PARISIAN MEDICAL NEWS. BIBLIOGRAPHY. Traité de la Diphtherie du Larynx (croup), (a Treatise on Laryngeal Diphtheria or Croup), by A. Millet, M.D., of Tours, (a). Mémoire sur le Traitement du Croup, Nouveau Procédé de Cauterisation laryngée, (Treatment of Croup, a New Procedure for Cauterisation of the Larynx), by Sérullaz, M.D., of Lyons, (b).-De la Tracheotomie dans le Cas de Croup, (Tracheotomy in Croup), by A. Pouquet, M.D., late Interne at Hospital Sainte Eugénie, (c). Mr. A. Millet, the author of a memoir on Pharyngeal Diphtheria, presented in 1861 to the Medico-Chirurgical Society of Toulouse, now presents the profession with a treatise on Croup, which has been considered deserving of a prize, by the Brussels Society of Medical Sciences. Assuming that croup is not yet perfectly known, and is often mistaken for laryngismus stridulus, the author, undeterred by the previous researches of Bretonneau and Trouseau, supplies us with an exhaustive description of laryngeal diphtheria, assuredly the most complete monograph extant on the subject. We have so frequently expatiated on the history of croup that we need not on the present occasion dwell upon the pathology, symptonis, or causes of the disease. But we cannot refrain from reproducing an extract from Mr. Millet's remarks on the various modes of propagation of diphtheria. Bretonneau opined that diphtheria was not disseminated by means of invisible effluvia conveyed by the atmosphere, but that like syphilis, it was always communicated by contact or inoculation. According to this view, croup should therefore be considered a highly contagious and inoculable affection. Despite his deep veneration for his illustrious master, Mr. Millet, on this point, expresses entire dissent from his opinions. In "If diphtheria," says Mr. Millet, "was transmissible by contact or by inoculation, it would be a far more frequent disease, especially amongst the medical practitioners who professionally attend persons labouring under its symptoms. every case of the kind, whether in the inspection of the throat, during cauterisation of the fauces, or in tracheotomy, the face of the physician is always exposed to contact with mucus or fragments of false membranes, which may in many instances touch the lips, nares, or conjunctiva. For my own part, I have very frequently incurred similar risk, and never thought it necessary to discontinue the operation or the inspection of the affected parts, for the purpose of wiping away the ejected particles, and yet on no occasion have I experienced fear of any evil consequences arising from the accident. Of course the same has occurred to many other surgeons, and yet we may well be surprised how few have suffered from diphtheria, when we reflect on the number of patients attended, and the chances so frequently incurred of the mode of contagion here alluded to. The author accounts for the fact by the necessity in which practitioners find themselves to visit many patients in a short space of time, thus absorbing but insufficient and minute doses of the morbid poison; when on the contrary they are compelled to remain for a long period with a person suffering from diphtheria, the permanent poisoning process will speedily remove the immunity previously enjoyed. "It was while watching by the bed-side of a child affected with croup, and who had recently undergone the operation of tracheotomy, that Mr. Blache, junior, perished on the battlefield of science. Dr. Gilette was also a victim to the same mode of transmission. 'Nothing can exceed my veneration for the memory of Bretonneau, but I cannot allow his doctrines on the subject of contagion to pass without a protest. In my opinion, diphtheria is propagated, like measles, scarlatina, cholera and typhoid, by volatile and invisible emanations conveyed by, and dissolved in the air, which may be transmitted to persons occupying the same room, or the same house with the patient. The existence of this mode of contagion of course does not affect the possibility of contagion by direct communication or by inoculation, but I am disposed to think it occurs much more frequently, and that the latter is very exceptional indeed." Mr. Millet has made in his own person several attempts at tonneau's views, and he has not, any more than Mr. Trousseau, inoculation, for the purpose of testing the accuracy of Bresucceeded in inoculating the virus of diphtheria. Mr. Millet divides the treatment in general, local and surgical. After an enumeration of all the remedies which have been recommended for the cure of croup, the author summarises his own opinions in the following aphorisms: Blood-letting is always pernicious. Emetics combined with other drugs are often most useful; Tartar emetic should be prescribed alone, or in combination with ipecacuanha. The efficiency of sulphate of copper has been greatly overrated. Mercurials are extremely dangerous. The calomel electuary alone should be resorted to, alternately with the alum electuary, in accordance with Mr. Miquel's recommendations :B Calomelanos, gr. XV.; Mellis, 3x.; B Aluminis, ijss.