CASES OE 
FIBROUS POLYPI 
-A. N'T} 
FIBROUS THIS (IT THE UTERUS. 
RV 
R. P. HOWARD, VI.I)., L.R.C.S.E., 
Proff*hok of Tiikory and Pkactio* Mkdipinf,, McGili. Cor.r.m* 
AND ONF. OF TT1K ATTKNniNO PHYSICIANS OF THF MONTRFAI, 
Oknkrai. Hospitai,. 
(RF*r PFFORE THE MEOICO-CHIRURGIOAL SOCIETY ON T3TH JIJNF.) 
MONTREAL: 
Printfd Attwk “(’amdian Im/Ustkatki) Nf.ws" Privtino Hotu. 
IK 7; i. CASES OF FIBROUS POLYPI 
A.3STX5 
FIBROUS TUMOURS OF THE UTERUS. 
BY 
R. P. HOWARD, M.D., L.R.C.S.E., 
Profeaaor of Theory and Practice Medicine, McOill College, and one of the 
attending Phyaiciana of the Montreal General Hotpital. 
(Read before the Medlco-Chlrurglcal Society on 13tli June.) 
1 have not selected for this evening’s paper the subject 
of Fibrous Polypi and Fibrous Tumours of the Uterus, 
because that any novelty is attached to it or that I have 
any original views to announce respecting the origin, 
symptoms or treatment of such growths, but that having 
several specimens of these neoplasms in my possession 
removed at various times I hoped a brief clinical history 
of them might be of sufficient interest to the society' to 
warrant me in intruding so practical a topic upon the 
consideration of its members. 
A. Fibrous Polypi.—Case I.—In September 1866 I was 
called to a village 50 miles from here to see an unmarried 
lady, about 30 years of age, who had been the subject of 
menorrhagia for a long time, and of intermitting metror- 
rhagia for several months. She presented a blanched 
exsanguine appearance, was very weak, depressed in 
spirits, devoid of appetite, and much emaciated. The 
pulse was shabby and frequent, and her mental condition 
nervous and despondent. Iron, ergot, sulphuric and 
gallic acids, acetate of lead, port wine, etc., had severally failed to permanently restrain the hemorrhage ; yet fron 
motives of delicacy the attending physician had not mad- 
a vaginal examination. I at once did so and found ; 
fibrous tumour about the size of a hen’s egg, but mor 
globular in form, projecting into the vagina, its upper ex 
tremity being tightly surrounded by the os uteri but no 
continuous with it. She at once accompanied me tc 
Montreal to have it removed. As the vaginal orifice wa 
very small, a piece of compressed sponge was introducec 
within it and secured by a T bandage the night befon 
the operation, and next day with the able assistance o 
Drs. Campbell and Drake the growth was removed in tin 
following manner : Chloroform having been administerec 
the growth was seized with a vulsellum, and a loop o 
broad tape passed over the latter so as to embrace tin 
highest portion of the polypus outside of the uterus- 
strong traction failed to draw out anymore of the tumoui 
from the uterus, it appeared to be very firmly attachec 
by its upper extremity rather than by a true pedicle—ii 
was rather sessile than pedunculated. Drawing the poly- 
pus almost into the ostium vagina I divided it close tc 
the os uteri by repeated strokes of a scissors. No hemor 
rhage follow-ed, although the cut surface, as may yet b* 
seen in the preparation (No. i), had a circular area aboui 
equal to that of a shilling. 
No constitutional or local disturbance followed ; the 
patient soon regained her health and has menstruated 
normally ever since. 
The growth is an example of the very dense uterine 
fibromata and was covered by a thin vascular membrane 
very like uterine mucous membrane. It was not con 
sidered necessary to dilate the os and ascertain the poinl 
of attachment of the growth, so that l am unable tc 
determine that fact in its history. Its removal by the 
scissors illustrates one of the most facile and in maqy 
instances the safest as well as the most expeditious 
methods of removing uterine polypi. Case II.—Mrs.— from New Brunswick, aged 49 years, 
consulted me in June 1870 respecting what she had been 
told was a “ prolapsus uteri.”’ She had been married 
twelve years without issue, and had been for several years 
subject to profuse menstruation every three weeks and to 
occasional attacks of severe metrorrhagia. During the 
year preceding this report these symptoms had increased 
in frequency and urgency, and several times she had 
been obliged to procure medical assistance. Vaginal 
injections of alum had been employed for a long time. 
