that the intestinal noose remains distended with gas after the inflammation has disappeared, which opposes some slight obstacle to the efforts at reduction. After reduction the gas becomes dissipated over the rest of the canal, relieving this portion of its distension. If a laxative enema were not usually given the stools would yet soon naturally appear. After the reduction we may even leave the patient without a bandage. The hernia projects externally, but without tension, pains, or resistance to reduction. It has returned to its normal state. In epiplocele our only object is to prevent the formation of adhesions, which take place much more rapidly than in enterocele; and, as they are especially organized at the fundus of the sac, they not only impede the eventual reduction of the hernia, but, by maintaining the pedicle of the omentum within the ring, render the escape of a portion of intestine much easier, and the application of trusses more difficult. Thus, when the first attempts at reduction have failed, we should treat the local peritonitis by appropriate means, but I always recur to the taxis in a shorter period than in the case of enterocele. If the inflammation is intense and has proceeded on to the suppurative stage, it is remarkable that, in general, false membranes and adhesions cut off the communication between the herniary sac and the peritoneal cavity. The former then resembles an encysted abscess which should be freely laid open, taking care not to destroy these useful adhesions, and then leaving the case to Nature. The same practice is indicated when the abscess is complicated with a fissure of the intestine. If, finally, the inflammation is too extensive to yield to treatment, the case becomes desperate; but at least it is better to let the patient die naturally than to hasten his end by an operation which nothing can justify."-Gazette des Hópitaux, No. 117.

[Perhaps the complication of Hernia by inflammation is too much overlooked in favour of relieving a real or supposed mechanical obstacle. Certain it is that M. Malgaigne in his hospital has successfully treated numerous cases upon the above principles, which, according to ordinary rules, would have been submitted to operation. When we recollect the urgent importance of this being quickly resorted to in the cases for which it is indicated, we see the element of difficulty added by M. Malgaigne's views to a question already sufficiently complicated. It must be borne in mind he limits his recommendation to specified cases, however are not of unfrequent occurrence."-Rev.]

which

ON THE INFLUENCE WHICH DISEASES OF THE UTERUS EXERT IN PRODUCING A FAULTY POSITION OF THE CHILD.

M. Tanchou read a paper in which he endeavoured to show, that although the abundance of the liquor amnii or the influence of external circumstances may contribute to the production of the anormal portions of the fœtus in utero, yet that prior or present disease of the walls of the organ is a more probable and the most frequent cause. Would it not, therefore, be proper, after a difficult delivery in which the child has occupied a faulty position, to investigate whether any latent disease of the womb existed, in order that by appropriate treatment the reproduction of this untoward accident might be prevented in future pregnancies. When, however, the anormal position is found to exist habitually in women who have never been ill, and in whom no disordered state of the uterus can be detected, may we not believe the faulty position is due to some primary vicious conformation of the organ, investing its planes of muscular fibres with unequal power and development? M. Dancel observed that difficult labours are met with chiefly in large towns in which diseases of the uterus are of frequent occurrence. In provincial towns they are rarely met with, and never among primiparæ in the country. The only difficult labours met with in the country arise in women who

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have already had four or five children, and have subsequently suffered from diseases of the uterus. M. Duhamel considered the question should be reduced to these terms. Is a faulty position of the foetus more frequently observed in women who have had several children than in primiparæ ? If so, a strong probability attaches to M. Tanchou's opinion. He believed in his own experience he had met more examples among women who had had children than in primiparæ : but he also has met with such in the latter. That there should be a larger proportion among the former is in no wise surprising, seeing that there are so many more accouchements of women who have had children than of primiparæ. M. Guersant observed that two points required consideration: first miscarriages, and secondly faulty positions. "As to the first, it results from my observation that pathological conditions of the uterus exert a great influence in their production. In young married women they are very frequent, which is attributable to the congested state of the womb. So true is this, that when the female adopts a severe regimen, bodily rest, and other precautions, she avoids miscarriage. As to false positions of the infant, I can say nothing of the effect of the diseases of the womb." M. Picard cited several cases in which diseases of the uterus induced miscarriage; but he considered the effect of these in the production of faulty position rather as a theoretical statement than a demonstrated fact.-Discussion at the Société de Médecine Pratique, Gazette des Hôpitaux, No. 119.

