present circumstances; to interfere no further than is absolutely necessary with the general plan of treatment; to assume no future direction, unless it be expressly desired; and, in the last case, to request an immediate consultation with the practitioner previously employed. §8. A wealthy physician should not give advice gratis to the affluent, because his doing so is an injury to his professional brethren. The office of a physician can never be supported as an exclusively beneficent one, and it is defrauding, in some degree, the common funds for its support. § 10. When a physician who has been engaged to attend a case of midwifery is absent, and another is sent for, if delivery is accomplished during the attendance of the latter, he is entitled to the fee, but should resign the patient to the practitioner first engaged. ART. VI. Of differences between Physicians. § 1. Diversity of opinion, and opposition of interest, may, in the medical, as in other professions, sometimes occasion controversy and even contention. Whenever such cases unfortunately occur, and cannot be immediately terminated, they should be referred to the arbitration of a sufficient number of physicians, or a court-medical. As peculiar reserve must be maintained by physicians towards the public, in regard to professional matters, and as there exist numerous points in medical ethics and etiquette through which the feelings of medical men may be painfully assailed in their intercourse with each other, and which cannot be understood or appreciated by ger eral society, neither the subject matter of such differences nor the adjudication of the arbitrators should be made public, as publicity in a case of this nature may be personally injurious to the individuals concerned, and can hardly fail to bring discredit on the faculty. ART. VII.-Of Pecuniary Acknowledgments. § 1. Some general rules should be adopted by the faculty in every town or district, relative to the pecuniary acknowledgments from their patients; and it should be deemed a point of honor to adhere to these rules with as much uniformity as varying circumstances will admit. FOREIGN BODIES IN THE EAR.-For the removal of foreign bodies we should first employ only the gentlest means, such as syringing the ear with warm water; and by this, substances of the most different form and composition-even lead-pencil-may be removed. Beyond a bent forceps, an earscoop with a long handle, and a small corkscrew, almost all the instruments recommended for this purpose are more or less toys, or dangerous. By means of the corkscrew, wadding and similar soft substances may be easily drawn out; and in many cases we can remove bodies by passing the earscoop behind them. We should never employ force, and never should pass any instrument a line farther into the meatus than we can follow it with the eye. For want of such a precaution many a patient has lost his life or his hearing. The first effect of rough procedures is to make matters more obscure, the bleeding and swelling which ensue rendering complete inspection impossible. If the gentlest endeavors (or syringing), during which the eye guides the hand, do not succeed, the body should be left at rest in the ear— aye, even were it a dagger's point; and strong as the expression seems, the author justifies it by reference to cases on record in which pointed bodies have remained for years in the ear with impunity. It is not meant to be said that bodies should in general be left in the ear, but that matters should not be made worse than they are by violent manipulations. Leaving the body in the ear, then, warm-water syringing a d soft poultices are to be daily resorted to, until the ensuing suppuration loosens it and gives it a new direction.— Dublin Med. Press, Jan. 27, 1864. The Boston Fee-Table. THE Boston Medical and Surgical Journal publishes the following Feetable, which was unanimously adopted by the Medical Association of that city on the 13th of June last. For each visit, either medical, surgical or obstetrical, in of regular $3.00 attendance, For the first visit in a new case, it shall be considered proper to make a charge of from three to five dollars, and a similar charge should be made in cases in which but a single visit is required. In cases also of extraordinary service, detention, or attendance, or when, for any reason, the case is one of unusual importance or responsibility, the charge should be proportionally increased; and the duty to make such increased charge shall be considered obligatory upon the practitioner. For a visit in consultation, from $5.00 to 10.00 In case of a consultation, the attending physician may also charge the usual consultation fee instead of the fee for an ordinary visit. For each subsequent visit in consultation, where the attendance is continuous, the fee may be from three to five dollars. $5.00 to 10.00 For a visit after 9 P. M., and before 8 A. M., from In cases of consultation or other extraordinary attendance in the night the fee for such extra attendance shall be added to that for a night visit. For attendance involving travel out of town, mileage shall be charged at a rate per mile, for short distances, of from $1.00 to 2.00 In cases of longer distances, travelled by railroad, the mileage may be reckoned according to the time saved to the practitioner, at from half a dollar to a dollar. For advice at a physician's house, according to the importance of the case, unseasonableness of the hour, or time occupied, from $3.00 to 20.00 For a letter of advice, according to the importance of the case, or the time occupied, from 