tween the second and third months after commencing to take the ergot, I was called to her in great haste and found her apparently in labor, the uterine contractions quite regular and very severe; a partially dilated os and the tumor presenting. This tumor was expelled after two or three hours. It was nearly as large as a child's head at time of birth. The patient made a complete recovery.

THE PRESIDENT: In what state was the tumor?

DR. WAXHAM: I can hardly say it was softened, but it was fleshy in character, and some pus upon it, as though it had suppurated. It was somewhat offensive, I remember. I attended her for some weeks subsequently; there was some febrile reaction, but no serious trouble followed.

THE PRESIDENT said: I have reported a case in which a tumor was thrown off without sepsis. I have had since quite a series of cases in which tumors have been thrown off; some have been absorbed and there has been a various history, which I hope to make the subject of a special paper, and would like the assistance of others in making up a history of these cases. I think we are specially favored in having with us Dr. Wm. H. Byford, who has had such extended experience in these

cases.

DR. WM. H. BYFORD, in closing the discussion said: MR. PRESIDENT, you are right in supposing that I feel great interest in this subject. I have made it a study for a long time. Perhaps as good a way as any to introduce my views on this subject to the society, will be to go back to the commencement of my own researches in this matter. In 1872, as Dr. Jaggard has said, Hildebrandt commenced a series of experiments for checking the hemorrhages connected with fibroid tu mors of the uterus, by giving hypodermic injections of the extract of ergot, and succeeded in a great many instances in suppressing the hemorrhage and relieving the patient from the inconvenient symptoms. During these experiments he also ascertained that the tumor would sometimes disappear. I think that his statistics were not large, and that he only reonly reported a very few, perhaps three or four, cases in which the tumors disappeared by atrophy during the time he treated them in this way. In 1874 I was elected to the chairmanship of the Section of Obstetrics in the American Medical Association, and as these experiments of Hildebrandt had attracted considerable attention, I thought it would be a good time to make some investigations as to the value of his facts. I commenced correspondence over a large portion of the

United States and Europe, but especially communicated with my friends in this part of the country, among whom were my immediate associates in this city, who had been engaged in using hypodermic injections of ergotine according to the method of Hildebrandt, once in two or three days. All of them bore testimony as to the efficacy of that kind of treatment, and as to the fact that these tumors could be made to disappear in a great many instances by atrophy, and in a great many more the symptoms could be relieved so that the patient was rendered comfortable, the presence of the tumor giving them but little inconvenience. Some of the gentlemen with whom I had correspondence had been using the ergot in different ways, giving it by mouth, giving it per rectum, and injecting it into the tumor itself, and by various other methods. I noticed one fact in my own practice and that of my friends, which was that the more frequently the ergot was given the more powerful its action was. In giving it two or three times a week hypodermically by the Hildebrandt method, there is very little distress produced by it; but the tumor may gradually disappear and the symptoms get better. I collected 103 cases from different parts of the country, and in all of them the attention of the practitioner was directed to the point of causing the disappearance of the tumor by atrophy. During the time I was making these investigations cases of fibroid tumors occurred in the practice of my friends, who consulted me. One was a remarkable instance in the practice of Dr. Merriam. I remember the particulars. The patient was a little Irish woman who had a tumor almost large enough to reach to the umbilicus. commenced the use of ergot in September, 1874, twenty drops of Squibb's fluid extract three times a day. It produced so much contraction of the uterus and so much pain as to alarm the patient and the doctor himself; he thought these pains ought to be suppressed, and as a consequence he would intermit the use of ergot, give anodynes to stop the pain and get relief from the sufferings of the patient, but would recur to ergot as soon as his fears had subsided. In January, 1875, be directed her to recommence the ergot and increase the amount. He gave her, I remember very well, twenty-five drops of Squibb's fluid extract three times a day. In March, which was about two months from the time he began giving her ergot in that way, the patient commenced having expulsive pains very much like labor, and not long after that, probably about March 20, there commenced to issue from the vagina a putrid liquid that

