ijWith the compliments of the Author. 
THE TREATMENT 
OF 
FIBROID TUMORS OF THE UTERUS. 
WASHINGTON L. ATLEE, M.D., 
OF PHILADELPHIA. ( 
BY 
Extracted from the Transactions of the 
INTERNATIONAL MEDICAL CONGRESS, 
Philadelphia, September, 1876. 
PHILADELPHIA: 
1877. THE TREATMENT 
OF 
FIBROID TUMORS OF THE UTERUS. 
BY 
WASHINGTON L. ATLEE, M.D., 
OF PHILADELPHIA. 
Extracted from the Transactions of the 
INTERNATIONAL MEDICAL CONGRESS, 
Philadelphia, September, 1876. 
PHILADELPHIA: 
1877. COLLINS, PRINTER, 
PHILADELPHIA ; 
705 Jayne Street. THE TREATMENT OF FIBROID TUMORS OF THE UTERUS. 
In opening the discussion on The Treatment of Fibroid Tumors of the 
Uterus, a question that has for many years engaged my attention, it will 
be imposssible to present the subject properly in the short space of time 
allotted to me; and 1 must, therefore, ask your indulgence if, in adhering 
closely to the text and compressing my material, I should fail in satis- 
factorily elucidating the several points in this paper. 
I beg, also, to premise that, in bringing this subject before the Section 
on Obstetrics, I shall not go into the detail of every method of treatment. 
This I think would be out of place before an assembly of such enlight- 
ened men, who are already familiar with its written history. I shall 
merely refer to rny own experience. Every gentleman, who will engage 
in this discussion, has an experience of his own, and if each one will 
bring his personal contributions, able architects of our profession will 
rear a structure out of these materials which no individual could erect 
from his own observations, and which will stand as a lasting memorial 
of this day’s work. In this way we will be likely to arrive at the best 
practical results for the benefit of Science, Art, and Humanity. 
My methods of treatment have been surgical and medicinal. In the 
use of medicine I have principally confined myself to iodine, ergot, and 
muriate of ammonia. Many years ago I lost faith in iodine, and now 
seldom use it, and only as a local application. As early as 1845,1 intro- 
duced the use of ergot in the treatment of uterine fibroids, and have ever 
since employed it. In proof of this I may refer to my essay on Fibrous 
Tumors of the Uterus, published in the Transactions of the American 
Medical Association for the year 1853. Ergot, no doubt, acts in two 
ways in influencing the nutrition of fibroids of the uterus: (1) on the 
muscular tissue of that organ, and (2) on the capillary circulation of the 
tumor itself by contracting its smaller vessels. Notwithstanding this 
action of the medicine, I have never been so fortunate as to see a fibroid 
quietly disappear under its sole influence, although in many cases the 
size has been diminished, while in others no effect has been produced. 
The reason of its variability in action may be explained in the course of 
this paper. Recently, Hildebrandt has introduced the hypodermic use 
of ergot, and with results, in his hands, quite extraordinary. I cannot, 
however, conceive how this agent can accomplish more by its subcutane- 
ous employment than by its administration by the natural passages. It 
certainly acts more promptly through the cellular tissue. But it is ques- 
tionable whether this increased speed of action is a sufficient compensa- 
tion for certain inconveniences to the patient from this mode of its 
application, as well as for the greater tax on the time, convenience, and 
patience of the medical attendant. 
[n the consideration of the treatment of uterine fibroids, it must also 
be kept in mind that spontaneous cures may result in consequence of 4 
ATLEE, 
fatty degeneration ; that diminution in the size of the tumors is often 
observed in advancing age, through senile atrophy of the muscular fibres; 
that fibrous induration sometimes occurs, the muscular tissue becoming 
scarcer as the connective tissue hardens, and that this induration is fol- 
lowed by calcification and an arrest of growth. 
With these preliminary remarks, I will proceed to discuss the subject 
of treatment more definitely. In doing so understandingly, it will be 
necessary to keep in view the relative position of the tumor with the 
uterus. Hence I will make the somewhat arbitrary division into the 
following heads:— 
I. Tumors usually accompanied with hemorrrhage, embracing (1) 
fibroids occupying the vaginal canal; (2) fibroids within the cavity of 
the uterus; (8) interstitial, submucous fibroids ; (4) interstitial fibroids 
proper ; (5) recurrent fibroids. 
11. Tumors usually not accompanied with hemorrhage, including (1) 
interstitial, subperitoneal fibroids; (2) sessile, peritoneal fibroids; (3) 
pedunculated, peritoneal fibroids; (4) interstitial, cervical fibroids; (5) 
myomatous degeneration of the uterus; (6) fihro-cysts of the uterus. 
I. Tumors usually accompanied with Hemorrhage. 
(1) Fibroids expelled from the Cavity of the Uterus, or occupying the 
Vaginal Canal.—The treatment of these tumors will vary according to 
their size. When small, with a slender pedicle, the tumor may be 
grasped as high as possible on its neck by means of Luer’s polypus for- 
ceps, or a similar instrument, and twisted off, or, in other words, removed 
by torsion. 
When larger, with a pedicle not thicker than a finger, it may be seized 
and brought down with some force so as to stretch the pedicle, which 
may then be severed at as high a point as possible with Cooper’s hernia 
bistoury, or a probe-pointed bistoury properly wrapped and protected. 
When quite large, distending the vagina or filling up the pelvis like 
the head of a child, a small obstetric forceps may be applied to it, and 
then placing the patient under the influence of an anaesthetic, with the 
assistance of supra-pubic pressure, the tumor may be gradually brought 
through the os externum. Having accomplished this, one of several 
plans may be adopted for the purpose of detaching it; (a) By means of 
the bistoury the proper coat of the tumor may be severed all around, about 
an inch or so beyond the insertion of the pedicle, and then the upper end 
of the tumor enucleated from its peduncular attachment; (b) the sub- 
stance of the pedicle may be directly severed by the knife; (c) the 
pedicle may be divided by the ecraseur. I have used all these methods, 
and it is best to be prepared for either operation, as the surgeon must be 
governed by the circumstances of each case. When it can be accom- 
plished, I prefer the first method, or that by enucleation of the peduncu- 
lated end of the tumor. 
Immediately after the removal of these large tumors we should use a 
tampon, charged with persulphate of iron or other efficient haemostatic 
and antiseptic, adapting it well against the amputated stump, and allow- 
ing it to remain from twenty-four to forty-eight hours. The raw and, 
usually, inflamed surfaces should afterwards be treated through the FIBROID TUMORS OF THE UTERUS. 
5 
speculum by suitable applications until they are brought into a normal 
condition. 
