Spencer Wells, and particularly Winckel, have recently again called attention to the auscultatory signs of uterine fibroids. These were earlier studied by M'Clintock.' Besides pure arterial sounds heard here and there, there is most constantly present a murmur resembling, in every particular, the familiar uterine souffle. Winckel heard it in 54 per cent. of his cases of uterine fibroma. It is by no means so infrequent as is commonly assumed, but is, usually, only observed in connection with large sized-tumors. McClintock states that he has heard it only in cases of interstitial, or, at least, never in cases of pediculated fibroids. This sign has no bearing upon the differentiation of pregnancy from fibromata. In one of Brichetean's cases,' his diagnosis of extra-uterine pregnancy was based upon the presence of the uterine murmur. Laparotomy was performed, the case was found to be one of sub-serous fibroma, and the patient died on the 6th day.
Many cases are recorded in literature in which the diagnosis fluctuated, for a long time, between fibroma and extra-uterine pregnancy.' The symp toms of pregnancy or the termination of the cases finally solved the problem.
Uterine fibroids are usually readily distinguished from ovarian tumors by the facts that the latter fluctuate and are not directly connected with the uterus, but are capable of independent motion. if these signs be absent the diagnosis may be difficult or impossible. Since the so-called fibre cysts of the uterus are to be separately considered, I refer the reader to the - chapter treating of the differences between ovarian cysts and fluctuating nivomata. Allusion may, however, be made to the fact that sub-serous fibromata, with pedicles, have often been regarded as solid ovarian tumors (conf. Spencer Wells, Fig. 4., p. 9), because they seemed to have no con nection with the uterus. Auscultation gives no aid in such cases.
Since solid ovarian tumors (ovarian fibromata) are rare, any solid, movable abdominal tumor originating in the pelvis is, probably, a pedicu lated uterine fibroid. Solid ovarian tumors have, in my experience, caused few symptoms, while solid uterine fibromata have occasioned much inconvenience. If ovarian tumors, especially small ones or those with solid walls, are adherent to the uterus, their differentiation from sub-serous uterine tumors is almost impossible, so long as they do not fluctuate. In such cases an exploratory puncture may furnish the desired information.
Those cases are especially complicated in which, besides a uterine fibroma, an ovarian tumor is suspected. In such a case there should be two tumors, plainly distinguishable from each other. One of these is
intimately connected with the uterus, while the other is distinct from it and independently mobile. • If the latter also fluctuates, an ovarian tumor and a uterine fibroma are, in all probability, both present. The diagnosis is very difficult if one tumor is fixed in the pelvis and the other freely movable above it, because either ovarian or uterine tumors may be fixed in the true pelvis. Ovarian tumors usually grow much more rapidly than uterine fibroids. Puncture of that tumor which fluctuates the more plainly will establish the diagnosis. The cases of Greaser,' Jules Simon,' and Bouchet ' belong in this category.
In a case of this kind I decided that the tumor which was the more closly connected with the uterus was a fibroid, because 1 had perforated the uterus with the sound, although the sounding was conducted with caution I assumed that such a change in the uterine parenchyma as would render it so friable, would rather attend the development of a uterine fibroma than of an ovarian tumor. The perforation of the uterus has not resulted prejudicially to the patients in those cases which have come under my observation. Although the diagnosis of fibroid was established in the case just referred to, I subsequently encountered a patient with an ovarian tumor, the parenchyma of whose uterus was so friable that every intro duction of the sound, unless very carefully conducted, sufficed to produce perforation of the uterus.
In a large number of cases the diagnosis rests between inflammatory pelvic exudation, liternatocele, and fibroma, and is often difficult, since doubtless all, or almost all, the cases of fibroid said to have been cured by baths have really been inflammatory exudations. The distinction between these morbid conditions should, ordinarily, be easy if the history and the symptoms be duly considered. In pelvic inflammation there is fever, and hfematocele is developed with great rapidity. In fibroid there is almost always a tumor with well-defined outlines, which is not the case in pelvic inflammatory exudations or in Immatocele. If these effusions are present they may, moreover, be shown to be firmly connected with the pelvic parietes and to be directly continuous with the soft parts of the pelvis. This is true no matter how closely the uterus may be con• nected with, or how completely it may be displaced by, the extravasated blood or inflammatory exudation. Softness or fluctuation of the tumor usually speaks against the presence of uterine fibromas.