Klinik, p. 403.) Only carelessness in examination can cause advanced cases of preg nancy to be mistaken for uterine fibroids. Real difficulties in the differ ential diagnosis will be encountered only in the earlier months of pregnancy, when neither heart-sounds nor foetal members can be distin guished. Absence of menstruation and enlargement of the breasts are points in favor of pregnancy, although the mammas sometimes enlarge and discharge colostrum in cases of fibroid. The uterus is, ordinarily, soft and elastic in the earlier months of utero-gestation, while the sensa tion of a solid body floating in fluid is obtained on palpation of the ab domen. The other signs of pregnancy will also be present. The diag nosis can, however, in some instances, only be made with certainty after the observation of farther uterine development, or the discovery of the heart sounds.