It may be noticed that I have not referred to the ligature as one of the 
methods. I have long since abandoned this plan, preferring immediate 
ablation of the tumor. 
(2) Fibroids entirely within the Cavity of the Uterus.—The treatment of 
fibroids inclosed within the cavity of the uterus must depend somewhat 
on their size and locality. When large and of long duration, having dis- 
tended the body of the uterus and dilated the cervix as does the head of 
a child in the last months of gestation, an examination by the finger 
will discover a mere uterine ring, through which by firm pressure, par- 
ticularly when counteracted by supra-pubic support, a tumor within may 
be detected. This no doubt is the condition precedent to the first form of 
fibroid which we have considered, and the lapse time in all probability, 
if the patient should hold out, would accomplish the same state of things. 
It is, however, not always safe to wait, but safer to facilitate measures by 
imitating the processes of nature. To make the tumor more accessible, 
the os uteri should be dilated by the usual means, and at the same time 
ergot administered to excite and maintain the contraction of the expul- 
sive fibres of the organ, and in this way also aid in opening the uterus. 
Or, instead of using dilators to open the os uteri, the action of ergot may 
first be established, and afterwards the tense edges of the os may be 
nicked with a bistoury, thus successively dividing the circular fibres, and 
accomplishing the object in much less time. As soon as the mouth of 
the womb is sufficiently expanded, a small obstetric forceps may be intro- 
duced and applied to the tumor in the same way as it is to the head of a 
child. Traction should now be made on the tumor under the influence 
of an aneesthetic, and if the circular fibres, as will probably be the case, 
should resist its escape, the bistoury must be employed until all resist- 
ance is overcome, and the tumor is brought into the cavity of the vagina. 
It is now in the position described under the first head of our subject, 
and may be managed accordingly. 
There is, however, a very important difference between a tumor pass- 
ing from the uterus into the vagina spontaneously and one brought 
there by violence, and that difference involves a very grave practical 
point. This will be at once apparent when it is stated that in the former 
case the tumor alone occupies the vagina, and that in the latter it is very 
apt to be accompanied by an inverted uterus. This is particularly liable 
to occur when the pedicle is attached to the fundus. Usually too, in vagi- 
nal fibroids, we find a moulded and elongated pedicle which is readily 
and safely managed, but in the tumors under consideration the pedicle is 
usually sessile, and affords but small space for any surgical appliance. 
Hence, the inverted fundus uteri is in great danger of injury and muti- 
lation, and unusual care is required in amputating the tumor. I believe 
the safest mode is to enucleate the upper portion of the tumor from its 
proper coat, and thus free it from its uterine connections. Of course, after 
this is done, the inverted uterus should be at once replaced after proper 
styptics have been applied to the raw surface, and the case treated upon 
general principles. 
These fibroids, however, are not always as simple and as easily 
managed as has been just described. From some cause or other the tumor 
may have formed adhesions to the surface of the uterus, independent of 
its original, peduncular attachment. These adhesions majr be so situated 
as to interfere materially with the dilatation of the os uteri, or with the 6 
ATLEE, 
introduction and application of the forceps. It is necessary, under these 
circumstances, as soon as they are recognized by the finger, to sever them 
with the bistoury until the surface of the tumor is free. If, in conse- 
quence of such adhesions, or of a lateral origin of the pedicle, the ordi- 
nary forceps cannot be applied, Museux’s forceps, or appropriate hooks, 
may be substituted to seize and bring down the tumor after the os uteri 
is sufficiently dilated. 
Besides the fibroids referred to, there are other tumors in the cavity of 
the uterus which are entirely concealed, and, either from their diminutive 
size or a very adipose abdomen, cannot be detected. The cervix uteri 
may be intact, and there may be no bulging of the uterine wall recog- 
nizable by the finger in the vagina. Yet the symptoms may be so diag- 
nostic of their presence that we are bound to be governed by them alone. 
In such cases we must dilate the cervical canal by sea-tangle, sponge 
tents, etc., until we are able to pass the index-finger and explore the in- 
terior of the uterus, and get access to the tumor. The dilatation must 
now be carried further, so as to admit, in addition to the finger, the 
necessary instruments for the removal of the growth. These are usually 
a strong, slender forceps, or hook, and a long-handled, probe-pointed bis- 
toury, or a probe-pointed, semicircular knife. A small wire ecraseur, 
passed above the forceps, will answer the same purpose. If the tumor 
have a small pedicle, it may be removed by torsion. 
(3) Interstitial Submucous Fibroids.—These are tumors which, originating 
in the wall of the uterus, develop mainly towards the mucous surface. 
Like the two preceding forms, they more urgently demand the surgeon’s 
attention in consequence of inducing uterine hemorrhage. When the 
cervix is not implicated in this class of tumors, and the body of the 
uterus alone is involved, it is best not to be too precipitate in resorting 
to surgical means for relief. As long as hemorrhage can be controlled, 
and blood saved to the patient, it is best to depend upon the judicious 
employment of ergot and other remedies, rather than to resort to a hazard- 
ous use of the knife. A tumor thus situated, with muscular walls on 
one side of it and a mere raucous covering on the other, will be in a 
favorable condition for ergot to gradually expel it from its muscular bed, 
and force it into the uterine cavity, and, in proportion as this is accom- 
plished, we secure the aid of all the longitudinal fibres of the uterine 
walls in propelling the growth against the circular fibres of the cervix, 
and in causing a gradual opening of the os uteri—thus finally reducing 
this form of tumor to the second variety before considered. 
If, however, exhausting hemorrhages cannot be controlled, and fatal 
consequences threaten, other and more decided measures must be adopted. 
The os and cervix should he well dilated, so as to get free access to the 
interior of the uterus, and to be able to command the surface of the 
tumor. As soon as this is done, efficient doses of ergot must be adminis- 
tered, and, when its action is established, a long, probe-pointed bistoury, 
guided by the index finger of the left hand, should be passed up fiat- 
wise into the uterus, as in using a sound, and carried over the face of the 
tumor until it reaches its upper border. An assistant should now grasp 
the lower part of the abdomen and steady the uterus. The bistoury is 
then turned with its edge against the tumor, and boldly pressed into it 
and drawn downwards through its dense tissue, so as to slit open both 
its mucous covering and its proper coat, burying the knife well in the 
fibrous mass, and carrying it downwards until it makes its exit at the 
lower border of the tumor. As the knife passes through the dense tissue, FIBROID TUMORS OF THE UTERUS. 
