With Compliments of Author. 
A CONTRIBUTION ' 
TO THE 
HYPODERMIC ERGOT TREATMENT 
OF 
UTERINE MYOMATA. 
LARGE INTERSTITIAL MYOMA-COM PLETE DIS- 
APPEARANCE AFTER ERGOT HYPODERMI- 
CALLY-SPEEDY PREGNANCY-RETURN 
OF TUMOR-ABORTION-SEPTICE- 
MIA-DEATH-REMARKS. 
BY 
ADOLPH KESSLER, M.D., 
NEW YORK. /•> V- 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XIII.. No. III., July, 1880. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1880. A CONTRIBUTION 
TO THE 
HYP0DERMI6 ERGOT TREATMENT 
OF 
UTERINE MYOMATA. 
LARGE INTERSTITIAL M YOM A-CO M PLETE DIS- 
APPEARANCE AFTER ERGOT HYPODERMI- 
CALLY-SPEEDY PREGNANCY-RETURN 
OF TUMOR-ABORTION-SEPTICE- 
MIA-DEATH-REMARKS. 
BY 
ADOLPH KESSLER, M.D., 
NEW YORK. 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XIII.. No. III., July, 1880. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1880. A CONTRIBUTION TO THE HYPODERMIC ERGOT TREATMENT 
OF UTERINE MYOMATA. 
LARGE INTERSTITIAL MYOMA-COMPLETE DISAPPEARANCE AFTER ERGOT 
HYPODERMICALLY-SPEEDY PREGNANCY - RETURN OF TUMOR- 
ABORTION-SEPTICEMIA-DEATH-REMARKS. 
BY 
ADOLPH KESSLER, M.D., 
New York. 
The many interesting and instructive features of this case 
have induced me to report it at a length which I think it 
merits and which I trust will meet the approval of my readers. 
Mrs. a tall, blonde, handsome lady of American parentage 
and good family, aged thirty-seven, had suffered a miscarriage in 
the first year of her wedded state, about seventeen years ago, for 
the purpose of preventing offspring, and this resulted in serious 
and long-continued disorders of the generative organs. The 
patient came under my professional charge in 1872, suffering from 
endometritis, menorrhagic and metrorrhagic flows, uterine dis- 
placement, etc., but recovered her health almost entirely in the 
course of time, only remaining unfruitful in spite of her earnest 
desire of becoming a mother. 
The tedious, protracted illness and subsequent death of her 
husband, in the winter of 1878, caused a return of some of her 
previous troubles, and being in a state of great mental dejection, 
she imagined the presence of a uterine tumor-a spectre that had 
haunted her for many years past. I found, on a careful examina- 
tion, no sign of a foreign growth, and in order to fully disarm the 
suspicions which yet lingered in her mind, sent her to Dr. T. G. 
Thomas, who entirely corroborated my view. When seeing the 
patient again, six months later, after her return from travel, I 
found her afflicted with severe frontal and occipital neuralgia of 
a malarial type, and with furuncular abscesses, all of which 
troubles yielded readily to an appropriate medical and surgical 
treatment, but seemed to leave her in an anemic and somewhat 
exhausted condition. She complained further of a profuse flow 
at the menstrual periods and of occasional sharp pains in the 
pelvic region and back, but ascribing these symptoms to constitu- 
tional debility, and being also partially accustomed to them by 
previous long suffering, she felt disinclined to submit at the time 
to any special treatment, and preferred, with the aid of a tonic 
regimen and diet, to trust to nature for her entire recovery. 4 
I did the best that could be done under the circumstances, but 
neither iron, quinine, milk, beef-tea and Burgundy wine, nor the 
vis medicatrix naturae-for which I certainly entertain an un- 
bounded respect-appeared to exercise any beneficial influence 
upon her general condition, or to cause an abatement of her 
menstrual derangements. Feeling at last dissatisfied with this 
purely symptomatic mode of treatment, and suspecting a deeper, 
yet to me unknown cause of the persisting hemorrhage and 
pelvic irritability, I strongly urged an examination, to which the 
patient finally yielded. 1 was indeed surprised and startled to 
find an extremely large fibrous uterine growth, of the existence 
of which the patient had not the slightest suspicion, and of 
which only nine months previously neither Dr. Thomas nor my- 
self had detected the faintest vestige. 
On inspection, the abdomen appeared quite prominent, and en- 
larged by a nearly uniform swelling resembling gravidity between 
the sixth and seventh months, and upon palpating I felt through 
the yielding abdominal parietes a large and but slightly resistant 
tumor, of apparently smooth surface and rounded form, which 
moved simultaneously with the uterus on bimanual manipulation. 
