a last effort was made, for I was satisfied that I could not be deceived in the fact that the depression, felt through the abdomen, was slowly becoming larger. Drs. Sabine and Elliot, after a few moments, desisted from their efforts, as the latter gentleman had advised a frequent change, so that the hand of each operator having rested, the power exerted would be maintained in a more uniform manner. Dr. Thomas, in turn, also passed his hand into the vagina, and, as he describes it, drew down the mass so as to reproduce the inversion, and on immediately returning it, found that it did so beyond its previous position; he repeated this manœuvre, and on returning it again, on the point of his finger (without force on his part, as he stated), the fundus passed on and the reduction was completed, after an effort of three hours and fifty-five minutes.

This point is one of great clinical interest, and worthy of discussion by the Society, as to the bearing of this manoeuvre on the result, as well as the exact point at which it should be resorted to. My own impression is, that Dr. Thomas is mistaken as to the extent of reduction made by him. The portion below the constriction was flaccid and could be readily drawn down, but above the engaging point, where the surfaces were forced into such close proximity, it is a question whether more force would not have been required to reproduce the condition existing at the beginning, than it was possible to have exerted. The final effort, doubtless, hastened the issue, yet as the widest portion of the uterus was already so far advanced within the canal, it is possible that the muscular action of the organ itself might at this stage have soon completed the reduction, as, from the result, the canal was evidently already dilated sufficiently for the purpose. We see the principle demonstrated in an India-rubber ball which has been indented; as soon as the action of recovery has once commenced, the progress of restitution rapidly increases to the consummation.

She speedily recovered her consciousness after the ether, and during the vomiting following, as a precaution, I passed the index-finger directly into the relaxed canal of the uterus, which was presenting immediately within the labia. It was fortunate that I did so, for on the instant I felt a portion of the posterior wall near the fundus indented. With the other hand on the abdomen, I seized the organ and restored the portion on the point of my finger, and retained it in the canal until the paroxysm had passed. It was the only effort at vomiting, and there was no return.

At 5 P.M., with a pulse of 130, twenty-five drops of Magendie's solution of morphia was administered with beef-tea by the mouth. At 9 P.M., pulse 128, as she was suffering from pain generally over the abdomen, thirty drops of Magendie's solution was repeated. She was sleeping quietly at 10:30 P. M.; pulse 112 per minute. At midnight the pulse was 108, and she had been sleeping since the last visit.

11th.-At 9 A.M., the pulse was 110; she was free from pain, and had passed a quiet night. As there was some tenderness on pressure over the abdomen, a large poultice was ordered. At noon her condition was comfortable; pulse 120, with some increase of tenderness over the abdomen; ordered the morphia to be repeated. Half-past 2 P.M., was free from pain, and sleeping quietly; pulse 105. At 7 o'clock P.M., pulse the same; repeated the morphia.

12th.-Nine A.M., pulse 100; she was entirely free from pain, and had passed a very comfortable night. From this time she was kept quiet in bed for twelve days without any further treatment being necessary.

16th.-I made a digital examination and found the os patulous, but the uterine canal contracted above the vaginal junction so as to admit the point

of the index-finger only for a short distance. The sound passed a little over three inches readily to the fundus, with the organ somewhat anteverted.

Nov. 28th.-She visited me after taking a long drive. I found that the uterus had returned nearly to its normal size. She had menstruated naturally a few days before, and was rapidly regaining her health and flesh.*

On presenting the case to the Obstetrical Society, it was the opinion of several members that the condition of the patient at the point in question favored a rapid reduction in the last stage, and as the dilatation was complete, the innate force of the organ itself might have soon completed the reduction. Dr. Budd remarked that Dr. Noeggerath had some years ago succeeded in reducing an inverted uterus by a similar process, and that the case was published in the "Transactions of the Academy of Medicine."t Dr. Noeggerath being called on, related the case in full, and remarked that in recent cases, and where the fundus had not yet escaped from the cervix, the dimpling process recommended would sometimes succeed, but not always where the inversion was complete. He also gave the particulars of a subsequent case where he succeeded only by confining his manipulations entirely to the return of one side alone, until the reduction was complete.

CASE II.-REDUCTION OF AN INVERTED UTERUS OF EIGHT MONTHS' STANDING, BY THE SAME METHOD.

(Read before the New York Obstetrical Society, March 6th, 1866, and published in the American Journal of the Medical Sciences for April, 1866.)

Dr. Gouley, on the 17th of February last, requested Dr. Noeggerath and myself to see a case of inverted uterus under his charge in St. Vincent's Hospital, in this city. With his permission I have reported the case, from

*Nov. 2d, 1866.-Her husband called upon me to state that she was in excellent health, and now five months advanced in pregnancy.

