BY SEPTIMUS SUNDERLAND, M. D., M. R. C. P., Obstetric Physician at the French Hospital, Lon

don: Physician Royal Waterloo Hospital for Children and Women, London; Chief Physician Royal Maternity Charity of London; Corresponding Fellow of the American Climatological Association, etc., etc. London, England.

Fibroid tumor or myoma of the uterus is one of the most important causes of uterine hemorrhage, oftentimes most difficult to treat, and certainly one which, in the present day, requires the most careful consideration as to treatment, owing to the great advances which have been made in the surgical art during the past few

years.

Uterine myomata are extremely common. It is probable that twenty per cent of all women over thirty-five years of age have fibroid uterine growths, although in many instances they do not cause trouble. The actual mortality is unknown.

Mr. Roger Williams considers that the deaths due to fibroids, excluding operation cases, amount to one in each two thousand cases, and that the number of those who suffer severely as the result of such growths is small, probably one in five hundred. They are most common between the ages of thirty and fifty. Bearing in mind the proportion of married to unmarried women, it is found that a large proportion of women suffering with fibroid tumors are single, and amongst the married the tumors are more frequent in sterile women. It appears that maternity lessens the chances of the occurrence of fibroids.

During pregnancy they increase in size, become softer and more vascular, and shrink again during involution.

The menopause is often delayed for several years, during which time the tumors may continue to grow, and the incidental hemorrhage and other troubles may increase rapidly. If the patient pass satisfactorily through the protracted or delayed menopause, the tumors generally decrease in size. Fifty-two to fifty-four may be roughly stated as the age at which the menopause occurs in such satisfactory cases. Bleeding from fibroids is sometimes alarming, but seldom fatal; sudden flooding is more common with malignant disease.

Menorrhagia, possibly with dysmenorrhea, is generally the first symptom of fibroids. (Menorrhagia is sometimes present with ovarian tumors, and it is not always easy to distinguish a soft edematous fibroid from an ovarian tumor.) After a time the bleeding may persist in the intervals between the catamenia. Sometimes irregular hemorrhages occur, or the bleeding will persist for months, and then appear only at the menstrual periods for a time.

The amount of loss varies to an extraordinary degree, without any direct ratio to the size of the growth. Sometimes one sees a small fibroid uterus, causing almost continuous bleeding, whilst a large growth

will, after gradually increasing in size over a period of years, still cause a menorrhagia of perhaps double or treble the normal amount of menstrual flow, and the patient with care and suitable treatment may, other complications being absent, carry her tumor with comparative comfort to the end of her life.

Mr. Roger Williams, after exhaustive research, definitely asserts, "Myomata have no special proclivity to malignant disease," and that "they are less prone to originate such changes than are the morphological elements of the uterus itself." This is important, for although occasionally malignant disease may occur in a myomatous uterus, there can be no argument to hurry on the operation of extirpation, through fear of the supervention of

cancer.

Treatment. When menorrhagia or metrorrhagia is a marked symptom of uterine myomata, the choice of treatment of the hemorrhage lies with the following, or a combination of two or more:

1. General and dietetic. 2. Rest and postural. 3. Local. 4. Drug. 5. Climatic. 6. Minor operative. 7. Major operative.

1. General and Dietetic.-Everything should be done to keep the patient in the best possible condition for bearing the strain of the hemorrhage, one great point being to attempt to relieve the attendant anemia. I shall refer to that when speaking of drug treatment. Warm clothing should be advised, and in many cases, the use of an abdominal belt will be found beneficial. It is uncertain to what extent diet may be serviceable, but the too free use of alcohol and red wines is to be deprecated, as also a dietary consisting largely of meat. During the catamenial flow, fluids should be taken in restricted quantities.

2. Rest and Postural.-Exercise should be abstained from, if possible, for two days preceding the usual onset of the catamenia, and the patient should rest in bed or on a couch during the first two or three days of the flow, or longer, if possible. Between the periods, exercise likely to cause increased flow of blood to the uterus should not be encouraged, such as the use of the sewing machine. With regard to bicycling, I must say I have patients with bleeding fibroids who insist on bicycling,

and whose condition does not appear to be aggravated by it. Possibly the resulting general improvement in the circulation, both venous and arterial, may account for this.

