menstruation ceased, until, during the last week of October, they became labor-like in character. Examination now revealed that the uterus had righted itself, the os was becoming patulous and its edges thinned out; through its opening the projecting tumor could be felt. On the second day of November, pieces of the broken-down mass, horribly offensive, could be seized with the forceps, pulled out of the uterus and cut away.

Chilly sensations began to be felt by the patient, sweatings came on, the temperature ran up to 101° F., and a mild septicemia was established. During the following week the pains never ceased. Quinia was administered freely. The vagina and uterus were irrigated with hot carbolized injections, and the mass removed as fast as any of it could be reached, and at the week's end the last remnant was gotten away. The patient was very much reduced physically, but rapidly convalesced, and is now perfectly well, with her menstruation normally re-established. Fully a quart of soft pultaceous pieces of the growth were removed.

Case IV.-Mrs. L., German, 34 years old, one child, was seen first November, 1885. She had been suffering with increased menstrual flow for a year. She came to me to be treated for an external, painful, labial swelling. It proved to be a vulvo-vaginal abscess. It was opened freely and gave no further trouble. A uterine tumor was noticed and examined. It was found to be of considerable size-could be detected above the pubis.

She was put upon one-half-drachm doses of fiuid extract of ergot every six hours.

This she continued for six months steadily, with varying conditions of pain and hemorrhage, until, in April, 1886, the hemorrhage ceased, pain became very severe, and a shreddy, foul-smelling discharge manifested itself. She was removed to the St. Joseph's Hospital, and after ten days of antiseptic washings and removal of masses of broken-down tissue, the mass was entirely extruded. This patient had also quite a severe septicemia, but finally recovered and is now well.

Remarks.-Aside from crucial demonstration, it seems reasonable to assert that these four cases were cured by means of the remedy used, and by that alone. It is well known that the most of authorities state that no positive reliance can be placed on the use of ergot. My experience surely, as here illustrated, and confirmed by other cases seen, leads me to think that this adverse judgment must be qualified, especially in the treatment of the submucous bleeding fibroids of the uterus. If the growths be partially interstitial, the less the thickness of uterine tissue between them and the mucous covering the more certain will the remedy be curative. Of course it will be impossible to demonstrate the exact amount of uterine wall forced contractions will destroy, hence a trial of its worth is desirable in all cases not purely subperitoneal and pedunculated, Still I am quite convinced the se

verity of the hemorrhage gives one a good reason to speak positively of the results to be accomplished by its use. I have not deemed it necessary to look up the history of the first use of this remedy for stimulating uterine contractions. It is sufficient for me to say that my confidence in the remedy and persistence in its use, even when failure of good results seemed certain, has followed directly as the result of the teachings and experience of an honored Fellow of this Society, Dr. Wm. H. Byford, who has never lost an opportunity to urge upon the profession his belief in the specific action of the remedy, and its absolute certainty of cure in many cases. I am quite sure that Dr. Byford deserves the credit of being the first to make use of ergot with the idea of destroying the vitality of the growth, as well as of causing its expulsion from the uterus.

The third case shows plainly how absolutely unnecessary any operation would have been. The removal of the appendages might have stopped the hemorrhage, but such a perfect cure as now exists could never have followed operation, to say nothing of the harm done by unsexing the woman; still no case could present better reasons for such a procedure, none in which it would have been more justifiable from the indications present. To me it brings the lesson to make oöphorectomy the dernier ressort in all cases, certainly to give the remedy used at least a six months' trial without result before operation be sanctioned.

The difficulties attending the differentiation between a sac of fluid and the soft myomata was well illustrated by this case. The sensation communicated to the touch was scarcely distinguishable from fluctuation. It was only after repeated examinations under ether, and the use of the sound, that the diagnosis was satisfactorily settled.

The fourth case, for a time, seemed one in which the treatment would come to nothing. Every one became discouraged. The suffering was increased, and no advance was made, apparently. By persistence the cure was accomplished. In this case operative interference was solicited by the patient, and would have been most readily submitted to, without any urging. If I read aright the indications which authorities give to justify the resort to removal of the uterine appendages, they were all present in this case, and more too, if that were needed. Certainly the final result has proven any such interference would have been uncalled for and lamentable.

I am quite well aware that four cases cannot be considered absolutely demonstrative of any rule, still these four increase the number already published in proof of the curative action of ergot, administered thoroughly, for submucous uterine growths. It is im possible for me to understand how some good authorities can still assert their disbelief in ergot; in fact, calling it the most inert and disappointing of all drugs. No possible argument can disabuse

my mind of the belief that its action was positive and certain in the cases related. No law has as yet been evolved fixing, even by approximation, the period of time required for the effects of the medicine to show themselves. The idiosyncrasies of the patient, the thickness of the uterine envelope, the distance from the mucous membrane, the purity of the drug, and many other conditions, render it scarcely possible that any such law can ever be laid down. The trial should be made patiently and persistently, just so long as the patient's condition will warrant its continuance, and a complete expulsion of the growth, followed by rapid recovery, will be the reward.

DR. F. E. WAXHAM read the following paper, entitled:

OCCLUSION OF THE OS UTERI AS AN IMPEDIMENT TO LABOR, WITH A REPORT OF TWO CASES.

Having met with occlusion of the os but once in several hundred cases of labor, and knowing of a number of physicians of extensive practice who have never seen this condition present at the time of confinement, I am convinced that it must be of rare occurrence, and the history of two cases may not be uninteresting.

Mrs. S., primipara, 29 years old, German, fell in labor about 9 P.M., February 21st, 1885. The membranes ruptured soon after the commencement of labor and the amniotic fluid gradually drained away.