+This paper was read before the Academy of Medicine, March 5, 1862, and published in the Medical Times, New York, April 26, 1862. Since reporting the case I have read the article for the first time, and with great interest. But the method employed by myself was entirely different. I grasped the circumference of the mass as near the seat of inversion as possible, and, by upward pressure, the extremities of my fingers acted as a wedge laterally to roll out first the portion last inverted. And, in addition, the manoeuvre was facilitated in a great degree by the action of the other hand over the abdomen.

Dr. Noeggerath's case was of thirteen years' standing. He first resorted to the method proposed by Professor White, of Buffalo, but without success, and states in his paper as follows:"Almost discouraged by these fruitless efforts, and feeling that the strength of my right arm was nearly exhausted, I was about to desist from any further attempts, when the idea struck me to proceed on a different plan of manipulation. I at once changed the position of my hand in such a manner that the fore and middle fingers grasped the right section of the tumor; while the thumb was implanted on the left side at a point where the upper two-thirds of its length met the lower one. In this manner a pressure was exerted by the thumb on the lateral border of the body of the womb, which pressure took an upward as well as a lateral direction, and resulted in the formation of an oblong groove, the long diameter of which pointed below towards the left horn of the uterine fundus, and upwards to the spot where the inverted and the non-inverted portion met on the left side. The object of this first step of the operation was to completely double up the uterine cavity, so that the right-now inner-wall touched the left one. After this was completed, the dimpled portion was carried upwards by the thumb, and in doing so it could be observed that the right side of the upper section of the inverted cervix passed first of all through and beyond the os uteri. During the progress of this manipulation, the right lower section of the uterine body followed, and re-assumed its normal position, while the opposite part of the fundus continued to remain outside the os, only much shortened and doubled up. As soon, however, as half of the tumor had disappeared inside the abdominal cavity, the intravaginal section slipped suddenly out of my fingers, and the operation was completed." Dr. Sims, in his late work on Uterine Surgery, reports a case of twelve months' standing, which he reduced by a method similar to that used by Dr. Noeggerath.

the fact that the reduction was effected by the method proposed by myself, as described in the preceding case. The patient was about twenty-four years of age. In June last, at full term, and in perfect health, she was delivered of her second child by a very rapid labor, in which she had but one severe expulsive pain, just as the head was expelled. Until within a few moments previous to delivery, she had not found it necessary to lie down. The after-pains came on at once; they were severe, and lasted longer than had been the case after the birth of her previous child. From a short time after delivery until the reduction, there had been a constant show, which frequently amounted to a hemorrhage, and she presented the appearance of one who had been suffering from an excessive loss of blood. Her condition had been attributed to the existence of a polypus, which was supposed to be protruding from the os uteri, and she had been sent to the hospital for the purpose of its removal.

After much difficulty, the patient was gotten under the influence of ether by Dr. Ward, the house surgeon, at half-past two o'clock P.M. An examination was then made by one hand in the vagina, lifting the uterus above the pubes, and the other hand on the abdominal parietes; the two were thus so closely approximated as to leave no doubt in regard to the true condition. Dr. Gouley, as well as Drs. Wm. H. Van Buren and Samuel D. Moses, who were present, concurred in the opinion of Dr. Noeggerath and myself. At my request, Dr. Noeggerath, after Dr. Gouley, attempted the reduction by his method of depressing one side into the canal and carrying this portion up first, as described in the note appended to the preceding case. After an attempt of some fifteen minutes, he found it impossible to indent the body sufficiently, and desisted. I passed my hand into the vagina, and for a while, endeavored to put his method into practice, but found it impossible to do so to any extent. In fact, the organ was so dense, and contracted to so nearly its natural size, that the case was not a fair one for testing his mode, nor one which could have been reduced by pressure at the fundus, as proposed by Professor White, while it was in every respect favorable to the method I resorted to. With the left hand in the vagina, the four fingers were passed as far up as possible between the inverted portion and the neck, with the thumb in front, so that the body was encircled by the fingers, and the fundus rested in the palm. Then, with an upward and outward pressure at the same time, the neck was gradually dilated until the seat of inversion was reached by the frequent extension of the fingers. This manœuvre was persevered in, while during the whole time the organ had been lifted above the pubes, so that the other hand could assist in the rolling out of the parts by sliding the abdominal walls upwards, with a steady pressure over the posterior portion of the ring formed by the inversion. In less than half an hour the mass, as felt through the abdominal parietes, had doubled in size, the depression in the centre had become larger, and the shape had changed from a circle to an oval. The fundus gradually passed entirely within the cervix, but, after this, the progress, as appreciated from the fingers within the uterus, was almost imperceptible, though the rapidly increased size of the mass and diameter of the depression at the seat of inversion was recognized by all present. At the end of an hour, my hand in the vagina became so powerless, that without the aid of the hand over the abdomen, I was unable to feel the body of the uterus within its grasp. I finally requested Dr. Noeggerath to relieve me, and, by his continued manipulation, in about ten minutes the reduction was completed, after a conjoined effort of an hour and twenty minutes. The patient has continued to do well up to the present time, and has not had a bad symptom.

