is also soon reproduced. It is a disease which especially affects children, and seems to be connected with a general condition of the system, rather than of a mere local nature. It would not seem to be contagious, for in the four cases here recorded but one eye was affected although the other eye was frequently exposed to the contact of the diseased secretions. It is a very severe affection, but it is curable. The treatment chiefly to be relied upon consists in the application of leeches, the injection of solution of nitrate of silver, and the internal administration of the chlorate of potass.

X. On a New Mode of Operating for Cancer of the Lip. By Professor O'Shaughnessy. (Indian Annals of Medicine, July, p. 435.)

Professor O'Shaughnessy observes, that when cancer of the lip is confined to a limited spot, it is easily removed by the ordinary V-shaped incision, but that this procedure does not suffice when the whole lip, and perhaps one or both commissures, are involved in the disease. In a case which occurred in his own practice, the cancer not only occupied the whole lower lip, but the right commissure and a part of the upper lip also, on that side. "I thought nothing could be done in such a case, until the plan struck me of making a lip by detaching a triangular portion of the cheek on either side of the mouth, in the following manner:The whole of the diseased lip to be removed by making two incisions meeting at a point in the centre of the chin, the cheeks then to be divided by two horizontal incisions extending from the angle of the mouth on either side, and continued backward as far as the masseter muscles; these to be joined, at their posterior extremities, by two oblique incisions carried upwards and backwards, from either side of the chin, leaving two triangular flaps to be dissected forwards, so as to admit of the apposition of the edges of the V-shaped gap left by the removal of the cancer." An excellent lip was in this way made, and most of the lines of incision had united by the first intention, when about the tenth day the patient was carried off from the effects of retention of urine.

QUARTERLY REPORT ON MIDWIFERY.

By ROBERT BARNES, M.D. LOND.

PHYSICIAN TO THE ROYAL MATERNITY

CHARITY.

I. PATHOLOGY OF THE UNIMPREGNATED FEMALE..

1. On the Cure of Vesico- Vaginal and Vesico-Uterine Fistula. By Dr. GUSTAV SIMON. (Monatsschr. f. Geburtsk., July, 1858.)

2. A New Procedure for Plugging the Vagina. By M. MONTAMIER. (L'Union Méd., Dec., 1858, and Gaz. d. Hộp., Sept. 1858.)

3. Medicinal Trials of Carduus Maria, Carduus Benedictus, and Onopordon Acanthium. By LOBACH. (Verh. d. Phys. Med. Ges. zu Würsburg, viii., 3, 1858.)

4. Ovarian Cyst in a Puerperal Woman cured by Spontaneous Rupture and Discharge through the Colon. By Dr. LUMPE. (Zeitsch. d. Ges. d. A. zu W., No. 22, 1858.)

5. Cancer of the Fundus and Body of the Uterus perforating the Rectum. By Dr. HARRIS. (North Amer. Med. Chir. Rev., Sept. 1858.)

6. Report of a Case of Inversion of the Uterus successfully reduced after Six Months. By Dr. WHITE. (Amer. Journ. of Med. Sc., July, 1858.)

1. Ar a meeting of physicians held at Darmstadt in 1857, Dr. Gustav Simon detailed the methods he had pursued in the treatment of vesico-vaginal and vesico-uterine fistulas, and submitted eight of the patients who had been operated upon, to examination. Of 19 fistula treated, 10 had been completely healed; in 5, cure was nearly complete; 1 was abandoned as incurable; 2 women died after operation. One case was a vesico-uterine fistula-that is, the fistula passed from the bladder into the cavity of the uterine neck, without injury to the vagina; the urine passed through the os uteri. The incontinence of urine was cured by the obliteration of the os uteri, which was effected by uniting the split and freshened

lips together by seven sutures. The woman retains her urine. The communication between bladder and the uterus persists; menstruation is entirely effected through the bladder. The woman remained well two and a half years after the operation.

In a second woman, the anterior lip of the os uteri was destroyed, with a part of the vaginal wall of the bladder, so that a deep vesico-utero-vaginal fistula resulted. This fistula was healed by using the posterior lip of the os uteri as a flap to be united to the walls of the bladder. In this woman also the menstrual secretion passes through the bladder. The woman is well three years after the operation.

