After what has been said, it might seem almost impossible to con found the conditions in question. But the so-called incarcerated fibroids easily lead to errors. Kiewisch ' and Spiegelberg designate as incarcer ated fibroids only those which are originally interstitial, and which, grow ing downward, more or less completely fill the true pelvis, and can neither be moved in or displaced from it. This designation is certainly applicable to a large series of tumors, susceptible of exact anatomical differentiation. These tumors may grow so far downward as to become retro-vaginal, and may be occasionally mistaken for vaginal neoplasms. Since incarceration and its phenomena can only become the basis of a clinical classification, it is proper to include among the incarcerated fibromata all those tumors which, having either developed in or sunken into the pelvis, have not escaped from it in the process of growth. This definition has special reference to those fibroids which have become fixed in the pelvis by in flammatory processes.
The interesting case reported by Leopold' proves that tumors devel oped from the fuming may become fixed in this manner. Since such displaced and firmly fixed tumors readily become oedematous, soft, or even fluctuating, from venous congestion, it may often be quite impossible to distinguish between them and pelvic exudations, particularly since the latter frequently complicate fibroids. So long as there are no inflamma tory deposits the diagnostician can, usually, succeed in passing his finger between the globular tumor and the pelvic parietes, or in producing an indentation between the symphysis and the tumor by abdominal palpa tion, thus rendering the presence of a uterine neoplasm probable.
Rectal palpation is unavailing in these cases. Whenever it can be utilized the case is not one of incarcerated fibroma.
Exploratory puncture is of value in differentiating Inematocele and pelvic exudations from fibroids, but is not an entirely safe procedure. In incarcerated fibroids it is specially liable to result in circumscribed pelvic peritonitis. Even gangrene of the fibroma has been known to follow the operation and lead to a fatal issue. Spiegelberg' saw this accident result from frequent examinations of the fibroma.
My experience impels me to disparage the use of Dieulafoy's aspirator in these cases. The forced action of the instrument often produces ex travasation into the tissues of the tumor, accompanied by gangrene of the latter, or hemorrhage into Douglas's pouch attended by inflammatory symptoms.
In a majority of these cases one must rest content with a diagnosis of probability, and must not aggravate the condition of the patients by a resort to dangerous aids to diagnosis.
The prognosis in cases of uterine fibromata, if received from a purely anatomical standpoint, might be unhesitatingly pronounced good. These local and homologous tumors are, par excellence, of a benign char acter, so that the patient may be regarded as absolutely cured after their successful removal. On the other hand it is obvious, from the preceding clinical history of these neoplasms, that they constitute grave morbid conditions and may jeopardise life in many ways. No farther explana• tion of this point seems necessary, since no individual case resembles any other with reference to the prognosis. Particular attention must be given to the location and the size of the tumor, to the chief symptoms, and to the age and general condition of the patient. An accurate ap preciation of these varying conditions constitutes the chief skill of the gynecologist.