largely of the means calculated to relieve such symptoms as endanger
the life of the patient or materially affect her general health. When
these are unavailing resort is had to measures calculated to get rid of
the tumor. Some remedies necessary to the relief of symptoms act as
very powerful curative agents; hence, while it is convenient to speak
of the treatment of symptoms under one division of the subject, and the
methods employed for radical cure under another, we cannot, in fact,
completely separate these two branches.
Hemorrhage is by far the most important of the symptoms connected with
these growths, because it is at the same time the most frequent and
hazardous. It is also the symptom that leads to most suffering in
consequence of depriving important organs of the blood necessary to
support them in their functions. Every reasonable means should be made
use of, not only to prevent fatal losses, but also to prevent moderate
hemorrhage. In the outset, therefore, I would insist upon watching with
great vigilance to prevent any unusual loss of blood. It is not
advisable to temporize by adopting the milder and less efficient
measures as being sufficient for cases not likely to prove fatal, but
we should treat all hemorrhages arising from this cause with
promptitude and energy. Fortunately, in many cases we can anticipate
the attacks of hemorrhage, because we know when they will occur, and we
are generally able to judge of their probable severity. To discharge
our duty in this respect effectually, our patient should be properly
provided with remedies and fully instructed how to use them. She should
be made to understand that unusual hemorrhage at the menstrual period
may be checked without endangering her general health. Among the
remedies are--dorsal recumbency with the hips elevated, cold to the
hypogastric region and cold to the dorsal spine and sacrum, ergot, and
some form of tampon. The best fluid extract of ergot in drachm doses,
if the stomach will bear it, is probably the most efficacious, but the
fresh drug in the form of infusion is also very efficient. Full doses
should be given every half hour when there is much loss, until some
effect is produced upon the hemorrhage, and then continued every four
hours as long as necessary. Compressed sponges saturated with the
solution of sulphate of alum make the best tampons for the patient to
make use of. These may be made and kept in readiness, so that they can
be introduced as soon as they are found necessary. The patient or nurse
can make them by taking a fine sponge, large enough to fill the vagina,
passing a piece of string through the centre to aid in its removal, and
then, after dipping it in the solution, winding it with twine from one
end to the other, compressing it into as small {258} a space as
possible. The twine should so compress the sponge as to make it assume
an elongated form. It should then be laid aside and permitted to dry.
Several sponges should be thus prepared. When necessary the twine may
be unwound and the sponge introduced. Its size when in the dry
condition will allow of an easy passage into the vagina, where the
moisture will cause it to expand, and fill up and seal the vagina so as
to absolutely check the discharges. If the attending physician is
present, he may tampon the vagina with pellets of cotton secured by
thread and moistened with a solution of alum. The inconvenience
experienced from this plug will be more than counterbalanced by the
saving of blood. This form of tampon has the additional advantage of
being antiseptic. I have allowed it to remain for three days, and upon
removing it satisfied myself that there was no decomposition of the
blood or the vaginal secretions. When the tampon is removed it will not
be found difficult to wash out all the granular clots caused by its
presence. It may be repeated as often as necessary, but usually, if
allowed to remain forty-eight hours, the hemorrhage will not return. It
may be said that for small losses this is unnecessary, but it is
convenient and harmless, and will answer the purpose. In dangerous
cases no one will question the propriety of its employment.
Another very important means of arresting hemorrhage which can be used
by the physician when necessary is the introduction of a compressed
sponge into the cervix uteri. This will temporarily act as a tampon and
stimulate the uterine fibres to contraction. The free incision of the
cervix, as directed by I. Baker Brown, may be tried between the times
of the paroxysms of hemorrhage.
