mmmm& v* BILIARY CALCULI; PERINEORRHAPHY; HOSPITAL GANGRENE, AND ITS KINDRED DISEASES; WITH THEIR RESPECTIVE TREATMENTS. BY C. H. von TAGEN, M.D., LATE PROFESSOR OF OPERATIVE SURGERY, HOMCEOPATHIC HOSPITAL COLLEGE, CLEVELAND, OHIO, AND HAHNEMANN MEDICAL COLLEGE, CHICAGO, ILL., ETC., ETC., ETC. BOERICKE & TAFEL, NEW YORK: PHILADELPHIA: 145 Grand Street. 635 Arch Street. 1881. T\2 5\: 1281 Copyrioht, Boericke 6r* Tafel, 1881. PREFACE. The author tenders to his professional brethren the contents of this little volume, his first contribution in book form, trust- ing that it may prove worthy of their recognition, as a work of reference, in the treatment of the various surgical subjects, herein contained. It has been his earnest effort to be concise and brief; and yet to make the work as thoroughly practical as the busy practitioner and surgeon, in his daily routine, could desire. He would especially call attention to the treatment of Hos- pital Gangrene by Bromine. The reader will notice that there is appended to this treatise a tabulated statement of some 1100 cases, many of them complicated with other grave diseases, showing the smallest percentage of loss on record. It was only after persevering efforts, long maintained, and by thoroughly testing the many and various remedies recom- mended by the profession at large, for the arresting and curing of hospital maladies like these, that the author was enabled finally to light upon this remedy; from the skillful use of which were obtained the results noted. In conclusion, the author respectfully requests, at the hands of the professional reader, a fair and just criticism of his efforts; and a thorough and complete test of the treatment, just referred to, when the opportunity offers. C. H. v. T. (5) AS A TRIBUTE OF HIGH APPRECIATION AND MARKED ESTEEM, THIS, MY FIRST VOLUME, I MOST RESPECTFULLY DEDICATE TO MY DEAR FRIEND AND FIRST PROFESSO- RIAL INSTRUCTOR IN THE SCIENCE OF HOMEOPATHY, NEARLY A QUARTER OF A CENTURY AGO, AND NOW PRESI- DENT AND PROFESSOR OF THEORY AND PRAC- TICE IN HAHNEMANN MEDICAL COL- LEGE OF CHICAGO, ILL., PROF. A. E. SMALL, M.D., WHO MAY BE JUSTLY* PRONOUNCED THE "NESTOR" OF HOMCEOPATHY IN THE GREAT WEST. THE AUTHOE. INTRODUCTION. There is little for us to offer, by way of extenuation, for bringing before the medical profession a volume of this kind, except the fact that all of the subjects selected are well known to be of a formidable class of diseases that are but partially and imperfectly understood, even by physicians of years ex- perience; as the failures as A\Tell as mortalities that have oc- curred will attest. These special diseases come more appropriately within the province of the surgeon; and yet most, in fact all of the works on surgery, of the present day, are deficient in information with regard to the ailments and accidents, which give rise to the conditions herein noted. Nor is the needed instruction to be found in any of the medical Avorks in general. Our intention and purpose then, is to present a concise but comprehensive and practical de- scription of these diseases, with surgical and medical treat- ment, embracing all that is new up to the present date; thus meeting a demand which no doubt exists. BILIARY CALCULI: EMBRACING THE HISTOLOGY, ANATOMY, PHYSIOLOGY, and PATHOLOGY of the LIVER, WITH HISTORICAL CASES AND TREATMENT. [Read before the Chicago Homoeopathic College of Physicfans aud Surgeons. June, 1S7S.] BILIARY CALCULI. With a ATiew to the proper comprehension of this subject, assigned the writer at the last monthly meeting of this honor- able bod}', it is deemed an essential feature to preface our remarks with some of the histological and physiological feat- ures, etc., of such portions of the hepatic structures, embraced in the term biliary or bile-secreting. Another reason for presenting these remarks, is to lay before the members of this society, for their earnest consideration (and especially for the benefit of any who may not have rendered themselves familiar with them), some of the researches and ob- servations recently advanced by modern investigators and authors. It may be said of the liver, that it is unlike any other gland, elaborating its secretion not out of arterial blood, but from the venous blood of the vena porta. It possesses a very richly developed capillary net-work, into which the vena porta pours its contents; and thus not only constitutes the starting point of the hepatic vein, but likewise receives the blood from the hepatic artery, after it has flowed through a peculiar and intricate system of capillaries destined for the nutrition of ves- sels, gall-ducts and nerves. The secreting cells of the liver are arranged in such a manner as to bring them into a much more intimate and extensive relationship and contact with the capil- laries, than is the case in other glands. Moreover, the number of the canals into which these cells pour their secretions, is much greater than in any other gland, in proportion to the number of cells composing its structure. (17) 18 biliary calculi. We Avill now consider the arrangement of the hepatic ducts and bile ducts, in the lobules of the liver. The hepatic duct enters the liver in company with the hepatic artery and portal vein, at its transverse fissure, and passes Avith these \ressels to the lobules. In its course it gives off a great many arborescent or diverg- ent brandies; the larger of which anastomose frequently with each other; the smaller ones remain solitary, and thus continue on to the surfaces of the lobules. From these minute peri-lobular ramifications arise a set of capillary tubes, which enter the substance of the lobules super- ficially, and there terminate in blind extremities; being lined within by a simple epithelial layer made up of the smaller or hepatic cells. If the scrapings from the incised surface of a fresh liver be placed under a moderately high power of the microscope, the field of vision will be found covered with numerous round, ovoid, or irregularly polygonal cells, from ttVo t° toVtf °f an inch in diameter. In their normal condition they are more frequently ovoid than otherwise. When polygo- nal in form, their corners are always rounded. These cells present sometimes with two, again AA'ith one, and also without nucleoli; and the presence of numerous small pigmentary gran- ules imparts to the cells a peculiar and characteristic appear- ance. In addition, nearly all of them contain a few granules or minute fat globules. At times the pigmentary and fatty mat- ter is so abundant as to render the nuclei obscure. The addi- tion of Acetic Acid, however, will cause a paleness of the cells, and thus make them more distinct. By appropriate agents, animal starch (glycogenic matter) may be demonstrated in the substance of these cells. Cells taken from a hardened liver appear as polyhedra, or many-sided cells, possessing variable shapes, sometimes pre- senting peaked angles; and when seen in profile, their edges and their surfaces appear at one time sharply and darkly out- lined; at another, irregular, indistinct and ragged, as if torn. The cell body is darkly granulated; the nucleus has a sharp outline, which is often double. So long as these cells remain in situ, they appear to be separated and even isolated from each BILIARY CALCULI. 19 other. Again, there is often seen a fissure, which is an indica- tion of commencing, or incipient dissolution. At times, the cells are intimately united with the walls of the capillaries, though usually the two are found separated by an intervening space. Besides the forms already described, hepatic cells are often found of varied shapes and calibre. One variety p-esents a scale-like appearance, and these are piled up on the capillaries like spindles, and vary in length. All except tnose first de- scribed may be regarded as anomalous conditions, and may be accounted for, in a measure, from the fact that the living liver- cell consists of a semi-fluid mass, which can be made artifici- ally to assume a great variety of shapes, which it will retain after it becomes stiff, or has been hardened. The large hepatic cells are usually connected with each other in pairs; these fill up the meshes or interspaces of the capillary plexus of the lobule; and in their aggregate mass constitute an epithelial net-work, which is found interwoven thus with the web of capillary vessels. Late researches have shown, pretty conclusively, that the following is probably the true relation of the ultimate ramifi- cations of the bile ducts, in the lobules, to the hepatic cells. The Biliary Ducts, Avhich possess a diameter of about -^ of a line, according to Kolliker, are lined with pavement epithe- lium, which is replaced by a cylindrical epithelium. The hepatic ducts proper and cystic duct, also the ductus communis choledochus present muscular fibres in their walls and also a considerable number of racemose or grape-like clusters of glands. The hepatic artery accompanies the biliary ducts to the lobules and supplies them with numerous branches, and finally terminates in the fine capillary plexus of the portal vein. The biliary ducts, and hepatic capillaries, thus constitute a tubular gland. The liver then is made up of two sets of glands, which are intimately intermingled with each other. One of these, a blood gland, is concerned in the secretion of sugar, and the other, a tubular gland, is engaged in the secretion of bile. Xo less an authority than the world-renowned and recently deceased M. Claude Bernard established this circumstance, 20 BILIARY CALCULI. and makes mention of it in his Physiology of the Liver, as ay ell as in his work on Comparative Anatomy. The mode of origin, of the radicles of the hepatic duct, has been the subject of close and varied researches. The number of theories, which have been advanced in explanation of this point, are evidence of the uncertainty which formerly surrounded the subject. We have admitted that the liver is made up of two distinct forms of gland structure, and have also described the radicules vasculaires of the hepatic ducts as tubes terminating in blind termini or ends; Avhich fact we have witnessed in syphilitic and cirrhotic livers. These latter observations were also noted by Professor Kuss, of Strassburg, Germany, and by Professor C. Morel, of France. In the substance of the lobules is found an exceedingly fine and regular net-work of vessels of uniform size, about the 1o^0o of an inch in diameter, Avhich surround the hepatic or liver cells, each separate cell lying in a space bounded by inosculating branches of these canals. This plexus is entirely independent of the blood-vessels, which seems to embrace in its meshes each individual cell, extending from the periphery of the lobule, (Avhere it is in communication with the inter-lobular bile ducts,) to the intra-lobular vein in the centre. These vessels have exceedingly thin and homogeneous walls,—the existence of which have not yet been practically demonstrated, and are devoid of epithelial lining; being much smaller than any epithelial cells ever yet discovered, or of Avhich Ave have any knowledge; and it may also be added that this arrangement has no analogue in any other of the secreting organs. It is only within a few years past, that the reticulated or net- like bile ducts of the lobules of the liver have attracted much attention; they were discovered by Gerlach in 1848, in the sub- stance of the lobules, near the periphery. It is stated, however, at an earlier period, viz., in 1843, that Kiernan first described and figured this " biliary plexus " in a paper entitled the Anatomy and Physiology of the Liver; Avhich appeared in the Philosophical Transactions, London, 1843, part 1st, page 741 and plate 23, figure 3. His figure is diagram- matic, and not taken from nature; and has appeared in many of the works on descriptive anatomy of the present time. BILIARY CALCULI. 