FIBROID TUMORS OF THE UTERUS. 151 



when it is more like an ovarian cyst in consistence ; or else the his- 

 tory of the case would show a preexisting pelvic inflammation, had 

 any occurred. Subserous fibroids attached only by a thin fibrous 

 stem are often thought not to belong to the womb, and, although too 

 hard to be mistaken for ovarian cysts, may be diificult to distin- 

 guish from a solid ovarian growth. The examination should further 

 determine that the object felt is not the womb itself, displaced and 

 enlarged. An anteflexed or retroflexed womb may simulate a tumor 

 lying in the uterine wall ; but conjoined manipulation will demon- 

 strate that beside the tumor in question a second one exists, which, 

 in situation, form, and consistence, corresponds to the womb ; and, 

 if necessary, the introduction of a sound will show by its direction 

 that it does not enter the tumor, but takes an entirely normal course. 

 Sometimes by means of the sound we can tell that the uterus, al- 

 though distorted and displaced, by no means corresponds in length 

 with the volume of the tumor. 



Submuoous fibroids lie hidden within the womb, and distend it ; 

 hence they may be confounded with other conditions which cause 

 uterine enlargement above all, with pregnancy, uterine infarction, 

 and hsemometra. Unless the history of the case and other circum- 

 stances distinctly preclude the supposition, the tumor may be mis- 

 taken for a gravid womb, because the same general disorders which 

 characterize pregnancy, as well as the changes in the breasts which 

 then arise, may likewise be met with now. The condition of the 

 vaginal portion is of great value in the diagnosis. In pregnancy it 

 is remarkably soft and flabby. In a case of fibroma the cervix 

 rapidly disappears, and the os uteri will gape so that the tumor 

 within it can easily be found. The uterine souffle so regularly 

 heard in pregnancy is, nevertheless, not a sure sign of that condi- 

 tion ; for it also is heard in cases of fibroma, and in rare instances 

 where there is an ovarian growth. In chronic metritis the tender- 

 ness of the womb to pressure stands in contrast to the insensibility 

 of a fibroma. Moreover, in infarction the vaginal portion is thick- 

 ened and not obliterated, and the sound enters easily ; whereas a 

 fibroma opposes an obstacle to its passage, not always readily over- 

 come. 



After excluding pregnancy, the diagnosis may be sometimes 

 facilitated by the introduction of a sponge-tent into the cervix. 

 The canal being thus dilated, it becomes practicable to examine 

 precisely the tumor with the finger and sound, and particularly to 

 determine whether the tumor is attached by a broad base or by a 

 slender pedicle a matter of the utmost importance as regards 

 therapeutics and prognosis. Interstitial tumors bulge less distinctly 

 60 