-ziv.; Mellis, 3x. M. Dose-One teaspoonful of either every hour. Alkalies and the bicarbonate of soda, are useful in pharyngeal diphtheritis, but act too slowly to be trusted to in croup. Chlorate of potash and sulphur are both inoperative. The sesquichloride of iron, iodine, both externally and internally, bromine and the bromide of potassium are remedies which require further experiment. Counter-irritants are dangerous. After alluding to the benefits hitherto derived from cauterisation, Mr. Millet expresses his partiality for the use locally of powders or liquids, applied to the diseased parts, according to the method recommended by Loiseau, of Montmartre. On the surgical treatment, it is unnecssary to dwell. We may, however, remark in concluding that Mr. Millet's remarks on the indications of tracheotomy, on the operation itself, and on the after-treatment, are fully worthy of the other chapters of this interesting monograph. The object of the new procedure for cauterisation of the larynx proposed by Mr. Sérullaz, is the application to the diseased surface of the sesqui-chloride of iron. The instrument employed is a curved whalebone rod, ten or twelve inches in length, and about two lines in diameter, supplied at one extremity with an olive-shaped sponge, and at the other with a piece of lint of the same form. The child being firmly secured, an assistant places a small wooden wedge, as far back as possible, between the teeth. The operator then lowers the tongue with the index and middle finger of the left hand, while with the right he inserts the end of the rod armed with the sponge. The fingers inserted in the child's mouth answer the purpose of conductors, and the sponge is pushed into the larynx beyond the chorda vocales; the larynx and the upper part of the trachea are then rapidly cleansed with the sponge, and the operation is discontinued for a short time, in order to allow the little patient time to recover his breath, and to expectorate the detached secretions. The same procedure is then repeated, with the other end of the instrument, the lint having previously been dipped into a diluted solution of sesquichloride of iron. solution of sesquichloride of iron. The entire process should last but a few seconds, and is at first repeated every half hour, and, afterwards, every hour, until decided improvement has set in, when the cauterisation is required only at distant intervals. If the application determines considerable dryness and constriction of the fauces, the inhalation of the steam of hot water may be resorted to, and if the cauterisation has been efficient, the symptoms promptly yield. The solution used with much benefit by the author in a case which he relates with full particulars, was a mixture containing one part of the liq. ferri sesquichloridi, at 30 deg. areom., and two parts of distilled water. The method is obviously but a simplification of the procedure originated by the late Mr. Loiseau, of Montmartre. Mr. Pouquet informs us that the first bloody operation he witnessed was one of tracheotomy performed by Professor Velpeau on an infant affected with croup. Entire ignorance of surgical matters, and the emotion naturally induced by so painful a scene, witnessed for the first time, prevented the young student from watching the details of the operation, but what he will never forget is, that after a few minutes the infant was carried away dead, by the house-surgeons on duty. Mr. Pouquet, therefore, conceives that classical works | mislead their readers when they represent tracheotomy as an unimportant operation; the contrary assertion would be nearer the truth. It is prudent, therefore, in cases requiring active surgical interference to express a guarded opinion, but at the same time it is well to be aware that the difficulties arise less from the nature of the proceeding than from the means adopted to carry it out. Mr. Pouquet's instructive pamphlet reposes on 214 operations performed in the wards of Mr. Barthez, in 462 cases of croup, and the author chiefly invites attention to the bad effects of various procedures generally adopted, and which in his own, or in other hands, have too often produced mischievous results. The author disposes of the question of the expediency of tracheotomy in a very few words: "It is proper," says he, "to have recourse to the knife when asphyxia is caused only by mechanical obstruction of the larynx; and to refrain from interference when numerous and threatening signs of the absorption of the morbid poison into the system are observable; neither should any operation be attempted when in addition to diphtheria some other serious and almost fatally destructive disease is present; such are the obvious practical rules which may boldly be asserted, and which all surgeons are bound to obey." The tender age of the infant is no obstacle to the operation, and with each succeeding year a greater number of children under two years are now cured. Mr. Pouquet further remarks, that it is never too late to have recourse to tracheotomy, but that the favourable chances are increased by an early resort to the knife. With regard to the operative process, the author expatiates on the following points, which he conceives to be of paramount importance. 1. The advantage of crico-tracheotomy in children. 2. The inutility and dangers of the blunt-pointed bistoury. 