The pressure of the tumor upon the pelvic viscera is another
inconvenience which calls for attention. This takes place usually at a
time when the tumor has acquired a size sufficient to fill the pelvic
cavity. Consequently, the elevation of the tumor above the pelvis is
the remedy. This may be done sometimes by placing the patient in the
knee-elbow position and pressing the growth upward. The powerful
influence of atmospheric pressure called to our aid by the position and
opening of the vagina is a very material auxiliary in the process of
elevation. If this is not sufficient, we may pass the fingers into the
rectum and elevate the tumor. I once succeeded in this operation by
using an ivory-headed cane in the rectum when the fingers failed to
reach high enough. If we cannot elevate the tumor by any of these
means, we may introduce into the vagina or rectum a gum-elastic bag,
and by means of a powerful syringe fill it with water to as great
distension as the patient will bear, permit it to remain, and thus do
the work more gradually.
Dysmenorrhoea is another symptom of fibrous tumors, and sometimes a
very distressing one. It depends, no doubt, on the imprisonment of
blood in the uterine cavity in consequence of the tortuosity of the
canal causing the closure of some part of it. The remedy consists in
dilating these narrow places. I know of nothing so well calculated to
effect this object as the slippery-elm tent. One or more of these
tents, long enough to reach the fundus uteri and of sufficient size,
moistened so as to render them very flexible, may be passed up through
the tortuous places with great facility. If introduced as soon as the
symptom begins to manifest itself, and allowed to remain an hour or
two, the relief will be pretty {259} certain. If used once a day for
four or five days before the attack, and three or four hours at a time,
dysmenorrhoea may be generally avoided.
Curative Treatment.--When we broach the question of the permanent cure
of these affections, we find that great difference of opinion exists
among the members of the profession as to the value of medicines. One
party, perhaps a majority of the profession, believe that no medicine
has any direct effect upon them, and these ignore any means of
permanent relief but surgical. There is, however, a respectable number
of medical men who place great reliance upon the administration of
certain medicines, and, if I am not greatly mistaken, recent
observation has added greatly to their number. They do not, however,
wholly agree as to the therapeutic processes that should be instituted,
and consequently do not employ the same kind of medicines. Some
gentlemen have more confidence in what I will term the sorbefacient
medicines and processes of treatment. They endeavor to institute
measures that will cause the absorbents to attack and remove the
neoplasm in the same way that tumefactions caused by effusions are
removed. This they do by friction, pressure, and the administration of
the old-fashioned sorbefacient medicines. The most popular among these
are the iodides, chlorides, and bromides of mercury, potassium, sodium,
calcium, and ammonium. Reports may be found in books and periodical
medical literature of cures by several if not all of these articles and
their combinations. The late W. L. Atlee, whose experience was very
extensive, had great confidence in the action of hydrochlorate of
ammonia. He administered it internally, applied it externally, and used
it as vaginal injections. The iodide of potassium has long enjoyed a
great reputation in causing the absorption of these and other forms of
tumors. There is no professional fairness in assuming that the faith in
these remedies derived from the observation of their effects or the
promulgation of cures from the use of sorbefacient measures are
fallacious. Some of the men arrayed in favor of the opinion that cures
may be effected by a patient and long-continued administration of some
one of the articles I have mentioned stand high as men of honesty,
accuracy of observation, and faithfulness in their records; and
therefore I give full confidence to their statements. Yet I must also
say that I have not witnessed the good results which I unhesitatingly
believe others have seen from the sorbefacient treatment alone.
Others who expect much from medicinal treatment look to that class of
medicines which cause contraction of the unstriped muscular fibres as
the most promising. With these medicines they expect to diminish the
supply of blood to the tumor by causing contraction of the arterioles
traversing their substance, and thus disturbing their nutrition to such
a degree as to stop their growth, lessen or destroy their vitality, and
so render them subject to the influence of the absorbents, whereby they
may be removed. Some of the more energetic of these medicines--as ergot
and belladonna, for instance--often affect these growths very promptly.
