Little need be said about the clinical history of polypoid growths. If not opportunely removed, they may induce extreme asthenia from hemorrhage, yet they may be tolerated during a life-time without great inconvenience. If the pedicle grows thin, owing to long-continued existence of the polypi, or to their rapid development, the latter are often spontaneously separated, and thus disappear. This frequently results from examination and use of the sound. In rare instances the tumors become gangrenous, and may, for a time, simulate carcinoma of the por tio vaginalis, owing to their foetid discharge and their eroded appearance.
The diagnosis of polypoid growths is easy, so soon as they have effected their escape from the external os. Their softness and the presence of a pedicle render them recognizable by touch and by the speculum. By the same methods we may discover whether the growths are connected with the external os, the portio vaginalis or the cervical canal. This dis tinction is difficult only when the tumors have a short pedicle, protrude but slightly from the uterus, show a lobulated structure, or are gangren ous, as is not often the case. In such cases the tumors have been mistaken for epithelioma.
Small polypoid growths which only reach and protrude into the os externum, have been overlooked or considered as erosions of the cervical mucous membrane. In these instances they were at fault for the persist ence of the erosions.
Remnants of the membranes, shreds of decidual tissue and even a small ovum, in cases of abortion, have been mistaken for polypi. Careful ex amination by palpation and inspection protects against these and similar errors. It may often happen, however, that a small polypoid growth is plainly recognized at one examination, but can not subsequently be dis covered, since polypi are often easily separated by manipulation.
While polypoid growths originating in the cervix may thus be diag nosticated without much difficulty, those situated in the uterus are often overlooked, because they cannot be recognized until the os uteri has been dilated. Patients with polypi are often subjected to a long course of treat ment for menorrhagia, leucorrhcea and slight enlargement of the uterus, as cases of chronic metritis, until, finally, the dilatation of the os discloses the presence of a small polypoid growth. When the above-mentioned symptoms are present, and particularly when the hemorrhages are ir regular, or the uterine discharge is sanguinolent, the attendant should dilate the cervix with sponge tents, or by other means, and convince him self either of the presence or of the absence of a polypus.
If the dilatation be carefully executed, it can result in no harm, and even a negative result of the examination will be useful with reference to the subsequent treatment. The use of the sound does not lead to so certain or easy a recognition of intrauterine polypi, many authors to the contrary notwithstanding. Dilatation of the os internum must never be omitted if, in addition to the above signs of polypus, spontaneous dilatation of the os occurs, or the portio vaginalis assumes a semicircular form.
The diagnosis of the various forms of adenoma uteri (diffueum et poly postern) is only possible after the cavity of the uterus has been made ac cessible. In all cases of profuse and long-continued hemorrhage, it will be necessary to scrape the internal surface of the womb with a Simon's scoop, or simply with a curette. A microscopical examination of the removed masses will then have to be made, in order to determine the true nature of the affection. It is, however, by no means easy to always reach a diag nosis, especially as there occur transitional forms from simple endometri tis fungosa to adenoma, and because the number and size of the uterine glands varies within physiological limits. Nevertheless the larger the
glandular formations and the greater their numerical preponderance over the interstitial tissue, the more certain it is that we have to do with ade noma. But microscopical examination will scarcely justify us in deciding as to the possible malignancy of an adenoma. For if we find cellular hy perplasias in the gland structures, and nests of atypical formations, we are no longer in presence of an adenoma. but are already dealing with cancer. Thus the clinical history of a given case, such as rapid recur rence of the growth, will afford more valuable evidences on the point in question than the microscope alone can furnish.
The only treatment for polypoid growths consists in their removal. The removal of most of these tumors is very simple, owing to the tenuity of their pod idles. It is only necessary to seize them with appropriate for ceps, and to separate them by torsion or evulsion. This method is not appropriate to the removal of large polypi with thick pedicles, which should be out off. Should there be grounds to apprehend hemorrhage, which in some cases of cervical glandular polypi may, indeed, be consider able, the pedicle should be ligated before it is cut, or the wire ecraseur or galvano-cautery be employed. ' In general, however, one may dispense with these troublesome proced ures and make use of the vaginal tampon, or of cauterization of the cut surface to arrest the bleeding. Serious injury hardly over results from the removal of polypoid growths, unless metritis or parametritis are ex cited by dilatation of the cervix, undertaken for the purpose of removing the polypi.
Brown' saw tetanus follow the removal of an intra-uterine polypus by means of torsion.
His description plainly shows, however, that the case was one of mucous, and not of so called fibrous polypus. All the instruments in vented for the removal of " polypi," and which are called " polypotomes," are superfluous, as has been previously explained.
The treatment of erosions is the same as that of catarrhal conditions, although at times it will be necessary to resort to surgical measures. But for follicular hypertrophy of the lips, ablation of the affected portions is called for.
The therapy of true adenoma is less simple. Curetting the cavity of the uterus under antiseptic precautions is necessary in the first place. Personally I am in favor of following this up by an injection of tincture of iodine, with the idea of preventing or retarding a return of the growth.
But the more clearly the case is one of adenoma, the smaller will be the benefit derived from this method of treatment. Preliminary dilatation of the cervix is not, as a rule, necessary for the performance of this opera tion.
If repeated recurrences of the new formations show that they are ma lignant, it only remains to practice supra-vaginal amputation, or to do total extirpation of the uterus, either by laparotomy or per vaginam.
The principles underlying our actions, as well as details of the technique, will be found under the head of cancer of the uterus. It may be said here, however, that the prognosis in adenoma is better than in carcinoma.
Schroder, Muller and myself have performed supra-vaginal amputation for adenoma diffusum without recurrence of the growth. Schriler, Schatz, A. Martin and others have done total extirpation of the uterus for this variety of adenoma. Martin reports that he has twice observed a recurrence of the adenoma, or the formation of cancer in the cicatrix. In these cases the uterus was removed per vaginam.