REPRINTED FROM O W GYN/T.C6L6GY •ANp-PTtDiniRY A Monthly Review of Gyntccology, Oheietrics, AixlotalmU Surgery, and the iXaeaucs of Children. ERNEST W. CUSliiNC. KO.. BmK B1CHARO C. NORRIS* M.O, PKIaMpHa Subjcuplion Price, $1oo a year in advance. •■■a •" W erm. MHlADtLPHU UNIVERSITY CF PEItNSY' LVA.NIA PRESS The Present Status of the Treatment of Uterine Fibroids. RY X. O. WERDER, M.D., PITTSBURGH, PA. The Present Status of the Treatment of Uterine Fibroids. BY X. O. WERDER, M.D., PITTSBURGH,' PA. Uterine fibroids differ clinically from the growths originating in the ovaries in that they are not necessarily fatal, as are the latter, becoming dan- gerous to life principally by complica- tions to which they very frequently give rise. The treatment is, there- fore, not uniform, as in the case of ovarian tumors, where the only safety for the patient lies in their safe re- moval. It is greatly influenced by the nature and seat of the tumor, by the symptoms produced and by the condition, and frequently also by the age, of the patient; for it is a long- recognized fact that many of these neoplasms cease to be a source of danger after menopause has become fully established. No hard and fast rule can, therefore, be laid down for the treatment of these cases. On the contrary, the conscientious practi- tioner must learn to individualize; he must use his best judgment and be guided by the conditions found in the particular patient before him. A large percentage of cases will probably require no treatment, as the tumors are not accompanied by any symp- toms and are not affecting the health of the patient. Among these are especially the small subperitoneal and pedunculated fibroids. Others are amenable to symptomatic treat- ment which, while not producing an anatomical cure, relieves their serious complications and places the patient in a condition to enjoy life in spite of the presence of the neoplasm. Many, however, are such a serious menace to life and health that only the resort to operative measures gives promise of permanent relief. For the sake of convenience, I will, therefore, divide the subject of the treatment of uterine fibroids into two paragraphs, the symptomatic and the radical treatment, and will confine myself to those views which seem to be generally accepted by the leading and unbiased author- ities of the present day. SYMPTOMATIC TREATMENT, The principal symptoms produced by uterine fibroids requiring our atten- tion are haemorrhage and pain. Haem orrhage is one of the most constant and dangerous complications, and is due to a diseased and hypertrophied condi- tion of the uterine mucosa and hyper- 2 X. O. WERDER. plasia of the blood-vessels (Wyder), or according to the later researches of Semb,1 to a hypertrophy of the uterine muscles accompanying the growth of the myoma with a simul- taneous hyperplasia of the blood- vessels. Among the medicinal agents ergot still claims first rank as a uterine haemostatic, though it is less persist- ently and energetically used than a few years ago, when the profession was still under the influence of the enthusiastic claims of Hildebrandt. That it frequently and often promptly controls haemorrhage we are willing to admit, and that by inducing power- ful uterine contractions it often pro- duces a temporary diminution of the size of an interstitial fibroid, we can scarcely deny, but complete cures by its administration, ever so long con- tinued, must certainly be regarded as extremely rare. Its best effects are obtained in small interstitial fibroids, especially near the menopause, when it is sometimes able to tide the patient safely over that period. Submucous fibroids are occasionally atrophied by its use, or it may cause their intrusion into the uterine cavity, where they can then be removed as ordinary polypi. Second only to ergot is hydrastis Canadensis, which often proves of value in bleeding fibroid tumors. While ergot influences the unstriped muscular fibres of the uterus, hydrastis seems to confine its action to the small vessels of the uterine mucosa, which it causes to contract. In 1890 Falk introduced hydrastinin, prepared from hydrastin, an active principle of hydrastis Cana- densis, for which he claims very marked results in uterine haemor- rhage, whether due to myoma or other diseased conditions of the uterus. Czempin and others also speak very highly of it. He adminis- ters it in doses of 0.025 (one-fourth grain) in capsules or subcutaneously four times a day, six to eight doses usually being sufficient to produce the desired effect. Other medicinal agents which from time to time have been recommended in the treatment of uterine fibroids scarcely deserve mention, as they are absolutely valueless. Reported cures effected by them have probably been merely coincidences. The agent which during the last few years has given rise to the most animated discussions in our medical societies, and in not a few instances to very bitter contro- versies in connection with the subject now under treatment is electricity. Introduced to the profession by Apostoli, about eight years ago, its true worth has by this time been sufficiently tested to allow of a critical survey of its