Percussion yielded a dull note corresponding to the area marked 
by the borders of the growth, and auscultation revealed a faint, 
but plainly audible sound, closely simulating the uterine souffle. 
There was nothing particularly noticeable about the vagina. 
The vaginal portion of the cervix was remarkably shortened, 
looked downwards and backwards and could be reached pretty 
easily. To determine the length and direction of the uterine 
cavity and the exact anatomical character and location of the 
tumor, I introduced the sound with great difficulty, and under 
varied manipulations, but succeeded in reaching the fundus. From 
the considerable enlargement and elongation of the uterine cavity 
and its crooked direction, the unequal outline of the uterus, the 
prominent bulging out of its posterior wall, and the peculiar 
curve described by the sound in passing up to the fundus, I was 
enabled to ascertain that the growth belonged to the intraparietal 
order, imbedded in the muscular parenchyma of the anterior wall 
of the uterus, and that it did not project into or fill any portion 
of the uterine cavity. A rectal exploration confirmed this diag- 
nosis to the exclusion of any other disorder and complication. 
The growth, which gave to the palpating hand the impression of 
being rather soft and elastic, appeared to be a pure myoma; it ex- 
tended vertically about six centimetres above the umbilicus, and 
measured transversely a little more than twenty centimetres. 
Profiting by my limited yet highly successful experience in the 
treatment of fibrous growths by means of subcutaneous injections 
of ergot, and chiefly encouraged by the gratifying result obtained 
in a case of considerable importance, I resolved to employ the 
same method in this instance. The case referred to just now 
concerned an extremely large submucous fibrous tumor of many 
years' standing, together with a cervical polypoid growth project- 
ing from the uterine canal far down into the vagina, which had at 5 
various times given rise to almost fatal hemorrhages and induced 
a chronic state of exhaustion from anemia, and the many and 
serious functional disturbances due to continued pressure on the 
abdominal and thoracic viscera. 
I removed the polypoid growth with the ecraseur, and com- 
menced injecting ergot subcutaneously, not with the ulterior view 
of affecting the tumor itself, but for the purpose of combating 
the most urgent and threatening symptoms. Noticing the 
splendid effect of the injections in checking the profuse menor- 
rhagic and metrorrhagic flow, in ameliorating all other morbid 
symptoms, and improving the patient's general health, I persisted 
in their application, and was finally gratified to observe a notable 
diminution of the size of the tumor. It also became tenser, 
harder, and more contracted, from which changed material bulk, 
consistence, and feel, I felt justified in inferring that it was under* 
going cirrhotic, atrophic induration. I made seventy-five injec- 
tions which were well borne and caused no unpleasantness what- 
soever, and although more than two years have elapsed since, the 
tumor has remained in statu quo without producing hemorrhage 
or any other derangement, and it promises to make no further 
mischief in its present innoxious state. 
In some of my previous cases I had made use of the formulae 
first suggested by Hildebrandt, Langenbeck, and others, but hav- 
ing found these solutions altogether too irritating and giving rise 
to inflammation and painful hardening of the tissues with a ten- 
dency to abscess, I have discarded alcohol, glycerine, salicylic 
acid, and other vehicles that were in vogue, and substituted a 
simple, aqueous solution, carefully filtered and freed from all in- 
herent impurities. The formula which I can most heartily 
recommend from personal experience, and which has invariably 
rendered me good service within the last three years, is Squibb's: 
Sixty grains of the extract of ergot dissolved in two hundred 
and fifty minims of water-the solution filtered and made up to 
three hundred minims by passing water through the filter to wash 
it and the residue upon it-makes a solution which 'represents 
ergot in the proportion of minim for grain and is of the same 
strength as the fluid extract of ergot, but is free from alcohol or 
other irritant substance. 
Having obtained the patient's consent, I commenced the sub- 
cutaneous injection of ergot on the 31st of January, 1879, with a 
hypodermic syringeful, slightly diluted with distilled water. The 
first six were made every second day, but finding that they were 
well borne in every respect, I made the subsequent ones every 
day regularly and uninterruptedly, and especially and intentionally 
during the course of the menstrual flow, which they appeared to 
regulate and control in a remarkable manner. I speedily gained 
the opportunity of perceiving their beneficial influence in checking 
the profuse quantity of the flow and shortening the duration of 
the latter, but operating under the firm belief that fibrous growths 
of the uterus were particularly amenable to this method of treat- 
ment during the menstrual period, I hoped furthermore to be 6 
able to effect a reduction in the size of the tumor, and in this 
expectation I was not deceived, thus fully confirming in that 
respect the observations of Hildebrandt, Leopold, and others. 