She was a stout, rather fat, and cheerful person, and 
although very pale, was with the above exception quite 
healthy. 
A pear-shaped firm polypus about the volume of a 
small-sized hen’s egg occupied the vagina, and its pedicle 
>f the thickness of my index finger, could be traced 
through a large and flabby os uteri to its insertion into 
the posterior wall of the cervical canal, about an inch 
above the os externum. 
On the 17th June, with the assistance of Dr. Ross, then 
the House Surgeon of the Montreal General Hospital, l 
passed the chain of an ecraseur within the cervical canal 
a-, close to the uterine attachment of the polypus as pos- 
sible and slowly separated it. Moderate bleeding from 
the stump of the pedicle ensued, but under injections of 
cold water soon ceased. A pledget of cotton wool satu- 
rated with a mixture of 1 part of Liq. Kerri Perchloridi 
Fort, and 4 parts of water was placed within the os 
against the divided pedicle, and a tampon of cotton wool 
introduced into the vagina. 
The tampon was removed next day—bleeding had not 
recurred. No constitutional disturbance followed the 
operation, and no inconvenience was experienced beyond 
a moderate discharge from the uterus, and for a few days, 
a slight pain in the right ovarian region. She left for 
her home quite well on the 3rd July and might safely 
'■ave done so at an earlier date. Case III.—Resembles in many respects the one last 
related but has some interesting peculiarities, more espe- 
cially in the symptoms which followed the removal of 
the polypus. 
In May 1866, Mrs.— sought my advice with reference 
to very profuse menstruation of long standing. She was- 
about 46 years of age and the mother of six children, of 
whom the youngest was eleven years old. A vaginal 
examination disclosed a slightly patulous os through 
which the sound detected an intra uterine growth. A 
strict observance of the horizontal posture during mens- 
truation, and the administration of ergot and sulphuric 
acid moderated the monthly loss very satisfactorily and it 
was agreed to wait for the extrusion of the polypus from 
the uterine cavity before attempting its removal. On the 
24th July following, she experienced uterine pains and felt 
that a body had descended into the vagina. Visiting her 
by request the next day, I found a pear-shaped polypus 
(specimen 3) as large as a large hen’s egg in the vagina, 
and attached by a pedicle of about the thickness of my 
index finger to the inside of the uterus, upon its interior 
wall—and at least an inch above the patulous os. On 
the 28th with the assistance of Dr. Drake, the patient 
having been etherized, I passed the chain of an ecraseur 
over the pedicle and within the uterus, and slowly divided 
the attachment of the growth—no hemorrhage occurred— 
but on the 3rd March a rigor ushered in a smart attack 
of metritis attended with offensive discharge from the 
vagina. This however soon yielded to treatment and she 
was quite convalescent by the end of the month. Her 
health became perfectly restored and better than it had 
been for years. 
Two things appear to be worthy of notice in connexion 
with this case—first, the satisfactory result of palliative 
treatment while the polypus was yet intra-uterine, and 
all the more apt to produce obstinate menorrhagia— 
second, the occurrence of metritis after the careful re- moval of the polyp by means of an ecraseur. Most 
persons familiar with uterine disease, must have observed 
the varying degrees of tolerance of surgical interference 
with the uterus manifested by different women. In some 
persons, fortunately they are exceptional, the introduction 
of an uterine sound or sponge tent, the division of the 
cervix, the twisting or snipping off of a small glandular 
polypus, an intra-uterine injection, etc., will be followed 
by severe pelvic cellulitis or metritis, while other persons, 
not distinguishable from the former by the most ex- 
perienced physician, will suffer without any unpleasant 
sequence, similar and much more severe mechanical in- 
terference. 