3. The perils attendant on the use of dilators, and the expediency of inserting the canula with the finger. Mr. Pouquet is convinced that before long a portion of the numerous instruments now recommended for the performance of the operation will be laid aside, and that when it has been simplified, the procedure, which even now may be viewed as one of the most brilliant achievements of modern surgery, will yield results more favourable than can at present be recorded. MISCELLANEA. We were present on Sunday last, Nov. 2, at the fifth annual meeting of the General Association of the Medical Practitioners of France. After a short address delivered by the President, Mr. Rayer, and a brief statement of the financial condition of the Central Society by Mr. Legouest, Mr. A. Latour presented a return of the proceedings of the Institution during the last twelvemonth. In illustration of the increasing popularity of the Association, Mr. A. Latour brought forward the following figures: In the first year of its existence the number In the second it rose to In the third year to 1577 3088 4416 In the fourth to 5033 And in the fifth it has attained the large figure of 5746 "all demands for assistance having been more than complied with," said the Secretary-General, "and all expenses paid, our capital amounts to 11,0007. Under these circumstances, the Council proposed the creation of a fund for annuities, and the motion was unanimously adopted. In our next impression we shall present our readers with an abstract of Mr. Paul Andral's Memoir on the Illegal Practice of Medicine. The Administration of Public Assistance has just taken possession of the edifice constructed at Issy as a substitute for the insufficient buildings for married indigents in the Rue de Sèvres. "The Asylum of Issy is erected on a piece of ground left by will to the Administration of Hospitals by Mr. Dumetz, the Mayor of the borough. The surface exceeds 60,000 metres. "The situation and aspect of the buildings are excellent, the ventilation of the wards has been carefully attended to, and covered galleries have been constructed, in which the inmates can exercise in all weathers. "The first section contains 428 rooms for couples, and 451 for widows and widowers. The wards of the second section are adapted for the reception of 436 beds, accommodation being thus provided for 1746 persons. The Infirmary contains 80 beds. The total cost of the Asylum is 177,8667. "Another small edifice has been also erected in the neighbourhood to replace the Devillas Asylum, at present situated Rue de Regard; the number of in mates is limited to 80; a Catholic and a Protestant chapel have been, in accordance with the express desire of the testator, added to the establishment. The re-opening of the School of Medicine of Paris took place on the 16th of November. Precautions had been taken to prevent the recurrence of the disturbances complained of last year; the students appear to have taken offence at the placards cautioning them against a repetiton of the disorderly scenes enacted at the last solemn re-opening; the large amphitheatre was therefore comparatively empty, and the ceremony passed off in the most freezing and spiritless manner. - On this occasion, Mr. Tardieu pronounced the panegyric of the late Professor Adelon; alluding to the state of Forensic Medicine abroad, he observed: "In all countries, the very existence of forensic medicine is entirely dependent on the state of the legislation, and may be taken as a fair test of its excellence. In support of this remark I may adduce as a striking illustration the fact that forensic medicine does not exist, or to speak more accurately, manifests its existence only by accident in England. In that country the Bench never requires from the medical expert a report in the sense we attach to the word. In a criminal action the counsel for the defendant, or for the prosecution, summon as a witness the medical man whose testimony is likely to be in their favour, and it is not, as in France, by judicial authority that evidence is collected, or proofs sought for. If A separate inquiry is instituted by the accused and accuser, each of whom brings forward his own witnesses. a medical practitioner has chanced to attend the victim of an alleged crime, according to the opinion he has formed of the guilt or innocence of the prisoner, he is subponed by the defence or by the prosecution, and in either case is examined in chief and cross-examined. In reply to the questions put to him he must confine himself to the bare statement of what he has seen; inferences he is not permitted to draw, and if he presumes to adduce in illustration of his opinion any circumstances not the result of his own direct personal observa The finances of the Association are equally prosperous; tion, the judge does not allow him to proceed. The interven tion of the medical witness is required in cases of murder probably none more appropriate could be applied, inasmuch as it only, and then, but for the purpose of eliciting facts, the duty conveys to the mind a portraiture of the malady, more faithful of drawing conclusions devolving on the magistrates. than could perhaps be rendered by any other title; so faithful in "You perceive, gentlemen, that, restricted as it is by the truth, and so complete is his delineation, that scarcely any feature remains to be filled in-the picture is too true to Nature, too well general principles which obtain in the legislation of Great finished by the master-hand of that great physician and acute Britain, the evidence of medical witnesses must perforce be observer, to require from another any, save the lightest touches, and much curtailed. Therefore, despite the remonstrances of the those, less to add fresh, than to renew the former colouring. Profession, which, in a recent case