At the beginning and end of three consecutive menstrual 
periods I made accurate measurements-vertically and trans- 
versely-and every time I had the satisfaction of recording a not- 
able shrinking and diminution of the size and volume of the 
growth, together with a denser, harder consistence of its mass, 
probably due to the contraction of its own muscular fibres. 
Three months after the inauguration of this treatment, the case 
presented the following features. The menstrual discharge was 
almost normal in quantity and duration, and marked by a total 
absence of any unpleasant symptoms, the painful sensations about 
the pelvic region and along the thighs, together with the tencsmic 
feeling in the bladder and rectum, had disappeared, the anatomical 
size of the tumor was reduced to about seven and a half centi- 
metres; while the general health, strength, appetite, and cheerful- 
ness of the patient were better than for years past. 
Such was the state of things about the first of May, when the 
first mishap in connection with my treatment occurred, owing to 
an imprudence on the part of the patient, in leaving the house 
and walking for several consecutive hours almost immediately 
after being injected, instead of resting in bed and applying cold 
compresses, as she had invariably done in the past under my 
directions. The immediate result of this indiscretion was a 
sudden and painful inflammation and hardening of the tissues in 
the neighborhood of the last point of insertion which rapidly 
spread and was followed by a pretty severe abscess. As the 
abdominal walls were more or less involved in the inflammatory 
process and the patient was suffering great inconvenience, I was 
compelled to suspend the injections, of which up to that date 
seventy-eight had been made. The patient, indeed, was anxious 
to have them continued, but my judgment did not approve of it. 
While the abdominal tissues remained in a partially inflamed 
and indurated state and the subcutaneous injections were imprac- 
ticable, some other method of employing the ergot, either inter- 
nally or by means of suppositories, suggested itself, but upon a 
careful consideration of all the circumstances, I resolved to sus- 
pend the specific ergot treatment altogether for the time and give 
all my attention to the speedy cure of the abscess. Apart from 
other reasons, I was fortified in this resolution by my anxiety to 
test the efficacy of the hypodermic method and the permanency 
of its effects. And happily there was no occasion for regret, for 
the patient proved no loser by my passive attitude, while I was 
enabled to gain a new and valuable experience. The next men- 
strual period passed without any unpleasant symptoms, and 
accurate measurements of the tumor made three weeks after the 
suspension of the ergot treatment failed to show any demonstrable 
increase in its size and volume. 
The abscess having kindly healed and all pain resulting from it 7 
having subsided, I resumed the subcutaneous injections and con- 
tinued them without further interruption to the last day of the next 
menstrual period, when the number amounted to ninety-five in all. 
The uterus appeared then still somewhat larger than in the nor- 
mal state-more markedly so in the transverse than in the longi- 
tudinal direction-but I could not detect any appreciable vestige 
of the growth itself, and that determined me to discontinue the 
injections and all further active treatment and to transfer my 
patient to the healthful and invigorating sphere of country life, 
where the warm sunshine, air,bathing, exercise, and nutritious food 
promised to complete the restoration of her health and strength. 
In less than two months from the date of her departure, I was 
summoned to her residence in the city and notified that for the 
first time in seventeen years the menstrual flow had failed to make 
its appearance which under the circumstances-the lady being a 
widow-caused my surprise and raised her alarm. She complained 
also of occasional distressing pains in the pelvic region and back, 
and ascribed these sensations, as well as a feeling of tightness and 
a considerable swelling above the pubes, to the abscenco of the 
catamenia, which she was exceedingly anxious to have restored 
either by medicines or instrumental interference. Insisting upon 
an examination in order to see my way clearly before me, I 
detected a considerable prominence in the middle line, a distinct 
uterine tumor, resembling in form and size a gravid uterus in the 
third month, an indistinct swelling reaching up almost to the 
umbilicus, and found besides the os accessible to the index-finger, 
the cervix soft and patulous, the mammae somewhat turgescent- 
symptoms which greatly puzzled me, but strongly tended to arouse 
my suspicion of existing pregnancy, complicating a new develop- 
ment of the former, apparently absorbed fibrous tumor. I declined 
to introduce the uterine sound as requested by the patient, but in 
order to quiet her fears and mental agitation prescribed some 
harmless medicine, and doubtful of the issue, yet suspecting 
pregnancy, resolved to maintain a temporizing and expectant but 
watchful attitude. 
In the course of a few weeks, during which the patient's physi- 
cal and nervous condition began greatly to suffer, the rational 
and sensible signs of pregnancy, together with the rapid growth of 
the tumor, were so marked that I felt no further doubt as to 
the unfortunate complication, and her appeals for the relief from 
the distress becoming more urgent and desperate, I called Dr. 