ON GRANULATIONS OF THE CERVIX UTERI. By M. VELPEAU. Granulations of the Cervix Uteri are of such frequent occurrence, that we may state it is generally the affection which really exists when ulcerations are said to be present; for, by a medical attendant not accustomed to observe them, they may easily be mistaken. One reason why they are so imperfectly known is that examinations are not made when the woman, as in this affection, does not complain of severe pain. It is a current but erroneous belief that cancer is a disease attended with dreadful pain, and if this symptom is so slight as not to excite a fear of it, examination is generally neglected. In fact, cancer may proceed very far with little pain, and most of our patients have explained their not applying for advice at an early period by this circumstance. Some women, however, suffer dreadfully from cancer, and it is from such cases the pictures in books have been drawn; and most suffer greatly towards the termination of the disease, when probably the broad ligaments and nervous plexus become involved. As to the numerous varieties of ulceration, such as the scrofulous, scorbutic, &c., described by various writers upon the diseases of this part, we have never been able to distinguish them.

The granular condition of the cervix is always indicated by a more or less abundant whitish discharge; and, although a lactescent, yellowish, discharge, sometimes tinged with blood, may certainly be a symptom of some other diseases, it generally indicates granulations, especially when accompanied with pains in the bowels, groins, and loins, and by loss of flesh. When an examination is made by a sufficiently-exercised finger, the cervix is found slightly enlarged and imparts a sensation of granulation to the finger, just as if a raspberry were spread out into a firm membrane. The granules are easily recognized by one accustomed to search for them, and more so by the finger than by the speculum, which, unless in very experienced hands, may lead to error. When this instrument is introduced it raises the mucous membrane of the vagina into two folds, which may easily be mistaken for the cervix, or it may only discover one side of the cervix, and that the healthy one. Of the two means, then, the finger is preferable to the speculum, but each may be advantageously used to controul the results obtained by the other. Sometimes the granulations are disseminated, at others, assembled

together in patches. Generally they occupy the os, but at other times they are found within the cavity of the cervix. It is in this last case that the speculum is chiefly useful, as, on exerting a little pressure when the neck is engaged in its extremity, the orifice is somewhat expanded; and, if we then see muco-purulent fluids flow out, granulations certainly exist. Granulations only affect the mucous membrane. The epithelium is destroyed, and the papillary layer denuded, but the proper tissue of the organ remains unaffected. It is seldom that we find any marked tumefaction present. Frequent as is the disease, it presents no other varieties. It is true that ulcerations are sometimes produced by excoriations of the granulations, but they are hardly worth notice, and change nothing as to the nature of the disease. A very important question presents itself—Are granulations dangerous? Some practitioners reply to it affirmatively, believing them as the departing point of cancer: but this has never been demonstrated. Such a number of women have had granulations for a long period without cancer ever resulting, that it is doubtful whether it ever so arises. Granulations, indeed, admit of cure in almost every case, certainly in 19 out of 20-cauterization being the means par excellence. The nitrate of mercury is the most efficacious, as well as the most convenient caustic, and never does any mischief. A small pencil moistened with it should be applied to the granulations once a week for five or six weeks, but not for a longer period; inasmuch as, if we prolong the use of the application, the little ulcers it induces are prevented healing. A few baths and some tonic medicine complete the cure.

