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NLM DSEMESfifi 3
NATIONAL LIBRARY OF MEDICINE
ARMY MEDICAL LIBRARY
FOUNDED 1836
WASHINGTON,  D.C
NLM052425883 
DUE TWO WEEKS FROM LAST DATE
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              BRUEN'S POCKET BOOK
                             OK

     PHYSICAL  DIAGNOSIS.

A  Guide  for  Students  and   Physicians.

              By DR. EDWARD T. BRUEN,
Demonstrator of Clinical Medicine at the University of Pennsylvania,
                     Medical Department.

           WITH ORIGINAL ILLUSTRATIONS.

      POCKET SIZE.  CLOTH.   PRICE $2.00.

              «»NEW  RECOMMENDATIONS.
  "The method and arrangements are, too, very reliable and judicious.
Indeed, the volume is so good in these respects, and in others, that it is
accepted by the University of Pennsylvania as a good guide and text-
book."—American Medical Journal, May 27th, 1882.
  " To students engaged in mastering physical diagnosis, and to practi-
tioners who need to freshen  their memories on the subject, we know of
no work which contains more or is better and more conveniently arranged,
and withal written in a clearer and  cleverer way, than is this of Dr.
Bruen's.  Its form is so compact that it may be conveniently carried in
the pocket, while  the value  of its contents must  insure its ready sale.
It is  a scholarly and  thoroughly honest book."—American  Practi-
tioner, Louisville, Ky., June, 1882.
       P. BLAKISTON, SON & CO., Medical and Scientific Publishers. 
LACERATIONS
OF THE
FEMALE  PERINEUM,
AND
   VESICOVAGINAL FISTULA.

THEIR HISTORY AND TREATMENT.
WITH AN ACCOUNT OF THE METHODS OF PERFORMING THE
   OPERATIONS, AND INSTRUMENTS USED. ILLUS-
           TRATED BY CASES.
BY
  D. HAYES AGNEW, M.D.,
Professor of Surgery in the University of Pennsylvania.
SEVENTY-FIVE ILLUSTRATIONS.
      PHILADELPHIA :
P. BLAKISTON, SOX & CO.
     ioi2 Walnut Street.
Copyright. All Rights Reserved, 
11° 
LACERATION OF THE FEMALE PERINEUM:

           ITS HISTORY AND TREATMENT.
  When it is considered that the female perineum measures
in its normal  condition from one  to one and  a half inch,
and yet, during the final act of parturition is extended to
four and a half—perhaps five—inches, and of course greatly
attenuated, it is not surprising that a separation  in its con-
tinuity should frequently occur.
  Such accidents doubtless take place in a large majority of
cases from ignorance or carelessness on the part of the medi-
cal  attendant, and  yet may and do happen in  the  hands of
the most  competent and expert practitioners.   The conse-
quences which  often ensue are so peculiarly distressing and
mortifying to the  female, as to debar her from the compan-
ionship  of friends, render her offensive to herself, and seri-
ously  to undermine her  health.  In some  degrees of this
injury the patient's situation is infinitely worse  than  when
afflicted with  a vesico-vaginal fistula; and like the latter,
until a comparatively recent period, was deemed beyond the
compass of surgical resource.  It is almost exclusively the
result of  parturition, though occasionally we  hear of such
lacerations from external  violence, as falling astride the back
of a chair, or  as in the case related by Prof.  II. H. Smith
(Smith's Surgery, vol. ii., page  555), where the  injury was
produced by the horn of an enraged deer.
  Partial  lacerations are  by no  means uncommon, and even
extensive  ones, I am disposed to  believe, exist to  a degree
not generally suspected.   Many females,  from  motives  of
delicacy, timidity, or hopelessness, carefully conceal such, suf-
      2
385091 
10        LACERATION  OF  THE FEMALE PERINEUM.
fering  in  silence the many evils  which  they entail.  The
successful management  of these, in  any degree,  constitutes
one of the most important triumphs of modern Surgery;
and if there  is any class in this world, more than another,
placed under unbounded obligations to cherish and  respect
our art, it is the mothers of the land.

           Anatomy of the Female Perineum.
  The subject of this paper cannot be well understood with-
out some  presentation of the anatomical  components of the
female perineum.  It extends, in a restricted sense, from the
commissural  connection of the labia majora to the anus.
The two canals, vagina and rectum, as they approach their
terminations—vulva  and  anus—recede  from each   other,
leaving a triangular space into which the deep portions of
the perineum extend.  (Fig. 1.)

                          Fig. 1.
   1. Vagina; 2. Rectum; 3 Triangular notch or space into which penetrates
                       the perineum.

  Just within the posterior commissure of the labia majora,
is a transverse duplicature called the fourchette.  This is al-
most constantly torn across in the first labor, but is followed
by  no inconvenience whatever.  The skin and superficial
fascia being  removed, the muscular  apparatus is  exposed;
consisting of  the external sphincter ani.  Its origin com-
mences at the coccyx.  At the posterior side of the bowel it
separates into two elliptical planes which  surround the anus,
unite in front, and become inserted  into the perineal  centre. 
ANATOMY OF THE FEMALE PERINEUM.
11
Below this lies  a strong muscular ring, surrounding the
lower end of the bowel, the sphincter ani internus.   At the
perineal  centre commences the sphincter vaginae, continuous
with the fibres of the sphincter ani, and passing forwards on
either side of the vagina, is inserted into the cavernous por-
tions of the clitoris.
  On either side, arising  from the ramus of the ischium, are
the transverse perineal muscles, inserted into the constric-
tor vaginae.  In like manner, on each side, there is a levator
ani stretching between the pubic  bone and the spine of the
ischium, and  inserted into the side of  both  the vagina and
rectum.   (See Fig. 2.)  With a knowledge of these muscles,

                           Fisr. 2.
  1. Sphincter vagina; 2. Sphincter ani externus; 3. Internus; 4. Transversus
          perinei; 5. Levator ani et vaginae ; 6. Perineal centre.

their attachments  and direction, it will not  be difficult to
understand the displacement of parts which  follows lacera-
tions, and which we shall have occasion to refer to presently.
  Period of Occurrence.—As  might be expected, these acci-
dents are largely confined to primiparse.  I.  Baker Brown,
whose experience has been very great in this as in many
other diseases  incident to the female sexual  system, states 
12        LACERATION  OF  THE FEMALE PERINEUM.

that in  eighty-six cases operated  upon,  sixty-four occurred
in first labors, and in those which have suggested this paper,
all were in the persons  of primipaiw, none of whom but two
at the time of the injury exceeded twenty-five years of age.
  Causes.—These may be arranged under three heads.  First,
such as relates to the mother; second, to the child ; and third,
to instruments.   Under the first, may be mentioned powerful
expulsive uterine contractions extruding the fcetus before the
parts are sufficiently extended; or an unyielding perineum,
its tissues being rigid; or where the muscular  structure is
deficient in tone and inadequate to react against  the pressure
of the advancing  head  ; and again, where the uterine contrac-
tions are suspended at  a period when the perineum is greatly
stretched, and then, without premonition, recommence with
unusual power.   In such  a case laceration  occurs in  one of
two modes ; either by  the muscles contracting powerfully to
meet the emergency; or by their being so enfeebled by pro-
tracted extension, as to be powerless to resist.
  The form of the perineum  itself must not be overlooked.
There are  congenital peculiarities which  complicate the  me-
chanism of a labor, resulting from redundancy of tissue asso-
ciated often with an unusual straight  sacrum, in  consequence
of which, the presenting  part of the foetus tends to direct
protrusion, instead of being deflected in the axis of the pelvic
curve.   A very narrow pubic arch may predispose  to  the
accident by preventing the usual extension.
  Under the  second head are such as relate to the child.   Of
these may be specified  unusual size of the head or breadth
of the  shoulders, either from natural or morbid causes, de-
manding for  their passage an extraordinary  dilatation of the
vaginal outlet; or, unusual position  of  the fcetus.  It  is a
question by  no means clear, whether the passage of  the
shoulders does not often produce  the damage ascribed to the
head.
  The  third cause of lacerations is the use of instruments.
These come in usually  for a very large  share  of animadver-
sion, but it is only in unskilful hands they can be said to do
harm in this way.  If a  child is dragged through the  ma- 
ANATOMY OF THE  FEMALE PERINEUM.
13
ternal  passages without  regard to the existence of a pelvic
curve or the  principle of the lever, then, indeed, great dam-
age may be  done;  or if the accoucheur, before he  has the
blades of his instrument adjusted, allows himself to be sur-
prised by  the  sudden  expulsion  of head  and instrument
together, the parts  may, indeed, be seriously wounded.   One
of the most fearful  perineal lacerations I have  witnessed,
extending some distance up the rectum, was produced in this
manner.  In the  hands of an expert, instruments I regard as
among the most valuable resources of obstetric surgery, pre-
venting the very results which they are often charged as
bringing about.
  Degrees  of Ruptured Perineum.—First. Where the lacera-
tion extends back from the posterior commissure toward, but
not into the  perineal centre.
  Second.  Where the laceration extends from the posterior
commissure of the  vagina to the verge of the anus, but only
involves the skin and subcutaneous cellular tissue.
  Third.   Where the laceration  extends from vagina to rec-
tum, dividing not only the skin and fascia, but both the
sphincter vaginae and sphincter ani externus, and  in  some
instances  the vagino-rectal septum with the sphincter ani
internus.
  Fourth. Where  the perineum is perforated  by the  head
passing through the perineal centre, and leaving the sphincter
of the vagina and the sphincter of the bowel  unsevered.
  Results.—These will depend on the degree of injury.  If
it be only the division of the posterior commissure,  it amounts
to nothing;  but if  beyond  this, then every line entails  some
disqualification.  Then  follows  a descent  of  some or all of
the  pelvic viscera.   This displacement is often accompanied
with irritability of  the bladder,  compelling  the  patient to
pass urine very often; dragging sensations, pain, and great
weariness in the  loins, and inability to  walk without great
inconvenience.   Symptoms of  indigestion will  frequently
appear, the appetite fails, bowels become distended with flatus,
and a train of  nervous troubles comes on apace.  But  there
is still a greater calamity, before which all others sink into 
14        LACERATION OF THE  FEMALE PERINEUM.

insignificance.   It is present  when  the  laceration  involves
the sphincters of the bowel, and perhaps the vagino-rectal
septum.  All control over the intestinal contents is lost; the
faeces and gas pass incontinently; the person is ever and anon
soiled  with the  dejections; the escape  of  wind from the
bowel  produces  necessarily mortification; a  disgusting odor
adheres to and emanates from the body; friends shun her;
those who  should cherish  her, minister  with reluctance to
her necessities, and she is  compelled to  impose a seclusion
worse than death itself.   To rescue a patient from so dread-
ful a prison-house, ranks among the  noblest achievements of
surgery. It not only blesses the miserable sufferer, but it is
reflex.   It makes the surgeon go on his way rejoicing, in the
consciousness of being instrumental in  the  hand of God of
doing so great a good.   Such are  the threads of gold which
run through the complex mechanism of professional toil, and
inspirit the heart amid so much calculated to weary and  de-
press.
   Deformity from Laceration.—When the  laceration is slight,
it only seems as though there was an unusual  anteropos-
terior extent of the vulva.   When, however, the muscles are
severed, the departure from the normal  appearance is very
marked.  The anal extremities of the labia majora are drawn
widely asunder by the transverse perineal  muscles, and curled
upward by the contraction of  the segments of the sphincter
vaginae toward  their origin aided by the anterior fibres of
the levator ani.   When the septum between the rectum and
vagina is torn, the mucous membrane of the former often
projects in redundant folds into and  even above  the fissure,
also downward, resembling in  some degree a prolapsus ani,
which,  indeed, it is, brought about by those fasciculi of the
levator ani muscles, which  influence  the anterior  portions of
the sphincter, dragging them upwards when once  disengaged
from the perineal centre.  These deformities increase by age,
and the chasm grows wider until cicatrization is completed,
when there is some little diminution.
   Prevention.—Every obstetrical writer devotes a portion of
his chapter on  the  process of labor to  the  support  of  the 
ANATOMY OF THE FEMALE PERINEUM.
15
perineum.  This would seem to be a very natural and rea-
sonable demand, but  there  is considerable  discrepancy of
opinion about it.  There are not  wanting those who deny
entirely the  necessity for such a precaution.  Among the
Germans, there  are  Sacombe,  Faust, Wigand, of the older
class;  and Mende (Beobachtungen und Bemerkungen aus
der  Geburtshiilfe und  gerichtlichen Medizin,  Gottingen,
1825),  who are entirely opposed to supporting the perineum.
Mende declares  nature provides all remedies against  its in-
jury.   V. Siebold (in  the  Journal fur Geburtshiilfe, Bel. v.,
Hft. 1, s. 63) takes occasion  to contradict and expose these
views at some length.
  In France, Pinel Grand-Champ, Danyau expressed them-
selves  opposed to support, asserting that such was positively
injurious.  And in England, Thompson (Frorieps Notizen,
Bd.  7, Wo.  18, 1824)  uses very similar  language.   In the
latter part of the fourteenth  century,  Eros or Trotula, in the
twentieth chapter of  his  book (cle Passionibus  Mulierum,
quoted in I. Spachii  Gynaeciorum, etc., ed Argentinae, 1597,
fol. 50),  says, "Ad periculum  evitandum  (ruptures  puden-
dorum) eis in partu sic  providendum est: praeparetur pan-
nus in modum pilae oblongae  et ponatur in ano ad hoc, ut in
quolibet  connatu ejiciendi puerum, illud firmiter ano impri-
matur, ne fiat hujusmodi continuitatis solutio."
  Roder and  Stein virtually agree with him, as they advise
the insertion of two  fingers  into  the  rectum to guide the
head in the proper direction.   Schafner (Hufeland's Journal
der praktischen  Ileilkunde,  Bd. xiii.,  3 st., 1802)  recom-
mends one hand placed on the  os sacrum, and drawn, while
pressing  softly, toward the perineum, in order to gain  more
skin for  the  latter, at the same time, with the palm of the
hand, to give the head an upward direction.  Wigand also
recommends rubbing the skin  upward from  the thighs to-
ward the genitalia.  Such manipulations can be of Very little
use.   Nedel, Stark, and Stein, Sr., counsel "proper support
with the hand and the use of fatty oils.
  ISHemyer sustains the perineum in the hollow of the hand,
leaving one inch back of the posterior commissure free, the 
16        LACERATION OF THE FEMALE PERINEUM.

pressure to be made in the axis of the inferior strait.   Bar-
low  advises support until  the  perineum  is well distended,
then allows it to take care of itself.  ]STedel  places onl}- his
thumb across the fourehctte (Vorschlag einer  neuen verfah-
rungsart die Ruptur cles Perinaums bei der Geburt zu ver-
hiiten  und die Erfolgte zu heilen.  Magdeburg, 1806, s. 51).
The  object of this method is to sustain the point only where
usually the rent commences.                i
  Hohl recommends a  particular method, placing  the  ends
of four fingers on the foetal head, close to  the posterior  com-
missure, and the thumb on  the  opposite side of the  head,
near the arch of the pubes, thus  both restraining and  guid-
ing its delivery.  There is certainly very little support fur-
nished to the perineum  by such a plan, but it is not without
its value in preventing the  too sudden expulsion of  the child
before the maternal tissues  are prepared.
  Heine and Mliller counsel  the  side position  as calculated
to prevent rupture.
  Burns advises pressure, uniformly applied over the entire
perineum, until the head passes, and particularly to the pos-
terior commissure,  charging the  woman  not to bear  clown
during the presence of a pain.  Mr.  Burns  evidently never
passed through the throes of childbearing, or he would  have
omitted the last recommendation of the sentence ; not to bear
down in such an extremity is simply impossible.
  Denman retards the head partly by pressure made directly
against it, and  partly by the hand planted against  the  peri-
neum.   The object here is to detain the head until  the parts
are sufficiently yielding.
  Hamilton so applies the hand that the part which sustains
the   greatest pressure  shall  receive the  principal  support.
During the  intervals of pain he  directs  the perineum  to be
rubbed with  lard, and, when the head is emerging, to lay the
fingers against the posterior part of the vulva, and pressing
the perineum toward the pubes.
  Busch recommends the fingers  being planted against the
head, to prevent its  being driven out too suddenly, and, when
this is not likely to  occur, to support the parts by placing the 
ANATOMY OF THE FEMALE PERINEUM.
17
balls of the hand on the posterior commissure, the palm on
the perineum, and  the fingers  along the sides of the  anus;
supporting only during  the presence  of a pain, and  never
strongly opposing the foetal advance.  During  the  escape of
the head and the retraction of the perineum the supporting
hand should  follow the  latter  carefully.  He is unfavorable
to using the uncovered hand.
  V.  Siebold, during the intervals of pain, rubs the skin of
the thighs toward  the perineum, and during the presence of
pain gives a very gentle  support.  He does not, as Busch ob-
serves, sufficiently insist  on uniform pressure.
  Carus says it is only necessary to  give  the posterior com-
missure sufficient  background  by pressure.  He evidently
has in mind the old maxim, obsta princijnis.
  Mesnard thought it only necessary to push the coccyx back-
ward, or place two  fingers between the head and perineum.
  Pinel Grand-Champ says support is  not only useless, but
injurious.
  Mende, of  Gottingen,  published the same opinion.
  Dr. Hodge enforces  pressure, especially supporting the
posterior commissure.
  Dr. Meigs  enjoins the same, using a napkin supported by
the hand.
  Ramsbotham uses a napkin as a matter of delicacy, main-
tained against the perineum by the hand.
  Cazeaux employs the hand alone.
  Velpeau directs the hand to be wrapped in a napkin and
placed transversely, the cubital edge toward the coccyx.
  What is to be done when, in consequence of the great size
of the foetal head, or some unusual peculiarities of  the peri-
neum, its laceration becomes inevitable ?
  Michaeles  (Lucina, Bd. vi., Hft.  1) recommends  incisions
in the perineum; and  Siebold, in discussing this same sub-
ject, insists the incisions  should be made where  there is least
tension, or where the head presses least.
  Ritgen takes a similar view, but confesses there  is such a
repugnance to it in  civil  practice that he has not been able
to do it.  Xeither has he done it in hospital service. 
18        LACERATION  OF  THE FEMALE  PERINEUM.
  Blundell not only advocated, but practised slight incisions;
to be made laterally, and to be  done during the presence of
a pain.
  M. Paul Dubois also directs an oblique incision.
  Chailly-Honore' concurs in the same practice, believing that
even should  the  incision become a laceration, its direction
will be such as not to incur the disastrous consequence which
ensue in a tear through the raphe.
  Dr. Simpson, of Edinburgh, advocates the practice.
  Dr. Penrose, Professor of Obstetrics in the Medical Depart-
ment  of the  University  of  Pennsylvania, teaches the pro-
priety of incisions in extreme cases.
  Dr. Wallace, of the Jefferson Medical College, thinks the
necessity for such a course can scarcely arise.
  Dr. E. Wilson,  long  connected  with  the Nurses' Home as
a teacher of Obstetrics, opposes the practice as unnecessary.
  In speaking on this subject D'Outrepont objects  to the
operation, on  the ground that this cut, once  started, may
soon be converted into a tear, extending even to the anus.
  Busch thinks these  incisions should be confined to cases
of organic anomalies only.
  The cases demanding  such an operation must certainly
be extremely rare, and the clanger in inculcating it is, that it
will be abused  by practitioners of limited experience be-
coming unnecessarily alarmed, and resorting prematurely to
the knife.
  The accident may be prevented again by resorting to the
forceps—a practice advocated by Moreau, Busch, and Hiitter.
  The employment of ether or chloroform will conduce to
the preservation of the perineal structures  by the relaxation
which is  secured, and  also by rendering the patient  insen-
sible to that acute suffering  which provokes the violent con-
tractions of the perineal muscles.
  I think, from all that has been quoted, we may conclude
the perineum demands support as a precautionary measure.
That  the  bare hand is the  proper support, as it  communi-
cates to the mind information which could never be per-
ceived through an interposed  napkin, and should  not  be 
HISTORY OF LACERATED PERINEUM.
19
applied  too  early.   That the degree of pressure should be
properly graduated and  regulated by  the  necessities of the
case, and only  made  during the existence of pain, and the
direction, so as to prolong the  curve  which coincides with
the axes of the straits.  To this end, the palm  of the hand
should  be applied  against the  perineum, so that the balls
of the thumb and little finger shall rest just in  front of the
anus, and the  fingers on the posterior commissure  of the
vulva.  Thus adjusted, the pressure should be, at first, firm-
est posteriorly, so as to deflect  the head toward the pubic
arch, and then, during its exit,  well and securely applied to
the posterior margin of the vulva.

            History of Lacerated Perineum.
   There is a grand ongoing in all human  history.   And in
no department of science or  art is the march more rapid
than  in our own.  ]STo physician imbued with the true spirit
of  his profession  can fail to be interested  in  tracing the
progress of  a great  surgical problem through all the stages
of supposition, experiment, and  fact.  Such a study  will in-
crease greatly our faith  in this  noble calling, and moderate
surgical dogmatism.   A sound surgical  mind will be ex-
ceedingly cautious in asserting impossibilities.  The  experi-
ence  of the last fifteen years goes to add significance to this
observation.  The methods  of cure may be arranged under
two heads—Position and Suture.
   Lacerations about the perineum did not escape the notice
of Celsus, but he  had no remedy except securing the limbs
together and enjoining perfect rest.
   Ambrose  Pare*  recognizes the  injury,  and  recommends
the use of sutures.   The same  may be said of Mauriceau,
but there is no evidence on hand  to  show either had  ever
employed them.   The first recorded case of operation,  is
that of Guillemeau (Surg., page 354, chap. viii.).  The rent
occurred in a former labor, and  was of an aggravated kind,
extending through the whole length of the perineum, and
laying both  cavities into one.   This case  must have  in-
spired all future operators.   The edges were pared  alike— 
20        LACERATION OF THE  FEMALE PERINEUM.
not cutting  much  flesh, but principally skin and fascia—a
needle was passed  through the sides of the wound,  and a
thread wrapped  about it,  by which the parts  were drawn
together.  This formed the twisted or hare-lip suture.  He
next inserted several interrupted sutures, and in fifteen days
the case was cured.  As  Guillemeau was a  pupil of Fare's,
it  is probable he received  from his master the hints, which,
in this case, were  reduced to practice.  The valuable work
of Busch and  Moser contains an excellent article on  the
plans of various authors.
  Among those who advocate position alone are to be found
many distinguished names.  (Thymoeus Collect, de Peonet,
tome iii., page 96.  Peu, Pratiq.  des Accouchemens, page
422.)
  These  parties assert that complete  ruptures, by which  is
meant lacerations  extending to the anus, heal without  any
treatment.   De la  Motte,  however, does not seem to  repose
implicit faith in their assertions, as he mentions one of their
cases which  did not heal.
  Deleurye (Traite des Accouchemens, page 320) agrees with
the above authors, in some degree, saying large ruptures can
be cured  without any suture: and to the same import  is the
language  of Puzos  (Traite des Accouchemens, page 134).
u These wounds," says our author, " can be cured  as well by
approximating the thighs as by sutures."
  Aitken (Principles of Midwifery, 1788) rejects  sutures al-
together.
  D'Outrepont  says extensive lacerations  heal   spontane-
ously by position ; and such  is the opinion of Busch  and
Moser.  Besides these may be mentioned  Paletta, Exercita-
tiones  Pathologicae, pars,  ii., Mediolani,  1826.   Gardieu
Traite complet d'Accouchemens, tom. iii.  (Sedillot, Recueil
periodique de la Societe Medicale de Paris, tom. iv.).   Boyer
and  M. Duparcque (the latter  the  author  of the  paper pub-
lished in Paris in 1836, entitled Histoire complete des Rup-
tures et des  Dechirures del'Uterus, du Vagin, et du Perinee).
To these  may be  added  the name  of Dr. Waller, who  de-
clares having seen ruptures traversing the entire  perineum, 
             HISTORY  OF LACERATED PERINEUM.           21

and laying both cavities into one, get well, and the control
over the intestinal  contents  return;  no treatment having
been adopted  but  position and cleanliness.   And  not  only
so, but goes further and states, " most cases which have come
under my observation have done well."  It would have been
more  satisfactory had he  defined his understanding of the
term udone well."  An injury to the extent  just stated can
never do well.
  Blundell thinks there is little to be hoped from operations,
failure being the rule; and the same testimony is furnished
by Dr. Davis.   Ramsbotham  describes the injury,  but as he
indicates  no  treatment, it is  not  probable he viewed the su-
ture with favor.
  Dr.  Cockle,  in a paper  published on Laceration of the
Perineum, in  1853, as quoted by I. Baker  Brown, advises
against sutures, especially in the early stages.
  The Suture.—The advocates for suture are both numerous
and  respectable, among whom we  may name Moreau  and
Smellie, neither of whom, Busch says, ever performed  it, al-
though it received their sanction.  De la Motte (Traitd com-
plet de Accouchemens, page 761, Obs.  401).  Also Morlanne
(Journal des Accouchemens, tom. i. p. 188). Saucerotte (Jour-
nal general, tom. iv. p. 417).   Noel  (Idem, tom. vii. p.  187).
Montain (Idem, tom. lxxvi. p. 140).   Mayo (London Medical
and  Physical  Journal, September, 1828).  Bond (The  Lon-
don  Medical Repository, etc., by G. M. Burrows,  No. 128,
August, 1824).  Churchill (Idem, No. 126,  June).  Alcock
(The London Medical and Physical Journal, vol. xliv., Sep-
tember, 1820).  Rayer (Edinburgh  Medical and  Physical
Journal, No. lxxvii., October, 1823).  Campbell (Idem).  Zang
(Darstellung  blutiger heilkunstlicher  Operationen, iii. Th.
1, Abth.).  To this list we may add, Osiander, Williams, v.
Fabrice, Ritgen, Meissner, Langenbeck, Royer, Hafer, Mer-
cogliano.  D'Outrepont, Dupuytren, Rauley,  Roux,  and  Dief-
fenbach, all of whom record  cases with good results by the
suture.  Roux asserts there never was a case of satisfactory
cure if left to nature (Gazette Med., 1834, p. 18).  His method
consisted  in approximating with quilled  sutures,  aided by 
 22         LACERATION OF THE FEMALE PERINEUM.

 interrupted ones at a few intermediate points, and the  use
 of semilunar incisions where there was much strain on  the
 sutures.  Duparcque says no union, in a proper sense,  can
 occur unaided.
  Chelius may be named as an advocate for the suture; also
 Menzel, Wutzer, M. Verhaeghe, and Kilian.  Velpeau recom-
 mends the suture and Dieffenbach's incisions.  Chelius (vol.
 ii. p. 38), while  he  favors an operation,  thinks the  conse-
 quences are very uncertain, and on  page 39 of the  same
 volume, the editor, Mr. South, records a successful case by
 Dr. Davidson taken  from the pages of the Lancet, 1838-9,
 vol. ii.  The suture  used was the  quilled, and to counteract
 the tendency to eversion, the gum cylinders were drawn to-
 ward each other by a piece  of tape.  Roux, in order to cor-
 rect  this effect of the quilled suture, inserted  a few inter-
 rupted ones.
  Burns (Principles of Midwifery,  vol. i. p. 58, edition 1820)
 recommends  sutures strongly,  when reunion  cannot  be
 effected by other means; although the  American  editor,
 Prof. James, in a footnote on same page, says they (sutures)
 should rarely be had recourse to, as they give great  irrita-
 tion.  I. Baker  Brown incorrectly states  Burns makes  no
 mention of the accident.
  Dieffenbach, in 1829, turned his thoughts to rupture of the
 perineum, and after a thorough  contemplation of the  entire
 ground, concluded these accidents ought  not to be left to
 nature.  The substance of his conclusions may be summed
 up briefly  as follows:  Immediate operations;  the  use of
 either the twisted or interrupted sutures; in secondary ope-
 rations, the edges being previously well  pared; semilunar
 incisions on  either  side,  when  the approximation  makes
much strain on the sutures ; transplantation in cases attended
 with great loss of substance; opium in sufficient amount to
keep the bowels  bound for several  days, and the removal of
the urine by the catheter as occasion may requiue.
  Nevermann (in a  German  translation of  Duparcque),
having  noticed that stonemasons, receiving lime into  the
eye,  in twenty-four hours had the lids and  ball adherent, 
HISTORY OF LACERATED PERINEUM.           23
suggested that the margins of a  laceration  should be sub-
jected to a similar treatment by applying  quicklime, and
then securing the limbs together.
  Langenbeck, with his usual ingenuity, presents us with a
method which is  termed perinaio  synthesis, the description
of which is  given by M. Verhaeghe, of Ostend (in his Me-
moire sur un Nouveau precede Operatoire pour la Guerison
des Ruptures Completes du Perinee, Bruxelles, 1852).  This
monograph I have  not been able to  peruse, but glean the
leading features of the plan from I. Baker Brown's excellent
treatise on rupture of the perineum.   The first  step consists
in freshening the free border of  the  recto-vaginal septum ;
next, splitting the septum, the  anterior layer of which  is
designed, after the laceration is united, to be brought down,
and stitched by its  angles, to the front part of the newly
joined perineum, thus protecting the parts against the vagi-
nal discharges.  After this, the edges of the laceration are
pared, extending forward to the posterior commissure of the
vulva, avoiding the mucous membrane of the vagina.  Then
comes the approximation.   After the  cessation  of bleeding,
the rectum is first closed by a suture, inserted with Wutzer's
curved needles;  then the  perineum  by  interrupted and
twisted sutures, and  lastly, the attachment  of  the anterior
part of the septum.   To relieve tension, he  employs the in-
cisions of Dieffenbach, directs vaginal injections of an infu-
sion  of chamomile,  catheterism, low diet, and  opium in suf-
ficient quantities  to  maintain constipation until after the
removal of the sutures.
  Bernard and Huette (Operative Surgery, page 454) are
very  brief, recommending position, if the case  is recent;  if
old, vivifying the  edges, uniting by  the quilled suture,  as
practised by Roux, and making the Dieffenbach incisions if
demanded.   They state the threads  should be allowed to re-
main until complete  cicatrization takes place, union by the
first intention not being expected.
  Guerin  (Chirurgie  Operatoire,  page  578)  approves   of
Roux's operation with Dieffenbach's incisions.
  Se'dillot (vol. ii.  p. 441) reiterates the same views. 
24        LACERATION  OF  THE FEMALE  PERINEUM.

  Vidal  (Pathologie Externe, tome v.  p. 755) speaks favor-
ably of Roux and Dieft'enbach's methods; and so also Du-
gere (Des Dechirures du Perinei, 1856).
  C. Clay, speaking of  the accident, in  1856, advises  quilled
sutures, catheter for twelve or fourteen days, rest and  cleanli-
ness.  The sutures, he  says, should  be  removed the seventh
day.
  Miller (Princip. Surg.) treats the  subject with great brev-
ity, but is not adverse to operations.
  Skey, in his Operative Surgery, (1858) makes no very en-
couraging allusion to the subject, but recommends the oper-
ation of Brown.
  Holmes's Surgery, vol. iv., has an article on ruptured per-
ineum, written by Mr.  Hutchinson.  He recommends an im-
mediate operation  and position ; observing, that even should
the lochial discharge and  bruised condition defeat the heal-
ing, occasionally, nothing will be lost by the attempt.  Where
the sphincter ani is torn, he  thinks relief from incontinence
may be promised,  but  not so surely that  from prolapsus of
the uterus.   A great  deal,  he says, depends on extensive
denudation, so as  to have a deep mass  to support  the pelvic
viscera.  The sutures  recommended are  either the quilled,
or what he likes  better, a perforated metal bar, with wires
passed  through, on the ends of which are clamped shot, and
secured by being twisted round cylinders of wood.  He also
advises dissecting  up from the septum a  flap consisting of
mucous membrane, after Langenbeck  or  Fricke,  and bring-
ing it down to be attached to the  restored perineum.  The
sutures he removes the sixth  or seventh day.
  M. Jobert  (De  la  Reunion en Chirurgie, 1864) advocates
the use of what he terms the serpentine suture, to  be formed
out of silk thread,  and inserted  by curved needles.  The
description is not clear.
  There  is,  however,  one  name  among  British surgeons
prominently  associated w7ith this  subject;  it is  that of I.
Baker  Brown.  His experience in  the  treatment of injuries
of the  perineum has unquestionably been greater than that
of any other  surgeon.  From 1853 to  the present time his 
TIME FOR OPERATION.
25
cases have been accumulating, until  they number, as pub-
lished  in the last edition of his book, 1866, 112 cases, 104 of
which were  cures.  So completely has  the operation  been
vindicated, that  no treatise on surgery,  recently published,
fails to devote a chapter to lacerated perineum.
   The leading features of Baker Brown's  operation are ex-
tensive denudation; quilled sutures,  with interrupted ones ;
division of the sphincter ani on each side, and keeping the
bowels quiet with opium.
   Among American writers, it may be said very  little atten-
tion has been  given to the  subject.   No allusion is made to
the injury either in the works of Dorsey or Gibson.  Prof.
IT. II.  Smith (Smith's Surg., vol. ii. page 555) describes the
accident  and  its treatment, adopting the plan of Baker
Brown.
   Dr.  Mettauer, of Virginia,  published  a  remarkable case
(American Journal of Med. Sciences, vol. xiii. p. 113, 1833),
in which  the  rent extended  three  inches up the rectum.
The edges were properly  vivified,  and  closed by leaden
sutures.
   Prof. W. E. Horner (Am. Journal  Med. Sciences, vol. xx.
p. 329, 1850) furnished the history of a severe  case of lacer-
ation,  attended with  such  loss of tissue as to induce him to
undertake the  relief of the patient by raising two flaps from
the  contiguous  parts,  and, turning  them on their  bases,
united them across the chasm.  This case, as related by Dr.
Smith, although not cured  entirely of incontinence, was
much  benefited.
   Prof. Gross (Gross's Surgery, vol. ii. p.  1051) treats of the
subject, agreeing in the main with the plan of Baker Brown,
except in the particular of dividing the sphincter, which, he
says, he has never found necessary to  do.

                   Time for Operation.
   The operation is divided into primary and secondary.  By
the term primary is meant the employment of the suture at
a period when  the surfaces are raw  from laceration, by the
term secondary, at any period when the knife  is required
       3 
26         LACERATION OF THE FEMALE PERINEUM.

to freshen the margins of the laceration.  If the case  is one
demanding sutures, the sooner they are inserted the better.
If called at a period when, in consequence of the extreme
distension, the parts are cedematous, contused, and threaten-
ing gangrene, it is thought best by many to avoid the suture.
If, however, the  metallic thread is  used, I do  not see  any
objection to its application, even under such  unfavorable
local conditions.  Should only a few points of  adhesion be
secured, it  is a positive gain, the rest ma}' granulate.   Those
who object to primary or  immediate operations allege,y?rs£,
there is danger of vaginitis or metritis;  second,, the lochial
discharges  diffusing  themselves  over the parts prevent heal-
ing ; and third, cases  make a  good recovery when a  proper
position is maintained and the process left to nature.
  With regard to the first the dangers apprehended are for
the most part imaginary.  If the metallic thread be used,
there is really less irritation and  suffering than if left  un-
touched, because the exposed  raw  surface is almost com-
pletely closed.   And for the same reason the second objection
is answered, inasmuch as an accurate adjustment precludes
in a good degree any prejudicial effects  from the lochial
flow.   The last objection rests on a peradventure, and puts
the exception before the rule.  Nature,  unaided, in the large
majority of cases, makes but a sorry restoration of the peri-
neum.   The  retraction which the muscles undergo  before
and  during the slow progress of granulation  and cicatriza-
tion, diminishes  very much the proper execution of their
functions;  and hence the value  of immediately introducing
the suture.
  When the primary period has passed, and  the secondary
operation becomes necessary, the question arises, when  should
it be done?  In general we say, whenever the patient's gene-
ral health is well established and the parts thoroughly healed,
sound and free from all inflammatory and suppurative action.
It is imperative that such should be  the case, otherwise  the
tissues  will not sustain the pressure of the suture.  This  will
demand ordinarily two or three months, but if it even should
require a year  or more, it must not be disregarded. 
PREPARATION OF THE PATIENT.
27
  Is it  impossible to undertake an operation during gesta-
tion?  Such, until recently, has  been the opinion of most
surgeons.   They have supposed that, during this period, the
attractive forces concentrated  upon the uterus and its asso-
ciate  organs would defeat  the healing process in the peri-
neum.  This view is not sustained by facts.  The cure may,
therefore, be undertaken during the early months of preg-
nancy;  that is to say, antecedent to the fourth month. Such
is the opinion and counsel of Baker Brown, who says, in no
instance in which he has operated, have  there arisen  any
symptoms threatening miscarriage.
  Beyond this period there are two reasons rendering it  im-
proper  to undertake  an operation.  First, the reflex influ-
ence, inviting uterine contractions and endangering the safety
of the embryo; and second, the time is too short to secure to
the perineal components the requisite  physical and vital  pro-
perties  of elasticity and contractility, so as to run  no risk of
a second laceration.
  The  menstrua] flow constitutes another contraindicating
circumstance.   The third or fourth day after its cessation is
the  favorable  period.  The presence  of a  catarrhal attack,
accompanied with cough or  sneezing, is  of sufficient  im-
portance to defer any operative measures, as the antagonism
which exists between the diaphragm and perineum would be
the  means of greatly disturbing the  dressings.  There are
some, among whom may be named Roux, who oppose opera-
tion while the mother is nursing.  The same counsel is given
in cases of vesico-vaginal fistula, under a belief that there is
great danger of subsequent pyaemia.    I haye not regarded
this caution in cases which have come under my own care,
and in no instance have I seen any unpleasant results.

              Preparation of the Patient.
  Whenever the surgeon assumes the management of such a
case, the condition of the different organs should be carefully
inquired into.  He will often find such patients suffering from
diarrhcea, disturbance of the digestive  organs^ and a train of
distressing nervous symptoms.  To correct these, a propeiTy 
28         LACERATION OF THE  FEMALE PERINEUM.

regulated diet, fresh air, the subnitrate of bismuth, together
with tonics, either vegetable or mineral, are necessary.
  The medical attendant should discountenance the habit of
taking laudanum, opium, or other narcotics, in order to keep
the bowels costive.   A patient cannot continue to do so long
with impunity.   The digestion will be, sooner or later, im-
paired.   It is much better to secure consistent stools by a
careful study of  the food.   An animal diet, with stale bread,
boiled milk, and a very moderate allowance (if any) of vege-
tables, will  usually effect this  result.   Thirty-six  hours
before the operation  the  bowels should be  emptied  by a
gentle cathartic, such  as  castor oil, after which a sufficient
amount of opium should  be administered to render them
quiet.  The hair is to be removed from the parts, and a very
moderate amount of food  taken the morning  of the day ap-
pointed for the  operation, so as in no way to interfere with
the anaesthetic.
  The bed on which the patient is to lie should be a firm
mattress, protected by a piece of oil-cloth, over which may be
spread a  folded sheet.

                       Operation.
  Assistants.—To have every appointment consummated in
the  most satisfactory manner, there should be not less than
four assistants, although three will answer ; one to take charge
of the anaesthetic, one to support either lower extremity, and
one to attend to  the  sponges and  instruments  which may be
required by the surgeon.
  Position.—Three positions have been advised.
  First.  On the side, with the nates brought over the edo-e of
the bed and  the thighs strongly flexed on the body.   This
is the position recommended by Busch and Moser, and they
claim for it complete relaxation of the perineal tissues and
less risk  of cold, as  there is very little of the person unpro-
tected by clothing.
  Second.  The  kneeling posture, the body well bent forward.
  Third.  The dorsal position, the patient resting on the back
the hips  projecting over the side of the bed; the legs flexed 
operation.
29
on the thighs, and the  thighs  on the abdomen : this is  the
lithotomy position.
  The one preferred by most operators, and which is unques-
tionably superior to all others, is the third.  It offers in every
respect the best control of
the parts.                  Fig. 3.   Fig. 4.        Fig.  5.
 Instruments.  The instru-
ments required are few
and simple.  An ordinary
scalpel (Fig. 3); a pair of
my long-bladed forceps,
with  an adjuster  at one
extremity (Fig.  4); three
or four good-sized  needles
to insert the more super-
ficial  or secondary inter-
rupted sutures ; a needle
supported  on  a  handle
(Fig.  5, Fig. 7), to intro-
duce  the deep or primary
sutures; iron wire, coat-
ed with silver, perforated
shot,  shot compressor and
scissors (Fig. 6);  tenacu-
lum,  silk ligatures, and
sponges.  Such  comprise
the list of instruments re-
quired  for the execution
of the operation.  Should
the   method  of   Baker
Brown be preferred, there
will be wanted a blunt or
probe-pointed bistoury to
divide the sphincter, and
pieces of  cane or  elastic bougie, together with waxed twine,
to form the  quilled suture.
  Lamediate or Priia</ry Operation.—If the accident is discov-
ered immediately  after its occurrence, it  should be promptly
436313 
30         laceration of  the female perineum.
treated with  the  suture within twelve hours.   Simple ap-
proximation  by position  is  not  reliable.  The  number of
  Fig. 7 —1. Needle for introducing the deep sutures.  This I have had modified,
making it a more useful instrument.  It consists of two parts, the holder and the
needle.  2 and 3 give two views of the needle.  The lower extremity is square, with
a notch, designed to fit into the shank 4, either at its extremity, so as to be in a line
with the handle, or at a right angle, and secured by a spring which sinks into the
notch.
sutures will  be determined  by the  extent of the laceration.
The advantages  of such a course will be apparent, when  it
is considered the perineal tissues are flaccid in consequence
of the extreme extension to which they have been subjected, 
OPERATION.
31
 and,  therefore,  there  will be  little  strain on  the  threads.
 Again there is an innate tendency in the parts to heal when
 thus  immediately adjusted.  The mode of using the suture
 will be explained under the head of the secondary operation.
 The  parts must be kept  perfectly clean,  being frequently
 bathed with a solution of the permanganate of potash, and
 all the subsequent treatment carried  out in the manner de-
 scribed hereafter.
   Secondary Operation—The Method of I. Baker Brown.—The
 woman being placed in the lithotomy position, and the parts
 carefully shaven, an assistant gives the  requisite tension to
 the sides of the laceration, while the surgeon pares away the
 parts half an inch external to their  edges, and sufficiently
 deep  to reflect inwards the mucous membrane.  The recto-
 vaginal septum must  also be carefully freshened.  The next
 step consists in dividing the sphincter ani on both sides about
 a  quarter of an  inch  in front of its  coccygeal attachment.
 This  is done by a blunt-pointed  bistoury, conducted by the
 finger within  the margin of the anus, and  then pressed
 through  the tissues to  the extent Of one or two inches ex-
 ternal to the anal opening, and through the more superficial
 fasciculi  of the muscle, leaving the  deeper portion undis-
 turbed.   Dr. Van Buren paralyzes the sphincter by extreme
 extension.  The third stage comprises the insertion of the
 sutures.   For this purpose a strong  needle, armed  with  a
 double thread, is passed  through one side, entering one inch
 external to the edge and coming out at  the termination of
 the denuded surface, after  which it is  made to traverse the
 opposite side, entering and emerging at  points  correspond-
 ing to the first.   Each suture is to be inserted  in the same
 manner, the one nearest the anus always first.   The needles
 used for this purpose, I presume, are such as are figured in
 Dr. Brown's  book, and a representation of one of which is
 seen in Fig. 5.
  The threads thus passed present loops on one  side and  free
ends on the other.  Two pieces of cane, or elastic bougie, are
next placed in position, one piece passed  through the loops,
and the other laid between the free ends, and  both  parallel 
32         LACERATION OF THE FEMALE PERINEUM.

with the wound.  The approximation is effected by  pressing
the sides of the laceration together and tying the free ends
securely around the cylinder which lies betweeu them.
Introduced from I. Baker Brown's book, with a view to exhibit the pared edges, the
       quilled sutures in position, and sphincter divided on each side.
  To prevent eversion of the edges, a result of the quilled
suture, interrupted metallic sutures are inserted between the
others.  Langenbeck and Verhaeghe employ for this purpose
the twisted or hare-lip suture.   Before closing the operation
one finger should be carried into the vagina and another into
the rectum, in order to ascertain the accuracy of the adjust-
ment.  The parts are next cleansed ; a piece of lint, wet with
cold water, laid over the  parts ; upon this a folded  napkin ;
the whole secured by a T bandage. The urine is to be drawn
every four or six  hours  for four or five days, or an elastic
catheter maybe placed in the bladder and allowed to remain
for twelve or fourteen hours, the free end being placed in a 
OPERATION.
33
liquid-proof bag to receive the urine.   One grain of opium
is immediately given, and repeated every six hours for the
first twenty-four ;  afterwards one grain night and morning.
Fig. 9 exhibits the parts closed.

                          Fig. 9.
  The diet is to consist of milk, arrow-root, beef-tea, mutton
chops, and, if required, port wine.
  Forty-two hours after the operation the deep sutures should
be removed, and the superficial ones  about  the  seventh day.
  The opium  is to  be continued, so as to keep the bowels
constipated for two or three weeks after the parts have united,
after which they may be  moved with castor oil  and enemata
of warm water.
  In  this method of Baker Brown  it will be found, on  re-
viewing  the historical part of  our article, there is nothing
new.  The quilled suture had  been  used over thirty years
ago by Roux, Davidson, and others.  Incisions of the skin
and subcutaneous tissues had  been inaugurated by Diefleu- 
34        LACERATION of the female perineum.
bach; of the sphincter muscle by Saucerotte; and the use of
opium to constipate the bowels had been  taught by Dieffen-
bach and others. The particular point and direction  at which
the sphincter is divided belongs, however, to Baker Brown;
and  not  only  so, but by combining all  these peculiarities
into a method, and illustrating their value by a  record of
cases greater than any other man, he  has  clone a great work
for surgery, and gained a strong hold over the mind of the
American profession.

  Author's Operation.—In every operation our aim should be
to render it as simple as  may be consistent with efficiency ;
and, therefore, the question comes up, can any part of the
Brown method be omitted without diminishing the value of
the operation?  In support of  the affirmative, I submit the
plan pursued by myself, and illustrated by a sufficient number
of cases to give it some claim to public confidence.
  Preparatory Treatment.—This is pursued in accordance with
that already laid down, except in the matter of opening the
bowels with a gentle cathartic, which I  prefer being  given
very early the day before the operation, and followed by one
or two grains of opium, so that no faeces  shall  descend into
the rectum, and everything be quiet when the period comes
round.
  Position.—The position on the back, or the lithotomy posi-
tion, is the one always preferred.  The hips should be brought
over the edge of the bed, and the  limbs, flexed, should be
supported by an assistant on either side.
  Operation.—The operator takes his  position, either sitting
or kneeling, in  front of the perineum, and  seizing  one side
of the laceration,  commences  the denudation  from behind
forward,  including a little of the labium.  In  breadth  it
should extend  inward, so as to  include a little of the vaginal
mucous membrane, and outward towards the buttock.   The
paring should  not  extend deep, but merely skim the surface,
and, when completed, should  be over one inch broad.   The
opposite  side is to be treated in the  same  manner, the  raw
surfaces in form and extent being as near alike as  possible ; 
OPERATION.
35
next, let the assistants supporting the limbs take hold of the
parts on either side, and make the recto-vaginal septum tense,
in which  condition  its  surface  can be freshened, without
difficulty, to the extent  of three-quarters of an inch, or the
operator may  insert  his finger into the rectum and make it
sufficiently tense, using  the scissors  to freshen.   Let every
attention  be given to ascertain no portion escapes the knife.
The bleeding is  usually free, but it will be seldom  necessary
to apply a ligature.  Should it not cease under the application
of ice-water, a stream from the nozzle  of a  syringe, applied
steadily for some time,  will  rarely fail.  Should both fail,
introduce the  sutures, and rely on the adjustment.
   Sutures and, their Introduction.—The approximation  is to be
effected by the  interrupted  suture—one series  termed the
deep, and  the  other  the  superficial—the materials composing
the  thread being iron wire, coated with silver.  As every-
thing depends upon  the proper disposition of the first thread,
I prefer iron wire, in order that it may not break.   The deep
ones are to be  first introduced, commencing with the posterior
or one next to the rectum.  Three or four of these will gene-
rally suffice, even in extensive cases.  The  superficial ones
are to be inserted intermediate to the others.
   The first stitch.—The needle is threaded with the iron wire
and entered three-quarters of an inch from the margin of the
wound, below its lowest point at the  anterior part of the
ischio-rectal fossa, and carried forwards and upwards  until it
appears on the middle of the septum, just above the line of
denudation; the thread is then pulled out of the eye of the
needle,  the latter withdrawn, and  made  to pass  unarmed
through the corresponding parts on the opposite side, emerg-
ing on the septum, close  to the first.  The wire is now passed
through its eye, and as  the needle is withdrawn, makes the
complete circuit of the wound (see Fig. 10), so that when it
is tightened,  the parts  are pursed  together.   Three other
deep equidistant sutures are inserted, and  then comes the
approximation.
  Adjustment.—The  blood being carefully sponged away, the
nates are  to be pressed toward each other  by the  assistants, 
36        LACERATION OF THE FEMALE PERINEUM.
and the ends of the suture first introduced (the one nearest
to the anus) are to be passed through the hole in the adjuster,
at the end  of the forceps, and being strongly drawn upon as
the \itter is carried down,  the  parts are brought together
                          Fia\ 10.
  Represents the parts freshened and the sutures inserted, ready for the approxima-
tion.  The point of entrance and exit of the first suture should have been shown J inch
lower down.
with  great accuracy.  To maintain and secure the approxi-
mation, a perforated shot is next  run down over the wires,
and firmly clamped  between  the  jaws  of  the  compressor.
After the treatment of the other  sutures in a similar man-
ner, the operator proceeds to  deposit the superficial threads.
These must be  placed between the others, to effect which a
good-sized  curved  needle, armed with  a silver  wire, is en-
tered  three-eighths  of an  inch from the edge, on one side,
made to penetrate the skin and some little into the cellular
tissue, and emerge an equal distance from the edge  on the
opposite  side.   These may be  secured by twisting the ends
about each other.  This done, the sutures are to be cut off— 
OPERATION.
37
the superficial ones at the twist, and the deep ones on a level
with the  shot.  I have  performed  the operation omitting
the superficial sutures, and with entire success.
  The appearance presented by the parts when thus adjusted,
is well seen in Fig. 11.

