CASES OF UmiM FIBROIDS FROM PRIVATE PRACTICE AND THEIR TREATMENT. BY D. W. PRENTISS, M.D., Washington, D. C. [Reprinted from the American Journal of Obstetrics and Diseases of Women and Children, December, 1889.] NEW YORK: WILLIAM WOOD & CO., PUBLISHERS, 56 & 58 Lafayette Place. 1889. CASES OF UTERINE FIBROIDS FROM PRIVATE PRACTICE AND THEIR TREATMENT. BY D. W. PRENTISS, M.D., Washington, D. C. [Reprinted from the American Journal of Obstetrics and Diseases of Women and Children, December, 1889.] NEW YORK: WILLIAM WOOD & CO., PUBLISHERS, 56 & 58 Lafayette Place. 1889. CASES OF UTERIKE FIBROIDS FROM PRIME PRACTICE AND THEIR TREATMENT.1 The cases which I report to-night are essentially clinical in their character, taken from private practice during a number of years past. I have made no attempt at anything like an essay upon the subject of uterine fibroids, nor in discussing the treatment have I aimed in any degree to cover the question exhaustively. I have stated the treatment followed in the cases reported, and purposely leave the subject open for discussion by the Society. Case I.-Mrs. B , aged 55 years, mother of six children, youngest 16 years of age. Has always been well nourished and in fairly good health, though not strong. Last confinement in 1873. Labor normal, but involution slow. In 1878 began complaining of heavy feeling in pelvic region, backache, and pain down limbs. Vaginal examination revealed hypertrophy of uterus and retroversion, and tumor in anterior wall of uterus near the fundus. She was kept in bed for several months, under treatment for endometritis and retroversion, until the uterus could be kept in place by a pessary. The tumor en- larged to size of fetal head, and could be readily felt above the pubes. She was put upon fluid extract of ergot treatment-from twenty 1 Read before the Washington Obstetrical and Gynecological Society, May 17th, 1889. 4 Prentiss : Uterine Fibroids and their Treatment. drops to a teaspoonful three times a day, according to the amount of hemorrhage-and took it constantly for one year, and most of the time for five years. The ergot did not disagree with her in any way, but she frequently became very tired of taking it. She was 44 years of age when the tumor was discovered, and she did not have the menopause until 50 years of age. During this time menstruation was profuse, lasting seven or eight days, and recurring every two or three weeks. By the use of the ergot, however, it was kept within bounds, and she was able to attend to household duties and measurably enjoy life. She was assured that the tumor would diminish in size and give her no further trouble after the menopause. This turned out to be the case, although the climacteric did not occur until the age of 50, the menstruation being prolonged, as is usual in fibroids of the uterus. She is now 55 years old, and has enjoyed good health for the past five years. The tumor can no longer be felt above the pubes, and only with difficulty through the vagina. Case II.-Mrs. L., aged 41 years, brunette, rather stout. Has always been in good health, with the exception of uterine disorders. Menstruation has always been profuse. Has been married twenty-two years; never had any children or been preg- nant. Had an attack of pelvic cellulitis when 15 years old, caused by jumping from a wagon. This was followed by exces- sively painful menstruation. This latter trouble was treated by Dr. Theophilus Parvin by dilating the uterus with sponge-tents. No cellulitis followed the use of the tents on this occasion. My first attendance was in 1872, for malaria. Following the malaria ensued an attack of pelvic cellulitis, for which she was under treatment for several months. During the winter of 1873, the os uteri was dilated with sponge-tents, with the double object of relieving the dysmenorrhea and removing the sterility. This use of tents caused an attack of cellulitis. Subsequently, on re- covery from the cellulitis, an attempt was again made to cure the sterility by dilating the os with sounds, but without effect. March, 1881.-In making an examination in consequence of pain and menorrhagia, a tumor the size of a cocoanut was dis- covered low down on the right side of the uterus, which caused pain in the bladder and rectum by pressure. The tumor was diagnosed as a subperitoneal fibroid connected with the uterus. A belladonna plaster was applied, and fluid extract of ergot, fif- teen drops three times a day, ordered, the dose to be increased to a teaspoonful if necessary for hemorrhage. It was taken in this way pretty constantly for eight years, up to the present time. The second tumor made its appearance five years ago, in 1884. It was low down on the left side, and about one-third the size of the first mentioned. This added to the distress from pressure and menorrhagia. The latter symptom was always fairly well controlled by the ergot, so that Mrs. L. was able to be about and enjoy life to a reasonable degree. The third tumor Prentiss : Uterine Fibroids and their Treatment. 