21 In 1853, M. Lareboullet published a prize essay, in Paris, on the Minute Structure of the Liver; in which he corroborates Kiernan's theory and concludes that the biliary plexus is de- monstrable; although after long and laborious research, he was not able to demonstrate the existence of the membrane form- ing the walls of the tubes composing it. In a monograph by Lionel S. Beale, On Some Points in the Anatomy of the Liver of Man and Vertebrate Animals, London, 1856, the following is the summary of his able and interesting investigations on this subject. He states: "The liver-cells lie Avithin a tubular net-work of basement membrane, which sepa- rates them from the walls of the capillaries. In many cases, however, these thin membranous tubes cannot be separated, and are, no doubt, incorporated with each other. The cell- containing net-work is directly continuous with the most min- ute ducts, which ramify at the circumference of the lobule, and it terminates in the centre by loops, which lie close to the intra- lobular vein." It appears that both Lareboullet and Beale describe the tubes composing the "cell-containing net-work," as larger in diameter than the " minute ducts," which are the radicules of the hepatic duct. " The tubes of these cells are about -j-^qt °f an inch in diameter, the finest of them not more than -g-oVo, and even less"..... " The finest ducts are lined with a very delicate layer of epithelium; composed of flattened cells of a cir- cular form; contrasting remarkably with large secreting cells" —the hepatic cells proper, which occupy the cell-containing net-work, or biliary plexus.—Beale, page 74. The Biliary Ducts are the hepatic, the cystic, and the ductus communis choledochus. The last named, the largest of the series, is the common excretory duct of both liver and gall- bladder. Its length is about three inches, and its calibre that of an ordinary goose-quill, and is formed by the junction of the cystic and hepatic ducts. In its course to the duodenum it joins the pancreatic duct near its termination; then passes with it obliquely between the muscular coats; the two opening by a common orifice, a little below the middle, and on the in- 22 BILIARY CALCULI. ner side, of the descending portion of the duodenum, upon the summit of a papillary prominence. The Hepatic Duct is composed of two trunks, of nearly equal size; which proceed from the liver at the transverse fis- sure, one from either side. These unite and pass downwards, and toward the right side, for an inch and a half; and there at an acute angle join the cystic duct, to form the common duct of the liver. Its calibre is about one-third less than the ductus communis choledochus, or common bile duct. The Cystic Duct, or duct of the gall-bladder, is about an inch in length. It passes obliquely downward, and to the left, from the neck of the gall-bladder, and joins the hepatic duct; the two combining to form the common duct. In calibre it is about one-third the size of the first named duct. The mucous membrane, lining its interior, is thrown into a series of cres- centic folds, some five to twelve in number, which project into the duct in regular succession, and run obliquely around the tube, presenting somewhat the appearance of a spiral valve. They are only found in the human species. When the duct has been distended, the interspaces between these folds are dilated, thus giving to its exterior surface a sacculated appear- ance. The coats of the biliary ducts are composed of an exter- nal, or fibrous, and an internal, or mucous layer. The fibrous, or outer layer, is composed of strong areolar fibrous tissue. The mucous, or inner coat, is continuous with the lining membrane of the hepatic ducts and gall-bladder; also with that of the duodenum; is also liberally supplied with two sets of glands, Avhich open by means of minute tubes, which have their termini either separately, in the hepatic duct, or into the ducts of the tubular glands. The Gall-Bladder, or reservoir for the bile, is a conical or pear-shaped sac, lodged in a fossa on the concave or under sur- face of the liver,—right lobe. It is some four inches in length; one inch in breadth, at its widest portion. Its capacity is from eight to ten drachms. BILIARY CALCULI. 23 The gall-bladder is held in situ by means of the peritoneum which, as a rule, passes over its under surface. In exceptional instances its entire surface is found invested with a peritoneal covering. It is then connected to the under surface of the liver by means of a kind of mesentery. It is divided into a body, fundus, and neck. When distended with bile, or when occu- pied with calculi, the fundus may ordinarily be felt through the abdominal parieties; except in plethoric subjects. Symptomatology.—Biliary calculi, as a rule, induce symp- toms only Avhen they are passing through one or more of the biliary ducts and toward the bowel; as long as they remain in the gall-bladder they produce no active symptoms, even though they be numerous and of considerable size. It is then during their egress, and especially when becoming lodged, that they create the most intense suffering. Instances are knoAvn, in Avhich gall-stones, in vast numbers, have accumulated in the gall- bladders of persons, who during their life time have never been known to suffer pain about the liver, nor yet to evince symptoms of jaundice, nor any token denoting the presence of any such concretions. We may infer from this that while they remain quiescent in the gall-reservoir, they are comparatively harmless. When of small size and smooth, they may even pass through the cystic and common ducts, or remain lodged there for a time, and their presence be only declared upon ex- amination after death; the patient having died of some other ailment. Pain is induced Avhen the ducts are put upon the stretch, causing a spasmodic action, followed by contraction; and ac- cording to the extent of this condition will be the severity of the pain. Usually it comes on suddenly in the epigastrium, and toward the right side, and can be generally located at a point corresponding Avith the orifice of the common duct, thence shooting to the back; occurring in paroxysms, although there is constant dull pain during the intermissions. When severe, the skin of the entire body becomes pale, pulse small and feeble;—nausea and vomiting, anxiety and restlessness, hurried respiration, faintness and marked prostration, are then 24 BILIARY CALCULI. constant symptoms. Paroxysms of pain may occur thus sev- eral times in an hour, or may be much longer prolonged. Relief follows, as soon as the calculus passes into the bowel, unless it be of unusual and large proportions. Inflamma- tion sometimes ensues, from prolonged irritation, caused by the presence of the calculus, and direct pressure or distending force; and again, from bilious accumulations Avhich they may occasion. This condition may pass on to suppuration, and ulceration; and, through the medium of adhesions between the contiguous peritoneal surfaces, the discharge of the calculus may occur externally, through the parieties of the abdomen, or may drop into one of the internal cavities. Recoveries some- times take place even under these circumstances. Occasionally a long-continued jaundiced condition pre-exists, which, taken in connection with the foregoing symptoms, indicate the pres- ence of gall-stones. Another condition, worthy of consideration, is the fact that a duct may be distended by a concretion of this nature, and even produce spasms of pain, irritation, inflammation, and ul- ceration, without a complete stoppage of the flow of bile; which may trace its way along the sides of the calculus. It is the absence of bile in the alimentary canal, the consequent de- rangement of digestion, etc., that induces the jaundiced condi- tion and white stool;—the bile being absorbed, and carried into the general circulation. Biliary calculi or gall-stones, occur more frequently in the gall-bladder; exceptionally in the larger and smaller gall-ducts. Their number, size, form and properties, change according to their constituents, and are often found single; not unfrequently they exist in large numbers. Properties and Constituents op Gall-stone or Biliary Calculi.—These are composed mostly of cholesterin and the coloring matter of the bile, which Wagner terms, bilirubin, also carbonate and phosphate of lime, mucus, biliary acids and margarin. Gall-stones form, sometimes, in consequence of an abnormally increased proportion of cholesterin, and biliary coloring matter, in the bile; these form precipitations, at times facilitated by BILIARY CALCULI. 25 the presence of catarrh of the mucous membrane; their nuclei are rarely composed of a foreign body. According to Matten- heimer (Archives of Anatomy, Physiology, etc., 1872, page 509), " Many gall-stones arise perhaps from inspissation (thickening) of the bile and chalky substances in the villi, sometimes occur- ring on the mucous membrane of the gall-bladder." Usually, this variety of calculi may be distinguished as fol- lows: Calculi of Cholesterin.—These may be single, or few; small, or of the size of a hen's egg; of a round or oval shape; smooth, or rough and granular, on their surfaces; of a Avhitish or yellowish-brown color, or black; rarely triangular; always presenting a crystaline striation of their surfaces, when frac- tured, or section is made. Calculi of Cholesterin and Biliary Coloring Matter.— These are found with a small quantity of carbonate and phos- phate of lime, varying in proportions, of these constituents; generally, brown or green, in color; varying likewise in pro- portions; usually numerous in point of numbers; in shape round or angular, most frequently the former, and then usually smooth, with chalky section, like the external surface, or vari- ously colored in the different stria or layers. At times Biliary Calculi, are composed alone of biliary coloring matter, of a broAvn or green color, their calibre small, not numerous, and in shape round or pointed. This variety is rare. Calculi of Carbonate of lime, exclusively, presenting a crys- taline surface, when fractured. These are likewise not common. Gall-stones, as a rule, are not of a hard consistence, and may sometimes be easily compressed and mashed up between the fingers. Large gall-stones, with the exception of their centres or nu- clei, consist almost entirely of cholesterin, and are, therefore, whitish and crystaline. Small gall-stones, resembling grains of black pepper, and of 26 BILIARY CALCULI. an irregular tuberculated form of almost black color, are occa- sionally met with; these consist almost entirely of pigment and earthy properties, such as the carbonate and phosphate of lime. It is not an improbable theory that they form by the pigment granules becoming cemented—they coalesce—together by mu- cus, and then form a nucleus aroiind which the cholesterin gathers and forms, and is thus deposited in layers. Sometimes the reverse of this occurs, as in two cases witnessed by the writer, in which the central formation, or nucleus, was com- posed of cholesterin, and the successive layers without were formed of the phosphate and carbonate of lime, etc. The largest of the two weighed 437£ grains, the smaller 300 grains. Cases are on record in which the nuclei of biliary calculi were composed of a pin, a lumbricus, a portion of a distoma, etc. Calculi found in the ducts are usually cylindrical, occa- sionally aborescent or branched, or entirely amorphous or non- cry stalized. Numerous chemical analyses have been made; among the most prominent and satisfactory is that by Chevreul, although not of recent date. According to this authority, gall-stones are composed of the yellow coloring matter of the bile and cho- lesterin; the last named usually predominating, and forming in many instances the entire bulk of the concretion. Prof. Thompson, a noted authority of the Glasgow University, states that all biliary concretions may be embraced in three species, the cholesteric, mellitic, and inspissated varieties. The first named is composed nearly, if not entirely, of cholesterin; is of a pearly white lustre, with a slight brown shade, spherical in form and of a crystallined laminated structure; is of low specific gravity, void of smell or taste, free from acid or alkali properties, insoluble in water, but partially soluble in boiling alcohol, fusing at a temperature of 279°. The mellitic variety, pronounced by the author as by far the most common form, has been thus named by the Professor from its dark, honey-like color. In consistency it is soft, smooth, and ahvays of a polygonal shape, being composed usually of two tetrahedrons, applied base to base, with their angles and edges BILIARY CALCULI. 