Ergot not only lessens the calibre of the small blood-vessels, and thus
causes a diminution of their nutrition and disappearance, but it causes
strong contractions in the muscular fibres of the uterine walls, which
lessen more decidedly their supply of blood. It sometimes squeezes and
chafes the tumor until it is disintegrated and rendered a foreign
substance. {260} The capsule finally becomes ruptured, and the tumor is
expelled either piecemeal or en masse.
When properly administered, ergot frequently greatly ameliorates some
of the troublesome and even dangerous symptoms of fibrous tumors of the
uterus--_e.g._ hemorrhage and copious leucorrhoea; it often arrests
their growth; in many instances it causes the absorption of the tumor,
occasionally without giving the patient any inconvenience: at other
times the removal of the tumor by absorption is attended by painful
contractions and tenderness of the uterus; by inducing uterine
contraction it causes the expulsion of the polypoid variety of the
submucous tumor; in the same way it causes the disruption and discharge
of the intramural tumor. There are many cases on record to substantiate
every one of these propositions.
From what I consider well-authenticated sources, including the cases
under my own observation and in the practice of my friends and
neighbors, I have collected 136 cases of fibrous tumors treated by
ergot. Of these, 25 cases were cured without giving the patients any
inconvenience from painful contractions. In 46 cases the tumors were
diminished in size and the hemorrhage was cured. In 27 others the
hemorrhagic symptom was relieved, while the size of the tumor was not
affected. In 8 other instances the tumors were broken to pieces and
expelled piecemeal.
For examples of cases in which the first conditions obtained, I would
refer to those cured by Hildebrandt; of the other examples, 4 were
reported to me by the late J. P. White of Buffalo, N. Y., 1 each by the
late Hodder of Canada and Jukes, and 11 that occurred among my
immediate acquaintance and in my own practice.
Among those in which the hemorrhage was cured and a diminution of the
tumor took place, 11 occurred to Hildebrandt, 2 to Chrobak, 5 to White
of Buffalo, and the remainder to gentlemen upon whose veracity I have
implicit reliance. The most remarkable case of which I have any
knowledge was reported to me by the late G. C. Goodrich of Minneapolis,
in which absorption of a large tumor took place under the
administration of ergot and belladonna. I subjoin his description: "The
treatment was commenced in 1870, and continued two years. The uterus
filled the whole space between the ilia, and measured in the transverse
diameter twelve inches and in the vertical nineteen inches--extended up
under the ensiform cartilage and close up to the margin of the
cartilages of the ribs. The treatment was followed by cramps in the
uterus, which produced a wild enthusiasm in the mind of the patient and
inspired her with strong hopes of recovery. Without consulting me she
doubled the dose of medicine, which was administered internally, and as
a consequence she was attacked with very strong uterine contractions
and symptoms of metritis. This caused me to abandon treatment for about
one month, and had it not been for the urgent determination of the
patient I would not have resumed it. She insisted that as this was the
first medicine which had ever affected the enlarged organ, she believed
it would cure her, and promised to obey my directions if I would
proceed. She so promptly and rapidly improved that I doubted if it were
not a coincidence with, rather than a consequence of, the treatment.
Prompted by this doubt, I abandoned the use of the ergot and belladonna
and continued alterative {261} treatment. The patient soon assured me
that she no longer felt the griping pains caused by the remedy, and
that the tumor was softer and larger than when she took the ergot
prescription. The ergot and belladonna were again resumed, and in four
months she was able to make a trip to Boston alone. While absent she
continued to take the medicine. From this time she continued rapidly
convalescing, and is now in the enjoyment of fine health."[1]
[Footnote 1: The author's address before the American Medical
Association at its meeting in 1875.]
