of SIMS. The fact is, the time during which uterine surgery has had its birth and growth is so short, that our experience has not been sufficiently mature to establish fixed principles. Many of the operations alluded to give immediate relief, and even a year or two passes before we discover that new troubles follow the operations, and that some change, from the contraction of cicatrices or other causes, leaves the patient in worse condition than before the operation.

In confirmation of this I will take the liberty of quoting from some conversations I had with Dr. EMMET in my recent visit to his hospitals. Dr. EMMET may now be considered as one of the first living authorities; for few men anywhere have had such a wide field of observation, and he seems to be endowed by nature with those peculiar qualities of head and hand that fit him particularly for the special department of science he has selected. Having great confidence in the results of his large experience, I noted down the following conclusions:

I. He never resorts to the lateral incisions of Dr. SIMS for the relief of dysmenorrhoea, sterility, engorgement of the uterus, or anything else; for the reason that after the bilateral incisions the two flaps are apt to flare or open out, and to leave an unhealthy surface which often leads to other unpleasant consequences.

2d. He does not amputate the elongated cervix for dysmenorrhea or sterility in those cases in which Dr. SIMS usually recommends it, but only in cases of very extreme abnormal elongation.

Instead of amputation, or bilateral incision in all the above cases, he recommends as sufficient, an incision backwards in the cervix, extending from the os nearly up to the posterior reflexion of the vagina. This answers all the ends that can be reached by incisions-it heals up sound and well, and does not leave the os with that hog nose expansion above alluded to.

3d. It is in cases of anteflexion especially that he recommends this posterior incision of the cervix, and instead of attempting to straighten the channel by continuing the posterior incision on through the os internum posteriorly, after making his posterior incision through the cervix, he introduces a blunt-pointed knife and divides the internal os by making his incision forwards in the concave part of the flexure nearest the pubes. He contends that the channel in this way is better opened, and remains more permanently so, than where the incision is made in the opposite direction as recommended by SIMS. I saw him perform this operation in the Woman's Hospital" with his accustomed dexterity.

..

While he considers this operation of great value in ante-flexion, he asserts, that a similar incision in the opposite direction for retroflexion, is worse than useless. There is no cutting operation, he thinks, which can cure retroflexion. All that can be done, is to replace the organ frequently, keep the patient quiet, and resort to such remedies as relieve local engorgement, or other uterine disease, and at the same time attend to the general health. In some cases a pessary is useful.

There are several remedies on which he lays much stress: 1st. Injections, not of tepid but hot water, freely and frequently into the vagina-a gallon at a time. He says it relieves greatly congestion of the uterus, improves the condition of the vagina and gives tone and contractile power to it. This remedy he dwells much upon. Cold water injections into the vagina, the doctor says, do great harm, produce neuralgia, uterine pains, etc. 2d. When granular erosions, or fungoid granulations exist about the cervix, he says they always exist within the uterus, and a favorite remedy for this condition is the introduction of a flexible silver probe, wrapped at the extremity with a little cotton, and dipped in Churchill's tincture of iodine, which is a very concentrated preparation. The probe thus armed is passed up to the fundus and moved freely about. This is done two or three times a week. Sometimes he uses the nitrate of silver, twenty to forty grains to the ounce, but prefers the iodine. 3d. In engorgement of the cervix uteri, and in those cases where it is covered over by disease of the follicles, looking like miliary tubercles, he vesicates the surface by brushing it over with Nichols' acetic acid solution of cantharadin. This should be carefully managed, so as not to get on the vaginal surface; and then the part should be covered with the cotton glycerole. This treatment he says is very potent in relieving engorgements and indurations of the cervix. In those granular erosions, or granulations, where they are within view, he speaks in strong terms of the beneficial effects of chromic acid and water in equal parts. So much for medication.

4th. Whenever amputation of the cervix does become necessary, he does not do it with the ecraseur, or any instrument which leaves the stump to heal by granulation; but invariably treats it just as he would an amputation of leg or arm-he draws the mucous membrane over the cut surface, like skin flaps, from before and behind, and fixes the edges together with silver sutures, after the manner recommended by SIMS, thus healing it up in a few days by the first intention. His reasons for doing so are his own. He says that where the cervix is allowed to heal by granulation, or a cicatrix is allowed in any way to form over it, the cicatrix contracts, the os is drawn up, and a neuralgic condition of the cervix ensues, from the constriction upon the nerves. This formation of a cicatrix is a leading objection to many of the cutting operations about the cervix. A cicatrix on the cervix, whether from knife, caustics, or ulcer, is apt to be followed by neuralgic pains, like those sometimes seen in stumps, and to relieve them he often peels off the cicatrix with scissors and draws the surrounding mucous membrane over with silver sutures. He always uses scissors instead of the knife, because there is less bleeding.