In a third woman, a large fistula extended from the neck of the bladder to the os uteri. Dr. Simon split the os uteri and covered the loss of substance by means of the so-made moveable anterior lip, and united it to the walls of the bladder. This woman is well three years after the operation, and has borne a living child since.

In five other women, in whom vesico-vaginal fistula, varying from the size of a bean to that of a shilling, existed in various parts of the vesico-vaginal wall, cure was effected by the union of the walls of the bladder.

Others in whom the fissure was very small, were healed by cautery alone.

In three cases, the fistula were so large, that the deficiency included the entire bas-fond of the bladder to the urethra, so as to render the attempt to unite the borders of the fistula hopeless. In these cases Dr. Simon resorted to an operation to be presently described, which he calls the cross-obliteration of the vagina. Two women subjected to this operation have found their condition so much bettered, that both in sitting and at night they can hold their urine and void it at pleasure, and follow their occupations.

In the case of the only incurable fistula, the woman had a very large opening, the sphincter vesica being wanting.

The two women who died had fistula of medium size in the vicinity of the os uteri. In one who died of pyæmia seven days after the operation, the walls of the bladder had united. In the other, who perished seventeen days after the operation from suppuration in the cellular tissue between the bladder, uterus, and rectum, and consequent perforation of the peritoneum, the wall of the bladder had become united with the freshened anterior lip of the os uteri. In the operation upon the first patient, the uterus had been drawn down by Museaux's hook-forceps, in the second not.

A third woman died under Dr. Simon's care, after making a considerable division of a strong adhesion of the vaginal walls. She died on the sixth day of oedema of the lungs following on pyæmic pneumonia, before the operation proper for the fistula had been undertaken.

The operation performed by Dr. Simon consists in the free freshening of the edges of the fistula, and union by the knotted sutures.

We will now describe briefly his operation of cross-obliteration of the vagina. It consists in this that the remains of the vesico-vaginal wall are brought into union with the freshened hinder wall of the vagina, or bladder with rectum in a transverse direction. Thus a receptacle for the urine is formed, which is embraced by the upper part of the vagina, the roof of the vagina and the defective bladder, and directs the urine into the urethra. A portion of the vagina bow the seat of the operation remains as before. The operation is so carried out, in cases were the deficiency of the bladder is so very great, that of the hinder wall of the bladder only the urethra remains, that the upper edge of the remaining urethra is freshened over a space of two to three centimetres, and on the level of this edge, especially on the side and posterior wall of the vagina, a similar extent is freshened in like manner. The apposition of the wound is effected by six or seven sutures. With a very bent needle the wound mado in the vagina is transversed and surrounded by one thread. The freshened part of the rectum-wall and the hinder edge of the urethra are thus united when the loops of the suture are brought together. The closure of the vagina forms a transverse—often, on account of the great yielding of the recto-vaginal wall, an arched line. Dr. Simon extols the advantages of this operation over the other mothods, episiorrhaphy and transplantation for obliterating the vagina. It promises greater certainty in healing, it is free from danger, since only superficial mucous parts are divided, and so far answers the purpose, that it prevents incontinence of urine and preserves a portion of the vagina, and exerts no after bad influence. This operation he has performed three times, with so much success as to have only very small fistulæ remaining. By it the greatest deficiencies of the bladder may be remedied.

2. M. Montamier recommends a modified form of Gariel's air-pessary for plugging the vagina. He urges, and with truth, the objections to the simple air-pessary, that it is apt to slip, that it fails to compress perfectly the os uteri, and does not admit of the application of medicaments to the uterine neck. He covers the air-pessary with a linen-cap which admits of being tied on by a slip-knot; on the summit of the cap a layer of fine sponge is sewn.

The pessary thus armed completely fills the vagina, without its being necessary to over-distend it; and the sponge can be saturated with any liquid thought desirable.