I am convinced, from experience, of the utility of insisting that blocks of wood four to six inches high should always be kept under the lower legs of the bed or couch. If retroflexion or retroversion exist, the patient should go to sleep lying on the abdomen, or lie as much as possible in a similar position when awake.

In cases where the tumor descends into the true pelvis, efforts may be made to press it up, and a suitable pessary inserted. It is remarkable what relief is sometimes afforded by posture and pessaries; inconvenience with the bladder and rectum are frequently corrected by these agents.

3. Local.-Pessaries, preferably cellu loid or metal, are useful when flexions are present, especially when pelvic discomfort is experienced.

Hot Douches at a temperature of 115° to 120° F. may be used after the first day of the flow and continued two, three or four times daily till the period ceases. In some cases they seem to do good; in others only a temporary effect is produced.

For their satisfactory application, the patient should lie on her back. At least a gallon of water must be used, and care should be taken that the nozzle of the vaginal tube is not passed too far. It is a common occurrence for women to give themselves unnecessary pain by impinging on the uterus with the vaginal tube.

Plugs, either plain glycerin or glycerin with fifteen per cent of ichthyol, may be used once daily for a week preceding the flow, with the hope of withdrawing serum and lessening congestion of the uterus.

Tamponing the vagina through a speculum is useful in severe cases of menor. rhagia, and may be done once daily dur ing the flow with clean cyanide gauze, well packed around the cervix, and in the vagina. An antiseptic douche should be given before applying a fresh tampon.

Intra-uterine applications would be lim ited to a very few cases of small fibroids in which bleeding has not improved under other treatment; a solution of chromic

acid (one drachm to the ounce) could be applied, but I do not recommend this treatment as a routine procedure.

Dilating, tenting, or plugging the cerrical canal.-In the occasional very severe and dangerous hemorrhages from fibroids, the cervical canal should be plugged with iodoform gauze, or a tent inserted, and the vagina tamponed.

4. Drug. The effect of treatment by drugs is variable. In some cases very little effect appears to be produced, but in many instances the bleeding can be kept within bounds, and marked diminution in the menorrhagia is noticed. The oldfashioned ergot really appears to hold the first place on the list of drugs. The administration of drugs with the idea of absorbing the growths is probably useless, but a long course of small doses of ergot twice or thrice daily, either alone or combined with nux vomica or strychnia, given continuously for months, will, in many cases, check the bleeding and control the growth. The difficulty is to ensure that the patient takes the medicine, so that it is perhaps more advisable to administer the extract of ergot in pill form, one grain of ergotin twice or thrice daily; when the catamenia appear, the dose may be doubled or trebled for a few days. If patients will not take medicine, a hypodermic injection of ergot may be given in the buttock, or over the abdomen, three drops once daily of the British Pharmacopeial solution.

The injection should be specially prepared for the case, and the skin and syringe carefully sterilized before each injection.

After a few weeks, if no uterine colic be produced, the daily injection may be increased gradually up to six drops. Sometimes the hypodermic injections cause uterine pain and irritation.

I have never seen, or at least I have never recognized, any injurious effects from the continued use of ergot extending over a period of several months, in women taking it from various causes. Occasionally, with large doses, uterine pain may be complained of, but the addition of two or three drops of laudanum to each dose will usually check it. I have often given drachm doses of ergot for months at a time to patients with subinvolution or fibroids; occasionally they complain of

headache and giddiness, and some women say they get headache after small doses. When heart disease is present, ergot should be given with caution, and it may be entirely contra-indicated in some cardiac cases.

The ammoniated solution may also be advised.

Time back I prescribed a standardized preparation of ergot; called ergole, but could not convince myself that its action was any better than ordinary liquid extract, if the latter be obtained from a good chemist.

In sudden severe floodings, a hypodermic injection of citrate of ergotinin (onefiftieth of a grain) could be used, and another one-fiftieth could be injected in a bad case. The amount of the dose of ergot when administered continuously for a time, should be regulated by the amount of bleeding.