7 
a decided grating is perceptible. It is a remarkable and interesting fact 
that, if hemorrhage have existed before this incision, it will cease after it 
has been made, and it will sometimes he found that when nothing else 
will arrest hemorrhage, a free use of the knife will accomplish it. Im- 
mediately after the section, an attempt should he made to enucleate the 
tumor from its bed, which can often he accomplished if the tumor be 
not too massive. Should it not be removed at once, it is apt soon to 
become disorganized and dead, throwing off a very offensive, dirty, 
watery discharge, and endangering septicaemia. Ergot must be con- 
tinued, to maintain the contraction of the uterine tissue, antiseptics 
administered by mouth, lungs, and vagina, and the patient sustained 
until the tumor is removed by the surgeon, or is discharged in a soft- 
ened mass resembling wet tow. The danger to be apprehended after 
this operation is blood-poisoning from dead matter. This is very much 
diminished when the tumor is removed by one operation, but, even then, 
the extent of raw surface remaining after the tumor is taken away, some- 
times causes toxsernic symptoms. 
(4) Interstitial Fibroids Proper.—These are tumors which originate 
deeply in the substance of the uterine wall, and during their growth and 
development are surrounded by a pretty uniform coat of uterine or mus- 
cular tissue, neither impinging on the raucous lining on the one side nor 
on the peritoneal covering of the organ on the other. As a general rule, 
the demand for active treatment in these cases is not as great as in the 
submucous varieties. These intra-mural tumors, however, are the very 
ones most amenable to the mode of treatment that has recently claimed 
the attention of the profession, viz., the hypodermic use of ergot. I can 
understand how the tonic contraction induced by ergot can impede nutri- 
tion in a tumor so located, hut I cannot conceive how absorption could 
be promoted under a similar amount of compression obstructing the 
absorbent vessels. In the treatment of interstitial fibroids I think it 
best to use ergot periodically and not constantly; employing it in anti- 
cipation of and during the menstrual periods, and associating with it the 
continuous use of an alterative sorhefacient, such as muriate of’ ammo- 
nia. If ergot acts mechanically in destroying the life of a tumor, then, 
when that is accomplished, the stress or pressure should be removed, so 
that this dead matter may be absorbed. As long as this dead material 
is hermetically encased in living tissue, unaffected by atmospheric influ- 
ences, it is not likely to become offensive or toxic, and may he carried off 
by the absorbents like other molecules of dead matter in the regular pro- 
cesses of repair, without infecting the general system. As there is a 
tendency for fibroids to increase in size before each menstrual period, in 
consequence of the greater determination of blood to the organs of gene- 
ration, so there is a diminution in their size after menstruation subsides. 
Hence ergot is calculated to act beneficially, when given in time, in 
arresting this supply of blood to the tumor ; and yet we must not always 
attribute the diminution in size, which usually follows menstruation, to 
the influence of ergot, as it is a natural physiological sequence. 
These interstitial fibroids often assume a great size, and in doing so 
stretch the cavity of the uterus to an unusual length, increase the vascu- 
larity of the organ and the size of the vessels pervading the correspond- 
ing mucous covering, and, during the menstrual period, these unsupported 
vessels are rendered turgid and congested, and, giving way,produce copious 
and dangerous hemorrhages. When this is the case, and danger cannot he 
averted by medication, surgical means are demanded. A bold, free inch 8 
ATLEE, 
sion through the rnuco-muscular envelope of the tumor, and through its 
proper coat, burying the knife into the tibroid substance, will be attended 
by an arrest of the bleeding. This may be followed by an enucleation 
of the tumor—the several steps of the subsequent operation being the 
same as detailed under the head of Interstitial Submucous Fibroids. 
Sometimes the interstitial tibroid, even when very small, may produce 
the most violent symptoms, both local and reflex, leading even to death; 
and may be so situated that, under certain circumstances, its existence 
may not be suspected, and that, even if correctly diagnosticated, it could 
not be removed by any ordinary operation. This is particularly the case 
when the tumor originates in the lateral part of the fundus uteri and 
becomes intradigamentous. Such cases, fortunately, are extremely rare, 
and I will endeavor to illustrate them by the detail of one which recently 
proved fatal;— 
Mrs. I). G. S., aged 34 years, was brought from the interior of the State to 
Philadelphia, and placed under my care. She was small in stature, but exces- 
sively corpulent, particularly in the abdominal wall. For a long time she had 
suffered the greatest agony and distress, and had had frequent and most violent 
convulsions. All the symptoms were distinctly traceable to the uterus. There 
was decided endo-metritis, and the slightest touch of the sound would cause 
terrific spasms. There was also extreme tenderness confined to a small spot 
in the hypogastric region, on the right of the linea alba, so that she could not 
tolerate the most gentle pressure. The treatment during the winter of 1874-75 
relieved the endo-metritis and several of the reflex symptoms, and, although 
she had not fully convalesced, she went home with the expectation of gradually 
regaining her health. But she again became worse, and her husband, an intel- 
ligent physician, conducted the treatment, but without controlling the symp- 
toms. I visited her several times during the winter of 1875-76, and I never 
saw a greater sufferer. The spot in the hypogastrium was the point of trouble. 
IShe had not been able to lie down for months, and the right thigh was kept 
flexed all the time. Her suffering was so constant and intense that both she 
and her husband begged me to open her and remove the womb. She required 
the constant use of the most powerful anodjmes to afford the least comfort. 
Finally of cerebral congestion supervened, and in a few days after, 
on the twenty-third of March last, death came to her relief. In exposing the 
abdominal cavity after death, about four inches in thickness of adipose tissue 
had to be penetrated. The uterus was enlarged and highly congested. Its 
cavity was three and a half inches long. The lining membrane was normal. 
In the right wall of the fundus was an interstitial fibroid, not over two inches 
in diameter, surrounded by a dense wall of uterine tissue, and so closely adhe- 
rent to its capsule that it could not be shelled out or enucleated. The capsule 
had evidently been in a state of inflammation, and this was thought to be the 
cause of the intense and fatal suffering. Both openings of the Fallopian tubes 
were obliterated. 
In reference to this interesting case I wish to state that I had ap- 
pointed the very day on which I witnessed the post-mortem examination 
to visit the patient to decide upon the feasibility of extirpating the 
uterus. In consequence of the extreme amount of abdominal fat, as shown 
by the examination, this would have been very difficult, if not impracti- 
cable. For the same reason it was impossible to make a correct diag- 
nosis of the case, and the fibroid discovered after death was not at all 
suspected to exist before. Of course the case might possibly have been 
made out by the barbarous practice of exploring with the hand through 
the rectum. If such an extreme case were again to present itself to me, FIBROID TUMORS OF THE UTERUS. 
9 
particularly in a thin patient, I should think it my duty to remove the 
diseased organ. 
