The Methods and Limitation 
of Treatment for Uterine 
Fibroids. 
BY 
PAUL F. MUNDE", M.D., 
NEW YORK. 
REPRINT FROM VOL. XIV. 
(&t)necofoflic<tf traits actions. 
1889. THE 
METHODS AND LIMITATION 
OF 
TREATMENT FOR UTERINE FIBROIDS. 
BY 
PAUL F. MUNDE, M.D., 
PROFESSOR OF OYNECOLOQY AT THE NEW YORK POLYCLINIC, AND AT DARTMOUTH COLLEGE; 
GYNECOLOGIST TO MT. SINAI HOSPITAL; CONSULTING GYNECOLOGIST 
TO ST. ELIZABETH HOSPITAL. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN GYNECOLOGICAL SOCIETY, 
YOL. XIY., 1889. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1889. THE METHODS AND LIMITATION OF TREAT- 
MENT FOR UTERINE FIBROIDS. 
By Paul F. Munde, M.D., 
New York. 
The recent impulse given to the subject of the conservative 
treatment of fibroids of the uterus, chiefly by means of the 
galvanic current, has raised in my mind the query whether 
the pathological importance and pernicious influence of these 
tumors really warrant so much enthusiasm and such extrava- 
gant praise as have been accorded to this new method by a 
large part of the profession. 
It is by no means my intention to detract either from the 
method or from the credit due its genial and persevering 
originator or his faithful disciples, but I cannot help think- 
ing that the relative value of the treatment has been exagger- 
ated and its indications extended beyond actual necessity. 
Being myself, to a certain extent, a believer in the value 
of galvanism as a substitute for the too ready use of the 
knife in fibroids, I am anxious to see this method relieved 
from the danger of suffering by the too urgent advocacy of its 
apostles, and to have it placed upon the secure and rational 
basis which it deserves. 
Aside from the conservative treatment of fibroid tumors by 
electricity, there has been a recent revival of bold operative 
measures, chiefly among the laparotomists of Germany, for 
the removal of these same growths. The reports of brilliant 
and proportionately dangerous operations of this kind may be 
said to be steadily on the increase in the journals of that 4 
TREATMENT FOR UTERINE FIBROIDS. 
country. Not content with removing the entire uterus with 
its fibroid additions by laparotomy, they have many times 
successfully opened the abdomen, split the peritoneal capsule 
of the tumor, enucleated the latter, and closed the wound by 
deep sutures. Furthermore, several operators have recently 
reported the removal of the myomatous uterus per vaginam— 
an operation which hitherto was supposed to be limited to 
malignant disease of that organ. I do not wish to criticise in 
an adverse sense these radical operations, since the names of 
the operators are, almost without exception, a sufficient guar- 
antee for the correctness of the indication. But I am afraid 
that their example may tend to increase and enlarge the 
operative proclivities of gynecologists less fitted to judge of 
the necessity for such dangerous operations and less qualified 
by experience to carry them out. 
My own observation leads me to believe that there exists 
among the profession at large more or less of a tendency to 
look upon all cases of fibroid of the uterus as requiring treat- 
ment of some kind or another, more or less active, more or 
less urgent. Within recent years I have been consulted a 
number of times by physicians in cases of fibroids which occa- 
sioned comparatively little discomfort to the patients, which 
were not visibly growing, and in which the future did not 
seem to offer any grave apprehensions, but for which the phy- 
sicians in charge seemed to think speedy operative relief called 
for. Thus, I was invited to visit and operate upon a patient 
in Vermont “for uterine fibroid,” and on my suggesting the 
advisability of bringing her to my office in order that I might 
see whether the operation was really called for, I heard nothing 
further of the case until, quite accidentally, I learned some 
time afterward that she had been operated upon by a Boston 
surgeon with a fatal result. Her physician had urged imme- 
diate operation, I was told, and she had to suffer for his 
haste. Again, a physician from New Hampshire requested 
me to operate on a patient of his for a fibroid, stating quite 
incidentally that a complication existed in the shape of a PAUL F. MUNDE. 
5 
pelvic abscess opening into the rectum. Evidently his idea 
was that the fibroid was the salient feature of the case, 
whereas I took the ground that in all probability the pelvic 
abscess produced more distress and required relief much rather 
than the uterine tumor. I could cite numerous instances 
where patients have consulted me for perfectly innocuous and 
not rapidly growing fibroids of the uterus which did not even 
cause the common symptom of menorrhagia, chiefly because 
their fears had become excited by the injudicious utterances 
of their physician or friends—an apprehension which I was 
able to allay very speedily by the assurance that there was 
absolutely no reason for worry or anxiety about the growth. 
In the minds of very many ladies a tumor always means 
something that is likely or sure to kill. They do not under- 
stand the difference between fibroids of the uterus and tumors 
of the ovary, and I have usually found it necessary to explain 
wherein these growths differ as regards prognosis, rapidity of 
increase, and pernicious influence, before I could convince the 
patients that their tumor, being a fibroid, was comparatively 
harmless. 
