at once to discontinue mammary irritation, and prescribe rest in bed, abdominal fomentations, and the frequent use of the hip-bath. In cases of this description, as in ordinary attacks of dysmenorrhoea, we may often not only relieve pain, but accelerate a resolution of the inflammation, by administering opiate enemata.―Association Med. Journal, March 25, 1853, p. 254.

135.-Dry-Cupping a Substitute for Ergot.-The Charleston Medical Journal and Review for January, 1853, quotes a paper on this subject from the 'Nashville Journal of Med. and Surg.,' of which we give an abstract.

DR. WASHINGTON has recently discovered that dry-cupping, applied to the lowest part of the sacrum, produces dilatation of the os uteri; and, applied higher up, contraction of the uterus.

In a case, where the pains had endured fourteen hours without producing any perceptible effect, in consequence of rigidity of the os uteri, Dr. Washington applied a dry-cup as low down on the sacrum as possible, so as to cover the origin of the nerves to the os uteri. Complete relaxation ensued; at the next pain, the head descended to the outlet; and at the second pain the patient was safely delivered; and that in less than ten minutes from the application of the cups. In tedious labour, the cup should be applied first to the lowest point of the sacrum, and if, in the course of ten or fifteen minutes, the patient is not delivered, another should be applied higher up, so as to cause the uterus to contract. The lower one should always be on when the upper one is applied, so as to ensure relaxation of the os uteri when the pains

come on.

In retained placenta, the cups are to be applied higher up, so as to cause the uterus to contract at once, the relaxation of the os uteri being always sufficient after the foetus has passed.

When ergot is administered, the woman is delivered by main force, without any relaxation except that produced by the most fearful pains. By dry-cupping, two or three pains are sufficient, and the amount of suffering is not more than ordinary.Association Med. Journal, May 27, 1853, p. 469.

136.-EMPLOYMENT OF THE GALVANIC CAUTERY IN CASES OF VESICO-VAGINAL FISTULA, PROLAPSUS UTERI, AND VASCULAR GROWTH IN THE URETHRA.

Under the care of Mr. MARSHALL, University College Hospital.

[The great value of this cautery is, that as the parts are divided the caustic action is sufficiently powerful, at the same time, to check any bemorrhage which may arise.]

It may, perhaps, be as well to premise that this instrument consists solely of a platinum wire, heated to a red or white heat by means of a galvanic battery, and that its superiority over all others intended for the same purpose consists in the circumstance, that its temperature is sustained, or, if by accident reduced, is immediately replenished, by the galvanic current, without any need to suspend the operation in order to re-heat the wire. All who have had experience in the use of the ordinary cauteries in delicate operations, will be aware of the difficulty of getting through the necessary steps, especially if the surface to be touched be large, before the iron has become too cool for use. The moisture of the part very rapidly extracts the heat from a wire which has been removed from the lamp, and the surgeon is consequently under the necessity of continually interrupting his operation to change instruments, or to renew the temperature of his original one. From this objection the wire heated by galvanism is entirely free, as it sustains or constantly renews its heat as long as it continues in contact with the battery. The wires communicating with the trough are made long and flexible, so as to permit of the terminal rods being easily moved about; and as the culminating point may either be a slender piece of wire or a coil, so wound as to present a surface of any wished-for breadth, the whole constitutes a very manageable piece of apparatus. We need hardly XXVIII.-18.

state that this kind of heat does not differ in its properties, so far as is known, from that obtained by other means.

The first of the cases we have to mention was one of vesico-vaginal fistula, which had occurred as the result of laceration and sloughing from pressure during childbirth, in a woman aged 34. She had suffered from the disease for three months before her application at the hospital, and had been rendered miserable by the almost constant incontinence of urine which it induced. In October last, we witnessed the first application of the cautery to the edges of the fistula. The patient having been placed on her back on the operating-table, Mr. Marshall introduced into the vagina a speculum, having an aperture in its upper surface through which the posterior sur face of the bladder bulged. The opening, which was so large as to admit three fingers easily, and had indurated borders, was thus brought well into view. Mr. Marshall applied the cautery, a coil of wire, heated to white heat, pretty freely to the whole of the exposed edge. The woman was removed to bed, and did not afterwards suffer any pain worth mentioning, or any kind of constitutional disturbance. The operation was repeated in exactly the same manner in November, at which time the aperture had diminished very considerably. It has since been done seven times, at intervals of from three to eight weeks. The diminution in size of the fistula has been progressive, and, at the present date, June 25, the patient is fulfilling all the duties of a regular nurse in the hospital, and is subject to very little of her former inconveniences. As generally occurs in these cases, great difficulty is found in getting the hole to close up entirely, and there still exists a small slit, through which the point of a common-sized penknife might be passed. Mr. Marshall informs us, that, in a case under his care in private practice, in which the same procedure has been had recourse to, he has attained a like degree of success, without, however, being able, as yet, to induce a perfect cicatrization.