5 appeared in the spring of 1888, one year ago, is situated in the anterior wall of the uterus, and is about the size of a fetal head. Since the development of the last tumor, there has been a great increase in the menorrhagia, the flow continuing two weeks, and sometimes so profuse as to be alarming. The ergot in full doses controls it only to a limited extent, and the general effect of the ergot is so unpleasant that the patient will only take it in full doses as an absolute necessity. This peculiar effect of the drug I will refer to again. It was proposed to try electricity with a view to controlling the hemorrhage, and in the hope that it might stop the growth of the last tumor, if it did not cause it to diminish in size. This was readily assented to by the patient, and treatment by electricity was begun October 6th, 1888. At this date the following was the condition : Four fibroids found -two subperitoneal in the right iliac region, one measuring five inches in length, the other three and one-half inches, and irre- gular in shape; one tumor in left iliac fossa three and one-half inches long, subperitoneal. All of these tumors have become smaller under the use of ergot during the past two years. A fourth tumor, which has appeared within a year, is globular and in the anterior wall of the uterus, four and one-half inches in diameter. Since the development of the intramural tumor, menorrhagia has become worse. Electrical treatment: Battery used is Waite & Bartlett cabinet, 40 Leclanche cells, constant current. October 6th.-8 cells. Positive pole over abdomen-7 x 9 wire gauze electrode wrapped in soft towel saturated with salt water. Negative pole in the uterus-50 milliamperes, 15 minutes. Then current was reversed for 5 minutes. Resistance, 200 ohms. Dis- tention of speculum caused pain. 13th.-Electrodes as before, 4- on abdomen, - in utero, 7 cells, 50 milliamperes, 20 minutes. November 16th.-10 cells. + over abdomen, 30 milliamperes, - on lumbar region, 30 minutes. Reverse 10 minutes, 4- in utero. 20th. b on abdomen, - on lumbar region, 10 cells, 40 milliam- peres, 15 minutes; 4- in utero, - on abdomen, 3 cells, 20 mil- liamperes, 15 minutes. December 5th.-9 cells, 40 milliamperes, 15 minutes, and re- verse. Dr. H. L. E. Johnson assisting. 11th.-9 cells, 45 mil- liamperes, 4- on abdomen and reverse, 15 minutes. 14th.-8 cells, 45 milliamperes, 15 minutes. Reverse. 29th.-7 cells, 25 milliamperes increased to 40 milliamperes. Last period con- tinued 9 days. January 2d.-8 cells, 40 milliamperes, 15 minutes, and reverse 10 minutes. 5th.-10 cells. 50 milliamperes, 15 minutes. Re- verse. 8th.-8 cells, 50 milliamperes, 15 minutes, and reverse. 24th.-As above. Menstruated from 13th to 22d, 9 days; quite profuse and painful. 29th.-9 cells, 50 milliamperes, 4- in utero, 15 minutes. No pain. February 5th.-7 cells, 45 milliamperes, 4- in utero, 15 min- utes. 20th.-Has been menstruating 13 days; used 35 napkins; Prentiss : Uterine Fibroids and their Treatment. 6 no pain. Took during the time decoction of % lb. cotton-root bark, which seemed to prevent pain but did not check hemor- rhage.-10 cells, 55 milliamperes, + in utero, 15 minutes. Cen- tral tumor lower down, but not reduced in size. From this time, February 20th, the use of electricity was dis- continued. It seemed to do no good, and its application was attended with much suffering. It was impossible with one pole in utero to use stronger currents than fifty milliamperes, on ac- count of the pain produced, both at the time of application and continuing for hours after her return home. The use of electricity in this case was unsatisfactory, both as to relief of the hemorrhage and relief of pain. There was also no perceptible effect on the size of the tumors. But this latter was not to be expected from the strength of cur- rents and mode of application. The pain caused by the elec- tricity was described as a bearing-down and intolerable aching pain-evidently from contraction of the uterine muscle. As to the use of ergot in this case, the fluid extract was used and taken nearly constantly for eight years, in doses of from fifteen drops to a teaspoonful