The patient was seen between 3 and 4 A.M., at which time the pains had become very severe and frequent. Upon examination the head was found low down in the inferior strait, almost presenting at the vulva, and covered apparently by a thin membrane through which the advancing head threatened to burst with every pain. Upon the most careful digital examination no os could be discovered, nor the slightest indication of one. Dr. Nelson was summoned and promptly responded. His more experienced finger detected a very slight dimple in the centre of the presenting tissues. By keeping the finger upon this slightly thickened tissue he discovered that it became very much thinner with every pain, while as the pain subsided the tissues assumed a very slightly umbilicated appearance. By firm and continued pressure upon this suspicious spot an opening was at length effected and the os gradually dilated. As the labor proceeded slowly, and fearing the result to the child of so long a delay of the head in the pelvis, and the os being fully dilated, the forceps were applied. The child was delivered without injury to the mother, but it was asphyxiated and required considerable effort in resuscitation. Dr. Nelson stated that this was the second case that had ever come under his observation, and kindly gave me the history of the following one: He was called to attend a lady in her first confinement, a Swede, 23 years old, and married about one year. Making a hasty exami

nation, he found a well formed cervix, but did not detect the os.. On returning a few hours later, the head had descended to the inferior strait and was, indeed, presenting at the vulva and covered by the cervix, which had become so thin as to resemble the membranes. The membranes had already ruptured and the amniotic fluid had gradually escaped. There was no appearance whatever of the os. It could not be detected with the finger, and the head seemed about to burst through the uterine tissue. The patient was placed before a window, the labia separated and careful search made for the os. Only after a most careful search was it found. It was patulous only to the extent of admitting the very finest surgeon's probe. After this had been introduced and worked about a second probe was passed, and by separating them the os was gradually and sufficiently dilated to allow the finger to enter. The os was then rapidly dilated and labor progressed normally.

I find the literature on this subject quite meagre, many of our writers on obstetrics omitting the subject entirely, while others refer to it very briefly.

Schroeder alludes to it in the following terms:

66

"As complete atresia of the os prevents conception, it follows that an occlusion of the os, observed in labor, must have taken place during pregnancy.

"Very frequently there is a superficial and easily separable agglutination of the external os. It is due to an inflammatory process of the lips of the os from a previous blennorrhoea. During labor the advancing head is seen to push the lower uterine segment forward to the outlet, and to thin it more and more. This thinning may be so great that the head appears to be covered only by the membranes. By an accurate examination the os feels like a small and soft dimple directed greatly backwards. If, during a pain, the finger or uterine sound be forcibly pressed against the dimple, the agglutination of the os will suddenly give way. The os itself now very readily dilates, and labor proceeds without impediment. Often the pains themselves succeed in breaking down the adhesions of the os.

"It very rarely happens that the os only partially dilates after the agglutination has been torn through and remains rigid so as later to require incisions. There is very seldom so firm an adhesion between the maternal and fetal membranes, in the immediate vicinity of the internal os, that the lower uterine segment cannot retract over the ovum. Separation by the finger or rupture of the membranes renders possible the dilatation of the os."

Schroeder also refers to the fact that a firm cicatricial band may occasionally occlude the os, resulting from inflammation of the cervix or cauterization:

When these firm adhesive bands prevent dilation of the os, there is danger of rupture of the vault of the vagina, unless incisions are made and assistance given. The cicatricial closure of the os is frequently incomplete; more or less fine openings remaining pervious, rendering con

ception difficult but still possible, is believed by Schroeder to frequently result from ulcerative inflammation during the lying-in state.

Leishman, in discussing this subject, remarks that

"There are some cases in which there seems to be actual occlusion of the os. Impregnation in the case of an absolutely occluded os is as impossible as that the normal function of menstruation should be carried on, and therefore we must assume, in such cases, that the closure must have taken place subsequently to the entrance of the seminal fluid. It is, of course, possible that the os may remain open to a very limited extent, and yet the state of the tissues renders distention impossible, so as practically to constitute an impediment as insurmountable as actual occlusion would be."

Playfair gives the following brief mention of this condition: "Agglutination of the margins of the os uteri is occasionally met with, and must, of course, have occurred after conception. It is generally the result of some inflammatory affection of the cervix during the early months of pregnancy. Usually it is not associated with any rigidity or hardness, but the entire cervix is stretched over the presenting part and forms a smooth covering in which the os exists only as a small dimple, and may be very difficult to detect at all. Occlusion of the os from inflammatory changes sometimes so alters the cervix that no sign of the original opening can be discovered."

All our authorities agree that the occlusion of the os is the result of inflammatory change occurring subsequent to impregnation. It a noteworthy fact that in both these cases the membranes ruptured and the amniotic fluid escaped in the very early stages of labor, showing that the membranes were adherent to the uterine tissue about the internal os. As the internal os dilated, rupture of the adhesions and of the membranes necessarily followed. The discussion of the papers read by Dr. Parkes and Dr. Waxham was, on motion, deferred until the June meeting.

Mr. Lawson Tait, of Birmingham, and Dr. T. Gaillard Thomas, of New York, were elected Honorary Fellows of the Society. Dr. E. C. Dudley proposed for honorary fellowship Protheroe Smith, M.D., M.R.C.P., of London.

TRANSACTIONS OF THE FIRST MEETING OF THE GERMAN GYNECOLOGICAL ASSOCIATION.

HELD AT MUNICH, JUNE 17TH, 18TH, AND 19TH, 1886.

REPORTED BY M. WIENER, M.D., BRESLAU.

(Continued from p. 885.)

Second Day-Morning Session.

President, DR. WINCKEL.

DR. KALTENBACH (Giessen) exhibited several specimens: a hypertrophic tubal wall due to carcinoma of the uterine fundus, and a