3. M. Lobach relates his experience of the uses of the Carduus Mariæ, Carduus Benedictus, and Onopordon Acanthium. He says the seeds of the Carduus Mariæ have a surprising efficacy in arresting uterine hæmorrhage. Not only does this remedy check the discharge at the time, but by continued use prevents the return, and this in cases where krameria, sesquichloride of iron, phosphoric acid, tannin, &c., had failed. It especially operates in cases where the floodings are associated with portal obstruction, diseases of the liver and spleen, hemorrhoids, &c., but not where the flooding depends on wounds, ulcerations, or heterologous formations. It may be used in the form of decoction or tincture.

4. The case of ovarian dropsy related by Dr. Lumpe illustrates one of the modes in which this disease is sometimes spontaneously cured. A weakly pluripara had exhibited since her second labour pain in the left ovarian region. After the third week, the abdomen remained perceptibly enlarged, and an ovarian cyst that admitted of being grasped was formed. At the same time a smart peritonitis occurred. To diminish her suffering, a puncture was made, and some fluid withdrawn; this was greyish-green, curdy, distinctly smelling of fæces. Her condition mended, but soon the cyst grew to its former size. A second puncture was determined on, when, without obvious cause, diarrhoea set in, and daily increased with colicky pains. At first the evacuations were of a fæculent brown, gradually paler, and lastly of the same colour as the contents formerly drawn from the cyst by puncture. These discharges persisted for nearly five weeks, when the woman recovered, and might be considered completely cured. Rupture was apprehended. The diagnosis between retroversion and a descent of an ovarian cyst was doubtful. The appearance of the fundus uteri in the abdomen was especially opposed to the first supposition. In either case, the treatment appeared clear. If the tumour could not be pushed back above the pelvis, the trocar must be used to empty it, for a rupture seemed imminent. About eight o'clock on the 13th, the pains were violent and unintermitting. The patient was deeply narcotized by chloroform, and attempts made to push up the tumour. This, after great effort, was effected, and then another very smooth and elastic swelling came down into the pelvis; this was the bag of membranes, which soon burst, discharging a remarkable quantity of water, the two feet of the child immediately following. Delivery was soon completed. The foetus was of six months' gestation; it lived for nine hours. The patient recovered favourably. After-examination revealed no sign of ovarian tumours. The fluid sac felt in the pelvis could only have been the posterior wall of the uterus distended into the form of a pouch. The designation retroversion seems misapplied.

5. Dr. Harris records an interesting and rare example of cancer affecting the fundus and body of the uterus. The subject was a married lady, aged fifty-four. The disease gave evidence of its presence more than four years before death. She suffered from sanguineous discharges, at a later period mixed with broken-down cancerous tissue and purulent secretion. For about two years and five months she suffered no pain, she lost flesh very slowly. For the last twenty-one months she suffered daily from severe lancinating pains in the iliac regions. When a vaginal examination was first permitted, which was only at an advanced stage, the uterus was found enlarged, its cervix very hard, but smooth upon its vaginal surface. Seven or eight months before death pus was found in the excrementitious matters from the rectum. About four months before death, fæcal matter began to pass by the vagina, and toward the latter period of life nearly the whole of the excrement passed through this channel. Death ensued from exhaustion.

Autopsy. The omentum was joined to the fundus of the uterus; and in front of this adhesion the cavity of the womb communicated with the cavity of the abdomen by an irregular aperture, with very soft and rotten edges. The uterus filled the pelvis, with the exception of the space occupied by the contracted rectum and bladder. The ovaries were cancerous; the os uteri was oval, soft, patalous; the cervix short, and had lost its scirrhous condition. The posterior wall of the uterus was united to the rectum, and the cavities of the two viscera communicated by an ulcerated opening an inch wide and three inches long. The soft cancerous matter exhibited broken-down cells. The cancer-tissue proper was of a medullary character, easily breaking down under pressure; it contained an abundance of oval cancer cells, with nuclei and nucleoli. This cancer tissue appeared to the naked eye to be infiltrated in the tissue proper of the uterus, constituting infiltrated medullary carcinoma.

6. Dr. White, of Buffalo, relates two cases of inversion of the uterus in which forcible reduction was effected, in the one case after eight days, in the other after six months.