Lusk into consultation. He found the cervix uteri much softened, 
and a general feel to the uterus which led him also to suppose 
that, while the case was one of fibroid tumor of the uterus, it was 
complicated by pregnancy. There were no fetal movements dis- 
cernible at the time-the 21st of August-nor could ballotte- 
ment be obtained. 
While I had suspected pregnancy from the beginning, I was, 
as can readily be imagined, not in a position to give utterance to 
my suspicion; the lady not being in a married state, highly edu- 
cated, refined, and of a most respectable family; but her anxiety 8 
to learn the truth became so great that I was finally obliged to 
reveal it. The consciousness of being pregnant, together with the 
alarm about the fearfully growing tumor, were a great shock to 
her, and frequently she threatened to take her life, unless speed 
ily relieved of her pains, and the disgrace that would follow the 
discovery of her condition. To paint a faithful picture of her 
bodily and mental sufferings, of the ever-shifting scenes of hys- 
terical exaltation and depression, of her nervous irritability and 
prostration, of the constantly present tenesmic feeling of weight, 
and dragging about the bladder and rectum, and the continual 
bearing-down pains, which deprived her of all natural rest and 
sleep, as pregnancy advanced, would be beyond the scope of this 
paper, and I must content myself with merely alluding to that part 
of the unfortunate woman's history. From that terrible state she 
was relieved on the 21st of September, by giving birth to what 
appeared to be a four-months' fetus. The delivery was sudden and 
rapid, comparatively painless, and free f rom all bleeding; it had, 
in fact, taken place before I had a chance to reach the patient's 
bedside. Anxious to avert all possible danger from hemorrhage, 
I determined at once to remove the placenta, but upon introduc- 
ing my hand, found the tumor projecting into the os, and so 
entirely blocking up the passage, that there was no room left for 
a single finger to pass up into the uterine cavity and reaching the 
placenta. Repeatedly made efforts to gain an entrance, and to 
lift up the tumor from its apparently fixed and immovable posi- 
tion, proved unavailing, and seeing that no help was to be ex- 
pected from nature, I administered ergot in large and frequent 
doses, and inserted, with great difficulty, placenta hooks, but 
made no progress in accomplishing my object. All these meas- 
ures, and several other modes of procedure, which I adopted for 
the removal of the placenta, miscarried, and feeling satisfied in my 
mind that the interfering tumor and high point of insertion of 
the adherent placenta rendered the forcible removal of the latter 
under the administration of an anesthetic imperative, I called in 
Dr. Lusk on the second day after the birth of the fetus. Up to 
this time, the patient had not had a distinct chill, but complained 
occasionally of chilly sensations; and there was a disagreeable 
odor, slightly perceptible in the sick-room. It was agreed to pro- 
ceed at once to remove the placenta, and for that purpose the 
patient was anesthetized, placed upon her back, and the entire 
hand introduced into the vagina, and two fingers alongside the 
tumor into the uterus, but the placenta was not reached. An 
attempt was then made to remove the placenta by means of Dr. 
Thomas' wire curette, and with it Dr. Lusk succeeded in removing 
a considerable portion of what appeared to be, under close exam- 
ination, decidual membrane. He then pushed the instrument up 
higher, and found that it was only long enough to reach a part of 
the placenta, and we decided, therefore, to postpone further inter- 
ference until an instrument suited to the purpose could be made. 
About half an hour after the anesthetic was discontinued, the 
patient was seized by an intense chill that continued for nearly 9 
an hour, and when it subsided, the temperature rose to 107° F. 
Owing to the severe symptoms which so rapidly followed upon the 
operation, we hesitated with regard to repeating it, especially as 
large pieces of the placenta occasionally came away with the intra- 
uterine injections that had in the meanwhile been decided upon. 
We contented ourselves with washing out the cavity of the uterus, 
as thoroughly as possible, with a disinfectant fluid consisting of 
carbolic acid. 
Dr. Chamberlain's glass tube was first used, but it was found 
that it was too large, and that it did not have the proper curve. 
A silver catheter was then used, but it could not be made to pass 
around the tumor; the smaller English catheters bent too readily, 
but with a large English catheter Dr. Lusk succeeded in reaching 
the fundus of the uterus, and injecting a quart or more of carbol- 
ized witter. The water returned freely, but, in the course of an 
hour, symptoms of collapse developed which were quite alarming. 