27 ovoid, or rounded. Externally, it is composed of thin, concen- tric layers, or lamina, of cholesterin; found lying over a nucleus of indurated bile, resembling very much granulated honey. The inspissated, or third variety, as its title indicates, is com- posed Avholly of inspissated bile. It presents a yellowish or dark saffron color, sometimes a cinnamon hue, of a semi con- crete consistence, and is much less frequently met with than either of the other species. Historical Cases. Prominent foreign and native authorities furnish us with the following on this subject: Dr. John Hunter, of England, examined a case in which there were over a thousand gall-stones, of various sizes and forms. Morgagni, a French authority, reports a case in Avhich there were three thousand six hundred and forty-six, most of which were very small in size,—of the calibre of a bird-shot. When thus numerous they are usually small. Hildanus makes mention of one that weighed eighteen drachms (2 oz. and 2 drachms). Dr. Baillie reports one the size of a hen's egg. Dr. Powell states that gall-stones are comparatively rare in hot climates. This may be due to a more liquid consistence of the bile itself. Thos. Watson, M.D., author of " Watson's Practice," reports a case of a remarkably strong, healthy man, over 60 years of age, who, while engaged in inflating an air-bed, by blowing into it through a tube, suddenly felt a pain in the right side of the epigastrium, near the edge of the false ribs. The pains recurred at intervals; and a jaundiced condition ensued, in two or three days, until the skin became intensely yellow. This attack came on June 1st, 1854, and continued more or less until the folloAving August 29th. Liver became much enlarged, during this period, and very prominent. He had been subject to pains similar to these from his boyhood, which were referred by his former advisers to spasm of the diaphragm. He had a con- siderable accumulation of fat about the abdomen. The liver became enormously distended before his death. Post-mortem 28 BILIARY CALCULI. revealed the liver full of bile, also the gall-bladder; the latter being much thickened, and was found occupied with nu- merous calculi, moulded one upon another, presenting irregu- lar forms and outlines. One large one presented the form and shape of a horse's hoof; and this one completely plugged up the ductus communus choledichus, near the duodenum. Brandies of the hepatic ducts, in the liver, Avere so distended as to present little reservoirs of bile and mucus. " Some of these calculi must have been of very old date; " continues the writer, "his life was extinguished in thirteen weeks by the mere occlusion of the biliary ducts, and the complete barring up of the bile in the liver." Dr. Budd relates a case in which a patient was tolerably Avell preserved and nourished, for a period of thirteen months, in a state of deep jaundice; and another in which a woman lived eight months in that condition, and five months after jaundice set in, bore a child which she was able to nourish up to the time of her death, viz., three months. Biliary concretions seldom form in children; and they are much more common in women than men. They occur more frequently in persons of corpulent habit, and those who lead sedentary lives, use generous food, sleep much, and neglect their bowels. It is stated that in England five-sixths of the cases occur among women. Dr. E. Wallace presents an instance of a gall-bladder entirely filled with upwards of forty large calculi. Dr. Budd's work presents an illustration of three large calculi, contained within the gall-bladder, and the cystic duct likewise occupied; all of Avhich were encrusted over with pure choles- terin. Watson states that the ordinary biliary calculi consist in a great measure of cholesterin; which Dr. Prout adds is some modification of the oleaginous principle. He also states that cattle are subject to these formations, when long confined to their stalls in Avinter time; and it has been noted that they re- cover from the ailment after being turned out into the green pastures. Gall-stones are more common between the ages of forty and fifty than at any other period of life. BILIARY CALCULI. 29 Dr. Bence Jones reports a case of gall-stone, (proportions not stated), presenting a brick-red color. Beale accounts for the red color, by suggesting that it is due to disintegration of the blood corpuscles depending upon the activity of the oxydizing process going on in the organism; and he adds, "but the whole subject of the production of the peculiar coloring matter in the living body is still involved in the greatest obscurity." Dr. Watson, whom Ave haA^e already quoted, reports a case from Avhich 1300 gall-stones were removed after death. Gall- stones are sometimes found in the tubuli billiferi and biliary ducts, and occasionally in the bowels. In the Memoirs of the Royal Academy of Surgery, at Paris, Vol. I, London edition, 1770, page 3, Memoir I, by M. Petit, reference is made to the case of a lady, to AArhom the author was called in consultation. She was afflicted Avith a tumor, in the region of the liver, which was regarded as an abscess by all present, except M. Petit; and accordingly it Avas proposed to open it; he declined to do so, as he did not agree Avith his compeers, but rather regarded the tumefaction due to accumu- lated bile in the gall-bladder. One of the consulting surgeons changed his opinion, and agreed AATith the author; the balance followed their own Avay and operated. The tumor was opened Avithout him; and he states he never knew how it Avas opened, or the quality of the matter it discharged; but only learned by public report that the wound remained fistulous. Seven or eight months afterwards, the patient consulted M. Petit for the cure of her fistulous opening; Avhich discharged a yellowish liquid; and to ascertain its nature he tasted it and found it to be pure bile. She then passed into other hands; the fistula Avas then dilated and a gall-stone, or calculus, Avas extracted, such as often form in the gall-bladder. On another occasion, prior to this, the author Avas about to proceed to open a tumor, in the region of the liver, and of so large a size as to closely resemble an encysted dropsy. Tapping was accord- ingly performed, but instead of serum it discharged tAvo pints of A'ery green and glutinous bile. Another case Avas also mis- taken and operated on a few days later, and with a like result. Both cases proved fatal. In a third case that occurred to the au- 30 BILIARY CALCULI. thor, he was about to make an operation, and went so far as to in- cise the integument, when the thought of bilious matter entering his mind, he decided to go no further, closed up the wound, and let it unite. In the same volume, pages 25 and 26, will be found a report of another case by M. Petit, of an operation for the removal of a biliary calculus, in the case of Madam Tibergeau. He states, "The puncture of the gall-bladder being made with a grooved trocar, Ave are to let part of the bile run off, and whilst the rest is running out, introduce into the canula#of the trocar a button probe of a due length, and so pliable as to yield to all the in- flexions necessary to make an exact search in every part of the gall-bladder. Then, if we perceive any stone, we are to Avith- draw the probe, and without taking out the canula of the tro- car, slip a sharp bistoury into -its groove, and make as large an incision, as we think proper, to open at once the teguments of the gall-bladder Avhich adheres to them. Then we are to in- troduce the forefinger of the left hand into the cavity of the bladder, in order to feel for the stones; and aftenvards by the assistance of the finger, and a pair of forceps proper for this oper- ation, we lay hold of the stones Avith the instrument, and ex- tract them; after which we make a fresh search with the probe, and, if Ave find any more stones, extract them as the others, and Avhen Ave are very sure there are no more, the patient is to be dressed, as we shall hereafter direct on other occasions." He describes the case then of Madame Tibergeau, who was operated upon, as follows: "In reality this lady had a tension of bile in the gall-bladder, Avhich was opened on the supposition of its being an abscess, and the wound did not reunite but remained fistulous. Some months after, the patient desirous of having her fistula cured, submitted to the operation proposed to her, and accordingly there was found at the bottom of the fistula, that is, in the gall- bladder, a stone as large as a pigeon's egg, which was extracted." Nothing further is stated by M. Petit as to Avhether the case was a success or not. It is to be presumed, however, that it was, as he strongly advocates this method of extracting biliary calculi, when thoroughly diagnosed as such. BILIARY CALCULI. 