(5) Recurrent Fibroids.—The recurrent fibroid is polypoidal in charac- 
ter, and is supposed to be reproduced, after its removal, from the same 
pedicle. These cases are very troublesome, because, after one tumor is 
removed, there may be repeated recurrences of others, resembling in 
this respect, and in this only, the several forms of malignant disease. 
The operation for their removal is the same as for that of the ordinary 
uterine polypus, but, as this is a much more grave trouble, I wish to 
submit to the Section a proposition embracing more extensive surgical 
interference. This proposition is based upon the treatment of two cases 
of very great interest, which I beg permission to relate. 
In the first case I removed eleven successive tumors, after which the 
patient recovered and had no return. 
On December 27, 1860, I visited Mrs. T. W. S., aged 31 years. Menstrua- 
tion for the first four years was small in quantity and free from pain, but after- 
wards was accompanied with extreme during the first day. She married 
at the age of 24 years, in one year after gave birth to a child, and had a mis- 
carriage afterwards. The menses were regular, having only missed the last 
period. In April, 1858, she first discovered something wrong in not being able 
to pass water. A large quantity was drawn away by the catheter, which opera- 
tion had to be repeated. Several physicians saw her, and diagnosticated mal- 
position of the womb, and very violent efforts were made to restore it to its 
normal position, but without effect. June, 1860, she had a sudden attack of 
severe pain, which so entirely disabled her that she could not walk for several 
weeks, suffering much of the time with the most dreadful bearing-down pains. 
After a period of intermission the expulsive pains again returned with extreme 
violence, and, on November 28, 1860, while using the catheter, she felt a 
tumor in the vagina which she supposed to be the womb. The pain now dimin- 
ished, but the size of the tumor gradually increased, and it finally protruded 
through the os externum. During the above period she had copious discharges 
from the vagina of bloody clots and a greenish, slimy, and. offensive fluid, 
changing usually about twenty-five napkins in a day. 
When I saw the patient she was perfectly blanched and anaemic, with a small 
thread-like pulse, and evidently in a state of toxicohseraia. A tumor, as large 
as a small adult head, protruded from the vagina, and was lying between the 
thighs. It was in a gangrenous condition, and gave off a most offensive odor. 
The index finger, passed into the vagina in front, came against the anterior lip 
of the os uteri about two inches up. It was stretched across the front face of 
the tumor, which was continued into the uterus as far as the finger could reach. 
The sound struck the fundus uteri one inch above the anterior lip. The vagina 
behind the tumor was also explored. A cul-de-sac was reached at the distance 
of one and a half or two inches, formed apparently by the inverted vagina 
coalescing with the tumor. The growth had clearly been developed in the pos- 
terior wall, and had been extruded b}r the uterine efforts from the cavity of 
the organ. The circulation was still maintained in the posterior portion of 
the mass. The pedicle was about two inches thick. With the assistance of 
Drs. Drysdale and Burpee, I removed the mass by means of the ecraseur. 
Although much decomposed, its weight was one and a quarter pounds. For 
several weeks the patient continued to be very ill with septicmmic fever, but 
finally fully recovered. 
April 17,1862, the patient consulted me again, stating that she had remained 
well until three months before, when she had had a copious puruloid discharge, 
and that one week before seeing me another tumor had begun to protrude. On 
examination, I found that the relative positions of the tumor and uterus were 
now different. The former, instead of being behind the os tincse, was anterior to 
it, and the expanded posterior lip could be distinguished in the hollow of the 
* 10 
ATLEE, 
sacrum. This second tumor increased to a considerable size, and was removed 
in the same way. At the same time a hard tumor was felt occupying the hy- 
pogastric region. A few weeks after the removal of the second tumor it was 
followed by a third, which was also taken away. A mass still occupied the 
hypogastric region. 
The following December she was taken with excessive hemorrhage, requiring 
the use of the tampon. Subsequently quite a large tumor was expelled from 
the vagina, and at the same time the supra-pubic tumor disappeared. This, 
the fourth tumor, was removed by the ecraseur on the 9th of January, 1863, and 
the operation -was followed bjr a rapid recovery, June 1, 1863, another large 
tumor, the fifth, was removed in the same way. January 21, 1864, the sixth 
tumor, less in size, was removed. I could plainly trace this one into the cavity 
of the uterus, and the anterior lip of the os stretched over it, the sound en- 
tei'ing anterior to the mass two and a half inches. At the same time I recog- 
nized a hard tumor in the right inguinal region. August 24, the same year, 
the seventh tumor was removed. The eighth, ninth, and tenth were subse- 
quently removed up to the 20th of May, 1866. The eleventh tumor was taken 
away on the 18th of August, 1867, with the assistance of Dr. J. Nicolaysen, of 
Christiania, Norway, now Professor of Surgery in the University of Norway. 
After this no tumor could be detected anywhere. 
After the eleventh operation there was no return, and the patient regained 
her health, at least for two or three years, after which I lost sight of her. 
In reviewing the above case—its extraordinary features, its long dura- 
tion, its imminent perils, and its almost endless recurrence—the question 
has often presented itself to me: Would not extirpation of the uterus at 
an early period have been not only justifiable but preferable? 
A question also of great interest—the pathology of the so-called Recur- 
rent Fibroids—might be discussed with profit, but this is not compatible 
with our present subject. Both questions will be in a measure involved in 
the detail of another case, which I think would have exhibited the same 
features as that above narrated, but which was terminated quickly and 
happily by a different mode of treatment:— 
On May 15, 1874, Mrs. C. T. was brought from the interior of Pennsylvania 
for treatment. She was 30 years of age, had first menstruated at the age of 14 
years, and had continued to be regular until her marriage in 1870. Two years be- 
fore marriage she began to suffer from a burning sensation in the pelvic region, 
and from bearing-down pains, which gradually grew worse. Soon after mar- 
riage menstruation became more copious, and, eighteen months after, she was 
seized with great pain, accompanied with excessive flooding. Subsequently 
she was confined almost constantly to bed by copious hemorrhage, intense suf- 
fering, and constant nausea and vomiting. She had never conceived. Pros- 
tration, emaciation, and anaemia were very strongly marked. 
The uterus was enlarged to the size of a four-months’ pregnancjq the cervix 
fully expanded, and the os, round and ring-like, merely admitted the point of 
the index finger. A hard, smooth tumor could be felt within. I immediately 
put her on the use of iron and ergot, but, notwithstanding, she had an over- 
whelming attack of flooding and pain. By the 22d of June the condition of 
the patient and of the os uteri was such as to warrant me to proceed with an 
operation. Assisted by my son, Dr. W. Lemuel Atlee, I introduced a forceps 
into the cavity of the uterus, and, grasping the tumor, made traction while the 
patient was under the influence of an anaesthetic. As the os was not suffi- 
ciently open to allow the tumor to escape, it was nicked by the bistoury as 
it tightened over the descending mass, which finally was delivered into the 
vagina with a sudden slip, and afterwards through the os externum. The 
ecraseur was now applied, but, proving to be faulty, was removed, and the 
pedicle was severed by the bistoury. While preparing for this part of the FIBROID TUMORS OF THE UTERUS. 