MATERIA MEDICA AND THERAPEUTICS-TOXICOLOGY.

1.- Use of Counter-Irritants. By Prof. HEBRA, Vienna. [Edinb. Med. Journal, Nov., 1867, from Allg. Wiener med. Zeitung: in Amer. Fourn. Med. Sciences, April, 1868.]

Prof. Hebra, the celebrated dermatologist, declares his opposition to the use of counter-irritants (revulsives), which form so large a part of ordinary medical practice. He professes to show that the theory by which their use was originally suggested and is now maintained, is erroneous; and he brings forward clinical and experimental facts and arguments to demonstrate the evils which result from the practice. Physicians were, he maintains, led to adopt counter-irritants for the cure of internal diseases, by observing the alterations and apparent antagonism of cutaneous affections and internal lesions. When, for example, a patient, the subject of a skin disease (as psoriasis), was attacked by fever, the chronic cutaneous eruption was observed to fade and disappear while the febrile state lasted, but reappeared during convalescence. Again, in exanthematous fevers the febrile symptoms often subside on the appearance of the specific eruption; and, moreover, the eruption continues fully out only under a favorable condition of the internal affection; while, on the contrary, if the internal symptoms are aggravated, the cutaneous eruption diminishes, and, before a fatal issue, becomes altogether invisible. Hence the popular idea among physicians and the laity, that the suppression or metastasis of the cutaneous affection is the cause of the fatal issue of the general disease. But these opinions are erroneous, for the chronic skin disease does not vanish first, to be replaced by the fever; but, on the contrary, the dermatosis only begins to fade after a prolonged continuance of an intense febrile state. In like manner, in every general disease of great intensity and prolonged duration, the anæmia which supervenes is first noticed on the skin, and hence the fading and disappearance of red eruptions in these cases, since even syncope will cause their temporary vanishing. Another erroneous opinion, prevalent from ancient times to the present day, which probably lent support to the use of counter-irritants, was the idea that every disease consisted of something material, which attacked sometimes one part, sometimes another, and which it was the physician's chief aim to eliminate; hence the terms materia peccans, acrimonies of the blood. acids, phlegm, black and yellow bile, etc. These notions, in spite of modern pathology, still retain their influence on practice. It is, however. certain, that we can not judge of the use of remedies on such grounds. but only by a knowledge of the action of the remedy on the healthy body on the one hand, and an acquaintance with the natural course of disease. uninfluenced by remedies, on the other. This was first stated by GIDEON HARVEY, in his work, “Ars Curandi Morbos Expectatione, Amstelodami, 1695," where he says boldly that it would be proper to write on the

patient's prescription only the word, Expecta." But this expectant method seemed a neglect too cruel to be practiced in dangerous diseases, until HAHNEMANN showed that fevers and inflammations were often as successfully treated by decillionths as by the Hippocratic apparatus of venesection and counter-irritation; whereupon physicians and clinical professors, convinced of the real nothingness of decillionths, resorted to the treatment of febrile and non-febrile diseases by the pure expectant method, and were thus enabled to study accurately the natural course of disease. Wherever their results were as successful as the older heroic practice pursued "lege artis," it was obvious that the latter was at least unnecessary, that the cure was done by nature in spite of heroic remedies: "Natura et morbum et medicum vincit." Nevertheless, some practitioners, who admit all this in regard to certain diseases, plead for counter-irritants to the skin in the class of affections called rheumatism, believing that the peripheral irritation will relieve the deeper seated parts. But how often do these remedies, from simple rubefacients up to the "horrible invention of the moxa," fail; so that where cases improve, it is rather during than by the treatment. An impartial examination would show that as many rheumatic affections get well under homœopathy, hydropathy, electricity, or the plasters of quacks, as under counterirritants.