He

was very offensive and which contained small pieces of organized substance. He became alarmed and entirely withdrew the ergot, supposing he was doing mischief, but the death of the tumor had been produced, and as a consequence the uterus continued its action to throw off this foreign body, until April 5, 1875, he was summoned in great haste to see his patient. I was also summoned. Upon arriving at the house, which he did before me, he found the tumor expelled, part of it lay in the vagina and part between the limbs of the patient, a protruding mass almost the size of a child's head. It was not expelled in a lump, but was broken in pieces that would represent that size. The patient at that time had septic fever, with increased temperature and increased frequency of pulse, etc. The doctor and I both felt uneasy about her, but she very soon rallied and in a short time was well, and since has given birth to a child.

That was my first observation as to expulsion of tumors of that kind. It started a train of thought in my mind, and led me to think about increasing the ergot beyond the amount that had usually been given for producing atrophy. In the same year, July, 1875, I commenced giving it with a view of expelling a tumor. I gave my patient at first fifteen drop doses of Squibb's fluid extract three times a day, and increased it until the patient was taking a teaspoonful of ergot three times a day. On August 15, about five weeks after I commenced using it, the tumor was broken up and expelled from the vagina. It was expelled by pieces, the first piece about as large as my thumb, of a grayish kind of substance that smelled very badly. The action continued; I was somewhat alarmed, and gave the patient anodynes, but the uterus had already commenced to act on the tumor and expelled it, as it would any foreign body. In December of the same year I had an opportunity of repeating the experiment, and the case terminated in the course of six weeks, by the same method of administering the ergot. In 1876, on returning from the World's exposition at Philadelphia, I was requested to call at Coldwater, Mich., to see two patients, one with cancer and one with a tumor. I found one of these patients with a tumor as large as my head, the measurement of the cavity being fully six inches. I told her I believed the tumor could be expelled if she was willing to go through the process. I felt uneasy, however, to leave her to use such medicine by herself, and tried to teach her how she should proceed when the expulsion should take place. She took the ergot three months without much effect,

except that occasionally she would have a paroxysm of pain; after that, however, the pains became so very severe that she could not take the ergot much of the time. But, brave and intelligent as she was, she repeatedly resumed it, and finally the tumor commenced to come away. It came away in about five weeks from the time the first symp toms of expulsion occurred. She wrote me a description of the method of expulsion. She said at first small lumps made their appear auce and passed out of the vagina; after the second day they became larger, and on the third and fourth days they seemed large enough to fill up the vagina. With her scis sors she cut off pieces of it, and pulled at it to assist its removal. She labored at it two or three days until it was all expelled. In about three weeks thereafter she came to see me, and the uterus had shrunk back to near its natural size. She has since had the menopause, and is now in good health. She sent me at that time a quart cup full of this expelled fibrous substance.

Another case occurred in the western part of this state, under the care of Dr. Crandall, of Sterling. The patient came, by his direc tions, to see me, and I found a tumor of considerable dimensions, and advised her to take ergot. She went home, and in about fifteen or twenty days she got her work done up, as she expressed it, took three doses of thirty drops of Squibb's fluid extract of ergot, and started up such a process of expulsion that, notwithstanding the efforts of her physician to stop it, the pains went on to the expulsion of the tumor, which was completed in about three weeks.

DR. Wм. Fox, of Milwaukee, three years ago sent me a report of another similar case. In summing up these observations, I have known personally of twenty six cases of expulsion of the tumor in this way. With reference to the dangers connected with the ex pulsion, I would say that only one out of these twenty-six cases proved fatal. They all had septicemia to some extent, but as soon as the mass of dead tumor was removed, the pa tients commenced to recover, and got well. Some of the patients had no assistance. This one patient in whom it proved fatal lived in Monmouth. It occurred about six years ago. She was a lady who, like other foolish women, distrusted her home physicians, and she came here, supposing she would find better treatment. I advised her to take ergot, and in about three months the pains commenced that caused the tumor to be expelled. She came here with the lower part of the tumor hanging from the vagina and uterus, while the up