I subjoin two cases in which the tumors were expelled piecemeal under
the administration of ergot, which came under my own observation:
A woman of Sterling, Illinois, called on me December 13, 1875. She was
thirty-five years old, married, and had never been pregnant. On the
first of the preceding June she noticed a circumscribed hard lump two
inches below and to the left of the umbilicus. She was the subject of
serious uterine and sympathetic symptoms, for which she had at
different times had treatment. She had profuse menorrhagia,
leucorrhoea, and great sense of weight in the pelvis. Upon examination
I found a hard, round, movable tumor extending up to within two inches
of the umbilicus, filling up the whole of the right iliac, the
hypogastric, lower half of the umbilical, and more than half of the
left iliac regions. The contour of the tumor was somewhat uneven,
though not distinctly nodular. The cervix was long, pointed, and thrown
backward and to the left. The sound entered the small uterine mouth and
passed upward, backward, and to the left five and a half inches. The
diagnosis was a fibrous tumor of the right anterior wall of the uterus.
I prescribed thirty drops of Squibb's fluid extract of ergot, to be
taken three times a day. She went home, but did not commence taking the
medicine until the 20th of December. On the 26th of December J. B.
Crandall was called to see her, and describes her condition as follows:
"The patient was in a state of great nervous prostration and worn out
by severe pain and loss of sleep. The pains commenced soon after taking
the second dose of ergot, and were excruciatingly severe for about
three hours, after which they continued less severely for two days and
nights. She had more or less hemorrhage from the uterus after taking
the ergot. Her pulse was feeble, 110 to 120 to the minute. The skin was
hot and dry, and she complained of great pain and tenderness over the
uterus and lower bowels. The feet were drawn up, and the face wore a
pinched and peculiar expression." Under these circumstances the doctor
administered anodynes, tonics, and nourishment, to the great relief of
the patient. On January 11, 1876, the patient began to pass from the
vagina small masses of fibrous substance, from the size of a chestnut
to that of an English walnut. The substances thus discharged were firm
and gray in color, and were exceedingly fetid. This discharge continued
up to the 21st of January, when the uterus was very much diminished in
size, the tenderness had subsided, and the patient appeared
comparatively comfortable. Up to that time she had taken but three
doses of ergot--on the 20th of the preceding month--and the doctor
ordered it to be resumed again. This time the ergot produced no pain,
and after three or four days was discontinued. From the 21st of January
there were no more pieces discharged, but up to February 1st a
yellowish, thin, offensive fluid passed from the vagina in considerable
{262} quantities. On the first day of February the ergot was again
ordered and continued two weeks, when, as no results ensued, it was
finally dropped. Crandall states that on the 14th of February the
uterus was reduced to its normal size, and on the 26th the patient was
up and about her work, completely cured. He remarked, in this
connection, that the first three doses of ergot taken by the patient
was the cause of her recovery.[2]
[Footnote 2: This case is published in the August (1875) number of the
_Chicago Medical Journal and Examiner_, as reported by Crandall.]
Mrs. L. D. M., aged forty-seven years, had a fibroid tumor in the
anterior wall of the uterus, which, with the enlarged uterus, arose to
within two inches of the umbilicus. She commenced taking thirty drops
of the fluid extract of ergot on the 22d of September, 1876, and was to
increase gradually the dose with the object in view of causing the
disruption and expulsion of the tumor. The ergot at first produced no
perceptible effect until she had taken it ten days, when she began to
experience the pain of contraction. The pain became so severe and
continuous that it was necessary to omit it for two or three days at a
time. The patient was intelligent and understood the object and mode of
action of the ergot, and when the pain entirely subsided she
courageously resumed it in the smaller doses, and increased again until
the pains became intolerable. On the 13th of January, 1877, small
pieces of the tumor showed themselves in the vaginal discharges, and by
the 26th of the same month the whole of it had been discharged
piecemeal. She wrote me on the 30th of January, saying, "I think I
wrote one week ago to-day. At that time the tumor was passing. It
continued to pass until the 26th, when, I think, the last was expelled.
