T II E ADDRESS IN OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN. BY WM. IT. BYFORD, A.M.,M.D. EXTRACTED FROM THE TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. PHILADELPHIA: COLLINS, PRINT ER, 705 JAYNE STREET. 1875 THE ADDRESS IN OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN. BY WM. H. BYFORD, A.M.,M.D. EXTRACTED FROM THE TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. PHILADELPHIA: COLLINS, PRINTER, 105 JAYNE STREET. 1875. ADDRESS IN OBSTETRICS, DISEASES OF WOMEN AND CHILDREN. Mr. President and Gentlemen : The great extent, varied character, and rapid advancement of the subjects connected with the department of practical medicine represented by the Section of Obstetrics and Diseases of Women and Children render a complete and profitable annual resume, of progress a very difficult if not an impracticable undertaking in the time allotted to.this address. I hope, therefore, to be pardoned for selecting some one subject for more extended consideration and research than could be embraced in so short a general summary. This course will, I believe, permit of an accumulation of facts from which important inferences may be drawn that will serve as a basis for the forma- tion of rules to guide us in the practice of our art. This brief introduction will enable me, without further apology or loss of time, to invite your attention to the Treatment of Fibrous Tumors of the Uterus by Ergot, the subject which I have chosen for my address. It is a very short time since all forms of fibrous tumors of the uterus, except the polypoid variety, were considered entirely beyond the reach of legitimate medicine or surgery. Recent writers, with very few exceptions, teach the entire inefficiency of any form of treatment for the cure of intramural fibrous tumors of the uterus except by enucleation, and that this operation is so dangerous and difficult as not to be thought of except in desperate conditions. All who have been under the necessity of performing this hazardous operation will readily concur with the teachers in the cautionary precept that this must be a last resort of surgery, instead of a chosen means of relief. To the advantage of the medicinal treatment of these tumors we may justly say, that it is not a final venture, but a safe means, 4 ADDRESS IN OBSTETRICS, which can be employed before dangerous symptoms present them- selves, and thus save patients from the inconveniences and perils of a resort to surgery. Even in extremities, we are encouraged to hope and believe that the dangerous symptoms which have hitherto been considered as calling for surgical interference may be removed, so that we can wait in safety for the further and more curative effects of the same remedies. On account of the safety of this treatment, all cases, both trivial and grave, will be included in the field of its usefulness. Experimental therapeutics has taught us that ergot and some other medicines exert a special influence on the unstriped muscular fibres. This property is not confined to ergot and belladonna, the popular medicines now used for this purpose. It is also possessed by quinia, some preparations of lead, alum, bromine, and iodine in a high degree, and by most of the astringents. Remembering the double system of unstriped fibres entering into the composition of the uterine tissues, we can easily under- stand how much more efficiently these agents may be made to act upon the uterus than upon any other organ. While the unstriped fibres form the muscular structure of the walls of the uterus they also enter into the composition of the arterial tubes supplying blood to its substance. Both ergot and belladonna act upon the uterine walls in a three- fold manner, and cause a diminution in the flow of blood to the morbid as well as to the healthy tissues in the uterine structure. First: the calibre of the arterial tubes is diminished by the con- traction 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 to the pro- cess of disintegration and absorption. If we are correct in the histology and pathology of the parts in question, and in the therapeutical action of ergot and the other medicines mentioned, then we have just grounds upon which to DISEASES OF WOMEN AND CHILDREN. 5 base hopeful curative means for the removal of morbid growths of the uterus. And I think the published observations of the enthu- siastic laborers who have entered upon record their results in treat- ing these tumors with ergot give us much reason to hope that fibrous tumors of the uterus can be cured by the use of medicine alone. One great difficulty that besets the introduction of any new method of treating disease, and which is now operating adversely to the introduction of this new process of cure, is that we expect too much. The great success of Hildebrandt has exceeded that obtained by most of his followers, and these latter, becoming disheartened by their early failures, are likely, many of them, to reject the whole as a plausible mistake. A more tempe- rate expectation would enable us to secure reasonable results. It is quite probable that only partial benefit will accrue in the majority of instances. As is well known, many multinuclear tumors become dense as cartilage, while some of them, through processes of degeneration still more complex, are transformed into masses of earthy matter. These of course can no more be absorbed than the chalky deposits of gout. Neither have they vitality enough in them to permit of any disorganizing influence from pressure; and there is so little blood circulating through them that their nutrition cannot be affected by the action of ergot or belladonna on their arterial tubes. Then, again, in tumors with multinuclear centres of origin, the fibrous structure of the uterus is sometimes so completely replaced by the multitude of morbid growths that its power of contraction is almost destroyed. While, on the other hand, tumors with but a single nucleus are generally associated with a very vascular condition of the uterus, and the muscular fibres are hypertrophied much as they are in pregnancy. These are the most rapidly growing and most mischievous tumors; they are also the most easily affected by ergot. Between these extremes we may expect a great variety of results in treatment. The degeneration in the more vascular forms of the tumor under the influence of ergot is probably similar to the pro- cess of involution of the uterus after parturition. As the circula- tion is diminished in quantity and retarded in motion, the vitality of the tumor is lowered until fatty metamorphosis is fully effected. The substance of the tumor and the hypertrophied fibres of the uterus are thus at the same time converted into material most easily absorbed. 