per portion was clinging to the cavity in which the whole of it had been lodged. She was then laboring under a high fever. The smell was terrible. She came to the Tremont House, and it was several hours before I could see her. When I arrived, it was a very simple matter to enucleate it, and I removed it in a few minutes. But she had already re ceived a fatal poisoning from the retention of the dead tumor. This is the only case I have known to prove fatal. I do not get a history from other gentlemen of any more unfavorable results. They all tell me they are frightened at the symptoms, and they are afraid the patients are going to die, but they do not die. When the mass is taken away and the vagina washed out, the symptoms disappear. Since thinking of this matter and observing the effects of this remedy, I have thought I could come to definite conclusions as to the condi tions under which we might predict the expulsive effects of ergot by the appearance of the tumor. You know that it is not a very common thing to find a case in which there is a single tumor in the fibrous tissue of the uterus. More frequently these tumors are complex. Quite a number of nuclei of formation-we often see in one uterus four or five, sometimes fifty different points of solidification. Now a single, or even a double tumor, located within the circle of the fibrous arch of the uterus near the mucous membrane, is the kind that I think may almost certainly be expelled. If you find a case of symmetrical development, where the uterus seems near its normal shape, no matter how big, so it is normal in shape, oval, or globular, without any large projections standing out in various directions, feeling somewhat elastic to the touch, and attended with hemorrhage, you may be pretty sure you can expel the tumor by commencing with small doses of ergot and increasing them in size, and then when the pains begin, not to stop them. The presence of severe pain frightens a great many men from finishing what they have begun. If I were to try to explain this operation I would say when ergot is given in this way, after a while the tumor becomes starved, the supply is cut off so there is not blood enough to support it, and very soon it dies in consequence of this strangling process. When it dies there is, at the same time, gangrene of the mucous membrane covering it; then it becomes a foreign body, and you cannot keep the uterus from expelling it. The expulsion is a consequence of this starvation and killing process in the tumor. As to the action of ergot in tumors that are not submucous, of course I know that tumors not submucous cannot be expelled.

There is what is called the interstitial tumor, developed in the central stratum of the fibrous walls of the uterus, these are the proper subjects of the Hildebrandt process for atrophization. Then with reference to the effect of ergot upon subperitoneal tumors. I have often been asked the question, Can ergot affect these subperitoneal tumors? I think they are frequently starved out and cured; when not too near the peritoneum there is no danger of their becoming detached and putrid in the peritoneal cavity, because the action is from the tumor. In the submucous tumor the contractions are all towards it and none from it. There is one circumstance to be taken in connection with these tumors and the action of ergot upon them, that has not been sufficiently considered. A large proportion of them growing to any considerable size contract attachments to the peritoneal membrane, the intestines, omentum, or the walls of the abdomen, and in making this attachment they get a new supply of blood, which makes the life of the tumor more tenacious than it would be otherwise. This very process of adhesion to the walls of the abdomen is, more than any other, the cause of their great size and the change from a fibrous to a fibro-cystic tumor. We need not expect such tumors to be affected by ergot. There are a good many other things that interfere with the successful use of ergot, of which I cannot now speak. I am grateful to my western associates who have assisted me by facts and experiments on this subject. If you go to the eastern part of the United States they will tell you that ergot is of no use in the treatment of fibrous tumors, or it is too dangerous; the patient cannot live under the pains of expulsion, etc.; but if these same gentlemen had a patient in labor, they would urge the pains instead of stopping them. Most physicians who do not believe in the efficacy of ergot, use Hildebrandt's method pretty much altogether, which produces tonic contraction of the fibres of the uterus, but does not go to the extent of causing expulsive pains. Then, again, there is too great apprehension on the part of the profession generally of the dangerous poison of ergot. I do not know whether the history we have of the poisonous influence of ergot in producing nervous diseases, gangrene, and so on, is true; whether the observations that led to that teaching were correct at one time or not; but I know that after the use of ergot persistently for two or three years in the same case, I have never seen any evil influence produced by it, unless it is in cases where the violent action of the uterns would be regarded as such. I have purposely avoided saying anything

about the modus operandi of ergot in causing contractions in the uterine fibres, because that is now sufficiently understood by the profession. But, Mr. President, I feel that I have occupied too much of the valuable time of the Society already, and will say no more. III.-A STUDY OF THE CAUSE AND TREATMENT OF PELVIC HEMATOCELE.

