painful to the patient than the continuous counter-irritation Simpson recommends. The allied condition of super-involution of the uterus, which is comparatively rare and of secondary importance, is made the text for a very full and able essay on the subject of amenorrhoea, which is well worthy of study, but which we have no space to enter into. It is of interest, however, as containing a recommendation of the intra-uterine galvanic stem pessary in cases in which the absence of menstruation can be traced to the presence of an under-sized and imperfectly developed uterus. There are few of Simpson's peculiar methods of treatment which have been so freely criticised or more opposed. There can be no doubt that it is a plan capable of doing much injury from the excessive local irritation it may produce, and that it is recommended without sufficient warning of its possible evil effects. It is equally certain that in properly selected cases it may prove of much value. The true explanation of the very contradictory opinions held with regard to its failures is that it has often been employed when the uterus is in a state of chronic irritation and congestion, especially in cases of retroflexion, when it will almost certainly do harm. In cases of amenorrhea, such as are described in this paper, dangerous results will not be so apt to follow its use, and to such, it seems to us, the use of the intrauterine stem should be exclusively limited. Even then, however, its effects should be watched with a degree of care and even anxiety, the necessity of which Simpson apparently failed to see. Passing over several papers of subordinate interest we come to a series of lectures on fibroid tumours of the uterus in which a very complete account is given of this common form of uterine disease, of the changes which these tumours may undergo, and of the best means of treatment, both medical and surgical. It is interesting to note that so accurate an observer as Simpson recognised the fact, recently stoutly denied, that nature occasionally does for us what art is unable to accomplish, and completely removes these tumours by a process of spontaneous absorption. This fact is no doubt a strange one and difficult to believe, but it is supported by such a mass of evidence that it is not easy to understand how the occurrence is yet received with so much scepticism. It is satisfactory to those whose opinions on this point have been received with ridicule to find them supported by so high an authority. The explanation which Simpson gives of the phenomena seems unquestionably to be the only way of accounting for this obstetric puzzle. He says "When we remember that they are not heterologous growths, but a mere nodose hypertrophy from the middle coats of the uterus, and when we see the change of growth and involution that occur in the fibres of that middle coat during pregnancy, and after parturition, we may surely hope that the adventitious fibroid masses may become reduced in the same way by a sudden process of fatty degeneration." As an illustration of what Simpson actually observed we may quote the following cases "There are two ladies from the north of England whom I have seen from time to time; one from Alnwick during the last five years, the other for three years, both of whom are the subjects of fibroid tumours of the uterus, and both of whom believed, the last time I saw them, that they were completely cured. In both of these the tumours, when I first saw them, reached nearly to the umbilicus, and now they are so far reduced in size as to have passed beyond the patient's ken." The most sceptical will hardly suppose that Simpson could have made an error of diagnosis in cases of this kind. It is to be deplored that we are, as yet, quite ignorant of any means of originating this change; but, surely, it is not too much to hope that eventually a careful study of nature's occasional cure may enable us to hit upon some method of promoting or favouring it. The account given of his surgical treatment of fibroid tumours can scarcely be considered as embodying our most recent knowledge on the subject, and the papers of Matthews Duncan and others who have written on the subject, teach us that much more can be done in controlling hæmorrhage than is generally believed to be the possible. Indications, too, are not wanting that gastrotomy for the removal of large uterine tumours, imperilling the life of the patient, may yet come to be considered a more hopeful and justifiable operation than it is now thought to be. Those who wish to learn what success may attend such apparently desperate measures will find some valuable cures narrated by M. Péan, of Paris, reported in the last number of the Review. The remaining papers treat of the various forms of metritis and their treatment, and the author recognises the necessity of suitable intra-uterine applications, although he evidently had not paid much attention to this most valuable method of treatment, and used very imperfect means of applying it. Finally, we have some lectures on flexion of the uterus, a favourite subject with Simpson. It is to be feared that the extreme, and, as we believe, in the main, mistaken opinions he held on this topic have done much to foster the exaggerated estimate which many modern gynecologists take of the importance of these affections. We have no space, however, to do more than allude to the subject, nor is it necessary, since we have fully discussed it in a recent number of this Review. That this volume will explain to posterity the position which Simpson had gained for himself cannot be questioned, and in studying it it will be easy for the obstetrician of the future to see why its author had acquired so great and well-earned a reputation, IV. The Pathology of Hysteria.1 IN a paper read at the annual meeting of 1871 of the British Medical Association, by Dr. Tilt, the point consisted in drawing the attention of the profession to the sharp division into two camps of those who have interested themselves in the pathology of Hysteria. To the one the female generative organs are the whole and sole seat and origin of the disease; to the other its essential nature is quite independent of these parts, and its existence is no evidence of their being abnormal. In the first are ranged those who have devoted their lives to midwifery and the diseases peculiar to women; in the second a number, a smaller number by Dr. Tilt's reckoning, whose business it is to teach general pathology and therapeutics. As far as this country is concerned, the sketch of the state of parties at that date seems accurate; and, indeed, one can scarce read any publication on the subject without being offended by the evident tone of advocacy, and the frequent use of the words "triumph," "contend," "confess," "assert," "allow," "pretend" as if truth were worth less than victory. No one can help joining with Dr. Tilt in thinking this discreditable to the 11. On Hysteria and its Interpreters. (British Medical Journal,' Dec. 16th, 1871.) By E. J. TILT. 2. Article "Hysteria." (System of Medicine,' vol. II, London, 1868.) By J. R. REYNOLDS. 