                          Fig. 11.
  A strip of adhesive plaster, two and a half inches wide and
twelve or fourteen inches long, may now be placed across the
nates, to give additional support, and the woman- put to bed,
with the knees bound together with a roller, taking care to
interpose a  napkin between, to prevent excoriation.   The
position  to  be  maintained is either on the back or the side,
the patient not being rigidly confined to either.
  After-treatment.—As a matter of primary importance the
bowels are  to be kept quiet, and to this end,  opium must
be administered in sufficient quantities to effect the  object.
Half a grain three or four times a day will usually answer.
The urine must also be drawn morning and evening or oftener 
38        LACERATION OF THE FEMALE PERINEUM.
if the state of the bladder demands it.  Should the nurse not
be able to use the instrument—and the patient be at such a
distance as to render it inconvenient for the surgeon to make
frequent visits, then, a relf-retaining catheter with a piece of
gum tubing attached  may be worn, and the  end passed  into
a vessel.   After four or five days the patient may turn care-
fully over upon her breast and pass the urine into a bedpan,
dispensing altogether with the use of the catheter.
  Generally I have  found it most  convenient to  use a male
gum catheter guided b}- the finger to the  urethra, as the in-
strument has  to be passed the patient being on the side.
  Should  the patient be annoyed  by painful accumulations
of flatus  in the  rectum, it may be  removed by carefully in-
troducing a female catheter into the bowel.
  Diet.—This should consist of milk, beef essence, soft-boiled
eggs, meat once a day, tea, coffee, and wine.
  Removal of Sutures.—On the seventh day after the opera-
tion, all the sutures should be removed,  commencing  with
the anterior one and proceeding back, the  reverse of their
introduction.   In accomplishing this, the wire is cut on one
side of the shot, then the curve or hook at its end  straight-
ened,  to  prevent scratching, and  finally, the  loop drawn
away by pulling on the shot while pressure is  being made
against the thread so as not to allow its  cutting into the flesh.
Should the suture next the rectum be found well  in place and
no cutting or ulceration,  it may  be  permitted to remain
another day.
  Baker Brown recommends the removal of the deep sutures
forty-two  hours after their insertion, and the superficial
sutures not to be disturbed for four days longer.
  On the  second or third day the hips  of  the patient—lying
on the side—are  to  be brought over the edge of  the bed—a
piece of oil- or rubber-cloth  being interposed—so as to reach
into some vessel, and then a stream of tepid water, contain-
ing a solution of the permanganate of potash, thrown  upon
the parts with a syringe.   The effect of this is  always  very
grateful to the patient, and exercises a good influence  over
the healing process.  This is to be  repeated every day.   On 
OPERATION.
39
the eighth or tenth clay the bowels may by opened.  This is
to be accomplished with the greatest care.   A teaspoonful of
oil, or some saline should be give every five or six hours, and
when the feelings of the patient indicate the near approach
of a stool, the utmost caution  is to be observed in securing
its evacuation.   The nurse should be directed to support the
nates, the patient to avoid any great straining affbrts, and if
necessary the contents of  the  rectum may be  softened by
throwing into  the bowel  very gently  a little tepid water.
It may happen  that the  rectum becomes impacted with  a
large fecal  mass,  the expulsion of  which  would certainly
tear asunder the tender line of  union; and then it is proper
to core the mass, by picking  a channel through its centre
and enlarging this opening until its peripheral Avails fall to-
gether, allowing its safe expulsion.   Once opened, the bowels
should  be locked  up again four or five  days, in  order that
the  cicatrix may  become solid.  And it may be well for a
few times  to observe the caution of  having the evacuations
in  the  recumbent position.  If  everything has  progressed
favorably, the patient may be allowed to sit  up after the four-
teenth or sixteenth day.
   In cases where the recto-vaginal septum is torn to any con-
siderable extent it  is thought by some to be  necessary to
modify the operation. The borders of the chasm must be well
freshened, and  brought together by silver threads, passed
transversely by  means of short, slightly curved  needles, and
their ends cut off close. This completed, the resoration of the
perineum may be  next executed.   In the first  case of this
nature which came under my care, two operations were done
at an  interval  of four weeks,  the  first to close the septum
between the two canals and the second to restore the perineum.
By the method  described there  is no necessity for this delay;
both are done at a single operation.

 Report of Cases  treated by the Interrupted Silver Suture alone,
          and without division of the Sphincter Ani.

   Case  I.—Mrs.----, ret.  22, from Kentucky, during her
first labor had  the perineum  torn,  not only dividing the 
40        LACERATION OF THE FEMALE PERINEUM.

sphincter  ani, but extending up  the vagino-rectal  septum
over half an inch.   Her parturition  was difficult and pro-
longed, extending over thirty-six hours, and requiring instru-
mental delivery.  Two operations had been performed for her
relief without success before her arrival.  She was a lady of
delicate organization, with not much muscular tone, and her
health not well established when arriving in the city.   Her
disability was of such a character as to render her incapable
of exercising control  over either flatus or faeces.  At the re-
quest of Dr. Wilson,  under whose  care she had  been placed
for professional aid, I was asked to examine the case, with a
view to determine what could be done for her relief.  It was
concluded that a short time should  be employed in improv-
ing, as far as possible, the health of the patient by appropriate
diet and mineral tonics, after which, an operation should  be
..done to close up the vagino-rectal septum, and afterwards, a
second, to reconstruct the perineum.   After the  lapse of two
weeks, it was deemed proper to proceed with the operation.
The day previous the bowels were  opened, after which  an
opiate was administered.  The patient, being etherized, was
placed on her back, the hips being brought to the edge of the
bed, and the limbs, flexed, given to assistants, one on either
side. A Sims speculum was next introduced into the vagina,
drawn towards its anterior wall, and  intrusted to one of the
assistants supporting the limbs.   The edges of the vagino-
rectal  septum were  now seized with a  pair of long, rat-
toothed forceps, and freshened, each in its entire length,
making the raw surface as extensive  as possible.  The hemor-
rhage  was trifling.   Five silver threads were next  inserted
transversely, introducing the upper one  first,  and twisting
together the ends of each suture, to prevent  the  different
threads from  becoming  entangled.   Next followed the ad-
justment, by  passing successively the  ends of each  wire
through the adjuster at the extremity of the  forceps, and
drawing on  them  as the latter was pressed  down on the
wound.  The set thus given to the wire sufficed temporarily
to  retain the edges  in close proximity, and then, to secure
permanently the approximation, a perforated shot was run 
REPORT OF CASES.
41
down over each thread and clamped by  being  compressed
between the blades of the compressor.  The wires were next
cut off close to the shot, and the patient placed in bed upon
her back.  The urine  was removed, morning and evening,
from the bladder, and the bowels kept quiet by the exhibition
of half a grain of opium, twice daily; the diet to consist of
cream toast, eggs, tea, with arrow-root, and animal food once
a day.  On the eighth  day following the operation the parts
were  examined, and the  stitches removed, when  union was
found to be complete.  The patient was replaced  in bed, and,
after three  days, the bowels opened, by  administering one
teaspoonful  of ol. ricini every six hours.
   The next  step was to restore the perineum.  Four weeks
were allowed to elapse, that the patient might recover from
the confinement and effects of the first operation, after which
the same preparatory measures were adopted  as at the first.
She was again etherized and placed in the  usual  position on
the back, with the limbs flexed on the body, and controlled
by assistants.  The vaginal  surface of the vagino-rectal sep-
tum was freshened for a little distance  up, after which the
knife was made to transfix the tissues on one  side  of the
perineal rent, paring away a broad surface from below  up-
ward.  The  opposite side was  subjected to a similar treat-
ment, and as soon as the bleeding ceased,  four long,  curved
needles, each bearing a silver thread, were deposited across
the wound, the  lower one  first, and each  made to enter and
come out one inch from its margins, so as  to include  a large
amount of tissue.   These were secured as  in the first opera-
tion, and the subsequent treatment conducted in the same
manner.  The sutures  were removed on the seventh day, the
union being complete.

   Case II.—Mrs.----, aged 23, from Pennsylvania,  fell in
labor with  her  first child.  Last  stage protracted, demand-
ing the  use of the  forceps.  The perineum  gave way,  the
rent passing through the perineal centre, and severing  the
two segments of the sphincter ani  and  constrictor vaginae
muscles.   The  accident  entailed  incontinence of the faeces,
       4 
42        LACERATION OF THE FEMALE PERINEUM.

rendering her exceedingly miserable.  Eight weeks after, I
was invited by Dr. E. Wilson to visit this lady and see what
could be done in  her case.  An examination satisfied us as
to the curability of the distressing accident.  The following
week the operation  was  performed.  The  patient,  being
brought  under the influence of ether, was placed on  her
back before  a good  light, at the side of the  bed, the hips
resting on its edge,  and the limbs flexed on  the body and
sustained, each, by assistant.   The  sides of the  laceration
were next pared  by  transfixing with a  sharp-pointed  bis-
toury at their posterior  extremities, and  cutting  forward,
including to some extent the base of each labium ; the de-
nuded surface being  over one inch in breadth.   The sides of
the recto-vaginal  septum were  now  carefully  freshened for
a little  distance.   The bleeding having  ceased, two  silver
sutures were first  placed  across the vagino-rectal chasm, and
its sides brought together and  secured by pellets of shot;
this  restored the septum.  To effect  the approximation and
union of the sides of the perineum, four  stout  needles, two
and  a  half  inches long, and moderately  curved,  threaded
with silver wire, were carried  first  through one  side from
without in, and then  through the other from within out;  the
one next the anus first, and all deeply inserted, entering and
coming  out  one  inch beyond  the  denued surfaces.   The
parts were now readily  brought in  contact by sliding  the
adjuster  down over  the  wires while they were drawn upon,
and  then securing  the   retention   by the shot-clamp,  as
previously described, cutting  each  suture off close  to  the
leaden  pellets.  The  patient was then  placed  in bed, an
opiate administered  consisting  of opium one grain, a  nutri-
tious diet of animal  broths directed, the urine removed from
the bladder twice daily by the catheter, and the bowels kept
closed by the  exhibition of half a grain  of opium morning
and  evening.  On the seventh  day following the  operation,
the stitches were  removed, the union being well established.
This lady has never  complained of  any inability to control
perfectly the alvine discharges.  She has likewise given birth
to a child without any lesion of the cicatrix. 
REPORT OF CASES.
43
  Case III.—Mrs. Y., 39  years of age, residing a few miles
from the city, married late in life.  She became pregnant and
fell in labor at full  term.  The structures of the perineum
were rigid and unyielding, and the foetal head was for several
hours engaged at the inferior strait, the delay not being due
to any malposition or disproportion between the head and
pelvis, but from the obstinate  resistance of the soft  parts.
Proper measures had been employed to overcome this source
of difficulty  by her physician, a very intelligent and com-
petent gentleman ; and notwithstanding support was applied
to the perineum, as the head emerged, a slit occurred, passing
from the posterior commissure of the vulva into the anus, and
extending  in depth through the perineal centre, separating
the muscles  concentrating at this point.   The  accident in-
volved incontinence  of the faeces, unless stools were very con-
sistent.  Three months were allowed to elapse in order to give
the parts time  to recover completely from the injury, and
the general health of the  woman to be well established.  At
the expiration of this time I performed the operation for her
cure, assisted by Drs. Read, H.  Corson, and Townsencl.  The
details of  this case differed very little from those already
described.  The  patient was etherized, placed  on her back,
and the hips brought down to the edge of the bed, the limbs
being properly supported. A broad surface, three-fourths of
an inch in width, was pared away  from either  side of the
fissure, and  the  recto-vaginal  septum denuded for half an
inch on the vaginal  surface, by supporting it over the finger,
introduced into  the rectum while the knife was being care-
fully applied. Four silver threads were next deposited across
the wound (observing to  insert the lower one first), adjusted
and clamped with shot, with intermediate ones of less depth,
and the subsequent treatment, as to catheterism, opiates, and
diet,  conducted  on  the  same  plan as  already  indicated in
previous cases.   Seven days after,  the sutures were all re-
moved,  and  the union found  complete.   The patient was
kept in bed for five  days  longer, the bowels being opened by
the exhibition of small doses of castor oil, at intervals of five 
44        LACERATION OF THE FEMALE PERINEUM.

or six hours.  The function of the bowel was completely
restored.

  Case IV.—M.  A.,  an Irish  woman, aged  24 years, was
admitted into the Pennsylvania Hospital by Dr.  Hunt.  Her
first labor, she stated, had been difficult and prolonged, al-
though she had  received no  intimation of there being any-
thing  unusual in  either the presentation or  position.  An
intense pain expelled  the head quite suddenly and unexpect-
ed!}' at last,  the perineum being without support, and pro-
duced  a laceration, which extended through  the sphincters
into the bowel, entailing incontinence of the rectum.  The
mucous membrane of the intestine was considerably pro-
lapsed,  forming  a  reel tumor  at  the outlet of  the  anus.
Three  months after the accident  had  elapsed, her  health
being  good, the operation was performed  by Dr.  Hunt, as-
sisted  by  Drs. Morton and  Agnew, and in the presence of
the resident physicians of the Institution.  The  edges, being
well pared, were  united  by  four silver  threads, deeply in-
serted and  maintained  securely in position by  the shot-
clamp, the intermediate ones being less  deeply placed, and
their ends twisted  together.   The treatment was similar to
that adopted in the cases already detailed.  All the sutures
were removed by the eighth day, and the parts found accu-
rately  closed.  This woman was discharged without  any de-
fect in the function of the bowel.

  Case V.—Mrs.------, aet. 25 years, during her second la-
bor,  which was tedious, though in no way complicated by an
unusual position of the cephalic presentation, had the peri-
neum torn, but not to such a degree as to render her incapa-
ble of faecal control, except when the discharges were lacking
in consistence.   Two  years after she gave  birth to a third
child, in which act the laceration was greatly extended, quite
one  inch  up  the bowel, and  rendering her utterly powerless
to restrain either flatus or alvine discharges.  Imagining her
case hopeless, and  being  exceedingly retiring  and sensitive,
she became greatly depressed, and for six years was obliged 
REPORT OF CASES.                  45
to live secluded from society.  At the suggestion of a medi-
cal relative, she was prevailed upon to allow me to examine
her case, when an  operation was agreed on.  It is unneces-
sary to repeat the  formalities of the etherization, position,
etc.   The parts  being properly exposed  by the Sims specu-
lum, the margins of the recto-vaginal fissure were freshened
on the vaginal side,  and afterward those of  the  perineum.
Six silver threads were passed through the sides of the first,
the upper  one taking precedence, and the closure effected by
the shot-clamp.   Four sutures were next inserted  through
the sides of the perineal rent, and these brought in accurate
contact  by the  adjuster and  shot.  The  catheter was em-
ployed morning  and evening  to relieve the  bladder; the
bowels kept quiet by  McMunn's  elixir  of  opium, and a
nutritious  liquid diet directed, with a glass or two of wine
daily.  The sutures were all taken out by the seventh day,
the parts having united well.  This lady, not long since, was
delivered of a child without any accident to the perineum.

   Case VI.—Mrs.----,aged 24 years, residing some distance
from Philadelphia, fell  in labor with her first child.  There
was nothing unusual in the position of the fcetal head, but
its progress was very slow, and  finally demanded  the use of
the forceps. While  being  adjusted, a violent  pain  came on
 with  great suddenness, expelling head  and instruments to-
 gether,  dividing   the perineum and involving  the  recto-
 vaginal septum.   The  child did  not  survive.  She  asserts
 with great positiveness the wound was inflicted by the blades
of the forceps.
   The consequences entailed were unusually distressing, not
only affecting the function of the bowel, but producing such
 displacement of the  pelvic  viscera as to disqualify her from
 taking exercise on foot, and affecting her general health and
 spirits.  At the  suggestion of Dr. Shultz, whose patient she
afterwards became, I was consulted, and, after examination,
 advised an operation.   This was subsequently performed in
 the usual manner,  and the after-treatment skilfully conducted
 by the  Doctor.  The  only  thing worthy  of  note  was the 
46        LACERATION  OF  THE FEMALE  PERINEUM.
giving way  of  the middle  deep suture,  and which most
likely was due to some defect in the wire.   This part, how-
ever, healed up by granulation, being occasionally stimulated
with the sulphate of copper,  and although the progress was
slow, yet the result  was perfectly satisfactory, both in regard
to the retentive power of the bowel and the capacity to take
exercise.

  Case VII.—Mrs.----, aet.  23 years, in a first labor; head
presentation, delivery by forceps; had the perineum lacerated,
extending into the  bowel.  Dr. Hunt was called to see the
case, by Dr. Reid, and, after  examination, recommended an
operation.  The  retentive function of the bowel was in a
great measure destroyed, and her condition necessarily very
uncomfortable.  On the  day of the  operation I was invited
by Dr. Hunt (by whose consent this case is reported) to aid
him in its performance.   After etherization the parts were
extensively denuded and then brought together by four deep
and three superficial interrupted sutures, the former secured
with the shot-clamp and the latter by the twist.
  The after-treatment was judiciously conducted by Dr. Reid
on the plan described in former cases.   On the seventh day
the sutures Avere removed and union found complete.  Four
days after, the bowels were opened carefully, and at the ex-
piration of eight days  more  the woman was sitting  up.  I
have heard frequently since  fj'om this lady, and am assured
her restoration is perfect.

  Case VIII.—Mrs.----, aet. 24, in a first labor, with a head
presentation,  delivered  of a dead child with the forceps; re-
ceived  an extensive injury of the perineum.  She  does not
think there was  anything peculiar in the position of the pre-
senting part, having heard nothing from  her  physician to
that effect.   The terminating stage of  her labor, she states,
was unusually long and severe, the head  resting several hours
on the distended perineum.   The laceration passed through
the perineal  centre and three-quarters of an  inch up the
recto-vaginal  septum.   Her condition she believed to be irre- 
REPORT OF CASES.
47
mediable.  After the birth of a second child she passed into
the care of  my  friend, Dr. Spooner, a skilful  obstetrician,
and at his suggestion, consented to an operation.  At the
date of its performance her child was four months old  and
nursing at the breast.   She  had no control whatever over the
intestinal  contents, and  her situation was peculiarly  dis-
tressing.
   Aided by  Drs. Spooner, Andrews, and  Sherk, I executed
my usual operation.  The only event worthy of notice during
the progress of the case was  the accumulation of a large mass
of hardened faeces  in the lower bowel, which, on the ninth
day, was expelled with great difficulty, remaining for some
time in the anus, which was excessively distended, and tear-
ing open  the cicatrix for a little distance forward from the
verge of the bowel.  An experienced nurse could have  pre-
vented this occurrence by an early recognition of the trouble
and the employment of injections.  An  examination, how-
ever, revealed the fact  that the separation extended simply
into the fascia, while the deep portion remained uninjured.
The chasm rapidly  granulated up, and the cure proved  suc-
cessful beyond our expectations.

   Case IX.—Mrs.----, aged 30, in a tedious labor, eighteen
years ago, the particulars of which I am  unable to learn, re-
ceived a perineal  rupture, extending to, but not through the
muscular centre.  While the ability to control the intestinal
contents was not lost, yet the support to the pelvic viscera
being  diminished,  it was followed  by displacement of the
uterus and a train of distressing nervous symptoms.   The
employment  of  mechanical  appliances to correct  the mal-
position of the womb was  frustrated from the want of a
proper base of support.   An operation to restore  the peri-
neum was suggested by her physician, Dr. Ellwood  Wilson.
The operation was  shortly  after executed, assisted by Drs.
Wilson,  J. Forsyth Meigs,  and W. Pepper, Jr.   Nothing
unusual  took place in the  subsequent conduct of the case,
and the result proved a complete success.  The effect on  the
general health of the patient justifies us in stating that ex- 
48        laceration of the female  perineum.

ercise on  foot  could  be taken with  comparative  comfort,
although her nervous condition was not materially benefited.
The  time, however (three months), which has elapsed since
the recovery, is too short to determine what results may
accrue.

  Case  X.—E. M---, aged  52 years, admitted into the
Pennsylvania Hospital suffering from  complete procidentia
of the uterus.   Fig. 12, from a sketch  taken at the  time  by
Dr. George  Pepper, represents with great faithfulness the
appearance presented  at  the  period  of the  operation.  She
states that 20 years previous she  had given birth to twins.
The labor was tedious, but no instruments were used.  She
thinks it was at this time the perineum was  torn.  Five
years after, she was delivered of another child, and the rent
increased ; shortly after which the uterine displacement came
on, becoming gradually worse, until almost disqualified for
work, she sought medical advice.  Believing that the resto-
ration  of the continuity of the  perineum would  offer an
obstacle  to the escape of the uterus, Dr.  Hunt performed
the operation, assisted by Drs. Morton and Agnew, and in 
report of cases.
49
the presence of the Hospital  residents.   The patient being
previously etherized and placed on the back, the limbs sup-

                           Fig. 13.
Fiar. 14.
ported in the usual  manner, the  margins were extensively
denuded, as shown in Fig. 13. Four deep silver sutures were
IGTON, O. 
50        laceration of the  female perineum.
inserted and secured by clamps of shot, and  intermediate to
these, two superficial sutures, fastened by twisting the ends
about each other.   A  broad piece  of adhesive plaster was
next drawn across the nates to relieve the sutures of tension,
and an elastic catheter placed in the  bladder for a time.  Fig.
14 exhibits the operation completed.
  The drawings from which these cuts were taken were exe-
cuted by the skilful pencil of Dr. George Pepper.
  On the fourth day the deep sutures were removed, and  on
the seventh the superficial  ones, union being complete.  A
week later this woman  was discharged from the  Hospital
perfectly well and free from all displacement.

  Case  XL—Mrs. B----, a lady from the West, suffered
from an extensive laceration of the  perineum, involving the
sphincter and recto-vaginal  septum.   The accident  occurred
in her first labor, which  was tedious, though, I believe, not
instrumental.   There  was considerable displacement of the
pelvic viscera, in consequence of  the absence of perineal sup-
port.
  The operation described in the text was performed in the
presence of Drs. E. Wilson, Albert H. Smith, and others.
After careful denudation of  the sides and septum, four deep,
interrupted wire sutures  were deposited  as  directed in the
text, and securely clamped.   Seven days after, the stitches
were removed and the union found complete.

  Case XII.—Mrs.----, a resident  of an  adjoining county,
in her first labor, ruptured the perineum, divided the sphinc-
ter, the rent extending full three-quarters of an inch into the
septum.  The  insufficiency of the bowel was most distress-
ing.   In the presence  of Drs. E. W. Baily, Morrison, and
Martin, I performed my usual operation.  The lady was left
in the care of Dr. Baily,  who removed the sutures, (four in
number) after the lapse of seven  days, the union being com-
plete. This lady has never complained of any difficulty with
either the fasces or flatus  since the restoration. 
REPORT OF CASES.
51
  Case XIII.—An Irish woman, at an adjoining town, in her
first labor, before assistance could be obtained, ruptured the
perineum.  The  septum was involved to such a degree as to
entail incontinence, unless the faeces were quite consistent.
  Twelve weeks after the accident, with  the assistance of
Drs. Uhler, Goodell, Jenks, and Hunter, the parts were closed
with four deep, and two superficial, stitches, after the man-
ner already laid down.  Seven  days afterward  I  removed
the sutures, and found the adhesion perfect, and  since have
learned of her entire recovery.

  Case XIV.—Mrs.----, of a neighboring town, after a long
and tedious instrumental labor tore the perineum, the fissure
extending so far into the septum as  to lay both  canals into
one, for the extent of one inch.  Two months after the occur-
rence I closed the gap after the usual manner, assisted by Drs.
Reed, Beaver, and Hunter.  As I was securing the last and
anterior wire,  the posterior or first suture, from some defect,
gave  way.  Unwilling to open the wound, the case was
allowed to take  its course, as the other sutures appeared to
maintain the  approximation.   I said at the time, this will
test the value of the  first stitch, on which I have always
placed so much  importance.  The usual time of seven days
elapsed, and the sutures were removed; union of the peri-
neum  had taken place,  but not of  the septum, leaving, of
course, an opening between the  rectum and vagina.  After
four weeks I  repeated the  operation, the  restoration being
complete.

  These last four cases  are selected from  a  large  number
which I have treated since the first publicatien of my paper,
merely because  they were extreme  cases, and  which, at one
time, and even at present by some surgeons, would have been
subjected to two operations—one to close the septum, and a
second to restore the  perineum. In view, therefore, of my
past experience  and observation, the following  points are
conclusively settled in  my mind. 
52         laceration of the  female perineum.

  First.—That  laceration  of the perineum  and  the recto-
vaginal septum  can be satisfactorily cured at a single opera-
tion.
  Second.—That by the peculiar method of inserting the first
suture there  is no necessity for a series of stitches to close the
septum independent of those used for the closure of the peri-
neum.
  Third.—That  the interrupted can  be substituted for  the
quilled suture.
  Fourth.—That the division of the sphincter is  not neces-
sary to a cure.
  Fifth.—That the superficial sutures maybe dispensed with.


           Literature of Lacerated Perineum.

Midwifery, the Modern Practice of M.   Lond., 1173.
Gehler, J. C.  Progr.de ruptura perinsei in partu cavenda.  Lips.,
  1*781-4.
Denman, Th.   Introduction to the Practice of Midwifery.  Lond.,
  1188.  Chap, ii., sect,  vii., pp. 69 and 70.
Hagen, M. I. Diss, de  prsecavenda interfoeminei dilaceratione.
  Mogunt., 1190.
Oken.  Isis, Vergl.  1831.  Heft 8-10, s. 925.
Dieffenbach,  I. F.   Chir. Erfahrungen, besonders iiber die Wied-
  erherstellung zerstorter Theile des menschlichen Korpers nach
  einer neuen Methode.   Mit. 2.   Abbild.  Berl. 1829, 8.
Moreau.   Considerations  sur les perforations du perinee et sur
  le passage de l'enfant a travers de cette  partie. fRevue Medi-
  cale Francaise et Etrang.   Paris, June, 1830.)
Eohl.  Die geburtshiilfliche   Exploration.  Halle, 1834.   I3d.  11,
  s. 411.
Busch. Theoretisch-praktische Guburtskunde.  S. 351, Taf. xxix.
  Fig. 191-19.  Berl. 1834.
Oettingen.  De Diss, de  Perinaei Rupturis  ejusque cura.  Dorp.,
  1835.
Duparcque,  T.  Histoire complete  des  Ruptures et des Dechi-
  rures de l'Uterus, du Vagin, et du Perinee.  Paris,  1836. 
            literature of lacerated perineum.          53

Sehneemann.  Schmidt's Jahrbiicher der gesammten ineund aus-
  landisehen Medizin.   1885.  No. v., s. 368.
F. Duparcque's  Vollstandige Geschichte der  Durchlocherungen,
  Einrisse und  Zerreissungen des  Uterus, der Vagina, und cles
  Perin'aums, u.  s. w., in einem zehr erweiterten,  die Leistungen
  aller wissenschaftlich gebildeten Nationen der ganzen Erde
  beriicksichtigenden Masse bearbeitet von J. F.  W. Xevermann.
  Quedlinb. und Leipz., 1838.
Busch.  Die  geburtshiilfliehe Klinik  an der  Konigl.  Friedricli
  Wilhelms—Universitat zu Berlin. Erster Bericht. Berlin, 1831
  S. 110, und s.  230.
Noel.  Journal General de Me'decine.  Tom. iv.; Saucerotte, Idem,
  tom. vii.
E. v. Siebold1 s Journal  fiir Geburtshiilfe.  Schmitt, Bd. ii.,  s. 1;
  v. Siebold, Bd. v., i. s. 69.
Wendelstddt.  Hufeland's  Journal  der  Praktischen  Heilkunde.
  Bd. xv., st. iii., s. 85.

  The  above authorities  have  been  obtained from   Busch
and Moser, and I am greatly indebted to Messrs. Midler and
Must in for aid in translations and  searches of many  of  the
works.

Lancet, vol. i., 1849, p. 555.  Joseph Rogers's case.
Luncet, vol. ii., 1849.  Dr. Barnes's case.
Lancet, vol. ii., 1849, p. 661.  Higginbotham.
Lancet, vol. ii., 1849, p. 672.  Westminster Hospital.  Mr. Holt.
Lancet, vol. ii., 1850, p.  93.  Mr. Fergusson.
Guy's  Hospital  Reports,  vol.  viii., part ii.,  p. 401.  1850.   Dr.
  Lever's paper on Lacerated Perineum.
Guy's  Hospital Reports, vol. xi., 1865.   Cases detailed and method
  of treatment.
Lancet, September 9, 1865.  Lane's cases.
Boston Med. and Surg. Journal, \o\. x., page 405.   Report of five
  operations of M. Roux, of Paris  (1831-34).   Extract from
  Journal Hebdomadaire. 
54         laceration  of the female  perineum.
Boston Med. and Surg. Journal, vol. ix.  Operations of Dr. John
  P. Mettauer, of Virginia.
Boston Med. and Surg.  Journal,  vol. xxii., page 123.  Case of
  Spontaneous Adhesion of Lacerations of Perineum, Occlusion
  of Vagina, and Operation  for Relief, by Dr. Trowbridge  Wil-
  loughby, University of Lake Erie, 1840.
Boston Med. and Surg. Journal, vol. xxxi., page 319.  Operation
  for cure of Lacerated Perineum, by Dr. W. B. Lindsay, Plaque-
  mine, La., May, 1848.   (From N. 0. Med. Jour.)
Boston Med. and Surg. Journal, vol. Ix., page 61.  Union of La-
  cerated  Perineum by  position merely, by M.  Nelaton, Paris,
  1856.  (From Jour, de Me"decine, &c, Bordeaux.)
Boston Med. and Surg.  Journal,  vol. lv., page 511.  Article  on
  Treatment  of Laceration  of Perineum, by  Prof. Schuh, of
  Vienna.  (Wiener Med. Wochenschrift, 1851.)
Boston Med. and Surg. Journal, vol. Ivi., page 49.  Laceration of
  the Perineum followed by Prolapse of  Bladder and  Rectum,
  Cured by Operation, by William  Read, M.D.  Boston  Lying-
  in Hospital, December 13,  1851.
Boston Med. and Surg. Journal, vol. lix., page 308.  Operation for
  Restoration of Lacerated  Perineum, by William M. Morland,
  M.D., Dec. 1, 1851.
Boston Med. and Surg.  Journal, vol. lxi., page 111.  Case of Pe-
  rineal  Laceration.   Operation by  ---.  A Sacramento  Calf.
  August 16, 1858.
American Journal of Med. Sciences, vol. xi., 1822, page 525.  Case
  of Laceration of Centre of Perineum.  Operation.  Remarks.
  Baron Dupuytren.
American Journal of Med. Sciences, vol. xiii., 1833, page 113.  A
  Case of Ununited Parturient Laceration of Recto-Vaginal Sep-
  tum, successfully treated  with  metallic ligatures, by  John P.
  Mettauer, M.D., Prince Edward County, Virginia.
American Journal of Med. Sciences, vol. xxiii. (1838-9), page 495.
  A report of nine cases of Lacerated Perineum, treated by Prof.
  Dieffenbach.   (Berlin Med. Zeit., December 21, 1837.)
American  Journal of Med. Sciences, 1841, N. S., vol. i., page 99.
  Article on Laceration of  Perineum during  Labor (with opera- 
           literature  of lacerated perineum.          55

  tions for cure), by Dr. William H. Fahnestock, M.D., Borden-
  town, New Jersey.
American Journal of Med. Sciences, 1844, N. S., vol. vii., page 412.
  Suture of Perineum performed immediately after  Delivery, by
  M. Daujean, Surg. Maternite a Paris.   A report of six cases.
American Journal of Med.  Sciences, 1841, vol. xiii., page 314.  A
  report  of two operations, by John P. Mettauer,  A.M., M.D.,
  LL.D., Virginia.
American Journal of Med. Sciences, 1853, vol. xxv.  Discussion
  of a New Method of Operating for Lacerated Perineum, by I. B.
  Brown, M.D.
American Journal of  Med. Sciences,  1850, vol. xx., page  329.
  Hints  on Treatment of Lacerated Perineum  from Parturition,
  by W. E.Horner, M.D.
American Journal of Med. Sciences, 1854, vol. xxviii., page 404.
  Operation  for  Laceration of Perineum,  by  T. M. Robertson,
  M.D.
American Journal of  Med. Sciences, 1855, vol. xxix.,  page 214.
  Laceration of Perineum and Sphincter Ani during Parturition,
  cured  by Division of the  Sphincter and  subsequent closing of
  the  Perineum by Sutures, by Willard Parker, M.D. (Oct. 24,
  1849).
 New Jersey Med. Reporter, 1856, vol. ix., page 466.   Laceration of
  Perineum.  Case successfully operated on by Dr.  I. B. Brown's
  operation, by S. W. Butler, M.D., Burlington, New Jersey.
 Monthly Journal of Med.  Sciences, February, 1854.  Page 164.
   Proposal for the Effectual Cure of Prolapsus of the Pelvic Vis-
  cera and  Lacerated  Perineum.   By John Hilton, Esq., F.R.S.
  (Guy's Hospital Reports.)
 Medical Times and Gazette, August 30,1856.  Page 215.  Treat-
  ment of Ruptured Perineum. By Dr. N.  Wilson Varina.
 British  Med. Journal, August 11, 1861.   Page 111.  Rupture
  of  the Perineum during  Labor.   By Dr. Thomas Skinner.
  Liverpool.
 Guy's Hospital Reports, 1865.  Vol. ix.   Page 210.  On the Opera-
  tion for the Relief of a Lacerated Perineum and Sphincter Ani,
  &c, with some of its Complications.   By Thomas Bryant, Esq.,
  Assistant Surgeon to Guy's Hospital. 
56         laceration of the female  perineum.

Lancet, September 9, 1865.  Page 289.  Two Cases of Operation
  for the Cure of Laceration of the Perineum, under the care of
  James Lane, Esq., at St. Mary's Hospital.
Report  of  Columbia  Hospital for  Women,  1873,  by  J.  Harry
  Thompson, M.D., Surgeon-in-Chief. Thirty-four Cases of Lace-
  rated Perineum treated. 
VESICOVAGINAL  FISTULA:

       ITS HISTORY AND TREATMENT.
                        History.
  There is much  consoling in the  thought that, in most of
the diseases and accidents incident to the body, the sufferers
are not debarred the society, sympathy, and entertainment of
friends.   Such considerations greatly mitigate and sustain,
under the severest physical distress.  But there is one accident
liable to occur in the female—and that, too, in the exercise
of the highest function of her nature—which dooms her to
isolation and seclusion, renders her presence intolerable to
friends,  and compels her to exist in an atmosphere repugnant
in the highest degree to her own sense.
  Until  a very  recent  period, the unfortunate victim of
vcsico-vaginal fistula was obliged to confront  her situation
under the conviction that her case was  absolutely hopeless,
and has, in some instances, sought refuge from the mental
suffering by self-destruction.   One of the grandest triumphs
of American  surgery—for it is all her own—has been to step
in and lead such forth into the light of day, and restore them
to the bliss of family and social life.
  Antecedent to the  discovery of the forceps, such accidents
must have been of very frequent occurrence, although com-
paratively little is said  in medical or surgical works on the
subject,  as such  were,  by common  consent, regarded  to be
beyond the resources of obstetric surgery.
  Hippocrates speaks of a discharge of urine through the
vagina  sometimes following difficult labors, with some un-
important  remarks in  regard to cleanliness; no hint is any-
      5 
5*               VESICO-vaginal fistula.

where thrown out, leading to an  inference that such  cases
admitted of cure.   Without disturbing the repose of ancient
medical record, it  may not prove  uninteresting to interrogate
a few modern authorities.
  Mauriceau, in his work, published  in 1712, lays down the
following aphorism: " L'issue involuntaire de Purine causee
par une fistule qui s'est femme, est ordinairement incurable
si elle duze plus  si  trois mois."  No operation  does he pro-
pose, but only looks for a cure, when it does occur, as a purely
natural  or spontaneous  result.
  Hoffman, in 1724, describes the  accident, and refers  it to
the proper  cause:  " Quando enim fibrae  sub diuturnoribus
partus laboribus ad infantis capiti, ad os pubis compressae diu
manet fieri  deinde solet ut inflamentur, atque in abscessum
abeant,  aliquot denum a partu diebus consummandum; uncle
fluxus, et stillicidium urinae per  vaginam  tertio  demum, vel
quarto die contingit."  It is quite evident, too, the art of the
Genevan embraced no means of repairing the accident.
  Astruc, physician to the King of France in 1776, has  no
notice whatever of the  affection in his work.
  Smellie, in his publication of 1776, although  he describes
an operation for  this form  of fistula,  had evidently never
performed one himself  or even witnessed it performed, as  he
adds, " I wish the operation may not be found impracticable."
  Denman  alludes to ulceration and sloughing of the vagina
after difficult labor, but suggests no remedy.
  Burns, in his work on midwifery, edited in 1820 by James,
describes the lesion, and advises a catheter to  be worn for
some time, under the conviction nothing else could be done.
  Conquest, in his Outlines of Midwifery, published in London
in 1820, insists on the propriety of attempting a cure by an
operation, but does not designate any particular method, nor
does he intimate  a knowledge of any  cures  having been
effected.
  James, in his System of Midwifery,  of 1813, not only takes
notice of this form  of fistula, but advises the employment of
an elastic catheter, and adds, perhaps  it may heal. The same
author also speaks of the use of caustic when the opening is 
HISTORY.
59
small, and  freshening the edges when it is  large, conjoined
with the use of the catheter.
  Ashwell,  quite  a prominent  practitioner and  writer  in
London, in 1828, has no allusion to the subject whatever.
  William Campbell, of Edinburgh, in 1833, appears to have
given unusual  attention  to the subject.   The opening is
clearly described,  and its most  common location, near  the
neck of the bladder.  In his experience, the catheter and re-
cumbent position  perseveringly  employed  has, when  pro-
nounced by others utterly hopeless, permanently relieved cases:
the phraseology, it will be perceived, will not allow the con-
clusion that such were cured.
  Gooch, in 1831, alludes to  a  case having got well by a
gum-elastic bottle, with  a  sponge attached, being  pressed
into the vagina and kept opposite the opening.   This solitary
case of reported cure is treated as a very unusual and extra-
ordinary event.
  The cases reported  as  cured  by Lallemande, Phillips of
Rheims, and Vidal, in 1834, Velpeau most positively asserts
were not cures.
  Blundell, in  his work  published in 1834, disposes of the
subject in a most summary manner by stating, "a slough of
the vagina may lay open the bladder."
  Ramsbotham, writing as late as 1841, does not treat of the
subject.
  Davis, in 1841, describes the  manner in which such  an
opening is  made, with the additional statement, " it is almost
a universal fact, that they never do heal."
  Dewees,  in his work on  midwifery, makes  no mention of
it.
  Churchill, in 1844, speaks of all such openings as being
perfectly hopeless.
  Simpson, in his work published  in 1865  and 1866, when
describing  the result of long-continued pressure by the fcetal
head against the vesico-vaginal septum, speaks of the slough
separating and leaving an incurable  fistula.
  Reybard, in  1856, published  a  paper on the  palliative 
60
VESICO-VAGINAL FISTULA.
treatment of this form of fistula, believing the affection in-
capable of cure.
  Let  us now interrogate a few of  the eminent  surgeons
abroad and at home, and ascertain with what voice they tes-
tify on this subject.
  Ambrose Parens great work bears date 1582, and while the
subject of fistula in general is discussed, this form is not even
mentioned.
  Heister mentions it as incurable.
  Samuel Cooper, in his Surgical Dictionary, speaks of differ-
ent kinds of fistula, but does not in  any way allude to the
one under consideration.  In 1808, in the first volume  of his
Surgery, some methods of operation for the cure of  such
fistulae are described, but he evidently doubts their practica-
bility.
  Mr. Liston asserts that an operation only makes the patient
worse, by converting a small  into a large  opening, and adds,
" There is little  hope in a case  of any size."  To the same
conclusion tend  the testimony of Mr. Earle  and Mr.  Law-
rence, both of whom  state a successful operation impracti-
cable.
  Chelius says the prognosis is always very unfavorable.
  Miller believes a favorable result by any means improbable.
  Velpeau asserts of all cases reported as cured, there were
few free from doubt.
  Pirrie has not a word upon the subject.  The subject  is not
introduced by name into the works of Dorsey or Gibson.
  Desault, in  his Treatise on the  Urinary Organs,  confines
himself simply to the palliative  treatment.
  Dupuytren only hoped, by cauterization, to effect something.
  Mr. Earle, after thirty operations, succeeded in curing one
case; no wonder he pronounced  the operation the most diffi-
cult or  unsatisfactory one in surgery.
  Xelaton, as late as 1854, talked of autoplastic  processes
and the cautery.  These are but a few of the names which
might be introduced.
  In 1839, Dr. Hay ward, of Boston, succeeded  in  curing a
case by freshening the edges, and approximating them with 
CAUSES.
61
a thread suture.  In 1840, two additional cases were treated,
with a  similar result, and although twenty operations were
performed in attaining these three cures, yet, in a prospective
point of view, their value cannot be overestimated.
   In 1847, Dr. Pancoast, Professor of Anatomy in the Jeffer-
son  Medical College, reported two cases, cured  by a tongue,
and  grooved incision, the wound being adjusted by his silk-
thread  plastic suture.   In the same  year, Dr. Mettauer, of
Virginia, gave to the profession the history of a case success-
fully treated  by vivifying the edges,  and uniting the same
with leaden threads.  Such occasional cures, doubtless, tended
to inspire a hope of the ultimate curability  of this disgust-
ing disease; but it  was not, however, until about 1852, when
Dr. I. Marion Sims, then of Montgomery, Alabama, gave to
the profession the fruit of his labor and observation, by which
this operation was removed from the category of probabilities,
and  crowned  with  a success which  compared favorably with
any  of  the  established operations  in  surgery.  For this he
has placed the civilized world under a  debt of gratitude.

                         Causes.
   Among the causes inducing this lesion may be enumerated:
   First.  The  pessary.—When this instrument is  out of pro-
portion, and  fitting badly, or corroded, or  encrusted  with
saline matters, it may induce ulceration of the vagino-vesical
septum.  Profs. Beirards and Lisfranc each  relate a case of
the bladder and rectum both being  opened by a pessary; one
of the patients died of peritonitis (Journ. Nouv. Hebd. de Med.,
t.  1, page 263.)  A  case of Dupuytren, in the Hotel Dieu, is
recorded in the Dict:de Sciences Med., t. vii. p. 47, of a young
country woman, whose rectum, vagina, and  bladder freely
communicated, in  consequence of wearing a badly adapted
instrument; both of these were produced by stem pessaries.
A case of this kind is also  cited by Desormeaux, a French
physician.   In most of them,  doubtless, the ulceration was
brought about by saline deposit on the exterior of the  instru-
ment, the angularities  of which matter would very soon pro-
duce destruction of tissue.   Other cases might be introduced 
62
VESICO-VAGINAL FISTULA.
in illustration of the same point.   In earlier times it is pro-
bable such  accidents were common, when a great variety of
extraordinary materials were employed, not only for mechani-
cal support, but as means of introducing remedial  agents into
the organs of generation; at present, improvements in  the
form and substance of mechanical supports will not be likely
to furnish us a case illustrative of the condition  under con-
sideration.
   Second. Foreign substances in the bladder.—Under this head
may be mentioned vesical-calculi, examples of which are by
no means rare.  Fabricius Ilildanus relates  an  instance of
this  nature.  Sir Benjamin Brodie another, in  which  the
stone made its way into the vagina by ulceration; and a
third is given by Sir Astley Cooper.  Dr. Dunlap, of JNorris-
town, in this State, exhibited to me a calculus as  large  as a
hen's egg, which he extracted from  the vagina of a female,
who had long suffered from the disease, and which had per-
forated the vesico-vaginal septum.  A most  interesting fact
connected with this case, was the perfect  restoration of the
parts subsequently  by granulation.   A very singular case
occurred in the East London Lying-in  Institute,  reported in
the January number of the  French Lancet for  1838,  of a
woman who, in consequence of a chronic retention of urine,
had acquired sufficient dexterity to catheterize herself. From
some cause, being without the usual instrument,  she extem-
porized the catheter with the  stem of a clay tobacco pipe.
On one occasion it was broken, a portion remaining in  the
bladder, and which, in time, not only passed into the vagina,
but finally into the uterus, from which it was extracted.
   Third. Carcinomatous and other forms of ulceration.—Almost
every work treating of the diseases of the female genitalia, fur-
nishes examples of malignant growths, involving the uterus,
and gradually invading, by destructive  ulceration, the vagina
and  rectum, until  they  become  converted into  a common
cavity.   Phagedenic chancre may produce a  similar result.
Two cases of this nature came under my own observation in
the wards of the Philadelphia Hospital, rendering the poor, 
CAUSES.
63
unfortunate outcasts, objects of the profoundest  commisera-
tion.
  Fourth. Wounds of the vagino-vesical wall in the legitimate
and illegitimate use of instruments.—Under the first may be
enumerated the careless employment of the obstetrical vectis
or lever, bruising or  lacerating the  tissues by long-continued
efforts to modify a foetal position, or the slipping of a perfo-
rator in cases of craniotomy.  The forceps have come in for a
large share of animadversion, but they have  little agency in
producing such an accident; their earlier and more frequent
employment, particularly in educated hands, would have pre-
vented many which  have occurred.   Under the second  head
may be adduced  the violence committed by those ignorant
scoundrels who flourish in  every great city in their criminal
attempts to procure  abortion.
  Fifth.  Pressure of the foetal head.—This, above  all others,
is the most  common  cause  of  vesico-vaginal fistula.   It is
probably not going too far  to say 90 per cent, of such occur-
rences are due to the prolonged pressure  of  the foetal head.
The testimony of almost all authors harmonizes in this par-
ticular.  It was so  regarded  by Mauriceau; yet  singularly
enough, he was greatly opposed to the use  of instruments,
whereby a tedious labor might  be brought to a close.   This
prejudice  it is said was due to the failure of Chamberlayne
to deliver a woman in Paris after a public boast.   Not beino-
aware of the existence of a deformed  pelvis  he had torn the
vagina and uterus in several places in his ineffectual efforts
to extract the child with  the forceps of  which he was the
inventor.   Denman  attributed the  lesion to long-continued
compression of the soft parts.  Davis expressly declares that
it does not result from the  use  of instruments, but  delayed
labor.  Dr. Simpson stops to fortify  a  similar opinion by
stating  "these abnormal openings, if produced  by  instru-
ments, should appear at  once, while it is known they only
occur several days after their use."   Smellie, Colombat, and
Churchill, all ascribe the fistula to protracted  pressure dur-
ing labor, and an opinion of similar import is entertained by
Professors Hodge and Meigs.  Doctors Sims and Boseman, 
64
VESICO-VAGINAL FISTULA.
 whose opportunities for acquiring accurate  information  on
 this subject have been extensive, testify to the same fact, and
 except in a single case my own observation accords with these
 gentlemen.
   If the foregoing statements be correct, what is the modus
 —the manner in which the lesion takes place?   The head in
 passing through  the pelvic cavity presses the anterior wall
 of the vagina toward and  against the  posterior face of the
 pubic bones.   If in consequence of failure of the uterine ex-
 pulsive efforts, or a disproportion between the pelvis and the
 head, or a want of accord between the diameters of the two,
 the head long remains  thus engaged, the vitality of the soft
 parts so compressed and bruised will be destroyed, either by
 the formation of a slough or by inflammation and ulceration.
 It is asserted by some that a fold of the vagina is caught and
 pressed against the pelvic bones  until its death is insured;
 but  it does not  seem  probable any  such  folds would exist
 when the canal is so greatly distended.  The period when the
 opening occurs varies in different cases;  in some as early as
 the fourth or fifth day, and in others the event may be pro-
 longed—as in one which came under my own  observation
 (case 4)—until the twenty-first day after confinement. When
 the parts are so injured as to induce ulcerative inflammation,
 a longer time  is required to penetrate the vagino-vesical wall
 than where they  are  killed  outright, and  drop out as  a
 slough.

                     Classification.
   These fistulae may occur at  any  point from the middle of
 the urethra to the termination above of the anterior wall of
 the vagina, but practically the classification of  Sims or that
 of Dr.  Boseman, the two differing very little, answers every
 purpose.
  First. Urethro-vaginal;  the opening  being  between the
urethra and vagina.
  Second. In the trigone vesicate; the opening being situated
at the cervix of the bladder. 
FORM, SIZE, AND CONDITION.
65
  Third. At the bas-fond ; the opening involving the inferior
fundus of the bladder.
  Fourth. Vesico-utero-vaginal; where  the  opening commu-
nicates with  the bladder, vagina, and cervix, or body of the
uterus.
  Fifth. Fortunately quite rare, where the  entire vesico-
vaginal wall is destroyed, and  it may be the urethro-vaginal
also.
  The relative frequency of these varieties, as they have come
under my own notice, is as follows: First, at the vesical tri-
angle ; second, at the bas-fond ;  third, in the urethro-vaginal
septum ; fourth, the utero-vesical; and last, the one attended
with  a destruction which includes the first four classes.   This,
I think, accords with the experience of most observers.  Dr.
Boseman, I believe, states, according to his observation, the
vesico-utero-vaginal is the most  common.  I have  never but
in a single instance seen an example of this kind.

                        Direction.
  These  fistules may be transverse, oblique, or longitudinal;
determined, it may be presumed, in  a  great degree by the
particular  part of the foetal head  impinging, or the exact
manner in which the vaginal parietes  may be caught.  The
transverse variety has most frequently come under my own
notice.

                Form, Size, and Condition.
  The configuration or form of such openings may be oval,
round, linear, angular, and elliptical; the last most common.
A careful study of the muscular component of the vagina
will explain  this.  Its fasciculi are disposed  longitudinally
and circular; the former  the  most numerous and distinct;
and of these, those on the lateral parietes are so associated
with  the levatores ani that they contract less when divided
than those occupying an intermediate position, and hence the
ovoidal or elliptical form of most fistulae.  The dimensions of
the opening also vary from an  aperture so small as barely to
admit the introduction of an ordinary probe, to one through 
66
VESICO-VAGINAL FISTULA.
which  might  be passed a good-sized  egg.  So  far  as  the
patient's comfort is concerned, the small opening is quite as
bad  as  the  large  one;  in either case the urine will be con-
stantly passing the vagina.
  The  condition of the  borders of the fistula—like its size
and form—differ  much.   Sometimes they are, especially the
upper one, thin, inverted, quite pale and  smooth ; in other
instances thick, soft, spongy, and vascular;  and  again of
almost  cartilaginous  consistence,  inextensible  and sparsely
supplied with bloodvessels.  The  mucous  membrane of the
bladder often projects through the  opening, forming a red,
erectile-looking tumor.  Dr. Gross gives a remarkable case—
in his  work on the  urinary organs—of the entire bladder
escaping through  such a fistulous  orifice into the vagina.
The condition of the  edges as  to  thickness,  density, and
vascularity,  is  a matter of great practical moment  in  the
cure of disease.

                        Diagnosis.
  It is not usually a difficult matter to ascertain the existence
of this  affection.  If inquiry be made as to the state of the
bladder immediately succeeding the  labor, the patient or her
attendant will state  that  for two  or three days there was an
inability to  evacuate  its contents, with some pain or uneasi-
ness, requiring perhaps the use of the catheter; after  this a
stillicidium  of urine  through the urethra;' or this last con-
dition  may have been present from the first.  At some period,
however, varying  from  five to twenty days from the labor,
the incontinence is complete, the urine escaping entirely from
the  vagina.  The patient sometimes describes this state as
being  preceded by a sense of something giving way. The
labia, inner  surface of the thighs, perineum, and the buttocks,
being constantly bathed in the secretion, become red, inflamed,
and covered writh a crop  of pustules, which sometimes form
ulcers  of considerable depth.   The genitalia and surface of
the vagina frequently become incrusted with a saline deposi-
tion (urates), and a strong urinous odor is emitted from  her 
                      complications.                    67

person and clothing.  These may be regarded as the rational
signs of the disease.  Although they  do not in themselves
establish or justify the  conclusion that a fistula  exists, they
form a strong presumptive proof of the fact.  Only upon a
physical exploration of the parts can we ascertain with cer-
tainty the accident.  With this view let the patient be placed
in bed, on  her side, with the limbs well drawn  up, and the
hips on the edge of the same, before the window, with a good
light.   Introduce the duck-bill  speculum into  the  vagina,
and draw the perineum well back  toward the sacrum, until
the entrance of the air distends  the vaginal cavity.  If the
lesion exists, it will most likely be at once detected, unless it
should be so small  as to escape observation.   That it be not
thus overlooked, a pocket-case probe  should be introduced
into any suspicious pockets or depressions, and  moved care-
fully about until their nature and extent  are  determined.
Where the aperture is so small as not to be readily found, it
has been advised to inject through the urethra into the blad-
der  some colored liquid, distending its walls, and carefully
noting  if any can be discovered passing into the vagina.1
Some prefer having  the patient on her elbows and knees,
others on the back, in making the examination,  but the one
on the side answers  every end, and is more in consonance
with her feelings of  modesty and propriety.  With the aid
of the speculum  no doubt need exist; without it no exami-
nation is complete.  I have been called to cases said to be
vagino-vesical fistulae, which on ocular inspection proved to
be incontinence from defect in the muscular endowments of
the  vesical cervix, allowing the urine  to  find its  way back
into the vagina after escaping passively from the  urethra.

