is proved to be the fact. The principle maintained by Dr Mar shall Hall cannot, therefore, admit of application in this case; and this physician would not have made the application, if, less preoccupied with the greatness and truth elsewhere contained in this principle, he had directed his attention to the seat and the exact limits of the nervous disorders experienced by his patients, as well as upon the nature and the mode of action of the cause to which they are ascribed. It is not my opinion that there is any one order of succession necessarily followed in the development of the constituent phenomena of neuropathic disorders. I think, for instance, that, although there may be many relations between Anæsthesia and Neuralgia, between Palsy and tonic or clonic Convulsion; these are, nevertheless, in certain senses independent of each other. Neuralgia, for instance, is in so small a sense a degree more than Anæsthesia, that it, namely, Neuralgia, does not pass through Anæsthesia, that it is not transformed into Palsy of Sensation, when it gradually diminishes either spontaneously or under the influence of treatment. Finally, it ap pears to me that Dr Marshall Hall has imperfectly interpreted the facts which he has observed, that he has not taken into account all their circumstances and elements, and he has not rightly applied to them his own principles, which are in other respects very curious, upon the functions of the nervous centres.

Whatever opinion may be entertained of these critical remarks, the three cases which I have borrowed from the English physiologist are in no respect to me less valuable. Associated with

my own cases, they at the same time mutually lend to them and borrow from them great authority and force, in this respect, that they form together a body of facts which establish, in an irrefragable manner, the existence of a tribe of disorders, which, having been neither referred to their true seat, nor recognised as peculiar morbid states, remained, as it were, foreign to the science, and were to it accordingly lost. Restored to the position which they ought to occupy, it is hoped that they may become the subject of study and research, which may at length explain the method of treatment required by these disorders, and which is the great object of the labours of the physician. We have already seen that the analogy which the convulsive disorders of the face present, with neuralgic and paralytic affections of the same region, lead us to indulge the hope that electro-magnetism, suitably conducted and modified, may effect their cure.

Lastly, The intimate relations which subsist between these maladies and certain disorders of the Nervous System have made me think that several trunks and branches of the same system may be affected in the manner of the facial nerve. This fact has been already recognised and admitted by Dr Marshall Hall, who, in

work already referred to, has placed in one and in the same ass the hemifacial spasm, the spasmodic Strabismus, and some forms of Torticollis or Wryneck. Other nervous diseases, of seat. yet undetermined, will probably be at length placed in the same category.

Six months after this memoir had been presented to the Academy, and immediately after the reading of the Report of the Commission which the Academy had appointed, my learned colleague and friend, Professor Schwann, informed me, that he had just received the second part of the first volume of a work of M. Romberg of Berlin upon the Diseases of the Nerves, and that one chapter of this work was devoted to the subject of Convulsions of the Face.* I think that it may be serviceable to state in this place, as a supplement to my memoir, the principal points of this chapter, which is not lengthened, and for a translation of which I am indebted to M. Schwann.

1. During accessions, the patients are able to cause the convulsed muscles to act, neither simultaneously nor in an isolated nanner; but they possess the consciousness of the contractions of the whole of these muscles.

II. The general convulsive spasm is susceptible of being decomposed, and affecting only the parts subjected to the action of one single nervous branch, as in the instance of neuralgic attacks.

III. The disease may affect the whole of any nerve from its origin as well as at its divisions. The author saw one case in which the convulsive movements occupied the auricular muscles.

IV. The mimic convulsion may exist alone, or may be accompained with convulsive contractions in the muscles regulated by other nerves; the small root of the tergeminal, the accessory nerve, the cervical nerves, the spinal nerves, and others.

V. Facial Palsy may be transformed into Convulsions.

VI. The disease has its seat in the periphery, that is, the ramified extremities, or in the centre of the nerve.

VII. The causes of this disorder are,-rheumatism, a draught or current of wind, a reflected irritation, such as is produced in the instance of wounds of the diaphragm, and particularly in the diseases of the Trigeminal Nerve, Tic Douloureux, caries of the teeth, and similar affections; an irritation felt, such as the presence Of a grain of sand in the eye; an irritation not felt (and transmitted to the sentient soulf), as the existence of intestinal

* Lehrbuch der Nervenkrankheiten des Menschen. I. Band. II. Abtheilung. Berlin, 1843.

† This is marked within brackets, because it is not exactly correct to say that the imitation is not felt. It acts upon the mucous and muscular coat of the intestines; but of this the mind is not conscious.

worms, &c.; and, lastly, the diseases of the womb, moral affections, habit, imitation. Most frequently, however, the causes of these disorders are unknown.

VIII. Convulsive Tic is independent of diseases of the brain, excepting epilepsy.

IX. The treatment of the disorders now under consideration is not known. Nevertheless, partial convulsions seem to yield more easily to the action of remedies. In all cases it is essential to examine with care whether the convulsion is a reflected effect, and to ascertain the point of its origin. M. Romberg recommends the solution of borax and continued pressure, exerted by means of a pad conveniently applied. He quotes from M. Dieffenbach an example of convulsions in the muscles of the face in a man aged forty-three years, who, in consequence of a chill, was immediately attacked with a spasm of the orbicularis of the eyelids on the right side, and which extended to the whole of the same side of the face. While the wind was from the south these symptoms were abated; but they returned in an intermittent manner. The convulsions came on as soon as the patient wished to shut the eye; nor could he sleep, unless he closed it with precaution and slowly. The spasmodic contractions were suspended during sleep. M. Dieffenbach performed the subcutaneous section of all the muscles of the face by making four successive incisions; and after the lapse of fifteen months, the convulsions, he stated, had entirely disappeared. They were succeeded, however, by a muscular vibration, which, it is said, causes very little constraint to the patient.*

From the summary now given, it is seen that the German author has taken into consideration all the forms of Nervous Convulsions of the Face, whether idiopathic, or symptomatic, or sympathetic. The culminating point of the work of M. Romberg is the almost complete cure of spasmodic tic, by means of subcutaneous myotomy, an operation which has already rendered many services in other disorders, and which is certainly a great resource in the treatment of a disease against which all therapeutic means have been hitherto unsuccessful.+

* Dieffenbach, Ueber die Durchschneidung der Sehnen und Muskeln, Berlin, 1841.