three times a day. The effect in controlling hemorrhage was very decided, the larger dose being used when necessary for that symptom. The smaller doses were taken during the interim. The first and second tumors be- came smaller under the use of this drug, and I am certain that without it Mrs. L. would have been confined to bed most of the time, whereas she was able to attend to her household duties, go about and enjoy life. The ergot, when taken in teaspoonful doses, caused pain in the rectum and bladder, apparently from pressure of uterine con- traction. The ergot also produced a peculiar effect to which I wish to call especial attention, since it was uniform and very marked, and I have not seen it referred to in the literature of this drug. This was a peculiar depression of spirits with hysterical pheno- mena, more marked when taking the full doses of the fluid ex- tract, less marked when using the suppositories of ergotin. I neglected to state that for the past three years she has been using the suppositories of ergotin (0.30) three times a day, in- stead of taking the medicine by the stomach. After taking the ergot for three days in full doses, she feels like crying all the time, then on the fourth day is angry with every one and displeased with everything, and wants to quarrel; will lie in bed and cry all day; easily irritated-while her na- tural disposition is just the opposite, even-tempered and excep- tionally pleasant. The family soon came to recognize the state of mind and respected it accordingly. Husband and servants were very careful not to aggravate it, and even the little adopted daughter would say: "Mamma is taking ergot/' In consequence of this disagreeable action of the ergot, I tried to find a substi-^ tute, and on February 5th, 1889, prescribed the tea of cotton- Prentiss : Uterine Fibroids and their Treatment, 7 root bark, which she has been drinking since that date to the present. The tea is prepared according to the directions of Dr. Gar- rigues in the Quarterly Bulletin of the Clinical Society of the New York Post-Graduate Medical School and Hospital. The directions are to boil three heaping teaspoonfuls of the pow- dered root in a pint of water for fifteen minutes, and when cool, strain. Of this one-third is to be taken in the morning, one-third in the afternoon, and one-third at bedtime. Dr. Garrigues has used the cotton-root bark in one hundred and thirty-nine patients, in most of them with decided benefit. He has found that it checks the bleeding of uterine fibroids and also lessens the associated pain, while in carcinoma and sarcoma it limits or altogether suspends for the time the hemorrhage. He insists that the remedy should be used in the form of a freshly made decoction, and states that it fails to pro- duce any benefit in about ten per cent of the cases, which is certainly not an unsatisfactory showing. In the case here re- ported, it failed entirely to relieve the hemorrhage, and ergot suppositories had to be resorted to for that purpose; but it did relieve the pain and made the patient more comfortable. She rather liked the cotton-root tea as a beverage, and still takes it for its sedative effect. Case HI.-Mrs. S., a blonde, aged about 40 years, well developed. Previous health good. Has been married twenty years and has two daughters, aged 18 and 5 years. No miscar- riages. Has suffered from menorrhagia for two years; men- struation on time, but lasting sometimes for two weeks. Has had profuse hemorrhages for three months, without pain. In good health otherwise, except from the exsanguination. Is pale, anemic, weak and weary from the continued loss of^blood. I was first consulted February 16th, 1888. Found uterus en- larged ; cavity three and one-half inches ; os patulous. Hard tumor in anterior wall just inside of os internum, apparently about the size of a hen's egg. Can be felt readily both by in- ternal and external manipulation. Prescribed fluid extract ergot, teaspoonful three times a day. February 16th.-Applied electricity. Abdominal electrode, wire gauze, 5x7, wrapped in towel and thoroughly saturated with salt water. Positive over abdomen. Negative platinum, intra- uterine. Ten cells Leclanche, 50 milliamperes, for 7 minutes. Resistance, 300 ohms. Thick muco-purulent discharge from uterus. Electricity caused no pain. 18th to 20th.-Severe hemorrhage and pain. 21st.