On Wednesday, June 1, Mr. Marshall applied the galvanic cautery to three patients in succession. The first brought into the theatre was a young woman, from whom there had been removed, last Christmas, by another surgeon, a small vascular growth, situate just within the meatus of the urethra. It had been re-produced; and, as she described the bleeding which followed the former operation as having been alarmingly profuse (at least a quart), it was thought better to destroy it by means of the cautery, than to attempt another excision. Chloroform having been administered, the patient was laid on her back, and the parts exposed. The urethra was then dilated, and its lips held as widely separated as possible, by means of small blunt hooks. The growth, which sprang from the floor of the urethra, was thus brought well into view, and the heated wire freely applied to its whole surface, in some parts breaking up its structure. On account of its extending far back towards the bladder, Mr. Marshall encountered some difficulty in securing the application of the cautery to the most remote parts; but by further dilatation of the urethra, this was ultimately accomplished. The woman was an out-patient; and as soon as she had well recovered from the effects of the chloroform, left the hospital, and walked home. Mr. Marshall informs us, that she suffered but very little pain afterwards, and that the cicatrization was completed on the tenth day. The floor of the urethra now presents a small pale scar, about the size of a mustard seed. Mr. Marshall does not apprehend any inconvenient contraction of the parts after this operation, as he has had an opportunity of watching the behaviour of the cicatrix in four other cases, for long periods after its performance, and never witnessed any such result.

The next case was one of severe and long-continued prolapsus uteri, for the relief of which, as the vagina was very large, and its walls lax and distensible, it was proposed to make a series of eschars in the course of that passage, so as to diminish its calibre by the subsequent contraction of the cicatrices. Mr. Marshall pointed out to those present the principles involved in this method of treatment, and called attention to the superiority of the operation by means of the cautery over that by the knife, in avoiding all risk of hemorrhage, and in being very slightly painful, &c. He then exhibited a speculum of peculiar construction (a French instrument made by M. Leur), which he had procured for the purpose, as possessing great advantages over those in common use. It consisted of two very large blades, each of which was composed of a light framework of metallic bars, and enclosed double rows of fenestræ, about an inch in length, and half an inch in breadth. The instrument was

adapted only for a very full-sized vagina, and, when introduced and its blades set apart, it had the effect of widely separating the walls of the canal, and at the same time of allowing the mucous membrane to bulge inwards through the rows of apertures. This, of course, was exactly what was required for the easy application of the cautery. The patient, Emma Smith, aged 34, was a married woman, who had borne three children. Ever since her first confinement, March 1, 1850, she had suffered more or less from prolapse of the womb, and the inconvenience had been increased after each succeeding confinement, until it had latterly almost incapacitated her for going about her household duties. Chloroform having been administered, the patient placed in position, and the speculum introduced, Mr. Marshall proceeded to apply the cautery, which, on this occasion, as an extended surface was needed, consisted of a coil of wire, wound round a small bit of common tobacco pipe, to the surface of the mucous membrane, as exposed through the set of openings in the framework of the speculum. In this manner eight eschars, all of considerable size, were made on each side of the vagina; the operation being performed very quickly, and without any kind of difficulty, as it was scarcely necessary to withdraw the instrument once before its completion. As soon as the patient had a little recovered from the effects of the chloroform, she was carried to her bed, and another woman, suffering from the same disease, in a yet more aggravated form, was next placed upon the operating table. Sarah Humphrey, aged 58, the mother of five children, had been troubled with prolapsus uteri for seventeen or eighteen years. It had latterly been constantly down when in the erect posture, but passed into place without much difficulty when recumbent. The exposed mucous lining of the vagina had become greatly thickened, brawny, and in some parts hard and dry, like cuticle; in others, where it had sustained friction against the thighs, it was ulcerated. These conditions were apparent to all present when the patient was placed in position for the operation, for the protrusion was then down to the size of an infant's head. Mr. Marshall remarked, that it might, at first sight, seem advisable to take advantage of this position of the part, in order to apply the cautery; but, from his experience of a former case, in which that had been done, he was not inclined to again attempt it. The application itself was, of course, easy enough; but it was impossible to return and re-invert the protruded mass, without inflicting undue violence on the parts which had just been cauterized; the patient, in the instance alluded to, had suffered afterwards from a slight attack of peritonitis, which he (Mr. Marshall) was inclined to attribute rather to the violence thus done, than to the operation itself. The prolapsus having accordingly been reduced, exactly the same steps were gone through as in the case we have just described, with the exception, that, as the mucous and submucous tissues were much thickened, it was necessary to apply the cautery more freely, so as to allow it to act deeply.