CASE I.-January 28th, 1856, a young woman was delivered of her first child. She was

stated to have given birth to a male infant weighing ten pounds and a half. A large tumour descended into the vagina after the placenta. The hæmorrhage was "terrific," causing protracted syncope. A few days afterwards, when making an effort to evacuate the bowels, the tumour passed the os externum. When seen, the inverted uterus was as large as at the fourth month of pregnancy, inflamed and tender, hard and inflexible, the body apparently distended with blood from the constriction of the neck. An attempt was made to compress the uterus by the hand and return it; some blood was lost, and the patient became very faint. Fomentations were applied to the genitals; she had a severe chill in the night; pulse 144, feeble. Extract of belladonna applied to cervix. The next day (the eighth from the labour) reduction was again attempted under chloroform. Dr. White passed his right hand into the vagina, and firmly and continuously compressed the uterus; after some time it was found that the fundus could be "dimpled " by the thumb. Pressure upon this point was sustained until the hand became nearly powerless; a rectum bougie was substituted for the thumb, to give rest to the hand. Whilst pressing with the thumb on the fundus, the left hand was applied externally over the uterine tumour, to give counter-support. At length the fingers of the left hand, being pressed well down into the abdomen, seemed to fasten upon or hook over the anterior uterine lip and aid in its reflexion over the organ. Thus securely held between the two hands, the efforts at reduction were continued until the operator was nearly exhausted. The reduction was, however, effected. All hæmorrhage ceased from this moment. The patient died on the third day, having manifested great irritability of stomach. Autopsy. All tissues extremely bloodless. A little serous effusion within the peritoneum ; and between some of the convolutions a very little lymph was exuded. Externally the uterus presented its normal shape and position, the tissues were not softened, nor was there any laceration. The examination revealed no cause of death, unless the anæmic condition of the tissues may be considered as such.

CASE II.-A lady, aged thirty, was delivered in September, 1857, of her second child. The placenta adhered, but was removed in thirty minutes; this was followed by copious flooding, severe pain, and faintings. For three weeks she continued extremely weak. About this time she took an aloetic cathartic, which produced violent efforts at stool, and pains resembling those of labour; profuse hæmorrhage followed these efforts, and a large pearshaped tumour made its appearance through the os externum. This was returned into the vulva. A physician who then saw her passed his hand high up into the vagina; and applied astringents and cold to restrain the hemorrhage. During the succeeding three months she had occasional hæmorrhages. About the middle of January she had another severe attack of hæmorrhage, the tumour again presented externally, and was again returned. Prostration was very great. Nearly twenty-five weeks after the labour she was seen by Dr. White, who then proceeded to the operation of reduction under chloroform. The pressure employed was great and protracted. At length the tumour began to shorten at its neck, and the mouth of the organ to push upon the upper surface of the hand. No depression or dimpling of the fundus was at any time perceptible. The fundus finally passed out of the hand, and was easily pushed by a rectum-bougie (which had been maintained against the fundus) through the mouth and neck, up to its proper position. The bougie was left in sitú till the next day. The patient recovered favorably.

II. PREGNANCY.

1. Remarkable Case of Retroversion of the Uterus in the Sixth Month of Gestation. By Dr. HECKER. (Monatssch. f. Geb., Oct. 1858.)

2. A Case of Extra-uterine Pregnancy: Fatus extracted per Anum Four Years and Six Weeks after Natural Term. By CHRISTOPHER JOHNSTON, M.D. (American Journal of Medical Science, July, 1858.)

3. A Case of Extra-uterine Pregnancy which lasted Six Years, and was cured by Gastrotomy. By Dr. CHEVILLON. (Union Méd. de la Gironde; and Monatssch. f. Geb.,

Oct. 1858.)

4. A Case of Uterine Hydrorrhea. By GEORGE SHEDD, M.D. Medical Science, Oct. 1858.)

(American Journal of

1. Dr. Hecker records a case, described under the title of retroversion of the uterus, which has a special interest in a diagnostic point of view. A woman, aged thirty-five, had passed through several ordinary labours. In the pregnancy now described she suffered much from frequent impulsion to pass the urine, attended by pain and retention. On July 8th she began