-Uterus smaller and firmer. Gal- 8 Prentiss : Uterine Fibroids and their Treatment. vanism, 12 cells, 54 milliamperes, 8 minutes. No pain. Positive in uterus. Resistance, 200 ohms. Hemorrhage continued, and on March 9th I was sent for. Found the anemia extreme, with corresponding exhaustion. A soft white mass was presenting at the os. Uterus dilated with Goodell's dilator, and a mass, in amount about a tablespoonful, removed. Strong solution of tannin in glycerin applied to endometrium, and cotton tampon. This mass supposed to be a mucoid polypus. After this the tannin and glycerin were applied daily and the hemorrhage ceased. The uterus at this time was firmly contracted, and the fibroid in the anterior wall was just beneath the mucous mem- brane. Between the dates March 18th and April 10th the tumor was extruded through the endometrium and appeared at the os, dilating it just as in miscarriage; it was firm, hard, and tough. The finger, passed into the uterus and around the tumor, found a firm pedicle an inch in diameter. April 10th.-The os being well dilated, patient under ether, the tumor was seized with vulsellum forceps, drawn down and held by an assistant, while, with a pair of long-handled scissors curved on the flat, the pedicle was carefully cut through, the cutting being guided by the finger in the uterus. The tumor was then readily removed. It was a typical fibroid the size of a duck's egg. The uterus was wiped out with a fifty-per-cent so- lution of carbolic acid, and glycerin and tannin pad applied. There was no further hemorrhage. Mrs. S. made a rapid re- covery, soon gained blood and strength, and menstruated nor- mally at the next period. It is now one year since the removal of the fibroid, and good health has been uninterrupted. Men- struation regular and normal. In this case electricity was applied but twice. It had no effect in controlling the hemorrhage, but did cause contraction of the uterus. To the ergot and electricity I attribute the speedy expulsion of the tumor. • Case IV.-Mrs. R., aged about 30, multipara. Was consulted in consequence of uterine hemorrhage and pelvic pain. May, 1884.-Found on examination a polypus filling the ute- rine cavity and presenting at the os. Dr. J. Ford Thompson was called in consultation, and the tumor removed by the wire ecraseur. Recovery was prompt and complete. Case V.-In March and April, 1885, attended a lady, several years past her climacteric, who was suffering from irritation of the bladder. Micturition frequent and attended by great pain. Urine normal. General symptoms of extreme prostration, and cachectic appearance. Examination disclosed a tumor in anterior cul-de-sac between uterus and bladder, the nature of which was uncertain. I thought it to be hematocele, but with this opinion Dr. J. Ford Thompson, who saw her in consultation, did not agree, but was inclined, from the general condition, to think Prentiss: Uterine Fibroids and their Treatment. 9 there was cancer, if not in this tumor, somewhere in the pelvic cavity. She died, and at the autopsy' no cancer was found, but two round, hard fibroid tumors one and one-half and two and one-half inches in diameter. No other pathological condition was noted, but the autopsy was very superficial on account of the objection of friends. The symptoms pointed to these tumors as in /some way connected with the cause of death, but just why I have never understood. Treatment of Uterine Fibroids.-This resolves itself into three divisions: I. Symptomatic. II. By electricity. III. Surgical. I. Symptomatic.-I mean by this, treatment of such symp- toms as hemorrhage, pressure, etc. Hemorrhage is the most important, and the one which most frequently threatens life. The drugs of most value for the hemorrhage are, in the order of their importance, ergot, cotton- root bark, hydrastis, nux vomica, hamamelis, and ammonium chloride. In addition to the administration of medicines by the stomach, of great value and importance are rest in bed and local treatment at the times of profuse hemorrhage. A late writer lays special stress upon tampons with vinegar to control the hemorrhage. Ergot in some form is the most valuable medi- cine we have at command in this condition. Its action is two- fold : 1st. By contracting the small blood vessels, and thus dimin- ishing the amount of blood in the bleeding surface. 2d. Causing contraction of the involuntary muscular fibre of the uterus, which not only checks hemorrhage, but, in case of a fibroid tumor connected with the uterus, diminishes the supply of blood to this abnormal growth, thus checking its nutrition and limiting, or even lessening, its development. Hildebrandt was the first to recommend, in 1872, its use subcutaneously for uterine fibroids, and reported a number of cases thus cured. The objection to this mode of administration is the pain produced by the injection. The action of cotton-root bark is similar to ergot in causing uterine contractions, and in addition appears to have a sedative effect in relieving pain. Hamamelis, or witch hazel, is referred to in this connection as a possible substitute for ergot and cotton-root bark in cases where they cannot be taken or have lost their effect. 