                      Complications.
   Under this head may be enumerated stricture of the va-
gina, recto-vaginal fistula, obliteration  of the urethra, and
malignant disease of  the uterus or rectum.
1 Milk answers well for this purpose. 
68
VESICO-VAGINAL FISTULA.
                       Treatment.
  The treatment of vesico-vaginal fistula includes the prepa-
ration of the patient, the operation, and subsequent manage-
ment.
  Preparation.'—No woman can be in the best condition to
undergo an operation for her cure, until after the lapse of at least
eight or ten weeks from her confinement.  I have operated as
early as the fifth week, and with complete success, but, never-
theless, do not think so early a date should be fixed as a rule
in practice.  It requires at least two months before the system
has completely  recovered from the perturbating influences of
the parturient act, and her secretions duly established.  The
moral  and physical suffering induced  by the existence of the
fistula tend to put the woman out of health.  If we find her
pale, feeble, with loss  of appetite, and harassed by a train of
nervous symptoms, it  may require several months of prepara-
tion ;  during which  time a  carefully  regulated  nutritious
diet will be demanded, fresh  air, attention to the  intestinal
and other secretions,  conjoined with  the use of tonics, such
as the preparations of iron or infusions of the  bitter vege-
table class.   It is certain, no one familiar with the treatment
of this form  of fistula, will  be rash enough to  subject his
patient to  the  inconvenience of such  an operation, before
attending to these  preliminary measures.
  There is  no operation in surgery which depends so much
for its success on healthy constitutional conditions as the one
under  consideration, nor must we overlook the local treat-
ment.   All inflammation must have subsided, the connective
tissue  component  of the parts must be  well matured, and
sufficiently dense  to withstand the traction of the sutures,
the edges of the opening should have considerable  thickness
and a good supply of  bloodvessels.  All  this will be favored
by due attention to cleanliness, injecting tepid or  cold water,
with the addition of a little palm soap, or a decoction of oak
bark into the vagina every day.   Should  the edges continue
pale and thin, they must be subjected to a special treatment,
with a view to  make  them more voluminous.  This is best 
TREATMENT.
69
accomplished by making a few shallow incisions parallel to
their long diameters, and rubbing into each a little nitrate of
silver.   The caustic should be used about every third day.
In the course of a few weeks the requisite change will have
taken place.  The saline matters, which so commonly incrust
the margins of the  fistula and other  parts of the genitalia,
producing  much  uneasiness, may be counteracted  by the in-
ternal  administration of nitro-muriatic acid, as a good tonic.
The excoriation due to the urinous stillicidium is best relieved
either  by an ointment of the oxide of zinc, or by a mixture
of the black wash and gtycerine.  Attention  must also be
given  to her catamenial period, three or four days after its
accomplishment being the most fitting time for the operation.
If done during the latter half of the month, the irritation of
the parts, together with the prolonged etherization, are prone
to produce premature menstruation.  The day previous to the
operation, a gentle cathartic should be administered, after the
action of which, one grain and  a half of opium, in pill, should
be given to quiet all intestinal  irritation.
  Should the fistule  be the result of carcinomatous ulcera-
tion, any operation  will be futile, as everything tends  to a
fatal  termination.  When it  coexists with a recto-vaginal
opening, the escape of purulent  matter into the vagina will
be unfavorable to healing; yet, if the peristaltic movements
can be sufficiently controlled by opium or some of its prepa-
rations, there is  no reason  why the vagino-vesical  fistula
should not be closed, before undertaking that between the
vagina and intestine.
  The complication most commonly met with is stricture of
the vagina, and,  as  the opening is  usually above it, nothing
can be done for its relief until the dimensions of the canal
are properly restored.   Three methods may be employed for
this purpose.   First.  Incisions of the stricture through the
mucous and  submucous  tissues,  followed  by  dilatation.
Second.  A submucous division of the contracted bands, and
subsequent dilatation; and  third. Dilatation  alone.  Choose
which we may, there  is a strong tendency in the stricture to
return.  If'incision be selected, the reformed  parts have the 
70
VESICO-VAGINAL FISTULA.
same vicious tendency to contract, and  although this is true
of dilatation, it is less so than either of the others, and should
be selected as best adapted for our purpose.   It is effected by
either graduated bougies or sponge-tents.  I have practised
each method, and am confident the  last is the most certain
and least painful.

                       Treatment.
  This is divided into the palliative  and radical.  If, in con-
sequence of extensive destruction of tissue,  or the  presence
of malignant disease, an operation  is  contra-indicated, we
may resort to some means to palliate the distressing situation
of the patient.   These chiefly point  to  the collection of the
urine so as to defend  her person against  excoriation and
offensive emanations.  There is no task so  difficult and un-
satisfactory as  this.   Many receptacles, and obturators, and
other contrivances have been devised; such as a bag of gum-
elastic worn partly within  and partly without the vagina,
styled  by  Colombat the " trou  d'enfer" of Feburier;  or a
gum bottle with a sponge  on  its anterior  face, introduced
into the canal;  or  tampons of fine linen,  or  soft sponge
so  adjusted as  to  occlude  the  opening.   Of all  these
devices the metallic  shield of Prof. Meigs answers the best
purpose, yet it must be confessed all  are but  sorry contri-
vances, and will  be  soon abandoned.  A rigid  attention  to
cleanliness, by frequent ablution, and  the  use of an  inter-
femoral napkin or diaper, will, perhaps, give most satisfaction.
Fabricius Hildanus, as related by Colombat, furnishes an in-
stance of a case  which  was cured, after eight months, by
vaginal injections, consisting of barley-water and the mucil-
age of quince seeds.  The following passage, in his quaint
style, narrates the event:  "Ilia  autem  continuo usa medica-
mentis  (ut dixi) conglutinantibus,  et  per intervalla  etiam
purgantibus, intra menses octo, non sine admiratione omnium
eorum quibus  res cognita plane curata fuit, adeo  nunc Dei
optimi maxima gratia ne guttula quidem urinae involuntarise
affluat, sed a vesica colligatur,  retineatur  et excernatur non
aliter ac si antea nunquam male affecta fuisset." 
TREATMENT.
71
  Radical treatment.—It was only about the beginning of the
present century any attempts for the cure of this distressing
malady were thought  of, and only within the  last twenty
years that any encouraging results have  been  attained.  At
present  we approach the management of a  case of vesico-
vaginal fistula with the same degree of confidence as that of
stone or hydrocele.   The history of the various methods
practised for its cure—although  most of them  have  passed
into history—will  be presented, as they  furnish the most re-
markable  example of untiring, undismayed perseverance  in
the face of the most  unpromising results, and of a fertility of
professional resourse to be found in  no  other department of
medicine.  These methods may be arranged under the follow-
ing heads:—■
  1st.  By the catheter.
  2d. By the catheter, conjoined with the tampon.
  3d. By cauterization.
  4th. By the uniting apparatus.
  5th. By galvanism.
  6th. By transplantation.
  7th. By the suture.
  First. By the Catheter.—It is important to ascertain, at the
earliest moment, the existence of a  fistula, as a little well-
timed  attention may  procure a cure  without an operation.
There  are  cases in which there  exists a strong tendency to
spontaneous cure, and advantage should be taken of this, and
a catheter placed at once in  the bladder, and  worn for three
or four weeks, the patient being  confined to the recumbent
position, and due attention to cleanliness observed. A number
of such cases  terminating successfully have been placed on
record,  by  Fabricius  Hildanus, Blundell,  Ryan,  Sedillot,
Campbell, of Edinburgh, Nelaton, and others ; and, I doubt
not, similar ones may be recalled by many practitioners ex-
tensively engaged  in obstetric medicine.
  Second. Catheter conjoined ivith the Tampon.—This is usually
described as the method of  Desault, although it more pro-
perly belongs to  Boyer—the  name  of  the  former having
doubtless  become  connected  with it in  consequence  of the 
72
VESICO-VAGINAL FISTULA.
truss-like  apparatus which he devised to sustain and retain
the catheter.
  A large-sized elastic catheter is introduced into the bladder,
and its end slipped through an opening in a curved rod, one
end of which is to be opposite the urinary meatus, and the
other secured to an oval plate which rests on the pubes, and
is in turn  securely attached to a truss-spring surrounding the
pelvis.  This controls the catheter, by which means the urine
is  removed as  rapidly as deposited.   The margins of  the
fistula were  next pressed  towards  each other by  a  round
tampon or plug, made  of  fine  linen  filled with  lint, well
oiled, and  pressed into the vagina.   It does not appear, of the
many cases thus  treated by Boyer, more than a single one
recovered.  With  a very slight  modification of the vaginal
plug, others—as Baines, Guthrie, Young, and Barnes—have
reported cures, the treatment continuing from  six to  twelve
months.   Those curious to peruse these cases will  find  most
of them in the Med.-Chir.  Trans., vol. vi.,  page 582, and the
Edinburgh Med. and Surg. Journal, April No., 1824. Colombat
speaks favorably of this plan, provided the edges be  first
cauterized.  It  is probable  any such cases  reported as cured,
recovered, not from the  tampon, but  from the persevering
use of the catheter.  The tampon could exert  no influence
whatever  in  pressing together the sides of the fistula, but
just the reverse, by unfolding the rugae or plications of the
canal by distension.  Let any  one notice how a fistula gaps
when the speculum is introduced, and the canal  distended
with air, and then, in withdrawing, how the sides collapse,
and the demonstration will be  clear.
  Third.  Cauterization.—Of this  Colombat said: " It is the
best method we can oppose to vesico-vaginal fistula."  The
agents employed were  either the  nitrate of silver  or the
actual cautery.   The former was conveyed to the fistula by
fixing a stick  in a porte-crayon, and conducting it  to the
opening through a fenestrated  speculum introduced into the
vagina, and  repeated every four or  five days, followed by
emollient  injections to relieve pain.   After the edges begin
to assume a swollen or raw appearance, a catheter, according 
TREATMENT.
73
to Colombat, should  be placed  in the bladder.  A few suc-
cessful cases by this mode of treatment have been reported by
Dupuytren, Delpech, McDowell, of Kentucky, Liston, Colles,
and  Ferrall.  When the cautery  was  used,  a  bean-shaped
stylet, heated to a white heat, was applied to the opening, a
fenestrum  shielding  the vagina being first introduced—and
the parts lightly touched so as to induce a superficial slough.
The advocates for caustics have been  Chelius, Vacca, Ber-
linghien,  Czeekiersky, Ehrman, Monteggia, Guthrie, and
Colombat; for the  hot iron, Dupuytren,  Delpech, Bellini,
McDowell, Liston, Blasius,  and Dieffenbach.   The caustic
treatment was somewhat modified by Lallemand, principally,
who conjoined  with it a uniting  apparatus.  This surgeon
was so particular as to take an accurate cast of  the fistula
with a very plastic wax.  After the edges were made suffi-
ciently alive by the caustic, he adjusted his instrument, one
portion of which acted as catheter, and  through its openings
hooks were  made to protrude, penetrating the  posterior lip
of the fistula on its vesical surface.  A roll of lint, or charpie,
was next placed against the under surface of the  urethra, and
pressed upward toward the vagina  by  a movable  plate con-
nected to the anterior extremity of the catheter,  the object
being to press the lower lip of the fistula toward  the other
or upper lip impaled  by the hooks.  Dupuytren attempted the
same thing by a peculiarly  constructed catheter.   Langen-
beck very  properly pronounces such devices as  complicated,
and devoid of practical value.
   Fourth. The Uniting Method.—Laugier, in order to bring
the edges  together, invented a pair of claw-forceps,  the blades
of which  could be  introduced separately, and  after  being
implanted on opposite  sides of the fistula, secured together,
by which the coaptation was  effected.    Quite recently, an
instrument, acting on  the same principle, has been invented
by Dr. Betancourt, while  pursuing  his studies  in the  Uni-
versity of  Pennsylvania (Fig. 15).
   These processes, unlike the others, act on  the vaginal sur-
face of the opening.   As to their value, it may be said of all
       6 
74
VESICO-VAGINAL FISTULA.
of them, what Langenbeck pronounced of Lallemand's mode,
" they are theoretical, and devoid of practical value."
  Lallemand, as  far as I can ascertain, never reported more
than  a single case of cure, and even  this Velpeau declares
proved a failure.   Laugier confesses he  had not succeeded in
a single instance  with his uniting forceps.
  Fig. 15 is two light metallic plates connected by a hinge ; their margins are scal-
loped, and support sharp hooks, designed to seize the margins of ihe fistula  In one
plate are two eyes, and in the other two movable posts with shoulders, which are in-
tended to pass through the eyes and hold the plates together.

  Fifth. Gcdvanism.—The attempt to cure this  malady by
galvanism is due to Mr. Marshall, of the University College,
London.  The impression was  to be  made by bringing the
poles of a battery in contact with  the sides of the opening,
and was only another  phase of  the cautery.  It  only serves
to demonstrate the  straits into which  men are thrown when
they resort to such chimerical expedients.
  Sixth. Transplantation.—A  very ingenious operation  was
devised and executed  by Jobert; it was by transplantation
of tissue.   The circumference  of  the fistula, being  drawn
down, was freshened, a flap was raised  from the inner surface
of the labium, and, being turned into the opening, was secured
by a number of stitches; a  catheter was kept constantly in
the bladder during the treatment.  In one case the growth
of hair, the follicles of which were in  the flap,  induced a
vaginitis, and also interfered with the execution  of the  con- 
TREATMENT.
75
jugal act.  In one case the material to form this fleshy obtu-
rator was  taken from  the buttock and  thigh, and  proved
altogether  successful in effecting a  permanent  cure.  The
results  of  four cases reported,  furnish  us  with  one cure,
two failures,  and one  death.   Where a large part of the
vesico-vaginal septum has been destroyed, the operation of
Jobert might answer a valuable purpose.
   Seventh. By Suture.—The introduction of the suture marks
an important epoch in the history of vaginal fistulae.  It was
a step in the right direction.  The  credit of its introduction
is due to Roonhuysen, a  distinguished obstetrician at Am-
sterdam, who  proposed its use in 1663.  It was  violently
opposed long after by the celebrated Petit, who asserted that
incising and introducing a thread  in  parts so situated was a
task almost incapable of execution.
   The operation of Roonhuysen consisted in  freshening the
edges by means of a knife, scissors, or cutting  forceps, ope-
rating through a speculum, then pushing across the opening
needles, formed from the quill of the swan, and binding the
parts together by winding about these novel pins thread as we
apply the twisted suture.  Lewrinski,long after, in 1802, pro-
posed the interrupted suture.  It formed the subject of a thesis
before the Faculty of Medicine in Paris.   His instrument  for
placing the ligature was a catheter, carrying a needle which
had a spring  attached, and bearing a thread.  This instru-
ment was passed into the bladder, the spring pushed forward,
making the needle to pierce the posterior wall, afterward the
anterior wall, and securing by a serre-nceud.
   Volter recommended after paring the edges to coaptate by
the interrupted suture.   To execute this  he used  curved
needles, threaded with waxed silk, and passed them at short
intervals through  the margins  of the fistula, securing each
by tying in a knot.
  Nagele's method consisted in removing the circumference of
the opening with a knife or scissors, the edge of which was
guarded by a shield,movable at pleasure; then introducing the
thread sutures by a peculiar needle, one end of which was sup-
ported on a ring, through which the finger could be slipped, 
76
VESICO-VAGINAL  FISTULA.
and near to the other extremity, or the point, was an eye for
the thread.   The point was guarded  by the finger while
being carried to the fistula, and after the sutures were passed
the parts were drawn together by twisting their ends together
and allowing them to hang out of the vagina.  Not the least
important part of his plan was the use of the silver catheter;
but, singular enough,  its  utility was  destroyed in a great
measure by the attachment of a stopcock, only allowing the
urine to flow at particular  times.  The same authority pro-
posed the use of gilt or silver pins, and around them  silk
threads. He employed likewise the glover's suture; and for
stitching, a watch-spring with a needle point, and  concealed
in a La Forest  canula.
  Flamant manifested  most concern about paring the edges
of the fistula, to accomplish which he advised the use  of a
knife guarded  at the point to protect the  adjoining parts.
The attention of Le Roy was most directed to the same sub-
ject; and hence we find him proposing different  forms of
cutting instruments, and also a fenestrated speculum, with
hooks to unite  the sides, as a substitute for the suture.
  Shraeger freshened the edges with a pair of curved scissors,
deposited wax threads  by means of curved needles, supported
on a needle-holder, and made them secure by introducing the
ends  through a rosary of small wooden  balls or beads, and
making them  fast  by tying over a little  cross-piece.   The
same surgeon used the  glover's suture.
  Luke employed a bivalve s|»eculum to expose the parts,
angular knives to incise the borders of the  fistula, hooks to
draw it down, and curved needles to deposit the sutures.
   Malagodi used a leather thimble, which  he placed on the
left index finger, and,  hooking it  under  the margins of the
openings, pared the edges when thus stretched, the approxi-
mation being  made by silk threads introduced by curved
needles, manipulated  in the grasp of a needle-holder.  To
prevent urinary infiltration a catheter was worn in the blad-
der, and the vagina stuffed with lint or charpie.
  Ehrman recommended scarifying or cauterizing  the ed^es
and  then bringing them  together with sutures, passed by 
TREATMENT.
77
curved needles,  managed with  a porte-aiguille.  When  he
used cauterization, a tube was inserted into  the vagina, and
through it a brush, dipped in a mineral acid, was carried  up
to the  fistulous opening.  The speculum he  employed was a
trivalve, and his sutures were inserted by curved needles.
   Gosset, surgeon  at one time to Newgate, London, operated
successfully in 1834 on a case, by the following method: The
edges  were  carefully pared;  metallic threads, well  gilded^
were introduced  by  curved needles, passed with a  needle-
holder, and the sides brought together  and so retained  by
twisting  the wires.  To keep the bladder empty an elastic
catheter was worn, and  the patient requested to lie on the
breast.   It is worthy of notice here that this surgeon, in
executing his operation, placed his patient on her elbows and
knees.
   Kilian separated the walls of the vagina with blunt hooks;
used a silver catheter, curved similar to the male instrument,
to bring  the fistula forward  for  incising; and with curved
needles,  directed  by  a  Wutzer needle-holder, passed the
requisite  number of threads, which were secured by Desault's
knot-tightener.
   Blasius advised a grooved  suture.   The  margins of the
fistula were fashioned with a sharp-pointed knife, as follows:
Taking hold of one side with a hook or forceps, it was split
longitudinally, or parallel with  the long axis of the opening:
then seizing the other and everting  it, the knife was applied
to its surfaces in  such a manner as  to give it a cuneiform or
wedge-shaped form; needles armed  with thread sutures were
next passed, drawing the wedge-shaped side into the gutter
or slit of the opposite, constituting  a tongue and groove (as
he calls it) adjustment.  He claims  for this a more extended
apposition or contact of raw surfaces.
   Lewzisky's operation consisted in inserting the stitches by
means of a canula, traversed by a watch-spring, supporting  a
needle bearing a thread.  This  instrument was carried into
the  bladder, and the needle made to project  from the canula,
puncturing the septum from the vesical towards the vaginal
side.  By repeating this process  above  and below the open- 
78
VESICO-VAGINAL FISTULA.
ing, the ends of the sutures were all brought into the vagina
and secured on that  side.  This operation is similar in most
respects to that of Niigele, and includes the entire thickness
of the vesico-vaginal wall.
  Colombat furnishes us with an  operation much  more re-
markable for its ingenuity than utility.  The chief novelty
of his method consists in using a  spiral needle, not unlike a
corkscrew (Fig. 16), having a steel  point, with an eye for the
Colombat needle.
thread.  At the other extremity, where it conjoins with the
handle, there is a second eye, through which  the ends of the
thread are passed, after being wound  about the spiral of the
instrument.   After vivifying the edges with a pair of cutting
forceps, the needle is made, by a rotatory movement, to pierce
one side  of the  fistula; then the other, and so on, just as
one would bore a gimlet, until its entire length was traversed,
when by reversed turns it was  removed, leaving the  thread
in its  track, as  represented  in Figs.  17  and 18.  This is a
glover's suture.  The ends of his  threads  were twisted to-
gether and secured with  sealing wax.   Dieffenbach  very
facetiously remarks, this instrument  only needs a clockwork
attachment to go right.
  Deybers employed a wooden catheter, introduced through
the urethra, to control the edges of the opening while beino-
subjected  to the knife.  The stitching he  effected by means
of a curved tube inclosing an eyed stylet for the thread, and
which was controlled by a spring protruding or withdrawing 
TREATMENT.
79
the point at pleasure.   The sutures he used were either silk
or lead wire.
  Roux fixed the edges with a long pair of forceps while
they were being incised, passed across them silver pins, and
drew the wound  together by winding about  them threads
similar to our twisted suture.
  Wuther incised the fistula with either curved  scissors or a
sickle-shaped  knife, fixing it first with a  hook, and used
sometimes long-stemmed needles, sometimes short curved ones
passed with a needle-holder like that of Roux's; and at other
times insect-pins, surrounded with threads to bind the edges
together.  His patients during the operation kneeled, or were
kept  on their hands and  knees, and the vagina exposed by
introducing a hook speculum—really an  instrument similar
to the Sims speculum.   In order to defend the wound against
the  action  of the urine, and keep the bladder  empty,  the
organ was  opened above the pubes, a catheter introduced,
and the  patient  kept  upon her belly, buckled to a leather
cushion in which a hole was cut out.  On the sixth day his
ligatures were removed, injections of cold water having been
thrown into the bladder, through the catheter,and the vagina,
through  an oesophagus tube, every half-hour.   In eighteen
operations three  cases were  reported cured ; a  success pro-
nounced extraordinary, and  greater than that of any other
surgeon.
   Dieffenbach, to expose the fistula, used  a bivalve speculum;
seized the margins with a hook or long forceps while they
were being pared, and  united  them with the   interrupted
suture.   The position  in which  he  preferred having the pa-
tient for the operation was on the back, and the catheter was
used continuously to drain the bladder.  In  his hands  the
results wrere most discouraging.   On one woman he operated
eighteen times, and then failed  to effect a cure.  So great
was his interest  in the subject, that he gathered wards full
of women afflicted with  this malady, from all parts of the
country, but, as he states himself, making very few cures.
   Beaumont,  after paring  the edges,  introduced  double
threads; through the loops on one  side was inserted a cylin-
der of some round substance parallel with the border of the 
80
VESICO-VAGINAL FISTULA.
 opening, and along the other side a second, over which the
 free ends of the sutures were tied, forming a quilled suture.
   Thus far the fistula  under consideration has proved more
 than a match for the skill of the ablest of the old world, and
 now we turn to American surgery to have our hopes revived
 and faith strengthened.
   In 1839 Dr. George  Hay ward, of Boston, reported a case,1
 which he had  succeeded  in curing.  His patient  was  a
 lady aged 34 years, in excellent health, and who had  been
 delivered  15 }Tears previous, with instruments, after being
 in labor three  days, during which time no urine had  been
 drawn from the bladder.  A slough was  the consequence,
 opening a communication between the vagina and bladder.
 Attempts had  been made  with  the catheter and also by
 cauterization to close  this fistula, but without success.  Dr.
 Hayward operated on the 10th  of May.  The patient was
 placed on the edge of  the table,  upon her back, very much
 as in the position for lithotomy; the  parts well dilated  (he
 does not state how); a  large bougie passed into the bladder
 and carried back to the fistula, by which he was able to bring
 it into view.  Thus fixed, an incision was  made round the
 opening with a scalpel,  and after the bleeding ceased, the
 membrane of the vagina was dissected away from the bladder
 to the extent of three lines.   Three silk  threads were next
 introduced by curved  needles through its sides, drawn to-
 gether and  knotted firmly  down ; a  short silver  catheter,
 prepared for the purpose, was placed  in the bladder, and the
 patient put to bed. In five  days she was examined, the
 stitches cut away, and  the parts  found to be solidly united.
 In 1851 Dr. Hayward  published an  account of eight addi-
 tional cases, making in all  nine cases, three  of whom  had
 been cured after twenty operations.2
  In these cases of Dr.  Hayward there  was nothing  new, un-
less it was the peculiar catheter.   It had often been practised
before, but in  his hands was crowned with a success  calcu-
lated to inspire confidence in the curability of the affection.

   1 American Journal of the Medical Sciences, August, 1832.
    2 Boston Med. & Surg. Journal, vol. xliv., No. 11, April 16, 1859. 
TREATMENT.
81
  In 1847 Prof. Joseph Pancoast1 succeeded in effecting two
cures.  The posterior or upper lip of the fistula was exposed
by a Charri&re  speculum, and split one-half inch  deep in  a
longitudinal  direction; with a pair of scissors and bistoury
the lower lip was next pared  into a wedge-shaped form, and
this tongue of raw tissue drawn into the groove in the upper
border by  what he  called his plastic suture.  The bladder
was kept empty  by a gum-elastic catheter,  and after the
second day, injections of zinc were thrown into the vagina
to give tone  to the parts.  On the fourth day a solution of
the nitrate of silver was applied  over the line of apposition,
to favor  union by granulation, where that  by the first inten-
tion failed.   In this method we have a repetition of the plan
of Blasius.
  In the same  year Dr. John P.  Mettauer published in the
American Journal of the  Medical  Sciences, for July, 1847, the
history of a fistula, which he cured by inserting leaden sutures
after paring its circumference.  The bowels were kept closed
for eight days, and  the  stitches  allowed to remain thirteen
days, during which time a short catheter was worn in the
bladder.   The metallic thread used by the operator in this
instance  was undoubtedly the procuring cause of so fortunate
a  result.  Just at this point commence the most  important
facts in the history of our subject.
  In 1852 Dr. J. Marion Sims, of Alabama, solved the whole
difficulty, and  placed this vexed  and perplexed  operation on
a solid and substantial foundation.  The  discoveries which
he advanced as peculiarly his own were the following:—
  1st.  A method by which the vagina could be thoroughly
explored, its capacity greatly increased, and the fistula made
readily accessible.
  2d.  The introduction  of  a suture which would  remain  a
long time without inducing either irritation or ulceration.
  3d.  A mode of keeping the bladder drained of the urine.
  The first was accomplished by placing the  patient on the
knees and elbows, the hips being elevated, and using a spec-

  ' American Journal of the Medical Sciences, Oct. 1842.  Med. Exami-
ner, May,  1847. 
82               VESIC0-VAG1NAL FISTULA.

ulum which, from its form, is called the duck-bill speculum ;
the  second, by substituting  the ordinary thread  with  a
metallic (silver) one, aided by leaden clamps; and  the third,
by a self-retaining catheter.
  There can be little doubt that Dr. Sims reached this  im-
portant combination of improvements  quite  independent,
perhaps, of foreign  aid ; yet by  reference to  the historical
enumeration of methods which I have  detailed,  it will be
found almost all have  been  conceived and executed by pre-
decessors.   In  illustration of this, let them be examined in
detail.
  First. The Position.—This was recommended and practised
both by Chelius and Walter, the latter of whom employed a
blunt hook for opening the vagina, which executed in a good
measure the office of the duck-bill speculum.
  Second.  The Suture  Apparatus.—In 1834, Gosset, of Lon-
don, employed the metallic thread ; Deyber also; the former
gilded wire, the latter lead.   Beaumont carried his sutures
around little cylinders, placed one on each side of the fistula,
thus resembling the clamps.
  Third.  The self-retaining Catheter.—Dr. Mettauer employed,
in his case, a short  instrument which was worn  in the blad-
der during; the cure: so that reallv all these novelties have, at
some time or  other, engaged  the notice of surgeons during
the long years of experiment and device which have marked
the history of  vaginal  fistula.  Still,  however, the undivided
honor  of  combining, modifying, and utilizing, all belongs,
and  only belongs to Dr. Sims.

                   Dr. Sims's  Operation.
  Position  of the Patient.—A table is selected 2|  by 4 feet,
covered with  folded  comfortables;   on  this the  patient  is
placed, resting on her elbows and knees, the latter separated
six or eight inches,  the pelvis  being elevated, and the shoul-
ders depressed.  An assistant on either side, placing a hand
in the fold between the nates,  the fingers extending quite to
the greater labia, simultaneously draws them  asunder.   The
viscera gravitating  toward  the thorax, and the air rushino-
into the vagina on  the separation of the walls of the vulva, 
DR. SIMS'S OPERATION.                  83
distend the canal so as to offer a very complete interior view.
To increase its capacity for a more thorough exploration, the
Sims speculum (Fig. 19) is next introduced, and drawn back
toward the sacrum by  one of the  assistants. (Fig. 20.)

                           Fig. 19.


                H



          Vaginal speculum similar to Situs's—Cozerman"s pattern.

                          Fig. 20.
     Exhibits the speculum in situ, with the relative position of the organs.

  If the illumination is not sufficient, a mirror (Fig. 21) may
be used to reflect the light into the canal.
  Paring the Fistula.—For this  purpose a small sharp hook
or tenaculum  is  passed into  the circumference of the fis-
tula,  and  while  thus  brought  into  proper  position, and
 
84
Fi-. 21.
VESICO VAGINAL  FISTULA.

                   Fie. 22.
  Mirror to throw the sunlight
      into the vagina.

 made sufficiently tense,
 a long, sharp-pointed
 bistoury ' is   applied.
 (Fig. 22.)  If the vesi-
 cal mucous membrane
 concealed the margin
 of the  fistula,  inter-
 fering with its proper
 management,  a  soft
 sponge should be pass-
 ed through  the open-
 ing  into the bladder,
 and allowed to remain
 until the  stitches  are
 ready for  adjusting.
 The lining membrane
 of the bladder he does
 not disturb, unless it
 protrudes through the
 opening   in   excess.
 When the fistula was
very small he hooked
the tenaculum through
both sides, and raising
Tenaculum fastened in the-fistula, and the bistoury
        applied to its circumference. 
DR.  SIMS 3 OPERATION.
it up, cut out a circular portion with the bistoury.  During
the operation  little  mops  (Fig. 23),  to remove  the  blood,
should be on  hand.   These are readily made by securing
small bits of sponge to whalebone or rods of wood.
  Application of the Clamp Suture.—This may be divided into
three stages: the  introduction of the silver wires; the at-
tachment  of the clamps;  and  the  approximation  of the
wound, with  the  securing
Fig. 23.
Fig. 24.
of the apparatus.
  First. Introduction of the
Sutures.—In the execution
of this he  passed a  silk
thread through  the eye  of
a  long  awl-shaped needle
(Fig.  24), and  entering  it
half an inch from the fresh-
ened  edge of the  opening,
carried  it  downward  and
forward across the wound,
and bringing it  out half an
inch above the  raw margin
of the opposite  side, taking
care not to include the mu-
cous membrane of the blad-
der.   As the needle passes
through the distal side, the
tissues will require support,
that they press not away
from  the instrument,  and
thus counter-pressure is sup-
plied  by a blunt  hook be-
hind  the needle (Fig. 25).
   As soon as  the  needle
emerges,  and  the thread
comes fairly into view, a
long  tenaculum is hooked
into the loop, and one end
drawn  through (Fig.  26),  A sponge mop. Needle for passing sutures. 
86
Fig. 2o.
VESICO-VAGINAL  FISTULA.

                      Fi<r. 2ft.
The blunt hook between the
  needle and tissue to favor
  its passage.
Exhibits the tenaculum drawing the thread
            through.
after  which the needle is withdrawn, leaving the suture in
its track.  In  this manner  the requisite  number of threads
are deposited across the wound.   The  next step  consists in
substituting the silver threads for the silk, which is readily
accomplished by binding  the end of the former into a crook
or link, and making  fast  to it the distal  end of the latter. 
DR. SIMS'S  OPERATION.                 87
By drawing on  the proximal end of the thread  the wire is
towed into  its place; the  threads being  only designed  to
favor the insertion of the wires.   In this process a difficulty
         Fiir. 27.
Fio;. 28.
                                Upper clamp attached.

                      very naturally occurs—that of  the
                      threads or wires, as it may be, cutting
                      into or even tearing out of the tissue,
                      on the distal side of the wound, as
                      they are pulled upon.  To counteract
                      this he  employs  a  crescent-shaped
                      fork to push the suture  above  the
                      orifice while  traction is being made.
                      (Fig. 27.)   The silver  sutures being
                      all  passed, the second  stage of  the
                      process consists in the
Attachment of the Clamps.—Two little bars of  silver or lead,
A silver thread .-ecured to me
  silk one. with the fork in situ
  to fnvor the pass.ajre through
  the upper punctures. 
88
VESICO-VAGINAL FISTULA.
a trifle longer than the fistula, are perforated with a number
ot holes, corresponding to the number of sutures.   Through
these the  upper  end of each wire is passed, and fastened  by
widening  it  about the bar, or passing it  through a  shot.
               (Fig. 28.)  This completed, the lower ends of
    Fig. 29.     the wires  are drawn upon, when the clamp
               will be carried  into the vagina, and take its
               place above and parallel with the upper border
               of the wound.   During this adjustment a
               fork of another kind  (Fig. 29)  is  used as a
               pully, to prevent  the wires cutting into the
               flesh. In  the same manner, the other ends of
               the  wires are  passed  through the  second
               clamp. (Fig. 30.)
                  The Adjustment.—The proximal ends of the
               wires being  drawn  upon, and the clamp
               pushed up with the fork at  the same time,
               the raw surfaces are brought in contact with

                                 Fi<?. 30.
The adjusting fork.
Both clamps on the wires, and perforated
    shot behind the proximal one.
each other, in doing which, care and judgment are requisite
that they be pressed together sufficiently tight to prevent 
                   DR. SIMS'S  OPERATION.                 89

gaping, and yet  not so forcible as to endanger strangulation
or ulceration.  To maintain the apparatus in position, a per-
forated shot is passed down  each wire, and being pressed
                           Fig. 81.
Shot compressor.
against the  clamp, is  then fastened by  compression with a
strong pair of forceps. (Fig. 31.)  The wires are next cut off
short, and  bent over the shot.
                           Fig. 32.
          Exhibits the wound adjusted with the suture apparatus.
  The appearance of the wound, when  adjusted, with  the
suture apparatus in position, is represented in Fig. 32.
       7 
90
VESICO-VAGINAL FISTULA.
  The  After-treatment.—The operation being completed, the
patient is placed in bed, on the back, a self-retaining catheter
placed  in the bladder (Fig. 33), and a full dose  of opium

                          Fig. 33.
Self-retaining catheter of Sims.
administered,  to  be  repeated as often as may he necessary
to keep the bowels quiet.  The diet is to consist of  crackers
and  coffee or  tea.   During the  progress  of the case, the
vulva and other portions of the external  genitalia are to
be bathed with cold water, a  bed-pan being placed  under
the nates, to  collect the fluid as it runs from  her person.
The  urine is  to  be  received on old cloths  as it drops from
the catheter.   On the  ninth or  tenth day the  clamps and
sutures are to be removed, and, if well, the  patient  required
to wear the  catheter for several  days longer.  About the
twelfth or fifteenth day the bowels should be opened by some
mild cathartic.
  Such  are the general  features of Dr. Sims's operation, and
from this dates the successful surgical management of vesico-
vaginal fistula.

               Dr. Sims's Later Operation.

  To the clamp  there  are  objections, and  these were soon
discovered by Dr. Sims, and the operation so modified as to
add greatly to  its simplicity and perfection.  The modifica-
tions consist in the introduction of the metallic threads with-
out  those of  the silk,  and dispensing entirely writh the
clamps, adjusting the wound  and  securing  the wires  by
twisting alone, which he accomplishes by drawing, with a 
DR. SIMS'S LATER  OPERATION.
91
pair of forceps, the ends of the wire through  the  slit at the
end of his adjuster  (Fig. 34), and then,  while thus firmly

                         Fig. 34.
held,  the forceps, by a rotary movement, twirls  the  wires
about each other, so as to make them secure. 
92               vesico-vaginal fistula.


           Operation of Dr. Xathan Bozeman,
                   FORMERLY OF ALABAMA.
  The name  of Dr. Bozeman is  well  known,  both in this
country and abroad, in connection with vesico-vaginal fistula.
                Several papers from his pen have  appeared
    Fig. 35.      on £ne subject, all proving unusual dexterity
 /^■BH^^,   and  success as  an   operator.   The chief
 ^^^^^^^S|  novelty in his method is what  he terms the
 ^BIBSHJf   button suture (Fig. 35), composed of a piece
  Bozeman'slead    0r* ^nm ^ea(^ CU^  ^°  n^  ^he Opening, and
    button.       having in  it small holes answerino- to the
Fig. 36.    Fig. 37.   Fig. 38. Fig. 39.        Fig. 40.
 
dr. bozeman's operation.               93
41.
number of wire sutures  employed ;  also leaden crotchets to
secure the button.  The patient is  placed  in the  position
recommended  by Sims; a  duck-bill
Bozeman speculum introduced;  and
while the  parts  are  controlled  b}>- a
long tenaculum or forceps, the edges
are pared  by straight and curved bis-
touries—sometimes using  the curved
scissors.  (See Figs. 36, 37, 38, 39, 40.)
This  clone, the  requisite  number of
silk threads are introduced with short,
straight,  spear-pointed  needles, from
half an  inch to one  inch in length,
grasped in the jaws of a needle-holder.
(Fig. 41.)  The needle is entered some
distance from the freshened border,
and carried obliquely through,  first
the proximal side of the fistula, pene-
trating as  deep as the vesical mucous
membrane, and  then, after  being ad-
justed  to  the needle-holder, through
the distal side, being drawn through
with a pair of long forceps, counter-
pressure  being  made  with a  blunt
hook, similar to  Sims's  instrument.
The threads being all passed, each one
is securely fastened by its lower end to a
silver wire, and as the one is drawn out
the other takes its place, a fork being
used, as in Sims's method, to guide the
sutures and  support the soft parts.
   The  next step consists  in passing
both ends of each suture through an
instrument called an adjuster (Fig. 42),
and drawing on the wire, as it is run
down, the wound is  brought together
and a set  given  to the  thread, which
contributes to so maintain it. (Fig. 43.)
Bozeman's needle-holler—a
 long stem with two claws at
 its extremity, with a canula
 to slide up and down, clos-
 ing and opening the jaws.
 Also examples of the Boze-
 man needle. 
94
VESICO-VAGINAL FISTULA.

        Fisr. 42.
                           Adjuster.
 The wires are  next passed through  the perforations in the
 lead  button, and  the latter  pressed  down upon  the line of
                        approximation, and made to conform
        Fi£- 43-          to the surface against which it rests
                        by means of an instrument represented
                        in Fig. 44.
                          To  secure  the  button firmly  in
                        place, pieces of lead or crotchets are
                        run down  the wires  (Fig.  45) and
                        compressed  by  a pair of strong for-
                        ceps, both on wires and button.  The
                        operation is finished  by cutting off"
                        the wires a short distance above the
                       crotchets, and turning an end  down
on either side.  (Fig. 46.)  The  patient is placed in bed, on
her back, the catheter introduced, the bowels kept closed by
opium, and an unirritating diet allowed.
                           Fig. 44.
The sutures after being passed
   through the adjuster.
Bozeman's instrument, having an angular and concave extremity, to model
       the button to the surface of the vesico-vaginal septum.
Fisj. 45.
Fig. 46.
Button and crotchets
  adjusted, wires cut
  and turned down.
Exhibits the crotchets being
  passed down the wires. 
dr. Simpson's operation.
95
          Operation of Dr. J. Hunter McGuire,
                 FORMERLY OF PHILADELPHIA.
  The patient being placed in the position recommended by
Sims, the edges are to be pared with a long-handled bistoury,
and  brought  together  with the instrument  delineated in
Fig. 47.   This consists of
a plate of silver, having a              Fig. 47.
hole near each extremity,
and  three  needles, slight-
ly curved, soldered to its
front surface, a second  sil-
ver plate, of the same size
and shape as the first, hav-
ing  fastened  to each  end
a thread-screw,  and three
holes corresponding in po-
sition  to the three  needles
on  the  other plate,  and
lastly, two female screws.
   Application. — With  a
strong pair of forceps  the
plate supporting  the needles is grasped, their points passed
through the  posterior  lip  of the  fistula, and brought out
through the anterior one.  Through the perforations at either
end of this plate  are next passed  the thread-screws of the
other plate, and  through  its perforations the extremities of
the  needles.  The female  screws  are  next run down the
thread, forcing the clamp  together, until the  edges are in
close contact.

         Operation of the late Dr. J. Y. Simpson,
                        OF EDINBURGH.
  The operation of this distinguished  Scotchman,  certainly
one  of the representative  medical men of his age, differs
chiefly in substituting for the Bozeman button a wire splint,
prepared as follows: He takes ten or fifteen strands of metallic
thread and twists  them into a  cord, the ends of which are
Representing McGuire's instrument for
      vesico-vaginal fistula. 
96
VESICO-VAGINAL FISTULA.
Fig. 48.   Fig. 49.   Fig. 50.
Dr. Simpson's needle, with a wire in-
 serted. Simpson's crotchet and hook.
then doubled over each other
and plaited  round  into the
form of a circle, which may,
being very flexible, be pressed
into any figure desired.  With
an awl or any sharp-pointed
instrument the required num-
ber of holes may be made, by
passing it through among the
wires.  These perforations are
for the iron thread  sutures.
For the introduction of the
sutures Dr. Simpson  uses an
ingenious needle (Fig. 48), to-
gether with  a crotchet (Fig.
49), and a hook (Fig. 50).
   The  needle consists of  a
hollow  tube, with  a needle-
point, one opening being near
the end, and the other near
where the  handle and shank
join.
   The  mode  of  using  is
readily  understood. The wire
thread  being pushed within
a short  distance of the upper
orifice,  the needle is  carried
through both  sides  of the
fistula, after which the thread
is  thrust forward.  As soon
as it appears, it is to be seized
with  a  pair  of forceps, and
held while the needle  is beino-
withdrawn, thus leaving the
suture in  situ.   By a repeti-
tion of this process the requi-
site  number  are  introduced.
He prefers the iron  wire, as 
dr. Simpson's operation.
97
more easily managed than silver.   His  sutures are  next
passed through the openings in the wire splint (Fig.  51), the
latter  being pressed  down  over  the line of apposition, and
the wires secured by twisting with his wire-twister (Fig. 52),
constructed on a plan which was suggested by Dr. Coghill.

                 Fig.  51.                     Fig. 53.   Fig. 52.
            "*" -                          Simpson's wire-twister.
Simpson's splint adjusted, wires secured across the     The same, with the wire
               lower bar.                     in and partly twisted.
  The ends of the metallic threads are next clipped off close
to the splint (Fig. 54), and the after-treatment conducted on
the same principle as that of other operators. 
98
VESICO-VAGINAL FISTULA.
  Figs, from  20 to 34 inclusive have been copied from Dr.
Sims's paper on Vesico-Vaginal Fistula; from 35  to 46 from
Dr. Bozeman's illustrations of his method; and from 4S  to
54 from Dr. Simpson's contributions to the same subject.

           Operation of Dr. Isaac Baker Brown.
  For paring the fistula he uses straight and angular knives;
for the passage of the metallic sutures, Simpson's needle; and
for  securing the threads, little  crotchets or clamps of lead,
run down and compressed  with  a strong pair of forceps.  His
operation dates 1860.

            Operation of Dr. Robert Battey.
  The  peculiarity  of  Dr. Battey's  method consists  in  a
metallic (lead)  button (Fig. 55), having a series of holes on
                         Fig. 55.
                       Battey's Button.
one border, and on the other a corresponding number of slits.
The upper ends of the wire after being inserted  are  passed
through the holes, the  other ends forced into the slits, and
both fastened by twisting them about each other.  He claims
for it a water-tight adjustment.

                  Operation of Collis,
                        OF DUBLIN.
  This method, described in 1862,  consists  in splitting  the
vesico-vaginal septum  along the entire circumference of  the
fistula; turning the vesical side toward  the  bladder, and  the
vaginal side toward the vagina; the sutures he employs are
silk, and introduced as double threads, with Liston's needles
secured on long handles.   When the threads are all inserted
there will be a row of loops on one (the upper) side, and two
free ends on the other side of the fistula.  A vulcanized quill
is next passed through the loops above, and a second placed
along the lower border of the opening, and the approxima-
tion effected by tying the free ends of the threads firmly
around it; it is a quilled suture. 
author's operation.
99
             Operation of Dr. Alfred Meadows,
 PHYSICIAN-ACCOUCHEUR TO THE GENERAL LYING-IN HOSPITAL, LONDON.
  The novelty of this method consists in allowing the patient,
after the parts  are  pared, and  closed with silver threads, to
rise and  go about  as  usual, dispensing altogether with  the
catheter.  He publishes two  cases, which  it is alleged were
treated successfully in  this way.  I should not feel disposed
to subject a patient to  such a treatment without some further
accumulation of data.
                   Author's Operation.
   Having presented the various operations in historical suc-
cession, I proceed to state the plan of treatment practised by
myself for  several years, with  results  the most satisfactory.
Nothing original is claimed  for the method.  Except in a
few particulars, it does not differ from modes pursued by others.
   Arrangements for the Operation.—Among the first things to
be attended to is the bed on which the patient is to lie.  This
should be a firm mattress; but should the circumstances of
the patient  be such as not to command  this, a feather bed
may be well beaten  down  and covered  with two  or three
comfortables,  so  as to  give  it a  certain degree of solidity.
Over that part where the hips  are  to rest there should be
spread a  strip of oil-cloth, and over this a folded sheet, the
object being to protect the
bed.  A low stool should               Fig. 56.
be procured and turned
upon its side,  over which
should  be placed one or
two folded  blankets, and
over  these again a piece
of oil-cloth, the whole to
be secured by  a few turns
of a roller. (Fig. 56.) This
forms  an excellent sup-
port, across which the patient  is to be turned.   There will be
required two basins, one bucket for cleansing, and another for
Stool covered, over which to place the patient. 
100
VESICO-VAGINAL FISTULA.
the bloody water, several mops or sponges; readily formed by
securely tying small pieces of soft clean sponge to the ends of
sticks or pieces of whalebone; a six or eight-ounce syringe,
and some pieces of ice.  There is some difference of opinion
as to the exhibition of an anaesthetic.  In  no operation do I
think its exhibition more  imperative than  in vaginal fistula.
The position and exposure are calculated to shock the feelings
of any female possessed of ordinary sensibility, and I have in all
cases administered this agent with the most satisfactory result.
   Assistants.—There will be required four assistants; one for
the sponges, one  for each  lower extremity, and  one for the
anaesthetic.  As such an operation is rarely completed in less
than half an hour, and  may be prolonged to even two hours,
the assistant having charge of the anaesthetic should be per-
fectly familiar with his duty.
   Time to Operate.—As a  good light is all-important to the
successful execution of this operation, the forenoon  of a clear
day should be selected, and a  room whose windows have a
northern or southern exposure.
   Instruments.—The instruments which  have been and are
still being  invented  for this operation constitute a most for-
midable armamentarium.   I shall content myself by  pre-
senting a list of such as compose  my own case, and which I
have found to answer every purpose.
   A duck-bill speculum (Fig. 57); two long-handled scalpels
(Fig. 58); one pair of my  long  rat-toothed forceps, slightly
curved, with an attachment at the end of the handle, em-
bodying the adjustor, for running  down the  wires, and the
crotchet to favor by counter-pressure the passage of the needle
through the distal side of the fistula (Fig. 59); a needle-holder
which  can with one hand be detached  from the needle, or
again made to grasp it, and by which the needle can  be in-
troduced at any  angle  (Fig. 60);  one  pair of long scissors,
curved a little on  the flat  (Fig. 61); a shot compressor (Fig.
62);  this instrument, to  be  efficient, should have  strong
handles, and the articulation less than half an inch from their
extremities; a shot  perforator (Fig. 63); two sigmoid self-
retaining  catheters (Fig. 64); the  openings in which should 
Fig. 37.
AUTHOR S  OPERATION.




  Fig. 58.         Fig. 59.
101
Fig. 60.
Fig. 62.
Fig. 63.    Fig. 64.
 
102              VESICO-VAGINAL FISTULA.

be very small, otherwise the mucous membrane of the blad-
der will insinuate itself through them, and  become strangu-
lated, rendering  its withdrawal impossible  without tearing
the incarcerated portions;  one dozen of needles; these should
be constructed with great care, seven-eighths of  an inch in
length, slightly curved for one-fourth of an inch  at the ex-
tremity, the cutting-edge  confined only to the extent  of the
curve, and sufficiently wide to allow the proximal part to pass
without tugging and pulling, as is too often the case (Fig. 65).

                         Fig. 65.
The eye should be well sunken, so as to bury the thread, and
the whole so tempered as to bend rather than break; fine silver
wire; some ISTo. 3 shot; and twelve or fourteen inches of light
gum-elastic  tubing, to slip over the end of the catheter, and
thus convey the urine to a bottle or  other vessel placed be-
tween the patient's limbs.

                       Operation.
  The patient, having removed all her clothing, save a chemise
and night-gown, lies down upon the bed, and  is brought
under the influence of the anaesthetic, nothing having been
communicated to her about the position in which she is to be
placed.   When sufficiently unconscious, the stool, prepared
as directed, is placed  across the foot or side of the bed, and
the patient carefully lifted and placed over it, resting on her
abdomen, two or three  pillows being laid under her breast
and head in  such a way as to form an inclined plane.  The
head must be turned  on one  side, and a free access of  fresh
air  admitted to her face.   The person having  charge  of the
anaesthetic must take his position so as to have a full com-
mand of the pulse  and countenance, keeping her  perfectly
passive,  without  profoundly  impressing her.   There  are
periods in the operation when very  little need be  given, as
when the surgeon is waiting for the  bleeding to cease; and
again, when  the apposition and adjustment are being effected;
at such  times very little pain is  inflicted.  The  legs, being
next flexed  upon  the thighs, are given over to assistants. 
operation.                    103
The operator now takes the speculum, smeared with oil, and
introducing  it  into  the  vagina, commits it to one of  the
assistants having charge of the limbs, who draws  it firmly
toward the rectum, when  the air, entering  the vagina, ex-
pands the tube in the most satisfactory manner.   (Fig. QQ.)

                           Fig. 66.
Exhibits the woman resting on her abdomen over the stool placed across the bed,
  and the assistants supporting the limbs ; one of them also holds the speculum,
  which has been passed into the vagina.