31 The same author reports a case in his own field of practice, of a man forty-five years of age, who had "some fits of a fever and a cold." The patient came to him presenting the folloAving symptoms, Avhich give a striking feature in aiding the diagno- sis of the catarrhal form of such cases. Patient was emaciated; had a dry, frequent, short cough; had a good appetite, and slept well; digestion, however, was bad; was suddenly seized with a general extravasation of bile. Examination of the liver revealed no great amount of hardness, and patient felt no pain in it; there Avas some sAvelling in the hypochondriac region, bey on* 1 the mid- dle of the epigastric region; urine was copious, but turbid and red; his stools were whitish, resembling clay; a second swell- ing Avas noticed like a round, hard tumor, situated above the one already mentioned, and quite prominent above the surface of the abdomen. Patient lost his appetite and taste as the dis- ease advanced; he gradually grew weaker, and died. Autopsy revealed a tumor, formed of the gall-bladder, extending along the hypochondriac region, to the centre of the epigastric region, having the form of a large cucumber, its upper part adhering to the peritoneum, and the right side pressing the liver against the false ribs and pressing upwards the diaphragm; likewise the stomach, ileum and colon were pressed upon. The tumor proved to be the gall-bladder extremely dilated. It contained, upon opening it, five pints of a limpid but viscid and bitter liquid; beside, there were sixty gall-stones removed; these Avere of A7arious sizes, proportions not mentioned. This case appears to have been primarily from catarrh of the excretory structures of the liATer. Another case, from the same author's pen, and still more re- markable than any yet reported, is that of a lady about sixty- five years of age, avIio for several years was subject to "hepatic colics" and "hypochondriacal vapors." A tumor appeared on the right side of the abdomen of a "scirrhus" nature. This growth became enlarged to such extent, as to cover the side, from the floating or false ribs downward to the crest of the ileum. At this time the patient was not afflicted with her colic, or any other symptoms, Avhich would indicate any obstruction of the " biliary strumers" (ducts). She allowed her case to be 32 BILIARY CALCULI. neglected, until she became subject to "violent fits of the colic," which were accompanied Avith nausea, fever and restlessness. She now sought advice, and it appears that for a period of three years the patient underwent a course of heroic treatment, after which the tumor in the side became painful. The tumor Avas poulticed for two months; when it opened spontaneously, dis- charging for some months, following; which diminished this scirrhus tumor by dissolving it. Fistulous openings resulted; which closed and opened alternately, Avithout any marked symptoms, except slight pains in the part,and seat of the tumor. At a later period, the patient was again attacked with violent pains, followed by the re-opening of the old fistula; from which suddenly there flowed a large quantity of fluid, that presented the consistency and color and taste of bile. During twelve days succeeding, there escaped from this opening about two pints; after this period the flow of bile ceased; the opening also closed. For a third time, and at a still later period, a fistulous open- ing occurred; from Avhich alternately flowed a serous bile and fluid-like discharge. The symptoms of pain, nausea, restless- ness, etc., seemed to be present or absent, according as to whether the aperture, or fistula, was closed or open. Under the exhaust- ing effects, and by frequent and recurring attacks, as described, the patient became afflicted with a complication of phthisis, which terminated fatally. Autopsy being made, the gall-bladder was found adherent to the surrounding structures, viz., peritoneum, duodenum, stom- ach, etc. A probe passed through the main sinus entered up into what had been the gall-bladder, and, in its route, passed through a tube-like structure, of very dense nature, an inch and a half long, and communicated with the gall-bladder within. A diverging sinus from this, was also found leading to A\diat ap- peared to be an old abscess formation, in the same vicinity, but located in the muscles, viz., internal and external oblique mus- cles. The gall-bladder seemed to have lost its identity and form. There were also found some offshoots of other elonga- tions or sinuses; in three of which, gall-stones Avere found, one in each, embedded there. The location of these calculi Avas as BILIARY CALCULI. 33 follows: one at the side of the sinus that led into what had been the gall-bladder; the second one, near the outlet of the cystic duct; the third at a point midway between the two, and under the jejunum, to which the gall-bladder Avas firmly ad- herent. The parts about this region were so co-mingled, as to form an almost undistinguishable mass of disintegrated organs. We will here take occasion to propound the question that has revolved in our mind: Avhy cannot biliary calculi be satis- factorily diagnosed and located, then be removed through an incision made into the gall-bladder, same as in operation by lithotomy in urinary calculi of the bladder or kidney, and without necessarily causing a fatal issue ? It occurs to us that some American surgeon, Avhen an oppor- tunity offers, may inaugurate this operation, Avithout Avaiting for some European adept to set the example. In the Medical Perord, Vol. XVII, No. 9, page 238, N. Y., February 28th, 1880, an account is given of the presentation by Dr. Putnam Jacobi, before the N. Y. Pathological Society, of the gall-bladder and bile ducts from a patient, Avho during life had suffered at intervals from severe colic in the right hypochondrium. The first attack followed a painful confine- ment Avith twins. The paroxysm Avas preceded by a severe purgation, occasioned by the use of podophyllin, from the effects of Avhich the patient fainted. This first paroxysm lasted almost three days; was folloAved by great soreness in the hypochondrium, persisting for a Aveek. At this time the patient Avas seen by Dr. Sands, Avho naturally suspected biliary colic, but declined to give an opinion in the absence of jaun- dice, vomiting, etc., and the non-appearance of gall-stones in the faecal passages. An interval of freedom from pain for two and a half years folloAved. She then had a second attack, con- sequent upon great fatigue; a third about tAvo months later, which came on during dinner. She complained of intense pain upon pressure over the region of the gall-bladder; no apparent enlargement in the right hypochondriac region. The patient always referred her pains to the right half of the epigastrium, and described them as agonizing; the paroxysms lasting from one-half to tAvo hours; scarcely relieved by ano- 2 34 BILIARY CALCULI. dynes, not even much by chloroform. On one occasion, after the inhalation of chloroform, vomiting took place, and was followed by relief from pain; from which circumstance the doctor advised the use of an emetic, viz., sulphate of zinc, when- ever the attacks recurred, which was always followed by relief. During the latter years of the patient's life, these paroxysms returned at irregular intervals, generally of two or three months; but occasionally they happened twice in one month; usually occurred after a few hours of great fatigue, or of moral depression. In the later attacks, the entire epigastric region was involved. Post-mortem revealed the following conditions. The gall-bladder was found enlarged, adherent throughout to its fossa, not projecting beyond the free border of the liver, its mucus coat thickened, and in a chronic state of inflammation; its cavity was filled with mucus, and impacted gall-stones, nearly all the size of a cherry stone. One, however, was as large as a walnut, and lay just over the cystic duct, temporarily occluding it. None of the hepatic, or common ducts, were ab- normally enlarged. The pyloric extremity of the stomach was in a state of extreme hyperaemia, and the mucous membrane, lining the part, appeared as if abraded. There was no evidence of any gastric ulcers; and the mucous membrane of the stom- ach presented generally a pale color. Remarks.—The relief afforded by the emetic would have been due, on the one hand, to the evacuation of the contents of the irritated stomach; on the other hand, to the forcing back into the gall-bladder the presenting calculus. Since there is—nor- mally—a close concert of action between the pyloric valve and the gall-bladder,—the bile commencing to flow from its reservoir simultaneously with the dilatation of the pyloric valve (which permits of the escape of the chyme),—the question may be here asked, whether the chronic hyperaemia, found in the pylorus, was not the expression of a reflex irritation, taking its origin from the mechanical irritation, induced by the contents of the gall-bladder. The nerve connections, between the filaments of the hepatic plexus, and such branches of the cardiac plexus as go to supply the pylorus, viz.: the pyloric branch of this axis, are intimately related. By regarding, therefore, the pe- BILIARY CALCULI. 35 culiar points in this special case, the correct diagnosis of any similar case could not be readily mistaken; the most noteworthy fact being the absence of three important symptoms usually present in all such attacks, viz., jaundice, vomiting and tumefac- tion in the right hypochondriac region; and it might be ad- ded, the non-appearance of any "debris" or "biliary calculi" in the ahTine eATacuations. Prof. A. R. Thomas, in his Avork on "Morbid Anatomy," re- lates a case of a man aged sixty, Avho suffered from several se- vere attacks of bilious colic, and finally died in June, 1863, from an attack of four days duration, induced, as it appeared, from exertion, Avhile working in his garden, digging with a spade. The first symptom experienced was a sensation of something giving away in his side, and this was followed by an attack of se\rere pain. Chill and feATer soon succeeded, resulting in speedy peritonitis, and death on the fourth day. Autopsy revealed intense peritonitis throughout the entire abdominal cavity; AA'hich contained nearly a quart of greenish sero-purulent fluid. Also slight plastic adhesions at various points, uniting the intestines with the abdominal walls, while old, firm, and extensiA"e adhesions were found between the same, and the liver and gall-bladder. The latter had evidently been much distended; and through an opening or rupture, the con- tents of the gall-bladder had escaped into the peritoneal caATity; leaving behind, and in situ, a single calculus, of a regular oval form, and one inch in its longest diameter. Occasionally, gall-stones are vomited from the stomach; to Avhich point they may migrate either by reversed peristaltic action, or by ulcerating their way through the intervening structures, and thus establishing a direct fistulous opening, which may become permanent. Fatal results may ensue from the inpaction of large gall-stones in the intestinal canal. In rare cases, gall-stones haA'e worked their Avay into the ureter, portal vein, and vena cava. Prof. A. R. Thomas reports two additional and recent cases of single calculus. The first, Mr. B., a resident of Philadel- phia; of Avhom he states: "I was called in consultation Avith Dr. J. G. Howard, tAvo or three times before death. The promi- 36 BILIARY CALCULI. nent symptoms were jaundice, great prostration, congested liver and gall-bladder, with little pain or tenderness; diarrhoea, with white, offensive discharges, was also present and occasioned vomiting. Post-mortem revealed an abscess between gall-bladder and abdominal Avails, in which was a large gall-stone nearly an inch in its longest diameter; common bile duct, completely closed." The second case was: " A lady of about 75, always before healthy; had, while in the country on a visit, an attack of gas- tritis, with vomiting and pain in region of stomach. Upon re- turning to the city, in September, (1878), found her much jaun- diced, with poor appetite, clay-colored stools, pain and tender- ness in region of gall-bladder. She had no paroxysms of pain, as from gall-stones. Diagnosis.—Catarrh of common bile duct, with stricture of the same. A tumor was detected in region of gall-bladder, which continued to enlarge until it reached below the umbili- cus, pear-shaped and hard; considerable ascites and anasarca; white stools and bilious urine Avas very marked. Peritonitis finally set in, of which she died April, 1879. Post-mortem showed the ductus communus closed; gall-blad- der greatly enlarged, and containing over a pint of thin, watery bile; cystic and hepatic ducts enormously distended; nearly as large as the small intestine. All the parts were adherent from inflammation." Throughout our own experience, Avhich Ave will here briefly narrate, Ave have met Avith t\venty-two severe cases (beside a number of milder ones). Five of these occurred in our own field of practice; the remainder were consultation cases, to which Ave were called at various times. From this number we will select a feAv, on account of their striking character:— Mrs. S. W., resident of Canada West, noAv Ontario, was of English birth, set. 47, dark complexion, spare habit, nervo- bilious temperament, had been an invalid for seventeen years, having had five severe attacks of bilious colic during that time, and scarcely ever free from some disturbance of the liver. The patient stated that she had contracted the habit of taking BILIARY CALCULI. 