In corroboration of these statements, I can do no better than 
refer to a passage found on page 527 of Thomas’s Text-book 
of Diseases of Women, edition of 1880, where, after speaking 
of the great frequency of uterine fibroids and their comparative 
trifling influence on the general health, he says: “Let the 
diagnostician who has discovered a uterine fibroid, and feels 
prompted to give a grave prognosis concerning it, bear these 
facts in mind, and he may be prevented from injuring his 
patient’s comfort and his own reputation by so doing.” 
One of the first points for us to consider, it seems to me, is: 
Are fibroid tumors of the uterus so very common as to form 
one of the prominent ailmeuts of the female sex ? This ques- 
tion must unqualifiedly be answered in the affirmative, as is 
easy to demonstrate by reference to statistics and the records 
of our hospital, dispensary, and private practices. It is true 
that statistics differ widely as to the frequency of these growths, 6 
TREATMENT FOR UTERINE FIBROIDS. 
Klob speakiug of 40 per cent, of all women over fifty years ; 
Bavle, 20 per cent.; and, on the other hand, Richard of only 
7 out of 800 post-mortems, and Pollock only 89 out of 583 
uterine cases. My own observation, which during the past 
three years covers 2974 cases of pelvic disease in the female, 
shows a record of 123 instances of fibroid of the uterus, or 
4.14 per cent. This number may seem very small, but it 
must be remembered that only such cases consulted me as 
suffered either inconvenience from the tumor or were apprised 
of its presence by its increasing size. Hence it is exceed- 
ingly likely that fibroids are very much more common, but 
fail to attract the notice of their possessors. Of these 123 
cases, but 62 required treatment of any kind whatsoever—in 
my estimation. The remaining 61—that is, about one-half— 
afforded their owners so little inconvenience or gave so little 
prospect of becoming troublesome, that not even a medical 
treatment was thought necessary. 
Before proceeding to discuss the forms of treatment employed 
for the 62 cases referred to, I wish to state that the necessity 
for and the nature of the treatment depend, to a very large 
extent, upon, first, the location of the tumor; and, secondly, 
upon the symptoms which it produces. 
Subperitoneal fibroid tumors seldom call for treatment for 
any other symptom than their rapid increase or the pressure 
produced by the growth upon the neighboring organs. Inter- 
stitial fibroids, on the other hand, manifest their presence both 
by their bulk and by the profuse menstrual flow which they 
induce, and this latter symptom in submucous tumors is the 
one which usually prompts the patient to seek relief. Tumors 
of the cervix uteri manifest themselves either by crowding 
down into the cavity of the pelvis, and the consequent inter- 
ference with coition, defecation, micturition, and parturition ; 
or else, if they are polypoid in nature, by the mucous or 
bloody discharge which they produce. According as the 
tumors are situated in one or the other of the above-mentioned 
locations, their symptoms differ, and the indications and nature PAUL F. MUNDE. 
7 
of the treatment vary. Thus, in subperitoneal fibroids the 
radical operations would be the removal of the diseased uterus 
by laparotomy or the checking of the growth of the tumor by 
the removal of the ovaries. In interstitial tumors, chiefly of 
the myomatous variety, laparotomy and enucleation of the 
growth, with preservation of the uterus ; also, when this is not 
feasible, oophorectomy; in the submucous variety, removal 
by splitting of the capsule and digital and instrumental enucle- 
ation per vias naturales. The persevering and judicious use 
of agents calculated to produce and maintain contractions of 
the uterus will aid in reudering these three varieties of tumors 
more accessible—the subperitoneal being pushed upward, the 
interstitial it may be upward, it may be downward, and the 
submucous always downward into the uterine cavity. The 
advisability, therefore, of a prolonged and persistent course of 
ergot, assisted by the faradic current, is obvious in those cases 
where it is desired either to render a subperitoneal or inter- 
stitial tumor less pernicious, or, on the other hand, to force 
an interstitial or submucous tumor nearer the normal uterine 
outlet, and the possibility of removal per vaginam. 
I have thus repeatedly brought tumors of the latter varieties 
within comparatively easy reacli by a few months of patience 
and oxytocic treatment. Repeated dilatation by tupelo tents, 
incision of the cervical canal, and, if necessary, splitting of the 
vaginal portion of the cervix, have materially aided in render- 
ing the growths accessible. I wish to state at this point that 
my, I am happy to say, limited but sufficient experience leads 
me to fear most decidedly any attempt to remove a sessile 
fibroid situated near the fundus uteri through the utero- 
vaginal canal. I know of no more difficult operation in gyne- 
cological surgery, and of none more likely to prove disastrous 
to the patient. I should vastly prefer to follow the lead of 
the German operators who remove such growths by lapar- 
otomy and enucleation, or myomectomy, as they call this 
operation. Having uow very briefly laid down'the principles 
for operative procedure in cases of fibroids, I will proceed to 8 
THE A TMENT FOR UTERINE FIBROIDS. 
specify the methods of treatment employed in the 62 cases 
mentioned in my table. 
