very trifling discharge of serous fluid of most offensive odour. This continued for about a week, during which time the stomach rejected everything, and the pain in the head was so intense as almost, it was said, to deprive her of her senses. The state of weakness to which she was now reduced was such that it was thought she would scarcely recover; she did, however, rally, and to my surprise, in a letter dated Oct. 13th, I received much more cheering reports. It was stated that the patient had been improving in all respects, that the last three catamenial periods had been passed over naturally, without any hemorrhage or other untoward symptoms, and that sanguine hopes were now entertained by her relatives that she might ultimately be restored to health. The next report, however, showed that these hopes were not to be realized.

The catamenia again commenced on the 2nd of November, and progressed favourably, and during the following week she suffered much from constipation and headache. The former was relieved by medicine, yet the latter increased, and on the 8th and 9th became very severe. The night of the 9th was passed quietly, but in the morning Mrs. A. B. was found in a state of unconsciousness, with labouring respiration, and an erysipelatous redness on one side of the head and neck. From this comatose state she never recovered, but sank, and expired on the night of the 10th of November.

The post-mortem examination was conducted by Dr. Prothero, but, not having been made until a week after death, the uterus and appendages were the only parts examined.

The uterus was in a state of partial inversion. The Fallopian tubes and round ligaments were drawn inwards and downwards with the fundus, which protruded through the os, forming an oblong, rounded tumour, whose length was three quarters of an inch, its transverse diameter one inch and a half, and its circumference, at the widest part, which was close to the os, about four inches and a quarter. The mucous membrane, which covered it, was smooth, and of a deep purple colour. The anterior lip of the os uteri was thin and narrow, and rested upon the tumour without constricting it; the posterior was flattened and not easily recognised.

Some few fibres of lymph were found between the adjacent surfaces of the peritoneum covering the depressed fundus.

The left ovary was enlarged to the size of a hen's egg, and contained a cyst as large as a walnut, which enclosed a sanguineous fluid. It was found to be quite impossible, with all the force that could be used, the vagina being dragged down at the same time, to re-invert the uterus.

[The above is another melancholy instance of the fearful effects of inversion of the uterus after labour; and the case is a remarkable one, inasmuch as the constitution bore up for so long a period as eighteen months against the great drain which it had to support.]

In a few cases on record, the uterus from some cause underwent spontaneous reinversion, and in others, the patient was relieved of the source of her danger by sloughing of the tumour resulting from inflammatory action or constriction by the os; but these are rare and happy exceptions, and can scarcely be taken into account in estimating the value of the operation.

With regard to the possibility of reducing the inverted organ, it may be admitted on the testimony of the most competent observers, that unless this desirable end can be effected within a few hours after the accident has occurred, there is little or no hope of its being afterwards accomplished. Even with the aid of instruments carefully constructed and perseveringly employed, the attempt failed in a case of two months and a half standing, under the care of Dr. Bouchet, of Lyons. In Mrs. A. B.'s case, the pressure on the tumour gave rise to such pain in the abdomen that it could not be borne. A few instances, however, are recorded in which reduction was effected at later periods, but from their rarity they cannot be considered as affecting the general rule, nor can parallel results be anticipated in other cases.

The duration of life under inversion of the uterus, when it has reached the advanced stage, varies considerably, much necessarily depending upon the original constitution of the patient, and her ability to rally during the intervals of the monthly discharges. During the time of lactation the danger is of course lessened, and if the accident occurs at a comparatively late period of life, the tendency to hemorrhage is diminished by the natural cessation of the catamenia. The latter fact is

well illustrated by a case mentioned by Lisfranc, who found this displacement in a woman seventy years of age, to whom, he states, it gave no inconvenience. It was not discovered until after her death, which was caused by pneumonia. She suffered

neither from hemorrhage, leucorrhoea, uterine pains, nor difficulty in walking. Mr. Crosse gives reference to some cases which had been traced to their termination, though many others of which he speaks were lost sight of. It appears that of twelve cases

1 proved fatal at 8 months.

To these may be added Dr. West's case, in which the patient survived twentynine, and that of Mrs. A. B., who lived eighteen months. Dr. King also mentions the case of a lady who lived twenty years under this affection, though suffering from pain and frequent hemorrhages; and Lamotte gives a case in which the inversion had existed for thirty years.