The surgeon now takes his seat in a position to command  a
full view of the fistula, and seizing its lower margin with the
forceps, enters the knife  from three-eighths to half an  inch
from the opening, bringing  it out  just short of the vesical
mucous membrane, and  by  successive sawing movements
paring away until the entire circumference of the fistula has
been freshened.   Should the  mucous membrane of  the blad-
der protrude, a piece of sponge may be pressed through  the
opening to  keep it out of the way.   The  greatest difficulty
in executing this part of the operation will be experienced at 
104
VESICO-VAGINAL  FISTULA.
the angles or commissures of the opening, and too much care
cannot be observed that no  point  be  overlooked.  If it  is
properly  clone, there should be at least three-eighths of an
inch,  or  more,  of oblique raw surface visible  everywhere
around the fistulous opening.   The tendency to  inversion  of
the vagino-vesical septum is so great that, unless a consider-
able extent of tissue is removed, there will be danger of not
having a sufficient amount of raw surfaces apposed to secure
adhesion.  There will be cases and situations in this freshen-
ing process where the scissors come  in  more advantageously
than the knife ; such will  naturally occur to the  surgeon  as
he proceeds.  Where the fistula is very small, receiving, for
instance, only the end  of  an  ordinary probe, some advise
transfixing with a long  awl-shaped  instrument, and, raising
the sides, by a single stroke of the  knife cut out a sufficient
amount of tissue.  There is a very ingenious instrument (the
author of which I cannot recall) (Fig. 67), with a conical ex-
tremity standing  at  an  angle with  the  shank,  the base  of
which is surrounded with sharp  teeth, designed  for control-
ling the edges of such  fistulae.  The apex of the cone is in-
serted into the opening, and pressed through ; then, by with-
drawing it, the teeth become fixed into the circumference,
when the knife may readily excise at a stroke the included
tissue.
  There  is another  instrument  (Mr. Hilliard's, of Glasgow)
designed to secure the edges of large fistulae while being
pared, and which consists of a long  shank with  a small
thread at its  extremity, on which may be secured various
sized forks for transfixing, and on this shank a sliding rod,
bearing a bar which  may be pushed forward, and then drawn
back between the forks, so as to compress and secure the in-
cluded tissue.  Figs. 68  and 69 exhibit the instrument and
its application.   There is no  objection to having  all these
instruments, if the taste and the circumstances of the surgeon 
OPERATION.
105
vagina,
of  the
be met
allow it; but that such are essential or   Fig. 68.
even necessary to  the  proper execution
of the operation is certainly not correct.
  Arrest of Hemorrhage.—The  bleeding
which follows the foregoing process  is
not  generally  very profuse,  stopping
under  the application of  cold water,
or  a  lump  of  ice  inserted  into  the
or  even  under   the  styptic  influence
atmosphere;  but  occasionally  cases will
with  where  the discharge of  blood proves both
copious and  persistent.  To control  such irregu-
larities I have found a small stream of cold water,
steadily directed on the parts from a large syringe,
singularly  efficacious.   Should this  not succeed,
the stitches should be inserted and the edges drawn
firmly together,  when it  will cease, just as the
approximation in a  case  of hare-lip arrests the
hemorrhage.
   The Direction of Approximation.—Most operators
favor an approximation of  the sides of  the  fistula  trans-
versely, yet there  are no reasons why they may not be closed
longitudinally.  Case 15 is an example in point.  Such con-
ditions as the following will indicate such an apposition: as
when the fistula runs to any great extent longitudinally; or
when it is low, and either so great a loss of substance or so
unyielding a character of tissue as  to make too much traction
when brought  together on the lower wall  of  the  urethra,
endangering a subsequent incontinence of urine.
  Introduction of the Sutures.—This is regarded by  many as
the most difficult part  of the operation.   The needle bearing
the wire  is  placed in the grasp  of the needle-holder,  and
whilst the proximal border of the fistula is steadied by the
forceps, is entered  at the middle of the wound, three-eighths
of an inch from the freshened surface, brought out  at the
mucous membrane of the bladder (not including it), carried
across  the  opening, made  to  enter the  opposite side,  and
emerge the same distance above its raw surface.  The needle- 
106
VESICO-VAtilNAL FISTULA.
holder is now disengaged from the needle by simply pressing
the upper blade of the instrument while the spring is being
pressed forward by the thumb, made to seize the extremity
now through the upper  border of the fistula, and while the
parts are supported, by applying to them the hook at the end
of the forceps (Fig. 70), the needle is drawn  through, turned,
       Fig. 70.
                              Exhibits the threads passed.

                     and brought out of the vagina.   When
                     the  sides of the opening are too wide
                     apart, the needle cannot be made  to
                     penetrate both at once, and therefore it
                     must be drawn through them in succes-
                     sion.   In this manner  the requisite
                     number  of  threads  are  inserted, the
                     distance between  them  being  a trifle
                     less  than one-fourth of an inch. (FW.
                     71.)   As each is deposited in its proper
                     place the needle is to be removed, the
                     ends of the wire twisted  together, and
                     given in charge of one of the assistants
                     supporting the thighs.
                       Adjustment.—In the  important stage
                     of the adjustment the wire first inserted
                     is separated  from  the  others and the
                     ends passed  through the hole  of the
                     adjuster at the end of the forceps.  As
                     the latter is slid down, the wire is drawn
upon until the edges of the wound are brought into accurate
Needle in the grasp of the
 needle-holder    carried
 through the fistula, and
 the  hook  at the end of
 the  forceps placed be-
 tween the tissues and its
 point, to favor its pass-
 age by counter-pressure. 
OPERATION.
107
contact.   The set which the wire thus obtains is sufficient of
itself temporarily to maintain the apposition.  All of  the
threads are subjected  successively to this  process, and while
being done care must be observed that the edges be properly
everted so as to secure the contact of raw surfaces, and also
that no clot be permitted to lie between them.
  The next step is to secure the sutures permanently, and for
this purpose it has  been my almost uniform practice to use
perforated pellets of shot.  These are run down the wires,
then seized  with the strong compressing  forceps, and while
the metallic threads are being drawn upon, pressed  firmly
against the line of adjustment, and then compressed so  as
securely to maintain  their position.   The sutures are next
cut off close to the shot, leaving no projecting ends to irritate
the soft parts (Fig.  72), the speculum  withdrawn, the blood
sponged away, and the  patient placed on her  back on the

                          Fig. 72.
    Exhibits the edges of the wound apposed, the shot compressed on the wires,
                      and the latter cut off.

 bed prepared for her reception, after which the catheter is to
 be  introduced into the bladder and carefully Avatched to see
 if the urine flows freely through its canal.  In order to  keep
 the clothing of the patient and the bed perfectly dry, a light
 piece of gum-elastic tubing may be  drawn over the  end of
 the catheter, and its other extremity inserted  into a bottle
 which shall lie between the patient's limbs; or a small earthen
 vessel  or cup may  be  placed beneath the instrument, and
 receive the urine as it drops from its extremity.
  After-treatment.—Too much importance cannot be attached
to the  after-management of the case, as on this will depend,
in a great degree, the success of  the operation.  The nurse
should understand  the  manner of introducing and removing
the  catheter;  if she does  not, five minutes'  instruction, by 
1 OS
VESICO-VAGINAL  FISTULA.
showing her the mode, will suffice to enable her to do so,
unless she be unusually dull of apprehension or imitation.
It should be examined  frequently to see that no obstruction
exists, that it does not become misplaced, and  that the urine
drops freely.  This is imperative, for it often happens for the
first twelve or twenty-four hours that small coagulae of blood
are expelled  from the bladder, and which may obstruct the
instrument.   Two catheters should  be  always on hand,  so
that one may be introduced  immediately on the withdrawal
of the other.  After  thirty-six or forty-eight hours, twice a
day will be sufficient to  change the instrument, in the morn-
ing and at bedtime;  and it can best be cleared of mucus and
other matters by inserting the nozzle of a syringe  into one
end and forcing  through it a stream of water.  If the blad-
der is kept  perfectly empty, the  collapsed state of its walls
will prevent all tension on the sutures, and diminish greatly
the chances of urine getting between the edges of the wound,
an accident which will almost always defeat the union.  The
position  best suited  to the  patient is that  on  the back,
although  there   are  no  objections to  her  turning  for  a
short time on  the  side to  relieve a sense of weariness or
discomfort.
  The next important thought is to lock up the bowels and
keep her free from all pain and uneasiness.  For these  ends
we have no  better agent  than opium.  One  or two  grains
should be given as soon  as she is adjusted in bed, after which
from a third  to half a grain three times a day, for five or six
days, will answer.   From this  until the removal of the
stitches,  the  fourth  of  a  grain,  morning, noon, and  night,
will maintain the effect  produced.   I do not  think there  is
any advantage in exhibiting this  drug beyond what is just
sufficient to keep the bowels quiet;  more than this tends  to
impair the digestion, disturb  the secretions, and destroy the
appetite.  Occasionally  the patient will be seized with an
uncontrollable desire to bear down, or an involuntary con-
traction of the bladder,  often driving the catheter from the
urethra;  in such conditions we must resort to enemata, con-
sisting of two  or three  tablespoonfuls  of flaxseed tea  or 
OPERATION.
109
starch-water, with forty drops of laudanum, repeated once or
twice in the twenty-four hours, if necessary.   No  injections
of water into the vagina should be practised, as directed by
some; nor any  explorations with  the  finger; the  vaginal
mucus which collects about the wound and the sutures does
no  harm  whatever.   Should the  patient be annoyed with
tympanitic  distension of the  abdomen,  which not unfre-
quently occurs, a little  camphor-water and aromatic spirits
of ammonia may be given, or a little turpentine in mucilage
of gum acacia from time to time.
  Diet.—The patient should be allowed a liberal but unirri-
tating diet.  Milk, soft-boiled  eggs, cream toast, chicken or
beef broth, mutton chop,  with  coffee and tea, offer a suffi-
cient list from which to select her food.
  Removal of the Sutures.—On  the  eighth or  ninth day after
the operation the stitches should  be removed, and  for this
purpose the patient may  be placed on the  side, her  limbs
well drawn up, and hips over the edge of the  bed, before a
good light;  or she may rest on her knees and elbow.  The
removal of the sutures not being painful, the  administration
of an anaesthetic is unnecessary, unless the patient be timid
and shrink from the  exposure; in which event it  should be
given.  The number of assistants  requisite for the object in
view will be  determined by the  taking  or  not taking an
anaesthetic.  In the former, there will be needed one to take
charge of the ether or  chloroform, and two  to support the
limbs and manage the speculum.   In  the  other case a single
assistant will  be sufficient.  The  catheter being  removed,
the  patient is placed  in position and the  speculum inserted
and given to the assistant.  The  parts being  satisfactorily
exposed, the surgeon clears away the mucus from the sutures
with a piece of moistened sponge; then taking hold of a
shot with the long forceps, lifts it from the  parts until the
wire is distinctly seen, and with the  scissors clips it on the
proximal side (Fig. 73), straightening the end at the same time
by  pressing it  outward with the  blade of the instrument.
This done, plant the blade of the scissors against the loop on
the distal side, and drawing on  the  shot with the forceps the 
110
VESICO-VAGINAL FISTULA.
suture will come away by revolving about the blade of the
scissors as a point aVappui.  (Fig. 74.)
Fig. 73.
Fier. 74.
Exhibits one of the
  stitches after its
  removal, with the
  shot   attached.
  The loop should
  be  represented
  more open.
    Shows the suture seized with the forceps and being clipped by the scissors.
               From Simpson's work on Diseases of Women.

  The detail given in what may seem a very simple matter
will be appreciated when  the reader who has not, may have
occasion to  perform  the  operation.   If  neatly executed it
will save the patient  some sharp pain, and  not  endanger the 
OPERATION.
Ill
laceration of the cicatrix.   The stitches being all  removed
after the manner just explained, the result will be revealed;
if favorable,  the patient is to be  replaced in bed and  the
catheter again introduced.
  After two or  three days the bowels should be opened by
administering a  teaspoonful of castor oil or a seidlitz powder
every four or five hours, until a free  evacuation is procured.
The object in thus exhibiting the cathartic is to thoroughly
liquefy or soften the fecal  accumulations and prevent tension
or straining during defecation.   This result may be promoted
by the employment of an enema of tepid water just before
the evacuation.  Five or  six  days  after the removal of the
stitches the  patient must  continue  in bed, and  wear the
catheter, in order to take off all tension  from the cicatrix,
and allow it to attain considerable consolidation.  After this
the instrument may be removed and she may be allowed to.
walk about,  remembering  to pass  the  urine frequently and
not allow the bladder for several weeks to become distended.
Should  the union not have taken  place, and a considerable
portion  of the fistula remain  unclosed, the catheter may be
removed at once, the bowels opened, and the patient allowed
to rise and go about as usual.   When  it  is  discovered that
union has taken place save at a single point, so small, for
instance, as to be readily closed by  a single stitch, introduce
at once  that stitch, scarify well the  edges and approximate as
before ;  continuing the management of the case in all respects
as in the  primary operation, for six or eight days longer;
the probabilities are it will  succeed.   In one of my cases
(Case 3) it was so done, and with complete success.  No ap-
prehension need be  entertained in  regard  to keeping the
bowels so long confined.
  Causes of Failure.—These will be found referable to some
one of the causes enumerated below.  1st.  Imperfect freshen-
ing of the margins of the fistula.   2d.  Mal-adjustment.  3d.
Insufficient tissue from loss of substance, thereby rendering
the permanency of  the sutures uncertain.  4th. Diarrhoea
accompanied with tenesmus.   5th. Soft state of the tissues,
permitting the  sutures to  cut through  readily.  6th. En- 
112
VESICO-VAGINAL FISTULA.
feebled state of the health.  7th.  Thin condition of the sides
of the opening.  8th. Proximity to the cervix uteri.
  In regard to the first and second, the fault, being with the
operator, can  only be remedied by care and experience.  The
third  is not always  incapable of being remedied; much may
be done by deep stitches, incisions  to relieve tension, and,
rather than abandon the case as  hopeless, a plastic operation
as practised by Jobert, taking a flap from  the inner  surface
of the labium.   Should  these fail, then  it would  be better,
rather than  allow  the woman  to remain in so miserable a
condition, to  freshen the outlet of the vagina and close  up
the canal,  making  a common cavity of  it and the bladder.
The fourth complication (diarrhoea and tenesmus) will be best
met  by enemata of laudanum or  suppositories of  opium.
The sixth (feeble health) by tonics, nutritious diet, and pure
air.  Seventh (thin  edges of the fistula); these may be  greatly
improved by  scarifications and  the application of the nitrate
of silver every three or four days to the circumference of the
opening.  Eighth (proximity to the cervix uteri); when the
fistula is situated in or extends to the cul-de-sac between the
vagina and the anterior  part  of the cervix, any operation  for
its closure including only the vesico-vaginal septum  will be
likely to prove abortive.   To obviate this difficulty when the
ordinary method fails, the anterior semi-circumference of the
cervix should be freshened, and the  vesico-vaginal, similarly
treated, stitched to it, thus turning the os into the bladder.
In one  of  my cases (Case 2) such  a plan was successfully
adopted, and the woman continued  to menstruate  regularly
through the bladder without any inconvenience whatever.
  Failure ought not in  any way  to discourage either patient
or the surgeon.  The rule is to operate until the case is cured,
as such a consummation is certain,  unless there be some un-
usual state of things present.  One caution is necessary here:
The operation should not be repeated until at least six weeks
have elapsed.
   Sequels.—There  sometimes follows a successful  closure of
the fistula a certain degree of incontinence of urine, which
is due generally to one  of two causes.  First, loss of power 
REPORT OF CASES.
113
in the sphincter vesicae, permitting  the urine to escape when
the  bladder is  distended, or during coughing, sneezing, or
even laughing.  This condition may follow when fistula has
been at the neck of the bladder.  The second cause is short-
ening  of the  lower wall of the urethra, with  a  patulous
condition of the meatus—as in cases where the opening is
low  down,  with such  a loss of substance that when  the
stitches  are  inserted  and the parts drawn  together,  the
traction  produces  the effect already stated on the  urinary
canal.
   To remedy these defects, tonics, cantharides, and strychnia
have been prescribed; yet, after all,time is the great restorer,
as the parts tend gradually to assume their original condition.
Should the incontinence be  so great as to produce much  dis-
comfort, an elastic ring pessary may be passed within  the
orifice of the vagina.  In one case  (Case 14) I had to  resort
to this, with the most complete success.

Report of Cases of Yesico-Vaginal Fistula  Successfully
   Treated, and which  have furnished the  basis  of the
   previous Papers.
  Case I.—F. II. was admitted into the Philadelphia Hospital,
Blockley, suffering from a  vesico-vaginal  fistula.  The  fol-
lowing account of the accident was obtained from the patient:
In January, 1858, she gave  birth to a child.  Her labor was
exceedingly difficult and prolonged, to aid which ergot was
freely  administered  by  her medical attendant.  After  de-
livery, for several days she was unable to pass urine, which
continuing to accumulate, and not  being relieved by  instru-
mental interference, she suddenly felt a large  gush of  water
escaping  from the vagina, since which time the  urine con-
tinued to flow by this  route.  In May, 1858, her physician
performed an operation for her relief.  This failing, a second
was  tried two or  three weeks subsequently, with a similar
result.  The operation adopted was, I presume, that  of Dr.
Sims, with the addition of  the Bozeman  button, as she  de-
scribed the  employment of silver  wires  and a lead  plate.
Since the accident she informs me she has not menstruated; 
114
vesico-vaginal  fistula.
 but alleges that when the period comes round a very copious
 flow of urine takes place and continues for two or three days.
 I was invited to see her, July 1st, 1859, by Dr. R. K. Smith,
 Chief Resident Physician, and in company with  himself and
 Dr. Elwood Wilson,  made  an  examination.  An extensive
 transverse  rent was discovered, extending  from one side of
 the vagina to the other, and situated at the bas fond of the
 bladder.   Through this protruded a considerable  mass of the
 mucous membrane  of the  bladder.  At the  request of Dr.
 Smith, and her own earnest entreaty, I consented to attempt
 her relief  by an operation.
  On the 23d of August it was performed in the presence of
 Drs. Smith, Wilson, Levis,  McClellan, Darby, Nichols, and
 the internes of the house, the bowels having the day previous
 been well  emptied.  The steps of the operation  consisted  in
 placing the patient under the influence of ether,  turning her
 over, supported on  the arms and knees, and exposing the
 fistula by inserting rectangular or lever speculae along the
 walls of the  vagina, which  enabled  the  assistants to  draw
 the  parts  well asunder.   The  edge  of  the  fistula  was
 next seized with a pair of long rat-toothed forceps, and well
 pared by  means of a long-handled  straight  bistoury.   As
 soon as the bleeding ceased, nine stitches of silver  thread were
 inserted, the needles being guided by the needle-holder of Mr.
 Gemrig (see Fig. 60, page 101).   The wires being brought out
 of the vagina, the opening was drawn together by passing the
 two ends of each through an adjuster, which was slid down
 to the wound, while the threads were firmly maintained be-
 tween the fingers.   Not being  altogether satisfied with the
principle of the Bozeman button, as it prevented the operator
                        Fig. 75.
seeing the approximation, I had a fenestrated one constructed
out of lead.  (Fig.  75.)   Through  the perforations in  its 
REPORT OF CASES.
115
centre-bar the wires were next passed, the button run down
over the line of adjustment, and there maintained by passing
the ends of each suture through  a perforated shot, which,
being slipped down in contact with the button, was there
secured by compressing it between the blades of a strong pair
of forceps.   The wires  were next collected together, brought
out of the vagina, and  wrapped with adhesive  plaster to pre-
vent excoriation; and  finally, the  patient placed in  bed, on
her side, a catheter (Sims's) was introduced into the bladder,
and the urine received on cloths placed  beneath the end of
the instrument.  Half a grain of opium  was  directed to be
given twice daily, and the diet to consist chiefly of arrow-
root and cream.  The catheter was to be closely watched that
it should not become obstructed, to obviate which, it was to
be removed  once or twice a day, and cleansed.   No constitu-
tional disturbance occurred, nor was there any local soreness
experienced.  On Wednesday afternoon, September 1st, being
ten days after the operation, I proceeded to remove the button
and sutures, when  the  union was found to be  complete.   As
a precautionary measure, the catheter was directed to be worn
eight days longer.   On the  twelfth  day her bowels  were
opened, and again  locked up for five or six days. Ten days
after the removal  of the ligatures, she was allowed to  rise
from her bed and walk about.

  Case  II.—A. M., an Irish woman, about thirty years of age,
during a severe labor, with a first child, ruptured her uterus,
the child escaping into the abdomen.  The foetal head had
not passed below the superior strait of the pelvis, the diame-
ters of which were contracted.   The case being under the care
of the medical  officers  of the Nurses' Home, Dr. E.  Wilson
was immediately summoned to her aid by the attending phy-
sician, Dr. Scholfield.   The propriety of the abdominal section
admitted of no question.  The operation was  accordingly
performed by Dr. Wm. B.  Page, the child removed through
the parietes of the abdomen, and the life of the mother pre-
served.  Some time afterward it was discovered the rent in the
uterine  walls had extended through the cervix, and involved 
116
vesico-vaginal  fistula.
the vagino-vesical septum, giving rise to a fistula.  After the
restoration of the woman's general health, she was placed in
St. Joseph's Hospital, and at considerable intervals three un-
successful attempts were made to close up the orifice, which
was situated near the cervix uteri, and running in an oblique
direction, about three-quarters of an inch in extent.   Two of
these operations were skilfully performed by the Bozeman
method, employing as a retentive  mechanism a lead plate or
button.   The patient was afterward placed in the Philadel-
phia Hospital, under my charge, where, after some preliminary
treatment to improve her general condition, she was  operated
on by the usual  method, seven silver sutures being  required
to close it properly.  On the eighth day the stitches were taken
out, and  the wound found to be only about one-half  closed.
On carefully examining the parts, and reflecting over the for-
mer  failure, I thought I discovered the true source of diffi-
culty, which subsequent events  confirmed.  The proximity
of the fistula to the cervix uteri, the latter organ being some-
what retroverted, prevented an accurate adjustment;  indeed
the os was turned into the fistulous opening, and pressed to-
ward the bladder.   Profiting by this observation,  at the
second operation, undertaken nine weeks subsequently, I de-
termined to turn the os into the opening permanently.  With
this end in view, the  inferior semi-circumference of the fistula
was well  pared.   Next the posterior half of the cervix uteri,
after which eight silver sutures were introduced, and secured
by the shot, the ends of the wire being cut off close to the
latter.  The os uteri was  by this method turned  into the
bladder.   Nothing worthy of note transpired during the sub-
sequent progress of the case.  On the eighth day following
the operation, the parts were examined with a view to remove
the ligatures, which were found in such excellent  position,
without any surrounding irritation, that, at the suggestion of
Dr. E. Wilson, who rendered me valuable service in both ope-
rations, I was induced to allow them to remain for two days
longer.   On the  tenth day they were clipped out, and to our
great satisfaction the  fistula closed.   Since  that time  this
woman  has  menstruated regularly through the bladder; en- 
REPORT OF CASES.                  117
joyed comfortable health ; been able to support herself  as
servant to a private family, and certainly rid of a most dis-
tressing and disgusting malady.  Two years after I operated
on  this same patient for strangulated umbilical hernia, from
which she recovered without  any unusual symptoms.  It is
not often we meet with  an example of so many grave acci-
dents, operations, and good recoveries, in one person, as are
presented in  the narrative  of this poor,  friendless Irish
woman.

  Case III.—Catherine------, a young woman aged 19 years,
was seized with labor-pains, September, 1858, at the Philadel-
phia Hospital.  In consequence of the great size of the foetal
head, it became  completely impacted  in the pelvic cavity.
After ineffectual  efforts to deliver with the forceps, the ope-
ration of craniotomy was resorted to  by Dr. R. K. Smith,
Chief Resident Physician, and  the child readily removed.  In
consequence, however, of the prolonged pressure sustained by
the anterior wall of the vagina, a slough in a few days sepa-
rated, opening a communication between that cavity and the
bladder, through which the urine flowed. An examination,
some weeks after, showed not only the existence of this fistula,
but the canal of the urethra closed  by inflammatory deposit.
A trocar was at once carried through the obstructing material
into the bladder,  followed by a catheter, which was retained
for eight days, only being removed for the purpose of cleansing.
In this manner the  urethra was restored.
  On the 16th of December following, the parts  having be-
come sufficiently  callous, an operation was performed for her
cure ; her bowels being well opened the day  previous, after
which one and a half grain of opium was administered.
  She was placed under the influence of a mixture of ether
and chloroform, turned  upon her abdomen, over a stool well
protected, the limbs being supported by two  assistants, and
the parts exposed by a Sims's  speculum.   The fistula, which
was transverse through  the trigone vesicas, and exceeding an
inch in its  greatest diameter, could now be well seen.   The
edges were seized with the long rat-toothed forceps, and with 
118
VESICO-VAGINAL  fistula.
a long, straight, sharp-pointed bistoury, pared in their whole
extent.  Seven needles, slightly curved at their points, each
armed with a silver  thread, were  carried successively, by
means of the needle-holder figured  in  Fig. 60, through the
edges of the wound, down to but not into the vesical mucous
membrane.  These sutures, being brought out of the vagina,
were passed through  the adjustor in succession, and drawn
upon as the latter was passed down, thus approximating the
edges very completely. Perforated shot were next run down
over the wires, and clamped by  means of the compressor.
The sutures were now twisted together, and passed through
a small tube of rubber to protect the parts, and the catheter
carried into the bladder, to which was attached a flexible piece
of gum elastic tubing, designed to convey the urine into a
bottle properly placed  between the limbs of the patient for
its  reception.  The  patient being  placed in bed, an anodyne
was administered; the whole time consumed, including etheri-
zation,  did not  exceed one  hour.  Everything progressed
favorably until the third  day, when, notwithstanding opium
had been given to keep the bowels in a quiescent state, diar-
rhoea, attended with considerable straining, came on, but which
was at length controlled by enemata of laudanum.   To make
the case more embarrassing,  a cough, which  she had  been
troubled with for  some  time previous to the  operation,
harassed her so much, notwithstanding the free administra-
tion of opium, as sometimes to drive the catheter out of the
bladder.
  On  December the 27th, ten days after the operation, the
sutures were removed, and the wound found to have united,
save at one single point, which wTas subsequently and perma-
nently closed by a single stitch.  The catheter was kept in the
bladder  a few days longer, in order not to endanger the cica-
trix.  This patient  was  watched with great  care  by Drs.
Darby, Richardson,  and Taylor.

  Case IV.—Mary H------, aged 25 years, unmarried, tem-
perate, and a Philadelphian  by birth, was received into the
Philadelphia  Hospital in  September, 1858, pregnant.  This 
REPORT OF CASES.
119
was her second pregnancy.   In her first labor, she states, she
was brought to bed on Monday morning, and delivered the
following Thursday morning of a still-born child; the de-
livery being brought  about, as she says, by the physician in
attendance using " forcing powders."
  On  the 29th October, 1858, at 3J A.M., labor commenced.
At 6 o'clock P.M., it was sufficiently advanced to establish
the existence  of a breech presentation in the  first position.
At 2 P.M., the fcetus was expelled  as far as the umbilicus;
the limbs being much discolored from long-continued pres-
sure in the pelvic cavity.  The delivery of the head was de-
layed by the  chin leaving the breast, requiring finally the
agency of the blunt hook to bring it down ; the labor being
completed at 5 o'clock, making from its commencement thirty-
seven hours and a  half.  Alarming  hemorrhage followed,
which was arrested by the removal of the placenta, frictions
over the hypogastrium, and ice.  The child  weighed nine
and a half pounds, and measured twenty-two inches in length.
For twenty days the woman passed her urine naturally, aud
without  pain or difficulty.   On  the twenty-first day it com-
menced  to flow through the vagina;  a slough having sepa-
rated, and formed the fistula.  Its situation was at the trigo-
num vesicas, and about six lines in its greatest diameter.
   On the 14th of February, 1859, the parts having attained
the requisite  healthy conditions, the  operation for cure was
executed.  An aperient  was given the day previous.   The
woman was placed under an anaesthetic of ether and chloro-
form (three parts of the former to one of the latter, by weight),
turned over the padded stool on her abdomen,  the hips being
well elevated, and  the fistula being exposed by introducing
into the vagina the duck-bill speculum.  The edges were next
extensively denuded, and after the bleeding ceased, five silver
sutures were  inserted, and  their ends brought  out  of the
vagina, and the edges closed by the  adjuster.   Over each was
passed a shot, and the stitch made  secure by the compressor
clamping it on the wires.  The sutures were gathered together,
and passed through a piece of elastic tubing; the  woman
placed  in bed, and the catheter at  once  inserted into the 
120
VESICO-VAGINAL  FISTULA.
bladder, over the end of which was  slipped the light  gum-
elastic tube, to convey the urine into a bottle properly placed
in the bed.  The bowels were controlled by opium, one-half
grain, three times a day, for two days; after which, the one-
third of a grain three times a day.   The  diet consisted  of
nutritious broths, with  some farinaceous articles.  Nothing
unusual occurred ; and  on the eighth day the stitches were
removed, and  the  cicatrization found to be complete.   The
bowels were gently opened on the ninth day, and the catheter
continued five days  longer.  On the sixteenth day she was
allowed to sit up, and  on the  twentieth  day permitted  to
exercise in the ward.
  This case was reported in detail by Dr. Darby, in whose
care the patient was.  (Mediced and Surgical Reporter, vol. 1,
page 435.)

  Case V.—K. D., a Scotch girl, unmarried, 20 years of age,
was admitted into the Philadelphia Hospital in April,  1859,
pregnant.  Her  labor, which occurred  in September, was
difficult and prolonged, the  head presenting, although the
position  is not known.   She was finally  delivered by the
forceps, of a dead child, at the full  term.  One week after,
the urine was observed trickling  from  the vagina, and, on
examination some three weeks subsequent, a fistula was dis-
covered, about seven lines  long, and situated at the vesical
triangle.   Two months  after her parturition she was trans-
ferred to  the Woman's  Surgical Ward, and prepared for an
operation by washing out the vagina every day with a solu-
tion of tannic  acid, to give some tone  to the  parts;  regu-
lating the diet and improving her condition by tonics. After
the lapse of another month she was  considered well  enough
to justify an operation.  This was performed in the presence
of the house residents, in the manner already detailed in the
previous  cases.  Seven  silver threads were introduced (the
patient being under the influence of ether and chloroform),
and these stitches secured with the usual clamp  of  shot.
Instead of bringing  the wires  out of the vagina after the
adjustment, they  were cut off close  to  the pellets of  shot. 
REPORT OF CASES.
121
Opium was administered  in  doses  sufficient to  keep the
bowels closed, and the catheter kept in the bladder and care-
fully  watched that it  should not become  obstructed with
mucus or blood.  This girl proved to be a very self-willed
and troublesome patient.
  On the ninth  day after the  operation the stitches were
taken out, and the fistula, as we  believed, closed.  She was
kept in bed with the catheter in  the  bladder for five days
longer, after which she was allowed to sit up, the instrument
being  used four  times  daily, and worn at  night for three
days more, when  it was laid aside  and the patient allowed to
walk about.   She was retained in the house for two weeks
longer, and then discharged well.
  About  four months  later  this young woman returned,
seeking admission, alleging that  the  fistula had reopened.
She had evidently, from her own statements, been leading a very
irregular life.  On carefully inspecting the parts a small opening,
admitting the end of a probe, was detected in the middle of
the cicatrix.  There could be no doubt this fistula had opened
during her absence, as  the bladder  was perfectly retentive
and the urine passed voluntarily in a full stream for the two
weeks previous to her leaving the  hospital.  Four operations
were performed unsuccessfully to close this small hole, at in-
tervals of eight weeks, and requiring but three stitches when
freshened.  I was  satisfied there  was something wrong,  as
there was nothing in the case which could explain this indis-
position to heal.   I suspected the woman was more anxious
to have a home than to get rid of  her disease, and doubtless,
at night, in the absence of the nurse, withdrew the catheter,
introducing it herself before her morning visit. Accordingly,
on discovering my failure  in the  fourth operation, without
waiting for some time to elapse, the parts were again denuded
and two  sutures inserted;  relays of nurses were kept  night
and day by her bed, and on the eighth day the parts were ex-
amined and the sutures taken out. The opening was closed.
The bowels had been  confined for seventeen days, and after
wearing  the  catheter four days  longer she was allowed  to
dispense with its use.
       9 
122
VESICO-VAGINAL  FISTULA.
  My surmises  in  regard  to  the  cause  of failure were cor-
roborated by her own confession.   One  year after, this poor
unfortunate girl applied again for admission, not on account
of the fistula,  which  remained well, but  evidently  dying
from tuberculosis, induced by a life of dissipation.

  Case VI.—Ann H----, a native of Ireland, aged 33 years,
and a resident  of Delaware County, Pennsylvania, was ad-
mitted into the Philadelphia Hospital on  the 24th of January,
1860, with a vesico-vaginal fistula, situated  three-quarters of
an inch  below the  upper extremity of the vagina, four lines
in length, and  running oblique  to the  longitudinal axis of
the canal.  About  ten months before her admission into the
institution she had been delivered by instrumental means of
a child, after a  difficult labor of  thirty-six hours' duration.
I believe this was her second child.  A  few days succeeding
this she discovered  her urine dribbling  away without being
able to exercise  any control over its escape.  As the woman's
health was by no means good, the first attention wa3 directed
to its improvement, which,.under the employment of mineral
tonics and a good diet, was, in a few weeks, in a good measure
restored.   The last  of the succeeding month (February) the
operation was performed while under the influence of ether
and chloroform  as  an anaesthetic.  Four silver sutures were
introduced and secured by means  of a wire-twister.   The
wires were next cut off very near to  the wound, and the ends
turned down in such a manner as not to  irritate the posterior
wall of the vagina.  The catheter was worn uninterruptedly
and the bowels  locked up with opium.   The case  progressed
without  any unfavorable  symptoms whatever, and" on the
eighth day the stitches were removed and the union found to
be  complete.   The patient  was retained in  the  hospital
nineteen days  longer, as  a precautionary  measure, during
four of which she was obliged to  wear the catheter.

  Case  VII.—Matilda L----, aged 24  years, was sent from
Wilmington, Delaware, by Dr. Pepper Norris.  She entered
the hospital August, 1860.  An  examination proved the ex- 
REPORT OF CASES.
123
 istence of a vesico-vaginal fistula at the bas fond, transverse
 in direction, and about six lines  in  length.  It followed her
 first labor, which was sufficiently difficult to demand delivery
 of the child (dead-born) by the forceps.  The  presentation
 was a cephalic one, and she heard nothing  said about any-
 thing being wrong.  A few days after, she  could  not state
 how many, the urine  began to flow from  the vagina.  The
 woman was pale, anaemic, and had  but little appetite. She
 was placed on a regimen of tonics and nutritious  food,  in
 order  to improve her health.   Some progress was made, but
 by no means equal  to our expectations, and after waiting five
 weeks I  concluded to make an attempt  for her cure.  On
 paring the edges the bleeding became very profuse and con-
 tinued, notwithstanding the application of ice and a stream
 of cold water from the  nozzle of a syringe.   To arrest this,
 seven  stitches were inserted and  the edges drawn firmly
 together.  Even these did not entirely control the hemorrhage,
 some considerable oozing continuing.  The catheter was in-
 troduced into the bladder, and the patient placed in bed, with
 directions  to administer the usual pills of opium.  Difficulty
 was experienced in keeping the  catheter clear,  it becoming
 obstructed with clots of blood for- three or four days.  She
 suffered also throughout the whole  treatment with flatulent
 colic and  some diarrhcea ;  the last was controlled  by ene-
 mata of starch-water and laudanum, morning and evening.
 Her appetite failed  and her  stomach became irritable, for the
 relief  of which  alkalies were prescribed with benefit. At
 the expiration of nine days the sutures were examined, with-
 out being at all sanguine as  to a favorable result.   Several
 had ulcerated out, and  no disposition was  exhibited at any
 point to heal.   They were all removed, and the patient, in a
 few  days, ordered out to take exercise in the open air.
   Vegetable tonics, with an  occasional mercurial, followed by
 the  tincture of the chloride of iron, wrought a wonderful
 change in her condition, so that six  weeks  after we  deemed
 her health  sufficiently good to undertake a second operation.
 The edges of the  fistula had changed.  Instead of being
spongy and soft, they had become firm.   There was no more 
124
VESICO-VAGINAL FISTULA.
 than the ordinary bleeding after the application of the knife
 in vivifying  the  margins.   Six metallic threads were  intro-
 duced, secured each by the shot-clamp, and the usual treatment
 pursued.  Not a  single untoward  sjmptom  occurred, and
 after eight days  the stitches were removed,  and the  union
 found  complete.   Dr. Recio, one of the resident  physicians
 of the hospital, was unremitting in his care of this patient.

   Case VIII.—K. C,  born in Ireland, recently  from the
 vicinity of Bordentown, New Jersey, aged 28  years, entered
 the  hospital in the spring of I860,1  with  a  vesico-vaginal
 fistula situated a  short distance above the neck of the blad-
 der, oblique in position, and about five lines in extent.   The
 entrance to the vagina was much  constricted, rendering the
 exposure of the fistula difficult.  The accident occurred about
 eighteen months  before, in a first labor, in  which  a  dead
 female child was delivered by instruments.  She is not certain
 that the head presented.  Difficulty was experienced in ad-
justing the instruments, and  she felt  as though the vagina
 had  been torn at  the time.  As the fistula was seated above
 the stricture, it became necessary to institute the preliminary
 treatment of dilatation, which was effected by gum-elastic
 bougies, after two weeks.   This accomplished,  the operation
 was  performed in the presence of the  medical  residents, the
 patient being under the  influence of the usual anaesthetic  of
 ether and chloroform.  After  the  edges were sufficiently de-
 nuded, six metallic (silver) threads were introduced, the  parts
 brought in contact by passing each suture in detail through
 the adjustor, and  securing the apposition by the shot-clamp.
 The  rigid  character of the vaginal walls, in consequence  of
the amount of cicatricial tissue, rendered all  manipulations
 difficult.
  From this until the ninth day following, nothing of impor-
tance occurred.   The threads were on  this day removed, and
the fistula found  about  two-thirds closed.   She was allowed

  1 The record of this case being lost, I am unable to refer with certainty
to the date of her admission, my own notes only containing the details of
the operation. 
REPORT OF OASES.
125
 two months' respite, occasionally having a large-sized bougie
 introduced  to  counteract  the persistent tendency  to  con-
 traction of the vaginal canal, after Avhich a second opera-
 tion was executed, in which four stitches  were inserted.
 A good deal of bleeding from the bladder followed  for two
 days succeeding this,  rendering it difficult to keep the ca-
 theter  unobstructed.   On the third day  it ceased,  and the
 case progressed very favorably during  the remaining period
 of her treatment.   The stitches were cut out on the ninth day,
 the union having taken place throughout.  This woman, after
 getting about,  complained of some incontinence, and I was
 disposed to believe some minute  orifice must still exist, al-
 though undiscovered.  Since, however, the nurse informs me,
 this disappeared, and she left well.

  Case IX.—Mrs.  G., an Irish woman, aged  40 years, who
 married late  in life, fell  in labor with  a first child January,
 1863.   She  states  her  pains commenced  on a Friday, and
 gradually increased in severity until the following  Sunday,
 when she became so exhausted as to render the application of
 the forceps necessary to complete delivery.   The child, a male,
 head presentation, was born dead.   The bladder had not  been
 catheterized.  At no time after that had she a sensation like
 urine passing by the urethra.  Her getting up was slow, and
 it was  many weeks before she was able  to walk, in conse-
 quence  of a feeble state of the limbs, with diminished sensi-
 bility.   In November, 1863, she was kindly referred to me
 by Prof. F. G. Smith, of the University of Pennsylvania, to
 whose care she had been sent from the country.   On examina-
 tion, a fistulous opening was found between the vagina and
 bladder, situated at the  basfond, three-fourths of an inch in
 extent,  and transverse  in direction.
  On the 10th of November, I operated in my usual manner,
assisted by Profs. F. G. Smith, Penrose, Drs. La Roche, and
Boardman.  Nine silver threads were inserted and secured by
the shot-clamp.  The  usual course in  regard  to  opium, ca-
theter,  and diet was observed.  Nothing unusual occurred,
worthy of note, during the treatment.  On the ninth  day the 
126
VESICO-VAGINAL FISTULA.
stitches were removed, and  the  wound found united.   The
catheter was continued five days  longer, the bowels being
gently moved on  the twelfth day after the operation.  This
patient I saw over two years after, when  she stated she re-
mained  perfectly well, and was about four months advanced
in her second pregnancy.

  Case X.—L. L., aged 35 years, from Pennsylvania, was ad-
mitted to the Philadelphia Hospital in the month of April,
1364, suffering from a transverse vesico-vaginal fistula, three-
quarters of an inch in extent, and situated in the has  fond,
with the complete destruction of the urethra.   She was mar-
ried at the  age of 17 years, and 15 months after fell in  labor
with  her first child at full term.  She knows the child pre-
sented by the vertex.   After being in labor forty-eight hours
the forceps was applied, and after one hour the child was ex-
tracted  dead, a male, and more  than  ordinarily large.   Her
urine, she states, was not drawn off", and she  was  never con-
scious, after delivery, of passing her water the natural  way.
This fistula was, therefore, of over seventeen years' standing.
The vagina had undoubtedly sustained  much injury, as it was
greatly  narrowed in  its whole extent.   Her health was poor,
and in no  condition for an  operation.   She was placed  on a
tonic course of treatment, with some improvement, and on the
9th of June, 1864,1 concluded  to make an attempt for her
relief.  The edges were pared, and fifteen wire threads inserted,
securing each with the shot, which closed the vesico-vaginal
rent satisfactorily.  A catheter was placed in the bladder, and
worn for nine  days, when  the  stitches were removed ;  no
attempt even at union seemed to  have occurred.   Increased
attention was now given to her general  health, and on the
28th  of the following October, a second attempt was made,
twelve  stitches being  inserted, and with  an  unsuccessful  re-
sult, union having taken  place only to the extent of one-third
of an inch.  On the 3d of March, 1865, a third operation was
executed, nine  sutures being used, and the result was  again
unfavorable.  On the 2d of  June a fourth operation was per-
formed, in which nine threads were employed, and this time 
REPORT OF CASES.
127
with complete success.  During the period she  had been suf-
fering from this fistula she had five miscarriages, all occurring
at the fourth month.  It is contemplated to attempt next the
formation of a urethra for this patient.

  Case XI.—Mrs. H., aged  28  years, residing  in  an adjoin-
ing State, fell in  labor with a first child.  Her  parturition
was slow, vertex  presentation, and becoming exhausted, the
forceps was  applied for her  relief, and the process completed
by the removal of a dead female fcetus at full term.  Four or
five days following, her urine was discovered dribbling over
the genitalia, and on inquiry, by her  physician, little doubt
was entertained that  a fistulous opening existed between the
bladder and vagina.   On the 24th of May, 1865, eight weeks
after recovery, I visited her, and  on examination  discovered
the opening situated  near the cervix vesicae, oblique in direc-
tion, and about three-quarters of an inch in extent.  She was
placed under an anaesthetic  of ether, and after freshening the
margin of the opening, it was brought together by six sutures
of silver wire, and clamped with shot, the usual detail of
treatment being.observed.  In  consequence of some  pleuritic
symptoms occurring about the eighth day, the stitches were
not removed until the tenth day, when the wound was found
thoroughly  united.

  Case XII.—Mrs. M., of Philadelphia, aged 30 years, applied
to be relieved of a vesico-vaginal fistula.   A few months pre-
vious she had been delivered of a dead child (her first), after
being in labor forty-eight hours.  It was a breech presenta-
tion, and after the extrusion of the body, the head was re.
tained for several hours.  At what time after, the opening
occurred she could not determine, as  she had no sensations
decisive of the accident, but believes the urine dribbled ever
after her labor.
  On the 24th of November, 1864,1 operated, assisted by Drs.
McLerny, Wilson, and  Allen.   The  opening  was  situated
about three-quarters of an inch  above the cervix vesicae, trans-
verse in direction, and about  six lines in'extent.  It was freely 
128              VESICO-VAGINAL FISTULA.
freshened, and closed with eight silver sutures.  Nothing un-
usual occurred during the subsequent course of  the case, and
on the ninth day the sutures were removed, the opening to all
appearance closed.  After getting up she was under the im-
pression' all was not quite right, as she was conscious  of an
unusual moisture at the outlet of the vagina, and her cloth-
ing had a urinous odor;  still she was able to pass her water
in a fair  stream.  On examination  I failed to  detect any
opening, although the bladder was not injected, the cicatrix
looking so perfect.  I was disposed to believe the  urethra or
neck of the  bladder had not entirely recovered  tone, and al-
lowed some to escape, and advised the use of tonics, with the
extract of nux vomica, and not to allow the urine  to accumu-
late.  The difficulty was  not relieved, and, on a second care-
ful examination, an opening of almost capillary dimensions,
was discovered  at one angle of the  cicatrix.  The part was
denuded, and two stitches inserted, which completed the cure,
as she has since been perfectly well.

  Case XIII.—Airs.------, aet. 30, a small delicate lady from
a distant land, in a first  labor, greatly protracted,  discovered,
after five  days, her  urine running from  her without control.
She was informed that a fistula existed, and  was for some
time treated by cauterization.   Becoming in the  mean time
pregnant, all remedial measures were suspended.  Her confine-
ment took place in Philadelphia, under the care of Dr. Stroud,
seven weeks after which, I was invited by the doctor to visit
her, and examine the case.  The fistula was quite  small, and
situated in the vesical triangular space.  On  Sept.  12th, 1865,
assisted by Drs. Stroud, Hunt, Rodman, and Townsend, I per-
formed the usual operation, inserting, after the  edges were
properly  denuded, four  silver  sutures,  and securing  them
with shot.  The subsequent treatment was conducted by Dr.
Stroud.  The only troublesome symptom arising  in the pro-
gress of her case was occasionally  a  violent spasmodic  con-
traction of the bladder, expelling the  catheter, out  which was
overcome by enemata of a little thin starch-water with lauda-
num.  On the ninth  day I removed the  sutures, the opening 
REPORT OF CASES.
129
being successfully  closed.   Very recently I have heard from
this patient, who continues to enjoy perfect health.

  Case XIV.—Mrs. G., aet. 29, residing in a neighboring vil-
lage, went into labor with her first child.   Her pains were
severe  and exhausting.  The head of the child presented, and
after thirty-six hours, the forceps were applied, and the child
extracted, dead.  Her urine  had not been removed during
labor,  and she thinks that, four days after, it commenced
escaping from the  vagina.
  When I first visited her, she informed me a year and a half
had elapsed since the accident, and that three operations had
been attempted without success.  On  examination a double
fistula  was discovered, each running transversely through the
vesical triangle, and separated from  each other by about
three-eighths of an inch.  This condition was easily explained
by  referring to the previous operation—the middle of the
wound uniting, and the extremities remaining open.  Assisted
by Drs. Morton, Sutton, Agnew, and Weightman, I operated
a few clays after, by paring the edges of each, and closing one
with five and  the other with four sutures.   Everything pro-
gressed well until  the third  day, when she was seized with
pain in  the abdomen, with free bleeding from the vagina,
which  at first I was disposed to believe was a copious men-
struation.   Her bowels  also became disturbed, and her appe-
tite  failed.  Opium and warm  fomentations relieved her pain
and diarrhoea, but  the bleeding continued for seven days.  On
the  ninth day, the threads were removed, one fistula being
found  closed, and the other open.  After this the woman be-
came pale and clyspeptic, and in no condition  to justify an
operation.   Under a properly regulated diet and tonics, she
improved rapidly in general health, and in the mean time be-
came again pregnant.
  Two months after her confinement, on the 4th of Novem-
ber, 1865, assisted  by Drs.  Patterson, Hall, and Townsend, I
operated, closing the opening with nine metallic threads.
Not an unpleasant symptom  occurred, and the sutures were
removed on  the  ninth day  following, the wound proving to 
130
VESICO-VAGINAL FISTULA.
be closed soundly in its entire extent.  An  interesting fact
connected with this case was  the disposition, if she allowed
her bladder to become too much distended, to some incon-
tinence.  To correct this  an elastic-ring pessary was  intro-
duced, which,  by  its  pressure on  the neck of the organ,
effectually relieved the difficulty.

