"This band or constriction was as firm and resistant as a rope of steel. I could with the most determined effort force the points of one or two of the fingers between this and the neck, but for a time no farther. I certainly never had felt anything like it before, but recognized the condition called by that eminent authority, R. P. Harris, Philadelphia, "Tetanoid falciform contraction of the uterus,' and by Dr. Hosmer and Dr. Thomas C. Smith of Washington, D. C., Ante-partum hour-glass contraction of the uterus,' in the latter's valuable résumé of these cases in the American Journal of Obstetrics, volume XV, November, 1882.

·

"I, for a time, feared I would be foiled, but after a most determined effort, I finally succeeded in passing it and ultimately reaching the foot. Still the resistance did not entirely yield, and it was only after further powerful and persistent efforts that the constriction yielded and I was enabled to turn and extract. I am convinced that I could not, without injury, have succeeded during life."

Such is Dr. Miltenberger's account of this "rope of steel, a condition which he had never felt anything like it before." As his experience As his experience extends over a period of nearly fifty years, surely this falciform constriction must be extremely rare. In none of the systematic treatises on midwifery I have had access to is there the remotest allusion to the possibility of an ante-partum hour-glass contraction. Always, in treating of this condition of the uterus, it is with reference to retention of the placenta by this means. The first and only information I have received on the subject is from the article above referred to, supplemented by my own experience in the case under consideration. Although I had read Dr. Miltenberger's article attentively more than once, I failed to recall it at the time when its information would have been most welcome. Probably, however, it was fortunate after all that I did forget it; for with it fresh in my mind, affording as it

condition I was called to deal with; with his advice also about Cesarean section being the only proper proceeding in such cases, I very much doubt if I would have ventured to call to my aid the strong arms and powerful grasp of the woman's miner husband, and events might not have turned out as well for the mother and child.

With regard to this "rope of steel," "ring of Bandl," "tetanoid falciform contraction," "ante-partum hour-glass contraction," there seems to be as much diversity of opinion as to its location as there is to its cause. It is claimed by some to be a constriction at the internal os, while others contend that it is a tetanoid contraction of a band of the orbicular muscular structure higher up. My own experience in the few cases of hour-glass contraction that have come to me lead me to adopt the latter view. It does not seem probable that such powerful and long-continued contraction could be maintained except when the muscle is better developed than at the internal os.

The difficulty of making even an approximate diagnosis in this very rare accident is and must ever be very great, for there is no condition that would indicate its existence before a determined effort at extraction was made. Dr. Miltenberger speaks of the "precious results of systematic external exploration by palpation" in determining beforehand the existence of such a condition; but in the case now being considered this was exactly what was done when the woman called my attention to her size, saying she feared she was going to have twins. Just such an "exploration by palpation" was made in tracing the contour of the child in utero, and surely, if there had existed any sulcus at or below the woman's umbilicus in the abdominal parietes, indicating such a constriction in the body of the uterus, I could not have failed to observe the fact, although I might have failed. to appreciate its significance. Certainly, I observed nothing of the kind.

This brings up for consideration another part of the subject. May not this

ante-partum hour-glass contraction have been produced after I gave the ergot and by the ergot?

It has long been a conviction with me from watching the action of the uterus after the administration of ergot that it acted more powerfully on the circular and oblique fibers of the muscular structure of the uterus than upon the longitudinal, and that when the fetus filled the cavity of the organ the contraction caused by ergot had a greater tendency to crush the child than to expel it. Hence it is with the utmost reluctance that I ever give a parturient woman ergot until the child is born, or, if I greatly fear hemorrhage, when the occiput presents at the vulva. I gave ergot in this case with the distinct feeling that its administration was injudicious; but the woman was becoming so despondent and anxious at the prolonged, and to her unusual, effort at parturition, and as I could discover, after a most minute examination, no. possible obstacle to the ready delivery of the child when the pains should sufficiently increase in force, I acted contrary to my better judgment and gave it. I should have applied the forceps and terminated the labor in that way. Even podalic version would have been preferable, as difficult as that operation sometimes is. I cannot say certainly that the hourglass contraction did not exist before I gave the ergot, or that this drug caused it; but I believe it did, so much so, that never again could I be induced to give ergot in a normal labor.