6 ADDRESS IN OBSTETRICS, Those who have observed many cases of ergotism in the uterus containing these tumors must have noticed another more summary influence occasionally exerted upon them; viz., their expulsion through the mouth of the uterus into the vagina with inversion more or less complete. Not alone are the polypoids thus driven down from the uterine cavity and their immediate detachment effected, or strangulation and gangrene brought about, but the tumors situated within the walls of the uterus are also expelled. If the tumor is situated much nearer to the mucous than to the serous surface of the uterus, this is very likely to take place under protracted uterine contraction. Two remarkable cases of this kind have fallen under my observation within the last few years. One occurred in April, 1870, and was enucleated, before the class of the Chicago Medical College and in the presence of several of my colleagues. The uterus was inverted and was replaced without any difficulty after the tumor was removed. In this case the form of ergot used was the fluid extract, and it was administered internally in half drachm doses. It was taken continuously for almost three weeks, and caused a great amount of suffering from the pain of contraction. The pulse was accelerated and the uterine globe very tender to the touch for several days before the expul- sion of the tumor. The other case occurred a few months since. The expulsion was produced under the influence of ergot administered hypoder- mically and by the mouth. The medicine was administered in both of these ways for about a month by my son, Dr. II. T. Byford. While in the agony of expulsion, the patient, who resided some distance from us in another part of the city, sent for a physician in her neighborhood. That gentleman discovered the tumor partially expelled, encouraged the process by traction, and amputated the protruding mass with the galvano-caustic wire. The uterus I understand is at the time of this writing still inverted. I have been able to collect from journals and reports made to me by letters received from members of the profession an abstract of one hundred cases exhibiting the most favorable results from the treatment of fibrous tumors of the uterus. Cases. It is well known that Prof. Hildebrandt, in a communication to the twenty-fifth No. of the Berliner Wochenschrift as early as 1871, called the attention of the profession to the utility of ergotine in DISEASES OF WOMEN AND CHILDREN. 7 the treatment of fibrous tumors of the uterus. While administer- ing it by hypodermic injections to moderate the hemorrhages so often a troublesome symptom in connection with these growths, he was struck with the decided diminution in the size of the tumor. A continuation of the remedy thus administered, resulted in the entire disappearance of one of them in fifteen weeks. In eight cases, all but two underwent great improvement. The great pain caused by the injection rendered the treatment intolerable to one of these two patients. In the other the treatment was discontinued on account of ergotic intoxication. In four others, the tumors were greatly diminished, and promised speedy cures, but for various reasons the treatment was not continued. One tumor of huge size, reaching above the umbilicus, totally disappeared; while another extending to the ribs, and largely distending the abdomen, was greatly reduced. The debilitating hemorrhages and leucorrhoeal discharges were promptly relieved in six of them. In the American Journal of Obstetrics, for January, 1875, Dr. Hildebrandt gives a synopsis of nineteen more cases treated by him. Two of these were cured; and in six others the tumors were greatly diminished in size, and the hemorrhages relieved. In eleven of these cases all the disagreeable symptoms were relieved, but the size of the tumor was not perceptibly affected. The two last cases reported in this series of nineteen were not benefited. Soon after Prof. Hildebrandt made his first report of cases, Dr. Bengelsdorf read a paper upon the subject at a meeting of the Greifswald Medical Society. He alluded to four cases in which he had used the hypodermic injections of ergot. Two of these were in patients after the menopause; neither of them seemed to be influenced by the treatment. In the other two the patients were menstruating and the subjects of severe metrorrhagia. This symptom in both cases was very much mitigated, but the tumors were not materially, if at all, diminished in size. Treatment was interrupted in one of them after the administration of sixteen injections. Dr. Bengelsdorf was favorablv impressed by the treat- ment. Dr. Chrobak, of Vienna, reports, in the seventh volume, second number, of the Archives fur Gynsecologie, nine cases. In the first, the tumor the size of a small apple was partially expelled from the cavity of the body into the cervical canal; the mouth of the uterus was dilated by sponge, and the protruding segment removed with the scissors. In case second, after forty-three injections, the tumor, 8 ADDRESS IN OBSTETRICS, which was situated in the posterior wall of the uterus, was not reduced in size, but the hemorrhage was cured. The tumor in case third consisted of several nodules in the anterior wall of the uterus; after twenty-four injections, there was no diminution in size, but the hemorrhage was cured. In case fourth the tumor was situated in the posterior wall and reached up to the umbilicus; after three injections the treatment was discontinued on account of the pain and inflammation caused by them. In the fifth case the amount of hemorrhage was reduced, but the treatment was discon- tinued for the same reasons as in case fourth. The tumor in case sixth was large, the uterus rising above the umbilicus; after twelve injections without results, the patient could not be induced to receive further treatment. The seventh patient was fifty-seven years old, and the tumor showed a multitudinous development; the second injection, which was administered eight days after the first, caused severe symptoms of collapse, and the treatment was discontinued. The tumor in the eighth case was in the anterior wall of the uterus and reached above the umbilicus, and the monthly flow continued from eight to ten days; seven injections were used, with diminu- tion of the tumor and improvement in the hemorrhages; the treat- ment in this case he expected to continue