  Case XV.—S. G., aged 25 years, a native of Ireland, was
admitted  into  the Pennsylvania  Hospital October the 10th,
1865, suffering from a vesico-vaginal  fistula  since the April
previous.  It occurred as a consequence of a tedious labor
with her second child, forty-eight hours having elapsed before
it was delivered.  Her physician stated to her it was a cross-
birth.  No  instruments were  used, but the leg of the child
was broken in two places.  Of course the foetus  was dead.
The time she passed her  urine first through the vagina she
could not determine, but thinks before the second day after
her confinement.   At  the expiration of two  weeks she got
up, but found herself so weak on her limbs as to be unable
to walk.   Her  first labor was not difficult.  After her  re-
covery two operations were  performed for  the closure of the
fistula, by her  physicians; both unsuccessful.  On examina-
tion, after her admission, the fistula was found to extend lon-
gitudinally from the neck of the  bladder to the os uteri, and
inclining to the left of  the cervix  passed along its entire
length.
  On  the 24th of October,  assisted by Drs. Hunt,  Morton,
Hewson, and the hospital  residents, I executed the operation
described in the previous cases.  As the  neck of  the uterus
formed one side of the fistula above, the os looking into the
bladder, it was necessary  to freshen it, and secure it to the
opposite side.  The  opening was closed longitudinally with
thirteen sutures.  Not an unfavorable symptom followed the
operation, and  on  the ninth  day these stitches were taken
out,  and except at a  single point, where the vaginal wall
blends with the cervix uteri, a solid union secured.   To close
this  a second  operation was  performed,  eight  weeks after,
requiring three stitches, and resulting in complete  closure. 
ANOMALOUS SYMPTOMS.
131
    Anomalous Symptoms.—Death.—Pyemic Peritonitis.
      REPORTED BY DR. WILLIAM PEPPER, RESIDENT PHYSICIAN.
   Case XVI.—Cornelia Augusta Handy, aet. 24, colored, was
 admitted to Pennsylvania Hospital April 14th, 1866, suffer-
 ing with a vesico-vaginal fistula of very great size, resulting
 from prolonged second stage in her first  labor, six months
 ago.  She has been for years in delicate health, though evinc-
 ing no positive sign  of organic disease.  Dr. Agnew operated
 upon her, Thursday, April 19th, 1866, the edges being pared
 and brought  together, antero-posteriorly, Toy thirteen silver
 sutures,  clamped with shot; the two upper stitches including
 the involved anterior lip of the os uteri.  A full opiate was
 administered, and a  self-retaining  catheter introduced.  The
 urine came readily  through  catheter, and the woman did
 well  until the afternoon of  Saturday, April 21, 1866, when
 she had a very slight chilly sensation, followed by  scarcely
 any fever or sweat.  The following morning I found her with
 a dry hot skin, restless, lying on her back with legs drawn
 up, complaining much of abdominal tenderness.   The entire
 abdomen was sensitive to pressure, rather more  markedly so
 in the hypogastric region than elsewhere.  There had  been
 very little hemorrhage, and the catheter remained quite clear.
 She was at the time  under  mild opiate influence—having
 taken gr. j twice daily.   Bowels constipated.   Opium and
 emollient applications to abdomen were ordered, but during
 the day she had four or five thin serous stools, and vomited
 a number of times, the abdominal symptoms remaining un-
 abated.   No recurrence of chill.
  April 23d.  Much  the  same.  Diarrhoea and vomiting per-
 sisting.   Complains of abdominal tenderness.  Tongue furred
 in centre, merely dryish.  Pulse rapid and small.  Catheter
 runs freely, but  little blood passing.  No chill or chilly sen-
sation.   Opii gr. -|-, calomel gr. ss, q. t. h.  Hop poultice to
abdomen.  Light diet.
  April 24th.  Expresses herself as feeling better. Less abdo-
minal tenderness.  Belly not  distended. No vomiting.  Less 
132
vesico-vaginal fistula.
 diarrhoea.   There is, however, extreme huskiness  of voice,
 and mental dejection.
   April 25th, 26th, 27th, 28th.  Remained  in much  the
 same condition, excepting that  great jaundice came on, the
 conjunctivae being  deeply yellow, and the jaundice-tinge
 showing through the dark skin.  The vomiting has not re-
 curred; but, despite the free use of  opium, she had several
 thin stools  daily.  The calomel and opium were suspended
 after sixty  hours, as the  abdominal tenderness disappeared
 almost entirely;  the pulse became less frequent, and the  skin
 less parched and dry; and Huxham's tincture of bark, with
 nitro-muriatic acid and a small amount  of stimulus,  were
 ordered.  There  was nothing like a  chill or intermission in
 the febrile movement.  The voice  remained very husky and
 feeble, and she evinced great hebetude.
   April 29th. Expressed herself  as feeling more comfortable.
 Had some appetite.   Pulse  not  more  than 110.  Jaundice
 somewhat decreased, perhaps.  Bowels more quiet.  Tongue
 dryish and coated.   Abdomen not sensitive, rather retracted.
 No cough.   Heart sounds healthy.  No  delirium  or brain
 symptoms.   Voice extremely feeble, but  is a  little more
 animated.
   April 30th.  Stitches removed by Dr. Agnew.   The  an-
 terior half of fistula found to have  healed, this being the
 twelfth day.  The vagina was coated with  yellowish layers
 of lymph, mixed  apparently with  urinary salts.  Condition
 very much the same.
   May 1st. Much the same.  Pulse small, but not so frequent.
 Skin not harsh.  Tongue  dryish.  Jaundice marked.   Con-
siderable hebetude, but perfectly  rational, and expresses  her-
self as feeling more comfortable and  stronger.   Her appear-
ance, however, belies her, as she was evidently emaciating
rapidly.  Her voice  was almost  extinct.  She seemed to be
more easy when lying on her side, and yet was almost unable
to turn over. Made no complaint of pain.  Had no diarrhcea
or vomiting.   Took  nourishment quite well, and passed the
day much  as usual, but about 10 P. M., after having spoken 
                   anomalous  symptoms.                133

 to the  night nurse five  minutes previously, she was  found
 dead, lying quietly in the same position—on right side.
  Post-mortem fifteen hours after death.   Quite marked rigor
 mortis.  Body emaciated.  Spine not examined.
  Brain presented  no  abnormal  condition, save that it, like
 all other parts of the body, was deeply stained of a yellowish
 hue.   The blood in the cerebral veins was clotted, as  it was
 in most of the vessels of the body.
   Thorax.—Lungs  anaemic, congested postero-inferiorly, but
 contained  no pyaemic  deposits.  Bronchial  glands  not  en-
 larged.   Heart contained no fluid  blood, and a very  small,
 quite firm  coagulum in right  ventricle, extending  into pul-
 monary artery, but by no means  filling its calibre.  Healthy
 in structure, though these organs, as all the others, were
 stained yellow.
  Abdomen.—On  opening the  abdominal  walls, there was  a
 gush of thick yellowish, ochre-colored  fluid,  identical  in
 thickness, color, and smell, with the fluid so often seen  in
 pyaemic pleurisies,  and upon examining  the. cavity of the
 abdomen, it contained  at  least Oij  of this fluid.  All of the
 viscera were coated more or less with yellowish cheesy-look-
 ing lymph, although the spleen, greater omentum, and  ileum
 were so to a most marked degree.  Upon stripping off this
 lymph,  the subjacent  peritoneum  seemed  almost entirely
 healthy, not having even  an excoriated appearance.  In no
 place had any adhesion formed between two portions of this
 deposit.
  The liver was of normal size and consistence, but deeply
 stained  with the same yellowish  tinge  as were the  other
 organs.
  Gall-bladder pale and almost  empty.
  Spleen slightly  enlarged and rather soft.
  Pancreas healthy. Kidneys apparently healthy.
  There was an increase of these  appearances over  the  blad-
der and rectum, and upon opening the bladder, it was found
merely much discolored by chronic congestion. It was some-
what thickened, but no evidence of  any recent inflammation.
  The uterus was of fair size, firm,  and on section presented 
134
VESICO-VAGINAL  FISTULA.
 a normal appearance.  The mucous membrane of its cavity
 was dark and somewhat thickened.   No evidence of inflam-
 mation of uterine veins.  Fallopian tubes healthy apparently ;
 calibres free.
   The  fistula was found, as stated, reduced in  size.  Edges
 presenting a pale granulating surface encrusted with phos-
 phates.  The neck of uterus, we have seen, was turned into
 the bladder, and the highest stitches almost passed through
 tissue of the os,  but  no evidence existed of any uterine  in-
 flammation, or of the peritonitis having started from this
 point.
   Stomach  and intestines  presented nothing to account for
 gastro-intestinal  symptoms, excepting  some softening and
 thinning of the mucous membrane.
   Urine could not, of course, be obtained.
   The fluid in abdomen contained granular  corpuscles, with
 single or double nuclei (some with none apparent), large nucle-
 ated cells, a little haematin.  After addition of acetic acid, a
 few corpuscles showed trefoil nuclei.   Most of the corpuscles,
 however, had but one or two.   Some coagulation of mucus.
 The whole being evidently cacoplastic lymphy fluid.
  The blood, bistre tinted, pale and thin, clotting imperfectly
 though quite rapidly, forming large dark clot, full of white
 corpuscles.  No attempt at formation of rouleaux.   Red cor-
 puscles  crenated.  Quite numerous flakes of  haematin.
  There was no enlargement of inguinal, pelvic, or lumbar
 glands.

        REPORTED BY DR. ANDREWS, RESIDENT PHYSICIAN.
  Case XVIL—M. S., aet. 38 years, a native of Ireland, was
 admitted  into the Pennsylvania Hospital, February 13th,
 1866, suffering with vesico-vaginal fistula.  She was  a woman
 of good habits, but living in a miserable house, in the vicinity
 of one of our suburban towns.  The accident happened with
her fifth child; was delivered with instruments, after being in
labor two days.  Presentation, head.  In her former labors
she had experienced no trouble.   The fistula,  on examination,
proved to be longitudinal, and quite two inches and  a half in 
ANOMALOUS  SYMPTOMS.
135
length.  The tissues appeared healthy.  After a few days of
preparation, consisting in regulating the diet and opening the
bowels,  the operation for her  cure was performed  by Dr.
Agnew, in presence of Drs. Hunt, Morton, and  the resident
physicians of the hospital.   The patient being under the in-
fluence of ether, the edges were extensively pared, and four-
teen silver stitches inserted,  which were secured by the shot-
clamp ;  the approximation being effected longitudinally.  She
was now placed in bed, a catheter placed  in the bladder, and
one grain of opium ordered  morning and evening.  For four
days everything went on well; all the urine passing by the
catheter, appetite good, pulse normal, and abdomen soft.  On
the  5th she was taken with  a severe chill, followed by head-
ache, vomiting, and mental  aberration.  As she had suffered
     7        P"
from chills  before entering  the hospital, it was hoped this
might be nothing  more than a return of the intermittent
attack,  and accordingly quinine was  prescribed in  antipe-
riodic doses.
  6th. Vomiting continued;  bowels loose; delirium increased;"
eyes inflamed; tongue  dry  and crisped.  Lime-water  and
milk administered ; also camphor-water, with liq. morph. sul-
phatis.
  7th. Some abatement of vomiting ;  stomach retains a little
liquid nourishment; bowels  very loose, with  dyspnoea and a
sensation  of choking; also some tympany ; pulse 100.  Beef
essence, and an enema of tincturae opii gtt. 1, in a little starch
water.
  8th. Eruption made its appearance  over the  abdomen, re-
sembling  that  of typhoid  fever;  belly tympanitic; tongue
dry and brown ; dyspnoea less ; pulse becoming more frequent;
twelve of the stitches were removed by Dr. Agnew, with the
assistance of Dr. Hunt, the  union  appeared complete, save a
small point at the upper extremity of the wound.   The re-
moval was dictated by the feeling, that, possibly, they might
have kindled  up inflammation, which had extended to the
serous lining of the pelvis and abdomen.  Ten drops of oil of
turpentine,  in  mucilage, directed  every two  hours ;  beef-es-
sence ; milk-punch. 
136
VESICO-VAGINAL  FISTULA.
  9th.  Patient exceedingly exhausted ; pulse  very frequent;
muttering delirium; diarrhoea; enema of laudanum; con-
tinue stimulants and nourishment.
  10th. Died.
  Post-mortem, six hours after death.  Adhesions between the
margins of the fistula had given way, and were coated with
a dirty lymph ;  no inflammation of bladder or uterus.  The
viscera of the abdomen were much congested,  though not in-
flamed.  Peyer's patches healthy ; no signs of ulceration ;  no
peritonitis ;  no  metastatic  abscesses.  The lungs somewhat
congested (hypostatic);  the  pulmonary pleura covered with
soft  lymph.   During life, a blowing sound emitted with the
first  sound of the  heart was noticed,  but no lesion of the
organ appeared on  examination.  The blood was remarkably
fluid.  In all probability, had this patient been operated  on
outside of the  hospital, the termination  would have  been
otherwise.   A number of cases of pyaemia having occurred in
the wards, the atmospheric conditions were beyond all doubt
unsafe.   The same may be asserted of Case XVI.

  Case XVIII.—Rose------, an Irish woman, aged about
33 years, was admitted into the Pennsylvania Hospital in
June,  1866, for  vesico-vaginal  fistula.  On  examination, a
stricture of the  vagina  was found  about  the middle of the
canal,  the opening  not exceeding a quarter of an inch in ex-
tent.  The tissue around was dense, almost cartilaginous in
consistence, and the vagina greatly diminished  above.  It was,
of course, impossible to see just where the  communication
with the bladder existed, but of the fact no doubt existed, as
the  urine all passed through the vagina.  The accident oc-
curred  in a first labor, which had been tedious, lasting two
days.  Thinks no instruments were used.  Did not understand
an}7thing was wTrong.  It was of eight years' standing, and
had once been operated on by a surgeon  without success.   Her
health was  tolerably good, though  she was exceedingly ner-
vous.  I concluded to vivify the edges of the vaginal stricture,
and  unite them with the metallic threads, thus converting the
narrow upper part of the vagina and the bladder into a com- 
ANOMALOUS SYMPTOMS.               137
mon cavity.   This course was resolved upon, as the thickening
and extensive rigidity of the vaginal walls would have made
the process of dilatation very slow and unsatisfactory.  This
was accordingly done, and four sutures inserted, secured  in
the usual way.   The bladder was kept drained with the self-
retaining catheter, and everything passed satisfactorily until
the fourth day, when she complained of great abdominal dis-
tension, with severe paroxysms of pain.   All of this was due
to accumulation  of flatus, and  nothing  seemed to control  it.
Her appetite failed, and she was harassed with nausea.  On
the ninth day the stitches were taken out, but no union had
occurred.   She left the  hospital with the understanding she
should  return, with a view of  giving her some preliminary
general treatment before another operation should be under-
taken.

   I have now performed this  operation about  sixty times,
with  three deaths, all doubtless due to a hospital atmosphere,
and, as far as I know, with not more than four or five failures.
i
10 
 
INDEX.
 4 DJUSTMENT of lacerations, 35
/\    of fistulae, 88, 90, 94, 97, 106
Adjustor, 94
Anaesthetics, 100
Anatomy of perineum, 10-11
Approximation of fistula, 105
    direction of, 105
Assistants, 28, 100


"DERNARD and Huette's operation,

Bladder, irritable, 108
    treatment of, 109
Bleeding, how to stop, 35, 100, 105
Brown, I. Baker, on period of lace-
      ration, 11-12
    operation for laceration, 25
Bnrns's operation, 22
Button, lead, author's, 114
    Battey's, 98
    Bozeman's,  92
pATHETER, 100
\J  cleansing of, 108
    directions for use, 107, 138
    for carrying a needle, 75
    self-retaining, 90
Causes of failure to cure, 111
    of lacerations, 12
    of vesico-vaginal fistulas,  61-64
Clamps, 87
Classification of lacerations, 13
    of vesico-vaginal fistula, 64
Complication in vesico-vaginal fistu-
  la, 69, 112
Contra-indications to operate, 27, 68
Crotchets for button, 94
    Simpson's, 96
   DEFORMITY from laceration, 17
      Decrees of ruptured perineum,
        13
Diagnosis of vesico-vaginal fistula, 66
Diet after operations, 38, 109
Direction of fistulee, 65
E
XAMPLES of cases of laceration
    of perineum, 39-52
  of cases of vesico-vaginal fistula,
    113-137
  FECAL accumulations, 39
    Fistula,   vesico-vaginal,   con-
      founded with relaxed muscular
      walls, 67
    vesico-vaginal, failure to cure, 111
    signs of, 66-67
Fistulas with carcinoma, 69
Flatus, accumulations of, 38, 109
Forceps, Agnew's, 29, 101
Fork, adjusting, 88
Fork, Hilliard's, 104
G
UM tubing for catheters, 107
   HEMORRHAGE, its arrest, 105
     History of laceration, 19-25
        of vesico-vaginal fistula, 57-G1


 INSTRUMENTS for  lacerations,
 1    29, 30
    for vesico-vaginal fistula, 100,101


 T ACERATED perineum, 9
 Li  cases treated of, 39-51
    causes of, 12, 13
    deformity from, 14
»   degrees of, 13
    history of, 19-25
    literature of, 52-56
    period of, 11
    prevention of, 14-19
    results of, 13
M
EADOWS,  Dr., operation, 99
  Metallic shield of Meigs, 20
  Mirror, 21 
INDEX.
K
EEDLE for deep sutures, 29, 30
  Colombat, 78
     used by Sims, 85
 for silver wire, 102
 -holder, Bozeman's, 93
 Simpson's, 96
OPERATIONS for lacerations, 28
  Agnew's operation, 34
  Aitken's, 20
  Bernard and Huette's, 23
  Blundell's, 21
  Boyer's, 20
  Brown's, I. Baker, 21, 25, 31
  Burns's, 22
  Busch's, 20
  Chelius's,  22
  Churchill's, 21
  Clay's, 24
  Cockle's, 21
  Davidson's, 22
  Davis's, 21
  De la Motte's, 20, 21
  Delenrye's, 20
  Dieffenbach's, 21, 22
  D'Outrepont's, 20
  Duparcque's, M., 20
  Dupuytren's, 21
  Gross's, 25
  Guerin's, 23
  Holmes's, 24
  Homer's, 25
  James's, 22
  Jobert's, M., 24
  Kilian's, 22
  Langenbeck's, 23
  Menzel's,  22
  Mettauer's, 25
  Miller's, 24
  Nevermann's, 22
  Pare's, Ambrose, 19
  Roux's, 23
  Sedillot's, 23
  Skev's, 24
  Smith's, H. H., 25
  South's, 22
  Verhnege's, 23
  Vidal's, 24
  Wutzer's, 22, 23
  assistants for,  28
  contra-indications for, 27
  diet after, 38
  history  of, 19, 25
  instruments for,  29, 30
  position for, 28
  preparation of bed for, 28
  preparation of patient for, 27
  preparatory treatment for, 34
Operations—eoiitinued.
    primary and secondary, 25, 20,

    time for, 25
    treatment after, 37
    for vesico-vaginal fistulfe—
    of Agnew, 9!)
    of Beaumont, 79
    of Betanconrt, 73
    of Blasius, 77
    of Bozeman, 92
    of Boyer—Desanlt, 71
    of Collis, 98
    of Colombat, 73, 78
    of Deybers,  78
    of Dieffenbach, 79
    of Ehrman,  70
    of Fabricius Hildanus, 70
    of Gosset, 77
    of Hayward, 80
    of Jobert, 74
    of Kilian, 77
    of Lallemand, 73
    of Laugier,  73
    of Lewzisky, 77
    of Luke, 76
    of Malagodi, 76
    of Marshall, 74
    of McGuire, 95
    of Meadows, 99
    of Mettauer, 81
    of Niigele, 75
    of Pancoast, 81
    of Roonhuysen,  75
    of Roux, 79
    of Shrseger, 76
    of Simpson, 95
    of Sims, 81
    of Volter, 75
    of Wutzer, 79
 Opium, its use, 108
  PARING edges of lacerations, 34
    fistula, 22-92
Perineum, form of, 12
    its anatomy, 10. 11
    its measurements, 9
    its support, 15, 19
    period of lacerations of, 11
Prevention of lacerations—
    Blundell on, 18
    Burns, 16
    Bush, 16,  18
    Cams, 17
    Cazeaux, 17
    Denman, 17
    Hamilton, 16
    Heine, 16 
INDEX.
Ill
Prevention of lacerations—continued
    Hodge on, 17
    Hold, 16
    Meigs, 17
    Mende, 17
    Mesnard, 17
    Michaeles, 17
    Ritgen, 17
    Siebold, V.,17
    Velpeau, 17
Position of patient in lacerations, 28
    in vesico-vaginal fistula,  103
Preparation for operations, 100
AUILLED suture, 25
RECEPTACLES for urine, 70
  Results of lacerations of perine-
    um, 13
OHOT, 89, 102
U  compressor,  89, 100
    in position, 107
    perforator, 100
    removal of,  110
    removed, 110
Skin, incisions of, in lacerations, 33
Speculum, 83
    Bozeman's,  83
    in position, 83, 103
    Sims's, 83
    Wutzer's, 79
Sphincter, extension of, 31
    incisions of, in lacerations, 34
Sponge tents, 70
Supporting perineum, views of—
    Hodge, 17
    Meigs, 17
    Penrose, 18
    Sacombe, 15
    Schaffler, 15
    Siebold-, 15, 17
    Simpson, 18
    Stark, 15
    Stein, 15
Supporting perineum—continued.
    views of Stein, Sr., 15
          of Wilson, 18
Suture, 21-75
    advocates for, 21
    gilded, 77
    glover, 76, 78
    grooved, 77
    introduction of, 35,  105
    iron, 35
    lead, 81
    quilled, 31, 87
    removal of, 38, 109
    securing, 36, 94, 97, 98, 107
    silver, 82
    twisted, 79
  TIME to operate, 100
    Treatment of vesico-vaginal fis-
          tula, 79
        by catheter, 71
            and tampon, 71
        cauterization, 72
        galvanism, 74
        palliative, 70
        radical, 71
        suture, 75
        transplantation, 74
        uniting apparatus,  73
Tympanitis, 109
  UNITING apparatus of Dr. Betan-
      court, 74
    of McGuire, 95
    of Laguier, 73
Urethra, irritable, 108
Urinary stillicidium, 69
    incontinence, 113
Uterus in bladder, 116
AGINA, injections of, 70
  Vesico-vaginal fistula, 57
'IRE splint of Simpson, 97
     twister, 97 
 
CLASSIFIED  INDEX
(BY  SUBJECTS)

        OF
PRESLEY   BLMISTON'S  PUBLICATIONS
            NO.  1012  WALNUT  STREET,  PHILADELPHIA.
Pull Descriptions of these books will be found in the annexed Alphabetical Catalogue.
          ACTION OF MEDICINES.
Brunton, The Action of Medicines.  Pt. i.  Circula-
  tion.                                \In Press.
Headland, on the Action of Medicines. 6th Ed. $3.00
Ott, The Action of Medicines.  22 Illustrations. $2.00
Rutherford, Physiological  Action of Drugs or the
  Secretion of Bile.  100 Illustrations.          $3.00
                  ANATOMY.
         {See also Osteology, and Atlases.)
Bradly, Comparative Anatomy and Physiology.  .60
  Illustrations. Third Edition.                $2.00
Braune, Topographical Anatomy. Photo-lithographic
  plates,   ^to.     Cloth, $10.00; half morocco, $12.00
Heath, Practical Anatomy.   Fifth London Edition.
  Nearly 300 Illustrations.                   $5.00
Holden,  Anatomy and Dissections of the Human
  Body.  Fourth Edition.  170  Illustrations.    $5-5o
-------, Landmarks.   3d Edition.              1.25
Handy, Anatomy. Illustrated.              $3-oo
Jones, Sieveking & Payne. Pathological Anatomy.
  Illustrated.                               $5-5o
Morris, Anatomy of the Joints.  Colored Illus. $5.50
Virchow, Post-mortem Examinations.  Second Edi-
  tion.  Illustrated.                         $--25
Wilkes &Moxon, Pathological Anat. 2d Ed.  $6.00
Wilson's Anatomy.  10th Edition.           $6.00
                   ASTHMA
Berkart, Pathology and Treatment of.         $2.50
Thorowgood, Nature and Treatment of.      $1.50
    ATLASES, PLATES AND DIAGRAMS.
Bentley & Trimens, Medicinal Plants.  Full Botani-
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  4vols.  4to, half morocco.                 $90.00
Bock, Atlas of Anatomy, 38 Col. plates.  Roan. $15.00
Flower, Diagrams of the Nerves of the Human Body.
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Froriepi, Anat. Atlas.  75 PI. Plain,$5.00; Col. $10.00
Godlee,  Atlas  of Human  Anatomy.   48 Colored
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Hutchinson,  Illustrations of  Clinical Surgery, Con-
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Jones, Atlas of Diseases  of the Membrana Tympani.
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Liebreich, Atlas of Ophthalmoscopy.   12 Chromo-
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Martin,  Atlas of Obstetrics and Gynaecology.   98
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Marshall, Diagrams of the Human Body.  11 Lite-
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Schultze, Obstetrical  Plates.  Life Size. 20 in the
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Wedl, Atlas of the Pathology  of the Teeth.  Colored
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Sheppard, On Madness.                    $2-25
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Collis Diagnosis and Treatment of. Col. Plates. $3.00
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Reese, Syllabus of Medical Chemistry.        $1.00
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Vacher, Primer of Chemistry.                  .50
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Smith, Diseases of the Lungs in Children.     $2.50
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Wilson, The Ocean as a Health Resort.       $2-5o
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Edwards, Dyspepsia and How to Avoid It. .    .75
-------, Constipation.                        .75
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Coles, Deformities  of the  Mouth,  and Their Treat-
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Mac Ewen, Osteotomy. Illustrated.          $3.00
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■-------, Dental Mechanics. 140 Illustrations.  $3.00
-------, Dental Student's Note-Book. New Ed. $1.00
Flagg,  Plastics and Plastic Filling.   Illus.     $3.00
Heath, Diseases of the Jaws.   150 Illus.     $4.25
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Harris, Principles and Practice of Dentistry.  Tenth
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-------,  Dental and  Medical  Dictionary.   Fourth
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Leber & Rottenstein, Dental Caries.         $1-25
Richardson, Mechanical Dentistry. Third Edition.
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Sewell, Dental Anatomy and Surgery.  Illus. $1.50
Stocken,  Dental Materia Medica and Therapeutics.
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Tomes, J., Dental Surgery. Second Edition.  $5.00
Tomes, C. S., Dental Anatomy.   Second Edition.
  179 Illustrations.                      [In Press.
Taft, Operative Dentistry.  3d Ed.            $4-25
Wedl, Dental Pathology.   Cloth, $3.50; sheep, $4.50
-------, Atlas  of the Pathology of the Teeth.  $10.00
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ii
PRESLEY BLAKISTON'S
 Cooper, Surgical Dictionary.  Two Volumes.  $12.00
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 Burnett, Hearing and How to Keep It.  Illus.    .50
 Dalby, Diseases and  Injuries of the Ear. Illus. $1.50
 Jones, H. M., Aural Surgery.  Illustrated.     r^1-S°
 -------, Atlas of Diseases  of the  Mambrana Tym-
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 Woakes,  Deafness,  Giddiness,  and  Noises in  the
   Head.   Second  Edition.  Illustrated.         $2.50
                 ELECTRICITY.
 Althaus, Medical  Electricity.  3d Ed.  146 111.  $6.00
 Reynolds. Clinical Uses of Electricity.  2d Ed. $1.00
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 Daguenet, Manual of Ophthalmoscopy.  Illus. $1.50
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 Hay, Sarcomatous  Tumor of the Orbit in a Child.
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 "Liebreich,  Atlas  of Ophthalmoscopy.   59 Colored
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 Macnamara, Diseases  of the  Eye.  Third  Edition.
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 Morton, On  Refraction.                      $1.00
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 Wolfe, Diseases of the Eye.  Illustrated.  [In Press.
                     FEVERS.
 Allan, Fever Nursing.  Illus.                   .75
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 Liveing,  Megrim, or Sick Headache and Allied Dis-
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 Hayden,  Diseases of the Heart and Aorta.   81 Illus-
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 Sansom,  Diseases of  the Heart.   Illustrated.  $2.00
 Stokes, Diseases of the Heart and Aorta.      $3.00
                  HISTOLOGY.
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                   HOSPITALS.
 Burdett, Cottage  Hospitals.  Second Edition. Plans
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 Bible Hygiene.  By a Physician.               $1.00
 Bennett, Nutrition in Health and Disease.      $2.50
 Corfield, Sanitary Construction and Arrangement of
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 Frankland, Water Analysis  for  Sanitary Purposes,
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 Hartshorne, Our  Homes, Their Sanitary Arrange-
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 Lincoln, School Hygiene.                       .50
 Parkes, Practical Hygiene.   5th Ed.   Illus.   $6.00
 Teale,  Dangers to Health.  3d Edition.   Illus.  $3.50
Wilson, G., Hygiene and Sanitary  Science.    $2.75
 -------,  Health and  Healthy  Homes.  A Guide to
  Domestic Hygiene.  314 pages.               $1.00
-------, y., Drainage for Health.  Easy Lessons in
  Sanitary Science.  Illustrated.               $1.00
-------, Naval Hygiene, Human Health,  and  the
  Means tor Preventing Disease. Illustrated.     $3-oo
Edwards, On Malaria.                          .75
                    JOURNAL.
 The American Specialist.  A Journal of Medicine
   and Surgery.   Monthly.          Per Annum,$1.50
                    KIDNEYS.
 Black, Bright's Disease of the Kidneys.  20 Illus. $1.50
 Edwards, How Persons Afflicted with Bright's Dis-
   ease Ought to Live.                             .75
 Greenhow,  Addison's  Disease.   Numerous  Cases
   and Colored Illustrations..                   $3.00
 Tyson, Bright's Disease and Diabetes.  Illus.  $3.50
      LUNGS AND CHEST, DISEASES,  OF.
                 (See  also  Throat.)
 Bennett, Consumption, Treated by Hygiene, Climate
   and Medicine.   Third Edition.               $2.50
 Barth & Roger, Auscultation and Percussion. $1.00
 Dobell, Loss of Weight, Blood Spitting, etc.   $4.00
 -------, Winter Cough, Catarrh, Bronchitis, etc. S3.50
 Bruen,  Pocket-book of  Physical  Diagnosis.   Origi-
  nal Illustrations.  Just issued,   izmo.  256 pp.  $2.00
 Greenhow, Bronchitis.                       $1-50
 Waters, Diseases of the  Chest.  2d Ed.        $4.00
          MANUALS FOR STUDENTS.
 Mendenhall, Student's Vade Mecum.   Illus.   $2.00
 Atthill, Diseases of Women.  Fifth Ed. Illus.  $2.25
 Bernay, Notes for Chemical Students.          $1.25
 Carter, Practical Medicine.                   $300
 Charters, Practice of Medicine.   Illustrated.   $2.00
 Clay, Obstetrics.   Illustrated.                  $2.00
 Dalby,  On the Ear.   Illustrated.              $1.50
 Fenwick,  Outlines  of Practice.   Illustrations and
   Formulae.                                   $2.00
 Gallabin, Diseases of Women.  63 Illus.        $2.00
 Heath, Minor Surgery.   Sixth Edition.  Illus.   $2.00
 -------, Surgical Diagnosis.                   $1.50
 Marshall & Smith, Analysis of the Urine.     $1.00
 Mears, Practical Surgery.   Illustrated.         $2.00
 Roberts, Practice of Midwifery.  95 Illus.      $2.00
 Sewill, Dental Anatomy and Surgery.   Illus.   $1.50
 Smith,  Practical Gynaecology.   Illustrated.     $1.50
 Swain, Surgical Emergencies. 82 Illustrations.  J82.00
 Tyson, Practical Examination of the  Urine.  Third
   Edition.   Illustrated.                        $150
 Thorowgood, Materia Medica.  Illustrated.   $2.00
 Warner, Guide to Case Taking.               $1-75
                   MARRIAGE.
 Ryan, The Philosophy of Marriage.            $1.00
 Walker, Intermarriage, Its Effects on Health, Beauty,
   etc.   Illustrated.                            $1.00
              MATERIA  MEDICA.
              (See also Therapeutics.)
 Biddle, Materia Medica, Eighth Edition.       $4.00
 Royle & Harley, Materia Medica and Therapeutics.
   139 Illustrations.                             $5.00
 Stocken, Dental Materia Medica and Therapeutics.
   Second Edition.                             $2.25
 Thorowgood,  Guide  to Materia  Medica.     $2.00
      MEDICAL  JURISPRUDENCE AND
                  TOXICOLOGY.
 Ogston, Medical Jurisprudence.  Illustrated.   $6.00
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 Woodman  &  Tidy, Medical Jurisprudence and
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                 MICROSCOPY.
 Carpenter,  The  Microscope  and  Its  Revelations.
  Sixth Edition.  500 Illustrations.              $5-5o
 Beale, How to  Work with the Microscope.  Fifth
  Edition.  400 Illustrations.                   $7-50
—■----, The Microscope in Medicine.  Fourth Edi-
  tion.   500 Illustrations.                       $7-5o
 Marsh,  Section Cutting.  Illustrated.             .75
 Martin, Microscopic  Mounting.  140  Illustrations.
  Second Edition.                             $2.75
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Wythe, The Microscopist.  Fourth Edition.  252  Il-
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                MISCELLANEOUS.
Beale, Life and Vital Action.                  $2.00
-------, Life Theories and Religious Thought.  Illus-
  trated.                                      $z.ao
-------, Slight  Ailments.                      $i-7S
Bennett, Nutrition in Health  and Disease.   Third
Edition.
$2.50
Carson, History of the University of Pennsylvania.
                                              Jo.oq 
PUB LICA TIONS.
Cohen, Inhalation, Its Therapeutics, etc.       $2.50
Cobbold, Parasites; the Ento*oa of Man and Animals.
  85 Illustrations.
Dulles, Emergencies.
Edwards, Constipation.
'-------, Malaria.
           $5.00
             ■ So
             •75
             •75
           $3-SO
           $1.50
           $3.00
Second Ed. $3.50
Illus.
 Gross, American Medical Biography
        , Life of John Hunter.  Illustrated.
 Hardwicke, Medical Education.
 Hood, On Gout and Rheumatism
 Holden, The Sphygmograph. 300 Illustrations. $2.00
 Hunter, Phototype Portrait  of.                  .50
 Kane, On the Opium,  Morphia, Chloral and  other
  Habits.  Illustrated.                         $1.50
 Kirby, On Phosphorus.   New Edition.         $1.00
 Lizars, On Tobacco.                            .50
 Mathias, Legislative Manual and Rules of Order. .50
 Overman,  Practical Mineralogy.              $1.00
 Oldberg, Metric System in Medicine. Formul3e.  $1.50
 Piesse, The Art of Perfumery.   366 Illus.      $5.50
 Pennsylvania  Hospital Reports.  Each.    $2.00
 Piggot, Copper Mining  and Copper Ore.       $1.00
 Smith, On Ringworm and Its Treatment.  Illus. $1.00
 Smyths, Medical Heresies.                    $1.25
 Sieveking, Life Assurance.                    $2.00
 Transactions of the College of Physicians of Phila-
  delphia.  Four Volumes.  Each              $2.50
 Turnbull, Anxsthesia.  Second  Edition.  Illus. $1.50
 Virchow, Post-mortem  Examinations.  Second Edi-
  tion.  Illustrated.                            $1-25
 Warner, Medical Case  Taking.                $1.75
             NERVOUS DISEASES.
 Buzzard, Syphilitic Nervous Affections.       $i-7S
 Flower,  Diagrams of the Nerves.   7  Double-page
  Plates and Letter Press.  4to.                 $350
 Gowers, Diseases of the Spinal  Cord.  Second  Edi-
  tion.  Illustrated.                            $i-50
 Radcliffe, Epilepsy,  Pain and Paralysis. Illus.  $1.50
                   NURSING.
 Allan, Notes on  Fever Nursing.   Illustrated,      .75
 Domville, Manual for Nurses. Second Edition.    .75
 Smith. On the Training of Nurses.   Illustrated. $2.00
                   OBSTETRICS
 Cazeaux, Practical Text-book of Midwifery. Seventh
  Edition.  Illustrated.    Cloth, $6.00; sheep, $7 00
 Clay, Obstetric Surgery.  Illustrated.          $2.00
 Glisan, Midwifery. 130 Illus. Clo.$4.co; sheep, $5.00
 Meadows, Manual of Midwifery.  145  Illustrations.
  Second  Edition.                             $2.00
 Rigby  and   Meadows,  Obstetric  Memoranda.
  Fourth  Edition.                               .50
 Roberts, Practical Midwifery. 95 Illustrations.  $2.00
 Savage, Surgery of the Female Pelvic Organs.   Col-
  ored Plates.  Second Edition.           [In Press.
 Schultze, Obstetric Diagrams, Life Size,  ao in Set.
                  In Sheets, $15.00;  Mounted, $25.00
                  OSTEOLOGY.
 Holden,  Human  Osteology.    Colored  and other
  Illustrations.  Sixth Edition.                 $550
 Mac  Ewen, Osteotomy.  51 Illustrations.     $3.00
 Macnamara, Diseases of the Bones  and  Joints.  $4.25
 Wagstaffe, Human Osteology. 83 Illustrations.  $3.00
                  PATHOLOGY.
               (See also Histology.)
 Gibbes, Practical Pathology and  Histology.    $1.00
Jones, Sieveking & Payne, Pathological Anatomy.
  Illustrated.                                ^ $5-5o
 Paget, Surgical  Pathology.   Third Edition.' Illus-
  trated.                  Cloth, $7.00 ; sheep, $8.00
 Rindfleisch, Pathological  Histology.   208  Illustra-
  tions.                   Cloth, $5.00; sheep, $6.00
Thudichum, Path, of the Urine.  2d Ed.  Illus.  $5.00
 Virchow, Pathology.                         $5°°
 Wedl, Dental Pathology.  105 Illustrations.
                          Cloth, $3.50; sheep, $4.50
 -------, Atlas of Pathology of the Teeth.  Colored
  Plates.  4to.
 Wilkes & Moxon, Pathological Anatomy.
                  PHARMACY.
 Beasley, Druggists' General Receipt Book.
       -, Formulary.
 $12.00
  $6.00

  $2.25
  $2.25
Colored
Bentley  &  Trimens, Medicinal  Plants
  Plates and Descriptions of Every Plant Employed in
  Medicine, Their Properties and Uses.  Four Vols.,
  half Morocco.                              $90.00
Mackenzie,  Pharmacopoeia of the Throat Hospital.
  Fourth Edition.                             $1.25
Muter, Pharmaceutical and Medical Chemistry. $6.00
 Oldberg, The Metric System, Posological Tables and
   300 Prescriptions.                           $1.50
         ,  The Unofficial Pharmacopoeia.   Over 700
   Formula:.                                  $3.50
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   Soaps, Tooth Powders, etc. 4th Ed.  366 III.  $5.50
 Sweringen, Pharmaceutical Lexicon.   Cloth.  $3.00
 Tuson,  Veterinary Pharmacopoeia,  Materia Medica
   and Therapeutics.  Third Edition.            $2.50

                    PRACTICE.
 Aitken, The Science and Practice of Medicine. Third
   Edition.  Two Vols.    Cloth. $12.00 ;  sheep, $14.00
 Bruen, Physical Diagnosis.   Illustrated.       $2.00
 Beale, Slight Ailments, and their Treatment.    $1.75
 Carter, Elements of Practical Medicine.         $3.00
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 Dunglison,  Practitioner's Reference Book.    $3.50
 Fenwick, Outlines of Practice.  Formulas and II. $2.00
 Foster, Clinical Medicine.   Illustrated.         $3.00
 Maxson, Practice of Medicine.                 $3.00
 Power,  Holmes, Anstie  &  Barnes, Reports  on
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 Tanner,  Index  of Diseases and Their Treatment.
   Formulae, etc.                               $3-oo
 Warner, Student's Guide to Case Taking.       $1^75
                  PHYSIOLOGY.
 Beale, Bioplasm, or the Physiology of Life.  II. $2.25
 -------, Protoplasm, or Matter and Life. Col. II. $3.00
 Fulton,  Physiology.  Second Edition.  Illus.    $4.00
 Kirke, Physiology. Tenth Edition.             $5.00
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                            cloth, $6.00; sheep $7.00
 -------, Syllabus of Physiology. Second Ed.   $i.so
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            PRESCRIPTION  BOOKS.
 Beasley, 3000 Prescriptions, and Index of Diseases
   and Remedies.  Fifth Edition.                $2.25
 Oldberg, The Metric Prescription Book. 300 Formu-
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   Edition.                Cloth, $1.00,  Tucks, $1.25
 Wythe, Physician's Pocket Dose and Symptom Book.
   Eleventh Edition.       Cloth, $1.00;  Tucks, $1.25
             POPULAR MEDICINE.
 American Health Primers:
      I. Hearing and How to Keep  It. Chas H. Bur-
          nett, m.d.  Illustrated.                .50
     II. Long Life and How to Reach It.  f. G. Rich-
          ardson, M.D.                          .50
    III. Summer and Its Diseases. Jas. Wilson, m.d .50
    IV. Eyesight and How to Care For It.  Geo. C.
          Harlan, m.d.  Illustrated.              .50
     V. The Throat and Voice.  J. Solis  Cohen, m.d.
          Illustrated.                           .50
    VI. The Winter and  Its Dangers.  Hamilton Os-
          good, M.D.                            .50
   VII. The Mouth and the Teeth.  J. W. White,
          m.d.  Illustrated.                      .50
 VIII. Brainwork and Overwork.   H. C Wood.   .50
    IX. Our Homes.  Henry Hartshorne. Illus.  .50
     X. The Skin  in Health and  Disease.   J. D.
          Bulkley,  m.d.  Illustrated.             .50
    XI. Sea Air and Sea Bathing. J. H. Packard, m.d.
                                               •So
   X,II. School and Industrial Hygiene.  D. L. Lin-
          coln, m.d.                            .50
 Carter, Eyesight, Good and Bad. Illustrated.   $1.50
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 Ellis, What Every Mother Should Know.        .75
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  ease Ought to Live.                           .75
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-------, Malaria.                               .75
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Savory & Moore, Domestic Medicine.          .50
Tanner, Poisons and Their Antidotes.  Fourth Ed. .75 
tv
PRESLEY BLAKISTON'S PUBLICATIONS.
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                            Philadelphia, January 2d, 1882.

         ANNOUNCEMENT.
    The Copartnership heretofore  existing  between Robert Lindsay and
Presley Blakiston, under  the name of  Lindsay  &  Blakiston, Medical
Publishers and Booksellers, is this day dissolved, by mutual consent.
                                         ROBERT LINDSAY.
                                         PRESLEY BLAKISTON.
    PRESLEY   BLAKISTON  having  purchased  from  Mr. Robert
Lindsay all his interest in the late firm, will continue  the publication and
sale of MEDICAL AND SCIENTIFIC BOOKS, At No. 1012 Wal-
nut Street.
    His son, Kenneth  M. Blakiston, and Frank W. Robinion having an
interest in the business from this date, the name of  the firm will be

          P. BLAKISTON, SON & CO.


   MEDICAL,  DENTAL,  SCIENTIFIC
                                AND

           PHARMACEUTICAL  BOOKS
                            PUBLISHED BY
P. BLAKISTON,  SON  & CO.,  PHILADELPHIA.
   .ffig^Any book in this catalogue can be had from or through booksellers in the principal cities In
the United States, or will be forwarded free, by mail or express, upon receipt of the price by the
publisher.
AMERICAN  HEALTH  PRIMERS.
     Edited byW. W. Keen, m.d.  Complete in 12 volumes, handsomely bound in
    cloth.  Put up in a neat, strong box.                          Price $6.00
                                             Or sold separately, each .50
   I. Hearing and How to Keep It. With illus-
     trations. By Chas. H. Burijiett, m.d.
  II. Long Life, and How to Reach It. By J.
     G. Richardson, m.d.
  III. The Summer and Its Diseases.  By Jas.
     C. Wilson, m.d.
  IV. Eyesight, and How to Care for It.  With
     illustrations. By George C. Harlan m.d.
  V. The Throat and the Voice.  With illustra-
     tions.  By J. Solis Cohen, m.d.
  VI. The Winter and Its Dangers.  By Ham-
     ilton Osgood, m.d.

 " In their practical teachings, learning, and sound
sense, these volumes are worthy of all the compliments
they have received.  They teach what every man and
woman should know, and yet what nine-tenths of the
intelligent class are ignorant ot or at best, have but a
smattering knowledge of.";—Chicago Inter*Ocean.
 VII. The Mouth and the Teeth. With illustra-
     tions. By J. W. White, m.d., d.d.s.
VIII. Brain Work and Overwork.  By  H. C.
     Wood, Jr., m.d.
 IX. Our Homes. With Illustrations. By Henry
     Hartshorne, m.d.
  X. The Skin in Health and Disease.  By L.
     D. Bulkley, m.d.
 XI. Sea Air and Sea Bathing. By John H.
     Packard, m.d.
 XII. School and Industrial Hygiene.  By D.
     L. Lincoln, m.d.

 " These handbooks of practical suggestion deserve
hearty commendation. They are prepared by men
whose professional competence is beyond questk>n,.and
for the most part, by those who have made the  subject
treated the specific study of their lives."—New York
Sun. 
4
PRESLE Y BLAKISTOX' S
ACTON, THE REPRODUCTIVE  ORGANS.
      The Functions and Disorders  of the  Reproductive Organs.  Their Physio-
    logical, Moral, and Social Relations.  By Wm. Acton,  m.r.c.s. Fourth Edition.
                                                                       Price $2.50
  " In the work now.before us, all essential detail upon its subject matter is clearly and scientifically given.  Wo
recommend it accordingly, as meeting a necessary requisition of the day, refusing to join in that opinion which
regards the consideration of the topics in question as beyond the duties of  the medical practitioner."—The
London Lancet.
ADAMS,  ON  CLUB  FOOT.
      Its Causes, Pathology  and  Treatment.  A  Revised  and Enlarged Edition.
    By William  Adams, f.r.c.s.  106 Wood  Engravings and  six  Lithographic
    plates.  8vo.                                                       Price $5.00
  " It is a work not only valuable to the specialist, but should be read by every practitioner who has anything to
do with cases of club foot."—Medical Record.

AGNEW,  ON THE PERINEUM AND FISTULA.
      Laceratiqns of the Female Perineum and Vesico-vaginal Fistula.  Their His-
    tory and Treatment.   With  many Illustrations.  By D. Hayes Agnew, m.d.,
    Professor of Surgery, University of Pennsylvania.  8vo.             Price $1.50
      So many applications having been made for these papers, as originally issued,
    the author has thought best, after a thorough revision, to place them before the
    profession in book form.

AITKEN,  PRACTICE  OF MEDICINE.
      The Science and  Practice  of Medicine.  By William Aitken, m.d., Edin-
    burgh.  Third American from Sixth   London Edition, greatly enlarged,  re-
    modeled  and carefully revised;  with   additions  by Meredith Clymer, m.d.,
    formerly Professor of  Practice, University of New York.  With 180 Illustrations
    and large colored map, showing  the Geographical Distribution of Disease.
    Large 8vo.  2 vols.                           Price, Cloth $12.00;  Sheep $14.00
  "The  representative book of  Medical  science and    " The author has unquestionably performed a service
practice."—London Lancet.                      to the profession of the most valuable kind."- The Prac-
  " The additions that have been made by the Ameri-   titioner.
can Editor are copious and important."—American    " It would be difficult to point out anything that can-
Journal Medical Science.                       not be found in Aitken."—Glasgow Medical Journal.
ALLEN,  COMMERCIAL  ORGANIC  ANALYSIS.
      An Introduction to the Practice of Commercial Organic Analysis.   By Alfred
    H. Allen, f.c.s.  Vol. 1.  Cyanogen  Compounds, Alcohols and  their Deriva-
    tives, Phenols, Acids,  etc.  8vo.                                    Price $3.50
       Vol. h now ready.  8vo.                                        Price $5.00
       Being a treatise  on the Properties, Analytical Examination, and Modes of
    Assaying  the  various Organic Chemicals and  Preparations  employed in  the
    Arts, Manufactures, Medicine, etc.
ALLAN,  FEVER  NURSING.
       Notes on  Fever Nursing.   Addressed  to  nurses in hospital and private life.
     By James W. Allan, m.d.  i2mo.  Illustrated.                      Price .75
ALLINGHAM,   DISEASES  OF THE  RECTUM.
       Fistula, Haemorrhoids, Painful Ulcer, Stricture, Prolapsus, and other Diseases
     of  the  Rectum, their Diagnosis and  Treatment.   By William Allingham,
     f.r.c.s.   Fourth Edition, enlarged.  8vo.                            Price $3.00
  «' No book on this special subject can at all approach I   " It  is, as indeed  the verdict of the profession has
Mr. AUingham's in precision, clearness and  practical    already pronounced it, one of  the very best works on
good sense."—London Medical Times and Gazette.     Diseases of the Rectum."—American journal o/
                                         I Medical Science.
ALTHAUS,  MEDICAL ELECTRICITY.
       A Treatise on Medical Electricity,  Theoretical and  Practical, and its Use in
     the Treatment of Paralysis, Neuralgia,  and other Diseases.  By Julius Althaus,
     m.d.  Third Edition, Enlarged.  246  Illustrations.   8vo.           Price $6.00
       In revising this new edition  the author has carefully brought each section up
     with the latest knowledge of the subject. 
PUBLIC A TIONS.
5
ANDERSON,  ON  ECZEMA.
       The Pathology and Treatment of the various Eczematous Affections or Erup-
    tions of the Skin.   By McCall Anderson, m.d.   Third Revised and Enlarged
    Edition.  8vo.                                                      Price $2.50

ANSTIE,  STIMULANTS  AND  NARCOTICS.
       With  special researches on  the Action of Alcohol, Ether and Chloroform on
    the Vital Organism.   By Francis E. Anstie, m.d.   8vo.           Price $3.00
  " He is an original worker and independent thinker. His opinions  and conclusions are valuable, and cannot
be neglected."—American Medical Journal.

ATTHILL,  DISEASES OF WOMEN.

       Clinical Lectures on Diseases Peculiar to Women.  By Lombe Atthill, m.d.
    5th edition, revised and enlarged, with numerous illustrations.   i2mo.  Cloth.
                                                                         Price $2.25
  " It is the concentrated essence  of the knowledge of one who has become wise by reason of long and well-
digested experience in the subjects treated."—American Journal of Medical Science.
  " The work is one of great value to the general practitioner."—American Journal qf Obstetrics.

AVELING,  POSTURE IN OPERATIONS.

       The Influence of Posture on Women in Gynecic and other Operations.'  By
    J. H. Aveling, m.d.  Illustrated.  8vo.                             Price $2.00
       A  subject which hitherto has received but little attention is here treated in a
    very thorough  manner, showing the importance of certain postures, and  the
    various  diseases produced by  awkward and unhealthy positions.

BALFOUR,  ON  THE  HEART AND AORTA.

       Clinical Lectures on  Diseases of the  Heart and Aorta.  By  G. W.  Balfour,
     m.d.  Illustrated.  2d Edition.                                      {Preparing.
  "The whole work reflects much credit on its author, and firmly establishes his reputation as an authority on the
important diseases of which he treats."—London Practitioner.

BARTH   AND  ROGER,   AUSCULTATION   AND  PERCUS-
   SION.
       A  Manual for the Student.   By  M. Barth and M. Henri Roger.  Trans-
    lated from the 6th French Edition.   i2mo.                          Price  $1.00

BIBLE  HYGIENE;

       Or, Health Hints.   By a Physician.  This book has been written, first, to  im-
    part  in a popular and condensed form the elements of Hygiene; second, to show
    how  varied and important are the Health Hints contained in the Bible, and third,
    to prove that  the  secondary tendency  of modern Philosophy runs in a parallel
     direction with  the  primary light of the Bible.  i2mo.                 Price $1.00
  " The scientific treatment of the subject is quite abreast of the present day, and is so clear and free from unne-
cessary technicalities  that readers of all classes may peruse it with satisfaction and advantage."—Edinburgh
Medical Journal.

BIDDLE, MATERIA MEDICA.  Eighth Edition.

       Materia Medica for the Use of Students.  By John B. Biddle, m.d., Late Pro-
     fessor  of  Materia Medica at  Jefferson  Medical College,  Philadelphia.    8th
     edition,  Revised, Enlarged and Illustrated.  8vo.                   Price  $4.00
  " The additions are valuable, and we must congrat-
ulate the author upon having improved .what was
already so useful a work, both to the student and phy-
sician."— Phila. Medical and Surgical Reporter.
  " It has been the design of the author to present in
his work a text-book for the student.  It Is brief, and
yet sufficiently comprehensive.  His style is clear and
yet succinct.  He covers the ground—covers it well,
and cumbers his work with nothing superfluous."—
Atlanta Medical and Surgical Journal.          I  Canada Lancet.
  " One thing that particularly recommends this work
to the student is, that the book is not so large as to dis-
courage and cause him to feel that it is impossible for
him to get over it and so much else in the short time
before him."—St. Louis Medical and Surgical Jour-
nal.
  " It contains, In a condensed form, all that is valu-
able in materia  medica, and furnishes  the  medical
student  with a complete manual on this 'subject."— 
6
PRESLEY BLAKISTON' S
BLACK, THE  REPRODUCTIVE  AND RENAL ORGANS.

      The Functional  Diseases of the Renal, Urinary and  Reproductive Organs,
    with a General  View of  Urinary Pathology.  By D. Campbell Black, m.d.,
    f.r.c.s.  i2mo.                                                   Price $2.00
  " The title of this book  sufficiently indicates its character and scope. Some of the chapters are almost ex-
haustive of their topics.  Thus, in the chapter on spermatorrhoea, the whole philosophy and therapeutics
of this vexatious condition is given with unusual clearness."—Cincinnati Lancet and Observer.    t>
                               BY SAME AUTHOR.

DISEASES  OF THE  KIDNEYS.' '

      Lectures on Bright's Disease of the Kidneys. Delivered at the Royal Infirmary,
    Glasgow.  With 20 illustrations.  8vo.                             Price $1.50

BLOXAM. CHEMISTRY,Inorganic and Organic. Fourth Edition.

      With Experiments.   By  Charles  L. Bloxam, Professor  of Chemistry in
    King's College,  London,  and in the Department for Artillery  Studies,  Wool-
    wich.  Fourth edition.  With nearly 300 Engravings.  8vo.         Price $4.00
      A most complete Text-Book for Schools and Colleges.
  " Professor Bloxam has  given us a most excellent and useful practical treatise. His 666 pages (now 700) are
crowded with facts and experiments, nearly all well chosen, and many quite new, even to scientific men .  .  .
It is astonishing how much  information he often conveys in a few paragraphs.  We might quote fifty instances of
this.''— Chemical News.