10.00 to 20.00 For an opinion involving a question of law in which the physician may be subpoenaed, 50.00 The above charge shall also be allowed in cases in which the physician is subpoenaed in consequence of an opinion obtained under any other pretext but which is afterwards sought to be introduced as evidence in a suit or action. Also for attendance in court as an expert. In case of an opinion involving special study or experimental investigat'on, such additional service shall be charged in proportion to the time and 1.bor expended. In case of detention in court as an expert, or in a matter involving a professional opinion, for each day's attendance after the first, the fee shall be fifty dollars. For a certificate of health, $5.00 For a post-mortem examination in a case of legal investigation. $50.00 For a post-mortem examination made at the request of the family or relations of the deceased, For vaccine inoculation $20.00 $5.00 It is recommended that in the treatment of gonorrhoea or syphilis, the first charge shall be from five to ten dollars, the subsequent charges to be as in cases of ordinary attendance or advice. Midwifery. For attendance during labor in the day time, For do. if any part of the attendance is in the night, $20.00 $30.00 For attendance during tedious labor, it shall be considered obligatory to make such additional charge as, in the discretion of the practitioner, the extraordinary detention or service shall seem to demand. Obstetric operations, when necessary, shall be charged in addition to the usual fee for attendance. In obstetrical practice all subsequent visits shall be charged as in ordinary cases of attendance. In cases of labor when the child is born, but not the placenta, before the arrival of the accoucheur, the whole fee is to be charged. When both the child and placenta are born before the arrival of the accoucheur, half or the whole fee may be charged, according to circumstances. This rule is intended to apply to cases in which the services of the accoucheur have been previously engaged, and in which the delay does not arise from his fault. If, in any case of labor, a second physician is called in consultation, and subsequently detained in joint attendance, both attending and consulting physicians shall be entitled to the full fee for attendance, and also to such additional amount as may be deemed proper in view of the importance of the case, the unseasonableness of the hour, or any extraordinary detention, or service rendered. For capital operations, or operations of unusual difficulty, such as amputation of large limbs, ligation of large arteries, operations for stone in the bladder, removal of breasts or of other large tumors, operations for cataract, for strangulated hernia, for vesico-vaginal fistula, for cleft palate, etc., $100.00 to 500.00 according to the importance of the case and the pecuni- For operations of secondary importance or difficulty, such as $25.00 to 100.00 For minor operations, such as excision of tonsils, removal of nasal polypi, tapping for hydrocele or for ascites, opening abscesses, catheterism, stitching recent wounds, cupping, passing setons, excisions of wens, etc., $5.00 to 25-00 After surgical operations, all subsequent visits shall be charged as in ordinary cases of attendance. The provisions of the new table are to take effect after July 1, 1864. It was also voted to print the Report, together with a list of the members of the Association, in a pamphlet form for distribution. B On the Hypodermic Treatment of Uterine Pain. BY J. HENRY Bennet, M. D. I AM not aware to what extent the hypodermic injection of sedatives has been resorted to for the treatment of uterine pain since it was first introduced to the profession, but I am desirous of giving my testimony to its extraordinary efficacy in cases presenting that symptom. I may add that my attention was first forcibly directed to this mode of treatment by the valuable papers of Mr. Charles Hunter in The Lancet. During the present winter I have used, with prompt and marked success, the hypodermic injection in several cases of severe dysmenorrhoea, with or without hysterical complications, and in several others of uterine and ovarian neuralgia, and of facial neuralgia having a uterine origin. The relief has been obtained in from fifteen to thirty muutes, without being attended or followed by the headache, loss of appetite, or nausea which are so frequently the result of the use of opiates in any other way, even by injection into the rectum. This latter mode of administering opiates has hitherto been my sheet anchor in the treatment of uterine spasms and pain, and is certainly most ethacious; but it is not unfrequently attended by all the above-mentioned drawbacks, from which the hypodermic injection appears to be singularly free. In nearly all the instances in which I have tried this mode of introducing opiates into the system, the sedative result alone has been produced: there has been no subsequent bad effect whatever. In one case of severe uterine tormina and fain, the result of arrested menstruation from cold, I injected thirty minims of the solution of morphia. In half an hour, the pains which had been agonizing for the previous twenty-four hours were calmed. A good night's rest followed, and the next morning the menses had resumed their course, and my patient was all but well In another similar case the uterine pain was accompanied by severe hysterical symptoms. The injection was followed by the same favorable resultease, sleep, and rapid disappearance of all morbid symptoms. Owing to the