37 purgatives of various kinds since her earliest recollections ; and as a consequence chronic constipation ensued. These attacks were ahvays preceded by a deep-seated, heavy pain, folloAved Avith sAvelling in the right hypochondriac region; the former extending upAvards and under the right shoulder-blade. Severe headache, accompanied with nausea and vomiting of bile, fol- loAved, together with marked prostration. The patient's boAvels were costive ; urine scanty and high-colored. She stated that she had passed periods from fiATe to seventeen days Avithout a passage from the boAvels, excepting an occasional small frag- ment of hard stool, which was passed with considerable strain- ing. These periods were always folloAved by a bilious attack; relief from Avhich Avas obtained only after the passage of a number of biliary calculi, together Avith copious stools, induced by the free use of purgatives. These stools appeared undigested and like tar in color and consistency. There were severe cutting pains oA'er the region of the gall-bladder, later in the attack; also mumbling in the bowels. In this instance the symptoms Avere the same as in the pre- ceding attacks, for Avhich Ave prescribed Leptandrin, 3d trit, every tAvo hours, and also gave, in connection therewith, at alternate hours a tablespoonful of SAveet oil. After the sixth dose of Leptan. Avas given, the patient felt some relief; and co- incident Avith this relief, she passed a copious stool, in Avhich Avas found a biliary calculi of the color and proportions of a horse-chestnut, AATeighing 210 grs—Troy Aveight. The patient fully recovered from this attack; the remedy being continued for a period of three Aveeks, three doses daily, which overcame the constipation effectually. It Avas during the spring of 1859, that Ave were called upon to attend this case. We Avill here take occasion, to state that Ave had advised this patient, to take the remedy, Leptandrin, as a preventive to recurring attacks, as soon as any symptoms indicating such a return, Avere pres- ent. And Ave learned subsequently, some six years, that the remedy had performed its mission satisfactorily. Still later, in the fall of 1878, Ave Avere informed, through a reliable source, that the patient Avas still living, enjoying good health, and up to that time there had been no return of her former attack. BILIARY CALCULI. Tavo other cases, presenting similar symptoms, differing only in the size of the calculi, came under our care and treatment during the fall of 1867, and terminated in the same successful manner. Another case of interest Avas that of a gentleman, Capt. B. D., set. 56, American birth, light, florid complexion, sanguine, bilious temperament, full habit. He led a sedentary life, Avas given to high living, and using spiritous and malt liquors freely. Had been subject to biliousness for twenty years; and had passed through, on four previous occasions, very severe attacks of bilious colic; followed with the passage of numerous gall-stones, about the size of a pea; which, from his description, were of the inspissated or soft variety. The patient's symp- toms at the time Ave Avere called, were as folloAvs (he having suffered with threatenings of an attack for three days prior to our first visit): Severe pressure, as from incarcerated flatulence, under the short ribs on the right side. Contractive pain in the hypochondrias. Liver swollen and indurated, and very sensitive to contact. Jaundice; bowels costive; vomiting of light-green bile; urine of usual quantity, high-colored and show- ing the presence of bile. Taking into consideration the habits of the patient, together with these symptoms, Nux vom., 30th trit., was prescribed and repeated every two hours, until some relief was afforded. A favorable change set in after the twelfth dose was taken; all the symptoms abating, except the jaundice and constipation, for which condition Merc, dulc, 3d trit., was administered at two hour intervals. In the course of twelve hours, following the use of this remedy, a copious and firm stool passed; soon followed by several thin stools, in which were found three calculi, size of a hickory-nut, and still later, forty to fifty small ones, the size of a pea. The former were of a dense consistency, and of a dark mahogony color; Avhen fractured, critaceous around their exterior, and composed mainly of biliary concretions; their centres presenting a cir- cular, striated crystalline body, composed of cholesterine. The smaller ones Avere not closely examined, but their exterior ap- pearance presented the same consistency and color as the larger ones. The patient recovered from this attack sufficiently to BILIARY CALCULI. 39 regain a fair degree of health; but declined to change his habits of life. He remained under our charge for a period of six years, having occasional threatenings of his former attacks, Avhich the timely administration of Nux vom., 30th trit., ahvays averted. It is a noteworthy fact that this same patient, about one year after his recovery referred to, had a severe attack of renal colic; and three months later we extracted from his urethra at a point mid-Avay of this passage, quite a large renal calculus, the size of a coffee grain, Avhich presented a pale salmon color, and Avas of the consistency of chalk, being composed chiefly of phosphate and carbonate of lime. The patient then passed out of our hands and took a long sea-voyage to a hot latitude, contrary to our advice, in the vain search for health. While on his return, he was seized Avith a very severe attack of sea-sickness, followed with bilious colic, Avhich terminated fatally on the fifth day. Mrs. S. E. W., aged 43, American birth, dark complexion, spare habit, marked bilious temperament. The following is the history of the case as Ave obtained it direct: Had been subject to bilious attacks since her earliest recollections; aggra- vated no doubt by the abuse of cathartics and purgatives, to which she had accustomed herself. Had passed through four severe attacks of bilious colic, at irregular intervals, since her twenty-seventh year, accompanied, each time, with the passage of a considerable number of small gall-stones, varying in size from an apple-seed, to that of a small cherry. She had suffered, more or less, with a severe aching pain low down in the right hypochondriac region, extending toAvard the epigastrium. This pain migrated, and gradually changed its course and locality, descending perpendicularly, by slow stages, toward the right iliac fossa, and located there; having taken four years in making this change of base. She described a sense, accompanying the pain, as of a moving object within. At the last point mentioned, the seeming object referred to, re- mained stationary for a period of about three months, the pain continuing more or less. By the advice of her medical attend- ant, she took her usualsdoses of purgatives, which was followed by a severe catharto-emesis effect, accompanied Avith a move- 40 BILIARY' CALCULI. ment of the previously dormant object, and a return of the former severe pains. This condition continued for a period of two weeks, with scarcely an intermission of rest or relief from her pain, notwithstanding copious draughts of opium tincture were given. At this juncture the friends of the patient inter- fered, and demanded a change of treatment, and a dismissal of the attending physician, who, by the way, when asked for his opinion pronounced the case one of tape-worm, and remarked that he thought it would "pass before long." We were summoned to the bedside of the patient early in May, 1859, and found her laboring under the full effects of opium; and the air of the sick-room redolent with its odor. She was in such a deep stupor that we could not elicit any information from her; but were obliged to depend upon some of the relatives present for information regarding the former treatment, etc. We noted the following objective symptoms, viz.: the patient was extremely emaciated, the integument of the entire body was wrinkled, presenting a cadavaric, yellow, jaundiced hue. There was icterus of both conjunctiva, and contraction of the pupils, which were very sluggish under the stimulus of a bright sun- light. Breathing sonorous and measured; lips and tongue dry; patient uttered occasionally faint groans, as if in pain; pulse 110, rapid and small; temperature 103; abdominal walls collapsed. By making gentle manipulation over the right iliac and upper portion of the hypogastric regions, viz., along the as- cending and transverse colon, as far as the umbilicus, a tume- faction was discovered located at this point, about the size of a goose egg, its longest diameter being in a transverse direction. To the sense of feeling the mass was partially movable, and the patient experienced pain when attempts were made in this di- rection. Not knowing the history of the case up to this time, Ave now gathered the antecedents, (the particulars of which have already been given) and thereupon we made our diagno- sis, pronouncing it a case of obstruction of the colon, from the presence of a large biliary calculus. To overcome the ill- effects of the drugging which the patient had undergone, we administered Nux vom., 30th trit., prepared in AArater and given in teaspoonful doses, repeated every half hour, until six doses BILIARY CALCULI. 41 were taken, which were SAvallowed with difficulty. The remedy, however, accomplished the desired effect in good time. Learn- ing from a member of the family that the patient's bowels had been thoroughly evacuated of foecal matter, forth Avith we set to work to remove the obstruction, whatever it might be. A flexible stomach tube, Avell oiled, was introduced high up into the bowel until it met the obstruction; then by means of a stomach pump, an enema mixture, composed of heated lard and a Avine glass full of brandy to the pint, was thrown slowly up into the bowel until it Avas moderately distended, when the obstacle seemed to move sloAvly toward the descending portion of the colon. It then disappeared and could not be felt, and the patient experi- enced considerable relief from her pains, but still felt the pres- ence of something lodging deep down in the left iliac fossa. The patient at this time appeared very much exhausted, as her stomach being so irritable, could not contain anything except- ing a little cool water, which she desired to have frequently, but took only a sip at a time, though with avidity. Regarding Arsen. alb. the appropriate remedy for this condition, the 30th trit. Avas given every two hours in water, and an enema of four ounces of beef-tea, with half an ounce of pure brandy added, Avas gently passed up into the rectum, which was re- tained. After the third dose of the remedy had been taken, the patient passed into a quiet sleep; (this was at 6 p.m.) and re- mained so throughout the night, waking only three times to ask for water. To abbreviate our remarks in regard to the further treatment of the case, we will simply state that the patient regained her strength steadily, under the action of the last named remedy, given at longer intervals as she progressed toAvard recovery, together with three nourishing enemas, of four ounces each, per diem, throAvn well up into the boAvel; Avhich treatment Avas continued for a period of one week. She still complained of a dull, heavy, aching pain, however, which she located deep doAVn in the left iliac fossa, accompanied with a constant desire to pass stool, aggravated by sitting up, and es- pecially AAdien attempting to make stool, Avhich she had not accomplished for a Aveek past; otherAvise she continued to im- prove, and Avas then able to take nourishment via the stomach. 