11 
operation, I was struck with what appeared to be an unusual elongation of 
the pedicle, which was dotted over with several molluscum-like bodies. Ap- 
prehending that this might be the uterus itself inverted, I was careful to make 
the section close to the tumor. Immediately afterwards I tamponed the vagina 
with strips of muslin wet with MonsePs solution of iron. 
The operation was followed by intense pain, and in the course of two or 
three hours by hemorrhage, which was controlled by removing the first tampon 
and substituting small sponges. There were also incessant sickness and vomit- 
ing, which, the patient said, always followed the loss of blood or the use of 
anaesthetics. These symptoms were subdued by opiates in the course of twenty- 
four hours. The pulse increased in frequency, and the case looked rather 
alarming. ISText day the sponges were removed, an examination was made, and 
a rough, irregular, tumor-like mass still occupied the vagina. I could not divest 
myself of the apprehension of its being an inverted uterus. The parts were 
so very tender that a satisfactory examination could not be made. This sore- 
ness continued for eight or ten days. 
The regular menstrual period came on the first week in July, accompanied 
with very little pain and a moderate discharge. On the 13th I repeated the 
examination, and found the same state of things. The os grasped the tumor, 
and a sound passed up entered the uterine cavity the normal distance of two 
and a half inches. From this examination I inferred that there was no inver- 
sion, and that there still remained a portion of the original tumor. Pressure 
over the pubes did not enlighten me. Perhaps a finger in the rectum would 
have disclosed the true state of the case, I seized the body with a strong 
double tenaculum, brought it partially through the os externum, applied the 
ecraseur, and on working the instrument found the tissue unusually resisting, 
requiring much force and time in getting through it, and indeed having to finish 
the operation with the knife. On examining the mass, after its removal, I was 
surprised to find it to be the body of the uterus. 
[The specimen was then exhibited. The mucous surface was dotted over with several 
small tumors in different stages of development.] 
Great pain and sickness of the stomach succeeded the operation as before, 
but did not last so long. Much less bleeding accompanied the amputation, 
and none followed it. The patient had a rapid and excellent recovery, grew 
fat and hearty, and, with the exception of slight coccyodynia, has been in the 
continued enjoyment of perfect health. Menstruation has not occurred since. 
The speculum reveals a perfect os tincse, and the sound enters only one inch. 
Although the treatment of the above case was ultimately conducted 
on an error of diagnosis, does it not teach a valuable practical lesson ? If 
the history detailed to you this day explains and illustrates the patho- 
logy of the so-called recurrent fibroid of the uterus, and if each abnormal 
body on the surface of the womb is liable to be successively developed 
into a life-endangering tumor, will not the amputation of the body or the 
entire removal of such a diseased organ be the best mode of treatment, 
keeping in view the comfort and life of the patient ? 
11. Tumors usually not accompanied with Hemorrhage. 
(1) Interstitial Subperitoneal Fibroids.—These are tumors having the 
same relation to the serous coat of the uterus as tire’interstitial submu- 
cous fibroids have to the mucous coat. They are imbedded in uterine 
tissue except where they present towards the abdominal cavity, and there 
they are covered only by peritoneum. Their locality renders them much 
less serious in their consequences to the patient, and does not call so 12 
ATLEE, 
imperatively on the surgeon for interference. Still, circumstances might 
arise in which relief would he demanded. Treatment in these cases will 
accomplish a great deal, either with or without reference to an ultimate 
surgical operation. I have just hinted at the action of ergot in the sub- 
mucous fibroids. It is the same, in an opposite direction, in the sub- 
peritoneal tumor. The tendency of any foreign body, when acted upon 
by the contractile efforts of uterine tissue, will be towards the point of 
least resistance. Hence ergot, acting forcibly on the muscular substance 
of the uterus, in which the fibroid is deposited as in a closely-fitting nest 
covered merely by a delicate serous membrane, must, as a necessary re- 
sult, gradually diminish the bed of the tumor, and as gradually cause the 
mass to encroach upon the abdominal cavity. I have no doubt that nature 
herself sometimes converts this kind of tumor into a sessile or even pe- 
dunculated fibroid. And hence, by following her teachings, by means of 
ergot we are able greatly to aid her in accomplishing such results. Sup- 
posing, however, that this result has been reached, the tumor has not 
been destroyed nor diminished, but only changed in its locality, for I 
very much doubt whether ergot has influenced its growth in this situa- 
tion, Still, our patient has been benefited by relieving a very sensitive 
and irritable organ of a troublesome tenant, and by placing the tumor in 
a position more accessible to the resources of surgery if the case should 
ever demand it. 
In interstitial subperitoneal fibroids, it would be extremely hazardous 
to invade them by the knife from the interior of the uterus, and in this 
way attempt their enucleation or even disorganization and devitalization, 
as their thin serous coating would not be a sufficient barrier to protect 
the abdominal cavity from being entered, which would necessarily cause 
fatal results. It would be much safer, after the administration of ergot, 
to open the cavity of the abdomen, expose the surface of the tumor, 
divide its peritoneal coat with the knife, and enucleate the mass from its 
muscular bed. Should bleeding occur, the vessels could readily be secured 
as they are in ovariotomy, and to guard against oozing and accumula- 
tions in the abdominal cavity a siphon-drain could be carefully placed 
and brought out of the lower angle of the wound. At the same time, 
if deemed necessary, a communication between the bed of the tumor and 
the cavity of the uterus could be made, and thence through the cervical 
canal with the vagina, and a siphon introduced so as to assist in carry- 
ing off fluids also in that direction. These precautions would go very 
far in preventing septicaemia and fatal inflammation. 
(2) Sessile Peritoneal Fibroids.—These are tumors which present bodily 
into the abdominal cavity, but are closely seated on the exterior surface 
of the uterus, and have a broad base. They do not sink deeply into the 
uterine tissue itself, and do not elongate the uterine cavity. They may 
be removed in the same way as the subperitoneal variety, but the same 
precautions need not be exercised with regard to the uterine bed which 
receives the tumor. Indeed, in both varieties, a peculiarly formed tube 
of silver, glass, or hard rubber, around which the detached coats of the 
tumor could be fastened or ligated, might be secured with one end in the 
bed of the tumor, while the other could be carried out of the lower end 
of the abdominal wcmnd, thus acting as a siphon in drawing off the fluids, 
or as a conductor for the introduction of antiseptic washes from with- 
out. By the time the ligatures should have become loosened, the drain- 
age tube could be removed, and a fistulous track would remain to fill up 
and heal by granulation and cicatrization. FIBROID TUMORS OF THE UTERUS. 
