AN INTRA MURAL FIBROUS TUMOR 
REMOVED FROM THE 
ANTERIOR WALL OF THE UTERUS. 
By WILLIAM H. BYFORD, A.M., M.D., 
PROFESSOB OF OBSTETRICS, ETC., IN CHICAGO MEDICAL COLLEGE. 
[From the Chicago Medical Examiner.'] 
Mrs. McC., of Terre Haute, Indiana, is thirty-nine years of 
age; has been married twenty-one years; has four children, the 
first nineteen years old, the last eight, and had one miscarriage, 
twenty years since. Her health has been in every respect good 
until the last five years. Five years ago, she had severe neu- 
ralgic pain in her left side, extending to the hip and down the 
leg of the same side; from the history, most likely in the sci- 
atic nerve and its branches; for about one month the limb was 
partially paralyzed. She has since then almost continually been 
the subject of indigestion, constipation, etc. Eighteen months 
since, she commenced having profuse discharges of blood from 
the vagina. These discharges had continued to increase up to 
the time when Dr. J. B. Buchtel was called to see her, on Sep- 
tember 22d, 1868; when, according to the description given by 
Dr. Buchtel, she was anaemic to an extreme degree, with cedem- 
atous face and extremities, and effusion in the peritoneal cavity. 
She was almost constantly confined to her bed ; had pain in the 
left iliac region, and down the left leg; was constipated, and 2 
vomited a part of her food, and was also much distressed with 
the digestion of what she retained. Her menses were regular, 
but profuse; besides this, she had profuse floodings between 
times, which were controlled only by the most active treatment; 
sometimes it was necessary to use the tampon. Between the 
hemorrhages she had profuse leucorrhoea. An examination 
made by Dr. Buchtel was followed by alarming hemorrhage. 
By this examination he discovered the presence of a large 
fibroid growth in the anterior wall of the uterus. 
After a skilful and diligent course of treatment, consisting, 
for the most part, of tonics and alteratives, with good substan- 
tial diet, for about four weeks, Dr. Buchtel found his patient 
able to be brought to Chicago fur advice and surgical treat- 
ment. October 24th, Mrs. McC.'s health very much improved, 
but still so feeble that she passed much of the time in bed. 
She expressed great fear of another paroxysm of hemorrhage. 
A careful examination confirmed Dr. Buchtel's diagnosis. There 
was a large, hard tumor imbedded in the anterior wall of the 
uterus. When the probe was passed into the cavity of that 
organ, and a catheter in the bladder, their lower extremities 
crossed each other, while the wide separation of their upper 
ends showed an in- 
tervening substance 
of about five inches. 
The lower end of the 
tumor was about on 
a level with the arch 
of the symphisis pu- 
sbis, and had greatly 
developed and dis- 
tended the anterior 
wall of the cervical 
part of the uterus, 
while the upper 
could be felt high up 
towards the umbili- 
cus, a little more to 
the right than to the left of the linea alba. 
(Fig- I-) 3 
The os uteri was soft and dilated, so that one finger would 
easily enter it. A good idea of the tumor in situ is given in 
Fig. 1. The bladder is crowded up to the symphisis, and the 
cavity of the uterus may be seen very greatly elongated behind 
the tumor. 
I hoped to be able to destroy the vitality of the tumor by 
coring it after the method practised by Mr. Baker Brown, of 
London. With a view to an attempt of this kind, I placed the 
patient on the operating-table, on her left side, with her 
left arm behind her, so that she would lie well over on her 
breast, with the knees drawn up, the right bent the most, and 
drawn forward and over the left on the table. This is Sims's 
position for the operation for vesico-vaginal fistula. The in- 
troduction of a large-sized Sims speculum brought the lower 
end of the tumor full in view. After having anaesthetized the 
patient, in presence of the students of Chicago Medical College, 
at Mercy Hospital, assisted by Dr. Buchtel and some of the 
senior students, I commenced the operation. 
An incision was first made in the most dependent part of the 
tumor, in the anterior lip of the uterus, which extended trans- 
versely from one side of the pelvis to the other, and must have 
been over three inches long; another, commencing in the centre 
of this, was extended up the posterior surface of the tumor, in 
the cavity of the uterus, as far as I could guide the scissors by 
the finger, with the hand partly introduced into the vagina. 