BLOXAM.   LABORATORY TEACHING.   Fourth  Edition.
      Progressive Exercises  in  Practical  Chemistry. By Charles L. Bloxam,
    Professor of Chemistry in King's College, London, etc.  Fourth  edition.   With
    89 engravings.   i2mo.                                            Price $1.75
      This work  is intended for  use  in the Chemical Laboratory, by those who  are
    commencing the study of Practical  Chemistry.  It contains:—
      1. A series of simple Tables for the analysis  of unknown substances of all
    kinds.  2. A brief description of all the practically important single substances
    likely to be met with in ordinary analysis.  3. Simple directions and illustra-
    tions relating to Chemical Manipulation.   4. A system of Tables for the detec-
    tion of unknown substances with  the aid of the Blowpipe.   5.  Short instructions
    upon the purchase and preparation of the tests intended for those who have  not
    access to a Laboratory.
  *' A great amount of valuable practical information is here condensed into a book of 260 pages, such as only a
practical teacher could prepare. —New England Journal of Education.

BRUEN.   PHYSICAL DIAGNOSIS.  Just Ready.

      A Pocket  Book  of  Physical  Diagnosis,  for Physicians  and  Students.  By
    Edward T. Bruen, m.d., Asst. Prof, of Clinical Medicine, University of Penn'a.
    Illustrated by Original Wood Engravings. i2mo. Extra Cloth.     Price $2.00

BENNETT.   NUTRITION IN  HEALTH  AND  DISEASE.
      A Contribution to Hygiene   and Clinical  Medicine.  By J. Henry Ben-
    nett, m.d.  Third Edition,  Revised and Enlarged.   Cloth.          Price $2.50
                               BY SAME AUTHOR.

THE   TREATMENT  OF   PULMONARY  CONSUMPTION
  BY  HYGIENE,  CLIMATE AND MEDICINE.
      With an Appendix  on the Sanitaria of the United States, Switzerland and
    the Balearic Islands.  Third Edition much Enlarged.               Price $2.50
  "Any physician may take it up with every feeling of confidence that the views enunciated by the author will be
found to De able, honest and orthodox.''—Medico- Chirurgical Review.
BERKART, ASTHMA.
      The Pathology and Treatment of Asthma.  By Joseph B. Berk art, m.d.
    8vo-                                                              Price $2.50 
PUBLICA TIONS.
7
 BEALE  ON  SLIGHT  AILMENTS.
       Slight Ailments, Their Nature and Treatment.  By Lionel S. Beale, m.d.,
     f.r.s., Professor of Practice, King's Medical College, London.  i2mo. Price $1.75
                               OUTLINE OF CONTENTS.
  Introductory. The Tongue in Health and Slight Ailments. Appetite. Nausea. Thirst. Hunger.  Indigestion,
 its Nature and Treatment.  Constipation, its Treatment. Diarrhoea.  Vefcigo.  Giddiness.  Biliousness. Sick
 Headache.  Neuralgia.  Rheumatism.  The Feverish and Inflammatory State.  Of the Actual Changes in Fever
 and Inflammation.  Common Forms of Slight Inflammation, etc., etc.
  " We venture to say that among the numerous-medical publications issued during 1880, there has been none
 which will prove more useful to the young general practitioner, for whom it is really intended, than this volume,
 while the time of the older physician might be much more unprofitably spent."—American Journal of Medical
 Science.
                                 BY SAME AUTHOR.

 ON LIFE AND VITAL ACTION IN HEALTH AND DISEASE.
       i2mo.                                                            Price $2.00
 THE  USE OF  THE  MICROSCOPE  IN  PRACTICAL  MEDI-
    CINE.
       For Students and Practitioners, with full directions for examining the  various
     secretions, etc., in  the Microscope.  Fourth Edition.   500 Illustrations.   Much
     enlarged.   8vo.                                                     Price $7.50
  " We have before us Prof. Beale's work, The Micro-    "As a  microscopical observer,, and a histological
 scope in Medicine, a book which it gives us pleasure to   manipulator, his (Dr. Beale) skill and eminence are
 recommend to every student of microscopy, whether he   generally conceded."—Popular Science Monthly.
 be a physician or naturalist."—Journal of the Frank-
 lin Institute, Philadelphia.
 HOW  TO WORK WITH THE  MICROSCOPE.
       A  Complete Manual of Microscopical Manipulation, containing a full descrip-
     tion  of  many new  processes of investigation, with  directions for examining ob-
     jects  under  the  highest powers,  and for taking photographs of microscopic
     objects. Fifth Edition. Containing over 400 Illustrations, many of them colored.
     Octavo.                                                             Price $7.50
  "The Encyclopaedic character of this last edition of Dr. Beale's well known work  on the Microscope renders
 It impossible to present an abstract of its contents ; suffice it to say, that anything in his department upon which
 the physican can desire such information will be found here, and much more in addition.  It is, moreover, a store-
 house of facts, most valuable to the physician, and is indispensable to every one who uses the microscope."—
 American Journal of Medical Science.
 BIOPLASM.
       A Contribution to the Physiology of Life, or an  Introduction to the Study of
     Physiology and Medicine, for  Students.  With numerous  Illustrations.
                                                                         Price $2.25
 PROTOPLASM ;  or MATTER AND  LIFE.
       Third Edition, very  much enlarged.   Nearly 350 pages.  Sixteen Colored
     Plates;  Part 1. Dissentient. Part 11. Demonstrative.  Part in.  Suggestive.
     One volume.                              .                         Price $3.00
 LIFE  THEORIES;  Their Influence  upon Religious   Thought.
       Six Colored Plates.                                              Price $2.00

 ONE HUNDRED  URINARY DEPOSITS,
       On two sheets, for the Hospital, Laboratory, or Surgery.  Each Sheet $1.00, or
    on Rollers,                                                          Price $1.25

 BERNAY, CHEMISTRY.
       Notes for Students in Chemistry.  Compiled from Fowne's and other manuals.
    By Albert J. Bernay, ph.d.  Sixth Edition.   i2mo.               Price $1.25
BOCK,  ANATOMY.
       An Atlas of Human Anatomy.   By Prof. C. E. Bock, of Berlin.   Thirty-seven
    Colored Plates, containing about 200 figures.  Quarto.  Half Roan.  Price $15.00
       This is one of if not the best Anatomical Atlas now to be had, and  its produc-
    tion in Germany  makes it certainly the cheapest. 
PRESLE Y BLAKISTON'S
BEASLEY.  THE  BOOK OF PRESCRIPTIONS.
      Containing over 3100 Prescriptions, collected from the Practice  of the  most
    Eminent Physicians and Surgeons—English, French  and  American; a Com-
    pendious History of the Materia Medica, Lists of the Doses of all Officinal and
    Established Preparations, and an Index of Diseases and their Remedies.   By
    Henry Beasley.  Fifth Edition, Revised and Enlarged.           Price  $2.25
                               BY SAME AUTHOR.

THE  DRUGGIST'S  GENERAL  RECEIPT-BOOK.
      Comprising a  copious Veterinary Formulary; numerous Recipes in Patent
    and Proprietary  Medicines,  Druggists'  Nostrums,  etc.; Perfumery  and Cos-
    metics; Beverages, Dietetic Articles and Condiments; Trade Chemicals, Scien-
    tific Processes, and an Appendix of Useful Tables.  Eighth Edition.  Price $2.25

THE  POCKET  FORMULARY  and Synopsis of the British and
   Foreign Pharmacopoeias.
      Comprising Standard and Approved Formulae for the Preparations and Com-
    pounds Employed in  Medical Practice.   Tenth  Edition.  511  pp.   i8mo.
                                                                      Price  $2.25
BENTLEY AND TRIMEN'S MEDICINAL  PLANTS.
      A New Illustrated Work, containing full botanical descriptions, with an account
    of the properties and uses of the principal plants employed in medicine, especial
    attention being paid to those which are officinal in the British and United States
    Pharmacopoeias.   The plants which supply food and substances required by the
    sick and convalescent are also included.  By R. Bentley, f.r.s., Professor of
    Botany, King's College, London, and H. Trimen, m.b., f.h.s., Department of
    Botany, British Museum.  Each  species illustrated by  a colored plate drawn
    from nature.  In Forty-two parts.  Eight colored plates in each part.
          Price $2 each, or handsomely bound in 4 volumes, Half Morocco, $90.00
 " It would be impossible to enumerate all  the new
plants that are here delineated.  The result is a work
which, from all points ofview.isa credit to the scientific
  " This work may be recommended as a most useful
one to druggists, and all who desire to be familiar
with the Botany of Medicinal Plants."—Druggists'
Circular.
 " The work when complete (it  is now complete)
will be the most valuable compend of Medical Botany
ever published."—Boston Journal of Chemistry.
literature of the day."—London Lancet
  "It is an indispensable work of reference to every one
interested in pharmaceutical Botany."—London Phar-
maceutical Journal.
BRADLEY, ANATOMY.
      Comparative Anatomy and  Physiology.   By S. M. Bradley, f.r.c.s.   Sixty
    Illustrations.  Third Edition.                                       Price $2.00
BRUNTON,  ACTION  OF  MEDICINES.
      Experimental Investigation  of the Action of Medicines.   Part I, Circulation.
    By T. Lauder Brunton,  m.d., f.r.s.  Second Edition.            {Preparing.
BYFORD.  DISEASES OF WOMEN.   New Revised Edition.
      The Practice of Medicine and Surgery, as applied  to the Diseases of Women.
    By W. H. Byford, a.m., m.d., Professor of Obstetrics and The Diseases of Wo-
    men and Children, in the Chicago Medical College.  Third Edition.   Revised
    and  Enlarged, much  of it rewritten,  with numerous  additional  illustrations.
                                              Price, in  Cloth $5.00; Leather, $6.00
                                           " The author is an experienced writer, an able teach.
                                         er in his department, and has embodied in the present
                                         work the results of a wide field of practical observa-
                                         tion.  We have not had time to read its pages critically,
                                         but freely commend it to all our readers, as one of the
                                         most valuable practical works issued from the Ameri-
                                         can press."—Chicago Medical Examiner.
                               BY SAME AUTHOR.

ON THE UTERUS.   The Chronic  Inflammation and Displace-
  ment of the Unimpregnated  Uterus.

      An Enlarged Edition, with Illustrations.   8vo.                   Price $2.50
  "A good book from a good man."—American Journal Medical Science.
  "It is  a sensible, practical work, and cannot fail to be read with interest and profit."—Boston  Medical and
Surgical Journal.
 " The treatise is as complete a one as the present
state of our science will  admit of being written.  We
commend it to the diligent study of eVery practitioner
and student, as a work  calculated to inculcate sound
principles and lead to enlightened practice.—New
York Medical Record. 
PUB LICA TIONS.                                9
BRAUNE, TOPOGRAPHICAL  ANATOMY.

       An Atlas of  Topographical Anatomy.   Thirty-four  Full-page  Plates, Photo-
     graphed on Stone, from Plane Sections of Frozen Bodies, with many other illus-
     trations.   By Wilhelm Braune, Professor of Anatomy at Leipzig.  Translated
     and Edited  by  Edward Bellamy, f.r.c.s.,  Lecturer  on Anatomy,  Charing
     Cross  Hospital,  London.  Quarto.   Price, Cloth, $10.00; Half Morocco, $12.00
  " As a whole the work cannot fail to meet with a hearty reception by every progressive student of the human
body. To the surgeon it is a contribution to the study of topographical anatomy which needs to be known to be
properly appreciated   To such practitioners who reside in large cities, where anatomy can be studied upon the
cadaver, it will afford a valuable aid, while to those who are without such means of study it is an almost indis-
pensable addition to a working library."—New  York Medical Record.
  " We commend the book most heartily to the Profession."—American Journal of Medical Science.

BUCKNILL AND  TUKE  ON INSANITY.

       A  Manual  of Pyschological Medicine: containing  the  Lunacy  Laws,  the
     Nosology, Gitiology,  Statistics, Description,  Diagnosis, Pathology   (including
     morbid Histology), and Treatment of Insanity.  By John Charles Bucknill,
     m.d.,  f.r.s., and  Daniel Hack Tuke,  m.d., f.r.c.p.  Fourth  Edition, much
     enlarged, with twelve  lithographic plates, and numerous illustrations.   Octavo.
                                                                              Price $8.00
  " We have read no book in any language, and certainly none in English, which ought to be preferred to  this
 for a text book, by those who wish to make a thorough study of the subject.—Edinburgh Medical Journal.
  " We can heartily commend the work.—American  Journal of Insanity.

 BURDETT, HOSPITALS.

        Pay Hospitals and  Paying Wards throughout the World.   Facts  in support
     of  a rearrangement of the system of Medical  Relief.   By Henry C. Burdett.
     8vo.                                                                     Price $2.25
  " Mr. Burdett displays and discusses the whole  scheme of Hospital accommodation with a comprehensive
 understanding of its nature and extent.—American Practitioner.

                                    BY SAME AUTHOR.
 COTTAGE   HOSPITALS.
        Genefal,  Fever, and Convalescent:  their Progress, Management, and Work.
     Second  Edition, rewritten and much Enlarged, with many Plans and Illustra-
     tions.   Crown 8vo.                                                     Price $4.50
   Contents.—Chap.—i. Origin and Growth of the Cottage Hospital System.  2. Comparative Success  of
 Treatment in large and small Hospitals. 3. Finance. 4. Cottage Hospital Construction and Sanitary Arrange-
 ments.  5. The Medical and Nursing  Departments.  6. Domestic Supervision and General Management.  7.
 Cottage Hospital Appliances and Fittings.  8.  Cottage Fever Hospitals.  9. Midwifery in Cottage Hospitals.  10.
 Remunerative Paying Patients.   11. Convalescent Cottages.  12. Cottage Hospitals in America.  13. Mortu-
 aries.  14. A more Detailed Account of certain Cottage Hospitals, with Plans and Elevations.  15.  Selected and
 Model Plans criticised and compared, with a  detailed description of various Hospitals.  16. Peculiarities and
 Special Features in the Working of Cottage Hospitals. With an Appendix containing much statistical and useful
 information.
   " Mr  Burdett's book contains a mass of information, statistical, financial, architectural, and hygienic, which has
 already proved of great practical utility to those interested in cottage hospitals and we can confidently recom-
 mend this second edition to all who are in search of the kind of information which it contains. —Lancet.

 BUZZARD,  SYPHILITIC NERVOUS AFFECTIONS.
        Clinical Aspects of Syphilitic  Nervous Affections.   By Thos. Buzzard, m.d.
      i2mo.                                                                   Price *x-75

 CARPENTER, THE  MICROSCOPE.   Sixth Edition.

        The  Microscope and  its Revelations.   By W.  B. Carpenter, m.d., f.r.s.
      Sixth Edition.  Revised and Enlarged, with over 500 Illustrations.   Price $5.50
                                                  "As a text book of Microscopy in its special relation
                                               to natural history and general science, the work before
                                               us stands confessedly first, and is alone sufficient  to
                                               supply the wants of the ordinary student."—American
                                                Journal of Microscopy.
  " Not only the student of medicine, but amateurs,
and others interested in the study of natural history,
will find this volume one of great practical value. —
New York Medical Journal.
  " It is by far the most complete and useful treatise
now accessible to the student.''—The Technologist. 
IO
PRESLEY BLAKISTON'S
Oazeaux's  Great Work on  Obstetrics.


       THE MOST COMPLETE TEXT-BOOK NOW  PUBLISHED,

 GREATLY  ENLARGED  AND  IMPROVED.

               CONTAINING  175  ILLUSTRATIONS.

   k Theoretical  and Practical Treatise  on Midwifery, including  the Disease*

     of Pregnancy and Parturition,  by  P. Cazeaux, Member of  the Imperial

     Academy of Medicine; Adjunct Professor in the Faculty of Medicine of

     Paris, etc.,  etc.   Revised and Annotated  by  S.  Tarnier, Adjunct Pro-

    fessor in the Faculty of Medicine of Paris ; Former Clinical Chief of the

     Lying-in-Hospital, etc., etc.   Sixth American from the Seventh French Edv

     tion.  Translated  by Wm. R. Bullock, M. D.  In one volume  Royal Oc-

     tavo,  of  over 1100 pages,  with numerous Lithographic and other  Illustra-

     tions  on  Wood.

       Price, bound in  Cloth, bevelled boards,             .     .     .    $6.00
         "       "     Leather,         .          .....7.00

  M. Cazeaux's Great "Work  on Obstetrics  has become classical in its  character, and
almost an Encyclopaedia  in its fulness.  Written expressly for the use  of students  of
medicine, and those of midwifery  especially, its teachings are plain and explicit, present-
ing a condensed  summary of the leading principles established by the  masters of the
obstetric art, and  such clear, practical  directions for the  management of the pregnant,
parturient,  and puerperal states, as have been sanctioned  by the  most authoritative
practitioners, and confirmed by the author's  own experience.  Collecting his materials
from the writings of the entire body of antecedent writers, carefully testing their correct-
ness and value by his own daily experience, and rejecting all such  as were  falsified  by
the numerous cases brought under his own immediate observation, he has formed out of
them a body of doctrine, and a system of practical rules, which he illustrates and enforces
in the clearest and most simple manner possible.

                            OPINIONS OF THE PRESS.

  " It is unquestionably a work of the highest excellence, rich in information, and perhaps fuller in detaili
than any text-book with which we are  acquainted.  The author has not merely treated of every ques-
tion which relates to the business of parturition, but he has done so with judgment and ability."
British and Foreign Medico- CMrurgieal Review.
  " The translation of Dr. Bullock is remarkably well done.  We can  recommend this work  to thoe«
especially interested in the subjects treated, and can especially recommend the American edition."
Medical Timet and Gazette.
  " The edition before us is one of unquestionable excellence.  Every portion  of it has undergone a
thorough revision, and no little modification; while copious and important additions have been made to
nearly every  part of it.  It  is well and beautifully illustrated by numerous wood and lithographic
engravings,, and, in typographical  execution, will bear a favorable comparison with other works of  the
same class."—American Medical Journal.
  " In the multitudinous collection of works devoted to the propagation of human beings, and to  the
details of parturition, none, in our estimation, bears any comparison to the work of Cazeaux, in itc
entire perfectness; and if we were called upon to rely alone on one work on accouchments, our choioc
would fall upon the book before us without any kind of hesitation."— We«t. Jour, of Med. and Surgery.
  "We do not hesitate to say, that it is now the most complete and best treatise on the subject in  th*
English language."— Buffalo Medical Journal.
  "We know of no work on this all-important branch of our profession that we can recommend to  th«
Itudent  or praotitioner as a safe guide before this."—Chicago Medical Journal. 
PUBLICA TIONS.
n
CHARTERIS, PRACTICE OF  MEDICINE.

      Hand-Book of the Practice of Medicine.   By M. Charteris, m.d., Member
    of Hospital Staff and Professor in University of Glasgow.  With Microscopic and
    other illustrations.                                                Price $2.00
 " We have not often met with a book which can be so confidently recommended to physicians or men in general
practice.''—Lancet.
 " The style in which it is written is clear and at-traetive. The illustrations are a marked feature in it. It can
be recommended as a very reliable, handy book, well adapted for ready reference."—New Remedies.

CHAVASSE  ON CHILDREN.
      The Mental  Culture and Training of Children.  By Pye Henry Chavasse.
    i2mo.                                                           Price $1.00
  The mental culture and  training of children is of immense importance.  Many
children are so wretchedly trained, or rather not trained at all,  and so mismanaged,
that a few thoughts on this subject cannot be thrown away,  even upon  the most
careful.

CLAY ON OBSTETRIC SURGERY.   Third Edition.

      A complete Hand-Book of Obstetric Surgery, with Rules  for every Emergency
    and Descriptions  of the more difficuk as well as the every day operations.  By
    Charles Clay, m.d., with numerous illustrations.  From the Third London Edi-
    tion.  i2mo.                                                     Price $2.00
 " It is a useful and convenient book of reference; the illustrations are good, and the book will be found of value
to the student and young practitioner, as well as to the skilled Obstetrician."—American Journal of Obstetrics.

CLEVELAND, POCKET  DICTIONARY.
      A Pronouncing Medical Lexicon, containing correct Pronunciation and Defi-
    nition of terms used in  medicine and  the collateral sciences.  By C. H. Cleve-
    land, m.d.  Twenty-sixth Edition.   i6mo.
                                  Price, Cloth, 75 cents ; Tucks with Pocket, $1.00
  This is a most convenient size for the pocket, and contains all the principal words
in use, together with rules for pronunciation, abbreviations used in prescriptions, list
of poisons, their antidotes, etc.

COHEN, INHALATION.   Enlarged  Edition.
       Inhalation, its Therapeutics and Practice,  including a Description of the Ap-
paratus  Employed, etc.  By J. Solis Cohen,  m.d.  With  cases and Illustrations.
A New Enlarged Edition.   8vo.                                      Price $2.50
  " The book has the merit of containing much information that  cannot be found elsewhere."—N. Y. Medical
Journal.
  " One of the best treatises we have seen on this subject."—Medical Times and Gazette.
                                BY SAME AUTHOR.

CROUP,
       In its Relation to Tracheotomy.  8vo.                            Price $1.00

CLARKE,  SURGERY.
       Outlines of  Surgery and Surgical Pathology, including the Diagnosis and
    Treatment of Obscure and Urgent Cases.  By F. LeGross Clarke, f.r.s.
     Second Edition.  8vo.                                            Pnce #2-°°

COBBOLD, PARASITES.
       A Treatise on the Entozoa of Man and Animals, including some account of
     the Ectozoa.  By T. Spencer  Cobbold, m.d., f.r.s.  With  85  illustrations.
     8vo.                                                             rnce #5.00 
PRESLEY BLAKISTON'S
     DAY     ON      CHILDREN.
                 A  SECOND EDITION.   JUST  READY.
   The Diseases of Children.   A  Practical and Systematic Treatise,  for Practitioners
and  Students.   By  Wm.  Henry  Day,  m.d.   Second  Edition.   Enlarged.   8vo.
752 pp.                                                    Price,  Cloth, $5.00;  Sheep, $6.<y

          What  Prominent  Professors  Say   of  It.
  " The more I read Dr. Day's book, the more I like
it. I shall recommend  it to the students of George-
town College."—Prof. J. Tabeb Johnson, Washington,
D.C.
  " I pronounce the book a good one, and one that
promises to be useful to  both practitioners and stu-
dents."—Prof. W. A. Edmunds, St. Louis.
  " I think it admirably adapted to tho uses of practi-
tioners and students of medicine."—Prof. Hannah T.
Ckoasdale, Woman's Medical College, Philadelphia.
  " Believing the work well adapted to meet the wants
of the student as well as the practitioner, it will give
mo pleasure to recommend it  to the classes of  Rush
Medical College."—Prof. De Leskie Miller, Cliicago.
  " It  is the work for which we have so long felt the
want and need.  I take pleasure in recommending it."
—Prof. C. T. Bedford, Indianapolis, Ind.
  " The practitioner can confidently rely upon finding
in Its pages the very best and latest knowledge con-
cerning the diseases of children."—Prof. W. J. Conv.
un, Dayton, 0.

  " It is just what a student and  a busy practitioner
needs.  I can heartily recommend it."—Prof. J. M.
Dunham, Columbus, 0.

  "Itis, in my judgment, the most satisfactorily ar-
ranged and eminently practical work  upon the til-
ments of infancy and childhood yet published in the
English language."—Prof. F. L. Sim, Memphis, Term.

  " It is especially to be recommended for judicious
comments on infant feeding, etc."—Prof. H.G. Lan-
dis, Columbus, 0.
  "An excellent practical treatise, superior to any of
the reprints in the department of Diseases of Children
that I have seen."—Prof. E. O. F. Holer, Chicago.
  " It is fairly entitled to the highest rank among the
text-books on Diseases of Children,"—Prof. J.B. Kings-
ley, St. Louis.
PRESS  OPINIONS.
' "A careful examination of this book leads  us to
characterize it as a plain, straightforward treatise on
the Bubject upon which it treats,  ....  giving
sound practical advice."—Philadelphia Medical Times.
  " We heartily recommend this book to the profession
as a safe and reliable guide in the department of which
it treats."—Medical and Surgical Reporter.
  "Thebook is wonderfully readable."—British  Medi-
cal Journal.
  " The article on the true diseases of children, those
of the pulmonary, circulatory and renal apparatus, and
the nervous system, are in many parts exhaustive.  .
.  .  The  writing is clear and forcible, and to  the
point."—American Journal of Medical Sciences.
  " We have no doubt it will be read with interest,
which its style, as well as its matter, deserves."—Dub-
lin Medical Journal.
  " Taking the book as a whole, its correct classifica-
tion, its perfect style, and its comprehensiveness place
it in advance of all  other books upon the same sub-
ject."—Walsh's Retrospect.
 "a A  safe guide for the student and practitioner."—
College and Clinical Reoord.
  " One ef the most useful and valuable additions to
the medical literature of the present day. No medical
library should be without this book on its shelves."—
Medical Bulletin.
  " Dr. Day brings to his task a large experience, and
evidences a very thorough  knowledge of the litera-
ture, native and foreign, pertaining to  this special
branch of medicine.  The book has been written with
great care,  and the author is a good writer.   The pub-
lisher's part of the task has also been excellently per-
formed."—Boston Medical and Surgical Journal.
  "We advise  every physician  to  have a copy."—
Braiihwaite's Quarterly Epitome.
  " Altogether we can heartily commend this volume
to any students of this subject that desire to obtain the
latest and most judicious  compend of our knowledge
of Children's Diseases."—Detroit Lancet.

  " One of the most satisfactory guideB in the diagnosis
and treatment of diseases peculiar to children to be had
in the language."—New Remedies.

  " This volume, from the title-page to the end of the
last chapter, abounds in just such practical and well-
put information as  every man, in the course of his
treatment of children's diseases, must oftentimes feel
the need."—Medical  Herald, Louisville.

  " We commend it particularly for its practical worth,
being full of valuable hints in regard to diagnosis and
treatment."—Medical Annals, Albany,  N. Y.
  "Itshould be in the library of every medical stu-
dent and practitioner."—Southern Medical Record.
  " It is  full of valuable facts and suggestions that will
make a  welcome addition to the working library of
every practitioner."— Ohio Medical Journal.
  "Plain, full and  eminently  practical."—Southern
Clinic.
  " The book is up to the times, and we cordially com-
mend it  to those for whom it is written, but especial-
ly the studemt."—Therapeutic Gazette.
  " A safe guide in practice."—Pacific Medical and Sur-
gical Journal.

  "It is not too much to say of it that it Is probably
not equaled, and cprtainly not excelled, by any other
book on its subject."—Michigan Medical News.
  " A thoroughly practical work."—Independent Prac-
titioner.

  " It is just such a book as is wanted by the general
practitioner."—Medical Brief.
      Price: Cloth, $5.00;  Leather, $6.00.  lor sale by all booksellers,
or sent to  any address, postpaid, on receipt of price. 
PUBLICA TIONS.
13
COULSON, THE BLADDER.   Sixth  Edition.
       Diseases of the Bladder and Prostate Gland.  By Walter J. Coulson, f.r.c.s.
     Sixth Edition.   Revised and Enlarged, with 22 Engravings.  8vo.    Price $6.40

CRIPPS, THE  RECTUM.
       Cancer  of the Rectum.  Its Pathology, Diagnosis and Treatment.   By.  W.
     Harrison Cripps, f.r.c.s.   Illustrated by Plates.  8vo.              Price $2.40

CORMACK.   CLINICAL STUDIES.
       Illustrated  by Cases  Observed  in Hospital and  Private Practice.   By Sir
     John Rose Cormack, m.d., k.b., etc.  Illustrated.  2 vols.   1127 pp.  Price $5.00
  Contents.—Vol. i.—Chapter i.  Relapsing Fever,  ii. Cholera,  m. Scarlatinous Nephritis,  iv. Puerperal
Convulsions,  v. Glandular Degeneration of the Kidney, and Its Relation to Scrofula,  vi.  Infantile Remittent
Fever,  vn. Labor Complicated with Cauliflower Excrescence of the Uterus, vm. Value of the Dark Abdominal
Line as a Test of Recent Delivery,  ix. Dystocia from Cystous Kidney in the Mature Fcetus.  x. Hernia of the
Uterus.
  Vol. 11.—Chapter I. Air in the Organs of Circulation,  ii. Reflex Convulsions in Infancy,  in. Pharyngo-
Laryngo-Tracheal  Diphtheria, iv.  Diphtheria, v. Paralytic Affections,  vi. Paralytic Affections in  Enteric
Fever,  vn. Treatment of Paralytic Affections,  vm. Non-Venereal Discharges from the Urethra,   ix.  Scarla-
tinal Vaginitis,  x. Congenital Syphilis,  xi. Chronic Poisoning by Chloroform,  xn. Resection of the Shoulder
Joint,  xiii. Concussion of the Brain,  xiv. General Paralysis with Insanity, xv. Short Attacks of Insanity.

DAY ON  HEADACHES.
       The Nature, Causes, and Treatment of Headaches.  Third Edition.   Illus-
     trated.  By Wm. Henry Day,  m.d.                                    Price $2.00
  Summary of Contents.—Headache from Cerebral Anaemia, Cerebral Hyperaemia, Sympathetic, Congestive,
Dyspeptic or  Bilious Headaches, Headache from Plethora, from Exhaustion, from  Change in Cerebral  Tissue,
from Affections of the Periosteum, Nervous and Nervo-Hyperasmic Headache, Toxaemic, Rheumatic, Arthritic
or Gouty Headache, Neuralgic Headache, and Headaches of Childhood, Early and Advanced Life.
  " Well worth reading.  The remarks on treatment are very sensible."—Boston Medical and Surg. Journal.

DALBY,  ON  THE  EAR.
       The Diseases  and  Injuries of the Ear.   By W. B. Dalby, m.d.,  Surgeon and
     Lecturer on Aural  Surgery, St. George's Hospital.   With  Illustrations.  i2mo.
                                                                              Price $1.50
  'Asafe and readable introduction to aural surgery."  I   "The lectures occupy  226 pages, are clearly and
Medical Press and Circular.                       consisely written, contain a number of good illustrations,
  " Dr. Dalby has presented us with a very readable    a"d are well worth the careful study of both  student
litde book, which is destined to render much service in    ««* practitioner,  roauriststheworkw.il be most
the savingof ears."-iV. Y. Medical Journal.        I  welcome and valuable. -Specialist.

DILLINGBERGER,    WOMEN   AND   CHILDREN'S   DIS-
   EASES.

       A  Hand-Book of the Treatment of the Diseases Peculiar  to Women and Chil-
     dren.   By Dr. Emil Dillingberger.   i2mo.                        Price $1.50
  " It is a magnum infarvo.  The style is simple, clear, lucid, and free from theoretical discussion.  No one will
regret the small outlay for this volume.—Richmond and Louisville Medical Journal.

DUNGLISON, THE PHYSICIAN'S  REFERENCE  BOOK.
       The  Practitioner's  Reference Book, containing Therapeutical and  Practical
     Hints, Dietetic Rules, and  General Information.  By Richard J. Dunglison,
     m.d. ' Second Edition.   8vo.                                           Price $3.50
  " We can heartily commend this book as one that     " The demand for a second edition so soon after the
must orove very useful to the general practitioner."—   publication of the first volume shows that this work is
The Medical Record.                             appreciated by the profession."—Canada Lancet.

DURKEE,  VENEREAL  DISEASES.   Sixth  Edition.
       Gonorrhoea and Syphilis.  By Silas  Durkee, m.d.  Sixth Edition.   Revised
     and Enlarged, with Portrait and Eight Colored Illustrations.   8vo.   Price $3.50
  " We may, finally, recommend Dr. Durkee's book as eminently practical, well written, full of excellent counsel,
and worthy of being consulted by every member of the profession. A late number of  the London Medical Titnes
and Gazette also speaks of the book in terms of the highest approval."—Boston Medical and Surgical Journal. 
14
PRESLE Y BLA KISTON 'S
DAGUENET,  OPHTHALMOSCOPY.
      A Manual of Ophthalmoscopy, for the Use  of  Students.  By Dr. Daguenet.
    Translated from the  French, by Dr. C. S. Jeaffreson, f.r.c.s.e.   Illustrated.
    i2mo.                                                           Price $1.50
  "Its portable size, the condensed nature of its text, and the admirably systematic arrangement of its contents,
render it extremely useful as a pocket manual for Students.— Translator's Preface.

DOBELL, WINTER COUGH AND CATARRH.
      On  Winter   Cough, Catarrh,  Bronchitis,  Emphysema,  Asthma,  etc.  By
    Horace Dobell, m.d., Lecturer at the Royal  Hospital  for  Diseases of the
    Chest.   Third Edition.  With Colored Plates. 8vo.                Price $3.50

                              by same  author.

ON  LOSS OF  WEIGHT.   Revised Edition.
      Blood Spitting and  Lung Disease.  Colored Frontispiece of Lung.   Tabular
    Map, etc. Second Edition Enlarged.  8vo.                        Price $4.00

DOMVILLE,  ON NURSING.
      A Manual for Hospital  Nurses and  others engaged in attending to the  sick.
    4th Edition.  With Recipes for Sick Room Cookery, etc.            Price #1.00

DRUITT'S MODERN  SURGERY.  Eleventh  Edition.
      The  Surgeon's Vade Mecum; a Manual of Modern Surgery.   By Robert
    Druitt,  f.r.c.s.  Eleventh Enlarged Edition, with  369 Illustrations.  864 pp.
    1878.                                                            Price #5.00
  This is a most complete, accurate, and trustworthy Hand, or Text-Book of Sur-
gery.  Unrivaled as a book for  the  Student.  Fully illustrated, and  brought up to
the present state of  the science.  In use in many Medical Colleges.

DULLES, ACCIDENTS.
      What to do First, in Accidents and  Poisoning.  By C. W. Dulles, m.d.  Il-
    lustrated. i6mo.                                                  Price .50
  " Its usefulness entitles it to a wide and permanent
circulation."—Boston Gazette.
  " A complete guide for sudden emergencies.—Phila-
delphia Ledger.
 " So plain and sensible that it ought to be introduced
into every  female  seminary.—Evening Chronicle,
Pittsburgh.
EDWARDS,  BRIGHT'S  DISEASE.  New Edition.
      How a Person Affected with Bright's Disease Ought to Live.  By Jos. F. Ed-
    wards, m.d.  Second Edition.  i2mo.                              Price .75
                              BY SAME AUTHOR.
DYSPEPSIA.  Just Ready.
How to Avoid It.   i2mo.
•75
 Contents.—Chap. 1.—Food. 11. Digestion, m. How to Cook Food. iv. How and What We Ought to Eat.

CONSTIPATION.  New Edition.
      Plainly  Treated and Relieved Without the Use of Drugs.  Second Edition.
    i2mo.                                                             Price .75

MALARIA.
      Malaria: What It Means;  How to Escape It; Its Symptoms;  When and
    Where to  Look for It.  i2mo.                                       Price .75

  These  are invaluable little treatises upon subjects that enter painfully into the
life experiences of a large  majority of the human family.  Dr. Edwards shows not
only how they may be avoided, but in plain and simple language he tells those
already afflicted with them how they may find relief.  Many learned works have been
written upon their treament; but the authors have, in nearly every case,  neglected
to show to the public how to avoid them. 
PUB LICA TIONS.
15
EKIN, WATER  ANALYSIS.
       Potable Water.  How to Form a Judgment on the Suitableness of Water for
    Drinking Purposes.  By Charles Ekin.  Second Edition.   i2mo.    Price .75

ELLIS,  DISEASES  OF  CHILDREN.
       A Practical Manual of the Diseases of Children, with a Formulary.   By Ed-
    ward Ellis, m.d.   Late Physician  to the  Victoria Hospital for  Children,
    London.  Fourth Edition Enlarged.   Now Ready.                   Price $3.50

                                 BY SAME  AUTHOR.

WHAT EVERY  MOTHER  SHOULD  KNOW.
       i2mo.                                                               Price .75
  " It is only too true that our children have to dodge through the early part of life as through a labyrinth. We
must be thankful to meet with such a sensible guide for them as Dr. Ellis."—Pall Mall Gazette.
FENNER, ON  VISION.
      Vision;  Its Optical Defects, the Adaptation of Spectacles, Defects of Accommo-
                  By  C. S. Fenner, m.d.  With Test  Types and 74 Illustrations.
                                                                          Price $3.50
dation, etc.
8vo.
FENWICK,  THE PRACTICE OF  MEDICINE.

       Outlines of the Practice  of Medicine.   With Appropriate Formulae and Illus-
    trations.   By Samuel Fenwick, m.d., Physician to the London Hospital.  i2mo.
                                                                          Price $2.00

  "This little work displays a sound judgment in the arrangement of its subject matter, and an intimate acquaint-
ance with the practice of medicine possessed by but few writers, and should have been elaborated into a more
comprehensive work.  Of all the hand-books we have seen, this is certainly one of the best."—Medical Herald.
  " It is an eminently practical little treatise, pervaded with much  common sense, and  will doubtless be found
useful, particularly by advanced students."—Boston Medical and Surgical Journal.
                                  BY SAME AUTHOR.
ON  THE STOMACH.
       The Morbid State of the  Stomach and Duodenum, and Their  Relations to
    Diseases of Other Organs.   With 10 Plates.   8vo.                   Price $4.25

       Atrophy of the Stomach and Its Effect on the Nervous Affections of the Digest-
    ive Organs.  8vo.                                                    Price $3.20

FOTHERGILL,  ON THE HEART.   Second  Edition.
       The Heart and Its^Diseases.  With Their  Treatment.   Including the Gouty
    Heart.  By J.  Milner Fothergill, m.d., Associate  Fellow  of the College of
    Physicians of  Philadelphia.    Second Edition,  Entirely Re-written.   Octavo.
                                                                      .    Price $3.50
  " It is the best, as well as the most recent work on
the subject in the English language."—Medical Press
and Circular.
  " The most interesting chapter is undoubtedly that
on the gouty heart, a subject which Dr. Fothergill has
specially studied, and on which he entertains views
such as  are likely, we think, to be generally accepted
by clinical  physicians, although they have not before
been stated, so far  as we are aware, with the same
breadth of  view and extended illustration."—British
Medical Journal.
  " To many an earnest student it will prove a light in
darkness;  to many a practitioner cast down with a
sense of his powerlessness to cope with the rout and
demoralization of Nature's forces, a present help in
time of trouble."—Philadelphia Medical Times.
  " The work throughout is a masterpiece of graphie,
lucid writing, full of good, sound teaching, which will
be appreciated  alike by the practitioner  and the stu-
dent.—Students' Journal.
FULTON,  ON  PHYSIOLOGY.
       A  Text-Book of  Physiology.  By J. Fulton, m.d.,  Professor at  Trinity
    Medical  College,  Toronto.   Second  Edition, Illustrated  and  Revised.   8vo.
                                                                          Price S4.00 
16                         PRESLEY BLAKISTON'S
 FLOWER, DIAGRAMS OF  THE  NERVES.
       Diagrams  of the  Nerves of the  Human  Body.   Exhibiting their Origin,
     Divisions, and Connections, with their Distribution to the various Regions of the
     Cutaneous Surface, and to all the Muscles.   By William H. Flower, f.r.c.s.,
     f.r.s.,  Hunterian  Professor of Comparative Anatomy, and Conservator of the
     Museum of the Royal College of Surgeons.  Third Edition, thoroughly revised.
     With six Large Folio Maps, or Diagrams.   Royal Quarto.           Price $3.50
  "Admirably arranged, and  will be of incalculable aid to the student  of anatomy. Each of the large and
 beautiful plates is accompanied with explanatory text."—N. Y. Medical Record.
  " The nerves and ganglia are clearly represented. The impressions are well made, and no doubt the diagrams
 will prove useful."—Medical and Surgical Reporter.
 FLAGG,  PLASTIC  FILLING.
       Plastics and Plastic Filling; As Pertaining to the Filling of all Cavities of De-
     cay in Teeth below Medium in Structure, and to Difficult and  Inaccessible
     Cavities  in Teeth  of all Grades of Structure.  With some  beautifully executed
     Illustrations.  By J.  Foster Flagg, d.d.s., Professor  of Dental Pathology and
     Therapeutics in Philadelphia Dental College.  Octavo.              Price $3.00
  Contents.—Introductory.   Article i. Plastic Filling.  2. Amalgam.  3. Amalgam continued.  4. Amalgam
 continued.   5. Attributes of Metals used for Amalgam Alloys.  6. The Making of Amalgam Alloys.  7. Tests
 for Amalgam.  8. Preparation of Cavities. 9. The Making of Amalgam.  10.   Instrument for  the Insertion of
 Amalgam Fillings.  11. The Insertion of Amalgam Fillings. 12. General Considerations Pertaining to Amalgam.
 13. Gutta-percha.  14. Oxy-chloride of Zinc.  15. Oxy-sulphate of Zinc.  16. Zinc Phosphate.  17. Temporary
 Stopping.  18. Technicalities.  Conclusion.

 FOSTER,  CLINICAL  MEDICINE.
       Lectures and Essays on Clinical  Medicine.  By Balthazar Foster, m.d.
     Illustrated.  8vo.                    •                                Price $3.00
  " No one can peruse the thoughtful comments of our     " It is the record of honest work, such as Dr. Foster
 author upon every subject he considers, without feeling    may be proud of; we can recommend it to the profession;
 himself a wiser man for his pains."—N. Y.  Medical   it may be read with profit and advantage by both prac-
 Journal.                                     titioner and student.—Edinburgh Medical Journal.

 FOX,  ATLAS OF  SKIN  DISEASES.
     '  Complete in Eighteen Parts, each containing Four Chromo-Lithographic Plates,
     with Descriptive Text and Notes upon Treatment. In all 72 large colored Plates.
     By Tilbury Fox,  m.d., f.r.c.p., Physician to the Department for Skin Diseases
     in University College Hospital.   Folio Size.
                                Price $2.00 each, or complete, bound in cloth, $30.00
  No Atlas of Skin Diseases has been issued in this country for many years, and no
 complete work of the kind is now procurable by the Profession.  This one, brought
 out  under the editorial supervision  and  care of Dr. Tilbury Fox (the most distin-
guished writer on Cutaneous Medicine now in the English language), is partly based
upon the classical work of Willan and Bateman (now entirely out of print), but com-
pletely remodeled, so as to represent fully the Dermatology of the present day.
  " Preference will be given to this work over Hebra; not simply, however, because it is a home production, but
by reason of the manner of its execution, the excellent delineation of disease, and the natural coloring of the plates.
 . .   . The letter-press is entirely new. In the accuracy of the latter the subscriber may have  the fullest confi-
dence, since it is from the pen of Dr. Tilbury Fox."—British and Foreign Medico-Chirurgical Review.

 FRANKLAND, WATER ANALYSIS.
       Water Analysis, For  Sanitary Purposes, with Hints for the Interpretation of
     Results.  By E. Frankland,  m.d., f.r.s.   Illustrated.   i2mo.       Price $1.00
  " The author's world-wide reputation will commend     " The work is one which physicians  practicing i«
this manual to all sanitarians, and they will not be dis-    the country and in  villages and towns remote from
appointed in finding all the essentials of the important    medical centres cannot afford to be without."—Medical
subject of which it treats."— The Sanitarian.          and Surgical Reporter.

                                 BY  SAME AUTHOR.
 CHEMISTRY.
       How to Teach Chemistry; being Six Lectures to Science Teachers. Edited
     by G. George Chaloner, f.c.s.  Illustrated.   i2mo.                Price $1.25 
PUBLIC A TIONS.
*7
FOX,  WATER,  AIR AND  FOOD.
       Sanitary Examinations  of Water, Air and Food.
     m.d.  94 Engravings.   8vo.
By Cornelius B. Fox,
              Price $4.00
GALLABIN,  DISEASES OF  WOMEN.
       The Student's Guide to the Diseases of Women.  By A. Lewis Gallabin, m.a.,
     m.d., f.r.c.p.   Illustrated with 63 Engravings.   i2mo.               Price $2.00
  "Among all the various works on diseases of women
with which we are acquainted, there  is none which so
nearly approaches the perfection of  what  a student's
text-book should be .  . . The work is well illustrated."
—Students' Journal.
  " Though the book is a small one and the subject ex-
tensive, yet so admirable is the style of the  writer, and
so careful his selection of words, that each disease is
thoroughly treated of."—Philadelphia Medical Times.
  " Its style is clear, elegant, and concise.  It contains
a great amount of information;  indeed, we do not think
the student or practitioner will find any book which
will convey to him in so small a compass so much accu-
rate knowUdge about the pathology and diagnosis of
the diseases peculiar to women."—Medical Titnes and
Gazette.
GROSS, BIOGRAPHY  OF JOHN  HUNTER.
       John Hunter and His Pupils.  By S. D. Gross, m.d., Professor of Surgery in
    Jefferson Medical College, Philadelphia.  With a beautifully executed full length
    Portrait  of the Author in  his Study.  A Handsome Octavo volume.   Bound in
    Beveled Cloth.                                                         Price $1.50
  " It is refreshing to read  the story of a life so fully devoted to science, and the reader will readily appreciate
Professor Gross's enthusiasm for his subject, which led him to extend what was originally intended for an essay to
its present size.
  " The phototype of Sharp's well-known engraving of Sir Joshua Reynold's portrait is an excellent reproduction,
and forms a fitting and handsome frontispiece.
  " The volume will prove an ornament to the study table, where it will be a constant incentive to whatever is
best and noblest in a noble profession."—Boston Med. and Surgical Journal.

                                   BY SAME AUTHOR.

AMERICAN  MEDICAL MEN.
       American Medical  Biography of the  Nineteenth Century, with portrait of Dr.
     Benjamin Rush.   Large 8vo.                                           Price $3.50

GANT, A SYSTEM  OF  SURGERY.   Enlarged Edition.
       The Science and Practice of Surgery, including Special Chapters by different
     Authors.  By Frederick James  Gant, f.r.c.s., Senior Surgeon to  the Royal
     Free Hospital.   Second   Edition, rewritten  and much  enlarged  throughout.
     Illustrated by 969 wood engravings.  In two Octavo volumes.
                                                    Price, Cloth $11.00; Leather $13.00
  " After the most patient analysis our limited  time
has permitted, we f«el compelled to say that this  book
is a valuable and eomprehensive addition to the surgical
literature of the profession and a monument to the care-
ful, conscientious and  painstaking  industry of the
author."— Cincinnati Lancet and Observer.
  " This new and magnificent work on surgery sup-
 plies all that can be required, whether for the most com-
 plete study or for  constant reference in practice."—
' London Medical Press and Circular.
  " The reader has the advantage of mature experience
 in treating of special subjects, that are either omitted
 or very lightly referred to in  ordinary works on sur-
 gery."—London Lancet.
                                   BY SAME  AUTHOR.

ON THE  BLADDER  AND PROSTATE.
       Diseases of the Bladder and Prostate Gland and Urethra, including a Practical
     View of Urinary Diseases, Deposits and Calculi.  Fourth Edition, Revised and
     Enlarged, with New Illustrations.   i2mo.                             Price $3.00

GIBBES,  STUDENT'S PATHOLOGY.
       Practical  Histology and  Pathology.   By  Heneage  Gibbes, m.b.   i2mo.
     Cloth.                                                                   Price $1.00
  Chap' i Introduction  2. On Preparing Tissues for Examination.  3. On Cutting Sections.  4. On Staining.
s. On Double Staining.  6.  On Mounting. 7. Method of Obtaining Animal Tissues, etc.  Practical Histology,
Pathology, Memoranda and Formulae.
  " This excellent little work is admirably adapted to  fulfill the purpose for which it has been written.  It is
short^ ckar and eminently Practical.  The^uthor is evidently ™,^P^1""^^^ b°°k """^
the impression that it is based upon his own personal experience."-The London Medical Record. 
i8
PRESLEY BLAKISTON'S
GODLEE'S ATLAS  OF  HUMAN  ANATOMY.
      Illustrating most of the Ordinary Dissections and many not usually practiced
    by the Student.  Accompanied by References and an Explanatory Text.  Com-
    plete.  Folio  Size.  48 Colored  Plates.   By Rickman John  Godlee, m.d.,
    f.r.c.s.  Forming  a large  Folio  Volume, with  References, and an  Octavo
    Volume of Letter-press.
                    Price of the two Volumes, Atlas and Letter-press, Cloth, $30.00
  " It is likely to prove as useful to the physician and I   " The explanatory text is concise, well written, and
surgeon as to the anatomist."—Medical Titnes and   contains many valuable suggestions for the surgeon."
Gazette.                                |  —London Lancet.

GOWERS,  SPINAL CORD.
      Diagnosis of Diseases of the Spinal Cord.   With Colored Plates and Engrav-
    ings.  A Second Edition. Revised  and Enlarged.  By William R. Gowers,
    m.d., Assistant Professor Clinical Medicine, University College, London.  8vo.
                                                                   Price $1.50
                             by same author.

OPHTHALMOSCOPY.
      A Manual and Atlas  of Medical  Ophthalmoscopy.  With 16 Colored  Auto"
    type and Lithographic Plates  and 26 Wood Cuts, comprising 112 Original Illus-
    trations  of the Changes in the Eye in Diseases of the Brain, Kidneys, etc.  8vo.
                                                                   Price $6 00
GREENHOW, BRONCHITIS.
      On Chronic Bronchitis, especially as connected with  Gout, Emphysema, and
    Diseases of the Heart.  By E. Headlam Greenhow, m.d. i2mo.   Price $1.50

                             BY SAME  AUTHOR.
ADDISON'S  DISEASE.
      Being the Croonian  Lectures, delivered before the Royal College of Physi-
    cians, London.  Revised and Illustrated by Plates and Reports of Cases.  8vo.
                                                                   Price $3.00
  "The book forms a most interesting and valuable monograph, comprehensive and exhaustive."—British
Medical Journal.

GLISAN, TEXT-BOOK OF MODERN MIDWIFERY.
      A  Text-Book of Modern Midwifery.   By Rodney  Glisan, m.d., Emeritus
    Professor of Midwifery and Diseases of Women and  Children in the Medical
    Department of Willamette University, Portland, Oregon,  and Late President
    of the Oregon State Medical Society. With  129 Illustrations.   One Volume,
    octavo,  6*24 pp.                       Price,  in Cloth $4.00; in Leather $5.00
  Many years have elapsed since the appearance of an original American text-book
of obstetrics.  The author of this one, believing that there  is a demand for a work
thoroughly representing American obstetrical  practice, ventures to present this con-
densed treatise to the medical students and practitioners of his own country.   Many
years' experience as a practitioner and several as a teacher of midwifery, warrants
this effort to supply  the demand for a book fully brought up to the present time,
faithfully representing the peculiarities of American practice, and adapted to the wants
of obstetric teachers and busy practitioners.
  The book  is freely illustrated wherever its value and usefulness can be thus en-
hanced, and being brought out—owing to the unavoidable absence of the author-
under the supervision  of the well-known obstetrician,  Dr. Robert P. Harris, of
Philadelphia, the  publishers very confidently anticipate for it a favorable reception.