In some cases of menorrhagia from fibroids it will suffice to give the ergot during the menstrual flow only; say a drachm of liquid extract, or three to five grains of ergotin, three times daily till the flow ceases.

Liquid extract of hydrastis canadensis in doses of twenty minims will be found useful in some cases given continuously for a long period. In cases where ergot causes pain, a combination of hydrastis, viburnum prunifolium and Jamaica dog: wood, the latter a sedative and anodyne, will be found useful.

Stypticin (dose one-fourth to one-half grain), a coined name for hydrochloride of cotarnin, which is a product of the opium alkaloid narcotin, has acquired some reputation during the past few years as a uterine hemostatic, and may be tried if ergot and other drugs fail to lessen the bleeding. A very good combination is stypticin, ergotin, hydrastine hydrochloride, and cannabin tannate, in the form of pill or tablet; one, two or three may be given three times daily. The cannabin tannate has also a reputation for menorrhagia. These would be specially indicated if ergot alone should cause pain and should not seem to check the flow.

Calcium chloride, acting by its power of favoring coagulation of the blood, is recommended by some writers. It should be given continuously between the periods.

The dose is from twenty to forty grains. Dr. John Campbell, of Belfast, recommends it in combination with hydrastis.

The bromides will be found useful in neurotic and excitable patients, or when there is ovarian irritability, and may be combined with ergot or other drugs. Saline purgatives are useful, if constipation be present.

One important thing to remember with regard to drug treatment is that in cases where one is endeavoring to control the growth, medicines must be given for months at a time. When endeavoring only to check the bleeding temporarily, larger doses must be given.

Iodipin (iodine in sesame oil) has been used subcutaneously during the past eighteen months by my friend Dr. John Shaw-Mackenzie, who claims success in the treatment of some of his cases. He also recommends the intra-muscular injection of benzoate of mercury.

The treatment of the anemic condition produced by severe menorrhagia of fibroids is often difficult and the doctor is in despair; no sooner is the patient's blood getting into a more healthy condition than on comes the menorrhagia and his patient's strength again is sapped.

With regard to the use of iron during the interval, I certainly think it may be tried, especially if ergot be administered at the same time, although in some cases I have felt sure it did increase the menstrual flow, and was obliged to discontinue its use. I have a fancy for the peptonates of iron, and the Fer Robin, a French preparation, I consider excellent.

In some cases then, in preference to iron, the patient should take raw meat juice or some of the popular preparations of blood now sold by chemists. I can strongly advise cod-liver oil, or some of the extracts of cod-liver oil now to be procured.

5. Climatic and Spa Treatment.-In the London Lancet, of October 15, 1898, I published a paper recording the beneficial effects I had noticed on uterine hemorrhage in patients who had sojourned for a time at high altitudes. I can, therefore, confidently recommend prolonged residence at a high dry bracing place where the soil is dry and the air is as free from moisture as possible.

In order to improve the anemic condition of patients, advantage should be taken of fresh air and sunshine, and they should sit or lie out in the open air as long as possible in suitable weather.

In England the bromo-iodine waters o Woodhall Spa, in Lincolnshire, have a certain reputation for the treatment of myomata, and a systematic course of douching and baths, combined with the change of air, is sometimes of benefit in controling the growths and the hemorrhage.

The similar waters of Kreuznach, in Rhenish Prussia, are not so strong. Many women with fibroids go there for treatment, but the climate is somewhat relaxing, as Kreuznach lies in a valley. Recently a new spa has been brought to notice at Salzomaggiore, in Italy, with similar waters.

6. Minor Operative.-If a polypus growing from the cervical canal present at the external os, it should be removed with a snare or cut away with scissors, or a fringe of polypi around the cervix may be best treated by removing a portion of the cervix. When the cervix is found dilated, and intra-uterine polypus is suspected, the cervix must be further dilated, and the polypus, if present, removed.