at some future time. In the ninth case the uterus was anteverted, and the cavity measured four and three-fourths inches in length; after twelve injections the hemorrhages ceased and the tumor diminished in size; the uterine cavity measuring only three and one-third inches in length. Dr. Lombe Atthill records three cases in the Irish Hospital Gazette for September 1st, 1874. The first case was benefited in the diminution of the flow and the improvement of health. The second case was under treatment but a very short time; only five injections were administered, when the patient refused to permit another because of the severe inflammation following them. The third case was benefited, but abandoned from the same cause. Dr. J. P. White, of Buffalo, N. Y., writes me that he believes it is in this direction-the use of ergot-we must look for relief in the intramural and non-pediculated varieties of uterine fibroids. He says, that in the last year and a half, he has resorted to ergot in these varieties with marked benefit. In a few instances they have been completely absorbed, and in a larger number, the growth of them was arrested, the tumors were diminished in size, and the hemorrhages were suspended. He says that the number of his cases is fourteen, and that not more than one-third can be called DISEASES OF WOMEN AND CHILDREN. 9 cured, while in almost the same proportion, the growth has been stayed or diminished, and the bleeding arrested. Dr. E. W. Jenks, of Detroit, Michigan, in a recent letter, says he has used ergot during the past two years in the treatment of fibroid tumors of the uterus with the most gratifying results. Seventy- five percent, of all cases thus treated were benefited, as manifested by arrest of growth and control of hemorrhage. About ten per cent, of the patients he considered cured. Dr. C. G. Goodrich, of Minneapolis, Minnesota, sends me a very brief account of the most remarkable case I have yet heard of: The treatment was commenced in 1870, and continued two years. In describing it, he says 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, he says, produced a wild enthusiasm in the mind of his patient, and inspired her with strong hopes of recovery. Without consulting him, 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 him to abandon treatment for about one month, and had it not been for the urgent determination of the patient, he 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 his directions if he would proceed. She so promptly and rapidly improved that he doubted if it were not a coincidence with, rather than a consequence of, his treatment. Prompted by this doubt, he abandoned the .use of the ergot and belladonna, and continued alterative treatment. The patient soon assured him 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. Dr. II. C. Howard, of Champaign, Ill., sends me an account of two cases treated by him. The first case was in an unmarried woman. The tumor was one originating from a single nucleus, intramural, and as large as a pint measure. He administered 10 ADDRESS IN OBSTETRICS, hypodermic injections of ergotine for some weeks, and afterward continued treatment for eight months by administering internally the fluid extract of ergot and belladonna. This case, he says, was entirely cured by his treatment. His second case was in the person of a married woman forty years of age, and the mother of two children. When first seen by him she had been the subject of severe floodings for three years. He found, upon examination, a submucous fibroid as large as a quart cup. He used large quan- tities of ergot by vaginal injections and by the mouth for four months, at which time the tumor had entirely disappeared. Dr. A. Reeves Jackson reported to the Chicago Society of Physi- cians and Surgeons, April 13, 1874, five cases of fibrous tumors of the uterus treated by hypodermic injections of the solution of the solid extract of ergot The tumors in four of these cases were intramural; in the fifth the tumor was subperitoneal. The tumor in one case was entirely cured; in two others the tumors were greatly diminished in size. In another the tumor seemed un- affected, but the profuse hemorrhages from which the patient suf- fered were diminished in frequency and profuseness. The fifth, a subperitoneal tumor, was not benefited. Dr. Jackson reports to me three other cases. One was in a colored woman ; the uterus reached to the umbilicus: it was entirely cured in three months. In the second the tumor reached above the um- bilicus ; this was temporarily reduced in size by the ergot, but after treatment was abandoned, it regained its former dimensions. The treatment was discontinued by the patient because of the dis- tressing pain and contractions which occurred after eight weeks' use. The profuse uterine hemorrhage was checked, and health improved. At the same meeting of the Society of Physicians and Surgeons at which Dr. Jackson's first .five cases were reported, Dr. Etheridge reported one case entirely cured. His diagnosis was confirmed by Drs. Gunn and Miller, Dr. Etheridge's associate professors in Rush Medical College. Dr. Fisher also reported an intramural fibroid cured in six weeks. I saw this case, and have no doubt of the correctness of Dr. Fisher's diagnosis. On the same occasion, Dr. Merriman, one of my colleagues, re- ported three cases: one, intramural, in the anterior wall, cured; one, subperitoneal, pediculated; the health of this patient was much improved, and the growth of the tumor checked ; the patient was still under treatment. The tumor in the third was intramural. At the time of reporting, the size was gradually diminishing. DISEASES OF WOMEN AND CHILDREN. 