10 Prentiss : Uterine Fibroids and their Treatment. In the Philadelphia Medical News of April 6th, 1889, Dr. Reeves Jackson recommends fluid extract of hydrastis, 20-drop -doses, or hydrastin, | (0.015) to | (0.03) grain, in hemorrhage from uterine fibroids, and Dr. Baer recommends strychnia in combination with ergot. II. Treatment by Electricity.-This paper has already grown so lengthy that I shall content myself by referring very briefly to electrical and surgical treatment of fibroids, and leave details to the discussion by the Society. Treatment by electricity naturally divides itself into the ex- pectant and the radical treatments: expectant, to relieve suf- fering, control hemorrhage, and stimulate the uterus to con- traction; radical, to cause the absorption of the tumors by electrolysis, after the manner of Apostoli. My experience-which is very limited-with the use of elec- tricity for controlling hemorrhage and relieving pain has not been satisfactory. In Case IL it entirely failed to be of any benefit, and increased instead of relieving the suffering. In Case III. it was of value in hastening the expulsion of the tumor by stimulating uterine contraction, but it did not di- minish the bleeding. With the methods of Apostoli and other operators in elec- trolysis I have no experience whatever. It appears to me that this plunging of a needle into a tumor through the abdominal walls or through the uterus or vaginal walls, and the use of such powerful currents, cannot be devoid of risk, and I should class it as among capital surgical operations. III. Surgical Treatment.-The important questions for dis- cussion are the value of surgical interference in the removal of the tumors themselves, and the value of oophorectomy. Dr. Smith mentioned a unique case. The patient is a lady 36 years of age, twice married, and now living with her second hus- band. She has never been pregnant; menses have always been scant, and during the past ten years have scarcely showed at all. During the last six or eight months there had been no discharge whatever until last week, when a single drop, as she says, ap- peared. She called at my office, and on examination I found a fibroid as large as the fist. The tumor has now increased in size one-third. The case is unusual in that it shows the development and growth of a uterine fibroid in a patient in whom menstruation and ovarian activity are apparently in abeyance. Dr. Fry asked Dr. Smith how he knew there was no ovarian activity. Prentiss: Uterine Fibroids and their Treatment. 11 Dr. Smith.-There were no apparent symptoms, only some vague sensations. Dr. Fry.-Was there anything periodical about the sensations? Dr. Smith.-No. Dr. Busey.-What is the condition of her health? Dr. Smith.-Excellent. She is well developed and robust. Dr. Prentiss also presented one of his cases for examination. The President, having examined the patient, said: The condi- tions were the same as those of the second case in Dr. Prentiss' paper. She had two tumors on one side, two behind, and two on the other side. Her condition is an unhappy one, and she has a hard life to live. Her pelvis is full, the fibroids, extending to the umbilicus, have long pedicles, and there is constant danger of in- testinal constriction. She has frequent attacks of pain; painful defecation with hemorrhage, and has to be accompanied by some one at these times. She is now prosperous, but would end her life if poverty should overtake her. When not in pain she is com- fortable. He thought she should be operated upon. It was a case of rapidly growing fibroids with concomitant dangers. Death might result from hemorrhage, from kidney disease from pres- sure on ureters, or from pressure on other abdominal viscera. Her mother menstruated until she was 54; her sister, who is now 54, is still menstruating. He thought in her case it would be dangerous to wait for the menopause. The ovaries are probably so situated that they may not be reached without dangerously tearing surrounding tissues. He thought the operator should be prepared to perform hysterectomy; she might get on without operation, but he thought it doubtful. Hypodermics often pro- duced nausea and wakefulness instead of quieting her. After considering all the dangers, he would take the responsibility of performing the operation. Dr. Prentiss.