GILL,  ON  INDIGESTION.   Second Edition.
      Indigestion; What It Is; What It Leads To ; and a New Method of Treating
    It.  By John  Beadnell Gill, m.d.  Second Edition.   i2mo.      Price $1.25 
PUB LICA TIONS.
19
 HABERSHON, ON -THE  STOMACH.
        On Diseases of  the Stomach—The Varieties of  Dyspepsia—Their Diagnosis
     and Treatment. By S. O. Habershon, m.d., f.r.c.p*., Senior Physician to, and
     Late Lecturer on,  the Principles and Practice of  Medicine at Guy's Hospital.
     Third Edition, Revised.  Crown 8vo.                                Price $1.75
  " As an expression of the results of long personal experience in both hospital and private practice, conveyed in
 agreeable though not always perspicuous diction, this contribution of Dr. Habershon's has special value of its
 own, and is so far entitled to the favorable consideration of the practitioner, as is already testified by a demand for
 a third edition."—American Journal of Medical Sciences.                                    •
  " It is divided into twenty chapters,  fifteen of which are devoted to a consideration of the different forms of
 Dyspepsia, while the remaining treat  of Degeneration, Ulceration, Cancerous Diseases, and Spasms of the
 Stomach."  We can cordially recommend this book of Dr. Habershon's to the profession."—Medical Record.

 HALE, ON  CHILDREN.
        The Management of Children in Health and Disease.   A Book for Mothers.
     By Mrs.  Amie M. Hale, m.d.  Abounding in valuable information and com-
     mon-sense advice.   NeW Enlarged Edition.   i2mo.                    Price .75
  " We shall use our influence in the introduction of this work to families under our care, and we urge the profession
 generally to follow our example."—Buffalo Medical and Surgical Journal.

 HARDWICH  AND DAWSON,  PHOTOGRAPHIC  CHEMIS-
   TRY.
        Hardwich's Manual of Photographic Chemistry.   Illustrated.  Eighth Edition.
     Rearranged by G.  Dawson.  i2mo.                                  Price $2.00

 HARDWICKE, MEDICAL  EDUCATION.
        Medical Education and  Practice in All  Parts  of the  World.   Containing
     Regulations for Graduation at the Various  Universities throughout the World.
     By Herbert  Junius Hardwicke,  m.d., m.r.cp.   8vo.               Price $3.00
  " Dr.  Hardwicke's book will prove a valuable source of information to those who may desire to know the
 conditions upon which medical practice is or may be pursued in any or every country of the world, even to the
 remotest corners of the  earth.   The work has  been compiled with great care, and must have required a vast
 amount of labor and perseverance on the part of its author."—Dublin Medical Journal.

 HARRISON,  STRICTURE  OF  THE  URETHRA.
       On  Stricture and Other  Diseases of the Urinary Organs.   By  Renegall
     Harrison, f.r.c.s.   With numerous Illustrations.  8vo.              Price $2.75

 HAYDEN, ON THE HEART.
       The Diseases of  the Heart and Aorta.  By Thomas Hayden, m.d.  With 81
     Illustrations.  2 vols.   1232 pp.  8vo.                                Price $6.00
  " The author evidently has had a very wide and well used experience in that of which he writes; is well versed
 in modern physiology and pathology, and holds a fluent pen, consequently the book is an excellent one, and as
 the teachings of the text are abundantly illustrated by the reports of one hundred and fifty cases, Dr. Hayden's
 effort will probably attain the popularity it deserves."—Philadelphia Medical Times.
  "There is not an unnecessary page in Dr. Hayden's work."—N. Y. Medical Record.

 HOLDEN, HUMAN  OSTEOLOGY.    Sixth  Edition.
       Comprising a Description of the Bones, with Colored Delineations of the At-
    tachments of the Muscles.  The  General and Microscopical Structure of Bone
    and its Development.   By the Author and A. Doran, f.r.c.s., with  Lithographic
    Plates, etc.    By Luther  Holden, f.r.c.s.    Numerous  Illustrations.    Sixth
    Edition,  carefully Revised.                                            Price $5.50
                                  by  same author.
 ANATOMY.
       Manual  of Dissections of the Human  Body.  Fourth London Edition.  With
     170 Illustrations.                                                     Price $5.50

 LANDMARKS.
       Landmarks,  Medical and  Surgical.  ,  Third London Edition.   Revised and
    Enlarged.                                                             Price $1.25
  " Mr Holden is the happy possessor  of the faculty of writing  interesting works on Anatomy.  A part of the
charm consists in the frequent references  to practical points, and in the explanation of the advanta^s and objects
of details of structures."—Boston Medical and Surgical Journal. 
to                      PRESLE Y BLAKISTON'S
HEATH'S OPERATIVE SURGERY.
      A  Course of Operative  Surgery, consisting of a Series of Plates, each plate
    containing Numerous Figures, Drawn from Nature by the Celebrated Anatomi-
    cal  Artist,  M.  LeVeille, of Paris, Engraved on  Steel and  Colored by Hand,
    under his immediate superintendence, with Descriptive Text of Each Operation.
    By Christopher Heath,  f.r.c.s., Surgeon to University College Hospital, and
    Holme Professor of Clinical Surgery in University College, London.   One Large
    Quarto Volume.                                                Price $14.00

  The author has embodied  in  this work  the  experience gained by  him during
twenty years of surgical teaching.  It comprises all the operations that are required
in ordinary surgical practice.   He has selected for illustration and description those
methods  which appear to give the best results in practice, referring to the errors
likely to occur and the best methods of avoiding them.

                              by same author.

THE  STUDENT'S GUIDE TO  SURGICAL  DIAGNOSIS.
      i2mo.                                                        Price $1.50
  " Mr. Heath is so well known, both as a practical surgeon, teacher and writer, that anything from his pen re-
quires no introduction from the hands of reviewers, and scarcely any notice but the announcement of the fact that
he has written a book."—Medical Record.

A  MANUAL OF MINOR  SURGERY  AND  BANDAGING.
      Sixth  Edition,  Revised  and  Enlarged.   With  115  Illustrations.    i2mo.
                                                                   Price $2.00
  "This excellent work should not be termed a ' Minor' Surgery, but it really consists of the sum and substance
of Practical surgery.  We would not exchange it for any book in our possession."—Southern Clinic.

HEATH'S PRACTICAL ANATOMY.   Fifth London Edition.
      Practical Anatomy.   A  Manual of Dissections.  Fifth London Edition.   24
    Colored Plates, and nearly 300 other Illustrations.  Just Ready.     Price $5.00

INJURIES  AND DISEASES  OF  THE  JAWS.
      The  Jacksonian Prize Essay of the Royal  College of Surgeons of England,
    1867.   Second Edition, Revised, with over  150 Illustrations.  Octavo.
                                                                   Price $4.25
HOOD, ON GOUT AND RHEUMATISM.
      A Treatise on Gout, Rheumatism, and  the Allied Affections.  Their Treat-
    ment, Complications,  and Prevention.   By  Peter Hood, m.d.  Second Edi-
    tion, Revised and Enlarged.   With some Considerations on Longevity. Octavo.
                                                                   Price $3.50
  " f he Observations on Treatment are specially to be commended."—London Lancet.

HOLDEN, THE  SPHYGMOGRAPH.
      The  Sphygmograph.  Its  Physiological and Pathological  Indications.  By
    Edgar Holden, m.d.  Illustrated by  Three Hundred Engravings on  Wood.
    8vo.                                                            Price $2.00

HOLMES, THE  LARYNGOSCOPE.
      A Guide to the Use of  the Laryngoscope in General Practice.  By Gordon
    Holmes, m.d., Physician to the Throat and Ear Infirmary.   i2mo.  Price $1.00

                              BY SAME AUTHOR.

VOCAL  PHYSIOLOGY.
      Vocal  Physiology  and  Hygiene.  With  reference  to the Cultiration and
    Preservation of the Voice.   Illustrated.  i2mo.                     Price $2.00

HOFF, ON HEMATURIA.
      Haematuria as a Symptom of the Diseases of the Genito-Urinary Organs.   By
    0. Hoff, m.d.  Illustrated.  i2mo.                                 Price .75 
PUBLICA TIONS.
21
HUNTER,  MECHANICAL  DENTISTRY.
      A Practical  Treatise  on the Construction of the Various  kinds of Artificial
    Dentures, with  Formulae,  Receipts,  etc.  By Charles Hunter, d.d.s.   ioo
    Illustrations.   i2mo.                                               Price $2.25
 " It is the outcome of his own experience of some twenty years as a Mechanical Dentist, and contains, moreover,
much derived from practical knowledge of other dentists. The value of the book is also much added to by illus-
trations.  It will be very useful to the Dental Student, and to all Mechanical Dentists."—London Medical Times
*nd Gazette.

HUTCHINSON'S  ILLUSTRATIONS  OF  CLINICAL  SUR-
  GERY.   First Volume Complete.
      Consisting  of Plates,  Photographs, Woodcuts,  Diagrams,  etc.  Illustrating
    Surgical  Diseases, Symptoms,  and  Accidents;  also Operations and  other
    Methods of Treatment.  With Descriptive Letter-press.   By Jonathan Hutch-
    inson, f.r.c.s., Senior Surgeon  to the London Hospital, Surgeon to the Moor-
    fields Ophthalmic  Hospital, and to the Hospital for Diseases of the Skin, Black-
    friars.  In Quarterly Fasciculi.   Imperial 4to.  Volume 1.  (Ten Fasciculi) bound
    complete in itself.  Price $25.00. Parts Eleven., Twelve, Thirteen, and Fourteen
    of Volume 2,  Now Ready.                                          Each $2.50

HEWITT,  DISEASES  OF WOMEN.   Third Edition.
      The Diagnosis,  Pathology, and Treatment of Diseases of  Women, Including
    the Diagnosis of Pregnancy. Founded on a Course of Lectures Delivered at St.
    Mary's Hospital Medical School.  By Graily Hewitt, m.d., Lond., m.r.c.p.,
    Physician to the British Lying-in Hospital; Lecturer on Midwifery and Diseases
    of Women and Children at St. Mary's  Hospital  Medical  School; Honorary
    Secretary to the Obstetrical  Society of London, etc.   The Third Edition.  Re-
    vised and Enlarged, with New Illustrations.  Octavo.
                                                  Price, Cloth $4.00;  Leather $5.00
  "Readers of the former editions will not require to
be told that the additions now made are of the highest
possible excellence "— Times and Gazette.
  " It is one of the most useful, practical, and compre-
hensive works upon the subject in the English language,
a true guide to the student, and an invaluable means of
reference for the teacher."—N. Y. Medical Record.
                                            " The excellent work of Dr. Hewitt presents—in a
                                           form well adapted to conduct the student to a knowledge
                                           of the Diseases of Women, and to assist the young
                                           practitioner in his study of these diseases at the bedside
                                           of the patient—a very full and clear exposition of the
                                           views entertained by the most authoritative teachers as
                                           to their pathological treatment and  their correct Diag-
                                           nosis."—Amer. Med. Journal.

HAY,  SARCOMATOUS TUMOR.
       History of a Case of Recurring Sarcomatous Tumor  of the Orbit in a Child.
     By Thomas Hay, m.d.   Illustrated.   Paper.                         Price .50

HEWSON, EARTH  IN SURGERY.
       Earth as a Topical Application in Surgery, Being a Full Exposition of its Use
     in Cases Requiring Topical Applications.  By Addinell Hewson, m.d.   Illus-
     trated.  8vo.                                                      Price $2.50

HODGE, ON  ABORTION.
       On Foeticide or Criminal Abortion.   By Hugh L. Hodge, m.d.
                                                       Price, Paper, .30;  Cloth, .50
HODGE, CASE-BOOK.
       Note-Book for  Cases of Ovarian Tumors.   By H. Lennox Hodge, m.d. With
     Diagrams.                                                   Price, Paper, .50

HIGGINS, DISEASES  OF THE  EYE.
       A  Hand-Book  of  Ophthalmic Practice.    By Charles  Higgins,  f.r.c.s.
     Ophthalmic Assistant Surgeon at Guy's Hospital.   Second Edition.   i6mo.
                                                                         Price .60
 . Contents.—Section i. Discharge from the Eyes.  11. Intolerance of Light,  in.  Iritis and Glaucoma,  rv.
Diseases of the Eyelids,  v.  Watering of the Eye.  vi.  Acuteness of Visioa, Field of Vision, Anomalies of Re-
fraction, Astigmatism, Accommodation, Presbyopia,  vn. Disturbance of Vision, Use of the Ophthalmoscope,
Normal and Morbid Appearances, vm.  Injuries.
 " We have rarely seen so much important information condensed in so short a space."—American Medical
Journal. 
22
PRESLEY BLAKISTON'S
HARRIS, THE PRACTICE OF DENTISTRY.   Tenth Edition.
      The Principles and Practice of Dentistry.  Tenth Revised Edition.  In great
    part Rewritten, Rearranged, and with many  new and  important  Illustrations.
    By Chapin A. Harris, m.d., d.d.s.  Edited by P. H. Austen, m.d., Professor
    of Dental Science and Mechanism  in the Baltimore College of Dental Surgery.
    With nearly 400 Illustrations.   Royal Octavo.  Price, Cloth, 56.50; Leather, $7.50
  This new edition of Dr. Harris'  work has been thoroughly revised in all its parts,
more so than any previous edition.  So great have been  the advances in many
branches of dentistry that it was found necessary to rewrite the articles or subjects,
and this has been done in the most efficient manner by Professor Austen, for many
years an associate and friend of Dr. Harris, assisted by Professor Gorgas and Thomas
S. Latimer, m.d.   The publishers feel assured  that it will now be  found the most
complete text-book for the student, and guide  for  the practitioner in the English
language.
                             BY SAME  AUTHOR.
MEDICAL AND DENTAL  DICTIONARY.   Fourth Edition.
      A Dictionary  of Medical Terminology,  Dental Surgery, and the Collateral
    Sciences.  Fourth Edition, Carefully Revised and Enlarged.   By Ferdinand
    J. S. Gorgas, m.d., d.d.s., Professor  of Dental Surgery in the Baltimore College,
    etc.  Royal Octavo.                       Price, Cloth, $6.50; Leather, $7.50
  This Dictionary, having passed through three editions, and been  for some  time
out  of print, has  been again carefully revised by F. J. S. Gorgas, m.d., Dr.  Harris'
successor as Professor of  Dental Surgery  in the Baltimore College of Dental Surgery.
In his preface to this new edition, the editor says :—
  " The object of the reviser has been to bring  the book thoroughly up to the pres-
ent requirements of the profession, the Medical portion having been as carefully re-.
vised and added to as that devoted more especially to Dental Science, while  a
number of obsolete terms and methods have been  omitted.   In nearly every one of
the seven hundred and forty-three pages of the former edition corrections and addi-
tions have been  made, and many new  processes, terms and  appliances described,
some of which are not found in  any other work  published."

HANDY, ANATOMY.
      Text-Book of Anatomy and Guide to Dissections.  For the Use  of  Students.
    By W. R. Handy, m.d.  312 Illustrations.                         Price $3.00

HILLIER, DISEASES  OF CHILDREN.
      A Clinical Treatise on the Diseases of Children.  By Thomas Hillier, m.d.
    8vo.                                                          Price $2.00

HUFELAND, LONG LIFE.
      The Art of Prolonging Life.  By C. W. Hufeland.  Edited by  Erasmus
    Wilson, m.d.   nmo.                                          Price $1.00
  " We wish all doctors and all their intelligent clients would read it, for surely its perusal would be attended
with pleasure and benefit."—American Practitioner.
  " It certainly should be in the library of every physician."—Medical Brief.

HUNTER, PORTRAIT OF.
      Portrait of John Hunter.  From Sharp's well-known Engraving;  a copy  of
    Sir Joshua Reynold's Portrait.  For Framing.   Large size, 9x11;  sheet 16 x 20.
    Price, in the  Sheet,   sent free by mail, 50 cents;  or, Handsomely Framed
                                                                  Price $2.00 
PUBLICA TIONS.
*3
HEADLAND, THE ACTION  OF MEDICINES.  Sixth Edition.
       On  the Action of Medicines in  the  System.   By  F.  W.  Headland, m.d.
    Sixth American Edition, Revised and Enlarged.  8vo.              Price $3.00
 " It displays in every page the evidence of extensive knowledge and of sound reasoning; it will be useful alike
to those who are just commencing their studies, and to those who aje engaged in the active pursuits of pro-
fessional life."—Medical Times.
 " The very favorable opinion which we were amongst the first to  pronounce upon this essay has been fully
confirmed by the general voice of the profession, and Dr. Headland may  now be congratulated on having pro-
duced a treatise which has been  weighed in the balance, and found worthy of being ranked with our standard
medical works."—London Lancet.

JAMES, SORE  THROAT.
       On Sore Throat,  Its  Nature, Varieties and  Treatment, Including  its Con-
    nection with other  Diseases.   By  Prosser James, m.r.c.p.  Fourth Edition,
    Revised and Enlarged.  With Colored Plates and Numerous Wood-cuts.   i2mo.
                                                                        Price $2.25.
 " We can confidently recommend his therapeutic teachings as well worthy of the careful consideration of the
Profession, for they set forth the practice of an enthusiastic worker, whose special experience has been large and
lengthened."—British Medical Journal.
 " The practitioner who buys Dr. James' unpretending little book will provide himself with a wise and practical
clinical commentary, and with a well arranged digest of long and varied experience."—Westminster Review.

                                 BY SAME AUTHOR.

LARYNGOSCOPY AND RHINOSCOPY.
       Including the Diagnosis of Diseases of the Throat and Nose.  Third Edition.
    With Colored Plates.  i8mo.                                      Price $2.00.
 " It gives in a succinct form the approved methods of examination and treatment of diseases of the nose, throat,
and larynx.  The plan pursued is one well adapted to the needs of the general practitioner."—American Medical
Journal.

JONES,  AURAL ATLAS.
       An Atlas of Diseases of the Membrana Tympani.  Being a Series of Colored
    Plates,  containing 62 Figures.   With appropriate Letter-press and Explanatory
    Text.   By H. Macnaughton Jones, m.d., Surgeon to the  Cork Ophthalmic and
    Aural Hospital.  410.                       „                      Price $6.00.
 " The cases are well selected, the drawings executed from life, highly artistic and very conscientious, and the
commentaries indicate familiarity with  the subject and good judgment in dealing with it."—British Medical
Journal.
                                 BY SAME AUTHOR.
AURAL SURGERY.
       A Practical  Hand-Book on Aural Surgery.  Illustrated.   i2mo.   Price $1.50.

JONES,  SIEVEKING  AND  PAYNE,  PATHOLOGICAL AN-
  ATOMY.
       A Manual  of  Pathological  Anatomy.   By C.  Handfield Jones, m.d., and
    Edward H. Sieveking, m.d., Physician to St. Mary's Hospital.  A  New En-
    larged Edition.  Edited by J. F. Payne, m.d., Lecturer on  Morbid Anatomy at
    St. Thomas' Hospital.  With Numerous  Illustrations.  Demi 8vo.  Price $5.50.

JONES,  ON  SIGHT  AND HEARING.
       The Defects of Sight and Hearing, their Nature, Causes, and Prevention.   By
    T. Wharton  Jones, m.d.   Second Edition.   i6mo.                 Price .50.

KIRBY,  ON PHOSPHORUS.   Fifth Edition.
       Phosphorus as  a  Remedy for Functional Diseases of  the  Nervous System.
    By E. A. Kirby, m.d.  Fifth Edition.  8vo.                        Price $1.00

KOLLMEYER,  KEY TO  CHEMISTRY.
       Chemia Coartata,  or  Key to Modern Chemistry.  By A.  H. Kollmeyer, m.d.
    With Numerous Tables, Tests,  etc.                                  Price $2.25

KIRKE,  PHYSIOLOGY.   Revised up to 1881.
       A Hand-book  of Physiology.  By Kirke.  Tenth London Edition.   By W.
    Morrant Baker, m.d.   420 Illustrations.                          Price £5.00 
24
PRESLEY BLAKISTON1 S
KANE, THE OPIUM, MORPHINE AND SIMILAR HABITS.
       Drugs that Enslave.  The Opium, Morphine, Chloral, Hashisch and Similar
    Habits.  By H. H. Kane, m.d., of New York.  With  Illustrations.   Price $1.50
  " It contains a large amount of information collected with much labor and presented In a systematic manner.
The subject of the chloral habit has not been investigated by any one, we believe, so thoroughly as Dy Dr. Kane."
—Medical Record.
  " It deserves to be read by those who feel an interest in discouraging the use of these dangerous drugs.  The
book is embellished by an excellent phototype frontispiece of Laocoon."—American Journal of Pharmacy.
  " A work of more than ordinary  ability and careful research.  .  .  .  For the first time, reliable statistics on
the use of chloral are classified and published,  . .  .  and it is shown that the use  of chloral causes a more
complete and rapid ruin of mind and body than either opium or morphine. "—Druggists' Circular and Gazette.
KIDD, THERAPEUTICS.
       The Laws of Therapeutics; or, the Science and Art of Medicine.  By Joseph
    Kidd, m.d.  i2mo.   Cloth.                                        Price $1.25.
   Dr. Joseph Kidd, who, by the way, was Lord Beaconsfield's medical adviser, and
an eminent physician of the regular school, briefly but clearly sketches the history of
medicine from the earliest period.  He shows that the chief mistakes  have been
made through deference to theory and negligence of the teachings of facts.   Thence
he passes to an  assertion of the value of the homoeopathic principle of similia simili-
bus in the  treatment  of  many diseases.  He is not a follower of Hahnemann, and
does not believe in infinitessimal doses, but he claims, and enforces his  position by
the citation of cases in his own practice, that the homoeopathic principle has performed
wonders where  that of his own school was much less successful.
  " Dr. Kidd acknowledges two laws—that of contraria contrariis ana similia similibus ; but the cases he gives
in his chapter on ars medica show that, like a sensible practitioner, he does not allow himself blindly to follow
either the one or the other, but seeks out the cause of disease, and tries by rational measures to remove it.  The
cases are the most valuable part of the book."—London Practitioner.
LEGG,  ON  THE  URINE.
       Practical  Guide to the Examination of the Urine, for Practitioner and Student.
    By J. Wickham Legg, m.d.  Fifth Edition, Enlarged.  Illustrated.  i2mo.
                                                                         Price  .75
   This little work is intended to supply the Physician or Student with a concise guide
to the recognition of the different characteristics of the urine, and though small and
well adapted to the pocket, contains, probably,  everything that could  be gleaned
from a larger work.

LEARED, IMPERFECT DIGESTION.
       The Causes and Treatment of Imperfect Digestion. By Arthur Leared, m.d.
    The Sixth Edition.  Revised and Enlarged.   i2mo.                 Price $1.50

LIEBREICH, ATLAS  OF OPHTHALMOSCOPY.
       An Atlas  of Ophthalmoscopy,  containing  12 Full-page Chromo-Lithographic
    Plates,  with 59 Figures.  By R. Liebreich, m.d.  Second Edition, Enlarged.
    Large Quarto.                                                    Price $12.00

LIVEING,  ON  SICK HEADACHE.
       Megrim,  or Sick Headache and Some Allied Disorders. By Edward Live-
    ing, m.d.   With Plates, Tables, etc.   8vo.                          Price $5.50

LEBER  AND  ROTTENSTEIN,  DENTAL CARIES.
       Dental Caries and Its Causes.  An Investigation into the Influence of Fungi
    in the Destruction of the Teeth. By Drs. Leber and Rottenstein.  Illustrated.
    8vo.                                                               Price $1.25
  " The work gives the result of patient observation, presents the deductions of its authors with a perspicuity and
modesty calculated to secure for its positions a thoughtful consideration.  We heartQy commend  it as an educa-
tional work."—Dental Cosmos. 
PUBLICA TIONS.
*5
LEWIN, ON  SYPHILIS.
       The Treatment of Syphilis.  By Dr. George Lewin, of Berlin.  Translated
     by Carl Proegler, m.d., and E. H. Gale, m.d., Surgeons U. S. Army.  Illus-
     trated.   i2mo.                                                        Price $1.50
  " When such authorities as Dr. Drysdale (as we quoted a few weeks ago) condemn the use of mercury in syphilis
as " too dangerous," while, on the other hand, eminent surgeons, such as Professor Gross, will not treat secase
without that drug, general practitioners will gladly welcome any media via which gives us all the good effects of
mercurials without any danger of their ill results appearing.  This is what is accomplished by Dr. Lewin."—
Philadelphia Medical ami Surgical Reporter.

LIZARS, ON  TOBACCO.
       The Use and Abuse of Tobacco.   By John Lizars, m.d. i2mo.      Price .50

LONGLEY,   POCKET  MEDICAL LEXICON.
       Students' Pocket Medical Dictionary, Giving the Correct Definition and Pro-
     nunciation of all Words and Terms in General Use in Medicine and the Collate-
     ral Sciences,  with an Appendix, containing Poisons and their Antidotes, Abbre-
     viations Used in Prescriptions, and a Metric Scale of Doses. By Elias Longley.
     24mo.                               Price, Cloth, $1.00; Tucks and Pocket $1.25

   This is  an  entirely  new  Medical Dictionary, containing some 300 compactly
printed 241x10 pages, very carefully prepared by the author, who has had much ex-
perience in the preparation of similar works, assisted by the Professors  of Chemistry
and of Botany  in  one of our leading medical colleges.
  " This little book will be welcomed .by students in
medicine and pharmacy as a convenient pocket com-
panion, giving  the pronunciation,  acceptation, and
definition of  medical, pharmaceutical, chemical and
botanical terms."—American Journal of Pharmacy.
  " It would  seem to be just the book for dental and
medical students."—Dental Advertiser.
  " It is, we believe, also the only lexicon in existence
in which the pronunciation of words is fully and dis-
tinctly marked."—Canada Medical Review.
  "This is a very compact and complete little diction-
ary. We commend it as particularly useful to students."
—New York Medical Journal.
MARTIN,  ATLAS  OF GYNECOLOGY.
       An Atlas  of Obstetrics and  Gynaecology.  By Prof. A.  Martin, of Berlin.
     Translated and edited from the  Second German Edition, with additions, by Fan-
     court Barnes, m.d.,  m.r.c.p.   With 98 Full-page Lithographic Plates, con-
     taining over 400 figures, many being colored.  With full letter-press references
     to and explanations of each figure ; forming a thick quarto volume.   Bound  in
     heavy beveled boards.  Sold only by subscription.                  Price $12.00

  " This  valuable and classic series of illustrations
includes 98 pages of plates, with an average of  5 illus-
trations on each, many of which are colored, and some
drawn on a large scale, so as to occupy the whole page.
The subjects treated range through the whole of mid-
wifery and gynaecology, beginning with normal and ab-
normal pelvis, and ending with illustrations of some of
the most important obstetric  gynaecologic instruments
used in Germany and in  this country.  . .  The de-
scriptive letter-press is very full and accurate, and the
whole makes an extremely handsome volume."—Brit-
ish Medical Journal, July 10th, 1880.

MACDONALD,    MICROSCOPICAL    EXAMINATION   OF
   WATER.
       A  Guide to the Microscopical Examination  of Drinking  Water.  By J. D.
     Macdonald,  m.d.    With  Twenty Full-page Lithographic  Plates, Reference
     Tables, etc.   8vo.                                .                    Price $2.75
  " The volume is an excellent hand-book and will greatly facilitate the study of the subject."—Popular Science
Monthly.

MACEWEN,  ON  OSTEOTOMY.
       An  Inquiry into the ^Etiology and Pathology of Knock-knee, Bow-leg and
     other Osseous Deformities of the Lower  Limbs.  By Wm. Macewen,  m.d.   Il-
     lustrated.  8vo.                                                       Price $3.00
  "The atlas is the most complete and comprehensive
work of its kind.  .  .  Nearly every point, anatomi-
cal, physiological, obstetrical, and gynaecological, is
illustrated  in the best way, by  well known authors,
from whose works the late Dr. Martin culled his illus-
trations.  As a work of reference, to the practitioner,
the atlas is invaluable; while to the student who wishes
to refresh his memory in the readiest way and in the
shortest time, it will be very useful."—London Medi-
cal Record, July 15th, 1880. 
26
PRESLEY BLAKISTON'S
MACKENZIE,  ON  THE  THROAT  AND  NOSE.

       Including the Pharynx,  Larynx, Trachea,  OZsophagus, Nasal Cavities, and
     Neck.   By  Morell Mackenzie, m.d.,  London, Senior Physician  to the Hos-
     pital for Diseases of the Chest and Throat, Lecturer on  Diseases of the Throat
     at London Hospital Medical College, etc., etc.   Vol. i, containing the Pharynx,
    'Larynx and Trachea, with 112 Illustrations.  Now ready.
                                                     Price, Cloth, $4.00;  Sheep, $5.00

  Ig^"Author's  Edition,  with  the Original   Illustrations.   Published   from  early

sheets, by arrangement with Dr. Mackenzie.   Vol. 2 in preparation.

  "We have long felt the want  of a thoroughly  practical and systematic treatise on diseases of the throat
and nasal passages.  Admirable essays have  from time to time appeared ; no standard work has been written.
Any one familiar with laryngoscopic work  must appreciate the valuable addition now made to this special
department in the work before us.  The entire work will include the consideration of affections of the pharynx,
larynx, trachea, oesophagus, nasal cavities, and neck.  The matter now presented complete for the first time is
the  result  of the author's large and unrivaled experience, both in hospital and private practice, extending over
a period of twenty years.  There can be but one verdict of the profession on this manual—it stands without any
competitor in medical literature, as a standard work on the organs it professes to treat of."—Dublin Journal.

  " It is both practical and learned ; abundantly and well  illustrated ; its descriptions of disease are graphic, and
the diagnoses the best we have anywhere seen. To give examples of the thoroughness of Dr. Mackenzie's book,
we may cite the chapter on diphtheria, which  embraces 47 pages.  The chapter on non-malignant tumors of the
larynx would appear to be absolutely exhaustive.  Nowhere else have we seen so elaborate a statement of the sub-
ject.  We can  predict for this work a high position, and  congratulate its distinguished author upon its appear-
ance."—Philadelphia Medical Times.

                                  BY SAME AUTHOR.

THE  PHARMACOPOEIA of  the  Hospital  for  Diseases  of  the

   Throat  and  Nose.

       The Fourth Edition, much enlarged,  containing 250 Formulae, with Directions
     for their Preparation and Use.  i6mo.                                Price $1.25


DIPHTHERIA.   ITS NATURE AND TREATMENT.

       i2mo.                                                                Price .7 5

  Contents.—1. The Definition and History.  2. The Etiology.  3. The Symptoms. 4. The Paralyses.  5.
The Diagnosis.  6. The Pathology.  7. The Prognosis.   8.  The Treatment.  9.  Laryngo-Tracheal Diphtheria.
10. Nasal Diphtheria. 11.  Secondary Diphtheria.

  "The terse remarks on prognosis  are excellent;  and what the Author says of treatment, general and local, and
tracheotomy, we commend most cordially."—New York Medical Journal.


GROWTHS  IN  THE LARYNX.

       Their History, Causes, Symptoms, etc.   With  Reports and Analysis  of one
     Hundred  Cases.  With Colored and Other Illustrations.   8vo.       Price $2.00


MACNAMARA,  DISEASES  OF THE  EYE.

       A Manual  of the Diseases  of  the  Eye.  By C. Macnamara,  m.d.  Third
     Edition, Carefully Revised;  with Additions and Numerous Colored Plates,  Dia-
     grams of Eye, Wood-cuts, and Test Types.   Demi 8vo.              Price $4.00
  "As a book of ready reference on diseases of the eye it has no superior, and we may safely say, no equal in our
language."—Cincinnati Lancet and Observer.

                                  BY SAME AUTHOR.

ON THE BONES AND JOINTS.

       Lectures on Diseases of the Bones and Joints.  Second Edition.    Demi 8vo.

                                                                           Price $4-25

MADDEN,  HEALTH  RESORTS.

       Health  Resorts for the Treatment of  Chronic Diseases.  A Hand-Book, the
     result of the author's own observations during  several years of health travel  in
     many lands, containing also   remarks  on  climatology  and the use of mineral
     waters.   By T.  M. Madden, m.d.  8vo.                              Price $2.50

  " Rarely have we encountered a book containing so much  information for both invalids and pleasure seekers."
—The Sanitarian. 
PUBLICA TIONS.                            27
MARSHALL  &  SMITH, ON  THE URINE.
      The Chemical Analysis of the Urine.  By John Marshall, m.d., and Edgar
    F. Smith, m.d., of the Chemical Laboratory, Medical Department, University of
    Pennsylvania.  Illustrated by Phototype Plates. i2mo.              Price $1.00

MARSHALL, ANATOMICAL PLATES;
      Or Physiological Diagrams.  Life Size (7 by 4 feet) and Beautifully Colored.
    By John Marshall, f.r.s.   An Entirely New Edition, Revised and Improved,
    Illustrating the Whole  Human  Body.
The Set, Eleven Maps, in Sheets,                                     P»ce $50.00
                              handsomely Mounted on Canvas, with
                                             Rollers, and Varnished, Price $80.00
An Explanatory Key to the Diagrams,                                  Price .50
  Dr. Marshall's Plates, from their size and perfection of drawing and coloring, excel
any diagrams that have been published.  They have  proved invaluable in Medical
Schools and  Lecture Rooms. The low price at which they are offered brings them
within reach  of all.
  No. 1. The Skeleton and Ligaments. No. 2.  The Muscles, Joints, and Animal  Mechanics.  No. 3. The Vis-
cera in Position—The Structure of the Lungs.  No. 4. The Organs of Circulation.  No. 5. The Lymphatics or
Absorbents.  No. 6. The Digestive Organs. No. 7. The Brain and Nerves.  No. 8. The Organs of the Senses
and Organs of the Voice, Plate i.  No. 9. The Organs of the Senses, Plate 2. No.  10. The Microscopic
Structure of the Textures, Plate 1.  No. 11. The Microscopic Structure of the Textures, Plate 2.

MARSDEN, ON CANCER.
       A New and Successful Mode  of Treating Certain Forms of Cancer.  By Alex-
    ander Marsden, m.d.  Second Edition.   Colored Plates.   8vo.    Price $3.00

MARTIN, MICROSCOPIC MOUNTING.
       A Manual of Microscopic Mounting.  With Notes on the Collection and Ex-
    amination of Objects, and upwards of 150 Illustrations.  By John H. Martin.
    Second Edition, Enlarged.  8vo.                                 Price $2.75

MORRIS, ON THE JOINTS.
       The Anatomy of the Joints of Man.  Comprising a Description of the Liga-
    ments, Cartilages, and Synovial Membranes; of the Articular  Parts of Bones,
    etc.   By Henry Morris, f.r.c.s.  Illustrated by 44 Large Plates and Numerous
    Figures,  many of which are Colored.   8vo.                »      Price $5.50

MUTER,  MEDICAL  AND  PHARMACEUTICAL  CHEMIS-
   TRY.
       An  Introduction  to  Pharmaceutical and Medical Chemistry.  Part One.—
    Theoretical and Descriptive.  Part Two.—Practical and Analytical.  Arranged
    on the principle of the  Course of Lectures on Chemistry as delivered at, and the
    Instruction  given in the Laboratories  of, the South London School of Pharmacy.
    Bv Tohn Muter, m.d., President of the Society of Public Analysts.  A Second
    Edition  Enlarged and Rearranged.  The  Two Parts bound in one large octavo
    volume.'                                                         Price #6-°°
       Part Two.—Practical and Analytical. Bound Separately, for the Special Con-
    venience of Students.   Large 8vo.  Cloth.                        Price $2.50

MAC MUNN, THE  SPECTROSCOPE.
       The Spectroscope in  Medicine.  By Chas. A. Mac Munn, m.d.   With 3
    Chromo-lithographic Plates of Physiological and Pathological  Spectra, and 13
    Wood Cuts.   8vo.                                               Price $3.00
  " This book is  without question, the best that has yet been published on the subject; to those not familiar with
Physiological Spectroscopy it will prove interring, while to those who are worfcng m th.s field it .s a neces*
sity."—New York Medical Journal. 
28                        PRESLEY BLAKISTON'S
It is eminently a book which ■will teach the  Student.—Practitioner.

It forms one of the  most convenient,  practical,  and  concise books ye»
     published on  the subject. — London Lancet.


         MEADOWS'  MANUAL  OF  OBSTETRICS.

    THE THIED EEYISED AND ENLAEGED EDITION, NOW  EEADY,

         •  with one hundred and forty-five illustrations.

INCLUDING  THE  SIGNS  AND  SYMPTOMS   OF  PREGNANCY,
     Obstetric Operations, Diseases  of the Puerperal State, &c,  &c.   By
     Alfred  Meadows, M. D., Physician to the  Hospital  for Women, to
     the General Lying-in  Hospital, &c, &c.   Revised and  Enlarged  Edi-
     tion.  With numerous Illustrations.                         Price #2.oo«

  In this new edition,.. .not merely is the practical treatment of Labor, and also of the Dis*
eases and Accidents of Pregnancy, well and  clearly taught, but  the anatomical machinery
of parturition is more  effectively explained than in any other treatise that we remember;
besides this, the book is honorably distinguished among manuals of Midwifery by the ful-
ness with which it goes into the subject of the structure and development of the ovum.  On
all questions of treatment, whether by medicines, by hygienic regimen, or by mechanical or
operative appliances, this treatise is as satisfactory as a work of manual size could be; students
and practitioners can hardly do  better than adopt it as their vade-mecum.—The Practitioner.
  Upwards of ninety new engravings have been inserted in this edition, and, with a view to
facilitate reference, the author has furnished it with a very full and complete table of contents
and index.  We can cordially recommend this manual as accurate and practical, and as con-
taining in a small compass a large amount of the kind of information suitable alike to the
Btudent and practitioner.—London Lancet.
  It is concise, well arranged, and remarkably complete, as a guide to the student during his
lecture term; and as a  ready reference to the Physician, no work of similar character equals
it in value.—Buffalo Medical Journal.
  The systematic a/rangement of subjects, and the concise, practical style in which it is
written, make the work especially valuable  as a student's manual, while a very full table
of contents and index  renders it easily accessible as a work of reference.—Chicago Medical
Examiner.
  There can be  no doubt that this manual will be generally accepted as a brief, convenient,
and compendious guide to the  study and practice of  the Obstetric Art.—Richmond and
Louisville Medical Journal.
  We cannot but feel that every teacher of obstetrics has good cause to congratulate himself
on being able to put in the hands of the student a book which contains so much valuable
and reliable information in so condensed a form.—Philadelphia Medical Times.
  It is concisely and clearly written, and the information is on the whole on a level with the
most recent knowledge of  the day.—British and Foreign Medical Review.
  A work which embodies a larger amount of practical information than any other book on
the subject.—Pacific Medical and Surgical Journal.
  It is with great gratification that we are enabled to class Dr. Meadows' Manual as a rare
exception, and to pronounce it an  accurate, practical, and creditable work, and to unhesi-
tatingly recommend it to both student and practitioner.—American Journal of Obstetrics.
  It is a book of decided merit: every page teems with sound, practical common sense, advice
and suggestions.—Kansas City Medical Journal. 
PUBLICA TIONS.
*9
MENDENHALL,  VADE MECUM.
      The Medical Student's Vade Mecum.   A Compend of Anatomy, Physiology,
    Chemistry, The Practice  of Medicine, Surgery,  Obstetrics, etc.  By George
    Mendenhall, m.d.  Eleventh Edition.   224 Illustrations.  8vo.    Price $2.00

MEIGS AND PEPPER, DISEASES OF  CHILDREN.
      A Practical Treatise on the Diseases of Children.   By J. Forsyth Meigs, m.d.,
    Fellow of the College of Physicians  of  Philadelphia, etc., etc., and  William
    Pepper, m.d., Physician  to the Philadelphia Hospital,  Provost University of
    Pennsylvania.  Seventh Edition, thoroughly Revised and Enlarged.   A Royal
    Octavo Volume of over 1000 pages.          Price,  Cloth, #6.00;  Leather, $7.00
 "With the recent additions it may safely be pronounced one of the best and most comprehensive works on Dis-
eases of Children."—New York Medical Journal.
 " Must be regarded as the most complete work on Diseases  of Children in our language."—Edinburgh Medical
Journal.
 " We have seldom met with a text-book so complete, so just and so readable as the one before us."—American
Journal of Obstetrics.

MATHIAS,  LEGISLATIVE MANUAL.
      A Rule for Conducting Business in Meetings of Societies, Legislative Bodies,
    Town and Ward Meetings, etc.  By  Bent. Mathias, a.m.   Sixteenth Edition.
     i6mo.                                                               Price .50

MORTON,  REFRACTION OF EYE.
      The  Refraction  of the  Eye.  Its Diagnosis and the Correction of its Errors.
    With Chapter on Keratoscopy.   By A. Stanford Morton, m.b., f.r.c.s.  i2mo.
                                                                      Price $1.00
 " The author has not only given very thorough rules for the objective and subjective examinations of the eye in
the various conditions of refraction which present themselves, but has entered into an explanation of the phenom-
ena observed, which is at once scientific and elementary."—Edinburgh Medical Journal.

MEARS, PRACTICAL  SURGERY.
       Practical  Surgery.   Including:  Part 1.—Surgical Dressings;  Part 11.—Band-
     aging ;  Part in.—Ligations ; Part  iv.—Amputations.  With 227 Illustrations.
     By J. Ewing Mears, m.d., Demonstrator of Surgery in Jefferson Medical Col-
     lege, and  Professor of Anatomy and Clinical Surgery in the Pennsylvania Col-
     lege of Dental Surgery.   i2mo.                                   Price $2.00
  " Professor Mears has written a convenient and use-      " It contains a great deal of information upon the
ful book for students.   We can most cordially endorse   subjects of which it treats, in a convenient and con-
it as fulfilling well the promise made in its modest pre-   densed form.  Each division is well illustrated, thereby
face."—Cincinnati Lancet and Clinic.              rendering the text doubly clear."—New York Medical
                                          Record.

OLDBERG,  PRESCRIPTION  BOOK.
      Three Hundred Prescriptions,  Selected Chiefly from the Best Collections  of
     Formulae  used in  Hospital and Out-patient-practice, with a Dose Table, and a
     Complete Account of the Metric  System.  By Oscar Oldberg, phar. d., Late
     Medical Purveyor, United States Marine  Hospital Service; Professor  of Materia
     Medica, National  College  of Pharmacy, Washington, D. C.;  Member of the
     American Pharmaceutical Association, and of the  Sixth Decennial Committee
     of   Revision  and  Publication  of the  Pharmacopoeia of  the United States.
     i2mo.                                                             Price fc-S0
  The prescriptions given in this work are selected from the Pharmacopoeias  and
formularies of the great Hospitals of New York, Philadelphia, Boston and London,
or contributed from the practice of medical officers of the United States Service. The
Dose Table includes nearly  all of the remedies that  have a place in the  current
Materia Medica. 
30
PRESLEY BLAKISTON'S
                                BY SAME AUTHOR.

THE  UNOFFICIAL PHARMACOPOEIA.
      Comprising over 700 Popular  and  Useful Preparations, not Official in the
    United States, of the various Elixirs,  Fluid Extracts, Mixtures, Syrups, Tinct-
    ures, Ointments, Wines, etc,, etc., in constant demand throughout the country.
    Thick i2mo.  503 pp.   Half Morocco.                              Price 53.50
                              Sold by Subscription.
  Bgf It  Will Prove a Useful Supplement to  the Pharmacopoeia of the
United States ; the aim has been to make  it as complete as practicable.  The form-
ulae can, with a minimum of labor, be used with any system  of weights  and meas-
ures.   The virtual adoption of the metric system in the forthcoming Pharmacopoeia
of the United States will account for the  preference given to that system in this vol-
ume, which, however, does not prevent the ready use of the book with apothecaries'
weights and measures.  An extended account of the metric system has been given,
accompanied by full tables of equivalents.   The sources from which the formulae
have been gathered are believed to be the best.  They include the Pharmacopoeias
of England, Germany, France and Sweden.   The book is practically equivalent to
the possession of these various Pharmacopoeias, and the formulae were selected with
reference to their popularity, usefulness, and interesting character.
  "This volume is one of the most practical and valuable contributions to Pharmaceutical work of recent publica-
tion.  It has received high commendation from many of our best pharmacists."—LazeII, Marsh &* Gardiner,
Wholesale Druggists, New York City.

OTT, ACTION OF  MEDICINES.
      The Action of Medicines.   By Isaac Ott, m.d., late Demonstrator of Experi-
    mental Physiology in the University of Pennsylvania.   With 22 Illustrations.
    8vo.                                                               Price  $2.00
  " This work is the only one in the English language which can offer, with any degree of completeness, that assist-
ance and instruction so essential to the correct and successful study of pharmacology.  Filling, as it does, this gap
in medical literature, we have a work which cannot faU to be of the greatest value to students.
  " From the pen of a man himself no novice in the subject of which ne treats, it bears upon it the impress of relia-
bility, due to the author's own experience, a virtue too often wanting in mere compilations of the works  of oth-
ers."—American Journal of Medical Sciences.

PAGET,  SURGICAL PATHOLOGY.
      Lectures on Surgical Pathology, Delivered at the Royal College of Surgeons.
    By James Paget, f.r.s.  Third Edition.  Edited by William Turner, m.d.
    With Numerous Illustrations.  8vo.          Price, Cloth, $7.00; Leather, $8.00

PARKES, PRACTICAL  HYGIENE.   Fifth Edition.
       A Manual of Practical  Hygiene.  By Edward A. Parkes, m.d.  The  Fifth,
    Revised and Enlarged Edition.  With Many Illustrations.  8yo.    Price $6.00
  "Altogether it is the most complete work on Hygiene which we have seen."—New York Medical Record.
  " We find that it never fails to throw light on any hygienic question which may be proposed."—Boston Medi-
cal and Surgical Journal.
  " We commend the book heartily to all needing instruction (and who does not), in Hygiene "—Chicago Medi-
cal Journal.

PIESSE, THE  MANUFACTURE  OF  PERFUMERY.  Fourth
   Edition.
       The Art of Perfumery; or the Methods of Obtaining the Odors of Plants, and
     Instruction for the Manufacture of Perfumery, Dentifrices, Soap, Scented Pow-
     ders, Odorous Vinegars and Salts, Snuff, Cosmetics,  etc., etc.  By G. W. Septi-
     mus  Piesse.    Fourth  Edition.   Enlarged.   366  Illustrations.  8vo.   Cloth.
                                                                       Price $5.50
  " An excellent book."—Commercial Advertiser.       " Exceedingly useful to druggists and perfumers."—
  *' It is the best book on Perfumery yet published."—  Journal of Chemistry.
Scientific American.                             " Is in the fullest sense, comprehensive."—Medical
                                          Record. 
PUBLICA TIONS.
3i
PENNSYLVANIA HOSPITAL REPORTS.
      Edited  by a Committee of the Hospital Staff.  J. M. DaCosta, m.d., and
    William Hunt, m.d.  Vols. 1  and 2, containing Original  Articles by former
    and present Members of the Staff.  With Lithographic and other Illustrations.
    8vo.                                                Price, per volume, $2.00
  These volumes consist of papers of a practical character, based chiefly on obser-
vations made  at the Hospital, but containing the further experience of the Members
of the Staff.   In issuing the second  volume the Editors express their acknowledg-
ments for the  very favorable  reception of the first by the profession  and press of
this country and Europe.

PEREIRA,  PRESCRIPTION  BOOK.   Sixteenth Edition.
      Physician's Prescription Book.  Containing  Lists of Terms,  Phrases, Con-
    tractions  and Abbreviations used in  Prescriptions, Explanatory  Notes, Gram-
    matical Construction of Prescriptions, Rules for the  Pronunciation of Pharma-
    ceutical  Terms.    By Jonathan Pereira, m.d., f.r.s.   Sixteenth  Edition.
                         Price, Cloth, $1.00;  Leather, with tucks and pocket, $1.25

PIGGOTT, ON  COPPER.
      Copper Mining and  Copper  Ore.  With a full Description  of the Principal
    Copper Mines of the United States, the Art of Mining, etc.   By A. Snowden
    Piggott.   i2mo.                                                 Price $1.00

PRINCE,  ORTHOPEDIC  SURGERY.
      Plas-tic  and Orthopedic Surgery.   By David Prince, m.d.  Containing  a
    Report on the Condition of, and Advance made in, Plastic and Orthopedic Sur-
    gery, etc., etc., and Numerous Illustrations.  8vo.                  Price $4.50

PHYSICIAN'S VISITING  LIST, PUBLISHED ANNUALLY.
                   thirty-first year of its publication.
                               sizes and prices.
For 25 Patients weekly.       Tucks, pockets, and pencil,   ....  $1.00
    50            "            ."      "           "      ....   L25
    75    "       "             "      "           «...    .   t.50
   100    "                                              ....   2.00
          a       «     i     f Jan. to Tune)        «,                        „ _„
    5°              2vols-   | July to Dec.}              ....   2.50
          .1       n     i     f Ian. to June J        ,,                        „ __
   100            "2 vols.   {julytoDec.}              ....   3.00
                             INTERLEAVED EDITION.
For 25 Patients weekly, interleaved, tucks, pockets, etc.,     ....   1.25
    50    "       "          "        "      "            ....   1.50
                  ■1     i     f Ian.  to Tune}        „                        „ „.
    50    "       "2 VOIS.    |julytoDec.}               ....   3.00

  The Visiting List contains a  New Table  of Poisons  and their  Antidotes.  The
Metric or  French Decimal System of Weights  and Measures.   Posological Tables,
showing the relation of our present  system of Apothecaries' Weights and Measures
to that of  the Metric System, giving the Doses in both.
  This last is a most valuable addition, and will materially aid the Physician.  So
many writers now use the metric system, especially in foreign books and journals,
that  one not  familiar  with it is  constantly confused, and in many cases unable to
understand the measurements or doses.
  " It is certainly the most pdpular Visiting List ex-
tant."—New York Medical Journal.
  " Its compact size, convenience of arrangement, dur-
ability, and neatness of manufacture have everywhere
obtained for it a preference."—Canada Lancet.
  " The book is convenient in form, not too bulky, and
in every respect the very best Visiting List published."
— Canada Medical and Surgical Journal.
  "This standard Visiting List, for completeness^ aom-
pactness. and simplicity of arrangement, is excelled by
none in trie market."—New York Medical Record. 
32
PRESLEY BLAKISTON'S
POWER,  HOLMES,  ANSTIE  AND  BARNES  (Drs.).
      Reports on the  Progress of Medicine,  Surgery,  Physiology, Midwifery,  Dis-
    eases of Women and Children, Materia Medica, Medical Jurisprudence, Ophthal-
    mology, etc., etc.  Reported for the New Sydenham Society.  8vo.   Price #2.00

PURCELL,  ON  CANCER.
      Cancer.  Its Allies and other Tumors, with Specia  Reference to their Medi-
    cal and Surgical Treatment.  By F. Albert Purcell, m.d., m.r.c.S.  Surgeon
    to the Cancer Hospital, Brompton, England.  8vo.                  Price $3.75

RADCLIFFE,  ON EPILEPSY.
      On Epilepsy, Pain, Paralysis, and  other  Disorders of the Nervous  System.
    By  Charles Bland Radcliffe, m.d.   Illustrated.   i2mo.          Price $1.50
  " To no authority can the medical inquirer turn for an analysis of the phenomena of epilepsy with more satisfac-
tion than to the admirable essay of Dr. Radcliffe."—American Journal Medical Sciences.