of legal interdiction, Causes. These we would arrange under two heads; first, the unanimously protested against the undignified part allotted Predisposing, or the Remote; and secondly, the Exciting, or the to its members in the law-courts, and notwithstanding the To the former belong hereditary taints or tendencies, as of gout, praiseworthy efforts and important researches of many emirheumatism, neuralgic affections, hysteria, and more especially, if nent men, amongst whom I may quote as most familiar to both parents have been liable to, or are the actual subjects of, one your ears those of Male, Christopher, and Alf. Taylor. I am or more of the above named maladies; mere nervousness, provided surely justified in asserting that Forensic Medicine has no it be great and constitutional, will be transmitted from the parent recognised place or acknowledged existence in England. In or parents to their offspring, and that frequently without being at many things we may, doubtless, imitate our neighbours, but in all wanting in its intensity, nay, rather in many instances assuming this matter they would undoubtedly be benefited by a reform. an aggravated form, as though in their issue the condition of the parents had concentrated itself. borrowed from ourselves. We described some months since Mr. Amussat's instrument for cauterisation by means of electricity. It consists, as our readers will recollect, of two wooden blades united at one end by a hinge, and perforated with holes lined with silver tubes for the reception of a platinum wire. Mr. Amussat recently destroyed a hæmorrhoidal tumour with this appliance, which he has slightly modified; the wire now lies in a groove cut on the inner surface of the compass. Grenet's battery is used by this surgeon for the production of the electric current. Dr. Regnault, of Rennes, a former Interne of the Hospitals of Paris, recently performed ovariotomy with perfect success in a young woman of eighteen. On the twentieth day after the operation the patient was enabled to walk down stairs and take open-air exercise. DIED.-At Paris, Mr. Pierquin; Mr. Bergeron. At Saint Mandé (Seine), Mr. Roques. At Montpellier, Mr. Lescure. At Toulouse, Mr. Beteille. At Harfleur, Mr. Gouget, aged 44. The Medical Circular. ORIGINAL COMMUNICATIONS. "There is," says Dr. Gooch, "a painful and tender state of the uterus, neither attended by, nor tending to produce, change in its structure, and which I took for chronic inflammation, that would end in disorganisation, probably of a malignant kind; but experience, whilst it taught me that it was a very intractable disease, taught me, also, that it was not a disorganising process. I became familiar with its obstinacy and less apprehensive about its results, for I know cases, which have lasted upwards of ten years, in which the structure of the uterus is as unaltered now, as it was at the beginning of the disease." I think it worth describing," he continues, "that practitioners may know, what they are to expect in obstinacy, and what they need not apprehend in the result; what will do harm, what will do good, and the mode of treatment, which, however unsatisfactory to the Medical attendant and his patient, will slowly, but ultimately conduct most cases to recovery."-(See Dr. Gooch's work on 'Some of the most Important Diseases peculiar to Women,' edited by the New Sydenham Society, 1853.) This condition first minutely studied and accurately described by the author, whose name we have just mentioned, received from him the appellation of "The Irritable Uterus," a name, than which Proximate or Immediate. Though we most frequently meet with the malady in the nervo hysteric constitution, we are by no means prepared to assert dogmatically, that it is peculiar to such, since we find it existing in all classes, and in every kind of patient, with a seemingly total disregard for idiosyncrasy of temperament. Constipation, habitual or protracted, is to be ranked under this division, as are also those other affections, which we have already enumerated as hereditary-predisposing agents, but which we very often find to act as remote excitors, there having been no previous particular taint or diathesis: diarrhoea, dysentery, worms, or indeed any gastro-intestinal irritation, as well as cerebral or spinal, particularly, if it occur in the lower segments of the vertebral cord, -irritation, as in the "Pruritus Vulva," or that of the entire generative apparatus, mental worry and vexation, especially if there be superadded irregular discharge of the uterine functions, anemia, plethora, general constitutional derangement and debility, protracted and difficult labours, a previous attack of the complaint now under our consideration, or of rheumatism, or of syphilis in its several stages, will all come under the same category, being each of them powerfully predisposing. To the exciting, proximate or immediate causes we would assign the sudden check or cessation of the menstrual flow, any interruption to its wonted regular period of occurrence, or to its normal and healthy colour and consistence, any deviation, in fact, on the part of the system from the due vigour and wonted execution of this all important office of the human female economy, abuse of vaginal lavements, or their use at improper times, excessive sexual indulgence, masturbation, than which perhaps there is not a more powerful excitant, undue and too violent or