42 BILIARY CALCULI. Feeling convinced in our OAvn mind, that there was some- thing to come away, and that it Avas lodged in the sigmoid flexure of the descending portion of the colon, Ave proceeded to repeat the enemas of heated lard, minus the spts vini gal. Upon passing the tube up into the rectum, urging it on through the sigmoid flexure, Ave encountered an obstruction, firmly im- pacted at its uppermost portion. The pump Avas applied and the enema gradually thrown up. Two ounces were retained and the balance, some six ounces, Avere rejected; which result confirmed our opinion. Six other similar treatments Avere given at intervals of from two to three days apart, when at the close of the seventeenth day of our services, the patient passed a very large biliary cal- culus, folloAved by a copious stool and accompanied with ex- tremely severe pains, Avhich the patient termed "agonizing." The weight of the calculus was 510 grs.—Troy; its outward appearance Avas ovoid and egg-shaped, convex at the larger, and abruptly flattened off at the smaller end. Was covered over, on its outer surface, with a thick coating of inspissated mucus, so dense that it could not be readily removed Avith water. On making a transverse section through the centre of the mass, the greater portion of it was found to be composed of a dark broAvnish-yellow substance, of a semi-concrete nature, about the consistency of burnt lime; its chemical constituents were mainly of condensed biliary concretions, which Wagner terms "bilirubin," mingled with carbonate and phosphate of lime, biliary acids and margarin. Its nucleus or centre was much of the same shape, only con- vex at both ends, and Avas composed of pure cholesterin about the size of an almond. The patient exhibited excessive las- situde and languor, Avhich Avas aggravated by the efforts she made to pass the calculus; after which she fainted, and Avas restored with considerable difficulty by means of stimulants, and spts ammonia applied to the nostrils. Excessive debility followed, accompanied with cold sweat. For this condition we gave China off., 30th trit., and repeated every two hours, ordering a concentrated fluid diet to be given in small quanti- ties, as often as the stomach would bear it. BILIARY CALCULI. 43 Gradual recovery ensued from the action of the last-named remedy, and in the course of tAvo Aveeks she Avas able to leave her bed. We subsequently advised a course of treatment Avith China off., as a preventive to the recurrence of any further attacks, according to the recommendation of Dr. David Thayer; and when Ave last heard of the case, Avhich Avas in November, 1878, the patient had not been afflicted Avith any further severe attacks since the one we have reported, which occurred in the month of June, 1869. We Avill close the report of our oavii cases by stating that, in commendation of the remedy China, Ave desire to add our testi- mony to its efficacy as a specific and a preventive against re- curring attacks in that class of cases referred to by Dr. Thayer— having treated successfully, Avith this remedy, fifteen such cases. A case of biliary calculi of great interest, is reported by Dr. L. Hoopes, of Downingtown, Pa., in "The U. S. Med. Investigator," Chicago, June 15th, 1879, p. 527, Avhich terminated fatally. The patient, prior to her death, had passed through seAreral severe attacks of congestion of the liver, but in none of them had biliary calculi been suspected. Post-mortem examination, six hours after death, revealed the liArer much enlarged, weight six pounds. Upon opening the gall-bladder, Avhich was also much enlarged, it Avas "found to contain four hundred and eighteen calculi, ranging in size, from a grain of white mustard seed, to tAATo and three-quarter inches in circumference, and three-quarters of an inch in diameter. Dr. Hoopes reports, "these calculi appear to be composed chiefly of cholesterin, though I have not yet had them examined under the micro- scope. The lining membrane of the gall-bladder was highly inflamed, and the cystic duct completely occluded by adhesive inflammation." " The kidneys Avere somewhat congested and enlarged. The ovaries were considerably atrophied." There are several points of marked importance, embraced in the history of this case, that will serve as a Avarning, as Avell as a guide, to the careful reader and decerning practitioner. In one particular it is similar to the preceding one, reported by Dr. Jacobi, viz.: in the absence of the usual train of symptoms 44 BILIARY CALCULI. present in attacks of bilious colic; as may be noted by the fol- lowing indications reported by attending physicians, Drs. Hoopes and Pratt. "Region of the liver swollen, heavy and sensi- tive to contact; constant desire to take a full breath; constant nausea, as if she would vomit; pain in left side of back, lumbar region; throat sore on left side. Feels constantly too full, and would like to belch, but cannot; Avorse after eating. Arery Aveak and considerably emaciated; no appetite; remittent fever; rheuma- tism of left thigh, which Avas SAVollen to double its natural size, and also in the articulations of the jaws, so that she could not open them more than a quarter of an inch; liver very much con- gested; could not sleep on account of rheumatic pains; very nervous and despondent." We have purposely italicised the symptoms that might properly be termed biliary; but they are too limited in this instance upon which to base a definite diag- nosis; especially when accompanied with other and compli- cated ones, foreign to the diseased condition. Another point that militated against the nature of the disease, having been one of biliary calculi, was the age of the patient, only 26 years; as it is very rare to meet with a case in one so young, where calculi have been found of such proportions, character and number. This is the only case of the kind on record, as far as our knowledge extends. There is still another and important point to be considered, of which no mention is made, viz.: a thorough examination of the patient's alvine evacuations, at the time of any of her attacks. The question propounds itself to our mind, that if this had been done at the time of and after one of her earlier attacks, and before the occlusion of the cystic duct occurred, might there not have been found evidence in the stool, that would warrant a correct diagnosis? This being a valuable and accurate objective symptom, and a never failing one. Great credit is due to Dr. David Thayer, whom we have already quoted on this subject, who so succinctly describes the peculiar character of the stools, in many cases that he treated successfully; which would have been doubtful had he not re- cognized the presence of biliary concretions. He describes them as of a scybilae-like nature, and of a yellowish, bilious hue; somewhat of the consistency of a firm fcecal evacuation BILIARY' CALCULI. 45 and massed up together; compressed into various shapes and forms, Avhich by an optical examination alone might be readily mistaken for a portion of impacted alvine secretion; but by separating one of these irregularly shaped bodies from the mass, and compressing it betAveen the fingers, a sense of feeling may be noted as of a concrete substance. By dissolving them in oil, the residue will be found to be condensed or inspissated biliary secretions. These bodies Avhen imprisoned for a length of time in the gall-bladder, or any of the hepatic and biliary ducts become incysted, and gradually take on a calcarious for- mation, by the crystalizing process. After Avhich condition the usual course they take—when cystic occlusion is present— is by inflammatory action to suppurate their way through the Avails of the gall-bladder, or any other structure of the liver in Avhich they locate and form; and then dropping into the peri- toneal cavity, by their presence exciting mechanical irritation, followed first by circumscribed peritonitis, then abscess septi- caemia and death; as in the two cases heretofore noted, reported by Prof. A. R. Thomas. It strikes us that had the case in point been more clearly de- fined in its symptoms, and no occlusion of the cystic ducts present, it Avould have offered a fine opportunity for removal, by oj)eration with the surgeon's knife. Addenda. It will be remembered that Ave have already referred to efforts made in the direction of smrgical interference by M. Petit, nearly a century and a quarter ago; but Ave have only presumptive evidence that one operation, at the most, proved successful. Our attention has been attracted recently to a brief article on this point, vide Horn. Times, May, 1880, Vol. 8, No. 2, page 48, under the heading of " Treatment of Hepatic Calculi" which reads as folloAvs: "Dr. T. H. Buckler, N. Y. Medical Journal, in referring to Dr. T. J. Thomas' enumeration of the operation of cutting into the gall-bladder, as one of the recent surgical triumphs, asserts that such procedure is umvarrantable. Cholesteric gall-stones can always be dissolved away by large 46 BILIARY CALCULI. doses of chloroform, especially if combined Avith succinate of iron. The latter agent also may alone accomplish the desired solution and effect a cure. In Dr. B's last three cases, treated successfully, he gave ten drops of chloroform every four hours, and a teaspoonful of SteAvard's hydrated succinate of the per- oxide of iron, half an hour after each meal. He has some- times given a teaspoonful of chloroform every six hours, with- out causing any bad symptoms, and Avith the result of a cure within a Aveek. The succinate of iron contains, according to Dr. Buckler, more nascent appropriate oxygen than any other known therapeutic agent, and is one of the best ferruginous preparations, apart from its solvent powers on gall-stones. It is better than nitric acid in affections of the liver. Chloroform, we are told, on being swallowed, passes into the acini of the liver, then into the bile of the gall-bladder, Avhere it dissolves the gall-stone with the inexorable certainty of mathematics. Dr. Buckler's experience with ether, and Avith the various mineral waters has led him to consider them of no value in this trouble." We Avould here suggest the interrogation, and Avithout any desire on our part to cast doubt on Dr. Buckler's assertion, Ave would like to knoAV hoAv he proposes to diagnose a cholesterin calculus from any other variety, unless there is evidence of such, accompanying the stools passed by the patient; and if so, what warrant can he give us that he has accomplished the process of solution of a cholesterin calculus while in situ, in any of the ducts of the liver, the gall-bladder and its ducts, or while in its passage through the intestinal canal. Again, hoAv does he propose to dispose of the other varieties of bilious cal- culi, by any process of solution with medicinal agents adminis- tered to the patient? We are fully aware that there are many chemical agents that possess the power of dissolving any, or all of the many forms of biliary, renal and cystic calculi, Avhen immersed in a solution of these agents, and after a given time; but Ave have yet to learn that a process like this can be con- ducted with safety to the patient, or to the organ involved. Until Ave have further, and more positive evidence than this statement of Dr. Buckler, we cannot accept his theory, but will BILIARY CALCULI. 