To-day I send you by express a portion of the last that came. I think
the whole of it, including the portion I send you, would have weighed
one and a half pounds. I do not believe a quart can would hold it if
the whole had been preserved. It commenced to come on Saturday, and
from Saturday evening to Sunday morning there was a pint or more. After
that the stench was so disagreeable that we could not cleanse it;
consequently we threw it away. Wednesday and Thursday it seemed to be
in one continuous mass. I cannot better describe it than to say that it
came like sausage-meat from a stuffer. I would cut off about four
inches a day--that is, on Wednesday and Thursday. On Friday morning the
last of it came away." During and for some days after the expulsion she
suffered slight symptoms of septicæmia, but recovered from them, and in
the course of a month afterward she visited me, when I found the uterus
measured two inches and a half in depth. She then had some leucorrhoea,
but was fast regaining her health. She is now perfectly well, and has
passed in safety the menopause.[3]
[Footnote 3: This case--the abstract of which I have here given--was in
the May (1877) number of the _Archives of Clinical Surgery, N. Y._]
I have known 9 cases in which the tumors were expelled piecemeal by
ergot, with but 1 death. The death occurred in a patient who rode one
hundred and fifty miles on a railroad train to see me with pieces of
the tumor hanging from the vagina, which she would not allow her
physician to remove. When she arrived I passed my fingers up into the
contracted capsule and scooped out the remaining portion of the tumor.
She was so exhausted, however, by the journey and the sepsis that she
died three {263} days afterward. I cannot help believing that if she
had remained at home and submitted to the treatment of her physician,
her life need not have been sacrificed.
The influence of ergot over the uterus has been a familiar fact to the
profession for a long time. It is not long, however, since we were
aware of its effects upon the muscular fibres entering into the
formation of other organs. We now know that this medicine acts upon the
unstriped muscular fibre wherever found, whether in the viscera or in
the vessels of the body.
The fibres of the uterine walls, and the arteries supplying them with
blood, both belong to this class; this fact in the formation of the
uterus renders it particularly susceptible to the action of ergot. The
drug acts upon the uterus[4] in a threefold manner, and causes a
diminished flow of blood to the morbid as well as healthy tissues in
the uterine structure.
[Footnote 4: From the author's address before the American Medical
Association, 1875.]
First: the calibre of the arterial tubes is diminished by the
contraction of the muscular fibres which enter into their composition.
Second: the arterioles are diminished in size by compression from the
contraction of the uterine muscular fibres which surround them. Third:
these vessels are distorted and drawn in diverse directions by both the
contraction and compression, and hence are rendered less fit for
sanguineous conduits.
Another consideration of prime importance is that, under the influence
of these medicines, the nutrition of fibrous tumors is interfered with,
not only from diminution of blood in their tissues, but also from
compression of their substance by the proper fibres of the uterus, and
are therefore made more susceptible in the process of disintegration
and absorption.
The great influence exerted by ergot over the circulation of the uterus
is rendered more efficacious in the removal of fibrous tumors of that
organ, because of the peculiar organization of the growths. It is now
pretty well understood that this neoplasm is not very generously
supplied with arterial blood, and that its supply is derived from
numerous minute vessels instead of one or two of large calibre. From
these circumstances it results that its vitality is very low, its
circulation easily disturbed, and consequently its nutrition impaired.
I think we are justified from observation in assuming that the action
of ergot may be graded from an almost imperceptible to a very intense
degree. Probably the first degree affects the vascular supply; the
second, in addition to this, causes so much contraction as to merely
render the fibres tense without causing pain; and the third prompts the
uterine fibres to vigorous and painful contraction.
This inference is plainly deducible, I think, from the several modes by
which tumors are made to disappear under its action, as well as from
direct observation of the uterine fibres.
I will now venture to call attention especially to the manner of
expulsion of the polypoid and submucous intramural varieties. It will
be seen that when the uterus contracts all the fibres unite in pressing
the polypus through the cervical canal, which is usually already
shortened, and rendered dilatable in consequence of its increased
vascularity. The cervical canal dilates, and after more or less painful
efforts the polypus is expelled entire, covered by the mucous membrane.
This membrane is often in a {264} state of gangrene, but so far as I
have observed these cases the tumor is not broken to pieces.