too long continued exercise during the menstrual molimena or the resuming of the erect posture, of household and domestic duties too soon after delivery, acute retroflexion or retroversion, or other kinds of uterine displacements. Marriage in some patients seems to have acted as an exciting or immediate cause, since the disorder has been known to set in a few days subsequently, or almost immediately after, when there had been no previous manifestation. Nevertheless, though this be an incontrovertible fact, we are not warranted by an examination of cases to pronounce the married, as more frequently sufferers, than the unmarried; nor is there, we apprehend, any evidence before us, sufficient to show a preponderance in the former, both being apparently alike obnoxions. To the above division or classification, we might add another, and applying to it the term,-Mixed Causes-would comprehend in it, for the sake of convenience and greater perspicuity, influences already mentioned, as belonging to the predisposing or exciting. Symptoms.-A sensation of heat and throbbing, or of immense distension, sometimes to such a degree, as to lead the patient to "fear, that she may burst," pain, which although it be constant and abiding, is yet of a distinctly paroxysmal character, being aggravated, often when there is no apparent untoward circumstances to evoke it; these paroxysms are best marked during, previous, or subsequent to, the appearance of the catamenia, or after the administration of a purgative, (particularly when its special action is upon the lower bowel), and they are sometimes so violent as to cause the patient to start in her bed furthermore, this pain may be compared to a "stinging and darting, or, as if pins and needles were being driven into the part," and is present, not alone in the upright posture, but also in the horizontal, not only during walking or exercise of any kind, but when the patient is lying in complete repose; in the former conditions it is rendered excruciating and unendurable; nor is it confined to one region, being found to exsist in the pubic, hypogastric, umbilical, in the sacral and lumbar, or in the groins, while likewise very frequently, as particularly noticed by Dr. Gooch, it will run along the brim of the pelvis. There are high excitability and exalted sensibility of the viscus in question, and, as a consequence, external tenderness; all of which are increased by any causes, inductive of an erect and turgid state of the organ, such as obtains at the menstrual molimena; there may be amenorrhoea, menorrhagia, merging into metrorrhagia: none of these last conditions inay, however, be at all present, there being in every respect perfect regularity as regards the performance of the uterine function, with perhaps this solitary exception, that pain will co-exist with the discharge. Usually there is some deviation from health, either in the discharge itself, or in the periods of its return. Leucorrhoea, though not a necessary or constant symptom, is too often a concomitant to be omitted in our enumeration, external irritation, which we have seen will be productive of the malady, may likewise co-exist or even become a sequent. "Excepting tenderness," probably the resultant of a certain amount of vascular engorgement or turgescence, " and tension, the uterus feels perfectly natural in structure, there is no evidence of schirrhus in the neck, the orifice is not misshapen, its edges are not indurated;" when, however the "os" presents any slight alteration in shape alone, there being at the same time no organic structural change whatever, this condition must be viewed as a favourable sign, and indicative of a tendency to resumption of the original healthy functions. The os and cervix are soft to the touch, and when examined with the speculum, will be seen to preserve their natural condition, and even in their colour to be very frequently wholly unaltered. "This obscure malady," says Dr. Robert Ferguson, "adheres to all the modifications of structure and function incident to advancing age ;" and not even those who have passed the climacteric age can be reported as not obnoxious to the affection. The constitution does not, in the majority of cases, evidence very much sympathy; in some there are general irritability, a pulse quick and frequent, and in both these respects accelerated by the slightest physical exertion or mental emotion; indeed, it may be come so quick and sharp, as to resemble the pulse of inflammation, yet, in a few minutes it would subside to the ordinary state," the appetite will be most fastidious and as capricious as that which is attendant upon the worst forms of hysteria, the most nauseous, indigestible, and abominable substances being longed for and devoured; there will be likewise a most impassioned yearning for commiseration, a morbid craving for sympathy. Nature of the Disease.