The author cited the case of a non-suppurating, retro-uterine hematocele of six months' standing, which he evacuated per vaginam March 18, 1886, and then treated with antiseptic irrigations. She was up and about the house in eleven days. As the odor and discharge were still causing discomfort, the doctor, influenced by the advice of Apostoli and Doléris, curetted the cavity. He found no more blood or débris, but started up a mild attack of local peritonitis, which delayed in stead of hastening the cure. The patient left the hospital in a little less than a month after the cessation of all discharge. A small lump of induration extending from the abscess opening to the right sacro-uterine ligament was all that was left of the tumor.

The following résumé of interesting points in the case is given:

1. The length of time from the occurrence of the hematocele to the time of operation, about six months.

2. The method of opening the cavity, viz., by first tearing the vaginal wall, and after

wards the sac wall.

3. The absence of fluid in the tumor. 4. The breaking up of the mass with the finger without an attempt at thorough curetting or removal of the entire contents.

5. The complete disintegration and discharge of all bloody substance in thirteen days.

6. The absence of high temperature-102° F. having never been reached.

7. The small amount of anodyne requiredone dose (except the two doses to relieve the irritation from subsequent unnecessary curetting).

8. The toleration of strong antiseptic solutions. It was necessary to weaken them on account of their effect upon the vagina.

9. The absence of the usual amount of odor in such decomposing masses.

10. The large quantity of food taken throughout.

11. The absence of any kind of sickness from the beginning until the cavity was curetted.

12. The curetting of the cavity on the thirteenth day delayed her recovery, producing the only serious symptoms that were noticed. 13. Notwithstanding a setback of ten days

caused by the curetting, she was well enough to go home inside of a month and dispense with treatment.

14. The attack came on after a miscarriage. P. F. Mundé reports two new cases of hematoma successfully operated upon three and six weeks, respectively, after their occurrence, both large, and resulting from or after abortions. N. Y. Medicinische Presse, Vol. 1, No. 1, Dec., 1885.

Five other cases are briefly related, four extra-peritoneal hematomas and one large retro-uterine hematocele, which came under the writer's observation during the past two years, and which were successfully treated on the expectant plan. He was unable to find justificacation in any text-book for having operated in the absence of any threatening symptoms until he procured the last edition of Billroth & Lücke's "Frauenkrankheiten" and Schroeder's text book (both of 1886). He cautions against taking the advice of Bandi, to operate after the first subsequent menstrual period, or that of Apostoli and Doléris, to operate immediately by the galvano-puncture wherever and whenever found. Operations at such times are connected with what are designated as immediate dangers, viz., “a recurrence of shock, hemorrhage or (if hemostatic tampons be used) of inflammation; or of septicemia followed by inflammation, if antiseptic injections of sufficient strength be

used."

The dangers of the expectant treatment are mostly remote, and are such as "suppuration, septicemia perforation, and prolonged pressure upon, and displacement of, surrounding organs, with their results, viz., the aggravation and perpetuation of pre-existing pelvic disease, or the originating of new ones."

While recognizing the necessity for evacuation within the first three or four weeks in certain exceptional cases, he would, as a rule, delay operating long enough to avoid the immediate dangers, yet not long enough to incur the remote dangers of delay. The patient must invariably be kept in bed, and the tumor should be left alone until the primary acute symptoms subside. If the tumor remain hard and diminish in size, no matter how slowly, it should be let alone, as long as the symptoms do not become worse. If the tumor remain stationary and boggy to the feel, and the symptoms begin, after a few weeks, to increase in severity, it must be operated upon; or if the symptoms remain without improvement, while the tumor shows no signs of being absorbed, it is better not to wait for serious symptoms, but to operate in the subacute stage, or when the symptoms have subsided