to complain of pains in the hypogastrium, and took to her bed. The pains were of a cramplike character, and seemed to threaten premature labour. This state lasted till the 12th, when the pains increased in severity. The fundus uteri was about the level of the umbilicus; strong contractions in it were felt. No distension of bladder; it had been freely and spontaneously emptied. The internal examination was by no means in harmony with these symptoms. No appearance of an os uteri could be felt until after repeated examinations of the patient, placed on her side, back, and knees, when on the level of the upper edge of the pubis a depression in the mucous membrane was perceived. No presenting parts of a child could be felt. Behind, the finger traced a smooth elastic swelling, as if distended with fluid, passing down the posterior wall of the vagina. This filled the hollow of the sacrum. With every pain this tumour was driven down, the distension being so great that spontaneous rupture was apprehended. The diagnosis wavered between a peculiar form of retroversion of the uterus, and an ovarian cyst propelled before the womb. In either case the course to be adopted seemed the same-to push back the tumour above the pelvis, and, if this could not be done, to puncture it with a trocar. At eight A. M., 18th, the pains were still more violent, and without intermission; the distension of the tumour was so great that rupture seemed imminent. The patient being put under chloroform, attempts were made to reduce the tumour; these at length were successful. At the same moment another smooth elastic swelling was felt entering the pelvis; this was the bag of the liquor amnii, which burst spontaneously with great force, ejecting a large quantity of fluid. The child was a female, weighing one pound five-eighths, of the period of six months. It lived nine hours. The placenta followed. The woman did well. An examination made after the delivery satisfied Dr. Hecker that the case was one of retroversion; the tumour consisting of a distension of the posterior wall of the uterus in a sacculated form. [If the fundus uteri were really felt throughout the labour at the umbilicus, then the pelvic swelling was probably, as conjectured, the stretched-out hinder wall of the uterus forming a pouch; but this can hardly with propriety be called "retroversion."-REP.]

2. Dr. Johnston's case of extra-uterine pregnancy furnishes an illustration of the many varieties of termination of extra-uterine pregnancy. On March 18th, 1858, M. H., aged thirty-nine, was admitted into the Baltimore Infirmary. She had supposed herself labouring under dysentery for two weeks previously; was now extremely emaciated, much annoyed by abdominal pains, and frequent small muco-sanguineous intestinal discharges, always offensive, and at times mingled with dark semi-fluid fæces. On examination the uterus seemed to expand suddenly from the neck into a considerable tumour, which could be felt through the abdominal walls in the right iliac region. Within the anal sphincter, the same tumour could be felt through the thickened wall of the gut; but at the depth of a finger's length a culminating point was found, and upon this an opening, an inch and a half wide, in which was impacted a mass of bony plates. The patient believed she had been pregnant four or five years previously, but as no child was born she had abandoned this idea. Dr. Johnston determined to remove the body. On May 8th, the patient being under chloroform, a pair of stout polypus forceps, guided by two fingers in the rectum, was used to dilate the aperture of communication between the sac and the rectum, and to extract the cranial bones piece by piece. The limbs and body were successively removed. No trace of cord or placenta was discovered. The foetus was female, about sixteen inches long, and so much decomposed that the cranial and several other bones were denuded. The weight of the mass removed was about three pounds and a half. The sac contracted notably. About six ounces of blood, and a greater quantity of putrid ooze followed. The patient recovered favourably. Dr. Johnston satisfied himself by subsequent examination that the fœtal sac was distinct from the uterus, although adherent to it.

3. Dr. Chévillon relates a case of extra-uterine pregnancy cured after six years by gastrotomy. The patient had borne two children. In her thirty-sixth year she became pregnant a third time, in October, 1842; she received a blow from a fist, being then in her second month, in the right belly, which was followed by acute pains, inability to move, persistent dysuria, and great weakness. After four and a half months distinct foetal movements appeared; and in nine months labour-pains, which, however, after eight days' duration, ended in nothing, so that the midwife concluded there was no pregnancy. The patient, however, still held to her belief, and felt the foetal movements for two months longer, when the symptoms ceased. From January to March, 1847, menstruation appeared, then ceased; and the patient began to fall off in health. In July, 1847, she went into hospital with diarrhoea and hectic fever. Then was felt in the right abdomen, extending from the navel to the pelvis, a circumscribed tumour, but a fœtus was not made out. No internal examination then made. The patient left the hospital, and returned in November, 1847. At this time an abscess