In the small fibroid uteri, which are causing hemorrhage sufficient to injure the health of the patient, I always advise a preliminary dilatation of the cervix and exploration of the uterus with the finger, and curettage of the uterus. In some of such cases an ingrowth of myomatous tissue will be found in the cavity, possibly polypoid in form, in which latter case it can be removed by a snare. If the ingrowth is sessile it should be left without attempting removal, though it is possible in certain cases to shell out such a growth, but the risk of perforating the uterus does not, in my opinion, justify such a meas

ure.

Assuming a polypoid growth be foun 1 and be removed, the patient has a good chance of cure of the hemorrhage, though, of course, there may be other fibroids present which may after a time cause renewed bleeding, or another polypus may form.

If the endometrium which is scraped away be found very thickened, the prognosis as to diminution of the bleeding is

in my experience very good. In such small fibroid uteri I would never advise hysterectomy without a previous exploration or curetting. I know it is the fashion nowadays amongst some surgeons of undoubted skill, and whose mortality in the operation is very low, to remove many small bleeding fibroid uteri, but I most strongly urge that in such cases as I have just described, the patients should not be exposed to the rísk of a major operation without a previous exploration and curetting, the risk of the latter being only slight. In bygone years, when removal of the ovaries for bleeding fibroids was such a common operation, one saw from time to time that the hemorrhage from the uterus continued after the oöphorectomy, and that when an exploration of the uterine cavity was made, a polypoid ingrowth was found.

I am convinced that many of these small bleeding fibroid uteri which get removed by enthusiastic surgeons, would be relieved by the curettage, even if no polypoid growth were found. Especially if there be uterine pain and some dilatation of the cervix, should the presence of a fibroid polypus be suspected, the pain being caused by the efforts of the uterus to expel the growth.

Hemorrhage may occasionally occur from a large fibroid uterus which has previously given little trouble, and may lead the surgeon, not suspecting pregnancy, to extirpate the womb. I have seen the uterus in such a case removed, containing a three months' fetus.

If pregnancy occurs in a large myomatous uterus, and the patient commences to abort, it may be necessary to complete the abortion; this is not altogether an easy matter when the uterine cavity is of large size.

7. Major Operative.-(1) Oöphorectomy, In a certain number of cases, removal of the ovaries may be advised, and I would limit this operation to those cases of small uterine myomata which are bleeding profusely (and may be also causing pain), a few years before the average time for the expectation of the menopause, or to similar cases which have reached or passed the average time, assuming always that the bleeding can not be controlled by other measures, and that other symptoms

do not suggest the advisability of hysterectomy. An artificial menopause will then in all probability be produced if the whole of both ovaries be satisfactorily removed.

(2) Hysterectomy. It is not often in myomata that the symptom of hemorrhage per se will call for extirpation of the womb. It is usually when considered in conjunction with other symptoms and troubles that it turns the scale in favor of a radical operation. It may be as well to mention these other troubles which, of themselves make operation necessary in some cases of fibroids.

They are: (a) Pressure symptoms causing great pain, dysuria, retention of urine, and intestinal obstruction.

(b) Tumors which have become septic, or are inflamed by torsion of the pedicle or other cause. This, of course, includes sloughing or gangrenous fibroids. Cystic tumors become inflamed or twisted most readily, and, therefore, more frequently require removal.

(c) Enormous tumors causing marked deterioration of health.

(d) Certain tumors in pregnant

women.

In cases where the hemorrhage is of an alarming character on account of severe floodings occurring occasionally or frequently, or when menorrhagia is severe, causing a debilitated state of the whole system, or if hemorrhage continue dribbling without scarcely ever ceasing, also causing prostration and inability to carry on the ordinary duties of life, the symptom of hemorrhage alone, apart from other causes, may justifiably lead the physician to recommend extirpation of the uterus, either per vaginam or by the abdomen; the choice of the vaginal or abdominal operation would be decided from the size of the tumor, and other circumstances. One or both ovaries should be left, if possible, if the patient be under the age of forty.

In some cases the responsibility of deciding whether a patient shall undergo the operation of hysterectomy will tax the thinking powers of the conscientious and earnest practitioner, who, prompted by the desire to do his duty to his patient, and to guard her from unnecessary risk, as well as to maintain his own reputation