An instructive instance of this kind may not be out of 
place, more especially as it offers an example of a variety 
of ntcrinc polypus by no means of infrequent occurrence, 
although not belonging to the variety which forms the 
subject of this paper. 
Early in 1867 a lady put herself under my care in the 
following condition. About 34 years of age,she was sterile 
although married 14 years, and had all that time suffered 
from very profuse menstruation. She was very’ feeble and 
anxmic. Insisting upon a local examination, to which 
she was much opposed, I found, in addition to consider- 
able hypertrophy of the cervix (“Areolar hyperplasia of 
Thomas) and a patulous os, four nabothean polypi (speci- 
men 6) about the size of apple pippins, attached within 
the cervical canal, and two of those cysts so frequently 
seen embedded in the lips of the cervix in sterile women. 
The polypi were snipped off and the two cysts opened 
with the points of the scissors, and these little oper- 
ations. practised without violence and even without pain, 
were followed by a rather sharp attack of pelvic dlu- 
litis which lasted three weeks. The menorrhagia although 
decidedly improved by the removal of the minute polypi 
was not altogether cured, and as she was about to visit 
her friends in Scotland, I advised her to consult when there Dr. Matthew Duncan to whom 1 sent an abstract 
of her case. That gentleman dilated the cervix with 
sponge, found another small polypus higher up and 
removed it—severe inflammation followed and she was 
alarmingly ill for some time. 
Here then was a person in whom on two occasions 
serious inflammation of the pelvic viscera was induced by 
very trivial operations. 
Case 1V differs from those previously described in that 
tlie neoplasm was completely enclosed within the uterine 
cavity and as belonging to a class of cases intermediate 
between true polypi and sub-mucous fibrous tumours—viz: 
intra-uterine fibroid growths attached by a broad and 
sessile base but of a polypoidal shape (specimen 5). 
For the notes of the case up to the time of the removal 
of the tumour I am indebted to Dr. Roddick. 
“ R. R. aged 30, a tall, dark-haired woman, unmarried, 
was admitted to the Montreal General Hospital on the 
j 8th December 1872. It was difficult to get a very 
straightforward story from her, but her history and con- 
dition were pretty nearly as follows:— 
“ She had always enjoyed good health until a year ago 
when she met with an accident by falling down stairs 
while serving in a family residing at Murray Bay for the 
season. This fall was followed by excruciating pain in 
the back and headache ; so intense and persistent indeed, 
that her mistress becoming alarmed, after a few days sent 
her to Montreal, when she immediately presented herself 
at the hospital. While on the way to this city she com- 
menced to ‘flood ’ and in spite of all treatment lost more 
or less blood continuously for about a fortnight. No cause 
could be assigned for the loss although a uterine exami- 
nation had been made. Slight pain in the back remained 
after the hemorrhage, and appears indeed never to have 
entirely left her since. She positively asserts, however, 
that her menses became quite regular and of moderate 
amount until a week before admission this time, when a profuse blood) discharge again commenced accompanied 
by back, and headache quite as severe as before. She 
had been troubled with leucorrhcea for years. 
“ Her condition on admission was that of extreme pros- 
tration after hemorrhage, being blanched to a great degree, 
the pulse frequent and weak, and the appetite entirely gone. 
“ Uterine Examination.— Entire absence of neck of 
uterus—os extremely thin, and dilated sufficiently to allow 
of the introduction of the finger as far as the first joint— 
within was readily felt a body resting immediately against 
the os, and which gave way to the point of the finger 
pressed against it. The impression conveyed was that 
of a polypoid growth appended from some point in the 
cavity of the uterus. Dr. Howard verified this diagnosis 
at a subsequent examination.” 
On the 16th January 1 introduced a pretty large 
sponge tent into the os uteri with the view of fully ex- 
ploring the relations of the growth and removing it if the 
attempt should appear prudent. Next day the patient 
having been put fully under chloroform, the tent was re- 
moved and the finger passed well up into the uterine 
cavity. A firm globular tumour, with a broad sessile 
attachment to the very fundus uteri was easily made out 
(Figure i). After some little trouble and with the assis- 
tance of Dr. Ross, Braxton Hick’s wire rope ecraseur was 
passed over the growth and its attachments were gra- 
dually divided. Some difficulty was now experienced in delivering the 
detached tumour from the uterine cavity, and it was not 
until after I had made two vertical incisions half an inch 
long at opposite points of the dilated os, that a long and 
strong pull upon the tumour with a vulsellum at last ex- 
tracted it. No hemorrhage occurred and the uterine 
cavity was washed out with a weak solution of iodine. 
