[Reprinted from The Americ an Journal op Obstetrics and Diseases op Women and 
Children, Vol. XVI., Nos. 5 and 6, 1883.] 
SARCOMA AND MULTIPLE MUCOUS POLYPI OF THE UTERUS, 
IN A CHILD, j/r 
BY 
THOMAS C. SMITH, M.D., 
Washington, D.C. 
So little is to be found in the text-books and current litera- 
ture bearing on diseases of the sexual organs in female children, 
that I deem the following case worthy of a place in the records 
of unique cases : 
In August, 1882, I was requested to see a little girl, whose 
mother furnished the following history: 
About eight months previously, when three years old, a tumor 
appeared between the labia of the patient, and her mother took 
her to one of our most skilful surgeons, who, after examination, 
seized the tumor with forceps and snipped it off with scissors. 
Some two months afterwards another similar growth appeared, 
and the same surgeon, after administering ether, again operated 
on the child. On the recurrence of the growth I was asked to 
see the child. Her appearance denoted anxiety rather than suf- 
fering; she was pale and anemic, but able to play about with other 
children. Protruding from the vulva was a small growth very 
much resembling in shape and color a miniature liver; some 
bloody fluid was oozing from the vagina. The growth was not 
sensitive to the touch. I made an appointment to visit the patient 
the next day for the purpose of removing the tumor, but on 
reaching the house it was discovered that the protruding sub- 
stance, which was about the size of a Lima bean, had come away 
of itself. Upon examination, it was found to be composed en- 
tirely of fibrin, entangling some blood corpuscles—in other words, 
it was a hardened blood-clot. A few days later, a growth differ- 
ing in color appeared, but the weather being very warm and de- 
siring to watch the progress of the tumor, I advised the mother to 
wait until cooler weather set in before submitting the child to 
any operative treatment. She was placed upon tonic and support- 
ing treatment until October 4th; in the mean time, however, 
passing several pieces similar to that first described, and also hav- 
ing the same bloody fluid escaping from the vagina. On the date 
last mentioned, I proceeded to remove the excrescence, aided by 
Dr. E. C. Meriam and Mr. J. J. Darby, medical student. The 
patient being etherized, the tumor was seized with a dressing 
forceps, and on making slight traction, its attachment yielded, 
and the mass came away. It was about the size of a chestnut, 2 
Smith : Sarcoma and Multiple Mucous 
and on examination showed a distinct pedicle. Surprised at the 
facility with which the operation terminated, I determined to 
make further exploration while the patient was unconscious. On 
separating the labia, another mass was found to be tilling up the 
orifice of the vagina. This I likewise seized, and it came away as 
the first had done. Still another and another were removed, 
until no more continued to appear. The dressing forceps were 
now carefully passed into the vagina, and on separating the blades 
another growth came into view, which was removed by the exer- 
cise of very little force. Continuing in this manner, a dozen or 
more polypi, resembling the ordinary mucous polypus of the nasal 
cavities, were torn away, very little bleeding resulting from the 
operation. I now oiled the little finger of my right hand and 
gently passed it into the vagina, where it at once came in contact 
with a mass composed of polypi like those already removed. The 
upper portion of the vagina was filled with them. With the exer- 
cise of gentle force, I was enabled to detach a goodly number, 
and on withdrawing the finger many of them were expelled with 
a gush. Some, however, were too large to pass, and these 1 seized 
with forceps and removed. The maneuvre of introducing the 
little finger, detaching the masses, and removing them was gone 
through with several times, some of the growths being as large as 
walnuts, put the most of them were the size of peas. Finally it 
became impossible to reach any more of the growths with the lit- 
tle finger, and on trial I found that the index finger could be 
passed with facility. By making’counter-pressure, 1 was enabled 
to determine that the cavity of the uterus was distended by the 
same kind of growths as have already been described. Some were 
found pendent from the margin of the cervix; others grew from 
the cervical canal, and others still had their attachment within 
the cavity of the uterus. These I continued to remove until only 
a few very small ones, feeling more like villosities, were to be felt, 
when I concluded to desist from further efforts. The hand 
pressed over the uterus enabled me to determine by the finger in 
that viscus that the uterine walls were immensely hypertrophied. 
At the same time, an enlargement of considerable size was to be 
felt to the left of the uterus, but I did not feel justified in pursu- 
ing the investigation further just then, as the little patient had 
been under the influence of ether as long as it was deemed pru- 
dent to permit her to remain. She lost very little blood during 
the operation, and before the day was over seemed to have recov- 
ered entirely from the shock of the operation. The growths re- 
moved weighed half a pound, and numbered several hundred, the 
majority of them being as large as Lima beans. Nearly all of 
them had a pedicle, but occasionally a bunch could be found con- 
taining from four to six, which seemed to proceed from a common 
stalk or broad piece of tissue. 