real status obtained in the hands of competent and unbiased observers. The enthusiastic claims of Apostoli and his followers have only been partially verified. That it is a valuable agent to stop haemor- rhage and also pains in certain forms of uterine fibroids is generally admit- ted ; but that it checks the future growth of the tumor, causes its shrinkage and often its entire dis- appearance, are claims not borne out by our present experience. At a meeting of the Berlin Gynaecological Society, held over a year ago, in which the subject of the treatment of uterine fibroids by galvanism was discussed, A. Schaeffer reported forty cases treated by him at Veit's clinic; P. Broese, thirty-five cases; N. Nagel, 1 Archiv. fur Gynaekologie, Vol. xliii. TREATMENT OF UTERINE FIBROIDS. 3 thirty-two cases under treatment at Gusserow's clinic, and A. Mackinrodt, A. Martin's assistant, thirty-six cases, making a total of 143 cases. The treatment carried out was strictly according to Apostoli's directions, dosage from 70 to 240 milliamperes, depending on the susceptibility of the patients, the applications lasting from five to ten minutes and the length of treatment from six weeks to six to eight months. Of this large number of cases only one, a tumor of the size of a fist, was perfectly cured (P. Broese) ; another tumor of the submucous variety was expelled from the uterus after intra-uterine galvan- ism (A. Schaeffer). P. Broese re- ported three with considerable diminu- tion in size, one of which shortly after cessation of treatment regained almost its former dimensions. A. Schaeffer, Nagel and Mackinrodt were less for- tunate, as they distinctly state that in none of their 107 cases did they notice any appreciable diminution in size. They all agree that as an agent to relieve symptoms generally accom- panying these neoplasms, such as haemorrhage and pain, galvanism proved beneficial in from 60 to 70 per cent., but relapses were frequent among those relieved; 30 to 40 per cent, were either not relieved or made worse. I regard this report of special interest bearing on the electrical treatment of uterine fibroids on ac- count of the unusually large number of cases observed by very competent and unbiased men, and because of the opportunity of careful observation at the clinics at which these cases were treated. My own limited experience coincides with the observations above given. While I have seen symptom- atic improvement follow the use of galvanism in about half of the cases treated, I have never seen any per- manent shrinkage; on the contrary, in three cases the tumors continued to grow while under treatment, and one which at the time of treatment was of the size of a small lemon, had attained the size of a cocoanut a year after electricity had been discon- tinued. In looking over the literature of the subject I was greatly surprised to find how many men, formerly enthusiastic disciples of Apostoli, have grown lukewarm in their master's faith, or have abandoned it entirely. Never- theless the fact remains that in a cer- tain number of uterine fibroids, par- ticularly in small interstitial and sub- peritoneal growths accompanied by haemorrhage, we have in the intra- uterine positive electrode a very val- uable remedy, by means of which many patients will be able to enjoy life and comfort, and if near the menopause will be safely tided over that period. In large tumors, inter- stitial or subperitoneal, we will fre- quently be disappointed by its use, and in the pedunculated and sub- mucous nothing is to be expected from it; in the latter variety it is, in- deed, liable to do harm by causing suppuration and sloughing of the growth. In the oedematous and fibro- cystic tumors it is absolutely contra- indicated. If used in these selected cases it will rarely fail to relieve the urgent symptoms, though he who ex- pects it it to accomplish more will be sadly disappointed. Reports of cases of shrinkage of fibroid tumors during the electrical treatment are, no doubt, almost in- variably based on faulty observations, for it is a well-known fact that myo- 4 X. O. WERDER. matous tumors frequently enlarge un- der the stimulus of the menstrual molimina, and decrease after the sub- sidence of the menstrual congestion ; this fluctuation in size often being quite considerable. It can easily be imagined how the shrinkage follow- ing these physiological congestions may oftentimes be mistaken for the result of the electrical treatment. Then, again, measurements under- taken for the purpose of ascertaining the effects of the treatment are only too often deceptive ; if external, they necessarily must vary according to whether the intestines are distended or empty; uterine measurements are equally fallacious, especially when the uterine cavity is deep and capacious. The sound may be arrested by folds of the thickened mucosa, or it may penetrate to the fundus uteri in a straight line, and the next time may deviate to one or the other cornu, making a possible difference of a half to two inches. The modus operandi of the galvanic current, at first shrouded in consider- able mystery, is now pretty well un- derstood, and we recognize that what- ever effect