--Having enunciated its non-inflammatory character, as evidenced by there being no organic structural changes, Gooch pronounces it to be "a disease only of function," while at the same time he gives it as his opinion, that the organ will be found in a state of simple irritation. Dr. Fleetwood Churchill, than whom there is no higher authority, considers it "simple neuralgia of the uterus, of variable intensity, and of irregular duration, not very amenable to the resources of art, but not tending to disorganisation." Dr. R. Ferguson has found the nervous element so constant, that in it therefore, and in no doctrine of phlogistic action "can," in his estimation, "be placed the essence of this strange malady." With these opinions for the most part coincide the views entertained by Dr. Graily Hewitt. Valleix considers it a part only of a form of neuralgia, to which he has applied the term-lumboabdominal; while others again look upon it as essentially a sympathetic affection, the irritability of the womb being altogether secondary, that is, the sequence of irritation, primarily involving some neighbouring or more remote viscus or other part of the body, and which is communicated to the uterus by means of reflected action or sympathy. Without any doubt this malady "depends on a morbid condition of the nerves," a condition sometimes primary, at others purely secondary, and may, with no violation of physiological or pathological truisms, "be regarded as a local hysteric affection," indeed we cannot avoid viewing it, certainly in the majority, if not in the entire number, of our patients, as the local manifestation of an entire derangement of the economy, the developement of a depraved general condition at one particular region, or in one special organ; an organ ever readily participating in any, even the slightest, constitutional excitability, and always prone to take an unwonted action, when in the system at large there are as regards health abnormal deviations. We sometimes find as a complication, the same morbidly sensitive and deranged nervous excitability of the vagina, a condition to which the name of Vaginisimus has been attached. The affection of which we are now treating belongs to, and has been by Gooch placed in the same list as "the painful mammary tumour" described by Sir A. Cooper, the hysteric joints brought by Sir B. Brodie under the notice of the Profession, and the neuralgic testicle, which we know to be so intractable to every method of treatment. Sequences.-Owing to the constant presence of this-to speak of it in the mildest terms-source of discomfort, the health, even should it have been strong and our patient robust, will soon begin to be implicated; but since frequently there has been some general debility or constitutional deterioration, previous to the onset of the complaint, this implication will not be long in declaring itself, and the inroads of the malady upon the system at large will more or less speedily mark themselves, there being wanting in the patient the necessary powers of resistance. Anemia, either from the excessive "losses," since, as we have seen, the most usual, indeed, we would almost say, the undeviating, tendency of this ailment is to uterine hæmorrhages, or dependent upon the genera debility induced. Phthisis also has been remarked to be a sequenti and there are obvious reasons for its occurrence, the condition of health being most favourable to the deposition of tubercle. Again, sterility will result-firstly, because, specially, if the vagina be also engaged in the exquisite morbid sensibility, sexual congress is wholly impossible, owing to the extreme agony occasioned; and, secondly, because, admitting the possibility of congress and of conception, the deranged condition of the uterus denies to that viscus the power of retaining that which has been conceived-the ovum to its maturation, and hence must arise miscarriage or abortion. As we have stated above, one of the most distinguishing features of this malady is inability to move without great pain being experienced; however, as an exception to this, Dr. Churchill mentions the case of "a lady, who could not stand for five minutes without agony, yet who could travel in a half reclining posture in a carriage for days together, not only without the slightest inconvenience or aggravation of her sufferings, but with manifest local and general improvement." Treatment. This is, in truth, according to all observers and writers, behedged with numerous difficulties, and so tardy are remedial agents in obtaining relief, much more in effecting a cure, so liable are the entire train of symptoms to aggravation, or return after their alleviation or removal, as to weary the patient with the necessarily imposed restraint, and, indeed, with all modes of treatment, to intensify the harassing and wearing anxiety of her already over-anxious mind, to seriously depress her with fears, that recovery is hopeless, and that she must, despite all efforts, yield to her malady, and become a confirmed invalid; while with her must her medical attendant share these apprehensions, as day succeeds to day, drug to drug, and still scarcely any amelioration to the constant suffering; remedy after remedy fails in the administration and application, and at length baffled in his most careful attempts, he is forced to acknowledge, what he too often feels, his entire impotence. The indications of treatment are these-firstly, removal of the most urgent symptom, pain; secondly, prevention of its recurrence; thirdly, induction of regularity in the catamenia; fourthly, to brace and give tone to the parts immediately concerned, as well as to the constitution generally; and, fifthly, a careful selection of means to the fulfilling these several purposes, lest in removing the one, pernicious influence be exercised upon the other, and so should either be placed in a worse condition than existed before we commenced our treatment. Since this complaint is