It is worthy of notice that some have been the subjects of this accident in whom it occasioned but little or no distress, of which the following case, related by Boivin and Dugés, affords an interesting example. The patient came under the care of Dubois on the 18th of August, 1825, being the sixth day after her delivery. When first the inversion took place the hemorrhage was excessive and nearly exhausted her. The bleeding, however, had not recurred, and though completely blanched she now complained only of a sensation of weight in the pelvis, slight pains in the iliac regions, and frequent desire to pass water. The use of the catheter was for a short time required, but as the tumour, which reached to the labia on admission, diminished in size, this became unnecessary. Some whitish discharge was secreted from that portion of the uterus to which the placenta had been attached. On the eighteenth day after labour the patient travelled home by the diligence. On the 22nd of September, 1830, upwards of five years from the date of the accident, she again sought advice in consequence of the catamenia not having returned, the only appearance of them being a slight discharge of reddish mucus from the vagina occurring every fifteen or twenty days, and lasting but a few hours. The patient had grown fat, and the tumour was still found to exist.

It is unusual, however, to meet with cases of inversion of the uterus in which so few important symptoms are observed. The touching description of the younger Martin indicates with great accuracy the history of the majority of them. "In the rare cases," says he, "where the woman does not perish from hemorrhage, the inverted uterus lessens in size as it hardens, and becomes extremely painful; the patient falls into a state of marasmus; her powers are gradually exhausted under the uterine discharges, which there are no means of arresting; hysterical spasms disturb the general economy in its functions; the healthy hue of the skin fades, and a slow hectic fever terminates, sooner or later, her deplorable existence." With such a prospect in view, it becomes a matter of great moment in each case to decide whether any operation shall be performed in order to avert, if possible, the impending calamity. There are few, probably, who do not shrink, unless it should be imperatively demanded, from any active surgical interference with an organ of such delicate structure as the uterus, containing within it so large a supply of vascular and nervous tissues; or with a membrane like the peritoneum, so prone under these circumstances to take on fatal inflammatory action. Experience, however, has proved that in these cases a portion or the whole of the uterus may be removed with the result of arresting the hemorrhage, rallying the failing powers, and restoring the patient to health. On the other hand, it must not be lost sight of, that, in some cases, owing to the severity of the symptoms induced by the operation, its completion could not be effected, and in others it has itself been attended with fatal consequences.

The modes which have been adopted for extirpating the bleeding portion of the

uterus are simple excision with a bistoury, excision after the application of a ligature, and gradual strangulation by a ligature only.

The first of these plans was resorted to on one occasion by M. Velpeau, and though the subject of it survived all its dangers and ultimately recovered, the jeopardy in which she was placed was so great, that it will, doubtless, not be often repeated. The patient had suffered from inversion for three years. The tumour was excised, and the finger entered the peritoneal cavity, and felt the intestines. Though but little hemorrhage occurred, the acute pain, cramps, restlessness, and syncope, which followed and continued for three days, very nearly deprived her of her life. The uterus was removed, with the exception of a small portion of its neck.

The same surgeon afterwards performed the operation of extirpation twice by applying a ligature, and then excising the tumour. In both cases it proved fatal. The first was that of Albertine Holbe, of which he gives very full details in his Clinique Chirurgicale." The ligature was not tied tightly, and some hemorrhage followed the excision. The patient died in three days, and post-mortem examination revealed traces of peritoneal inflammation and extravasation of six or eight ounces of blood into the pelvic cavity. M. Velpeau attributed her death to the excessive loss of blood she had sustained. The other case was that of Josephine Roussin. Two strong threads were passed through the neck of the tumour, for the purpose of restraining any hemorrhage that might occur, but were not tied. The fundus of the uterus and part of its body were then removed, and the vagina was plugged. The patient died two days afterwards from peritonitis.

The simple application of a ligature around the neck of the tumour in order to destroy its vitality, appears to possess more advantages than the other modes of operating. The constriction may, in the first instance, be moderate, so as to excite sufficient inflammation to unite the adjacent surfaces of the peritoneum lining the inverted organ, without inducing severe pain and nervous symptoms; and if these should arise, the ligature may be loosened, which usually has the effect of arresting them. Whether the constriction can be more gradually applied and more steadily maintained by a flexible wire than by an ordinarily silk or thread ligature, is a matter to be decided by practical observation. In four out of his five successful cases, Dr. Johnson used a ligature made of fine well-annealed silver wire and silk twisted together.-Medico-Chirurgical Transactions, 1852, p. 135.

134.-GALACTAGOGUE AND EMMENAGOGUE EFFECTS OF WARM AND STIMULATING APPLICATIONS TO THE MAMMÆ.