the interpolar action of the current may have, we owe the beneficial results obtained principally to the direct caustic action of the intra-uterine electrodes on the mucosa. The experiments of Prochownick and Spaeth on the dead and living uteri not only corroborate the statements of Apostoli and others in regard to the different chemical action of posi- tive and negative pole, but they have also demonstrated conclusively that the immediate action of both is to destroy the uterine mucosa wherever they come in contact with it (the positive pole, other things being equal, being more intensely caustic than the negative), and to cause coagulation in the lymph and blood-vessels in the structures underlying the mucous membrane, the depth depending on the intensity and duration of the ap- plication ; this may later be followed by necrosis of the tissues involved. The structures beyond those in which the changes described occurred pre- sented nothing abnormal either mac- roscopically or microscopically. From this follows, that, after repeated posi- tive intra-uterine galvanism, a resti- tutio ad integrum of the uterine mu- cosa is not to be expected, but that it results in the destruction of its epi- thelial elements with increased con- nective tissue formation, and finally cicatricial tissue supplanting the uterine mucous membrane. This can be demonstrated clinically; not in- frequently the first few applications are followed by slight haemorrhages, which are caused by reactionary hy- peraemia around the slough. Again, we all have experienced how slowly cases with large uterine cavities respond to galvanic treatment; it is because it takes a much longer time to destroy the mucosa over a large surface than over a small one. These are all observations which go to show that it is not the interpolar action of the electrical current, or electrolysis in the strict sense of the word, not even its stimulating effect on the con- tractile tissues of the uterus and neo- plasm, though I am willing to assign to the latter a certain rdle in some cases, but that it is the polar or caus- tic effect produced by the intra- uterine electrode, on which depends its therapeutic influence. This ac- tion may even explain a certain amount of shrinkage of the tumor TREATMENT OF UTERINE FIBROIDS. 5 in the rare cases where such actually occurs, as it is but reasonable to sup- pose that the destruction of such a large vascular surface as the hyper- trophic uterine mucosa might affect the nutrition of the neoplasm to a considerable extent. The relief of pain which undoubt- edly follows galvanic treatment in a considerable number of cases, though by no means as frequently as that of haemorrhage, is usually attributed to that mysterious interpolar action of the current. Pain may be due to pressure on neighboring organs, dis- eased adnexa, adhesions, etc. When pain is relieved by electricity, how- ever, its most frequent source, I believe, has been the uterine mucosa, which is nearly always diseased in a myomatous uterus. That intra-uter- ine galvanism should be able to relieve pain of this character can, at least, be assumed from the study of its effect on that structure, but that it should be equally effective in pressure pains, pains from diseased adnexa, or caused by adhesions, is, in my mind, more than doubtful. I have good reason to question its utility as an absorbent of adhesions, as I have applied elec- tricity patiently and persistently in a number of cases of retroflexed adher- ent uteri with the result that it be- came necessary to open the abdomen to release the bound-down uterus and its adnexa. I have not referred to galvanic puncture because I regard that as dangerous as the radical treatment, i.e., hysterectomy, in skilled hands, while it is incomparable with it in its results. A favorite means of checking haemorrhage is the curette, with or without subsequent injections of iodine; the latter method being that so highly recommended by Max Runge and others who have certainly achieved excellent results by it. Curettement alone is a measure of scarcely more than temporary utility on account of the well known pro- perty of the uterine mucosa to rapidly regenerate itself. While it is more certain and prompt in its effect than electricity it is less permanent, at least when the latter is used persever- ingly, from the fact that the intra- uterine electrode destroys all epithe- lial elements, preventing the regener- ation of the mucosa and substituting for it cicatricial tissue. It is, how- ever, of the greatest benefit as a pre- liminary operation to hysterectomy when the patient has, from long- continued loss of blood, become so exsanguinated as to make a more radical operation for the time ex- tremely hazardous. It allows the patient to recuperate and to regain sufficient strength to bear the more serious radical operation. In several very anaemic cases 1 have preceded the application of electricity, which I feared would be too slow to affect the serious haemorrhage, by a thorough curettement, with very satisfactory results. I have always found the curette a perfectly safe instrument, even in myoma, when used with care and scrupulous .asceptic