13 
In cases of ovariotomy, when complicated with small sessile fibroids, 
I have not hesitated to enucleate them before closing the incision, being 
careful, if there were any oozing, to carry a tent from the raw surface to 
the lower angle of the wound. 
(8) Pedunculated Peritoneal Fibroids.—These are fibroids having a dis- 
tinct pedicle, either membranous or myomatous, attached to the exterior 
surface of the uterus, and contained within the cavity of the abdomen. 
These tumors, being beyond the limits of uterine action, are not usually 
influenced by the use of ergot, but do sometimes yield to the sorbefacient 
action of muriate of ammonia uninterruptedly maintained for a long 
time. If they fail to yield to medical treatment, and induce such severe 
symptoms as to destroy personal comfort or jeopard life, they may be 
removed, as are ovarian tumors, by abdominal section, and the pedicle 
secured by the clamp or ligature. The operation need not be described. 
I may, however, remark that, in proportion to the size of the tumor, the 
incision through the walls of the abdomen must necessarily be larger 
than that required by ovariotomy, and that the pedicle will need more 
careful attention. Should the pedicle be short, we can add to its length 
by incising the proper coat of the tumor around its base, two or three 
inches beyond the stem, and shelling it oft* and making it part of the 
pedicle. I have several times removed these tumors in this way. 
(4) Interstitial Cervical Fibroids.—These tumors occupy the vagina, but 
are not ejected from the cavity of the uterus, and consequently are not 
pedunculated, and are not capable of being treated in the same way as 
uterine polypi. They are surrounded by the tissue of the cervix, and are 
imbedded within it. When small, resembling a bullet submerged in the 
cervical structure, a simple incision carried through the tumor, so as to 
bisect it, will often be sufficient to lead to its decay and destruction. To 
make its disorganization more certain, the surfaces of the cut fibroid may 
be touched through the speculum with a pencil of vegetable caustic or of 
potassa-cum-calce ; or, better, the small mass may be entirely enucleated by 
the point of the finger after opening its capsule. When the tumor is large, 
swelling out a portion of the cervix to the size of a walnut or an orange, 
it will be necessary to make a free slit in its envelope and enucleate the 
mass at once. These tumors are so accessible to the finger that this pro- 
cedure can readily be accomplished, provided their capsule has never 
undergone inflammation. In all of these cases the vagina should after- 
wards be kept carefully cleansed by antiseptic washes, and the inflamma- 
tion of the cervical mucous membrane, which usually accompanies these 
tumors, should receive proper treatment. 
(5) Myomatous Degeneration of the Uterus.—The uterus sometimes seems 
to be overwhelmed with fibroids filling up the interstices everywhere, and 
even to harbor at the same time every variety of tumor heretofore con- 
sidered. When such a condition exists, it is not to be expected that 
medicinal means alone will be of much use, nor can the surgical treat- 
ment of each, individual, diseased mass be contemplated, but if anything 
is to be done, it must be the entire extirpation of the affected organ. As 
these cases cannot always be clearly diagnosticated, the surgeon must be 
prepared to vary his original course of action during the progress of an 
operation. He may commence with the expectation of removing only a 
pedunculated fibroid, or even an ovarian tumor, but will sometimes end 
by extirpating the entire uterus and its appendages. I will relate the 
following case:— 14 
ATLEE, 
On August 8, 1815, I visited, with Dr. Kurtz, Mrs. J. A, D., of Reading, Pa. 
She was 44 }rears old, had menstruated at 15 years of age, and had always been 
regular. When 21 years old she had married, and had had two children, and 
one miscarriage between them. In 1812 menstruation had become more free, 
and in the summer of 1814 she had had two or three attacks of bleeding during 
the menstrual intervals. In 1812 she had first noticed a tumor in the right 
groin. It was hard and movable, and fell over on turning her body. For 
two years its increase in size had been gradual, but during the last twelve 
months very rapid. As the tumor enlarged, her general health failed, and she 
rapidly emaciated. 
At the time of my visit, the abdominal enlargement was equal to that of an 
eight-months’ pregnancy. It was irregular in shape. There appeared to be two 
tumors, or one with a deep sulcus dividing it. The mass was hard, but slightly 
elastic, and upon the left side of its fundus there was a harder knob the size of a 
walnut. The two lobes were movable on each other. The uterus occupied the 
back part of the pelvis, admitted the sound two-and-a-half inches, and was not 
much influenced by manipulating the abdominal growth. While the sound was 
in the uterus, I discovered still another and much harder mass in the superior 
strait of the pelvis, which I diagnosticated as an intra-mural fibroid, but had 
some doubts in consequence of the abdominal enlargement having masked the 
examination. The diagnosis was obscure, but I inclined to the opinion that 
the abdominal tumor was pedunculated, and hence rather favored an operation. 
The patient’s health continuing to fail, she solicited relief. September 1, 
1875, I visited Reading, and met Drs. Kurtz, Brooke, Ulrick, Dundor, Kuhn, 
Coblentz, Cleaver, Weidman, Brodhead, and student Ellis Kurtz. The divi- 
sion of the tumor had now disappeared, and the mass was more consolidated. 
An incision seven or eight inches long was made below the umbilicus through 
a very attenuated abdominal wall. On exposing the tumor, the characteristic 
mahogany color at once disclosed its uterine nature, and further examination 
developed its real character: fibroid degeneration of the body of the uterus. 
There being no adhesions, the whole mass was easil}’ rolled from the cavity of 
the abdomen. The body of the uterus was now found to be occupied by intra- 
mural fibroids, while the cervix was normal. Both ovaries were seated on the 
lower portion of the enlarged uterus; the right one being healthy, and the left 
cystic, and as large as a walnut. A strong needle was now armed with a double 
ligature of strong plaited English silk cord, and with it the cervix uteri was 
transfixed just above the insertion of the vagina and below the ovaries. Each 
ligature was securely tied on its respective half of the cervix, and each 
was again made to encircle the whole cervix and firmly secured. The tumor, 
consisting of the uterus and both ovaries, was now cut away, leaving a large 
button beyond the ligature. To make it doubly safe the stump was embraced 
in Atlee’s clamp, and maintained outside. The cervical canal was plainly seen 
on the face of the cut pedicle, into which a probe was passed about three-eighths 
of an inch, and a finger introduced into the vagina entered the os tincm and 
felt the grasp of the clamp. The return circulation of the tumor, which 
escaped on excising it, was prevented from entering the abdominal cavity by 
protecting sponges. The Avound was closed with iron-wire sutures. The patient 
made an excellent recovery, and now enjoys good health. 