in its nature essentially complex, we cannot allow ourselves to rest satisfied with merely those appliances which medicine places at our disposal, more particularly when we have other most powerful operatives, which we can summon to our assistance. I allude to moral and mental powers on the part of our patient, and which she should be taught, if she have not previously learned, by her medical adviser to cultivate and exercise to their fullest extent, inasmuch as the complexity of the disease is dependent upon the engagement of the mental and moral, as well as of the physical or corporeal qualities and powers. To each case, since there is such an infinite variety of character and of phases in the characters of our patients, must we be prepared to adapt this mental and moral method of treatment, adopting at one time or with one class of cases, mild and persuasive measures, at another or in a different class, those which, being not so lenient, may to our patient and even her friends seem somewhat harsh and severe. I am fully persuaded that this latter plan will, in many instances, be absolutely necessary to the recovery of the invalid, and prove successful, when the former would or shall have altogether failed. We will now turn our attention to the more immediate and medical plan of treatment, and will first speak of Rest, the greatest adjuvant in the removal of almost every malady. This is to be insisted upon, not alone for the subdual of the pain and for the amelioration of all the symptoms, but likewise toward the ultimate and entire recovery; it should be maintained in the horizontal position, supination and pronation being alternately adopted. Opiates are generally advocated, and are applied locally, either directly to the "irritable uterus," through the vagina, or indirectly by the employment of powerful sedative liniments to the hypogastric or vesical region of the abdomen, or by covering the sacral region with a large belladonna plaster. A favourite liniment has for its ingredients belladonna, chloroform, and soap liniment, and no doubt it may be, in the allaying of pain, productive of happy results, though, if we have recourse to any local sedative, I should lean more towards their direct application, and would pass up through the vagina against the os uteri the opium or belladonna pessaries recommended by Dr. Churchill. While upon this part of our subject I would lay down, as an axiom, that the speculum had better not be used in the introduction of these pessaries, preference being given to the pushing of them up against the womb by means of the finger only; nor can we speak in too deprecating tones of the employment of cotton-wool or sponges for the purpose of maintaining these pessaries in situ, since the presence as must be obvious to all-of such a foreign body will tend to keep up the "I think it an important fact," says Gooch, "that in cases which remain uncured for may years, the patients had for the relief of their pain gradually accustomed themselves to a daily enormous allowance of opium." To bleeding, local or general, I also object, unless, indeed, there be very great plethora, a condition which we know obtains in some instances of this affection; upon the following I base my objections by the removal of blood; by its frequent draining away at each paroxysmal period of the pain (and such is the course pursued by its advocates); by this constant tax, levied upon the system generally and upon the parts locally, general and particular debility results, leading to an increase of general and particular irritability; reduction of the tonicity of the uterine vessels, as a sequence the allowance of their distension, perhaps, even of their engorgement and congestion, and so the perpetuating, nay more, the intensifying, of this functional derangement. I must again be permitted to quote from the book of Dr. Gooch, in confirmation of the inutility, if not the evil, of withdrawing blood in a great number of instances:-" When blood-lettings afford decided relief, and inflict no material injury on the constitution, their propriety is unquestionable; but in many cases after the disease has lasted long, and the body is emaciated and enfeebled, the relief afforded by blood-letting is so slight and temporary, and the debility it occasions is so great, that it must be discontinued altogether." (To be continued.) REVIEW OF BOOKS. On the Influence of Mechanical and Physiological Rest in the Treat- London: of a of These lectures, besides being delivered before the College of Surgeons of England, have already appeared in the pages Medical contemporary; but the importance of the subjects which they treat, and, we may add, their own intrinsic merits, fully justify their collection and preservation in the goodly volume Mr. Hilton informs us in his preface that now lying before us. they are published simply as they were delivered, as is indeed evident from their somewhat colloquial and unstudied tone, and that he hopes hereafter to treat the subject more at large in a systematic work. In choosing the subjects for his course of lectures at the College of Surgeons, Mr. Hilton was actuated by a desire to enter upon a field of inquiry as yet untrodden by the College Professors, and he therefore selected a department of surgery hitherto unoccupied namely, that of Therapeutics. By this term, he does not imply the action of drugs, but the influence of what may be called