We must not omit to mention here another advantage belonging to this operation,-viz., that, through all its steps, the surgeon is enabled to see distinctly what he is about. We observed, that, when the cautery was within the vagina, the brilliant incandescence of the wire sufficed to light up all the surrounding parts, in the clearest possible manner.

The after-treatment and progress of these two patients have been almost precisely similar, and destitute of any excepting negative features of interest. During the first fortnight, they were, of course, confined to bed, and, for the first few days, the bowels were allowed to continue costive; after which, a few doses of castor oil were given at different times, and constituted the sole medication pursued. Detergent injections were at first used twice daily, and, as the sloughs separated, were replaced by mildly stimulating ones. The ulcers have now healed, and there is in each case a very decided diminution in the capacity of the vagina. Both women have been allowed, during the last ten days, to sit up and move about the ward a little, and in neither has any prolapse yet resulted. It is intended, however, to repeat the operation very shortly on both of the patients.-Med. Times and Gaz., July 2, 1853, p. 12.

137.-TREATMENT OF DISPLACEMENTS OF THE NON-GRAVID UTERUS.

By DR. J. F. PEEBLES, of Petersburg, Virginia.

[The great objection to all contrivances yet introduced to support or rectify the position of the womb is, that, as they must be worn some time, they may produce irjury to some of the organs with which they are in contact. The instrument, and the only one which Dr. Peebles considers is free from this great disadvantage, is the one recommended by Professor Hodge, of Pennsylvania.]

Dr. Hodge's Pessary.

The instrument consists of two lateral bars, curved to correspond with the walls of the vagina, united at top by a rect angular bar (see fig.).

The instrument lying in the vagina maintains it in its original shape, and it is by doing that alone that it proves effectual in keeping the uterus in situ. It operates through the vagina, and rather presses away from than against the womb. It is, moreover, not liable to derangement, and readily permits the natural functions of all the pelvic organs to be performed without obstruction. It is worn without annoyance, and can be introduced and removed with great facility. From the principle of its action, it must appear that it is calculated to replace the womb, when displaced in any way. The principle is the only true one, in my opinion, and I am in the habit of using this form of instrument in every case of displacement where mechanical support is required. In retroversion, particularly, it is an invalu able agent; with no other have I succeeded so well in the removal of the distressing symptoms attending on that form of uterine displacement.

Its mechanism in the removal of retroversion must be obvious. It will be seen that the mere introduction of the pessary alters the position of the uterus completely. The posterior wall of the vagina is kept so distended by the back part of the pessary, that instead of yielding, as before, it becomes the seat of a force which bears the fundus uteri upwards and forwards, throwing its cervix downwards in the vagina, and keeping it there. Its mere introduction, in fact, alters the position of the uterus from retroversion to that of simple prolapsus in the first degree; and it is by the distension of the posterior roof of the vagina to its normal dimensions that the organ is kept in situ, and not by any force exerted against it. This constitutes the great merit of the apparatus; it completely rectifies the displacement without the danger of local injury. When well adapted to the dimensions of the pelvis and vagina, it can be worn without annoyance for months or years; and such is the signal relief which patients experience from it, that I have known them to object to its removal, long after all tendency to displacement had ceased to exist.