ROBERTS,  MANUAL OF MIDWIFERY.
      The Student's Guide to the Practice of Midwifery.   By D. Lloyd Roberts,
    m.d., f.r.c.p., Physician  to  St. Mary's Hospital, Manchester, etc., etc.  Second
    Edition.  With 95  Illustrations.  i2mo.                              Price $2.00
                                            " The present edition has been very thoroughly re-
                                          vised, some chapters having been entirely re-written.
                                          For its size, it forms a remarkably complete compendi-
                                          um of the subject, and can hardly be surpassed in the
                                          simplicity and clearness of its explanations."—Obstet-
                                          rical Journal of Great Britain and Ireland.
  " As an obstetrical manual, we think that of Dr. Rob-
erts one of the best now offered to the Profession, as it
comes with authority, and he  possesses the ability to
condense, and at the same time present a subject clear-
ly."—American Journal of Medical Science.
  "Concise, clear, and  practical."—Mediial Press
and Circular.
REYNOLDS,  ELECTRICITY.
      Lectures on  the Clinical Uses of Electricity.  By J. Russell Reynolds, m.d.,
    f.r.s.   Second Edition.   i2mo.                                     Price $1.00
  " It is thoroughly reliable as a guide, very concise, and will be found exceedingly useful to the general practi-
tioner."—Canada Lancet.

RICHARDSON,  MECHANICAL  DENTISTRY.   Third  Edi-
  tion.
      A Practical Treatise on Mechanical Dentistry.   By Joseph Richardson, d.d.s.
    Third Edition.  With 185 Illustrations.   8vo.  Price, Cloth, $4.00; Leather, $4.75
  " Taken as a whole, Professor Richardson's work is a valuable contribution to the dental art, and is beyond aH
question the best treatise  extant upon the general subject of Mechanical Dentistry."—Dental Cosmos.

RIGBY  AND  MEADOWS, OBSTETRIC MEMORANDA.
      Dr.  Rigby's  Obstetric Memoranda.  Fourth Edition.  Revised.  By Alfred
    Meadows, m.d.  32mo.                                               Price .50

RINDFLEISCH,  PATHOLOGICAL  HISTOLOGY.
      A Text-Book of Pathological  Histology.    By  Dr. Edward Rindfleisch.
    Translated by Drs. Wm. C. Kolman  and F.  T. Miller.   208  Illustrations.
    8vo.                                         Price, Cloth, $5.00; Leather, $6.00
  Recommended as a Text-Book at the University of Pennsylvania and other Med-
ical Schools.
  " To be up with the times our Pathologists must make themselves familiar with the thorough, clear and almost
exhaustive teachings of Professor Rindfleisch."—Ohio Medical and Surgical Reporter.
  " In conclusion we cordially recommend it as the best treatise on the subject."—American Journal of Medi-
cal Science.

RYAN,  ON  MARRIAGE.
      The Philosophy of  Marriage.  In  its  Social, Moral and Physical Relations,
    and Diseases  of  the  Urinary Organs.   By Michael Ryan, m.d.   Member of
    the Royal College of Physicians, London.  i2mo.                   Price $1.00 
PUBLICA TIONS.
33
  ROBERTS'    PRACTICE   OF   MEDICINE.

                  A New  Enlarged  Edition,

                              JUST  READY.
       Uniformly commended by  the Profession and the Press.

A HAND-BOOK OF  THE  THEORY AND PRACTICE OF MEDI-
     CINE.   By Frederick T. Roberts,  M.D., M.R.C.P., Assistant Pro-
     fessor and Teacher of Clinical Medicine in University College Hospital,
     Assistant Physician in Brampton  Consumptive Hospital, &c., &c.
     Third  Edition.   Octavo.   Price,  in cloth    ....    $5.00
                                          leather    ....     6.00
  The Publishers are in receipt of numerous letters from Professors in the various Med-
ical  Schools, uniformly commendrhg this book; whilst the following extracts from  the
Medical Press, both English and American, fully attest its superiority  and great value
not only to the student, but also to the busy practitioner.
  This is a good book, yea, a very good book.  It is not so full in its Pathology as " Aitken,"
so charming in its composition as " Watson," nor so decisive in its treatment as " Tanner;"
but it is more compendious than any of them, and therefore more useful.  We know of no
other work in the English language, or in any other, for that matter, which competes with
this one. —Edinburgh Medical Journal.
  We have much pleasure in expressing our sense of the author's conscientious anxiety to
make his work a faithful representation of modern medical beliefs and practice. In this he
has succeeded in a degree that will earn the gratitude of very many students and practition-
ers: it is a remarkable evidence of industry, experience, and research.—Practitioner.
  That Dr. Roberts's book is admirably fitted to supply the want of a good hand-book of
medicine, so much felt by every medical student, does not admit of a question. — Students'
Journal and Hospital Gazette.
  Dr. Roberts has accomplished his task in a satisfactory manner, and has produced a work
mainly intended for students that will be cordially welcomed by them; most of the observa-
tions on treatment are carefully written and worthy of attentive study; the arrangement is
good, and the style clear and simple. — London Lancet.
  It contains a vast deal of capital instruction for the student, much valuable matter in it to
commend, and merit enough to insure for it a rapid sale.—London Medical Times and Gazette.
  There are great excellencies in this  book, which will make it a favorite both with  the
accurate student and busy practitioner.  The author has had ample experience.—Richmond
and, Louisville Journal.
  We confess ourselves most favorably impressed with this work.  The author has performed
his task most  creditably, and we cordially recommend the book to our readers. — Canada
Medical and Surgical  Journal.
  A careful reading of the  book has led us  to  believe  that the author has written a work
more nearly up to the  times than any that we have seen ; to the student, it will be a gift of
priceless value. —Detroit Review of Medicine.
  Our opinion of it is one of almost unqualified praise. The style is clear, and the amount of
useful and, indeed, indispensable information which it contains is marvellous.  We heartily
recommend it to students, teachers, and practitioners. —Boston Med. and Surgical Journal.
  It is of a much higher order than the usual compilations and abstracts placed in the hands
of students.  It embraces many suggestions and hints  from a carefully compiled hospital
experience; the style is clear and concise, and the plan of the work very judicious.—Medical
and Surgical Reporter.
  It is unsurpassed by any work that has fallen into our hands as a compendium for students
preparing for examination.  It is thoroughly practical and fully up to the times.—The Clinic.
  We find  it an admirable book.  Indeed, we know of no hand-book on the subject just now
to be preferred to. it.  We particularly commend it to students about to enter upon  the
practice of their profession. — St. Louis Medical and Surgical Journal.
  If there  is a book in the whole of medjeal literature  in which so much is said in so
few words, it has never come within our  reach. So  clear, terse, and pointed is the style;
so accurate the diction, and so varied the matter of this  book, that it  is almost a dictionary
of practical medicine. — Chicago Medical Journal. 
34
PRESLEY BLAKISTON'S
SANDERSON  AND  FOSTER,  THE  PHYSIOLOGICAL  LA-
  BORATORY.
      A Hand-book of the Physiological Laboratory.  Being Practical Exercises for
    Students in Physiology and  Histology.   By J.  Burdon Sanderson,  m.d., E.
    Klein, m.d.,  Michael Foster, m.d., f.r.s.,  and  T. Lauder  Brunton, m.d.
    With over 350 Illustrations and Appropriate Letter-press Explanations and Ref-
    erences.                                                         '
              Price, Two Volumes, Text and Plates, separate,    -     -     -  $7.00
                 "   One                           bound  together, Cloth,   6.00
                              "      "       "        "       "      Leather, 7.00
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America and England.
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structions for performing a great variety of exper-
iments. A student could scarcely desire a better guide."
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                                          who are interested in the wide and fertile field of Phy-
                                          siological research."—New York Medical Journal.
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                                          every physiological student has lamented."—Chicago
                                          Medical Journal.

SANDERSON,  PHYSIOLOGY.   Second  Edition.
       A Syllabus of  a Course of Lectures on Physiology.  By J. Burdon Sander-
    son, m.d.   For the Use of Students.  Second Edition.   8vo.         Price $1.50

SANSOM, PHYSICAL DIAGNOSIS.  Third Edition just ready.
       The Physical Diagnosis of Diseases of the Heart.  Including the Use of the
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    Edition.  Revised and Enlarged.   With Illustrations.  i2mo.      Price  $2.00
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senting with singular clearness, one of the most difficult branches of diagnosis."—Philadelphia Medical and Sur-
gical Reporter.
                                BV SAME AUTHOR.

ON  CHLOROFORM.
       Chloroform.  Its Action and Administration.   i2mo.             Price  $1.50

SMITH, MANUAL  OF  GYNAECOLOGY.
       Practical  Gynaecology.  A Hand-book of the  Diseases of Women.   By  Hey-
    wood  Smith, m.d.  Physician to the  Hospital  for Women  and  to the British
    Lying-in Hospital.   With Engravings.                             Price  $1.5
  The object of the author has  been to present the busy practitioner with a  book
systematically arranged, burdened with  no discussions on vexed questions of pathol-
ogy, and giving at a glance the salient points of diagnosis and treatment with clear-
ness and brevity.
  Contents.—Chapter 1. On the Means of Diagnosis: On Touch—immediate and  intermediate.   On Sight
—immediate and intermediate.  On Hearing.—immediate and intermediate.  2. General Diseases. 3. Local
Diseases—Diseases of the Ovary.  4. Diseases of the Oviduct.  5. Diseases of the Broad Ligament.  6. Diseases
of the Uterus (unimpregnated). 7. Diseases of the Vagina. 8. Diseases of the Vulva.  9. Diseases of the Mam-
ma.  10. Functional  Diseases. 11. Diseases connected with Pregnancy. 12. Diseases connected with Parturi-
tion.  13. Diseases consequent on Parturition. Appendix of Remedies.

                                BY SAME AUTHOR.

DYSMENORRHEA.  Just Issued.
       Its Pathology and Treatment.   i2mo.                            Price $2.50

SMITH, RINGWORM.
       The  Diagnosis and  Treatment  of Ringworm.   By  Alder Smith, f.r.c.s.
    With Illustrations.   i2mo.                                         Price $1.00

SMITH, ON NURSING.
       The Efficient Training of Nurses for Hospital and Private Practice.   By Wil-
    liam Robert Smith.   Illustrated,   izmo.                         Price S2.00 
PUBLICA TIONS.
35
SMITH,  ON CHILDREN.
      Clinical Studies of Diseases in  Children.  By Eustace Smith, m.d.   i2mo.
                                                                    Price $2.50

MEDICAL HERESIES, HISTORICALLY CONSIDERED.
      A Series of Critical Essays on the Origin and  Evolution of Sectarian Medi-
    cine, embracing a Special Sketch and Review of Homoeopathy, Past and Pres-
    ent.  By Gonzalvo  C.  Smythe,  a.m., m.d.  Professor of the Principles  and
    Practice of Medicine, College of Physicians and Surgeons, Indianapolis, Indi-
    ana.  i2mo.  Cloth.                                             Price $1.25
 " This book gives, in a small compass, an excellent
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time."—Buffalo Medical and Surgical Journal.
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cal profession, but to the general reader."—Baltimore
Gazette.
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style, and has cost the writer much literary research."
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medicine will find a digest of the entire controversy
(between the various schools of medicine) presented in
this volume."—Journal of Education.
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fallacies."—Philadelphia Medical Times.
SAVAGE,  FEMALE  PELVIC ORGANS.   Author's Edition.
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    Organs.  In a Series of Colored Plates taken from Nature, with Commentaries,
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SAVORY & MOORE,  DOMESTIC  MEDICINE.
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    cine Chest.   By Drs. Savory and Moore.   Illustrated.   i6mo.       Price .50

SCHULTZE, OBSTETRICAL  PLATES.
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SCANZONI, DISEASES  OF  WOMEN.
      A Practical Treatise on the Diseases of  the  Sexual Organs of Women.  By
    Dr. F. W. Von Scanzoni.   Translated by A. K. Gardiner, m.d.   8vo.
                                                                    Price $5.00

SIEVEKING,  LIFE ASSURANCE.
      The  Medical Adviser in Life Assurance.  By E. H. Sieveking, m.d.   i2mo.
                                                                    Price |2.oo

SHEPPARD, ON MADNESS.
      Madness, in its Medical, Social and Legal Aspects.  A Series of Lectures de-
    livered at King's Medical College, London.  By Edgar Sheppard, m.d.   8vo.
                                                                    Price $2.25

STOCKEN, DENTAL MATERIA MEDICA.   Second  Edition.
      The Elementsof Dental Materia Medicaand Therapeutics with Pharmacopoeia.
    By James Stocken, d.d.s.  Second Edition.   121110.              Price $2.25
  The first edition of this book was disposed of in  a little less than four months.  In
making,this revision the author has endeavored to make it still more useful by the
addition of considerable new matter.

SUTTON, VOLUMETRIC ANALYSIS.   Fourth Edition.
      A Systematic Handbook  of Volumetric Analysis, or the Quantitative  Estima-
    tion of Chemical Substances by Measure, Applied to  Liquids, Solids and Gases.
    Bv Francis Sutton f c.s.  Fourth Edition.  Revised and Enlarged, with Illus-
    trations. 8vo.                                                   [Preparing. 
3<5
PRESLEY BLAKISTON'S
  " A valuable book for the general Practitioner who
& in want of a practical manual relating especially to
diseases of the teeth."—Medical Brief .
SEWELL, DENTAL  ANATOMY  AND SURGERY.
       A Manual of Dental Anatomy and Surgery, Including the Extraction of Teeth.
     By H. E. Sewell, d.d.s., m.d.   With yj Illustrations.   i2mo.       Price $1.50
                                              " It will be found useful to the general Practitioner in
                                            the management of many incidental affections connected
                                            with the teeth and  mouth, which cannot always be
                                            handed over to the specialist."—Pacific Med. Journal.

STILLE, ON  MENINGITIS.
       Epidemic Meningitis, or Cerebro-spinal Meningitis.   By Alfred Stille, m.d.,
     Professor of Practice at the University of Pennsylvania.  8vo.        Price $2.00
  " The name of the author is a sufficient guarantee that this monograph is elegant in style, exhaustive of its sub-
ject and rich with practical suggestions.''—Philadelphia Medical and Surgical Reporter.

STOKES, DISEASES  OF THE  HEART.
       The Diseases  of  the Heart and Aorta.  By William Stokes,  m.d.   Thick
     8vo.                                                                   Price $3.00

SWAIN, SURGICAL  EMERGENCIES.
       Surgical Emergencies:  Concise  Descriptions of the Various  Accidents  and
     Emergencies, with Directions for  their Treatment.  By Wm.  Paul Swain,  f.r.
     C.s.  Eighty-two Illustrations.  i2mo.                                 Price $2.00
  Contents.—Chapter I. Injuries to the Head.  II. Injuries to the Eye.  III. Injuries  to the  Mouth,
Pharynx, Oesophagus, and Larynx. IV. The Chest.  V. The Upper Extremity. VI. The Abdomen.  VII.
The Pelvis.  VIII. The Lower Extremity.  IX. Emergencies connected with Parturition.  X.  Poisoning.
XI. Antiseptic Treatment.  XII. Apparatus and  Dressing.
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fresher of hat/ forgotten knowledge.— The  Practitioner.

SWERINGEN,  PHARMACEUTICAL LEXICON.
       A Pharmaceutical Lexicon or Dictionary of Pharmaceutical Science. Contain-
     ing explanations of the various subjects and terms of Pharmacy, with appropriate
     selections from the Collateral Sciences.  Formulae for Officinal, Empirical,  and
     Dietetic Preparations, etc., etc.  By Hiram. V. Sweringen, m.d.  8vo.
                                                  Price, Cloth, $3.00;  Leather, $4.00
  " It is worthy of a welcome, and sure of a ready recognition of its merits."—London Pharmaceutical Journal.
  " It will prove of great service to the pharmaceutical student, apprentice, pharmacist, druggist and physician, as
a book of ready reference and as an aid to the study of scientific works."—American Journal of Pharmacy.

THOMPSON, LITHOTOMY  AND  LITHOTRITY.
       Practical Lithotomy and Lithotrity; or, an  Inquiry into the  best Modes of
     Removing Stone from the Bladder.  By Sir Henry Thompson,  f.r.c.s.,  Emer-
     itus Professor of Clinical  Surgery in University College.   Third  Edition.   8vo.
     With  87 Engravings.                                                Price $3.50
  " The chapters of most interest are those in  which Bigelow's operation is discussed, and the final one, in
which is a record of 500 operations for stone in cases of male adults under the author's  care.  Such  a table has
never before been compiled by any surgeon."—Lancet.

                                   BY SAME  AUTHOR.

URINARY ORGANS.
       Diseases of the Urinary Organs.   Clinical  Lectures.  Fifth London  Edition.
     8vo.  With 2 Plates and 71 Engravings.                             Price $3.50

ON THE  PROSTATE.
       Diseases of the Prostate.   Their Pathology and Treatment.  Fourth  London
     Edition.  8vo.   With numerous Plates.                               Priee $4.00

CALCULOUS  DISEASES.
       The Preventive Treatment of Calculous  Disease, and the Use of Solvent
     Remedies.  Second Edition.   i6mo.                                 Price $1.00
  " Catholic in his investigation of the fruit of the labor of others, cautious in all his deductions, rejecting all spe-
cious  theories in the effort to obtain practically useful results, as clever with his pen as he is with the sound or
lithotrite, one can scarcely wonder that he is esteemed the master that he is."—American Journal  q/~ Medicat
Science. 
PUBLICA TIONS.
37
TROUSSEAU'S   CLINICAL    MEDICINE.

                              COMPLETE.

                In Two  Large Royal  Octavo Volumes.

     EMBRACING ALL THE LECTURES CONTAINED IN THE FIVE
                VOLUME  EDITION AS ISSUED BY THE
                           SYDENHAM SOCIETY.

     Price, handsomely bound in cloth......% 8.00
                                 leather.....10.00


Lectures   on  Clinical   Medicine.

     Delivered at the Hotel Dieu, Paris, by A. Trousseau, Professor of Clin-
     ical Medicine to the Faculty  of Medicine, Paris, &c., &c.   Translated
     from the Third Revised and Enlarged Edition by P. Victor Bazire,
     M. D., London and Paris; and John Rose Cormack, M. D., Edinburgh,
     F. R. S., &c.   With a full Index, Table of Contents, &c.

  Trousseau's Lectures have attained a reputation both in England and in this country far
greater than any work of a similar character heretofore written, and, notwithstanding but few
medical men could afford to purchase the expensive edition issued by the Sydenham Soci-
ety, it has had an extensive sale.  In order, however, to bring the work within the reach of all
the profession, the publishers now issue this edition, containing all the lectures as contained
in the five-volume edition, at one-half the price.  Below are a few only of the many favora-
ble opinions expressed of the work :
  " It treats of diseases of daily occurrence and of the most vital interest to the practitioner.
And  we should think any medical library absurdly incomplete now which did not have
alongside of Watson, Graves, and Tanner, the ' Clinical Medicine' of Trousseau.
  " The work is full of the results of the richest natural observation, and is the production
of one who was enlightened enough to combine with new methods of investigation the vigor-
ous and independent ideas of the old physicians whom he so eloquently magnifies.  It is an
extremely rich and valuable addition to the library of p nysicians and practitioners generally."
— London Lancet.

  " This book furnishes an example of the best kind c f clinical teaching.  It deserves to be
popularized.  We scarcely know of any work better fitted for presentation to a young man
when entering upon the practical work of his life. Tie delineation of the recorded cases it
graphic, and their narration devoid of that prolixity w.'iich, desirable as it is for purposes of
extended analysis, is highly undesirable when the object is to point to a practical lesson."—
London Medical Times and Gazette.

  " The publication  of Trousseau's Lectures furnishes medical men with one of the best
practical treatises on disease as seen at the bedside.  The conversational style adopted by
the author lends animation to the work, and the translator deserves credit for having so well
preserved the easy and ready style of the original." — British and Foreign Medico-Chirur
gical  Review.
  " The great reputation of Prof. Trousseau as a practitioner and teacher of Medicine in all
its b-anches, renders the present appearance of his Clinical Lectures particularly welcome."
— Medical Press and Circular.
  '* A clever translation of Prof. Trousseau's admirable and exhaustive work,  the best book
of reference upon the Practice of Medicine." —Indian Medical Gazette. 
J8
PRESLEY BLAKISTON'S
TILT, THE CHANGE  OF LIFE  IN  WOMEN.
      The Change of Life in  Health  and Disease.  A Practical Treatise on  the
    Diseases Incidental to Women at the Decline of Life.  By Edward John Tilt,
    m.d.  Third London Edition.   8vo.                               Price $3x0

                               BY SAME AUTHOR.

UTERINE THERAPEUTICS AND DISEASES OF WOMEN.
      A Hand-book  of Diseases  of  Women and Uterine Therapeutics.  Fourth
    London Edition.   i2mo.                                          Price $3.50

TOMES, DENTAL  ANATOMY.  New Edition.
      A Manual of Dental Anatomy, Human and Comparative.  By C. S. Tomes,
    d.d.s.  With 179 Illustrations.  Second Edition.  i2mo.           {Preparing^

TOMES, DENTAL  SURGERY.
      A System of Dental Surgery.  By John Tomes, f.r.s.   The Second Edition,
    Revised and Enlarged.  By C. S. Tomes, d.d.s. With 263 Illustrations. i2mo.
                                                                     Price $5.00
  " We rejoice that such books as these (Dr. Tomes' Works) are demanded by the profession, and that the men
to write them are furnished by the profession."—Dental Cosmos.

TAFT, OPERATIVE DENTISTRY.  Third Edition.
      A Practical Treatise on Operative  Dentistry.  By Jonathan Taft, d.d.s.
    Third Revised and Enlarged Edition.  Over 100 Illustrations.  8vo.
                                                Price, Cloth, $4.25 ; Leather,  5.00
  "All the important operations, in all their modifica^  I  "It is a thorough and complete treatise on the Art
tions, are clearly  discussed by the author,  and the   of Practical Dentistry."—London Medical Times and
work is highly practical throughout."—Dental Regis-   Gazette.
ter.

TANNER, INDEX  OF DISEASES.   Second  Edition.
      An Index of Diseases and their Treatment. By Thos. Hawkes Tanner, m.d.,
    f.r.c.p.   Sixth Edition.  Revised and Enlarged.   By W. H. Broadbent, m.d.
    With Additions.   Appendix of Formulae,  etc.  8vo.                Price $3.00
  By this useful hand-book the character of any disease may be determined  in a
moment, and  the general outline of treatment pursued by the best authorities made
apparent.
  " This work, like others from the gifted author, has  j  " Finally, a chapter on the climates, countries, mine-
already won for itself a reputation.'  .  . . " It is   ral springs, etc., best adapted to the various classes of
in truth what its title indicates."—New York Medical   invalids, makes this work the most complete practi-
Record.                                   tioner's manual that we have yet seen.—Chicago Medi-
                                        \ cat Times.

                               BY SAME AUTHOR.

THE  DISEASES OF INFANCY.
      A Practical Treatise on the Diseases of Infancy and Childhood.  Third Edi-
    tion.  Carefully Revised and  much  Enlarged.   By Alfred Meadows,  m.d.
    8vo.                                                             Price $3.00
  Recommended as a Text-book at Jefferson  Medical College and other schools of
Medicine.
  "One of the most careful, ornate, and accessible
manuals on the subject."—London Lancet.
                                          "We consider the views of the author on the subject
                                         of therapeutics as  rational in the highest degree."—
                                         Boston Medical and Surgical Journal.

MEMORANDA OF POISONS.
      A Memoranda of Poisons and their Antidotes and Tests.  Fourth American
    from the Last London Edition.   Revised and Enlarged.               Price .75
  This most complete Toxicological  Manual  should be within reach of all physi-
cians and  pharmacists, and as an addition to every family library, would be the
means of saving life and  allaying pain when the delay of  sending for a physician
would prove fatal. 
PUBLIC A TIONS.
39
TIBBETS, MEDICAL ELECTRICITY.
       A Hand-book of Medical Electricity.  Giving full directions for its Applica-
    tion, etc.  By Herbert Tibbets, m.d.  64 Illustrations.  8vo.      Price #1.50

TOLAND, PRACTICAL SURGERY.
       Lectures on Practical Surgery.  By H. H. Toland, m.d., Professor  of Surgery,
    University of California.  Second Edition.  With Additions and Numerous Illus- .
    trations.   8vo.                              Price, Cloth, $4.50; Leather, $5.00

TRANSACTIONS  OF  THE COLLEGE OF PHYSICIANS.
       The Transactions of the College of  Physicians of Philadelphia.   New Series.
    Vols.  1, 11, 111, iv and v.   8vo.                         Price, per volume, $2.50

TYSON,  BRIGHT'S  DISEASE  AND  DIABETES.
       A Treatise on Diabetes  and Bright's Disease.  With Especial  Reference to
    Pathology and Therapeutics.   By James  Tyson, m.d., Professor  of Pathology
    and Morbid Anatomy in the University of  Pennsylvania.  With Colored Plates
    and many Wood Engravings.  8vo.                                 Price $3.50
  " This volume is the outcome of some fifteen years'  1   " The symptoms are clearly defined, and the  treat-
special study  and observation, and will be found to be    ment is exceedingly well described, so that every one
a very well prepared monograph.......His direc-    reading the book must be profited."—Cincinnati Lan-
tions are clear and minute.—Med. and Surg. Reporter.    cet and Clinic.

                                 BY SAME  AUTHOR.

GUIDE TO  THE EXAMINATION OF URINE.
       A Practical Guide to the Examination of Urine. For the use of Physicians and
     Students. With Colored Plate, and Numerous Illustrations Engraved on Wood.
     Third Edition.  i2mo.                                              Price $1.50
   Advantage has been taken, in bringing out a new edition of this work,  not only to
correct the previous one, but to make such  additions of new Facts and Processes as
would add to its value without materially increasing its size.
  " Dr. Tyson commences with a short account of the theory of renal secretion, the physical and chemical charac-
ters of the urine, and the reagents and apparatus used in its analysis.  Excellent rules are then given for detecting
the presence of albumen, sugar, coloring-matters, bile, urea, uric acid, chlorides, phosphates  and  sulphates ; and
minute instructions for approximative and quantitative determination of most of those ingredients by volumetric
analysis are supplied."—Philadelphia Medical Times.
  " We lfeve  experienced both pleasure and profit ftom the perusal of this book.  It is agreeably written, contains
much practical information, and is, we believe, a reliable and  satisfactory guide to the clinical  examination ol
urine.  We can recommend Dr. Tyson's book as one that amply supplies the clinical needs of the physician."—
Dublin Journal of Medical Science.

THE CELL DOCTRINE.   Second Edition.
       The Cell Doctrine.   Its  History and Present  State.   With a Copious Biblio-
     graphy of the subject.  Illustrated by a Colored Plate and Wood Cuts.  Second
     Edition.  8vo.                                                      Price $2.00

TURNBULL, ARTIFICIAL ANAESTHESIA.
       The Advantages and Accidents of Artificial  Anaesthesia;  Its Employment in
     the Treatment of Disease; Modes of Administration ; Considering their Rela-
     tive Risks;  Tests  of Purity;  Treatment of Asphyxia; Spasms  of the Glottis;
     Syncope, etc.  By Laurence Turnbull,  m.d., ph.g.,  Aural Surgeon to Jeffer-
     son College Hospital, etc.  Second Edition.   Revised  and Enlarged.  With 27
     Illustrations of Various Forms of Inhalers, etc.  i2mo.             Price $1.50
  " Anaesthesia is a subject of great interest and importance to physicians and dentists, and everything that will
aid them in better understanding the subject is sought with great avidity.  This work we regard as the best aid in
the study of the subject, and it presents the subject up to the present hour."—Dental Register.

TEALE,  DANGERS  TO  HEALTH.   Third Edition.
       A Pictorial Guide to Domestic Sanitary Defects.  By T. Pridjin Teale, m.d.,
     f.r.c.s.   With Colored Plates.  8vo.                                Price $3.50 
4o
PRESLE Y BLAKISTON 'S
VACHER, CHEMISTRY.
       A Primer of Chemistry,  Including Analysis.  By Arthur Vacher.  i8mo.
                                                                            Price .50

VIRCHOW, POST-MORTEM  EXAMINATIONS. Second Edi-
   tion.
       Post mortem Examinations.   A Description and Explanation of the Method
    of Performing them in the Dead  House of the Berlin  Charite Hospital, with
    especial reference to  Medico-legal Practice.  By Prof. Virchow.  Translated
    by Dr. T.  P. Smith.   Second Edition.   i2mo.   With 4 Plates.      Price $1.25
 "A most useful manual from  the pen of a master.     " Its low price and portability make it accessible and
 ....  For thorough and systematic method in   convenient to every surgical registrar and practitioner."
the performance of post-mortem  examinations, there is   —British Medical Journal.
no guide like it."—Lancet.

WAGSTAFFE,  HUMAN OSTEOLOGY.
       The  Student's  Guide to  Human  Osteology.   By William Warwick Wag-
    staffe, f.r.c.s.   With 23 Lithographic  Plates of the Bones, Showing Muscle
    Attachments, and 60 Wood Engravings.  i2mo.                    Price $3.00

WALTON,  DISEASES OF  THE  EYE.  Third  Edition.
       A  Practical Treatise on  Diseases of the Eye.  By Haynes Walton,  m.d.
    Third Edition.  Rewritten  and  Enlarged.   With five plain  and  three colored
    full-page Plates; and many other Illustrations, Test Types, etc.  Nearly 1200
    pages.   8vo.                                                        Price $9.00

WARNER,  CASE TAKING.
       The Student's  Guide to  Medical Case Taking.  By Francis Warner, m.d.,
    m.r.c.p., etc.  i2mo.   Cloth.                                        Price $1.75
  General Diseases.—Class i. Class 2. Arthritic Diseases.  Diseases of the Nervous System.  Of  the Vas-
cular System.  Of the Respiratory System.  Of the Digestive System. Of the Liver. Of the Urinary System.
Instruction for Case Taking.

WATERS,  DISEASES  OF THE CHEST.   Second  Edition.
       The  Diseases  of the Chest.  Their  Clinical  History, Pathology  and  Treat-
    ment.  By A. T.  H. Waters, m.d., Fellow Royal College of Physicians.   With
    Numerous Illustrative Cases and Lithographic Plates.   8vo.          Price $4.00
  "The present edition contains new chapters on haemoptysis, hay fever, aortic regurgitation, mitral constriction,
thoracic aneurism, and the use of chloral in certain diseases of the chest;  other chapters have received additions
of cases and remarks on treatment.  Some characteristic sphygmographic  tracings have also been added."—Bos-
ton Medical and Surgical Journal.

WEDL,  ATLAS  OF THE  TEETH.
       An Atlas of the Pathology of the  Teeth.  By Prof. Carl Wedl, of Leipsig.
     16 Full-page Lithographs, containing many figures, some colored.  Quarto.
                                                                        Price $10.00
                                 BY  SAME AUTHOR.

DENTAL  PATHOLOGY.
       With Special Reference  to the Anatomy and  Physiology of the Teeth.  With
     Notes  by  Thos. B.  Hitchcock, m.d., of  Harvard  University.   105 Illustra-
     trations.   8vo.                               Price, Cloth, $3.50;  Leather, $4-5°

WHITTAKER,  ON THE  URINE.
       Student's Primer  on the Urine.  By J. Travis  Whittaker, m.d., Physician to
     Anderson's College Dispensary.  With Illustrations Etched on Copper.   i6mo.
                                                                          Price $1.50
  Physiological Study of Urine—Sensation in Passing. Quantity.' Color.  Odor.  Specific Gravity.  History
and Behavior.  Sediment or Deposits. Chemical Study of Urine—Reaction.  Albumen.  Chlorides. Ammonia.
Urea.  Phosphates.  Blood.  Sugar. Bile.  Microscopical Study of Urine and Urinary Deposits—Amorphous
Urates. Uric Acid.  Triple Phosphates.   Phosphate of Lime.  Feathery Phosphates.  Oxalate of Lime.  Urate
of Soda and of Ammonia.  Cystine.  Tyrosine.  Leucine. Cholesterine. Epithelium.  Fat Globules,  etc.
  "The plates are possessed of great versimilitude, as well  as in other respects admirable."—Med. Times.
  " Neat and concise, and the illustrations are very good testimony of the claim which he makes of the  suitability
Of the etching needle for delineation of microscopical appearances."—Boston Med. and Surg.  Journal. 
PUBLICA TIONS.
41
WEST,  THE  DISEASES OF  WOMEN.   Fourth Edition.
       Lectures  on the  Diseases  of Women.   By  Charles West, m.d.   Fourth
     London Edition.   Revised and in part re-written by the Author.   With Numer-
     ous Additions  by J. Mathews  Duncan, m.d., Obstetric Physician  to  St. Bar-
     tholomew's Hospital  8vo.                                          Price $5.00
  Drs. West and Duncan are, perhaps,  the most  celebrated London  physicians
giving attention to the Diseases of Women, and together have made a most com-
plete work, either for the physician or student.

WILKES, PATHOLOGICAL ANATOMY.
       Lectures  on Pathological Anatomy.  By  Samuel Wilkes,  f.r.s.  Second
     Edition.   Revised and Enlarged by Walter Moxon, m.d., f.r.s., Physician to
     and Lecturer at Guy's Hospital, London.  8vo.                      Price $5.00
                                 BY SAME  AUTHOR.

DISEASES  OF  THE  NERVOUS SYSTEM.
       Lectures on  Diseases of the Nervous System, Delivered  at Guy's Hospital,
     London.  New Edition, with Additions, Numerous Illustrative Cases, etc.  8vo.
                                                                       [Preparing.
  " A book of great value, embodying as it does the results of the experience and observation of one of the most
accomplished of the London  Hospital Physicians."—American Journal of Medical Science.

WRIGHT,  ON  HEADACHES.   Ninth Thousand.
       Headaches, their  Causes, Nature and  Treatment.  By Henry  G. Wright,
     m.d  i2mo.                                                          Price .50

WILSON, ON  DRAINAGE.
       Drainage for Health; or, Easy Lessons  in  Sanitary Science, with Numerous
     Illustrations.  By Joseph Wilson, m.d., Medical Director United States Navy.
     One Vol.   Octavo.                -                                Price $1.00
  " Dr. Wilson is favorably known as one of the lead-
ing American writers on hygiene and public health.
The book deserves popularity."—Medical and Surgi-
cal Reporter.
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teachings may save much disease and perhaps many
lives."—Cincinnati Gazette.
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ger.
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sented."—Providence Journal.
  " Will be found of value."—Boston Transcript.
  " Worthy of praise as a popular statement of the
subject."—Boston Journal of Chemistry.
  " Will be sure to be a harbinger of good in every fam-
ily whose  good fortune it may be to possess a copy."—
Builder and Wood Worker.
                                 BY SAME  AUTHOR.

NAVAL  HYGIENE.
       Naval Hygiene, or, Human Health  and Means for Preventing Disease. With
    Illustrative Incidents derived  from Naval  Experience.   Illustrated.   Second
    Edition.   8vo.                                                      Price $3.00

WILSON,  DOMESTIC  HYGIENE.
       Health and Healthy Homes.  A Guide  to Personal and Domestic  Hygiene.
    By  George  Wilson, m.d.,  Medical  Officer  of Health.   Edited  by  Jos.  G.
    Richardson, m.d.,  Professor of Hygiene at  the University of Pennsylvania.
    314 pages.  i2mo.                                                  Price $1.00
  Chapter 1.—Introductory, page 17.  11. The Human  Body, 33.  m. Causes of Disease, 66.  iv. Food  and
Diet, 119.  v. Cleanliness and Clothing, 169.  vi. Exercise, Recreation and Training, 187.  vii. Home and Its
Surroundings^ Drainage, Warming, etc., 221.  vm. Infectious Diseases and their Prevention, 269.
  " A most useful, and in every way, acceptable book."-7vVw York Herald.
  " Marked throughout by a sound, scientific spirit, and an absence of all hasty generalizations, sweeping asser-
tions and abuse of statistics in support of the writer's particular views.      .  We cannot speak too highly of
a work which we have read with entire satisfaction. —Medical Times and Gazette.

                                 BY SAME  AUTHOR.

A  HAND-BOOK  OF HYGIENE
       And  Sanitary  Science.  With Illustrations.
    Enlarged.  8vo.
Fourth  Edition.
Revised and
  Price $2.75 
42
PRESLE Y BLAKISTON'S
WILSON,  HUMAN ANATOMY.  Tenth  Edition.
      The Anatomist's Vade-Mecum.  General and Special.  By Prof. Erasmus Wil-
    son.  Edited by George Buchanan, Professor of Clinical Surgery in the Uni-
    versity of Glasgow;  and Henry E. Clark, Lecturer on Anatomy at  the Royal
    Infirmary School of Medicine, Glasgow.  Tenth Edition.  With 450 Engravings
    (including 26 Colored Plates).   Crown 8vo.                         Price $6.00
  Recommended as a Text-book at Rush Medical College, Chicago ;  Bellevue  Hos-
pital, New York; St. Louis Medical College; Yale  and  Dartmouth Schools;  and
many other Colleges.


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  " Numerous additional wood cuts have been introduced, and full-page engravings
of the bones, which have been drawn and engraved with great care, to  secure ac-
curacy, and to make them not mere anatomical diagrams, but artistic pictures."

                               BY  SAME  AUTHOR.

HEALTHY SKIN.  Eighth Edition.
      A  Practical Treatise on the Skin and  Hair;  their Preservation and Manage-
    ment.  Eighth Edition.   i2mo.  Paper.                            Price $1.00

WILSON,  SEA  VOYAGES  FOR HEALTH.
      The Ocean as a Health Resort.   A  Hand-book of Practical Information as to
    Sea Voyages, for the Use of Tourists and Invalids. By Wm. S. Wilson, l.r.c.p.
    Lond., m.r.c.s.e.   With a Chart showing the Ocean Routes, and Illustrating the
    Physical Geography of the Sea.  Crown 8vo.                        Price $2.50
  Chapter 1. Curative Effects of the Ocean Climate. 2. The Various Health Voyages.  3. Time of Starting—
Choosing a Ship.  4. Preliminary Arrangements. 5. Life at Sea. 6. Climate and Weather.  7. Management of
the Health at Sea.  8. Occupations and Amusements at Sea.  9. Objects of Interest at Sea. 10. End of the
Voyage—Future Plans,  n. The Homeward Voyage.  12. Australia: its Climate, Cities, and Health Resorts.
13. South Africa and its Climate.  14. The Meteorology of the Ocean.
  Appendix A.—Outfit Required for a Voyage to Australia.  B. Names and Addresses of some of the  Principal
Shipping Firms.
  " All the information is supplied by, or based upon, trie actual experience of the author; and the book may b«
confidently recommended to all who have to undertake, without previous experience, a sea voyage of any length.
Medical men may consult it with advantage, and commend it to those patients whom they may advise  to try the
effect of a long voyage at sea."—Medical Times and Gazette.
  " We have read every page of this book, and have derived both instruction and amusement."—Lancet.

WELLS,  OVARIAN  AND UTERINE  TUMORS.
      The Diagnosis and Surgical Treatment of Ovarian and Uterine Tumors.  By
    T. Spencer Wells, m.d.                                [To be issued shortly.
  So long a time having elapsed  since Dr. Wells has collected  the results of his
large experience in book form, the present volume will be eagerly looked for by all
interested in this very important subject.

WOLFE, ON  DISEASES  OF THE EYE.
      A  Practical Treatise on Diseases and Injuries of the Eye.  Being a Course of
    Systematic and Clinical Lectures to Students and Medical Practitioners.  By M.
    Wolfe, f.r.c.p.e., Senior  Surgeon  to the Glasgow Ophthalmic Institution, etc.
    With 10 Colored Plates, and numerous other Illustrations.  Octavo.   Price $7.00

WALKER, INTERMARRIAGE.
      Intermarriage, or, The Mode in which, and the Causes why, Beauty,  Health
    and  Intellect result from certain Unions; and Deformity, Disease and Insanity
    from others.   Illustrated.  i2mo.                                   Price $1.00 
PUB LICA TIONS.
43
WOODMAN and  TIDY,  MEDICAL  JURISPRUDENCE.
       Forensic  Medicine  and  Toxicology.   By W.  Bathurst Woodman,  m.d.,
     Physician  to the London Hospital, and Charles Meymott Tidy, f.c.s., Pro-
     fessor of Chemistry and Medical Jurisprudence at the London Hospital.  With
     Chromo-Lithographic  Plates, representing  the Appearance of  the  Stomach in
     Poisoning by Arsenic, Corrosive Sublimate, Nitric Acid, Oxalic Acid; the Spectra
     of Blood and the  Microscopic Appearance of  Human and other  Hairs;  and
     116  other  Illustrations.   Large octavo.
                       Price, Cloth, $7.50; Medical Sheep,  $8.50; Law Leather, $8.50

  " We have no_ hesitation in  pronouncing the work to be one of unusual merit.  More readable than Taylor,
more systematic in  its arrangement, and more practical in its instruction, it will  prove to the medical jurist, not
less than to the general practitioner, a storehouse of useful knowledge, conveyed in an unusually graphic style."—
Dublin Journal of Medical Science.
  " The authors of this truly great work have largely supplied the want felt, sooner or later, by almost every
doctor."—Cincinnati Lancet and Observer.
  " All the best known works on Medical Jurisprudence have been laid under contribution for the production of
the present volume.  It contains almost everything that  can be found in other works on the subject; but it is no
mere compilation.  Dr. Woodman and Dr. Tidy have both thought out the subject for themselves, and, wkh rare
industry and acumen, have brought together a mass of facts which is little  short of astounding.  The book is
•worthy to take its place alongside of any work on the same subject, and must prove of great use  to all who prac-
tice in criminal courts, and to all medical practitioners.  We have no hesitation in recommending it to our read-
ers."—London Lancet.
  " Altogether the work will rank with the best of its class as a medico-legal hand-book, and cannot fail to gain
a wide popularity."—New York Medical Record.
  " It cannot be otherwise than a  valuable contribution to the boundless subject  of medical jurisprudence."—
Albany Lain Journal.
  "The scope of this book is very wide, and its execution worthy of all commendation."—Philadelphia Legal
Intelligencer.

WYTHE, ON  THE  MICROSCOPE.
        The Microscopist.   A Manual of Microscopy and Compendium of the Micro-
     scopic Sciences, Micro-Mineralogy, Micro-Chemistry, Biology,  Histology,  and
      Practical Medicine.   By Joseph  H. Wythe, a.m., m.d.   Fourth  Edition.   252
      Illustrations.  8vo.                             Price, Cloth, $5.00; Leather, $6.00

   An Index and Glossary  have been combined in this edition, so as to be  a source

of valuable  information.   Notices  of recent additions  to the microscope, together

with the genera of microscopic plants, have been given in an Appendix.
  " From what we knew of the author of this work, as
a skilled practical Microscopist, a successful teacher of
the science, and a practitioner of medicine and surgery
of long and varied experience, we had a right to expect
agoocTbook from his nands. Our expectations are fully
realized in the volume before us.  The style is  clear
and distinct, and one reads  the book with the utmost
facility of comprehension.  It is the more valuable to
the physician and medical  student  on account of its
closer application of the microscope to medical subjects
than we  find elsewhere. The  numerous plates, many
of which are beautifully colored, are not to be excelled.
We feel  proud of it as an American  production."—
Pacific Medical and Surgical Journal.
                                                 " This is one of the most valuable text-books on mi-
                                                croscopy ever offered to students or  practitioners  of
                                                medicine.  This edition has been greatly enhanced in
                                                value by the addition of chapters on the use of the
                                                microscope in pathology, diagnosis, and etiology, and
                                                numerous new illustrations, some of which are from
                                                Rindfleisch.
                                                 " The author very carefully brings out every neces-
                                                sary fact and principle relating to the use of the micro-
                                                scope, and now that this instrument has become an es-
                                                sential part of every  practitioner's armamentarium, a
                                                practical guide and reference book is  also a necessity,
                                                and we are fully warranted in reiterating the statement
                                                that this is one of the most valuable text-books ever
                                                offered to students and practitioners  of medicine."—
                                                The Cincinnati Lancet and Clinic.      .

                                       BY SAME AUTHOR.

DOSE  AND  SYMPTOM  BOOK.   Eleventh Edition.
       The Physician's Pocket Dose and Symptom Book.   Containing the Doses and
     Uses of all the Principal Articles of the Materia  Medica, and Original Prepara-

     tions.  Eleventh Revised Edition.
                            Price, Cloth, $1.00; Leather, with Tucks and Pocket, $1.25

  " The chapter on Dietetic Preparations will be found useful to all practicing physicians, niost of whom have but
little acquaintance with the modeiof preparing the various articles of diet for the sick."—Boston Medical and
Surgical Journal.

  " Many a hard-worked practitioner will find it a useful little work to have on his study table."— Canada Medical
and Surgical Journal. 
44
PRESLEY BLAKISTON'S PUBLICA TIONS.
WHEELER, MEDICAL CHEMISTRY.
      Medical Chemistry,  Including  the Outlines of Organic  and  Physiological
    Chemistry.  By C. Gilbert Wheeler, m.d.  Second Edition.  i2mo.
                                                                    Price $3.00
WOAKES, ON  DEAFNESS  AND GIDDINESS.
      On Deafness, Giddiness and Noises in the Head. By Edward Woakes, m.d.,
    London, Surgeon to the Ear  Department of the Hospital for Diseases of the
    Throat  and  Chest.   Second  Edition.  Revised and Enlarged, with additional
    Illustrations.   i2mo.                                             Price $2.50
 " The early demand for a  fresh edition of Dr.
Woakes' volume is a sufficient criticism of its merits.
      No brief summary of his views could do full
justice  to the cogency and subtlety of his reasons.
We prefer to commend the whole work to the thought-
ful perusal of all intelligent medical practitioners who
desire to rise above the level of mere routine empiri-
cism."—Lancet, August 28th, 1880.
  " This book, although small, is evidently the result
of much careful thought and observation.  .  .  .  We
cordially recommend the work as original and suggest-
ive, and as being likely to prove very useful in explain-
ing both the causation of symptoms otherwise puzzling,
and their appropriate treatment."—Practitioner, July,
         ILLUSTRATED   BOOKS.

                        MEDICINAL PLANTS.
Being  Descriptions, with original Figures, of the Principal  Plants  employed in
    Medicine, and an account of their Properties and Uses. By Robert Bentley,
    f.l.s., Professor of Botany in the  King's  College, and to  the  Pharmaceutical
    Society, and Henry Trimens,  m.b., f.l.s.,  late  Lecturer on Botany  at  St.
    Mary's  Hospital  Medical School.  In 42 Parts, each, $2.00, or in 4 vole., large
    8vo, with 306  Colored Plates, bound in half morocco, gilt  edged.        $90.00

        AN ATLAS  OF  TOPOGRAPHICAL ANATOMY.
After Plane Sections of Frozen Bodies.  By William Braune, Professor of Anatomy
    in  the University of  Leipzig.   Translated by Edward Bellamy, f.r.c.s., Sur-
    geon to  and Lecturer on Anatomy at Charing Cross Hospital.  With 34 Photo-
    lithographic Plates and 46 Wood cuts.  Large imp. 8vo.                 $10.00

                   ATLAS OF SKIN  DISEASES.
Consisting  of a Series  of Illustrations,  with  Descriptive Text  and  Notes  upon
    Treatment.  By Tilbury Fox, m.d., f.r.c.p., late Physician to the Department
    for Skin Diseases in University  College  Hospital.   With 72  Colored Plates.
    In 18 Parts,  each, $2.00 or, 1 Vol., Royal 4to, Cloth.                     $30.00

              AN ATLAS  OF  HUMAN ANATOMY.
Illustrating  most of the  ordinary Dissections, and many not usually practiced by
    the Student.  By Rickman J. Godlee,  M.S., f.r.c.s., Assistant  Surgeon  to
    University College Hospital, and Senior Demonstrator of Anatomy in Universi-
    ty  College. With 48 imp. 4to Colored Plates (112 Figures), and  a volume of Ex-
    planatory Text.                                                      $30.00

            A  COURSE  OF OPERATIVE  SURGERY.
By Christopher  Heath, f.r.c.s.,  Home Professor of  Clinical Surgery in Uni-
    versity College, and  Surgeon to  the  Hospital.   With 20 Plates drawn from
    Nature by M. Leveille, and colored by hand under his direction.  4to.   $14.00

         ILLUSTRATIONS OF CLINICAL  SURGERY.
Consisting   of  Plates, Photographs,  Wood   cuts,  Diagrams, etc., etc.,  illustrat-
    ing Surgical Diseases, Symptoms, and Accidents; also Operative  and  other
    Methods of  Treatment, with Descriptive Letterpress.  By Jonathan Hutchin-
    son, f.r.c.s., Senior  Surgeon to the London Hospital.  Vol. I, containing fas-
    ciculi I  to X, bound,  with Appendix and Index.                         $25.00
      Fasciculi XI  to XIV.  Ready.                                  Each, $2.50 
The     Microscopist.
                 FOURTH B3DITIOKT.

         WITH TWO HUNDRED  AND  FIFTY ILLUSTRATIONS,
                                 AND
Greatly Enlarged by the Addition of oyer 200 Pages of New Matter.
                By J. H. WYTHE, A.M., M.D.,
     Professor of Microscopy and Histology in the Medical College of the Pacific,
                        San Francisco, California.
  This Manual of Microscopy and Compendium of the Microscopic Sciences,
Micro-Mineralogy, Micro-Chemistry, Biology, Histology, and Practical Med-
icine, in which the Practice of Medicine  receives  the  largest attention,
makes this work one of the most complete Text-Books known on the sub-
ject.   Matters of mere  curiosity have  been but briefly  referred to, while
every necessary fact or principle relating to the microscope has been care-
fully stated and classified.
  The chapters on the use of the  microscope in Pathology, Diagnosis, and
Etiology, which have  been added to this edition, have  been largely illus-
trated with wood-cuts  from Rindfleisch.
  The Index and  Glossary have been combined in this edition so as to be a
source of valuable information, and notices of recent additions to the mi-
croscope, together with the genera of microscopic plants, have been  given
in an Appendix.
  No pains have  been spared to render this manual a useful companion to
the student of Nature, and an aid to the progress of real science.   Cloth,
$5.00; Sheep,  $6.00.

  "From what we knew of the author of this work, as a skilled practical Microscopist,
a successful teacher  of the science, and a practitioner of medicine and surgery of long
and varied experience, we had a right to expect a good book from his hands.  Our ex-
pectations are fully realized in the volume before us.  In a little over 400 pages he has
condensed almost everything of importance relating to the subject. The style, though
almost aphorismal, is clear and distinct, and one reads the book with the utmost facility
of comprehension.  It  is  the more valuable to the physician  and medical student on
account of its closer application of the microscope to medical subjects than we find else-
where.  Too much praise cannot be bestowed on the mechanical execution of the volume.
The numerous plates, many of which are beautifully colored, are not to be excelled.
Added to this, the large  and  clear type and  the fine quality of paper make it a most
comely book.  We feel proud of it as an American production, dividing its authorship
and execution between the extreme west and east  territorial limits of the Republic."—
Pacific Medical and Surgical Journal.
  "This is one of the most valuable text-books on microscopy ever offered to students or
practitioners of medicine.  This edition has been greatly enhanced in value by  the ad-
dition  of chapters on the use of the microscope in pathology, diagnosis, and etiology,
and numerous new illustrations, some of which are from Rindfleisch.
  " The author very  carefully brings out every necessary fact and  principle relating to
the use of the microscope, and now that this instrument has become an essential part of
every practitioner's armamentarium, a practical guide and reference book is also a ne-
cessity, and we are fully warranted in reiterating the statement that this is one of the
most valuable text-books ever offered to students and practitioners of medicine."—Tht
Cincinnati Lancet and Clinic.

                  P. BLAKISTON, SON & CO., Publishers,
                                               PHILADELPHIA. 
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