11 Dr. Merriman recently reported to me the following very in- teresting case: " Mrs. K., aged thirty, the mother of three children, came to me in September, 1874, in regard to a tumor in the abdo- men. First noticed it in March, 1873. It had caused trouble since October, 1873. Examination revealed a large tumor about the size of a four and a half months' pregnancy ; found to be inter- stitial; situated on the right side, and a little anterior; the sound passed in six and three-fourth inches. She was at once given twenty drops of the fluid extract of ergot three times a day. She came a month later, saying she was much better in health, but the tumor remained the same. Told her to continue the medicine, but to increase the dose to twenty-five drops, and after a time to. thirty. Saw her three or four times during the past winter, and twice had to suspend treatment and give opium on account of severe pain and tenderness in the uterine region. Finally, March 23, 1875, I stopped all use of ergot, as the patient was very weak, pulse 110, appetite poor, and a very offensive and abundant discharge came from the uterus. Os very patulous. April loth, summoned in haste. Something had just come away from the patient. Found it to be an offensive fleshy mass, evidently a partially disintegrated fibrous tumor. Examination showed no tumor in the abdomen, but per vaginain the os patulous, soft, and very sensitive, and the uterus still large. A week later the uterus had regained its nor- mal condition." Dr. John Morris, of Baltimore, Md., communicates to me a case that seemed to be decidedly benefited by the ergot treatment; but, on account of the violent uterine contractions produced by the remedy, the patient would not consent to continue the treatment. Dr. Charles E. Buckingham, of Boston, Mass., has tried hypo- dermic injections of ergot in the treatment of fibrous tumors of the uterus in but one case. The result was entirely negative. Dr. George Cowan, of Danville, Ky., reports a case in the person of a colored woman, unmarried, and about forty years of age. The hypodermic injections of ergotine were used for two weeks. At the end of this time, the greatest circumference of the abdomen was reduced from thirty-six inches, which it measured before the treatment was instituted, to twenty-eight and one-half inches. The patient, returning home, used the injections herself. Such frequent and painful abscesses ensued, however, that she discontinued them.. During the use of the injections an obstinate constipation was re- moved, and her general health much improved. The abandon- ment of the treatment was followed by a return of the constipation,. 12 ADDRESS IN OBSTETRICS, loss of flesh, great debility, and the abdomen increased in size until it measured thirty-two inches. A return to the treatment was fol- lowed by the same marked improvement in the general health, and a reduction of the size of the abdomen to twenty-seven and one-fourth inches. Dr. H. W. Dean, of Rochester, N. Y., sends me an account of two cases treated by him : The first case was that of a patient forty-seven years of age, the mother of three children, the age of the youngest nineteen. She suffered from pressure upon the blad- der and rectum, and was the subject of severe metrorrhagia. The tumor extended two inches above the umbilicus, and occupied the lower .half of the right lumbar, the whole of the right inguinal, and fully half of the corresponding left abdominal regions. The os uteri was a little to the left of its natural position, and suffi- ciently open to admit the finger half an inch. An elastic catheter was introduced into the uterine cavity between seven and a half and seven and three-fourth inches. The diagnosis was interstitial fibrous tumor of the uterus. Intrauterine injections through the elastic catheter of half a drachm of Squibb's fluid extract of ergot were made four times during each menstrual interval from April until October, 1874. Injections into the substance of the cervix were made with the same frequency from October to the middle of December. The results were, reduction in the size of the tumor until the upper margin sank two inches below the umbilicus, and the uterine cavity measured only four and a half inches. The second case was that of a woman forty-eight years of age, the mother of three children, the youngest of whom was sixteen. She flowed irregularly, the intervals varying from one to three weeks. The flow was profuse and attended with great pain. In the intervals there was a copious flow of serous leucorrhoea. She also suffered from pressure upon the bladder, and frequent mic- turition. The tumor occupied the right side of the abdomen, extending nearly to the umbilicus, and to midway between the linea alba and the left ilium. The vagina could not be satisfactorily •explored until the hand was introduced. When this was effected, the finger could be easily passed into the uterus. Between the finger, thus introduced, and the hand on the hypogastric region, the presence of an interstitial fibrous tumor was diagnosticated. A flexible catheter was passed into the uterine cavity to the extent of eight inches. Injection into the substance of the cervix was followed in fifteen minutes by continuous uterine contractions \which lasted twenty-four hours. This injection was repeated four DISEASES OF WOMEN AND CHILDREN. 13 times a month. When the amount was increased from fifteen to twenty minims, great gastric and cerebral disturbance, together with intense cutaneous engorgement and uterine pain, ensued. The injections were continued from November, 1873, to the middle of the year 1874. At this time the upper margin of the tumor was but one inch above the symphysis pubis, and the cavity of the uterus measured four and a half inches. Menstruation was quite normal as to time and quantity, and attended with little pain. The pelvic organs were not subject to disagreeable pressure. Dr. W. C. Wey, of Elmira, N. Y., in a lengthy and interesting letter, gives me the results of his treatment in one case. The patient was forty-seven years old. The bulk of the tumor was equal to both closed hands. It was reduced in six weeks about one-third, and in six months to one-half of its original size. The patient, before the treatment, was very much reduced; her ex- tremities had become oedematous, and exercise was almost im- possible from the effects of hemorrhage, which had become almost constant. These symptoms were relieved with great promptitude and in four months the menses had become normal in every respect. His treatment was continued twenty-seven months, but most of the good results, if not all, were obtained in the first six months. Dr. Edward M. Hodder, of Toronto, writes me that the number of cases in his note-book, since May, 1873, is twenty-five; but all of these reside at a distance, and therefore he saw or heard of them only occasionally. Nearly the whole of them were treated with ergot, but not exclusively, as he combined with it the bromide and iodide of potassium. In the majority of the cases, treatment ap- peared to arrest further growth, and after a time caused the tumors to diminish in size. In a few cases the tumors disappeared en- tirely. He gives four cases in minutiae: in one case the treatment was commenced May, 1873 ; the tumor nearly disappeared, and the patient is now six or seven months advanced in pregnancy. In the second case, the treatment was begun in June, 1873 ; the