In considering the propriety of extirpating the uterus by abdominal 
section, we must judge each case by itself. The condition of the pelvis, 
vagina, and cervix uteri, is of primary importance. If the cellular tis- 
sue is indurated in consequence of inflammation or other cause, or the 
vagina shortened and rigid, or the cervix occupied by fibroid deposits, it 
will not be a case favorable for operation. If, howrever, the pelvis is free 
from morbid deposits, the vagina long or extensible, and the cervix in a 
normal state, the chances of life may be considered almost equal to those 
of ovariotomy. FIBROID TUMORS OF THE UTERUS. 
15 
(6) Fibro-cystic Tumors of the Uterus.—The fibro-cystic tumors of the 
uterus, as far as my observations go, are developed upon the exterior sur- 
face of the organ, and are usually pedunculated. They are constituted 
of tibrous tissue, and are more or less cancellated in structure, and in 
consequence of their greater impressibility are called soft fibroids in con- 
tradistinction to the hard tumors heretofore considered. They grow some- 
times to an enormous size. These tumors, in my opinion, are entirely 
beyond the influence of ergot, while they seem at times to be controlled 
in their growth by muriate of ammonia. I have had no experience in 
the treatment of uterine fibroids by means of galvanism, hut I should sup- 
pose that this would be the kind of tumor most amenable to such an agent. 
There are, however, surgical means, both palliative and radical, which I 
have employed with benefit. The palliative treatment consists in pene- 
trating the abdominal wall with a long, large-sized trocar and canula, thrust 
into the centre of the tumor, withdrawing the trocar and passing a strong 
sound through the canula, and with it breaking up the interior, cancellated 
structure in every direction, and drawing off all the fluid possible. Usually 
after such a proceeding the tumor will diminish in size to a considerable 
extent. The operation, at proper intervals, may be repeated. As this 
treatment is original with myself, I must ask permission to illustrate it 
with a case:— 
On April 22, 1863, I was consulted by Mrs. A. E. S., of Washington City, 
D. C. She was 42 years old, had commenced menstruating at 14 years of age, 
and had been married at the age of 11. She had had three children, the 
youngest then 18 years old. About four weeks before seeing me, she had been 
seized with very acute pain in the right groin, which lasted for twenty hours, and 
was only relieved by strong opiates. This was followed by an enlargement of 
the right side. She was a fine, healthy-looking lady, disposed to corpulency, 
and exhibited no unusual abdominal prominence. An elastic, cyst-like, smooth 
tumor was detected occupying the hypogastric and right inguinal regions, and 
rising above the umbilicus. It was at that time diagnosticated to be an ova- 
rian tumor, and she was advised to let it alone. 
September 24, 1868, she consulted me again. The abdomen then was very 
much larger than that of a woman at the full period of pregnancy. It was 
smooth, elastic, compressible, semi-fluctuating, and of uniform shape. The 
uterus was normal in size, and movable, independently of the mass. In com- 
pany with Dr. David Burpee, I passed the large trocar into the tumor below 
the umbilicus, but no fluid escaped. The sound was then introduced through 
the canula, and passed round in several directions. It was very evident that in 
manipulating with the sound many fragile septi were broken up, which proved 
to be the walls of cells containing fluid. Two or three gallons of fluid, stained 
with blood, were removed in this wa}7, and it coagulated on exposure to air. 
The operation was followed by no unpleasant symptoms, and afforded great 
relief. Up to this time the case is reported in detail in my work on the Diag- 
nosis of Ovarian Tumors, page 285. Subsequently the tumor was invaded in 
the same way 7 at distant intervals three times, and each time with beneficial 
results—the last being in March, 1811. I saw the patient in November, 1872, 
when her general health was good, and her size very much diminished, although 
the tumor was still there. During all this time she had used the muriate of 
ammonia internally, and the combined treatment had had a very happy effect on 
her condition. Letters from her assure me that she still remains in comforta- 
ble health, that the size of the tumor is not nearly so great, and that its fur- 
ther development is probably arrested. 
I have treated other cases of fibro-cystic tumor of the uterus in the 
same way with similar results, but have never entirely cured them by 16 
ATLEE, 
these means. In one case, I cut up the interior structure with a small 
knife introduced through the large canula, and afterwards injected acetic 
acid. This was followed also by a decided diminution of the tumor, and 
by no unpleasant consequences. 
The only radical cure for these tumors I believe to be extirpation. In 
their removal, the surgeon must keep in mind their peculiar pathological 
relations with the uterus and with the peritoneum, as these differ mate- 
rially from those of ovarian tumors. As far as my observations have 
gone, the flbro-cystic tumor originates from the wall of the uterus at the 
junction of the cervix with the body, at or just below the point where 
the peritoneum is reflected from the uterus to form the recto-vaginal 
cul-de-sac. As the tumor enlarges it raises the pelvic peritoneum above 
it, and, dissecting it from its natural attachments, elevates it into the 
abdominal cavit}r far above the pelvis, so that a real peritoneal cul-de-sac 
almost surrounds the enlarged tumor between the umbilicus and pubes. 
The tumor now is covered by a peritoneal coat above, while its pelvic 
portion is free from peritoneum. The reflected peritoneum, therefore, 
acts like a coronary ligament in binding the lower portion of the tumor 
in the pelvis. To illustrate the operation, I will relate the case of Miss 
E. E., aged 57 years. The same case is detailed for another purpose in 
the work referred to above, page 279, but the manner of operating is 
omitted:— 
On June 5, 1868, in the presence of Drs. Mitchell, Brinton, Thompson, and 
Keen, and assisted by Drs, Drysdale and Burpee, an incision seven inches in 
length was made through the linea alba down to the tumor. Passing my hand 
through the incision, I found the tumor to be adherent to the abdominal wall; 
but these adhesions were readily broken up. I now particularly explored the 
interior of the left side, in the previously ascertained locality of the elevated 
uterus, but soon encountered an additional tumor, resembling an hypertrophied 
spleen and filling up the whole left side from the hypochondrium down into 
the iliac fossa. In carrying on the investigation downwards, over the large 
tumor, my hand was interrupted in its descent by a cul-de-sac of reflected 
peritoneum, extending around the tumor midway between the umbilicus and 
pubes, and firmly fixing it in position. It was, therefore, plain that the fundus 
of the tumor was covered by a coat of peritoneum which had been lifted from 
the pelvis by its development upwards. The membrane was vascular and thick- 
ened. I next cut boldly into the tumor, in the line and to the extent of the ex- 
ternal incision, and, passing my hand into the gap thus made, broke up the 
whole interior of the mass, freeing it of one or two gallons of yellowish fluid, 
which coagulated on exposure to air. After thus reducing the size of the 
tumor, I succeeded in shelling off the whole peritoneal coat, to which were at- 
tached several folds of intestines, and by this means relieved it of all points of 
attachment in the abdominal cavity. The entire mass was now readily dis- 
located and turned out of its bed. It was found to be attached by a fibrous 
pedicle, an inch to an inch and a half thick, to the uterus on the right side, at 
a point between the insertion of the vagina and that of the uterine peritoneum. 