The history of granulations is much connected with that of deviations of the uterus, the two affections so commonly occurring simultaneously. Prior to our investigations, some twenty years since, these deviations were not acknowledged, except as connected with pregnancy; but they are now known to constitute the commonest lesion of the female genital organs, although they are yet frequently mistaken and treated for other affections. Not only may there be anteversion, retroversion, or lateral version of the cervix uteri, but likewise an inflexion of the womb upon himself; and inflexion is of far more common occurrence than inversion. In inflexion we find the cervix in nearly its natural position, while the body of the organ is bent forwards, backwards, or laterally. The cervix is found normal, or nearly so, and as a lump, sometimes tender, can be felt in the pelvis, the case is set down as one of engorgement, and the patient submitted to injurious confinement and medication. Of 50 cases of pretended engorgments at least 45 are examples of deviation only. When the true nature of the case is ascertained, it is evident that we must rely chiefly on mechanical support; and, although this cannot always be effectually applied, we are at all events able to prevent the patient suffering from needless fears, and encourage her to take exercise and good diet, which are two important points. We do not deny that engorgements may exist, but we maintain that they are very rare; and, considering diseases of the uterus in the order of the frequency of their occurrence, we place granulations of the cervix first, then deviations-affections which are met with every day: after which come anormal productions, such as fibrous tumours, cancer, engorgements, &c."—Gazette des Hópitaux, No 117.

CLINICAL RESEARCHES UPON THE ORGANIC CAUSES AND THE MECHANISM OF THE PRODUCTION OF THE AFFECTIONS TERMED HYSTERICAL. By CH. SCHUTZENBERGER, Professeur de Clinique Interne á la Faculté de Strasbourg.

M. Schutzenberger has recently published an interesting series of papers upon the etiology and pathology of Hysteria, illustrated by several cases. We have only space to quote his conclusions, which seem to us to establish more precision

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in the distinction of the various causes of this distressing malady than heretofore prevailed.

1. The term "Hysteria" has historically two significations: the one symptomatical, the other etiological. 2. Under the symptomatic point of view, it is any thing but a rigorously determined pathological condition; for, if all our authors proclaim the extreme variety of its phenomena, some more especially confine these particularly to more or less general convulsive attacks, while others extend them to nearly all the nervous disturbances observed in women: so that, in practice, the symptomatic and purely nominal diagnosis is often a deception, no one knowing exactly what is to be understood by hysteria. 3. Examined under the etiological aspect, hysteria is in no wise more exactly specified. If there is want of agreement as to the symptoms, there is still more in respect to their cause. Admitted only by induction, and not being generally capable of a practical diagnosis, the etiological expression of the disease possesses scarcely any scientific precision, save in appearance. 4. Under these circumstances we should absolve ourselves from a specification more nominal than scientific, which impedes free investigation, and study the nervous functional disturbances less as nosologists who seek out the varieties of a given and known disease, than with the independent spirit of the clinical physiologist.

5. From a first series of facts investigated in this manner it results :—A. That certain local nervous excitements, generally continuous, may become the organic cause of intermitting functional disturbances-exhibiting themselves under the form of more or less general convulsive attacks, with or without the loss of sensibility-without the central organs of the nervous system in general being the subjects of any permanent pathological condition. B. That, among women, excitement of the ovaries is the most frequent cause of this kind of disturbance, producing it in a manner analogous to other reflex action. c. We recognize clinically the reality of this cause, since deep-seated pressure will induce local pain and reflex convulsive action. D. Other local irritation may produce analogous phenomena, and an attentive examination may discover such centres of irritation. E. These local irritations, capable of propagating excitement, when simple, and especially that of the ovary, are affections of slight gravity, unless they have been long neglected, or are conjoined with incurable organic conditions. F. In practice, it is of the first consequence to determine the cause of the local nervous excitement. G. As regards the ovary, it may depend on congestion, on inflammation, on degeneration, or on a purely neuralgic condition. H. Our indications

of treatment are-1, to remove the determining cause of the local excitement when it is appreciable; and 2, to directly diminish the excited condition of the nerves of the part which form the focus whence the local irritation is propagated to the system. 1. The means of effecting the first of these are as various as are the causes themselves. J. Certain substances, and especially assafoetida, castor, and galbanum, seem to exert a sedative effect upon the ovarian excitability; but their employment in no-wise excludes the application of other agents derived from general therapeutics. K. The intermittent nervous excitement or convulsion demands but secondary or palliative measures, ceasing, as it does, when the local irritation is relieved: unless, indeed, under the influence of the frequent repetition of the propagated pathological condition, a morbid degree of excitability of the spinal marrow does not become secondarily established, and henceforth capable of being induced by simple physiological stimuli. Although this is only consecutive to simple local irritation, propagated by reflex action, it now becomes an entirely new pathological condition.