On the following day, the operation for washing out the uterus 
was repeated with the same results as before, bringing away small 
placenta clots, but giving rise again to a severe chill and to great 
collapse, which left the patient for a long time in quite an ex- 
hausted condition. After the third intrauterine injection had 
been made, the patient seemed somewhat improved, although the 
temperature, which at one time reached as low a figure as 99.5° F., 
quickly rose again, and remained most of the time at a very high 
range-alternating between 102° F. and 104° F. The chills had 
not returned, the patient had a fair amount of strength and appe- 
tite; there was no vomiting or other gastric disturbance; no 
symptom of peritoneal tenderness or inflammation, and as most, if 
not all, of the placental tissue had apparently come away with the 
injected fluid, and the intrauterine injections were always attended 
with severe chills and the danger of collapse, it was resolved 
to discontinue them. Antiseptic vaginal douches, however, by 
means of a fountain syringe were incessantly made, which seemed 
to add greatly to the comfort of the patient, while rendering the 
discharge from the vagina almost odorless. For the purpose of 
eliminating the septic poison from the system, and keeping in 
check the high fever and temperature, quinine, salicylic acid, 
morphine, and brandy were freely administered, internally and sub- 
cutaneously, and the cutaneous surface was sponged with cold 
water at frequent intervals; restlessness and sleeplessness were 
successfully combated by chloral enemata, and the patient's 
strength sustained by a generous allowance of milk, beef-tea, cham- 
pagne, wine jelly, etc. There seemed to be thus a fair prospect 
of recovery-at least as far as the imminent danger threatening 
from septicemia was concerned-when all of a sudden, on the 
evening of the fourth day after the operation under narcosis had 
been performed, the patient awoke from a quiet and comfortable 
slumber, complaining of a very severe chill, and asking for more cov- 
ering. In the courseof an hour, a violent burning fever set in, and 
the temperature rose quickly from 100.5° F. to 100.5° F.. while the 
pulse ran up to 160, and became quite irregular, and at times 10 
wholly imperceptible. The patient fell into a soporons state from 
which she occasionally rallied with a clear and unclouded con- 
sciousness, realizing her approaching death by dictating her last 
will and testament, and disposing in a truly courageous and phil- 
osophical manner of her worldly affairs, and breathed her last on the 
following morning, the 2d of October (after having finished, in a 
loud and ringing voice, this sentence: " Oh, what a battle, I won't 
give up the struggle, and shall yet come out victorious! "). 
The autopsy was made thirty hours after death by Dr. Wm. II. 
Welch, in the presence of Dr. Lusk and myself, with the follow- 
ing result: 
Heart normal. Lungs: old adhesions on right side; edema, 
hypostatic congestion of the right lung. Peritoneum normal. 
Spleen large and soft, twenty-two centimetres in length, eleven in 
breadth. Kidneys: the right, thirteen centimetres long, the left, 
fourteen. Cortical substance swollen and cloudy, somewhat decom- 
posed. Liver decomposed, otherwise nothing noticeable. Intes- 
tines: slight catarrhal inflammation, evidence of coating with a 
thin layer of mucopus and enlarged solitary follicles. Uterus, etc.: 
the pelvic cavity and the remaining lower portion of the peritoneal 
cavity are filled with a tumor reaching to the umbilicus. The new- 
growth lies in front of the small intestines; across its upper border 
is stretched the transverse colon. The external surface of the 
tumor is smooth and glistening, it is found to occupy the ante- 
rior wall of the uterus. Its cut surface presents the usual appear- 
ance of a uterine myoma, its consistence is that of moderate 
firmness. It measures fifty-nine centimetres in circumference at 
its broadest portion, and twenty centimetres in length, and 
weighs about eleven pounds. The greater portion of the anterior 
wall of the uterus can bo traced over the front surface of the 
tumor. 
The uterine cavity lies behind the tumor, and is markedly 
curved to the left of the median line. The cavity of the cervix is 
five centimetres long, that of the body of the uterus, fifteen cen- 
timetres long. The thickness of the posterior uterine wall in the 
middle of the body of the uterus is two and a quarter centimetres; 
that of the anterior wall, which can be traced over the tumor, is 
three-fourths of a centimetre. 
The inner surface of the uterus is apparently devoid of a mucous 
membrane, is of a greenish color, and emits a foul odor. Near 
the left cornu is quite firmly attached a sloughy mass which pro- 
jects into the cavity of the uterus. This mass is six centimetres 
in breadth, three in length, and one in thickness. It consists of 
a fragment of retained placenta; otherwise, the inner surface of 
the tumor is smooth. Numerous wide veins can be seen both in 
the posterior uterine wall and in the muscular coat and the new- 
growth which constitute the anterior wall; but in none can be 
detected ante-mortem thrombi or puriform material. 
There is a second small myoma, rather smaller than a hen's egg, 
in the lower portion of the posterior uterine wall. 
The right ovary is four centimetres long, and contains a corpus 11 
luteum with yellow sinuous border one centimetre in length. 
There are several small cysts in the broad ligament between Fal- 
lopian tube and ovary (meso-salpynx); some occupy the site of the 
organ of Kosenmueller, the structure of which cannot be detected. 