complete control over the element of pain which the hypodermic injection of opiates appears to give, I have been able to carry on the necessary treatment in an interesting case of uterine disease, which I should otherwise have been obliged to treat under chloroform, or at a great disadvantage. The patient, a young German lady of twenty-four, came to Mentone last autumn, by direction of her medical attendants, with the view of spending the winter in the South. She was considered to be suffering from neuralgia, facial and general, and from nervous irritability of the system in general. She had been traveling with her husband from place to place, from bath to bath, in search for health for more than two years. On being consulted, I recognized the existence of a host of uterine symptoms, and found that the neuralgic and nervous illness had manifested itself after a severe confinement, which had occurred about three years ago. The discovery of extensive inflammatory ulceration of the neck of the womb gave the key to the state of ill health. Singularly enough, none of her previous medical attendants had suspected the uterine origin of the neuralgia. Such cases are always very difficult to treat-interference with the uterine lesion all but invrriably rousing the neuralgia. I have repeatedly had cases of the kind that I could only examine and treat locally by giving chloroform to the full surgical extent on each occasion, and this I have had to do twenty or more times in the same patient. With the patient in question, the surgical treatment of the ulceration was borne tolerably well at first, but as the diseased surface became more healthy, and consequently more sensitive, endurance diminished. Every time the sore was touched, severe neuralgia followed, and the general health began to flag. In former days I should have suspended all treatment, and have sent the patient to the country for a couple of months to allow the nervous system to calm down, and to let nature do her best. In this instance such a course was not desirable, my patient being very anxious to continue the necessary treatment so as to be locally cured before we separated in the spring. I thought, therefore, of the hypodermic treatment, and tried the injection of thirty minims of the solution of morphia immediatel after each uterine dressing. This course was attended with complete successy no neuralgia ensued, and I have been able to continue uninterruptedly th; treatment now all but brought to a successful issue. On one occasion I omite ted the precaution, and was sent for at ten o'clock at night. I found the patienf a prey to a most distressing attack of facial neuralgia, which had come on an hour before. She was positively convulsed, and shrieking with agony. Chlorodyne, sulphuric ether, etc., had been taken, with no relief. I injected the thirty minims of morphia solution, and in twenty minutes she was calm and free from pain. It was repeated next day, and the facial neuralgia has not returned. This lady will no doubt gradually recover her health and get rid of the neuralgia, when the uterine disease is thoroughly cured. In a case of pure neuralgia, attacking first and then another part of the body, I have injected from twenty to thirty minims af the acetate of morphia solution forty-two days in succession, without any unfavorable result. The neuralgia, which was very severe was entirely subbued by it for about eighteen or twenty hours, when it reappeared, gradually increasing in intensity until the injection again relieved it. At the end of that iong period the pains gave way, the treatment having been either curative, or having allowed the neuralgic attack to wear itself out. During the entire period of treatment, the patient, a very delicate lady, slept better than usual, ate as well, (her appeuite being usually bad, and the digestive powers weak,) and was able to take part socially in all that was going on around her. No one, indeed, was aware, except her family, that she was suffering from so painful a malady. To my surprise, I was able to suspend the morphia suddenly, without any of the distress or discomfort which is habitually observed when opiates have been long used and are abruptly abandoned. From what I have seen of the hypodermic system, I believe that its use is capable of great extension to the treatment of pain generally. I consider that the injection of a solution of morphia after any operation would deaden pain, and produce a general calm of the system both soothing and beneficial to the patient. I think also that this result might be obtained in most cases without the usual drawbacks of opiates taken internally. Some years ago I recommended in this journal the injection of opium into the rectum as a means of modifying and even arresting obstinate sea-sickness. Since then various additional cases have come under my notice illustrating its efficacy. The great difficulty to all medication in sea-sickness is the fact that the stomach absorbs fluids with difficulty. By injecting subcutaneously, the difficulty is got over. Moreover, a subcutaneous injection would be managed easier on shipboard than the rectal injection, to which most people have a very natural antipathy. I have used all but exclusively a solution of acetate of morphia in distilled water. Nine grains dissolved in two ounces of water gives a strength about equivalent to that of laudanum. The liquor morphiæ of the Pharmacopoeia contains spirit, and I have found that it constantly occasions small patches of painful inflammation; without the spirit, on the contrary, it appears to be |