It should have been stated before that, on the morning I 
operated on this child, the mother sent for me in great alarm to 
call my attention to an abdominal tumor situated in the hypo- 
gastric region. This had not been manifest on palpation at any Polypi of the Uterus, in a Child. 
3 
previous time to either the parents or myself, although I must 
say but few examinations of the abdomen had been made by me, 
my attention having been entirely directed to the excrescence pro- 
truding from the vagina. Nor was any tumor noticed by either 
of several physicians who had visited the child previous to my 
connection with the case. 
After removing the mass of polypi, as above stated, the ab- 
dominal tumor had sensibly diminished in size, and for a few 
days there was a bloody discharge, followed by one purulent in 
character. So little did the child suffer from the operation that 
she was able to go out walking a few days thereafter. The 
specimens removed from the child were presented to the Medical 
Society of the District of Columbia on the evening after their re- 
moval, and having been referred to the Committee on Micro- 
scopy, the following report was made after examination: 
“November 1st, 1882. 
“The specimen submitted by Dr. T. C. Smith, which was re- 
moved from the genital canal of a girl four years old, presents to 
the naked eye the following appearances: A multitude of soft, 
pale-yellowish masses, varying from the size of a pea to that of a 
walnut, some spherical, others pear-shaped, and others still ir- 
regular. On section, most of them were Avhite, and a few had 
small cysts with granular contents; in some, however, the white 
gradually merged into a red color. 
“On microscopical examination, these growths were seen to be 
covered with stratified epithelium; the periphereal portion of the 
growth shows a multitude of small round cells (leucocytes ?), but 
scattered, or collected in small groups. The intercellular sub- 
stance was a soft connective tissue, resembling that of mucous 
polypi in general. No glands were present.” The benignity of 
these growths is rendered manifest by the report of the micro- 
scopists, but the extrauterine growths referred to rendered the 
presence of malignant disease more than probable. 
As stated above, the child was able to go out of doors a few 
days after the operation. No further growths appeared at the 
vulva, but within a short time it was discovered that the ab- 
dominal tumor was rapidly increasing in size, and finally reached 
the ensiform cartilage. I no longer entertained doubts as to its 
malignancy, and informed the parents of the child that no hope 
of recovery was to be entertained. About two weeks after the 
removal of the intrauterine growths, edema of the lower extremities 
set in. The urine diminished in quantity, and contained con- 
siderable albumen. Dyspnea first appeared one week later, and 
soon became so severe that the little sufferer could only breathe 
when resting upon her hands and knees. This continued a week, 
when death occurred from exhaustion, November 6th, 1882, 
thirty-three days after the operation.' 
The parents consented to an autopsy, which I made a few 
hours after death. 
On opening the peritoneal cavity, a large quantity of ascitic 
fluid escaped. A large tumor of purplish color was now seen to 4 
Smith : Sarcoma arid Multiple Mucous 
distend the abdomen, and which, on examination, proved to be 
the uterus. On either side was a large growth, larger than an 
egg, united to the uterus by slight adhesions. The uterus was 
firmly held by adhesions posteriorly, and anteriorly was attached 
to the bladder in its lower portion only. Parts of the vagina and 
bladder were removed along with the uterus. The specimen was 
exhibited to the Medical Society, and the foregoing history given. 
The following description of the specimen was prepared by Dr. 
D. S. Lamb, and read to the Society at the same time: 
“ A portion of the greater omentum: the free margin is 
contracted and thickened, and on section is firm and white, 
as if a new growth. Spleen, normal; both kidneys presented 
some dilatation of the pelves; the right kidney also presented 
numerous pin-head-sized metastatic purulent foci, some isolated, 
others in groups, with a brownish-colored intermediate tissue 
between the individual purulent points of the groups; these 
points were, many of them, softened to a liquid. All of them 
projected slightly from the subcapsular surface; some of the 
growths involved nearly the entire thickness of the cortex. 
“ The base of the bladder was occupied by a flattened, nodu- 
lated, firm growth. 
“ The uterus measured four and one-half inches in length, and 
three and one-half inches in breadth at the fundus. The anterior 
wall of the body was three-quarters of an inch in thickness and 
the posterior wall one and three-quarter inches. The cavity mea- 
sured four inches in length and one inch in circumference. The 
walls were firm, somewhat elastic, and apparently homogeneous 
in structure; no cysts. The surface of the cavity presented 
irregular nodulations and a few small polypoid growths; the 
cavity itself contained a little glairy mucus. 
“ The ovaries presented each a few small aqueous cysts. 
“ The vagina measured about four inches in length, and was 
much distended. The walls were much thickened by a tissue re- 
sembling that of the uterine walls. The mucous surface pre- 
sented flattened nodular elevations of various breadths and poly- 
poid growths of various sizes. 
