situations, forms, and depths. The sulphuric acid has been found by the author preferable to it and to the nitric acid, while other practitioners give the preference to the perchloride of iron. The eschars once separated, styrax and aromatic wine proved the best of topical applications; while, when cicatrization was delayed, or there was a tendency to substitute the ulcerative form, citric acid, camphor, cinchona and carbon, tincture of iodine or nitrate of silver, and if necessary, nitric acid, imparted a new and favourable impulse to the cicatricial process. The formation of a crust or magma on the surface of the sore by means of some of the above powders has been found to encourage the healing process, and to diminish the patient's sufferings. For the chronic form the perchloride of iron is better adapted than the sulphuric acid. But let the local measures employed be what they will, success will be impos sible or transient, unless the general conditions and the necessity of removing the patient from the infected medium be borne in mind.

IX. On the Treatment of Carbuncle. By Dr. GUTZEIT. (Medicin. Zeitung Russlands, 1858, No. 12.).

Dr. Gutzeit of Riga recommends the following ointment as the sole treatment of simple carbuncle-viz. half a drachm of opium mixed up with two ounces of white ointment, spread as thick as the back of a knife on linen rag, and applied to the tumour and its circumference three or four times daily. He says he cannot feel surprised at the incredulity with which his recommendation will be received; but having in numerous cases derived great benefit from the employment of this means, he must insist upon its utility. Relief takes place in some cases with remarkable rapidity, the dreadful pain becoming sometimes supportable after half an hour, while the various stages of the affection are expedited. The general symptons, too, undergo a corresponding amendment. Moreover, the means is applicable to any stage of the affection, from the commencement of tumefaction to the separation of the eschar.

X. Fracture from Muscular Contraction. By Dr. BENEDIKT.

schrift, 1858, No. 12.)

(Wien Medecin. Wochen

Dr. Benedikt observes that in most of the cases of fracture produced by muscular contraction, pathological processes have rendered the bone liable to the production of solution of continuity. In such cases a slight contractile effort suffices to induce the fracture, and that repeatedly in the same bone. There still are cases, however, in which an entirely healthy bone may be fractured solely by muscular contraction. Two such were treated in the surgical division of the Wieden Hospital, near Vienna, during 1856. The first occurred in a healthy young weaver, sixteen years of age, while in the act of quickly raising his arm during snow balling; an oblique fracture at the upper third of the right humerus, manifesting all the usual signs, having been produced solely by muscular contraction. After thirty-six days of treatment, the fragments were found to be completely united. The second case happened in the person of an engraver, aged twenty-eight, who had always enjoyed good health. The accident occurred while he raised his arm in order to throw a stone, the humerus being fractured transversely at about its middle. Reparation was effected in the usual time.

XI. On Caoutchouc Bandages in Fractures. By Dr. EDWARD ZEIS. (Deutsche Klinik, 1858, No. 14.)

Dr. Zeis had already reported highly in favour of these bandages, and two years' additional employment of them in the Dresden Hospital has only confirmed his good opinion. They are especially useful in the cedematous swellings left after ulcers, in varix, and in general whenever pressure is advisable-as when the gravitation of pus is desired to be prevented, and uncertainty of progression remains long after subluxations. They succeed better than any other description of bandage; for if the swelling, under the influence of their gentle pressure, subsides, they still remain closely applied, while, when it increases, they gradually yield.

After several years' trial of the gypsum bandage in fracture, Dr. Zeis has come to the conviction that the praise bestowed upon it is undeserved. It is beautiful in appearance, and many prize it because it allows of the patient going about. The advantage of this going

about on crutches, with the limb suspended, is very questionable; for the foot hanging down becomes swelled, and the pressure of the unyielding bandage soon obliges the patient to return to bed. Moreover, however firmly this bandage be applied, it always becomes looser on drying, so that two fingers can be inserted between it and the limb. Hence, the cures by its agency are not satisfactory. It is also removed with great difficulty. The author having broken his own arm, has experienced the sensation both of a too tiglit and a too loose bandage; the first is insupportable, and the other is constantly reminding one of its uselessness, and of the danger of displacement. The elastic bandage alone can be so adapted as to produce neither of these effects; and when once put on properly, it may be safely left on without renewal longer than any other. Whenever the author has renewed it after a week or a fortnight, he has had to regret meddling with it, so well had it continued applied.