tumor was greatly diminished in size, the patient became pregnant, and was delivered late last autumn. In the third case the treatment was commenced in September, 1873; the tumor disappeared, and the patient is now pregnant. In the fourth case treatment was commenced in September, 1873, and the tumor is now nearly gone, and the patient feels quite well. Through the kindness of Dr. Hodder I have received the report of another case by Dr. Jukes, of St. Catherines. The tumor was discovered by Dr. Jukes at the time of delivery after a normal 14 ADDRESS IN OBSTETRICS, pregnancy. The history of the case shows that its existence had been recognized by Dr. Hodder before the patient was married. Dr. Jukes gave the fluid extract of ergot continuously to this patient for three months, first in doses of one half drachm, and afterward increased the dose to one drachm, combined with the vari- ous preparations of iodine. From the beginning, the tumor slowly decreased in size, and at the end of three months had entirely disappeared. Some weeks after delivery, he passed the sound into the uterine cavity six inches, and the organ reached very nearly to the umbilicus. After the three months' treatment the measure- ment by the sound showed the organ to be very slightly above its normal size. Dr. Strange, of Aurora, Canada, says that he had on several occasions given ergot internally to arrest the hemorrhage attendant upon fibroid growths in the uterus, and had observed that it tended to retard their further growth. Dr. L. F. Warner, of Boston, has used ergot in two cases of fibrous tumors of the uterus, but could perceive no beneficial effects. Dr. J. H. Thompson, Surgeon in Chief of the Columbia Hospital for Women and Children, reports three cases treated by ergot; in all of which, the tumors were reduced in size, the metrorrhagia cured, and the general health, which in all was much impaired, was entirely restored. In one of these cases Dr. Thompson injected the ergot into the substance of the tumor by passing this instru- ment through the cervical cavity, and thence penetrating the growth. No unpleasant effects followed this method of using the remedy. Dr. Russel, of Oshkosh, Wisconsin, reports one case in which the tumor of large size was very much reduced, and all the dis- agreeable symptoms were removed. During the year since the last meeting of the Association I have treated seven cases. One was not affected by the ergot, and the patient died six weeks after the commencement of the treatment. She was an(emic to a degree which I have seldom before seen. The remedy was administered hypodermically every day ; thirty drops of Squibb's solution of the solid extract being injected each time. The second patient was the subject of a uninuclear tumor, situated in the anterior wall of the uterus, about the size of the fcetal head. She had profuse hemorrhages at her menstrual periods, and copious leucorrhoeal discharges between them, and had become DISEASES OF WOMEN AND CHILDREN. 15 very anaemic. The discharge ceased and the tumor disappeared in five months from the time she first came under my care. The remedy was at first used hypodermically; but, on account of the pain and inflammation at the punctures, I was obliged to cease this mode of administering it, and gave it internally. Teaspoonful doses of Squibb's fluid extract were given twice a day for the last three months of the time the patient was under treatment. In three other cases, in which the medicine was given internally, the tumors were very much reduced in size, but did not disappear. The hemorrhages and leucorrboea were cured, and the patients restored to health. In another, the hemorrhages and leucorrhoea were rendered much less profuse, but the tumor was not reduced in size. In a colored senile patient, over sixty years of age, with a large multiple tumor, no effect was produced by the ergot. In four of my cases I was obliged to suspend the treatment several times for a few days, to give the patients a respite from the almost constant pain. Five of these complained of great heat and tenderness of the uterus after they had been under treatment about four weeks. In all, the pulse was accelerated and remained small and weak. As one«of my cases presented some features of more than ordi- nary interest, I will give it more in detail : The patient had been married twelve years, was thirty-seven years old, and sterile. She had been aware of the existence of the tumor for three years, but could not give a very clear history of its progressive enlarge- ment. The uterus extended three inches above the pubes, and was a little to the right of the median line, very hard and irregu- lar in shape; but I could not discover that there were subperito- neal nodules. Per vaginam the tumor could be felt to occupy the right side and anterior wall of the uterus, and fill up two-thirds of the pelvic cavity.' cavity of the uterus measured four and a quarter inches. A polypus, pyriform in shape, quite firm in con- sistence, about the size of a pigeon's egg, depended from the mouth of the uterus, and appeared to be attached to the upper part of the posterior wall of the cervix. The diagnosis was intra- mural fibrous tumor of the uterus, with two nuclei of development, and a fibrous polypus. The patient was somewhat anaemic from the long continuance of profuse leucorrhoea and metrorrhagia. Without removing the polypus, I commenced treatment by giving the patient three grains of the solid extract of ergot three times a 16 ADDRESS IN OBSTETRICS, day. The next menstrual flow was not so profuse, and the leucor- rhoea diminished almost from the beginning. At the end of four months, the menstruation was normal, the leucorrhoea had ceased, the tumor was reduced to half its former dimensions, and the patient's health restored. A continuation of the treatment two months longer causing no further reduction of the tumor, it was suspended. During the treatment, I watched with much interest the effects produced upon the polypus; examining it once in every ten or twelve days. It showed decided decrease in size at the end of the first ten days, and progressively decreased until, at the expiration of four months, it was not more than one-third the size it presented when first examined. It was twisted off at this time with great ease, and its removal was followed by almost no loss of blood. The only apology 1 have to offer for the brevity with which the cases in this paper are mentioned is my aim to give no more than was necessary to obtain a satisfactory exhibition of the results of treatment by the use of ergot. No. of cases. Cured. Diminution in size of tumor and cure of he- morrhage. 