Uterine Fibroids from October 1, 1886, to September 1, 1889, 
1 
S5 
Treatment. 
Summary. 
■tg s 
Oophor- 
ectomy. 
Curette. 
Enucle- 
ation. 
Torsion. 
Galvan- 
ism. 
Medica- 
tion. 
Treated. 
No treat- 
ment re- 
quired. 
Corpus Uteri. 
Subperitoneal 
64 
6 
2 
4 
12 
52 
Interstitial . . 
31 
1 
10 
2 
4 
5 
22 
9 
Submucous . . 
19 
10 
6 
3 
19 
Cervix Uteri. 
Interstitial . . 
2 
2 
2 
Polypi .... 
7 
7 
Total . . 
. 123 
6 
3 
20 
10 
7 
8 
8 
62 
61 
With 2 deaths, both after hysterectomy. 
123 fibroids among 2974 uterine cases, or 4.14 per cent. 
In only 8 cases do I find ergot mentioned as the sole method 
of treatment. Of these, 5 were interstitial and 3 submucous. 
This treatment would seem to have been effectual, for in 2 of 
the 31 interstitial and in 6 of the 19 submucous cases the 
tumor was subsequently enucleated per vnginam. Undoubtedly 
in the other cases the hemorrhage must have been arrested, as 
no further treatment was required. In 10 of the interstitial 
and 10 of the submucous the hemorrhage was controlled by 
means of the sharp curette, and in 4 subperitoneal and 4 inter- 
stitial tumors the galvanic current was employed. The 4 
interstitial tumors were treated by vaginal galvano-puncture; 
in 3 cases with the result of a complete absorption of the 
tumor after from one to five punctures respectively. In the 
4 subperitoneal tumors only intra-uterine galvanism was em- 
ployed (Apostoli’s method), and merely a general improve- 
ment as regards cessation of hemorrhage and diminution of PAUL F. MUNDE. 
9 
pain was achieved. From 12 to 36 sittings were given in 
these cases. Enucleation per vaginam was practised in 8 cases 
of corporeal tumors, 2 interstitial, 6 submucous, and 2 inter- 
stitial cervical. Torsion was practised in all the 7 cases of 
cervical polypi. 
Proceeding to the more dangerous operations, only in 3 in- 
stances was oophorectomy thought indicated—2 subperitoneal 
and 1 interstitial; the result in each instance being perfectly 
satisfactory, and a diminution of the tumor with complete ces- 
sation of bloody flow taking place. Laparo-hysterectomy was 
performed in 6 cases, all of the subperitoneal variety, with 2 
deaths, 1 from septic peritonitis and 1 from uraemia. In all 
cases the pedicle was treated by the extra-peritoneal method. 
In one instance the enucleation of a portion of the tumor was 
required, in order to form a serviceable pedicle. I have as 
yet had uo opportunity to test the operation of myomectomy, 
and I confess that I have not been able to reconcile myself 
quite to the justifiability of removing the whole uterus per 
vaginam for myoma. Still, in this latter respect, future 
observations may modify my judgment. 
Conclusions. 
1. On general principles the rule may be laid down that 
fibroid growths of the uterus situated near the fundus uteri 
and showing no tendency to downward development, if re- 
quiring active treatment, are best reached from the abdominal 
cavity. 
2. Tumors, on the other hand, situated near the internal os, 
and, either of their own accord or under the influence of 
oxytocic measures, showing an inclination to dilate that orifice 
and encroach upon the cervical canal, can almost always, after 
due preparation, be removed safely through the vagina. 
3. About one-half of all fibroid tumors which attract the 
attention of their possessors and come under the observation 
of the physician require no active treatment of any kind. 10 
TREATMENT FOR UTERINE FIBROIDS. 
4. Only interstitial and rapidly growing subperitoneal 
tumors call for or are benefited by galvanic treatment. 
5. The removal of the hypertrophied mucous membrane of 
the uterine cavity by the sharp curette will often relieve, at 
least temporarily, the menorrhagia, which is the chief symp- 
tom present in the interstitial variety. 
6. Enucleation, after splitting of the capsule by means of 
traction with the finger and some blunt instrument, usually 
offers a safe means of cure in cases of submucous corporeal 
and interstitial cervical tumors. 
7. In certain cases of interstitial tumors which are so situ- 
ated as not to be amenable to the compressing influence of 
ergot, but still affect the general health by profuse, uncontroll- 
able hemorrhage, and again, in certain cases of rapidly growing 
subperitoneal tumors in w’hich a thin pedicle cannot readily 
be formed, the removal of the ovaries may be confidently ex- 
pected to check the hemorrhage and the growth of the tumor 
respectively. 
8. Laparo-hysterectomy should not be lightly undertaken, 
aud should certainly never be performed merely to relieve the 
patient of a fibroid tumor which does not affect her general 
health, and is merely inconvenient or unsightly. 
9. The nearer the prospective menopause, the less likely is 
the fibroid to grow or cause trouble, aud, therefore, cceteris 
paribus, the less are active or operative measures called for.