The lateral portions of the Fallopian tubes are distended with 
serum (hydrops tuba?). 
Bladder, vagina, and ureters present nothing abnormal. Diag- 
nosis, Myomata Uteri. Cause of death, Septicemia from reten- 
tion and decomposition of a portion of the placenta. 
At the suggestion of Dr. Lusk, I presented the tumor at the 
stated meeting of the New York Obstetrical Society, on the 
7th of October, 1879, with a brief outline of the history and 
autopsy. Dr. Lusk and myself agreed that it was a case of 
pure septicemia, as there were no evidences of inflammation 
either in the uterus or the peritoneum revealed by the post- 
mortem examination, nor had there been any symptoms point- 
ing to such a complication during life. Dr. Lusk took occa- 
sion to explain the sudden development of intense symptoms 
soon after the use of the curette, to the inoculation produced in 
drawing portions of the decomposing decidual tissue over the 
Natural size. Length of whole instrument 16". Shank unscrews in 
middle. 
mucous surface of tlie uterine fibroid, and believed that the 
disinfectant injections were efficacious until they were sus- 
pended, twenty-four hours before death, and that the patient 
died in consequence of the intense septicemia developed within 
that time. He further suggested that a long piece of copper 
wire, with rounded extremity and long handle, both suffi- 
ciently long to enable the operator to reach the fundus with- 
out difficulty, would be an available instrument in such cases. 
It may be as well to state here that an instrument for this very 
purpose, resembling a large Thomas' curette, has since been 
devised by Drs. Lusk and Munde, independently of each other. 
The history of this case illustrates several points of interest 
to which I wish briefly to allude : 
First. The rapid development of the first fibrous growth. It 12 
is upon record that no diagnosis of a uterine fibroid tumor 
could be made in April, 1878, and yet only nine months later, 
in January, 1879, a fibrous growth was detected as large as a 
man's head, and which-to judge from comparison with the 
second-could not have weighed less than twelve pounds. In 
spite of its rapidly increasing bulk, it caused few if any 
marked symptoms, until late in the fall, and even then, after 
having attained unusually large proportions, its presence was 
unsuspected by the patient, who had up to a recent period, and 
for years past, been haunted by the fear and suspicion of harbor- 
ing a tumor. 
Second. The best observers deny that sterility and abstin- 
ence from sexual cohabitation predispose to the development of 
uterine fibrous tumor, as has been assumed by Bayle and other 
pathologists after him ; but it is pretty generally conceded 
that foreign growths induce very frequently barrenness. And 
yet, in this instance, we see a sterile married life of seventeen 
years' duration, followed by conception and pregnancy after 
the formation of a large fibrous tumor. How is this to be ex- 
plained ? Was impregnation at such a time, and under such 
circumstances as above related, a mere chance and coinci- 
dence, or is it more rational to look for a causal connection ? 
Is it altogether impossible to assume that the subcutaneous 
injections of ergot brought about such a vital change in the 
tissues of the ovaries and womb, and silch an improvement in 
the functional capacity of these organs, as to render them fit 
to obey the laws of nature, capable of conceiving, and of carry- 
ing and developing a fetus? 
I am, of course, wholly incompetent to answer these queries 
in the affirmative, but if a mere chance impregnation be 
excluded, as it well may be under all the circumstances of this 
case, the subject of inquiry is assuredly worthy of considera- 
tion. In one thing, however, I believe I am not mistaken, 
after my carefid, though limited observations, and that is in 
the tonic and highly beneficial effects which subcutaneous in- 
jections of ergot produce, not only upon the female generative 
organs, but also upon the whole system. 
Third. In studying the pathogenetic history of the second 
tumor, it is of great interest and importance to take into con- 
sideration its relation to the one that had preceded it, and to 13 
the pregnancy by which it was complicated. When I dis- 
charged the patient, and sent her to the country, the first 
tumor had apparently disappeared, as if by absorption, or, to 
speak more accurately, I was wholly unable to detect any 
anatomical proof' of its existence. Its rapid re-development, 
however, under the favoring physiological and pathological 
conditions of gestation, seems to prove that it was not entirely 
absorbed, but merely reduced to such small dimensions in size 
and volume as to become absolutely imperceptible to the 
digital touch, as much so as the patient's immunity from all 
morbid symptoms had made it imperceptible in an other diag- 
nostic sense. 
It is hardly necessary to entertain the theory that the second 
growth was a relapse. Although the testimony in regard to 
the relapse of myomatous growths of the uterus, after their 
removal or disappearance, is still conflicting, the preponderat- 
ing weight of evidence tends to prove that a tumor of that 
character, once effectually removed, does not reappear in the 
same place, thereby evincing its benign nature, as distinguished 
from sarcoma, carcinoma, etc. 