1 Hemorrhage relieved but tumor not affected. No result. Hildebrandt .... 3 11 9 4 Bengelsdorf .... 4 ... ... 2 2 Chrobak .... 9 1 2 3 3 Atthill 3 ... 2 1 White 14 4 5 5 Goodrich .... 1 1 Howard ..... 2 2 Jackson..... 8 2 3 2 1 Etheridge . . 1 1 Merriman .... 4 2 o Fisher ..... 1 1 Morris ..... 1 1 Buckingham .... 1 1 Cowan ..... 1 ... 1 Dean ..... 2 2 Wev 1 1 Hodder ..... 4 1 3 Jukes ..... 1 1 Warner ..... 2 2 Byford ..... 9 3 3 i 2 Allen ..... 1 1 Thomson .... 3 ... 3 Russel . . . >. . 1 1 Total .... 101 22 39 19 21 DISEASES OF WOMEN AND CHILDREN. 17 Summary of Cases. The total number of cases here cited is one hundred and one Twenty-two of them are reported cured. In thirty-nine more the tumors were diminished in size, and the hemorrhage and other disagreeable symptoms removed. Nineteen of the remainder were benefited by the relief of the hemorrhages and leucorrhoeal dis- charges, while the size and other conditions of the tumors were unchanged. Out of the whole number only twenty-one cases entirely resisted the treatment. This shows results decidedly favorable in eighty of the one hundred and one cases. We may still further appreciate the favorable effects of the treatment by the consideration that in twenty-one cases it was suspended, which is as great a number as resisted treatment. It is also a noticeable fact that some of the cases in which the treatment was suspended were very much benefited by it. I have no doubt that many more cases of fibrous tumors of the uterus treated by ergot might have been collected, had time per- mitted, as I have heard of cases the history of which I could not obtain. In collating my cases, I have in no way selected or arranged them to influence inferences as to results, but I have faithfully recorded all I have received from correspondents, or found in journals, which were given sufficiently in detail to enable me to arrive at a correct idea of the treatment and its effect. Modes of using Ergot. Not much uniformity has been observed by the writers above quoted in the manner of using ergot. Drs. Hildebrandt, Bengelsdorf, Chrobak, Atthill, and Jackson recommend, and use it hypodermically. Drs. White, Jenks, and Howard administer it hypodermically, internally by the stomach, and in the form of suppositories in the vagina and rectum. Some of the arguments in favor of the hypodermic injections are: 1st. It acts more rapidly and with more certainty. 2d. It does not produce the gastric disturbance sometimes caused by ergot when taken internally. 3d. It can be administered in this way when it is entirely impracticable to give it internally on account of the great exhaustion or gastric irritability of a patient. The main objections to the hypodermic method seem to be: 18 ADDRESS IN OBSTETRICS, 1st, the pain inflicted by the needle; and, 2d, the inflammation and suppuration which ensue. Dr. Hildebrandt has met with but one case where the pain of the puncture was an objection to its hypodermic use. With regard to abscesses he says: " I am sure I do not exaggerate when I say that up to the present time I have myself made one thousand hypodermic injections of ergotine for various purposes, or have seen them made and observed their results in the clinical wards in charge of my assistants." And he then adds: " I have never seen an abscess follow the injections made by me personally, and only in three clinical cases did this occur. The chief reason why no abscesses formed among the large number of other injections is that I always injected the fluid very deep into the subcutaneous cellular tissue-perhaps even into the abdominal muscles." Dr. Atthill met with this difficulty in all three of his cases, although he also injects the fluid deep into the tissues. Dr. Chrobak was obliged to desist from treatment on this account in four out of his nine cases. Dr. Cowan was interrupted in his case by the formation of abscesses. Thus it will be seen that much difficulty is experienced by many in carrying out the treatment. Dr. Hildebrandt's reason does not seem to be the only one why practitioners are so troubled with this objection, since Dr. Atthill and others have also injected deeply. As far as I can judge, very few have been able, even by the most careful efforts, to achieve the same happy results in this respect as Dr. Hildebrandt. Dr. Hildebrandt, and also Dr. Atthill, select the lower part of the abdomen as the part in which to make the injections. Dr. Keating, of Philadelphia, injects just posterior to the great trochanter. Dr. Jackson selects the deltoid region, and thinks it makes but little difference where the insertion is made. Dr. White, of Buffalo, injects over the abdomen, into the cervix uteri, and into the substance of the tumor if it is accessible, and has met with no bad results. Dr. Wey used over two hundred injections in the abdominal region above the pubes in one case, and abscesses occurred in the seat of the puncture as often as once in eight operations. Dr. Dean commenced using ergot in the form of Squibb's fluid extract by injecting it into the cavity of the uterus through a DISEASES OF WOMEN AND CHILDREN. 19 flexible catheter, but now he employs the solution of Squibb's solid extract dissolved in water-one grain to five minims. Of this he injects from ten to fifteen drops into the substance of the cervix about four times a month or once a week. He thinks the effects are more prompt and energetic than when administered hypoder- mically. His instrument consists of a barrel the same size as the common hypodermic syringe and a tube six inches long. He has known inflammation and suppuration to follow but once in his whole experience. Different Preparations. Believing the preparation of the medicine employed had much to do in causing the irritation thus observed, efforts have been made to find some form that would not produce the painful results thus described. Hildebrandt is now in the habit of using Dr. Wernich's formula for the watery extract of ergot, and Dr. Mundd thinks it is very similar to the preparation made by Dr. Squibb. Dr. Hildebrandt added pure glycerine in the proportion of about one part to four of the solution, and the amount of the injection was forty minims. This contained a little over two grains of the extract; probably representing ten to twelve grains of the crude ergot. Most American practitioners now use Dr. Squibb's preparation above referred to, some of them by dissolving it in pure water, while others add to the water a