This last incision must have been more than three inches loner 
also. The substance cut through was at least a quarter of an 
inch thick. The two incisions formed a ±-shaped opening into 
the cyst containing the tumor. The freedom with which I 
could separate the walls of the cyst from the tumor encouraged 
me to attempt the removal of the whole mass, instead of a part 
of it. For this purpose, I introduced my left hand into the 
vagina, and my fingers high up into the cyst; and after some 
exertion, had the satisfaction to break up the adhesions of the 
tumor to its envelope over much of its circumference, and w'ell 
up towards the upper end. 
I then seized the mass -with a strong vulsel forceps, and 4 
made traction upon it in various directions, twisting, with a 
view to loosen it from its bed, and changing the bearing of the 
instrument in numerous ways, with apparently but little effect. 
After much fa- 
tiguing effort, I 
passed the for- 
ceps up the pos- 
terior surface of 
the tumor, in the 
m a n n e r repre- 
sented by Fig. 2, 
and made trac- 
tion with great 
force, giving the 
instrument a 
swaying motion 
from side to side. 
Soon it became 
evident that the 
whole tumor was approaching the external orifice of the vagina. 
Thus I continued passing the forceps higher up from time to 
time, until, to my great delight, the whole mass engaged in the 
lower strait of the pelvis, through which it passed, after some 
resistance. The fingers were then passed up into the cavity of 
the cyst, in order to ascertain whether there was anything fur- 
ther to be removed. The uterus contracted very decidedly, 
and became firmer to the touch. I could not detect any other 
growth by the most careful examination. Not more than two 
ounces of,blood was lost, and the woman exhibited no signs of 
exhaustion. No more than forty minutes elapsed from the time 
the patient was placed completely under the influence of ether 
until she was carried to her bed. No treatment but rest, and 
opiates enough to allay pain, was directed. Twenty drops of 
tincture of opium is all the medicines she required or took. 
There was no symptom requiring attention, but the patient 
seemed comfortable and cheerful from the time of the opera- 
tion, and on the 10th of November she made the journey home. 
(Fig. 2.) 5 
December 1st I received a letter from Dr. Buchtel, saying that 
his patient was "quite well." 
The tumor was fibroid, oval in shape, the small end down. 
It weighed twenty ounces avoirdupois, was five inches and a 
half long, four inches and three-quarters broad, and four and 
a quarter thick. It was so firm in structure, that the forcible 
efforts at removal did not mutilate it scarcely at all. 
Remarks.-The profession is anxiously collecting facts, and 
comparing the results, in the treatment of fibroid growths of 
the uterus, with a view to the formation of rules of practice. 
Heretofore, and at present, there is very little on the subject of 
management in reference to them definitively settled. Yet, 
when we look back for only a few years, we .will find there has 
been progress enough to warrant the expectation that the future 
treatment of fibroids will be made better than the past. 
It is with a view to assist in collecting material upon which 
to base rational methods of cure in the formidable conditions 
connected with them, that I record this case, and venture upon 
these remarks in connection with it. The successful enucleation 
of intra-mural fibroid tumors of the uterus is acknowledged to 
be the best mode of treatment, especially when their removal 
can be done at once; yet most instances are attended with 
many difficulties and dangers. The principal dangers are- 
1st, Serious damage to the uterus; 2d, Injury to other viscera, 
as the bladder, bowel, and peritoneal cavity; 3d, Hemorrhage; 
4th, Subsequent inflammation; 5th, Toxaemia. 
The most important difficulties-1st, The remote situation of 
the tumor; 2d, Contracted and undeveloped condition of the 
os and cervix uteri; 3d, Too great size of the growth to pass 
through the pelvis and cervix, after the latter is well de- 
veloped. 
I am aware that these are not all the dangers and difficulties 
met with; for every case will present its own peculiar difficul- 
ties; to be surmounted, at the time, by the ingenuity of the 
operator alone; but I think we have in those above mentioned 
such as are to be feared in the majority, if not the whole, of the 
cases operated upon. One of the most important, in fact indis- 6 
pensable, items preparatory to treatment, and which will enable 
us to avoid much of the dangers, and overcome many of the 
difficulties, is to definitely determine the relations of the tumor 
to the different parts of the uterus, the pelvic viscera, and the 
peritoneal sac. 