On the other side, however, it may be fairly conceded that 
the tumor would very likely not have reappeared, or given any 
further trouble, had it not been for the complicating preg- 
nancy. The well-established experience of gestation exercis- 
ing a very marked influence over fibrous growths, especially 
those closely related to the uterus as to seat and structure, is 
fairly illustrated by this case. It shows a tumor wellnigh 
removed, at any rate reduced to a mere rudimentary, unappre- 
ciable size, perhaps only to a simple hypertrophied condition 
of the uterine parenchyma, again attaining such large propor- 
tions, in the third month of gestation, as to cause grave and 
numerous disturbances. But we need scarcely be surprised at 
that rapid and remarkable change, when we consider for a 
moment the precise anatomical structure of the tumor, as un- 
mistakably revealed by the autopsy. 
While the pure fibroma, chiefly consisting of rigid, unyielding 
fibrous connective tissue, will under such circumstances undergo 
but a trifling change, and more frequently still resist this 
altogether, the true myoma, on the other side, will the more 
readily participate in the steady growth and enlargement of 14 
the uterus the more its purely muscular elements predominate, 
the more vascular and contractileitis, and the more intimately 
it is incorporated in the uterine tissue without the separating 
boundary line of a capsule. 
The rather sudden, rapid, and powerful development of the 
second tumor, under the favoring condition of pregnancy, 
docs not in the slightest contradict the numerous observations 
of foreign growths having disappeared through gestation and 
child-bearing. Had the patient been so fortunate as to go to 
and be delivered at full term with safety, the tumor might 
have more or less undergone a retrogressive metamorphosis, 
corresponding to the physiological changes of parturition and 
childbed, and the consequent retrograde changes in the mus- 
cular tissue of the uterus. 
Fourth. If pregnancy affects to a greater or lesser degree 
the growth of uterine tumors, the influence of the latter upon 
gestation is no less marked and frequently of very grave im- 
port, as in the case here related. But this influence is not so 
much determined by general laws as by individual circum- 
stances, for while we see at times pregnancy run its normal 
course, though complicated by enormously large tumors, we 
see it at others interrupted by the presence of very small 
fibroids. Gusserow, in his excellent treatise, " Die Neubil- 
dungen des Uterus" furnishes the following statistical figures. 
Toloczinow met with 21 miscarriages in 119 cases of preg- 
nancy complicated with fibrous tumors ; West with 28 in 36 
cases; Winckel with 16 in 46 cases; Nauss with 47 in 241 
cases, and Sebile'au with 15 in 47 cases. According to For- 
get, Sebileau and Toloczinow, the tumors which are seated in 
the fundus uteri favor rather abortion, while the cervical 
growths are more apt to induce premature labor-a theory 
that requires further confirmation before it can be generally 
accepted. In the particular case before us, there was no 
specially predisposing cause for the abortion, such as hemor- 
rhage, uterine displacement, or fixation of the organ within 
the pelvis, and we must, therefore, conclude that it was brought 
about by the direct interference of the tumor, and by its 
irritating influence upon the walls of the uterus. 
Fifth. In studying more closely the relations between preg- 
nancy and uterine fibrous growths, we are struck by the 15 
singular observation that almost all accurately described 
cases of that complication, when properly examined and 
sifted, concern subperitoneal tumors (Gusserow). 
These growths, in consequence of their subserous attach- 
ment to the uterus, participate but slightly in the physiologi- 
cal processes that take place upon the mucous membrane of 
the uterine cavity during gestation, parturition, and childbed, 
and affect, therefore, but little, if at all, directly, these vital 
events. In view of these undeniable facts, it admits of but 
little doubt that the subserous tumors of the uterus form the 
chief, if not almost exclusive material for study and observa- 
tion in connection with the above conditions. And as a 
further deduction remains the true fact, that the number of 
interstitial and submucous myomatous tumors complicating 
pregnancy is-and must be by the very nature of things-ex- 
ceedingly small. 
Sixth. The treatment of uterine tumors with ergot, and 
more especially by the method of subcutaneous injections, has 
been for several years past, and is still, a fruitful theme of dis- 
cussion and controversy in the medical literature. Lauded 
by some to the skies as a true specific for the cure of uterine 
growths, it has by others again been rejected as utterly unre- 
liable and worthless. The truth lies here, as elsewhere, in 
the golden middle. 
Almost all observers concur now in the opinion that the 
administration of ergot, more especially in the form of subcu- 
taneous injection, exerts a positive influence in arresting hemor- 
rhage and correcting menstrual derangement resulting from 
the presence of fibrous growths; this fact is, I believe, placed 
beyond all doubt and cavil by the almost unanimous verdict 
of the profession throughout the world. 