6. A second series of clinical researches authorizes the reference of a great number of functional disturbances occurring in the sensitive sphere, to a special pathological condition, whose material element is unknown, but which is characterized dynamically by an exaggerated excitability of the sensitive nerves. The term hyperesthesia may be used to characterize this condition. A. We may

clinically recognize the existence of this organic condition, when physiological stimuli or slight causes of excitement produce functional manifestions in the sensitive nerves which appear spontaneous or exaggerated. B. This organic condition of the nervous system is sometimes idiopathic, a part of an original constitution, or it may become developed under the influence of a neglected hygiene. In such cases, too, hygiene offers our most valuable therapeutical resources; for medicines employed with the direct view of diminishing the general excitement merely procure a temporary relief, and the treatment of local excitement can only be regarded as symptomatic and palliative. c. At other times, the morbid excitability of the sensitive nerves is the consequence and effect of simple or chlorotic anemia. It is indeed an exaggeration which yet contains much truth, to say that chlorosis rules over the entire nervous pathology of woman-that hysteria is but a species of chlorosis, or as Sydenham expressed it, chlorosis is an hysteric affection. Here, too, we must attack the cause, and iron is our sovereign remedy, all attempts at directly reducing the excitement being mere palliatives.

7. A third series of cases reveals the existence of a more complex pathological condition, in which the hyperesthesia is associated with a particular morbid condition of the spinal marrow, unknown as regards its material element, but dynamically characterized by a pathological excitability, in virtue of which the reflex property of the organ becomes exaggerated: so that we may with propriety term this reflex excitability. A. This complex condition is recognized at the bedside by-1, characters already attributed to hyperæsthesia; 2, the existence of a greater or less number of permanent centres of sensibility, the artificial and mechanical excitement of which induces with facility reflex movements in the form of convulsive attacks. B. As in simple hyperæsthesia, simple or chlorotic anæmia often plays the part of cause of reflex spinal excitability; but this may also be developed suddenly, or it may be consecutive to the frequent recurrence of simple intermittent excitement, originally due to a local cause. c. In cases of this kind the multiple points of departure of the attacks only play a secondary part, and only furnish palliative indications, the importance of which is in an inverse ratio to the multiplicity of the centres of peripheric excitement. D. The fundamental indication consists in fundamentally modifying the organic conditions which incessantly revive the functional disturbance; the hyperæsthesia on the one hand, and the spinal reflex excitability on the other. E. The first of these we have noticed already; but we know of no means of directly acting upon the latter. Blood-letting is usually ineffectual, may prove in many cases injurious, and is really only indicated in those exceptional examples in which the spinal excitability is connected with local congestion or general plethora. Narcotics exert no durable influence; and antispasmodics, such as valerian, assafoetida, castor, &c. are not more useful. The metallic oxides and sulphate of quinine have not been sufficiently experimented upon in these special cases. The means which we have hitherto found most efficacious is the application of cold, either by means of lotions or baths. It is a plan, however, which must be employed cautiously. It is certain also that the exertion of the will may, to a certain point, triumph over this spinal excitability; so that voluntary motions methodically practised form one of the best means of preventing the reproduction of the reflex ones. As a principle, we may state that the reflexibility diminishes in proportion as the influence of the will over the spinal marrow is strengthened, and vice versa.

It results from what has now been stated that the well-proved presence of general excitability renders the prognosis serious. Although a cure be not impossible, it can only result from a well-digested plan of treatment pursued for a long period.-Gazette Medicale, No. 43.