A few very simple means of exploration are' necessary, and, 
ordinarily, sufficient, for this purpose. The tumor should, in 
the first place, be pressed down as low in the pelvis as possible; 
the finger, in the second place, should be introduced as far up 
into the rectum as practicable; 3d$ the probe passed up the cav- 
ity of the uterus; and 4th, a catheter introduced into the blad- 
der. If the tumor is in the posterior wall of the organ, the 
finger and probe will be separated as widely as the thickness of 
the fibroid intervening. The finger may further determine 
something of the shape and consistence of the tumor, as also 
whether it occupies the median or lateral parts of the wall. If 
the growth is in the anterior wall, then the distance between 
the probe and catheter determines its size. 
The hand pressed down from above.in the abdominal cavity, 
while the probe is in the uterus, will enable us to judge pretty 
accurately the vertical dimensions. By this sort of explora- 
tion we definitely determine the position of the bladder and 
rectum, and may thus have the knowledge that will guide us 
clear of them, and point out the places where the peritoneal 
cavity approaches nearest the field of operation. With this 
knowledge, a careful operator would not be likely to inflict 
damage upon any of these organs. 
The part of the uterus most in danger is that above the vagi- 
nal attachment, as it would seem that the segment ordinarily 
included in or pressed down into the vagina and developed by 
the tumor, will suffer almost any practicable mutilation, and 
recover from it without danger to life. It may be extensively 
excised and largely distended without serious hemorrhage, or 
other detriment resulting, as this and many other cases on rec- 
ord prove. If the vaginal portion is opened by incision or other- 
wise, so that the operator has free access to the cavity in which 
the tumor is imbedded, the uterine walls will bear great freedom 7 
of manipulation, on account of both their great elasticity and 
strength; for they are generally much hypertrophied. 
The most distended portion of uterine tissue, in the case re- 
ported, was one-fourth of an inch thick; and it is reasonable 
to suppose that this part was not thicker than elsewhere. I 
think it may now be considered as true, that in very few cases 
is the danger from hemorrhage great; yet we should ever be 
watchful against the possibility of the contrary. The free use 
of iron, pulverized rhatany, cold, and, if need be, the tampon, 
are the resources available and effective. Nor does there seem 
to be just grounds for suspecting that the operation for enucle- 
ation and avulsion of these tumors will be followed by more 
violent or dangerous inflammation than amputations or other 
capital operations. The means of avoiding it are, to establish 
the best possible condition of health, by the administration of 
iron, nourishing diet, and cod-liver oil, before the operation, 
keep the bowels quiet and suppress pain by the moderate use 
of opium after it. Toxaemia will not be likely to occur if the 
cavity of the uterus, vagina, and sac of the tumor be kept clear 
of blood, or the debris and sloughs of the injured structures, 
by the free use of tepid water, and, if necessary, solutions of 
antiseptics. 
When the tumor is high up, it may be impossible to reach it 
so as to attack it successfully; yet in many instances we may 
do much by pressing the tumor down from above. The unde- 
veloped state of the cervix and closed condition of the mouth 
of the uterus may often be remedied in a short time by the 
admirable means we now possess for dilating them; but I be- 
lieve the bruised and excited state of the tissues thus dilated is 
not as favorable for speedy recovery from damage as the con- 
dition left after simple incision, and should rather favor free 
division of the parts at the time of the operation. 
It will be seen that much of the incision made in my case 
was outside the cavity of the cervix, and that the os was not 
dilated, except by dragging the tumor through it. The plan 
practised by Dr. Scott, in a case recently reported by him in 
the California Medical Gazette, of dividing the tumor when too 8 
large to be delivered otherwise, with the eerasseur or scissors, 
until small enough to pass easily, is to be commended as a 
measure that will enable us to avoid the damage, that might re- 
sult from too great distention or pressure in forcing it through 
the external parts, and indispensable when too large to be de- 
livered otherwise. 
The only symptom that I think justifies an effort for the re- 
moval of intra-mural fibroids, where the operation is likely to 
be successful, is an exhausting or dangerous drain of blood; 
and even then the milder, though somewhat uncertain, measure 
recommended by Mr. Brown, of London, of incising the cervix, 
ought to be tried first, with the hope that nothing further will 
be necessary. Although these tumors of the uterus are very 
common, they comparatively seldom grow large enough to prove 
fatal by their size. Their presence alone, for the most part, is 
merely an inconvenience; but hemorrhage, when excessive, does 
great damage to the system-often directly, and oftener indi- 
rectly, bring about fatal results. We should not, therefore, 
operate because our patient has a tumor, but because the tumor 
is attended with damaging or dangerous hemorrhage.