As to the mode of application, a piece of damp linen is first applied over the bare skin, so as to lie nowhere in folds, and in the case of excoriations, these being first covered with mild ointment; and over this is laid a layer of soft wadding or cotton. The splints may be the same as in other modes of treatment, those of gutta percha being preferred in all those parts in which the thickness of the limb suddenly diminishes. In some cases the splints have been kept confined by strips of caoutchouc four inches broad, first moistened in warm water. Usually, however, the caoutchouc bandage is applied next the splints. Dr. Zeis has never known his patients complain of undue warmth, produced by the obstruction of transpiration.

XII. Case of Sudden Death after the Operation for Hare-lip. By Dr. VOLKMANN. (Monatsschrift für Geburtskunde, Band xi., p. 353.)

An unusually strong and powerful boy, a twelvemonth old, was operated upon by Dr. Volkmann, at two different periods, on account of hare-lip, with double fissure of the jaw and hard palate. On the first cccasion, the coaptation of the bony parts was commenced, and the result of the operation and of four weeks' after-treatment being favourable, it was determined to proceed to the union of the rudiments of the lip. During the application of the last needle the child became suddenly of a blue colour, and respiration ceased. Examination showed that neither mucus nor blood obstructed the pharynx; but as the child spasmodically closed the mouth, and seemed about to expire, all the sutures were at once removed. The child now took a deep breath, and recovered itself. As its condition four and a-half hours afterwards was found quite satisfactory, the uniting the parts was again undertaken with great circumspection. No ill consequence followed, and the child lay with its mouth wide open, and freely breathing. Dr. Volkmann then left his patient, but in less than three hours was sent for, as suffocation was again impending. He was on the spot two minutes after, and removed the sutures, but the child was dead, and all attempts at his recovery proved fruitless. Dr. Volkmann, in communicating this case to the Berlin Midwifery Society, refers to Busch's opinion that those children accustomed to breathe with closed mouth owing to the wide nasal fissure, continue from habit to do the same after the operation, and thus induce suffocative paroxysms. Dr. Gurlt had observed several similar cases; and Dr. Biesel drew attention to Langenbeck's precaution of always stationing an experienced nurse near the little patient, with the direction, immediately on the appearance of any difficulty in respiration, to open the mouth and press the tongue down with a spatula.

QUARTERLY REPORT ON MIDWIFERY.

By ROBERT BARNES, M.D. LOND.

PHYSICIAN TO THE ROYAL MATERNITY CHARITY.

I. PHYSIOLOGY AND PATHOLOGY OF THE UNIMPREGNATED FEMALE.

1. On a peculiar Discoloration of the Skin in Females. By Professor BANKS. (Dublin Quarterly Journal, May, 1858.)

2. Anatomical and Anatomo-Pathological Studies on the Statics of the Uterus. By Dr. F. A. ARAN. (Arch. Gén, de Méd., February and March, 1858.)

3. Apparatus for Ligature of Uterine Polypi. By Dr. DITTEL. (Wochenbl. der k. k. Gesellssch. der Aerzte zu Wien, July, 1857.)

4. On the Use of Purgatire Enemata in the Treatment of Uterine Catarrh. By Dr. ARAN. (L'Union Méd., May, 1858.)

5. On the Linear Ecrasement of the Cervix Uteri. By Dr. BRESLAU, of Munich. (Monatsschr. f. Geburtsk., January, 1858.)

1. DR.BANKS has contributed another case of that singular black discoloration of the skin which Dr. Neligan some time back described under the name of " Stearrhoea Nigricans," and Dr. Billard (Arch. Gén. de Méd., 1831) "Cyanopathie Cutanée." The memoir of Dr. Banks may also be referred to as being an excellent epitome of the history of this curious affection. The following is a sketch of the case observed by himself:

An unmarried female, aged twenty-three, was admitted into the Richmond Lunatic Asylum on the 17th of Sept., 1853. She had experienced a fearful mental shock from being suddenly shown the hanging body of her lover, who had destroyed himself in a fit of insanity. She became maniacal, with suicidal tendency. Soon after admission she had an attack of erysipelas of the face. After several months of amenorrhea, she became the subject of periodical hæmoptysis, evidently vicarious. When seen by Dr. Banks she exhibited a remarkable discoloration around the eyes, but chiefly beneath the noise; the parts looked as if they had been painted with Indian ink, or rather with Prussian blue. This has existed since the cessation of the catamenia, but it becomes more vivid during the periodical hæmoptysis. In the midst of her insane preoccupations, she is at all times most sensitive upon the subject of this discoloration.

Dr. Banks thinks the cases that have been described cannot be included under one nosological appellation. The most general feature appears to be some disturbance in the menstrual function.

2. The researches of Dr. Aran into the statics and means of suspension of the uterus form an important contribution towards the settlement of this vexed question. He observes that modern anatomists maintain that the uterus is kept in position by several ligaments-namely, anterior, or vesico-uterine; lateral superior, or round; lateral proper, or broad; posterior, or recto-uterine, ligaments. Latterly, Virchow has insisted with much force and reason on the part performed in the suspension of the uterus by the adhesion of the uterine neck to the bladder. Our space will not allow of the fulness of detail required for anatomical description. We can but summarise the author's conclusions. The posterior ligaments do not stop at the middle of the sacrum. Diverging over the sides of the rectum, they terminate in very fine filaments, which lose themselves in the sub-peritoneal cellular tissue from the middle of the concavity of the sacrum, as far as the body of the last, and even the penultimate lumbar vertebræ. If the uterus is lifted by its fundus upwards and forwards, the posterior ligaments are seen to be stretched, and become prominent under the peritoneum. If the uterus is depressed from above downwards, or if it is attempted to drag it down by the neck towards the vulva, the posterior ligament is not stretched at first; it is only when the rectification of the curve described by it is made that the ligament begins to stretch, and strongly resists traction. If the neck of the uterus is pushed backwards in the vagina, or the fundus is strongly depressed forwards, the posterior ligament is relaxed; but if the neck is drawn strongly forwards, or the fundus pushed backwards, the ligament is immediately stretched, and starts up under the serous membrane. There cannot, therefore, be a doubt as to the use of the posterior ligament. It serves to oppose, up to a certain point, the descent of the uterus, and to preserve the uterine neck in the posterior part of the pelvis.

The use of the so-called broad ligaments is merely to give passage to the vessels to hold the round ligaments, Fallopian tubes, and ovaries; and to maintain by lateral support the uterus in the centre of the pelvic cavity.

The disposition and uses of the round ligaments deserve to fix attention. The round ligament is nothing more than an emanation from the proper tissue of the uterus. If the external inguinal ring is exposed, and the uterus moved, its movements are seen to be communicated to the uterine cord, the fibres of which may thus be traced into the cellular tissue of the external genital organs. If the cord is pulled upon from the ring, the uterus is partly rotated on the corresponding side and bent forward. If both cords are pulled upon at the same time, the fandus of the uterus follows the diagonal of the two opposing forces, and is brought directly forwards. In this manner the most complete anteversion can be produced. These cords do not, then, suspend the uterus in the pelvis, they help to maintain the fundus forwards, and especially to limit its movements in the antero-posterior direction.

He

M. Aran attaches little importance to the supporting power assigned to the vagina. agrees that the experiment of Stoltz, who observed that the uterus kept its position when the

vagina was cut away, is decisive. Without discrediting the utility of the operations undertaken for the relief of prolapsus, he questions whether these, while acting on the vagina, have not often also extended their action to the utero-sacral ligaments and cellular tissue surrounding the vagina.