Helie (Playfair's System of Midwifery, p. 53, Ed. 1880), who seems to have studied the anatomy of the gravid uterus closely, has pointed out that its muscular structure, speaking roughly, is divided into three layers; an external, a middle, chiefly longitudinal, and an internal or circular. The external layer arises posteriorly at the junction of the body and the cervix, spreading upwards and over the fundus. The middle layer is composed of strong fasciculi which run upwards but decussate and unite with each other so that those which are at first superficial become most deeply seated, and vice versa. The internal

layer is mainly composed of circular rings of muscular fibers beginning around the openings of the Fallopian tubes and forming wider and wider circles which touch and interlace with each other. They surround the internal os, to which they form a kind of sphinc

ter.

Now it seems evident that the expulsive action of the uterus, the force that tends towards extruding the fetus, is derived from the first two layers of muscle; the third or circular layer is probably co-ordinating in its action, and gives strength and support to the organ as a whole while it is in action. Hence, if from any cause, the action of ergot or other, the action of the two first layers is suspended or much weakened, while the action of the circular or internal layer is stimulated to greater activity, we would have the very condition that I am sure I have noticed when the uterus is under the influence of ergot; powerful and almost continuous contraction attended with but little or no advance in expelling the child.

Again, Verrier says, in speaking of the irregular contractions of the uterus in hour-glass contractions, "in hour-glass contraction ergot is contra-indicated; and not without reason have several authors attributed to its administration the production of such spasmodic contractions." Now if its administration is recognized as the probable cause, in many cases, of post-partum hour-glass contraction, it requires but a feeble effort of the imagination to suppose that it may also produce ante-partum similar results and such I have no doubt will be the verdict of the profession after the effects of the drug in the uterus have been more closely watched and attentively studied. Ergot is a powerful remedial agent, but like all agents of pronounced beneficence, it is also powerful for evil, and to use it empirically is to wield a Hercules club, doing good or injury by accident.

IN presenting a case of this kind, it occurred to me that it would be interesting to know how frequently this condition occurs. After making a careful search of all the literature available on the subject, I find only fourteen cases on record, the first of which was reported by Dr. Edward T. Roe of Glasgow, Scotland, in 1836. Since that time I find thirteen others. Five of these have been reported by American. physicians; four by Europeans; and five from St. Stephen's Hospital, Delhi, India.

The causes of this complication are any ulcerative inflammation of the upper portion of the vagina and cervix uteri such as would be produced by syphilis, scarlet fever, diphtheria, etc. One case, however, has been reported which seems to have been congenital. The woman had been under the observation of several physicians for a long period and no opening of the uterus was ever discovered, nor did any menstrual fluid ever escape. As the uterus began to enlarge, it was supposed to be a case of retention of the menses, but as the fetus developed, it was diagnosed to be a pregnancy; and the woman was subsequently delivered of a full term child. There can be no doubt, though, that there must have been some minute opening sufficiently large for the entry of spermatozoa.

The most frequent cause given in the cases reported is the use of forceps in previous labor. This statement I do not think is fully sustained, as in order to have complete occlusion of the cervix, the exciting cause must occur after the ovum has been impregnated; and it is fair to suppose that all effects of the previous use of forceps have subsided. A more likely cause in my mind would be the treatment by caustics or the actual cautery, of ulcerations produced by

the use of forceps or other agents employed in delivery. In this statement I am supported by the fact that nine of the fourteen cases reported occurred in multiparae and but five in primiparae.