“Appended to the uterus and vagina were many subpcritoncal 
growths of a roundish shape; some pedunculated, others sessile; 
the size varied from that of a pea to as much as three inches in 
diameter; their structure was similar to that of the uterine and 
vaginal walls. Some of them presented patches of internal 
hemorrhage.” 
This specimen was referred to the Committee on Microscopy, 
who reported that it was a “round-cell sarcoma.” Four months 
after its removal, the uterus and appendages weighed thirty-one 
ounces. 
Reference may properly he called to a few points in con- 
nection with this case. 
First.—The existence of malignant disease of the uterus in Polypi of the 'Uterus, in a Child. 
5 
a child three years of age. While reference is occasionally 
found in text-books to the fact that cancer has been observed 
in the uterus of children, I have been unable to find a case re- 
corded in full of such an occurrence, and the specimen ob- 
tained from this case is the only one of the kind to be found in 
the Army Medical Museum in this city, as I am informed by 
Dr. Lamb. It is true that sarcoma has been occasionally ob- 
served in children. Tims Ur. T. G. Thomas closes a paper 
read before one of the societies (Amer. Journ. Ohst., 
1874-5, Yol. vii., p. 48) with the relation of a case of sarcoma 
of the labium in a young child, and in the Medical Record of 
March 31st, 1883, is found mention of a case by Dr. Arkovy 
of congenital sarcoma of the jaw. Cancer of the ovary, too, 
has been not unfrequently found in children, but the occurrence 
of cancer in the uterus is exceedingly rare. 
Second.—The association of such a multitude of polypi of 
a harmless character with a malignant disease in the same or- 
gan, has not, so far as my investigations go, its counterpart in 
medical literature. Even in adults the presence of multiple 
polypi is usually considered sufficiently rare to justify a place 
Nin the medical records of the day, but the union of malignancy 
and benignity is almost paradoxical. In the few cases I have 
been able to find where polypi were found in abundance, and 
malignant disease at the same time existed in the same organ, 
the polypi have partaken of the nature of the more serious 
disease. For instance, I find in the Transactions of the Ob- 
stetrical Society of London for 1868 (Yol. x., p. 224), the fol- 
lowing notes: “ Mr. Hereford gave the history and exhibited 
the specimens of the following case : 
A child, aged ten months, was brought to the East London 
Hospital for Children, having some large, villous-looking growths 
attached apparently to the vulva. Opinion was divided as to 
whether they were syphilitic or cancerous. 
On further examination, it was found that these growths ex- 
tended inward and lined a large sac, which represented an enor- 
mously enlarged and dilated vagina. 
Death shortly afterward took place, and at the post-mortem ex- 
amination it was disclosed that the rectum, bladder, and urethra 
were normally situated. 
The uterus (to which were attached healthy ovaries and Fallo- 
pian tubes) opened by its os uteri into the upper wall of the cyst. 
The microscopic examination proved the growths to be medul- 
lary in thei r character. 6 
Smith : Sarcoma and Multiple Mucous 
Their first appearance could not be traced beyond, at most, four 
months. 
There was no history of cancer ascertainable in the family. 
The coexistence of malignant disease with an evident malforma- 
tion of the vagina, is quite unique.” 
I find in the Lancet for 1877, Vol. i., p. 5, by Mr. John 
Clay, of Birmingham, under the title of “ Clinical Remarks 
on Diffuse Sarcoma of the Uterus,” a description which tallies 
very closely with that given of my case. After giving the 
history of seven cases which had been under his treatment in 
Queen’s Hospital, Birmingham, he continues: 
“ The objective signs furnished by the patients were tolerably 
uniform. On palpation, the uterus was found to be enlarged. 
Per vaginam, the os uteri was soft and thickened, its condition 
otherwise being normal, but invariably patulous, readily admit- 
ting the finger. The cavity of the uterus was enlarged, permit- 
ting the finger to move easily to explore the uterine cavity. One 
part of the uterus was felt to be thickened—cushioned as it were; 
and this part was rough to the touch and largely studded with 
prominent growths, varying in size from a pea to a hazel-nut. In 
other parts of the uterus smooth spaces were discernible. In one 
case the irregularity of surface appeared to be general. The 
space occupied by these growths was about half of the uterus, 
and was generally on the posterior surface.” Bladder compli- 
cations were absent in five of the seven cases. 
He refers to the treatment as follows : 
“ The treatment pursued in all the cases consisted in carefully 
removing the growths with a Sims’ curette. The quantity re- 
moved varied from a dessertspoonful to two-thirds of a teacupful. 
The growths always exhibited the same grayish-white, vascular, 
brain-like appearance, and varied from the size of a pea to one 
somewhat larger than a horse-bean.” Removal by the curette was 
repeated several times in some of the cases. 