small amount of pure glycerine. Dr. Squibb recommends a solution of this extract as follows: Dissolve two hundred grains of the extract in two hundred and fifty minims of water by stirring; filter the solution through paper, and make up to three hundred minims by washing the residue on the filter with a little water. Each minim of this solution repre- sents six grains of ergot in powder. Of this solution from ten to twenty minims are injected once daily or once in two days. This is the only preparation I have used in hypodermic injections, and I believe it the best we can at present procure. Dr. Wey properly lays great stress on the necessity of having the solution fresh, believing that in a very short time it deteriorates, and becomes more irritating to the tissues. He says, " ergot thus administered generally produces prompt effects. In most instances, in half an hour the patient experiences painful contractions of the uterus. The hand applied over the organ at once recognizes the increased hardness in the mass. These contractions increase in 20 ADDRESS IN OBSTETRICS, severity for the first two hours, and then continue with vigor for from six to ten hours, gradually becoming less until they cease entirely. Some patients suffer so much from these pains as to refuse to proceed in the treatment, while others bear them without much inconvenience. We do not always observe these painful effects even when the drug operates very beneficially. Sometimes the hemorrhages are controlled, as it were, insensibly, and the tumor slowly decreases in size without the patient experiencing any considerable discomfort. It seems highly probable, from the statements made by my correspondents, and especially Dr. Wey, as well as my own observations, that the benefits of the remedy are produced with more rapidity in the early part of the treatment. The preparation used internally more frequently than any other is the fluid extract, either alone or in combination with belladona. Each minim of Squibb's Fluid Extract is equal to one grain of ergot. Some recommend that it be given in doses of thirty drops three or four times a day. Others believe that it should be given in larger doses less frequently repeated, as for example one drachm once or twice in twenty-four hours. It is efficacious given in either way, but probably more so in the larger and less frequent doses. This preparation is so offensive, and causes so much nausea in exceptional instances, that it cannot be borne. Dr. Squibb claims that his solid extract does not offend the stomach so frequently as the fluid extract. This extract may be used in pills coated with gelatine. A pill of five grains is equal to twenty grains of the crude ergot, and may be administered twice or three times daily. From observation of the effects of the different preparations, I am satisfied that this is altogether the most efficient and agreeable for internal administration. A suppository for the rectum, which in Dr. White's practice acted satisfactorily, may be composed of fifteen grains of the solid extract, and enough gelatine to give it size and form. I have no doubt of the great usefulness of this method of administering ergot. I think it is also quite certain that the addition of belladonna in some cases increases the curative effects of ergot; how much I am not quite sure. Dr. Goodrich, who reached such splendid results, gave the fluid extract of ergot and belladonna together throughout the entire treatment of his case. From what has been said it may be inferred that hypodermic injection, if the most efficacious, is also the most objectionable DISEASES OF WOMEN AND CHILDREN. 21 method of using the ergot, and that in many cases the exhibition of it in this way is rendered entirely impracticable because intol- erable to the patients. The profession is much indebted to Dr. E. R. Squibb for his most eligible and efficient preparations of the drug, bo h for hypodermic injection and internal administration. May we not hope for great improvement still in the pharmacy of ergot ? Ergot produces many good effects besides reducing the size of the tumors and relief of hemorrhage. I have seen, and some of my correspondents mention, great functional improve- ment in the more important organs. Some patients are relieved by it of obstinate constipation ; the appetite is improved, and the general health restored. This remarkable salutary effect is obvi- ously due to its action on the ganglionic nervous system. In ex ceptional instances, ergot has very disagreeable effects. Dr. Goodrich mentions inflammation of the uterus as one, and my patients often complain of great heat and tenderness in the uterine region. Hildebrandt speaks of one case in which, after the sixth injection, the patient complained of vertigo, imperfect control of her lower extremities, and slight spasms of the flexor muscles oi the forearm. Dr. Wey observed severe general nervous perturba- tion to follow its use in one instance. And Dr. Morris's patient discontinued treatment because of the terrible and tumultuous effects upon the uterus. Dr. E. P. Allen, of Athens, Pennsylvania, sends me the report of a very interesting case of fibrous tumor treated by hypodermic injection of ergot, in which phlebitis supervened. A condition of one limb was produced precisely similar to phlegmasia alba do- lens, and ran its protracted course to a favorable termination. Prior to the accident the tumor had very much decreased in size, but after the treatment was suspended and during the course of the phlegmasia, it rapidly increased again, and the hemorrhages which had been controlled returned. After trying other methods of treatment without any good results, he and his patient in despair were driven to the use of ergot again. It was tried inter- nally with some good effects, but as the remedy thus administered disagreed with the stomach, it was again injected hypodermically with rapid improvement. The injections were used on the side of the abdomen, opposite to that formerly affected with phlebitis. After a number of injections, signs of inflammation of the veins were again observed, and the sound leg passed through all the stages of phlegmasia that had been observed in the first. From 22 ADDRESS IN OBSTETRICS, the intelligent observation of Dr. Wey and others, we may fairly conclude that it is not improper to continue the use of ergot during the menstrual flow. I can also add my testimony as to the entire harmlessness when given during that periodical flow. Auxiliary Treatment. With the exception of Drs. Goodrich and Howard, all