3. Clinical Lectures. Fourth Edition, 1865. (Lecture XXXII.) By T. KING CHAMBERS. 4. Studies on Functional Nervous Disorders. By C. HANDFIELD JONES. Second Edition, London, 1872. 5. Pathology, Diagnosis, and Treatment of the Diseases of Women. By W. GRAILY HEWITT. Third Edition, 1871. 6. Etudes cliniques sur l'hystérie. By E. CHAIROU. 7. Traité complet de l'hystérie. By H. LANDOUZY. 8. Traité clinique et thérapeutique de l'hystérie. 1859. 9. De l'état nerveux ou Nervosisme. By BOUCHUT. 10. On the Pathology and Treatment of Hysteria, Paris, 1870. Paris, 1860. Paris, By R. B. CARTER. London, British school of medicine; for the absoluteness of the platforms on an obscure scientific question is alone enough to convict both of error. Dr. Tilt attributes the sectarianism of the British profession to the fact of the feminine sexual ailments being made a speciality much more than is usual in other lands. In France, as he observes, either Trousseau, or Chomel, or Nélaton, would in his hospital ward examine and take charge of a case obviously and professedly uterine; whilst in London a Jenner or a Jones or a Salter would not even determine whether it were really uterine or not, but would hand it over to be examined by the Accoucheur. This is quite true, and is with some justice accused of leading to the narrowness of view detected by Dr. Tilt. It is not, however, the whole of the cause, for there may be traced even in French authors, under a de-specialised dispensation of hospital schools, still an undercurrent of party spirit on the subject, most unbecoming to scientific physicians. It appears to a calm looker-on that a vast deal of the disagreement about the pathology of Hysteria, not only as between the opposing hosts, but between many of the men who compose them, is due to hardly any two of the combatants using the name assigned to the disease in the same sense. This is shown by the inevitable length of the chapter on diagnosis in all monographs, especially French. And it may be observed that whenever any of these writers finds his arguments in peril of being shaken by the facts of some of his opponents' cases, he invariably says he does not consider these as examples of Hysteria at all—they are not what he calls Hysteria. Probably the broadest use of the appellation is made by Sydenham, who in a rough estimate says that it is applicable to at least one in six of medical cases, that is to say, to one half of the chronic cases among females. But that large proportion is accounted for when in the next paragraph we read that he declines to distinguish between Hysteria and Hypochondriasis, which he pronounces as like as two eggs-"vix ovum ovo similius quam sunt utrobique phænomena." And when shortly afterwards he admits us behind the scenes in his study, we learn that whenever his advice was sought by a woman with symptoms due to a cause not immediately detected by the common methods of investigation, he asked first if she had suffered any sorrow, anxiety, or other perturbation of mind, and then if she passed at times an excess of watery urine. An affirmative settled the diagnosis for Hysteria. On the other hand, the narrowest limits,—at least we cannot 16 Epistola ad G. Cole, M.D.,' 59. Dr. Swan is shocked at the colloquial ex: pression, and dilutes it into "we find a great similitude between them." conceive narrower, placed to the employment of the word, is due to the military precision of an army surgeon, M. Chairou, who defines it "a neurosis, which takes its origin in congestion of the left or both ovaries, and determines a paralysis of the epiglottis, first followed by other nerve disorders." He would not allow cases similar externally to be called by the same name, and says that the nerve-symptoms excited in cats by valerian cannot bear any relation to Hysteria, because the tom suffers as much as the puss. If men are ill in the same fashion, their convulsive sobbings are "hysteriform ;" and even a woman may have an hysterical fit without being classed by M. Chairou as hysterical, unless she have congestion of the left ovary and anesthesia of the pharynx:-" La crise hystérique, ou convulsive, ne constitue pas l'hystérie-la crise hysteriforme peut exister sans l'affection même." Did everybody's trumpet give as certain a sound as this, it would be clear enough what each author meant by his title. But that is far from being the case, and we are left to work out by the inference of internal evidence what ailments are to be included, and what not, under the common heading. Thus we find in 'Reynolds' System of Medicine' separate essays on Exstasy, Catalepsy, Somnambulism, and Hypochondriasis; so that Dr. Reynolds evidently, when he writes afterwards of Hysteria, does not view the aforenamed as part of it. On the other hand, the College of Physicians, by omitting all mention elsewhere of Exstasy and Somnambulism, implicitly includes such states as Hysteria. Dr. Briquet, in a work which heads this article, again specifies Catalepsy as a symptom of Hysteria, but designates Hypochondriasis as its direct antipode. He thinks it so different that it cannot be mistaken. On the other hand, Sydenham, as we have seen, makes little distinction between them; Dr. F. Dubois (a well-known alienist) thinks them at any rate so alike that he writes a stout octavo volume in order to draw the line. Far be it from us to blame; the substantive is common property, for each one to define as he likes. The only really annoying sinners are those who use it in a narrow sense in one part, and in a broad sense in other parts of their lucubrations, without giving notice, and often within the limits of a short paper or letter. Some pathologists are distressed at the established nomenclature, thinking that a connexion with the Greek, which lies on the surface of the name as written, unfairly prejudges the question. Such elaborate terms as encéphalie spasmodique (Georget) and neuropathie aigue cérébro-pneumogastrique (Girard) have been proposed. But these ponderous substitutes L'Hystérie,' p. 11. |