Natural Therapeutics in the cure of surgical diseases, and among the most important of these agencies is Rest. The other subject treated of is Pain, which is the natural expression indicating the existence of discomfort, pointing out its source to the eye of science, and demanding Rest as its method of cure. The topics of Rest and Pain are so trite, and apparently commonplace, that they seem almost beneath the notice of the orator who speaks from the professorial chair; but they really involve a host of considerations and inquiries which interest alike the Medical philosopher in his closet and the busy practitioner in his everyday duties. The fact is that when a part or an organ becomes diseased in any way, either trom internal or external causes, Nature make known the deviation from the healthy condition by the agency the nerves, which thus announce by their exalted sensibility the presence of mischief and the necessity for its removal or alleviation. It is true that the indication thus afforded is not always intelligible to the uneducated mind, and the presence of pain in one particular organ or part may be really due to the existence of disease at a distance. But although to the patient or to the ordinary observer the guidance of Nature may sometimes seem to mislead, the information thus conveyed is intelligible enough to the mind of the educated anatomist and physiologist, who by tracing the nerves from their origin to their distribution, or vice versa, and by studying the connexion of the different sets of nerves with one another, is led to discover the true seat of disease, and to devise appropriate means of cure. A great portion of Mr. Hilton's lectures is devoted to the indications thus afforded by Pain as to the seat of injury, and to the anatomical distribution and nature of the different nerves by which this kind of evidence is afforded. The efficacy of Rest as a remedial agent is so clearly shown in innumerable instances, that a very few remarks are sufficient to prove its importance in the treatment of diseases and injuries. A speck of dust falls upon the conjunctiva, and immediately the eyemation are set up until the unwelcome intruder is expelled, when lids contract and the tears ars poured out, and irritation and inflamrest alone effects the remainder of the cure; when a bone is broken, accurate apposition of the broken portions and absolute rest are sufficient for the promotion of perfect union, and when the parts are not adjusted accurately the effusion of callus in and around the fracture affords the repose which is necessary to the juncture of the injured fragments. In internal diseases the principle is the same, and the object of Nature is to procure rest for the injured part; the brain excited to phrensy or to inflammation by the cares of life or by over-exertion, is restored by repose, by silence, and darkness; the inflamed pleura, painfully grating against its own contiguous surfaces obtains rest by the beneficent effusion of coagulable lymph; and the fistulous opening, enlarged by movement, is closed by the combination of pressure and rest. Some of the illustrations brought forward are of an ingenious and novel character, and among them may be quoted the office assigned to the cerebro-spinal fluid, which is too often overlooked in anatomical examinations, but which exists between the base of the brain and the base of the skull, and thus forms, what Mr. Hilton not inaptly calls, a perfect water bed of the brain. To the presence of this fluid Mr. Hilton attributes the comparative immunity enjoyed by many persons who have received severe injuries of the skull or brain, and he relates a case in which a gentleman lived for thirteen days after receiving a fracture of the base of the skull, and who was able to pursue his usual avocations between the receipt of the injury and his death. The injection of opiates into an irritable bladder, the introduction of laudanum into the external meatus of the ear in ear-ache, or into an aching tooth, and the hypodermic injection of morphia, are all directed to the same object-namely, to procure rest to an injured or diseased part; and the application of splints and bandages in surgical cases, and the use of poultices are only imitations of and auxiliaries to the remedial powers of Nature, which dictates rest for the cure of disease. Such are some of the philosophical views and reasonings adduced by Mr. Hilton in his lectures; and even from this short and hasty notice, within which our limits compel us to confine ourselves, it will be seen that the subjects he has selected as his texts are full of suggestions for the rational treatment of diseases and injuries, and we may add that the numerous illustrative cases which he details make his work as practically useful as it is theoretically instructive. The Physicians', Surgeons', and General Practitioners' Visiting List, This little pocket-book presents a variety of features which render it valuable for all classes of the Medical Profession in whatever branch they may practise. Thus it contains an almanack, a wages, expenses, &c., ruled pages for visiting list, obstetric and table of fees claimable by medical witnesses, a life table, a table of vaccination engagements, and many other particulars, the whole being got up in very excellent style, and of good materials and workmanship. A Practical Treatise on the Human Teeth: their Loss and Restoration. |