47 suspend our judgment until then. We have heard of remedial solvent agents before, which have been recommended, and pro- nounced infalable curatives for renal and cystic calculi, as well as gouty concretions of the joints, but they have all passed away Avith other unscientific discoveries. In the meantime Ave rejoice to learn that Dr. T. J. Thomas has been successful in relieving his patients of biliary calculi by the skillful use of the knife, and that he justly deserves the credit of having con- tributed one more triumph to the science of modern surgery. As far as our knowledge goes, he is the first and only Ameri- can surgeon Avho has accomplished a successful issue in this direction. Therapeutics. The following remedies will be found efficacious in the treat- ment of biliary colic, when given according to the indications noted after each one. Aconite.—Inclination to vomit after eating anything sweet or fat, vomiting with nausea and thirst, general heat. Vomiting of blood, with or without mucus, or of green bile. Compression of the naA'el, Avith spasmodic pressure at intervals. Inflammation of the peritoneum. Drawing pains in the abdomen. Paroxysms of anguish, fear of death. Arsenicum album.—In violent cases, patient lies as if uncon- cious, countenance expressive of death, and is very pale, covered with sweat of anguish, in a state of marked apathy. Syncope, only in- terrupted by occasional and fruitless efforts to vomit. At a later period, Avhen the attack sets in Avith severe and increasing cardialgia, and colicky pains of the most severe and terrible kind, Avith much burning in the parts affected. Frequent vomit- ing, excessive weakness and prostration, constipation and the countenance betokens extreme distress with cold sweat. Chamomilla.—Best indicated in a case excited by chagrin, especially if at meal, and patient is of a choleric temperament; said attacks will invariably occur or set in, when these causes 48 BILIARY CALCULI. are present. Painful pressure in the pit of the stomach, and hy- pochondria, especially after eating; Avith regurgitation of injesta, followed by bitter or bilious vomiting; with restlessness, toss- ing about and violent headache, as if head AA'ould burst. Re- peat frequently. Colocynthus.—When attack is caused by internal gnawing and humiliation, or some severe and undeserved treatment, with bilious vomiting and painful pressure in the region of the stomach. Drawing, searching, digging pains, aggravated by expiration, or laughing. Pressure and flying pains in the hepatic region. Constrictive feeling in upper part of abdomen. Cutting pains in abdomen, with chilliness and lacerating feelings in loAver limbs, from hips down. At each accession of pain, agita- tion all over the body. Griping in the abdomen, especially about the umbilicus and up toward the liver, like a cutting or squeezing, relieved by bending forward or on evacuating the bowels. Stabbing pain, running to- ward the pubes. Viscid, scant stools. Pap-like or doughy stools. Bryonia alba.—Tension, burning or stinging in the region of the liver, particularly when touched, or coughing or taking full breath. Drawing in liver, extending to stomach and back. Hepatitis. Intolerance of least pressure, at pit of the stomach. Chronic constipation, hard, tough stool with protrusion of the rectum, or dry stool as if burnt. Hard swelling in hypochondrium, and at umbilicus. China off.—Pain in region of liver, as from ulceration when touched. Swelling of the liver. Infarctions of the liver. Violent colic. Pinching in the abdomen, obliging patient to bend double. Lassitude and languor, mental and physical. Excessive debility, with marked disposition to sweat, during sleep and motion. Yellow color of skin, jaundice. Excessive prostration, from loss of fluids. Dr. David Thayer, an eminent authority of the homoeopathic school, pronounces this remedy as the specific for this class of periodical colics, and reports many successful results, from all BILIARY CALCULI. 49 parts of the country, the patients having resided in and been sub- jected to the various climatic influences of the whole Qnited States. He designates the class of cases, especially calling for the use of this remedy as follows: " All the symptoms which arise from obstructions in the gall- bladder; the colic; the periodicity of its recurrence, (though the periods of its return are often very unequal and irregular,) also the yellowness of the skin and of the conjunctiva; the constipated state of the bowels; the scybalated character of the dark, greenish stools, the scybala A'arying in size from that of the largest nutmeg to that of sheep dung, and even smaller than the smallest peas." He also adds, that he distinguishes this form of colic from other varieties as follows: " I require my patients to lie flat on the back, with the legs extended. I then request them to tell me if I hurt them, A\rhile I make equal pressure, with the end of the finger on all parts of the abdomen; avoiding the exact location of the gall-bladder till my last pressure, when, if it is a case of gall-stone colic, they will cry out." "While this experiment will generally satisfy me, as to Avhether I have a case of biliary obstruction, or not, yet I do not pronounce it a case of gall-stone till I am con- firmed in the opinion by the corroborative indications above given." "In many of the cases of periodical colic, yclept bilious, gall-stone, etc., no calculi, properly so called, are found in the excrement, search for them as diligently as one may; the reason of Avhich may be found in the above mentioned small, hard, roundish and greenish-black scybala, which are passed with the dejection after the subsidence of the colic. Under the action of an aperient (3 or 4 I of olive oil, or even more if re- quired), the discharge of large quantities of these greenish- black ovales may be facilitated; greatly to the relief of the sufferings of the patient." Digitalis purp.—Most violent colic continually. Pinching or lacerating in abdomen. Lancination from pit of stomach to both sides and back, extending up the oesophagus. Tightness and 4 50 BILIARY CALCULI. constriction about the hypochondria. Sensitive, and sense of pressure, in the liver. Cutting in the abdomen Avith tenesmus. Shooting and prickings in whole abdomen. Jaundice. Cuprum acet.—Eructations tasting of copper. Constant nausea. Frequent violent vomiting. Frightful colic and convul- sions. Distended abdomen, painful to touch or violent spasmodic pains in the abdomen. Violent abdominal colic. Enteritis. Pressure aggravates the pains very much. Conium mac.—Aching in the liver, when walking. Painful lacerating in the region of the liver. Sharp drawing in the ante- rior part of the liver. Most violent colic. Swelling of the abdomen. Violent lancinations in the abdomen, daily, espe- cially on right side. Frequent urging with stool. Tremulous weakness after every stool. Lancinations in the abdomen, as if knives were being driven in. Violent emissions of flatulence. Cocculus.—Inflammation of liver and diaphragm. Com- pressive pinching in epigastrium, arresting the breathing. Lacerat- ing in the intestines. Violent spasm of the stomach, griping, lacerating sensation in stomach. Pain in the hypochondrium, as if bruised. Veratrum alb.—Distention of abdomen with ptyalism. Vio- lent pressure in pit of the stomach. Vomiting of injesta and green mucus. Vomiting of bile and mucus, then of black bile, and finally blood. Colic, from back toward umbilicus. Colic, after a cold. Sudden, pinching, colic, early in the morning. Marked prostration and debility of the whole body. Podophyllum.—Jaundiced hue of skin, or more of a bronze color; tongue coated white, continuous headache. Pulse quick, hard, and full, but small; urine very scant and dark colored; urine contains bile. Constipation and diarrhoea alternated. Pain in epigastrium, extending to right side. No trace of bile in stools, nor vomiting of bile. Patient grows stupid towards evening. Severe chill and fainting. White clay-like stools. BILIARY CALCULI. 51 Arnica montana.—Empty eructations, early in the morning. Eructations tasting of rotten eggs. Vomiting of coagulated blood. Stitches under the false ribs, arresting the breathing, when stand- ing. Cutting pain above the umbilicus, especially when taking deep breath, and at every step. Colic resembling dysentery. Pressure in the region of the liver, Avith pressure as of a stone, both during expiration and inspiration. Sharp thrusts through the abdomen, from one side to the other. Burning, stinging pains, in the epigastric region. Fermenting in the abdomen. Sore pain in the abdomen, when coughing or touching it. Frequent small stools consisting of slime. Calcarea carbonica.—Vomiting of sour water at night. Anguish in the pit of the stomach. Tension in the hypo- chondria. Sense of constriction below the hypochondria, Avith trembling and throbbing in the region of the stomach. Tension and pressure, in the region of the liver, as if the parts were very much enlarged, even unto bursting. Stitches in the liver dur- ing or after stooping. Frequent severe spasms in the intestinal canal, especially in the evening and at night, with coldness of the thighs. Writhing, cutting pain throughout the abdomen. Twisting sensation in the bowels. Pressure in the abdomen, with stitches in the pit of the stomach, from above downAvards. Enlargement and hardness of the entire abdomen. Pain, as of rawness in the liver. Lancinations in the right side, below the ribs. Laurocerasus.—Sticking pains in the liver, with pressure. Pinching pains extending from the hypochondria to the um- bilicus. Beating and throbbing in the liver, as from an abscess. Lame, bruised pain, from the liver to the shoulder, at every inspiration. Distension of the region of the liver, with pain, as from subcutaneous ulceration, or, as if an abscess would break. Inflammation, with induration of the liver. Cutting pains in the entire abdomen. Burning in the abdomen. Leptandrin.—Dull, aching pain, in the region of the gall- bladder ; also throughout the entire right hypochondriac region, 52 BILIARY CALCULI. extending to the umbilicus, with much rumbling in the bowels. Cutting pains in the locality of gall-bladder. Profuse black, undi- gested stools, looking like tar, in color and consistency. Burning and distress, in the back portion of the liA'er. Dull aching, burning and distress in the region of the gall-bladder, Avith frequent chilly feelings along the spine. Pain of a hot, aching character, or sharp, cutting pains, in region of gall-bladder. We will here take occasion to add, that we have had very decided, and prompt results follow the administration of this remedy in three cases, in which the foregoing symptoms italicised were present. Nux vomica.—Pressure, as from incarcerated flatulence, under the short ribs, on the right side. Contractive pain in the hypochon- dria. Tensive pain in the region of the liver, as if there were an abscess present. Stitches in the region of the liver, aggravated by contact and motion. Swelling and induration of the liver. Jaundice, aversion to food, with fainting spells. The region of the liver is very sensitive to contact; will not admit of lying on it. Hepatitis, either acute or chronic. Merc. dulc.