Referring to the diagnosis of these growths, he continues 
48) : 
“ If we compare these growths with those removed in the case 
of endometritis, the latter are seen to be intensely hypcremic, 
and under the microscope they show an increase of all the ele- 
ments of the uterine mucous membrane—dilated follicles, with 
abundant cell infiltration of the connective tissue—while in dif- 
fuse sarcoma the growths are of a grayish-white color, very vascu- 
lar, and presenting a soft, brain-like consistence, and are capable 
of being easily crushed between the fingers.” 
All of Mr. Clay’s patients were adults, and six of them had 
borne children. I fail to find reference to similar cases occur- Polypi of the Uterus, in a Child. 
7 
ring in the practice of any other physician. Emmet does not 
speak of such cases, and, as his work embodies nearly every- 
thing that is new in gynecology, I infer that the paper of 
Mr. Clay has escaped his observation. 
Third.—The absence of vesical symptoms, notwithstanding 
the invasion of the base of the bladder by the growth, as de- 
scribed by Dr. Lamb, is worthy of note. Still in Mr. Clay’s 
cases the bladder was affected only twice. 
Fourth.—The failure to discover an abdominal tumor in my 
little patient calls for more than a passing note. As stated 
above, the tumor was not discovered until the morning of the 
day on which the operation for removal of the growth pro- 
truding from the vagina was to be performed, and was then 
discovered by the mother. The only explanation I can give 
is that the growth was mainly below the symphysis pubis, and 
retracted into the hollow of the sacrum, and so remained until 
it had attained such a magnitude as to enforce its ascent into the 
abdominal cavity. In an adult this would in all probability 
have been discovered early, as vaginal examination would have 
been instituted early after the first appearance of a growth at 
the vulvar orifice, but the patient being a child, this course 
was not followed. 
Fifth.—The rapid advance of the abdominal tumor after 
the removal of the intra-uterine polypi. This, however, is 
many times observed after partial removal of malignant 
growths. 
Sixth.—The facility with which the vaginal examination 
was made is worthy of note. It rarely happens that a physi 
cian is called upon to pass his finger into the vagina of a 
girl of such tender years, and many of our oldest practitioners 
have assured me that they have never done so. In this case, 
the growth of the polypi and consequent dilatation of the 
vagina and its orifice made the examination exceptionally 
easy. Of course, I do not mean to recommend the frequent 
examination of children by this method, but only mention the 
circumstance to show that in suitable cases physicians may 
resort to such procedures without fear of doing injury to the 
little patients whose afflictions may seem to demand them. 
A few words and quotations in relation to sarcoma of the 
uterus will close what I have to say in this paper. Smith : Sarcoma and Multiple Mucous Polypi. 
8 
As to tlic frequency of the disease and the social condition 
of the patients, Dr. Emmet, in the last edition of his “ Gyne- 
cology ” (p. 509), says : “ It is of rare occurrence, and is fre 
quently mistaken for epithelioma. I have seen but seven cases, 
all, with one exception, occurring in women who had never 
borne children, and in five the disease developed in connection 
with supposed fibroid growths. All of these women had been 
under my care, and I had detected the existence of the fibrous 
growths long previous to the appearance of the sarcoma.” By 
a singular coincidence, Mr. Olay had seven cases, and the so- 
cial condition of the patients was exactly reversed; thus six of 
the patients had borne children (from three to eight), while only 
one was a virgin. Epimet refers to this point again (p. 85), 
where he says : “ This disease is rarely found in the female 
who has borne children; at least I have never met with it ex- 
cept in the unmarried and sterile.” He had only one out of 
seven who had borne a child. 
Dr. Emmet, speaking of the time of life most favorable to 
the growth of sarcomatous tumors, says (p. 85): “ Sarcoma 
may occur at any time during the active sexual life of a fe- 
male.” I have found no reference anywhere to the growth ot 
such a tumor in a child. 
The same author says of sarcoma (p. 495) : “ It originates 
in the connective tissue of the uterus; it has its seat generally 
near the fundus, and is seldom, if ever, found below the in- 
ternal os.” In this statement Dr. Emmet is substantially in 
accord with other authorities. 
The absence of pain in my patient may be referred to, inas- 
much as some have claimed this symptom to be characteristic 
of sarcoma in the earlier stages of the disease. Dr. D. H. 
Hayden (Post. Med. and Surg. Jour., 1874, Yol. xc., p. 593), 
after giving the history of a case of sarcoma of the uterus, gives 
the following as one of the clinical differences between that dis- 
ease and carcinoma: 
“ In sarcoma there is very great pain from the outset. 
This does not generally occur in carcinoma until the neighbor- 
ing organs are involved.” This dictum will have to be modi- 
fied.