The pedicle was short, almost sessile. It was transfixed by a strong double 
ligature, which was tied both ways and also encircled the whole pedicle. The 
tumor was then excised, so as to allow a large button beyond the ligature. 
The remaining tumor now presented itself at the opening. It sprang from 
the posterior surface of the left broad ligament just where it joins the posterior 
part of the uterus. The Fallopian tube coursed along in front of the pedicle, 
was wrapped around it, and its fimbriated extremity rose up on the tumor, and 
was attached to it. Several adhesions to the walls of the abdomen were 
broken up, and the tumor was turned out. The pedicle was very short, but 
was clamped, the Fallopian tube being included, and the tumor was removed. FIBROID TUMORS OF THE UTERUS. 
17 
The abdomen was afterwards carefully cleansed with soft sponges, as well as the 
pelvis, which was nothing but a raw surface having no peritoneal lining. The 
right ovary was found to be healthy, the left being absent and evidently in- 
volved in the small tumor. A large amount of loose peritoneum, which had 
been removed from the large tumor, now occupied the lower portion of the 
abdominal cavity. It had contracted very much, and appeared more thickened. 
It was allowed to arrange itself. The uterus was enlarged to more than twice 
ts normal size. On its anterior wall was a small sessile subperitoneal fibroid. 
I opened its capsule, enucleated, and removed it. 
The clamp was arranged across the middle of the wound, the ligated pedicle 
in the lower end, and five wire sutures were introduced above and five below the 
clamp; the fundus uteri occupying a position against the interior surface of the 
wound between both pedicles. Several ounces of blood were lost, but not suffi- 
cient to affect the pulse. One vessel was controlled by torsion, and one by silk 
ligature, cut short and dropped in. The large tumor was fibro-cystic, weighing 
thirty-five pounds. The small one was an ovarian fibroid, and weighed over 
five pounds. The patient made an excellent and rapid recovery, and is now in 
the enjoyment of perfect health. 
In presenting this subject for discussion, I am aware that I am open 
to criticism for having made such an arbitrary subdivision of fibroid 
tumors of the uterus. It is, however, apparent that this has been done 
for practical reasons. A much simpler classification would have been 
into suhserous and submucous, or extra-muscular, and interstitial or 
intra-muscular. But as the question to be considered was the treatment 
of fibroids, I preferred arranging these tumors as we find them in 
patients, so as to make the paper purely clinical and practical. In 
making the above division, it must not be inferred that each case can 
be classified under one or other head, for several or even all forms of 
fibroids may be present at the same time. According to my observation, 
however, the intra-muscular tumor is most likely to be solitary, while 
the extra-muscular is more frequently multiple. 
As a consequence of the limited time allotted to this paper, and which 
has already been exceeded, I have viewed this subject only from a per- 
sonal stand-point. In omitting to mention the various modes of treat- 
ment of which I have no experience, I mean no disrespect or disparage- 
ment to any of my medical brethren, who, perhaps, may have had better 
success than myself. These methods, it is hoped, will be stated by their 
advocates. With regard to the use of one agent, which has recently 
been extensively used, I may be excused for repeating that I commenced 
the use of ergot in 1845 in the treatment of fibroid tumors, and have 
continued to employ it beneficially ever since. I have, also, for many 
years, used muriate of ammonia alone, and in connection with ergot, 
and with such results as have satisfied me of its value. The dose is ten 
grains three times a day. A solution of one drachm to one pint of 
water is used twice a day as a wash to the abdomen and to the vagina, 
and an apron of silk oil-cloth is worn next to the skin. Neither patient 
nor physician should tire in its use, using it for months and even years, 
if the tumor does not disappear. lam satisfied that it often arrests the 
growth; so does ergot. It sometimes causes its entire disappearance; 
I have yet to see this result from ergot alone, except in mechanically ex- 
pelling polypi. It sometimes fails to produce any appreciable results ; so 
does ergot, I attribute the influence of muriate of ammonia to its altera- 
tive, resolvent, and sorbefacient power, as well as to its alkaline properties. 
1 am well aware that the remedial power of muriate of ammonia has been 18 
ATLEE, FIBROID TUMORS OF THE UTERUS. 
denied on the ground that inflammatory or plastic deposits have been 
mistaken for fibroids. I do not pretend to possess any more diagnostic 
tact than others, but the same remark will apply to all other remedies 
and to all other persons. Even if it accomplishes so much under an 
error of diagnosis, it certainly is a great boon to suffering humanity. 
I now present the following propositions, which will throw the whole 
subject of treatment open to discussion:— 
I. Fibroid tumors of the uterus, although frequently unaffected by 
treatment, are sometimes cured, and often controlled in their growth, by 
medicinal and other agents. 
11. Fibroid tumors of the uterus which are entirely harmless to the 
patient, should never receive surgical treatment involving the least 
danger. 
111. Extra-muscular, submucous tumors usually demand surgical 
treatment. 
IV. Hemorrhage, caused by a fibroid, uncontrollable by other means, 
may be, and should be, arrested by the knife. 
Y. In the surgical removal of fibroids, it is of the greatest importance 
to extirpate the living tumor. 
VI. When the living tumor cannot be removed, as is usually the case 
when the capsule has undergone inflammation, antiseptics must be dili- 
gently employed. 
VII. Extra-muscular tumors of the subperitoneal variety, when involv- 
ing health and life, should be removed by abdominal section. 
VIII. In cases of recurrent fibroids, it is justifiable, under certain cir- 
cumstances, to amputate the inverted uterus, or to remove the organ by 
abdominal section. 
IX. In exceptional cases of uterine fibroids, extirpation of the uterus 
by abdominal section is warranted. 
X. As a general rule, in all cases of fibroids which destroy the com- 
fort of a patient, or hazard life, and are not amenable to other treatment, 
surgical interference is to be commended.