Much time was lost in each case by the different methods at first resorted to. In the first one, the principle of the force exercised by expanding the fingers was not fully appreciated, beyond the facility given in reaching the seat of inversion with the object of returning first the portion last inverted. The cervix and the portion of the body not involved embraces in close contact the inverted portion within its course. By a glance, it will be apparent that these surfaces cannot be separated to any extent without rolling out the portion immediately at the seat of inversion, and at the same time necessarily pulling open, in proportion, the mouth of the canal formed by the external surface of the uterus. Through this dilated canal the inverted portion of the organ has to be returned. Until the fundus has passed well within the cervix, the chief effort should be directed to dilating the neck by expanding the fingers in an upward and outward direction. In other words, immediately below the seat of inversion, the uterus should be firmly grasped and (at the instant before expanding the fingers) pressed upwards against the hand over the abdomen, which at the same time should be making pressure downwards and outwards, by sliding the parietes over the portion within the cavity. The necessity, however, for augmenting this upward pressure increases directly in proportion to the advance made in the reduction, while the aid derived from expanding the fingers becomes proportionately lessened to the point of completior. No advance can be gained by main force, for it is impossible without rupture for any portion to pass until the necessary dilatation has been effected. Each step, therefore, is to be gained by a steady and persistent effort without violence. So long as the etherization is borne well by the patient, no case must be despaired of in consequence of the apparent want of progress, for at any instant the reduction may be suddenly completed.

In consequence of the continued action of the fingers necessary, I am satisfied that it is beyond the power of endurance fox one person to complete the reduction unaided, where the organ has already contracted to nearly its natural size. I fully recognized the necessity insisted on by Dr. Elliot, as stated in the history of the previous case, that a change of hands should be frequently made, and I believe that the progress of any case would be materially increased by fresh aid every fifteen minutes.

This mode of reduction is applicable to all conditions of inversion of the uterus, while it has been successful after the other methods had failed, and the principle is certainly correct in returning first the portion last inverted. The aid of the other hand in steadying the uterus, and assisting in rolling out the inversion, is a most important feature. It is calculated to lessen the risk of inflammation of the vagina, if not of the uterus, for I have seen the vaginal wall lacerated and the attempt abandoned, where the pressure was made at the fundus and the vagina put on the stretch with no counterresistance beyond the strength of its own walls.

Constitution and By-Laws of Galveston Medical Society.

ADOPTED MARCH 13, 1867.

We publish again the revised Constitution and By-laws of the Galveston Medical Society, with the Fee-bill changed to currency, and we also give a column of charges for the country. From the absorption of gold by the banks, it becomes necessary that currency instead of gold should be the standard. The fee-bill of Galveston Medical Society was modified from the Philadelphia and Atlanta Medical Societies, and the one prepared for the State is taken from the New Jersey State Medical Society. We have modified each to our own city and State. We do this hoping other counties and societies will follow our example. These fee-bills should be put into the back of the Journal and referred to when setting down charges. They are not intended for law, but as guides, subject to modification by county societies. Our only apology for publishing these rules again is, that we have quite an extended list of subscribers that did not receive our first No. of Jan., 1866, with the former Constitution and By-laws, and even those who did, have lost them or mislaid them :

CONSTITUTION.

ARTICLE I.-This Association shall be styled the GALVESTON MEDICAL SOCIETY.

ART. II.—The Officers of this Society shall consist of a President and two (2) Vice-Presidents, a Secretary and Corresponding Secretary, Treasurer and three (3) Censors, whose duties shall be defined by the By-laws, and who shall be elected by ballot, at the Annual Meeting in January of each year, and shall hold their offices until others are elected.

ART. III-This Society shall be composed of Physicians and Surgeons only, having Diplomas from a regularly constituted Medical College, recognized as such by the American Medical Association. All Physicians and Surgeons of this and other States and of foreign countries may be admitted as Honorary Members.

ART. IV.—Every Candidate for Membership in this Society shall make his