M. Aran cites with assentation, the observations of Paul Dubois, Forget, and Virchow, on the connexion between the uterine neck and the neck of the bladder. The uterus participates necessarily in all the changes experienced by the bladder. But he does not agree with Virchow, in regarding this adhesion as the principal means of suspension of the uterus. What gives especial importance to this adhesion, is the fact that at this point is also inserted the vagina, whose dartoid layer is lost in the cellular tissue which binds the uterus to the bladder, at the same time that it runs into the superficial longitudinal fibres of the uterus. Nearly at the same level, behind, the dartoid fibres of the vagina confound their insertions with those of the posterior ligament. Hence there results for the uterine neck, a true ring, comprising in front the adhesions of the bas fond of the bladder to the uterus, the insertion of the vagina on the neck; behind, the posterior ligament, the insertion of the vagina upon the neck. This point of union M. Aran proposes to call the axis of suspension of the uterus, in opposition to what has been described as the axis of the organ, and which is only its axis of inclination, or the properly called axis of suspension. It is upon this point that all the forward, backward, and side-to-side movements of the body of the uterus are effected. Movable in every other part, this point is truly that upon which the uterus reposes.

In the second part of his memoirs, Dr. Aran proceeds to give the result of researches into the frequency of deviations of the body of the uterus, and their causes. His conclusions are mainly drawn from the post-mortem examinations of 37 women-a number too small to secure against error. Anteflexion and antecurvature were found in half the cases, and this frequency is peculiar to youth and multiparity. Of 21 women who had had children, 7 only presented anteflexion. In reference to what M. Cruveilhier has called the indifferent position of the uterus, M. Aran says that in 5 cases he observed the greatest facility of displacement, so that when the body was laid upon the back, and the intestines lifted up, the uterus immediately fell back into the cavity of the sacrum. As to the causes of anteflexion, the author cites Huguier, who has shown that in foetal life the body of the uterus is a mere small membranous sac, with thin walls, greatly contrasting with the more developed and rigid cervix, and therefore easily bent upon this latter by weight of the abdominal organs, the anterior flexion being determined by the sus-pubic cords. He concludes that ante flexion is congenital. Thus, be says, under the influence of sexual congress and pregnancy, there is a tendency to the removal of this anteflexion. He shows, by measurements of the neck and body at different ages in virgins and multiparæ, that there is a progressive alteration in the relative length of these two component parts of the uterus; that the body enlarges at the expense of the cervix. This tends to diminish the angle formed by the body with the neck, and to convert anteflexion into antecurvature. Pregnancy especially tends to straighten the uterus. Dr. Aran's final deduction is, seeing the physiological origin of anteflexion, that mechanical means of rectification are uncalled-for and dangerous.

3. Dr. Dittel proposes to add another weapon to the cumbrous armamentarium provided against uterine polypi. It is especially designed in order to combine, what is not seldom wanted, a grasping and down-dragging power, with the apparatus for strangulation. The complete instrument nearly resembles the ordinary obstetric forceps. But one blade, which is made to separate from its handle, is pierced at the extreme end by a small hole for the transmission of a loop of silk-the ligature; and has at its lower end a screw-nut, also perforated, to receive the ligature brought down. The loop is first passed over the tumour, the ends are passed through the screw-nut, which, being turned, tightens the ligature; the blade then fixed in its handle is brought in apposition with the other blade. The two, when locked, grasp the tumour, and serve to bring it away, when the neck is cut through. [The difficulty of passing the loop around the pedicle of the tumour must be greater than with Gooch's double canula. The only advantage seems to be to obviate the inconveniences sometimes encountered with large polypi, of extracting them from the vagina after separation.-REP.]

4. Dr. Aran reports that he has obtained the most satisfactory results from the use of purgative enemata in cases of uterine catarrh. He insists that the cases selected for the application of this remedy be cases of chronic leucorrhoea without active inflammatory complication, and that the discharge proceed from the uterus.

The mode of administration recommended is, every day or every other day, according to the effect produced, at bedtime, to use a lavement of tepid water to clear out the bowel, and then an enema prepared of aloes and soap, of each five to ten grammes in one hundred grammes of boiling water. This is mostly retained until the following morning. In four or six days, says Mr. Aran, the uterine discharge is commonly arrested.