At the visit the day after the operation the patient 
presented well marked erysipelas of the right side of 
the face, apparently commencing in the meatus audi- 
torius which had been the seat of a small abcess for a 
couple of days previously. 
The erysipelatous inflammation gradually extended 
over the face and head, there was the usual constitutional 
disturbance of that affection; but throughout its course, no 
pain was complained of in the abdominal cavity, and the 
only medication addressed to the uterus was a daily 
vaginal injection of warm water containing a teaspoonful 
of Condy’s fluid to the pint. 
She made a speedy recovery and two weeks after the 
operation I found the body and cervix of the uterus of 
about their usual size, but the os somewhat enlarged by 
the incisions that had been practised upon it. 
The tumour is a firm almost globular fibrous neoplasm, 
measuring in its greatest circumference six inches. Its 
attachment to the uterus was circular and had a diameter 
of an inch and a quarter as may yet be seen by an ex- 
amination of the specimen (No. 4). 
B. Fibrous Tumours—Case V—is an example of a true 
fibrous tumour of the uterus, an affection very much more 
common than true fibrous polypus of that organ ; but on 
the other hand although more common it is less amen- 
able to treatment and its removal involves more trouble- 
some and dangerous operative measures. 
Mrs. W., aged 30, has been married several years, is 
sterile and for nearly the whole period has suffered from 
profuse menorrhagia, which she attributes to an uterine tumour ; in proof of which she shews me a pickle bottle- 
filled with coagula preserved in spirit, which she regards 
as expelled portions of the growth. 
The uterus is somewhat irregularly enlarged, the os 
slightly patulous and the sound touches a resisting body 
within the womb. A large sponge tent having been in- 
troduced into the os in the evening and removed in the 
morning, had dilated the uterine mouth sufficiently to 
permit the detection by the finger of a firm growth em- 
bedded in the posterior wall of the uterus, but projecting 
by one extremity into the uterine cavity so as to form a 
submucous outgrowth. 
The same day, assisted by Drs. Campbell and Drake, 
1 attempted the removal of the tumour by evulsion and 
enucleation. The patient having been rendered insen- 
sible with chloroform, a strong vulsellum was fixed in that 
portion of the tumour which projected into the uterine 
cavity and after pulling forcibly for a short time, its 
attachments suddenly gave way and the growth shelled 
out as completely and neatly as the kernel of a nut. 
No hemorrhage followed, and the patient made a speedy 
recovery without an unfavourable symptom. Her menor- 
rhagia also disappeared and she has enjoyed excellent 
health ever since—now some five years—but has not 
conceived. 
The tumour as you see (specimen 6) is somewhat pyri- form in shape and about as large as a hen’s egg. The 
narrow end projected into the cavity of the uterus and 
about three fourths of the growth including its broad end 
were embedded in the uterine walls. A thin bed of 
-areolar tissue separated the tumour from the substance of 
the uterus and permitted of its enucleation ; it was a 
knowledge of this anatomical feature of uterine fibroids 
that lead Velpeau to suggest their removal by enucleation, 
and although the operation is not free from numerous 
dangers especially when the neoplasms are large and 
deeply embedded, yet of late years very many such 
growths have been successfully removed, not a few of 
them of considerable dimensions. 
As it is well known that uterine fibroids are chiefly 
dangerous through the hemorrhage they induce, more 
especially when situate beneath the mucous membrane or 
in the walls of the uterus, and as their removal by exci- 
sion, enucleation, gouging, etc, is frequently impracticable 
and always more or less dangerous, I will conclude this 
paper with a few observations upon a method of curing 
the hemorrhage which is the sympton that mainly renders 
these and other uterine growths especially alarming. 1 
allude to Dr. Savage’s plan of dilating the os uteri with 
a sponge tent and injecting the uterine cavity with a 
solution of iodine. 