The most popular treatment of these cases to facilitate delivery seems to have been incision and the use of forceps. Of the cases reported, eleven were delivered in this manner, one by incision alone, one by Cesarean section, and one (Dr. Lusk's case) by rupture of the uterus, which occurred while he was making preparations for an abdominal section, the woman having been in labor several days. This accident resulted in the death of both mother and child, and was the only fatal case so far as the mothers are concerned. The other thirteen did well. But while the mortality in the mothers seems to be small it is somewhat higher in the children, as four out of the fifteen cases, including my own, were still-born. However, I believe that in all cases in which the condition is recognized early and the woman speedily delivered, the life of the child will be saved. It is almost superfluous to add that in the foregoing cases, incision and forceps have given very satisfactory results and seem to be the proper method of delivery in the majority of cases.

The following is an account of a case that came under my own observation.

Mrs. E., white, aged 40, had been married eighteen years, was eight months gone with first pregnancy. I was called to see this patient July 16, 1893, and obtained the following history. About three days previous to my visit. she had been seized with pain in the abdomen and had called in a physician, who upon examination pronounced it a case of threatened miscarriage. After prescribing something which I judged to be an anodyne, he left and did not

call again. Upon examination per vaginam, I found the patient suffering with a membranous inflammation extending over the whole surface of the vagina and partially over the labia minora. I diagnosed the case as one of diphtheria and treated it accordingly; but whether it was a case of diphtheria or not I am unable to say, as I did not have a microscopical examination made. During the next few days the patient passed several complete casts of the vagina, and in about ten days from the beginning of the attack she made a good recovery; the membrane had disappeared and the ulceration healed.

About one month after this I was again called, as it was thought the patient was about to be confined. When arriving at the house I found the patient's pains had entirely subsided. She told me that she had had intermittent pains for two hours of the day, but they had passed off and she had gotten up and gone about her household duties. I instructed her to send for me at once should the pains return.

After the lapse of a month I was again called, but being unable to respond, my friend Dr. Van Rensselaer did so for me. He found the patient suffering severe labor pains at intervals of three to five minutes. Upon examination per vaginam, Dr. Van Rensselaer was unable to discover the os, and believing it to be a case of occlusion of the cervix, called Dr.

Cuthbert in consultation, who

NEW FOOD FOR CONSUMPTIVES. Dr. Brewer of Chicago has a new idea concerning food for consumptives. In addition to inhalation of the fumes of vinegar he feeds them on peanuts, gives them all they can eat without dangering their digestive organs. Two young ladies who had been the rounds of cod liver oil and tonics without material benefit were put on his treatment and recovered. Concerning the diet he says: "I now commenced feeding (do not laugh) peanuts. One would think. this a very indigestible diet, but they craved them, and it has always been my policy to find out what my patients.

agreed with him in his diagnosis. In the morning I joined Drs. Cuthbert and Van Rensselaer and made an inspection of the parts through a Sims's speculum. There appeared in the region of the os nothing but a smooth, glistening surface and as far as the eye and finger could detect, there was not a vestige of the original opening.

Dr. I. S. Stone was called in consultation and it was decided to make an antero-posterior incision about one and a half inches in length and allow the head to dilate as the pains were still violent. The patient was anesthetized, the incision made and the head allowed to make pressure. At the end of an hour there was sufficient dilatation to allow the application of forceps to the head. The delivery was accomplished without event, except a slight laceration of the perineum. The child was still-born and had probably been dead for days, as it was in a state of maceration. The mother made a good recovery and, the perineum having united, the stitches were removed on the ninth day.

An examination made one month after delivery revealed simply an antero-posterior laceration of the cervix uteri.

I do not think my treatment of the case above criticism. If I had made the diagnosis of occlusion of the cervix at my second visit, when labor first began, I think the life of the child might have been saved.

desire to eat, and unless it is too unreasonable I humor them. Both young ladies have become quite plump, and after a year's inhalation have ceased coughing, and I pronounced them well. The peanut was long known as an excellent fat producer, and much more agreeable than rancid stark oil that of tentimes is sold for cod liver oil. While not all can digest peanuts, a great many, even with feeble digestion, eat them without discomfort. It beats the Koch lymph and is the most satisfactory treatment I have ever tried for these diseases.'