The caution to be observed in retroversion is to secure the full extension back. wards of the posterior vaginal wall, so that the long diameter of the womb should be brought to look in the direction of the umbilicus. Without this, the weight of the womb, by the swaying backwards of the organ, might rest on the hindmost bar of the pessary; in which event, its pressure then would so bear up the two lateral bars, that their anterior ends would excite irritation at their terminations under the pubic arch. This is the only inconvenience in wearing the pessary, and it is to be avoided by having the fundus uteri thrown well forward, so that its weight will sway anteriorly instead of posteriorly. This objection makes it necessary in some cases to adopt measures to lessen the volume of the posterior uterine wall before applying the instrument. The reposition of the organ by the uterine sound, and a few days' rest in bed in an appropriate position, is often all that is required for this purpose. I have given complete relief in retroversion immediately by this instru ment; in cases, too, in which all other measures had failed; and after a trial of most of the mechanical agents in use, including Dr. Simpson's stemmed supporter, I give it the preference, and rely upon it in my practice.

The globe pessary, highly recommended by some, in my experience aggravates the distress in re troversion; and the ring, and indeed all other forms of instruments in use, besides being less manageable, are ineffectual. I have used Dr. Simpson's instrument in one case; it could not be borne, and from its effects, I am not inclined to make a repetition of its use in this displacement, although it appears so admirably

adapted to its treatment. The great advantage in the mechanical treatment of retroversion, is to have an apparatus answering the purpose that can be easily worn, and that for a long time, without endangering local irritation, and this is the merit of Dr. Hodge's pessary.

The principle governing the mechanical treatment of anteversion is the same with that of retroversion. The same apparatus may be used for maintaining the integrity of the vagina, as it regards its length and firmness, with the addition of a front bar, uniting the anterior ends of the lateral bars, in a similar manner with the posterior ends. Such a pessary appears as a parallelogram, having its lateral bars curved in accordance with the proper shape of the vagina. The use of the front bar is to support the anterior vaginal wall, making it pull against the cervix, so as to draw the fundus upwards and forwards.

Where mechanical treatment is necessary in flexions of the uterus, I recommend the same apparatus; because the indications, at least those which can be fulfilled by such means, are the same in these deviations. By steadying the organ, local con gestion, upon which most of the distress in flexion depends, is removed, its recurrence prevented, and time is given for the bend in the womb to be rectified. In the case of anteflexion, alluded to in another part of this paper, I had the most signal success with the barred pessary. The patient, from being more or less bedridden, has become a strong woman, walking without annoyance, and never suffering from her womb complaints. The dysmenorrhoea has gradually been relieved, and the thinned parietes of the cervical walls, created by the flexion, have considerably filled up. She continues to wear the instrument by preference, and in time I believe the flexion will be permanently rectified. In retroflexion, from the principle upon which the instrument operates, there is a greater reason to expect decided benefit than in anteflexion, and such has been my experience.

In prolapsus of the second and third degrees, the apparatus constitutes an effectual and convenient method, as much so as any that can be devised, for keeping the organ in situ. In bad cases its effects are much enhanced by proper perineal support. At the same time that it keeps the womb at its proper elevation, it allows of the free application of such measures as may be required to impart strength to the relaxed vaginal walls.

Professor Hodge has his instruments made of silver, which are afterwards gilded by heat, and it is certainly the best material on account of its lightness and durability; yet the gutta percha furnishes an excellent substitute. I have modelled pessaries from this substance which have been used on an emergency; in cases requiring great nicety of form and arrangement, I have found it best to manufacture them of this material first, and afterwards use the model in forming the metallic one.—Am. Journal of Med. Science, July, 1853, p. 51.

138.-NEW OPERATION FOR THE CURE OF PROLAPSUS UTERI.

By M. DESGRANGES, Senior Surgeon of the Hôtel-Dien at Lyons.

[M. Desgranges believes his operation to possess the following advantages: it neither compromises life or even the functions of the organ; nor, should it fail, does it render the disorder more severe than before. He first reviews the various operations which have been proposed to remedy this disease.]

Narrowing of the Vagina.-Cauterization.-In 1823, M. R. Gérardin proposed to form contractile cicatrices, and thus to narrow the vagina, and increase the resistance of its walls. He went still further, and advised the complete obliteration of the canal. In 1833, Professor Laugier employed cauterization with acid nitrate of mercury. In 1835, M. Velpeau applied the actual cautery. The objections to cauterization are the difficulty, especially with the actual cautery, of limiting the extent of the part acted on, and the danger of injuring neighbouring organs, which renders it necessary to cauterize superficially, and hence often insufficiently. Success, however, may be expected from cauterization in a few cases, but it requires to be carried further than prudence allows.

Excision. Drs. Heming and Marshall Hall propose the removal of an elliptical piece from the anterior wall of the vagina; the edges being immediately united by