Moreover, the excuse that it is necessary to do something to relieve suffering, and that blisters, etc., do no harm, is incorrect, as they often leave indelible marks on the skin, while hot and cold douches, lotions, liniments, and plasters do not, and yet afford as much relief. In diseases of the eye, also, the applications of leeches and blisters, which were formerly always used, are now condemned by many ophthalmologists. Clinical experiment in HEBRA's practice gave similar evidence. Suppose on the thigh of a patient an eczema rubrum of the size of a crown piece; place at two inches distance on one side a blister of the same size, on the opposite side a sinapism, and at the two other poles, tartar emetic ointment and croton oil. The artificial irritants will produce here bullæ and redness, there pustules and vesicles, but without at all diminishing the intensity of the central eczema. On the contrary, the latter often spreads to and includes the irritated surfaces, and becomes larger than before. Now, if in the same organ or tissue (the skin) a peripheral irritant can not draw away and dispel a central affection of a similar kind, how can cutaneous irritation be expected to dissipate the morbid condition of the pleura, lungs, brain, peritoneum, eyes, sheaths of nerves, etc? What new path do revulsives open up for the elimination of morbid products deposited in these cavities and organs? But cutaneous irritants, continues Prof. HEBRA, are not only useless, but often do harm, and their pernicious effects may either last long, or even put life in peril. It is, for instance, a well-known fact that the exanthemata, smallpox, measles, and scarlet fever, are more fatal in proportion to the intensity and amount of the cutaneous eruption. And experience teaches that the eruption is more abundant on parts of skin where an irritation or dermatosis (e. g..

an eczema) previously existed. A sinapism, applied to the chest on account of dyspnœa, will cause a larger amount of pocks to appear there, and if there were a counter-irritant large enough to cover the entire integument, a simple varicella might be converted into a fatal variola. Indeed, even the irritation of cold water in excess, applied hydropathically around an eczema, will cause its extension over the whole skin; and often the abuse of acaricidal remedies—c. g., the sulphur fumigations in vogue a few years ago-produces a horrible eczema over the whole external surface; often hot baths, pushed by some as an infallible remedy, diffuse instead of arresting a skin disease. The tartar emetic ointment, applied to the scalp in chronic hydrocephalus, causes no diminution of the effusion, while the pustular eruption is very painful, and may give rise to purulent absorption and erysipelas. A blister behind the ear is often the starting point of an eczema which affects the concha, the face, and hairy scalp, and which under unsuitable treatment, may last for years, causing great pain, as HEBRA has often seen, without improving an ophthalmia in the least. Leech bites on the temples are followed by incurable white triangular cicatrices, which certainly are no ornament to a pretty face. The marks of cupping, too, on the neck and arms of women, are often a serious disfiguration. Issues in the arm to prevent relapses of ophthalmia, or of cerebral congestions, or as derivatives from skin diseases, are not only useless for their intended purposes, but are very troublesome and frequently become the source of eczemas which spread over the surrounding integument. Even the discolorations which sinapisms leave behind, entail a lasting defect when applied to the neck or chest in females. Sometimes, indeed, a fatal result may be caused through the application of counter-irritants in typhoid fever, pneumonia, or smallpox, in consequence of the blistered surface being the seat of cutaneous diphtheria. The tinct. of arnica, introduced by homeopathists, if diluted, as they use it, is harmless; but if applied in a concentrated form, it causes redness and swelling of the skin, which in sensitive individuals develops into an eczema which spreads over a large surface and even the whole skin, and requires months to heal, confining the patient to bed for a longer period and a worse condition than the affection would have done for which the arnica was administered. Many of these artificial skin eruptions, bullous, vesicular, and pustular, do not cease when the counter-irritant which caused them is removed, but last for weeks, months or years. They can then no longer be distinguished from the idiopathic skin diseases, eczema, pemphigus, ecthyma, impetigo; and were the common theory true of the protective influence of counter-irritation. these skin diseases ought to afford a security against internal diseases in proportion to their amount. In that case, no persons should be healthier than the subjects of general chronic pemphigus, which should afford means of eliminating all kinds of peccant matters from the system. On the contrary, however, experience teaches that exudative eruptions covering large surfaces, especially in the form of vesicles, blebs, or pustles, not only exhibit no preservative power but the reverse. exerting a disastrous influence on the general