There is further a mass of reliable and authentic testimony 
in existence which goes to show that ergot is very often effica- 
cious in diminishing the bulk of uterine tumors, in relieving 
their symptoms, and in checking their further growth either 
permanently or temporarily. 
And there have again been many cases, published by highly 
competent and trustworthy observers, proving that the subcu- 
taneous injection of ergot has been instrumental in bringing 
about expulsion, cirrhotic induration, atrophy, and complete 16 
absorption of uterine tumors. This latter radical effect of the 
treatment is, to be sure, still denied by our first gynecologists, 
who maintain at best a passive and skeptical, if not an inimi- 
cal attitude, but nevertheless the practice is constantly gaining 
new adherents and friends. 
Its universal adoption is only a question of time, and in my 
humble opinion it is destined to meet -with splendid and un- 
failing success as soon as the proper indications for its em- 
ployment shall rest upon a thoroughly scientific basis and a 
rational discrimination. 
The chief cause of its failure in so many cases, and of the 
discredit attaching to it on that account, lies undoubtedly in 
its improper and irrational use, when either the histologi- 
cal structure of the tumor, or its position, or the presence of 
unfavoiable complications, render success impossible. Apart 
from the mode and care of performance, the selection of the 
proper preparations, and the continuation of the treatment, 
the applicability and therapeutic value of the subcutaneous 
injections of ergot depend chiefly upon the location, structure, 
and consistence of the fibrous growths and the absence of 
complicating disease. Very little if any success will be ob- 
tained in tumors situated upon the serous surface of the 
uterus, irrespective of their form, size, and histological charac- 
ter. In the class of interstitial and submucous fibrous growths, 
however, the elementary structure and degree of consistence 
of the same furnish the most tangible criterion of success. 
The true fibroma, consisting almost exclusively of rigid, un- 
yielding fibrous connective tissue, will resist the action of the 
drug and remain unchanged, while the true myoma, of soft, 
elastic or only moderately firm consistence and structure, will 
be the more promptly and effectually influenced the more its 
muscular elements predominate, the more intimately it is 
incorporated with the uterine substance, the more vascular 
and contractile it is, and the more rounded in contour and 
uniform in development. The interstitial myoma, especially 
when uninvested with a capsule and forming, so to say, an 
integral part of the uterine parenchyma, offers by far the 
best chances for treatment, gives the happiest results, and 
undergoes frequently complete absorption or rapid diminution 
without causing the patient the slightest inconvenience. In 17 
the submucous myoma, the effect of the treatment is somewhat 
different, and in the smaller fibroid and the polypoid variety 
purely mechanical, for the action of the remedy in inducing 
persistent uterine contraction promotes the ultimate expulsion 
of these growths. In submucous myomatous tumors of 
larger size, the ergot not only greatly lessens the hemorrhage 
and relieves the general symptoms, but it also renders the 
tumors themselves often, by cutting off very largely their vas- 
cular supply, anemic, compressed, cirrhotic, atrophic, and 
therefore incapable of causing any further mischief or trouble 
except by their bulk and weight. 
Careful microscopic examination of myomatous tumors re- 
moved from patients who had been treated subcutaneously, 
but had died from diseases in no way connected with the 
foreign growths, and of tumors expelled under the use of sub- 
cutaneous injections of ergot, has almost invariably revealed a 
greater or lesser deterioration in their muscular elements, 
especially in the form of fatty degeneration of the individual 
smooth fibres; in two instances, at least, I was erftibled to con- 
firm this interesting fact by personal observation. 
But aside from the structure, consistence, and position of 
the tumors, there are other essential conditions requisite to 
render the ergot treatment useful and efficacious, viz., sound- 
ness and perfect contractibility of the uterine walls, and 
absence of any residua of previous or complicating disease in 
the tissues adjacent to the uterus. It is, therefore, worse than 
useless, because often mischievous, to employ a systematic 
ergot treatment in cases in which the uterine walls are rigid 
or atrophic, the organ incapable of contracting, bound down 
by adhesions and false membranes, its blood-vessels degener- 
ated, and its immediate vicinity affected with residua of para- 
or perimetritis and other pelvic exudations. While the 
rational employment of ergot, and more especially of the 
subcutaneous method, for the radical cure of fibrous uterine 
tumors is, under these circumstances, necessarily confined to a 
narrow and limited sphere, and while its claim of supplanting 
other modes of treatment would be utterly untenable and 
unjustifiable, it deserves nevertheless a front rank among our 
therapeutical agencies, if only as the safest, surest, and least 
dangerous means of arresting hemorrhage and of ameliorating 
symptoms resulting from fibrous growths of the uterus.