-What is the mortality? The President.-Great, but her danger is also great. Dr. Prentiss.-What per cent? The President.-Removing ovaries for the cure of fibroids, 95 to 97 per cent get well. In hysterectomy, death rates of all operators about 40 per cent. Dr. Smith.-Greig Smith says it should not be more than 15 per cent in the hands of skilled operators. The President desired to set Dr. Smith aright as to specialists. There might be no mortality. Keith had 33 cases with 2 deaths ; Bantock, 12 cases, no mortality. In his own cases, 5 in all, 3 died, but he meant to do better. Dr. Smi^h agreed with the President that the mortality should not be over 40 per cent. Dr. Fry thought that in deciding upon operations the natural history of the disease should be considered. We know death is almost never caused by an excessive hemorrhage or takes place suddenly except in the worst cases. In the treatment of Dr. Pren- tiss' cases, he thought that two currents should not be used at one time, as they differ in their effect. One counteracts the effect of the other. Anodes check hemorrhage, cathodes neutralize. We should always use the positive pole to check hemorrhage. When pain is produced, it is owing to the pole coming in contact with the cervix. He uses an electrode that is insulated, except at the point, which is made of platinum. Hemorrhage is often produced in fibroids by the presence of fungous endometritis, 12 Prentiss : Uterine Fibroids and their Treatment. which may be cured by the use of the curette. He would like to correct a wrong impression made by Dr. Prentiss. Apostoli does not pass needles through the abdominal walls into tumors, as they may produce sloughing, septicemia, and death. He passes one pole into the uterus and places the other over the abdomen. In cases where the tumor is low down and at the side, he punctures through the vaginal wall. This woman is too old for operation, and we should wait for the menopause, which may cure her. This may be apparently delayed by fungous endometritis. Curette the uterine canal and you can check the hemorrhages. Aside from cases of strangulation of intestines from long pedicle of fibroid, and sudden death, there are two factors which produce trouble : first, hemorrhage; and second, pressure. Death is very seldom caused directly by either. The worst cases let alone do not cause eight per cent of deaths, or Keith's mortality. The President thought the argument of Dr. Fry against the operation, because of the near approach of the menopause, faulty ; the patient might menstruate for nine or twenty years longer. He does not recommend hysterectomy for all cases of fibroids, but for such as cannot be cured otherwise. Oophorec- tomy is a great boon in these other cases. He has performed six oophorectomies in casesof fibroids, with success in all. Hysterec- tomy is suitable in cases where the woman's sufferings make her rather wish to die than live. Has performed five hysterectomies, with three deaths. Bantock's operation is very successful, but he has not succeeded in having no mortality. The operation requires time, patience, skill, and great resources. Dr. W. W. Johnston.-The question to decide is, whether mor- tality is greater in those cases let alone or in those subjected to operation. What is our experience ? Of a large number of fibroids we know of only one death ; all have seen deaths from hysterectomy. Dr. Fry's argument is a good one. The mental attitude of a patient should be considered in deciding about ope- ration. He cited the case of a lady with tubal disease who went to New York and consulted a prominent physician, who advised salpingectomy; a second, equally prominent physician, advised against operation; while a third agreed with the first. She declined operation, though she had at first decided to have it performed. Dr. Prentiss, in closing, said he was glad of the extended dis- cussion his paper had produced, but was disappointed with the opinions about operating. He thought the question not entirely decided. He thought oophorectomy but not hysterectomy should be performed in this case, in face of the great mortality attending the latter. He could not agree with Dr. Fry as to the opinions he had advanced about electricity. The positive pole checks hemorrhage and relieves pain; the negative causes pain. The positive produces contractions and adhesions of the electrode to the endometrium, requiring the reversal of the current to release it.