By DR. JOHN ROSE CORMACK.

[In preceding volumes we have inserted papers by Dr. M'William on the value of fomentations, with the leaves of the Ricinus communis and Jatropha curcas, as used in the Cape de Verd Islands, for producing a secretion of milk. Dr. Tyler Smith by a similar method produced a similar effect, even in the colder climate of London. Dr. Cormack believes that the warm fomentations were the chief cause of the excitement produced in the mammary gland, and that stimulating embrocations and cataplasms possess this power in a still higher degree. He says:]

My object at present is to establish, by the brief narration of a few facts, the following propositions:

1st. Warmth and stimulants applied to the mammæ often act powerfully as galactagogues.

2nd. Warmth and stimulants applied to the mamme often act powerfully as emmenagogues.

3rd. The leaves of the bofareira (or the ricinus communis) and jatropha curcas act as galactagogues and emmenagogues; but not from their possessing any peculiar or specific power.

I. Warmth and stimulants applied to the mamma often act powerfully as galactagogues.-Case 1. Milk restored to the mamma by hot fomentations. Last month, a lady, when nursing her infant, about seven months old, was attacked with acute bronchitis of moderate severity, which was successfully treated by low diet, and tar

tar emetic in small doses. At the end of four days, the bronchitis was cured; but the milk, which had previously been failing, almost entirely left the breasts. On the fifth day, from exposure to cold, she experienced a relapse of the bronchial affection. As she had been considerably weakened by the previous attack, and as the symptoms of the relapse were not sufficiently severe to justify recourse a second time to antimony, I ordered her to take a draught containing ammonia and chloroform, as an anodyne, expectorant, and diaphoretic, every eight hours; and to carry out similar intentions, I also directed a succession of pillow-cases, filled with heated moist bran, te be applied to the chest. When I saw her on the following day, after this treatment had been employed, she told me that she had profusely perspired for some hours; she was (after copious expectoration) free from cough and pain in the chest; and, what was equally a source of pleasure and surprise to her, her breasts had become distended with milk. This lady was able to resume nursing, and to continue it with the assistance of a suitable diet.

Case 2. Hot Poultices keeping up the Secretion of Milk when this was not desired.— A lady suffered, after her confinement, from a succession of abscesses and abortive abscesses in the breast. The surgeon who attended her treated her by antiphlogistic medicines, under which discipline she passed some wretched months, from mental and bodily depression, aggravated by hysterical attacks. The local affection did not seem to make any satisfactory progress; and the great obstacle to a cure was stated to be the impossibility of getting rid of the milk, in spite of saline purges being freely administered. The mammæ, during the whole of the period to which I refer, had been ceaselessly treated, night and day, with hot poultices and medicated fomentations. These applications were abandoned, and a general diet prescribed. In a few days there was not a drop of milk in the breas's; and the abscesses, actual and threatening, had ceased to give any pain, and had, in fact, almost disappeared.

II. Warmth and Stimulants applied to the Mamma, often act powerfully as Emmenagogues.-Warm clothing of the abdomen and limbs, hot hip-baths, and medicines which stimulate the bladder and rectum (such as ergot, cantharides, and aloes), have undoubted emmenagogue powers in properly selected cases of retarded or suppressed catamenia; and indeed, they constitute, in various combinations, the principal measures by which the physician usually endeavours to excite the ovarian nisus upon which menstruation depends. The observant physician knows well, that while his treatment is directed to the uterus through the ovaries, the effects produced upon the mammæ are generally very striking, and the first indications which he expects to find of the uterus being roused from its torpor are turgescence and tingling of the mammæ; phenomena which also usually precede normal menstruation. It is equally true, though not so familiarly understood, that measures which act directly and pri marily upon the breasts, such as warm clothing to the bust, and the application of stimulants, not only cause them to swell and throb, but likewise stimulate the ovaries, and cause the menses to flow. The practice adopted by some practitioners, of applying leeches to the mammæ in amenorrhoea, owes its efficacy to fomentations used, and the irritation of the bites.