precautions. Whether the operation first per- formed by Franklin Martin, and sim- ultaneously recommended on theo- retical grounds by Gottschalk, based on his researches in the " Hystogen- esis and Etiology of Uterine Myo- mata," 1 of tying both arteries and a portion of the broad ligaments, will prove to be more than a symptomatic • Archiv. fur Gyncekologie, Vol. i.xiii 6 X. O. WERDER. cure, and whether it will always bring about such a result further experi- ence will show. This ingenious oper- ation, as it certainly seems based on sound principles, deserves further trial in cases where a more radical operation is contra-indicated. RADICAL TREATMENT. There are many sufferers from myomata who, of necessity, will apply to the surgeon for relief, either because palliative measures were tried in vain, or because the social condition of the patient does not allow her to spend months of her valuable time under medical treat- ment, or because the nature of the tumor from the outset is one un- suited for any other but operative treatment. The operation for the removal of fibroid growths has, until very re- cently, been attended by a frightful mortality, which had a very disparag- ing effect on its performance. For this fatality was responsible not only the faulty technique, but even more so the delay in operating, based fre- quently on the erroneous idea, preva- lent even at the present day, that uterine fibroids are innocent tumors which, when safely tided over the menopause, would become harmless. While this is no doubt true in the majority of cases, recent observations have shown the fallacy of these ex- pectations in not an inconsiderable number of cases. Not only is the menopause unduly delayed, often far beyond the physiological limits, by these neoplasms, but we know that even after the climacteric period is safely reached they do not always shrink, but not rarely undergo certain changes, of which I will mention cystic and malignant degeneration, which always lead to a fatal termina- tion unless the tumor be removed? Another danger of fibroid tumors to which attention has frequently been called, very recently again by Leopold and Hofmeier, is muscular degenera- tion of the heart in consequence of long-continued loss of blood, which not only places the life of the patient in constant jeopardy, but is almost sure to lead to a fatal termination, often on the operating table, if an operation is attempted. Again, in- flammation and suppuration of the tumor may develop or it may reach such enormous dimensions as to be- come a danger to life. Operations in such cases,attempted for the purpose of saving life, are frequently unsuc- cessful on account of the reduced condition of the patient and the difficulties, tediousness and loss of blood attending such operations. The writer, a short time ago, was fortu- nate enough to witness, through the kindness of Dr. Joseph Price, an operation of this kind in which the tumor had attained an immense size, estimated at sixty to seventy pounds, with universal almost inseparable parietal and intestinal adhesions. Such deaths should evidently not be placed at the door of the operator or the operation, but they clearly are to be charged to the timid physician who counselled the fatal delay. The marked improvement of our present results are due both to a greatly per- fected technique and also to a clearer and more general understanding of the risks attending these tumors and consequently less delay than for- merly. The operative treatment of uterine fibroids has received so much atten- tion in our present medical literature by men of more ability and greater experience, that I shall not attempt TREATMENT OF UTERINE FIBROIDS. 7 to give a detailed description of the different operative procedures, es- pecially as in doing so I would necessarily go far beyond the limits of my paper, but I will confine my remarks as briefly as possible to the indications and results of the differ- ent methods enumerated below. The operations practiced for the radical cure of myomatous growths are: (i) Vaginal enucleation; (2) removal of appendages; (3) enuclea- tion by laparotomy ; (4) supra-pubic hysterectomy. (1) Vaginal enucleation has natur- ally a limited field and is only applic- able in fibroids of the cervix, in submucuus or interstitial myomata, which are partially born into the vagina, and also in submucous growths not exceeding the size of an infant's head, where previous dilata- tion of the cervix is required. The operation is a perfectly safe one, pro- vided suppuration and sloughing of the projecting mass has not taken place. (2) Removal of the appendages is practiced for the purpose of bringing on artificial menopause, with its ac- companying cessation of menstrua- tion and shrinking of the tumor. It is indicated in small fibroids of the uterus up to the size of a child's head. There is no unanimity of opinion as to the actual merit of this operation. Some operators, chiefly A. Martin, have discarded it because it gives in- sufficient guarantee of success ; while others, in fact the great majority, practice and recommend it, and are well satisfied with the results obtained. Whether failures