the writers and correspondents quoted, have depended exclusively on ergot for the removal of fibrous tumors of the uterus; in fact, the treat- ment has been experimental, and had for its object the solution of the question suggested by the publication of Hildebrandt's articles on the use of ergot; viz., will ergot cure fibrous tumors of the uterus? The course pursued was well calculated to, and I think did, test Hildebrandt's treatment pretty thoroughly, but it is doubt- ful whether this exclusiveness is the best practice. The well-known alterative and sorbefacient medicines have, in rare instances, been credited with the cure of these tumors without the aid of ergot, and it is not difficult to understand that absorption may be pro- moted with more certainty by the alkaline bromides and iodides, where the vitality of the tumor is first impaired by the action of ergot on its vessels and the muscular fibres surrounding it. Dr. Goodrich seems to have held this view of the alterative treatment, as he prescribed iodide of potassium and bichloride of mercury with ergot. Dr. Howard also employed alteratives in the same way. Both of these gentlemen combined belladonna with ergot. The efficiency of this combination, as represented by their reports, justifies us in believing that the alteratives employed by them were auxiliary in a high degree. How much may be effected by judi- cious alterative and other auxiliary treatment will doubtless be determined by future observation. Corrective Treatment. By this I mean treatment that will prevent or ameliorate the disagreeable effects of ergot in certain exceptional instances. The distressing pain caused by it may sometimes be made more tolerable by the administration of hydrate of chloral, without very materially influencing its other effects. Indigestion, constipation, hydraemia, and nervous debility may be corrected by tonics, alte- ratives, laxatives, and stimulants given simultaneously with ergot. In short, the general condition of the patient should be cared for in the same rational manner as if ergot was not being administered. DISEASES OF WOMEN AND CHILDREN. 23 General Conclusions. The fibrous tumor of the uterus may be affected by ergot in three ways:- 1. It may be gradually disintegrated and absorbed. In this way it disappears without any violent or disagreeable symptoms. 2. Its nutrition may be so interrupted as to produce a rapid destruction of its vitality; thus, decomposition may occur within the capsule, and a semiputrid mass be expelled a little later. This process is accompanied with evidences of inflammation of the uterus, and toxaemia more or less grave, according to the size of the tumor, the length of time between the commencement of de- composition and the expulsion of the tumor, and the vital resist- ance of the patient. 3. The tumor, inclosed in its capsule, may be totally or partially expelled from the cavity of the uterus, attended with a greater or less degree of inversion of the organ. In this condition it becomes amenable to surgical process for completing its removal. When these tumors disappear in the manner first mentioned, no evil consequences to the patient are experienced, but grave and even fatal effects are likely to arise during their gangrenous dis- integration within the uterine tissues. Even when the tumor is small, great suffering and peril to the patient supervene, and when large it is pretty certainly disastrous. I have not been so unfor- tunate as to witness fatal consequences from the effects of ergot, but I have seen the overwhelming results of gangrenous disinte- gration of large fibrous tumors arising from other causes. In the case of a large tumor now under treatment, I was upon one occasion forcibly reminded of what might happen by the violent and pro- longed contractions of the uterus, brought about by large doses of ergot. Very dangerous symptoms of inflammation were excited in this case. I Ergot is not always immediately, or even soon, followed by con- traction of the uterine fibres. Its effects are in certain cases cumulative; hence its steady administration for a length of time may be followed by extremely violent and prolonged action when it does occur. In the case above referred to, its effects were not observed until the patient had taken the medicine for two months; then with explosive suddenness the patient was attacked with terrific uterine contractions, which did not subside under the use of opium and chloral until the fifth day. The patient took the 24 fluid extract internally. This effect should be regarded as possible in all cases where the patient appears to resist the influence for several weeks, and when the tumor is large we should be cautious to avoid, and prompt to counteract, such consequences by appro- priate means. The violent action of ergot may also be brought about some- what suddenly by increasing the quantity beyond a moderate amount. From a review of the cases it will be seen that the gradual dis- appearance of the tumor takes place under doses too small to cause the violent action here referred to. Dr. Hildebrandt admin- istered hypodermic injections containing what was equivalent to fifteen or twenty grains of crude ergot once a day or every second day. Dr. Dean's treatment proved to be sufficient, although the amount was not greater than Hildebrandt's, and was administered but once a week. Our opportunities for observation have been too limited to enable us to arrive at accuracy of detail in the use of ergot for the cure of fibrous tumors of the uterus. I think, however, we are warranted in saying that moderate doses of ergot, say half-drachm doses of the fluid extract twice or three times a day given inter- nally, or five grains of the solid extract once a day hypodermically persistently used, is generally sufficient when we wish to cause a gradual disappearance of the tumor, and that this quantity should not be exceeded in the treatment of large multinuclear tumors. When, however, we desire to cause the expulsion or gangrenous disintegration of a tumor, it is necessary to give much larger quantities and persevere until it produces the violent action neces- sary for such effects. I conclude my address with the cautionary observation that ergot, in the treatment of fibrous tumors of the uterus, is a prompt and very powerful agent, which cannot be recklessly used without great danger; and that much careful observation is still necessary to enable us to determine the circumstances under which its ad- ministration will be both safe and effective. ADDRESS IN OBSTETRICS, ETC.