[Dr. CHARLES PATTERSON, in 1834, published a paper on the emmenagogue power of irritation of the mammæ by sinapisms. When at the Edinburgh dispensary, Dr. Cormack tried this plan with great success. The following is an abstract from Dr. Patterson's paper:]

"Mary Reardon, aged 24, of moderately corpulent habit, was admitted into the Rathkeale Hospital on the 10th of August, 1832. She laboured under slight synochial fever, which in a few days yielded to venesection and purgatives. On the 19th August, symptoms which were considered of a hysterical character presented themselves, with pain in the upper and outer part of the right side of the chest. For the latter affection, a small sinapism was prescribed; but from inattention of the nurse, it was made so large, that it covered a considerable portion of the mammæ. The sinapism remained on for half an hour. At the visit on the following morning, the 20th of August, Reardon complained that the right breast was exceedingly painful-the pain being very different in its character from that which she had before experienced. On examination, the whole of the chest was found considerably swollen; there was slight diffused redness of the skin; and though the mamma itself was enlarged to four or five times its natural bulk, yet there was no circumscribed hardness, nor any tendency to spppurative inflammation. On the 21st August, the right mamma and

adjoining parts of the chest were found much more enlarged than they had been at the preceding visit. The left mamma and side of the thorax were unaffected; and it was announced by the nurse that the catamenia had that morning appeared, and were then in considerable quantity. This discharge, which, as the patient stated, had been for two years and a half wholly suppressed, continued to flow for two days; then it began to decline, and with it the tumefaction of the mamma gradually dis appeared."

Dr. Patterson's attention having thus accidentally been directed to mammary irritation as an excitant of the torpid uterus, he resolved to try its efficacy when a suitable opportunity presented itself. His next case is thus described :

She

"Catharine Power, aged 19, applied to me on the 14th September, 1832. She complained of headache, languor, loss of appetite, and inability to attend to her usual business, that of a servant. She stated, that about the middle of April, the menstrual discharge being then present, she incautiously exposed herself to cold in washing clothes at a river. The catamenia then suddenly ceased, and had not since returned; and from that period she had been constantly subject to ill health had consulted different medical gentlemen, and taken a great variety of medicine, with little advantage. I directed that the clavicular half of the right mamma should be covered with a sinapism. It was allowed to remain on for thirty minutes; and on visiting her in six or seven hours after its removal, I found the whole right breast considerably swollen, hot, and painful. The next morning, the enlargement of the mamma was very much increased, the tumefaction having extended to the clavicle and axilla of the irritated side. There was no hard circumscribed or prominent tumour, but a painful, diffuse, elastic distension of the mammary gland, and surrounding sellular substance. On the evening of the day next succeeding the application of the sinapism, this poor girl with much joy reported that the catamenia had appeared. The flux having continued for two or three days in moderate quantity, she then found herself greatly relieved of the headache and other most distressing symptoms; and in a week her health was so far res' ored, that she ceased to require any further attendance."

[Dr Cormack concludes, therefore, that the galactagogue effect is not produced by any specific property of the leaves before mentioned, but merely by the determination of blood to the gland produced by the warmth and irritating properties of the juices they contain. But, he observes,]

Injurious effects may so readily be produced by excessive irritation of the mamma upon themselves, upon the ovaries and uterus, and (as a consequence of the undue excitement of any of these organs) upon the whole system, that, in following the practice recommended in this paper, it is necessary to proceed with caution.

First, as regards the mamma themselves, care must be taken not to produce too much irritation, lest troublesome inflammation be excited in them, and in the glands of the axilla;-consequences which I have seen produced in such a degree as to require, for several days, cooling lotions and general antiphlogistic measures.

In irritable subjects, or when the effects of the treatment cannot be daily ascertained, stimulating embrocations ought to be preferred to sinapisms. When sinapisms are applied every eight or twelve hours, for some days continuously-as is sometimes necessary-they ought to be compounded of two or three parts of bread to one of mustard; and a fold of soft linen ought to intervene between them and the skin. By attending to these conditions, patients will generally endure the poultice without injury for half an hour or an hour; and a greater amount of benefit will be obtained than by causing violent stimulation for a short period. It is always essential to maintain, during the intervals, great local warmth, by means of abundance of cotton wadding. If mammary irritation have been carried so far, through mistake or accident, as to necessitate recourse to refrigerating lotions and lowering treatment, it need hardly be remarked, that the object for which it was used is not likely to be accomplished.

Secondly, as regards the ovaries and uterus, the effects produced upon these organs must be attentively watched; for the very greatness of the power which irritation of the mammæ exerts over these organs, may constitute an element of danger. In endeavouring to excite menstruation, we must take care that we do not excite inflammation of the ovaries, or of the womb. When we find the patient complaining of severe pain in the loins, and suffering from general fever, we ought