are due to the fact as pointed out by Sinclair, that "the main arteries have not been tied to- gether with the venous plexuses, with the result that while the blood supply to the uterus is still free, the return flow is intc rrupted, the organ remains congested, and involution is retarded, even after the adnexa has been thor- oughly removed, menstruation con- tinuing for months and years " is still an open question. It is evident, how- ever, that the better the results of hysterectomy become, the less fre- quently will oophorectomy be per- formed, as it is certainly a less ideal operation than the removal of the of- fending tumor ; but for some time yet the removal of the adnexa will re- main a recognized operation for the reason of its perfect safety, at least, where the ovaries can be easily found and removed, and where the patient is not too much reduced from long continued loss of blood. It is in weak patients especially, in whom it would be hazardous to do a more radical operation, involving a greater amount of shock, more loss of blood, and longer duration, where oophorect- omy shows its advantage. (3) Enucleation of the tumor by laparotomy, originated by A. Martin, is an operation meriting a more gen- eral appreciation than it has received in this country. It consists in split- ting the capsule, shelling out the tumor or tumors from the uterine body, and the closing of the cavity thus obtained by deep, buried sutures. Its great advantage over other opera- tions lies in the fact that it leaves the uterus, no matter how crippled; and to a young woman this is a matter of sufficient importance to serve our at- tention, though it may very rarely be capable of conceiving and bearing a full grown child. The operation is particularly indicated in subperi- toneal and interstitial fibroids of young women, in which these neo- plasms can be enucleated without opening the uterine cavity, and in 8 X. O. WERDER. which a portion of the uterus can be preserved. With this limitation the operation gives a very favorable prog- nosis, at least equally as favorable as the more radical procedures. (4) Supra-pubic hysterectomy has the widest field of application in the treat- ment of uterine myomata. Thanks to the untiring efforts of the abdom inal surgeon, such progress has been made in the perfection of its tech- nique, that its mortality within the last ten years has been reduced a hundred per cent., and it is not an illusory dream when we think the time not very far distant to see the results of hysterectomy compare fav- orably with those of ovariotomy. While at present the extra-peritoneal treatment of the pedicle still shows the largest percentage of recoveries, the greatly improved intra-peritoneal methods are so rapidly gaining in favor, and hold out so many ad- vantages over the former, that they seem destined to supercede it entirely in the very near future. The opera- tions of greatest promise for the future are total abdominal hyster- ectomy, which, in the hands of such men as Martin, Polk, Krug, Boldt, Edebohls and others, has already given such enviable results, and that devised and so successfully performed by Baer. While personally favoring total abdominal hysterectomy, of which I have had two cases, both successful-with Dr. Baer's method I have as yet had no experience-the fact cannot be disguised that the operation is accompanied by more loss of blood, and, therefore, more shock. It is more tedious and time- robbing, and more difficult of per- formance than the extra-peritoneal methods. Items of sufficient import- ance to outweigh the disadvantage of the latter, chief of which are a longer convalescence and liability to hernia, when we deal with a patient greatly reduced by profuse haemorrhages and long-continued suffering. I would, therefore, not be willing to discard the extra-peritoneal operation, at least at the present stage of our experience. While my preference in good, vigor- ous subjects would be total abdominal hysterectomy, I would feel that the weak, reduced patient had a better chance for life with extra-peritoneal treatment of the pedicle for the rea- son given above. In concluding this rather too lengthy paper, I would like to lay stress again on one point, to which I referred in the introduction, and it is this, that for an intelligent therapy of uterine fibroids, whether surgical or symptomatic, it is absolutely neces- sary to make a careful investigation of the case before us. The diagnosis of myoma is insuf- ficient. We must determine its loca- tion, Character, rapidity of growth and the symptoms to which it gives rise. Then, again, it is necessary to consider the patient, her age, her so- cial surroundings, and her physical condition before we decide whether she is likely to be benefited by symp- tomatic treatment, or whether she de- mands surgical measures in order to get relief. Treating every case of fibroid by galvanism, can only result in harm; nor would it be justifiable to subject every patient possessing a myoma to an operation. Even when we have determined on an operation, we should use our best judgment in selecting that method which is likely to prove the least dangerous to our patient.