5. Dr. Breslau records 4 cases in which he removed all or part of the cervix uteri by the écraseur of Chassaignac. In 3 cases there was carcinoma, and in 1 chronic hypertrophy and induration. Of the 3 first, both lips were removed in 2 cases; in the third, only the anterior lip was removed. Two of the patients with cancer were quite well at date of report, without trace of local relapse. One case was operated in April, 1856; the other in September, 1856. In the third cancerous case all the disease could not be removed; the indication sought was to restrain the bleeding. A temporary amendment followed; but a fatal result is anticipated. The case of hypertrophy was quite cured, and remained well seven months after operation. In all the cases the bleeding was very trifling. In 2 cases an accident occurred very suggestive of caution. In tightening the écraseur-chain a piece of the anterior vaginal wall was caught and pinched off. In one case a hole was made, through which a piece of intestine protruded, which is not reported to have closed.

II. PHYSIOLOGY AND PATHOLOGY OF THE PREGNANT AND PUERPERAL FEMALE.

1. On Certain Points in the Anatomy and Physiology of the Mucous Membrane and Epithelium of the Uterus during Pregnancy. By Dr. CH. ROBIN. (Dr. Brown-Séquard's Journal de la Physiologie, Jan. 1858.)

2. On the Glycosuria of Puerperal, Suckling, and Pregnant Women. By Dr. RIEDEL. (Monatsschr. f. Geburtsk., Jan. 1858.)

Dr. Ch. Robin's memoir on the uterine mucous membrane contains several points which we feel it a duty to extract. He observes that the general belief, that the inter-utero-placental decidua is carried away by the placenta, as is the rest of the decidua by the chorion, is not altogether correct. The chorion carries away with it the decidua uterina and decidua reflexa, which adhere together and to itself. The internal aspect of the muscular coat is left, lined by the new substituted mucous membrane which has already begun to grow. This forms a thin, soft, rosy layer, moulding itself on muscular fibres, and leaving them sometimes quite bare, when torn, and at any rate visible by transparency. The free surface of this developing mucous membrane looks a little irregularly villous when examined under water. But in women dying seven or eight days after labour, it has already assumed a smooth surface, although its thickness is very little increased; it is somewhat shining, as if glutinous, and as yet too soft to be separated by dissection from the underlying coat. It is also seen that the placenta carries away with it the circular sinus which surrounds it, and which is slightly exterior to it, rather than inter-utero placentary. It carries away at the same time scarcely the half of the serotina, or inter-utero-placentary-decidua, because it tears through about the middle of the sinuses which traverse this membrane. Nevertheless it retains in this thin portion of serotina some portions of sinuses still entire, especially in the neighbourhood of the circular sinus, and in the sulci which separate the cotyledons. Thus the placenta, when it separates itself from the uterus, does not carry away the entire inter-utero-placentary decidua, as it does in the case of the remaining decidua vera. It leaves the greater part adhering to the uterus. The placenta exhibits the surface of its cotyledons covered by a greyish semitransparent soft membrane, varying a little in thickness in different subjects. Sometimes this membrane is smooth-sometimes rough. It does not present in its thickness any vessels comparable to the circular sinus, nor consequently to the sinuses of the serotina. This layer or membrane detached from the serotina by the placenta is represented by the thickened epithelium of the inter-utero-placentary portion of the uterine mucous membrane. Thus it is chiefly constituted of epithelial cells which have undergone a considerable hypertrophy of the body and nucleus, as well as odd deformations. [These cells of the maternal membrane are figured in Dr. Barnes's first memoir, On Fatty Degeneration of the Placenta, 'MedicoChirurgical Transactions,' vol. xxxiv.] The membrane also includes amorphous matter and different molecular granulations. It may further be observed, that at the periphery of the placenta, in approaching the decidua, it is continuous with that portion of this membrane which adheres to the chorion rather than with that surface of the decidua which is just detached from the uterus. The existence of this membrane, which is constant, demonstrates a series of very important facts. Thus the placentary villosities do not plunge freely and directly into the large sanguineous sinuses of the serotina. The ramifications of the villi traversed by the foetal blood are separated from the blood of these sinuses by the thickness of this membrane, and by the very thin membrane of the sinuses of the serotina.

The internal surface of the uterus at the seat of the placenta after the separation of this organ retains, as has been said, the decidua, with the exception of the thin superficial (epithelial) layer, carried away by the placenta. Indeed, this portion of the uterine mucous