Case VI.—A few years ago having seen in consultation 
with Dr. Drake a lady the subject of an interstitial uterine 
fibroid in the posterior wall as large as a small cocoa nut 
which habitually caused alarming menorrhagia, I sug- 
gested the injection of iodine into the cavity of the uterus 
and the operation at once checked the hemorrhage. On 
several subsequent occasions my friend resorted to the 
same measure with his patient and always with prompt 
success. 
Case VII.—Mrs. F., aged about 36, married several 
years, but sterile ; had been suffering from severe menor- 
rhagia and metrorrhagia for more than a.year and when first seen by me in November 1870 was very bloodless 
looking and much reduced in strength. On examination 
several fibroid tumours were found connected with the 
uterus. One occupied the anterior wall about midway 
between the os and fundus and was mainly subpcritoncal; a 
smaller one could be felt through the patulous os embedded 
in the substance of the womb but projecting slightly into 
its cavity ; and a third was seated high up on the posterior 
surface of the organ. The sound required some manage- 
ment to introduce it within the uterine cavity owing to 
the distortion caused by these neoplasms. As the removal 
of two of these fibroids was not practicable, I confined 
the lady to bed for several weeks, prescribed ergot in 
combination with iron and upon several occasions injec- 
ted the uterine cavity with the iodine solution recom- 
mended by Dr. Savage.* By the month of April the 
tendency to hemorrhage had been quite removed, mens- 
truation had been re-established in moderation at regular 
periods and the patient’s health and strength had been 
quite restored. 
Dr. Savage’s advice to dilate the os before employing 
intra-utcrine injections should as a very general rule be 
followed, and then the alarming symptoms which are 
occasionally induced by the operation would, if I may 
rely upon my own experience, be rarely observed. In 
the following case (\ III) the omission of the preliminary 
dilatation of the os was the indirect cause I think of the 
inflammatory symptoms that on one occasion succeeded 
the injection. 
Case VIII.—A colleague requested me to see with him 
a large fat, and young married woman who had long been 
the subject of alarming menorrhagia symptomatic ol a 
fibrous tumour which had enlarged the uterus to about 
the dimensions of that ortran in the sth month of gesta- 
* K lodi. l’ot. Io*l. Spirit: Vini Pect. : ii, Aq. ,^vi. tion. As a result of the consultation intra-uterine injec- 
tions of iodine were subsequently employed upon three 
several occasions. Upon the last occasion symptoms of 
metritis or of metro-peritonitis succeeded the injection 
within a few hours. These proved quite serious although 
manageable, and were followed by phlegmasia dolens. 
The patient, however, recovered and the tendency to 
menorrhagia was cured. 
I might cite other instances in which uterine hemor- 
rhage has yielded to the injection of a solution of iodine 
into the uterus, but these must suffice at present. Had 
the subject received the consideration that in my opinion 
it merited, in the late able treatises of Dr. Thomas and Dr. 
Graily Hewitt and indeed in various recent articles upon 
menorrhagia and uterine tumours, I would not have 
thought it expedient to have added my testimony to that 
of Dr. Marion Sims in favour of the efficiency and of the 
general safety of injections of iodine solution into the 
uterine cavity for the arrest and cure of menorrhagia con- 
sequent upon uterine fibroids, and I can add uterine 
polypi. 
Whether the repetition of these injections at every 
menstruation for five or six months sensibly reduces the 
volume of the tumours and in some instances effects their 
complete removal, I am unable to say. But this view 
will not appear improbable, when we bear in mind the 
fact that Sir C. Clarke, Rigby, Ashwell and more recent- 
ly McClintock, Mathew Duncan and Playfair have 
recorded cases of removal by absorptioii of fibroid tumours 
of the womb. It may be that the iodine excites inflam- 
mation of the substance of these tumours which, because 
of their relatively low organization, is followed by fatty 
degeneration of the inflamed tissue and subsequent ab- 
sorption. 
9 Beaver Hall Hill, 13th June, 1873.