† When I communicated this fact to the Academy, at the meeting of the 3d June 1843, M. Phillips, favourably known in the medical world by his labours in the department of subcutaneous Tenotomy, recalled to the Academy the fact, that he had, in 1840, stated in his work upon Strabismus, in speaking of subcutaneous sections, that henceforth convulsive contractions, tic douloureux of the face, of the lips, of the eyelids, &c., would no longer be considered as incurable.

Dr Robert-Lee on the Speculum in Uterine Diseases.

395

ART. VIII.—On the Use of the Speculum in the Diagnosis and Treatment of Uterine Diseases. By ROBERT LEE, M.D., F.R.S., Fellow of the Royal College of Physicians, Physician to the British Lying-in Hospital, Physician-Accoucheur to the St Mary-Le-Bone Infirmary, Lecturer on Midwifery and the Diseases of Women and Children at St George's Hospital. (Medico Chirurgical Transactions, Vol. xxxiii., p. 266.)

I. IN the first great class of organic uterine diseases, which comprehends fibrous, fibro-cystic, glandular, and all other tumours which are not malignant, I have derived little or no aid from the speculum in their diagnosis or treatment. When fibrous and other tumours are formed under the peritoneum, or between the muscular fibres, or under the lining membrane and distend the cavity, their existence can only be determined by a careful examination of the hypogastrium, and of the interior of the pelvis through the vagina and rectum. The uterus is usually felt large, hard, irregular, and the cervix shortened. Where these tumours have passed partially or completely through the os uteri, their size, density, the length and thickness of their roots, and the relations these bear to the os and cervix uteri, can only be determined by the touch. I have never detected a small polypus within the os uteri, or hanging through it, which I had failed to detect with the finger. In cases of this description I have, however, repeatedly employed the speculum to ascertain the colour of the polypus, and the degree of vascularity of the investing membrane, which, without ocular examination, could not have been determined. The knowledge thus acquired was of no use in the treatment.

In a case of fibro-cystic polypus of the uterus, which occurred at St George's Hospital upwards of eight years ago, under the care of Mr Cutler, the speculum was introduced, and we saw clearly the small cysts under the vascular covering membrane. The speculum was withdrawn before the operation for the removal of the tumour had commenced.

In a case of small glandular polypus in a sterile married lady, which I saw with Mr Painter, the speculum was employed, and it made us acquainted with the colour, and more perfectly with the nature and diminutive size, of the disease. The polypus was removed with the forceps, after the speculum had been withdrawn.

In a similar case which I saw with Mr Jonson of Grosvenor Place, the speculum was employed for the same purpose after the nature of the disease had been satisfactorily ascertained by

the touch.

The tumour was readily removed with the forceps after the speculum had been withdrawn.

Very recently I saw a sterile married lady, with Dr Meryon, who had a small polypus hanging through the os uteri. In that case the speculum had been employed before the patient came to London, and for that reason alone I had recourse to it. The tumour presented the appearance of a large bean, was of a bright red colour, like vascular tumours of the meatus urinarius, and bled freely when touched, though the surface was not ulcerated. The length and thickness of the root, on which the speculum threw no light, had previously been ascertained with the finger. The forceps was passed through the tube, and the tumour removed; but it is now my conviction, that the peduncle would have been more effectually destroyed, had the forceps been passed up along the fore and middle fingers of the left hand in the usual

manner.

More recently, with Mr Henry Charles Johnson, I removed a small polypus hanging through the os uteri, with the forceps, in a most satisfactory manner, without the speculum altogether. In all large uterine polypi it is obvious that the speculum can be of no use, and that it would not enable us in any case to decide, whether the tumour in the vagina was a polypus or an inverted uterus; a small portion only of the lining membrane of the uterus, in either case, being all that could possibly be presented to the eye. A case of large globular tumour in the vagina, now under the care of Mr Cathrow, strikingly illustrates the truth of what has now been stated respecting the use of the speculum in the diagnosis of inverted uterus, and fibrous tumours.

II. In all the varieties of malignant diseases of the uterus, scirrhus, fungoid cancer, and corroding or phagedenic ulceration, the speculum has given me no assistance whatever in their diagnosis and treatment, either in the early or in the advanced stages. I have never, in a single instance, failed to determine by the sense of touch, when cancer of the uterus had commenced; but I have repeatedly, after the most careful examination, both with and without the speculum, suspected that it would be developed, when the result proved that my fears were groundless. I am fully satisfied that the speculum does not enable us to decide earlier than the finger that cancer has commenced; and if it did so, as some maintain, and enable us to make applications to the os uteri, which could not be made without, not the slightest advantage would be gained in practice. When cancer of the uterus has advanced to ulceration, the speculum is not only useless, but positively injurious, and ought not to be used. In the year 1827, when I first became acquainted with the speculum, and saw it very frequently employed in a great public institution, a patient