—This remedy is an excellent one; especially if used as a preventive, in the threatenings which precede attacks of bilious colic. The following symptoms are usually present: throbbing headache, with giddiness; ringing in the ears; dry, bitter, pasty, metallic taste (and odor) of the mouth and throat. Dryness of the nostrils; jaundiced hue of the conjunctiva of the eyes; with deep-seated pains in the orbits, and heaviness of the eyelids. Patient complains of a dull, heavy, stupid feel- ing; inclining to sleep all the time, and awakes unrefreshed, at any time, with sluggishness of memory; which feelings dis- qualify him—mentally and physically—from attending to any business. There is intense throbbing in the carotids, accom- panied with palpitation of the heart, excited by moderate ex- ertion. Pulse full and bounding, not easily compressed; skin hot and dry, and yet the patient complains of chills through the back. Deep-seated, dull, heavy, aching fullness over the entire right hypochondriac region; extending up under the right scapula, relieved by pressure with the flat of both hands BILIARY CALCULI. 53 over the first named region; except at a point corresponding to the region of the gall-bladder, where a pain is felt on pressure. Pain and weight in the epigastrium, extending into the right hypochondrium. Vomiting of ingesta, mixed with yellowish- green bile, and quantities of bile when the stomach is empty of food. Urinary secretions scant, and of a deep, yellowish color. Stools costive and dry, and of a pale yellowish color. As a palliative measure, we suggest resorting to injections of warm sweet-oil high up into the bowels; likewise rubbed in Avhile hot to the hypochondria. If too sensitive, apply by means of hot flannel compress, sufficiently large to cover the parts involved; and reneAv frequently; also give the oil in- ternally, in as liberal quantities as the stomach will bear, and repeat frequently. PERINEORRHAPHY: its past and present history, WITH REPORT OF CLINICAL CASES. [Read before the Wisconsin State Homoeopathic Medical Society, held at Milwaukee, June 13th and 14th, 1878.] PERINEORRHAPHY The term, Perineorrhaphy, or Perineorrhaphia, is derived from the Greek -r^v, perineum; and pavy, suture. Literally trans- lated, means suture of the perineum, and is used in cases of laceration of the perineum. When Ave take into consideration the measurement of the female perineum, which is one to one and a half inches at its base, its shape being triangular when in its normal condition, and yet, during the last act of parturi- tion, is extended to four and a half, perhaps six inches, which, of course, greatly attenuates it, is it surprising, then, that a separation of its continuity should occur frequently ? Many of the cases, no doubt, are the result of ignorance, or a Avant of proper care on the part of the accoucheur and the midwife; the last-named being too often employed through mistaken econ- omy. There are occasions, hoAvever, Avhen this acciderft may occur in the hands of the most competent and expert practi- tioners. The consequences and evils that often ensue, are so com- plicated and distressing, as well as mortifying to the patient, as to exclude her from the companionship of friends, and render her offensiA'e, not only to herself, but likeAvise to every one near and dear to her, and seriously to undermine her health and strength. There is probably no one misfortune in the Avay of accident, that can befall a mother, and produce more misery and distress, than the condition which we are about to consider. Until a comparatively recent period, these cases Avere beyond the pale, or reach, of surgery. It is most frequently the result of parturition; rarely it has happened as a result of external violence, as falling astride of a chair; a kick, or a fall from a 58 PERINEORRHAPHY. height; the perineum coming in violent contact with some projecting object, as instanced in case XL In one or two in- stances it has been caused by the horn of an enraged deer. In several cases from the horn of an enraged cow. Partial lacerations are quite frequent, and, I doubt not, even extensive ones exist to a degree not generally suspected. From feelings and motives of delicacy, timidity, or hopelessness of cure, the sufferers prefer to carefully conceal their condition, and bear in silence the numerous evils thus entailed. It may be truly asserted, that the successful management and cure of these accidents, constitutes one of the most brilliant and important triumphs of either ancient or modern surgery. It may be added—and without fear of successful contradiction —that in no department of science or art, has the onward march to success been more rapid and wonderful than in the field of operative surgery. Is there a true physician, imbued with the proper spirit of his professional calling, that can fail to be deeply interested in tracing the onward progress and glorious solution of any of the great medical or surgical prob- lems of the day and times, through all the various stages; from the pre-supposed idea to the experiment, and finally, to the es- tablished fact ? The more closely we scrutinize these studies, in the same ratio will our faith be increased and established in this noble calling; and surgical dogmatism moderated. One possessed of a sound surgical turn of mind is, and should be, exceedingly cautious not to assert impossibilities; and the experience of the past quarter of a century, proves most signi- ficantly this observation. We will now proceed to consider, first, the HISTORY OF PERINEORRHAPHY. Lacerations of the perineum Avere recognized and noted by the ancients, possibly prior to, or at least from the time of Celsus. The only known means of cure then was that of secur- ing the limbs together, with perfect rest, and which is termed the expectant treatment. Ambrose Pare, who was cotempora- neous with, and followed Celsus, first recommended the suture; PERINEORRHAPHY. 59 likewise did Mauriceau; but we are not possessed of any evi- dence to prove conclusively, that either of these gentlemen had ever practically employed them. The first operation ever made, and on record, is that of Guillemeua, noted in his work on "Surgery," page 354, chapter viii, and published early in the seventeenth century, over two hundred years ago. He states, "the rent in this instance occurred in a former la- bor, and was of a severe and aggravated nature, involving the sphincter and entire perineum; thus both passages Avere as one." This case, then, according to tradition, must have in- spired all future operators. The operation, as he performed it, consisted in paring the torn edges alike, not cutting much of the deeper structures, as is now done in similar cases, but sim- ply integument and fascia. A needle was then passed through the margins of the freshened parts, and a thread wrapped snugly over the projecting ends, and by this means the parts Avere drawn and kept in apposition. This form may be termed the hare lip suture. After this he introduced several inter- rupted and more superficial sutures, all of which were allowed to remain for a period of fifteen days, when the case was pro- nounced a cure. Guillemeau being a pupil of Pare's, it is probable he received from his tutor, or master, the hints which he reduced to prac- tice in this case. The writings of Busch and Moser contains a valuable and excellent chapter, embracing the methods and plans of various authors and operators. Many distinguished names are found among those, who advocate position alone, and it is asserted by them, that complete rupture—and this includes the recto-vaginal septum—heals thus, without any surgical means. De La Motte, in 1771, does not, however, seem to repose much faith in such assertions. He states the fact of having met with one failure at least among the class thus managed. Deleurye, "Traits d'Accouch^mCns," page 320, states that he agrees with the authors of the expectant, or let alone treatment, in some degree only, and thus states, " large ruptures can be cured Avithout any sutures." About the same is stated by Puzos, " Traite" d'Accouchemens," page 134, wherein he states: " These 60 PERINEORRHAPHY. wounds can be cured as Avell by approximation and securing the thighs as by sutures." Aitken, in his "Principles of Mid- wifery," 1788, rejects sutures entirely. D'Outrepont claims, that extensive lacerations heal sponta- neously by position; and this is also the opinion of Busch and Moser. In addition to these authorities may be named Paletta, " Exercitationes, Pathological, pars 2d Mediolani;" 1826. Gar- dieu, in his "Traits Complete d'Accouchemens," torn III. Sedillot, in the " Recueil Periodique de la Socie'te' MCdicale de Paris," torn IV. Boyer and M. Duparcque, the latter being the author of an essay published in Paris, in 1836, entitled, "His- toire Complete des Ruptures, et des Dechirures de l'Uterus, du Vagin, et du P^rine'e." To these we will also add the name of Dr. Waller, who cjeclares he has seen ruptures involving the entire perineum, and leaving both cavities as one, get well, and the control over the intestinal canal and contents be- come restored; no treatment, but only position and cleanli- ness having been observed. He goes still further, and adds, "Most cases which have come under my observation have done well." We may here be allowed to make the remark : It would have been much more satisfactory had the last-named doctor defined what he really meant by the vague term, "done well." Blundell and Davis, also Ramsbotham, furnish much the same kind of testimony. Notwithstanding, such an injury to the perineum as just stated, we confidently believe, can never do well when thus treated. Dr. Cockle, in his paper on " Lacera- tion of the Perineum," published in 1853, and as quoted by I. Baker Brown, advises against sutures, especially in recent cases. It is to be presumed that the foregoing opinions are meant to apply to recent cases, as no mention is made of chronic or long- standing cases. The latter class do not seem to have been con- sidered nor provided for. It is but fair, since we have reviewed the opinions and ex- perience of those who advocate the expectant, or let alone treat- ment, that we should here also enumerate the principal portion of the prominent and distinguished names who are advocates of the suture and paring treatment. These will be found to be both numerous and highly respectable, aye, honorable. Early PERINEORRHA PHY. 61 in the field may be found the names of Moreau and Smellie, neither of whom, says Busch, ever performed, though they sanctioned and advocated the operation. De La Motte, Morlanne, Saucerotte, Trainel, Alcock and Bond, Mayo, of London, Campbell, Osiander, Williams, Fabrice, Rit- gen, Meissner, Langenbeck, Rover, Hafer, Mercogliano, D'Outre- pont, Dupuytren, Pauley, Roux, Noel and Dieffenbach; all of these record successful results by aid of the knife and suture. Roux, about 1831, obtained the most brilliant results from the operation, and no doubt its probable elevation to the position of an established surgical procedure. He furthermore asserts, there never Avas a satisfactory result obtained when left to na- ture. Roux's method embraced the use of the quilled suture, aided by interrupted stitches in the approximating and secur- ing of the edges, when the case was of recent occurrence. The last-named, or interrupted stitches, were placed at intermediate points between the sutures. In chronic, or long-standing cases, in addition, and prior to the use of the sutures and stitches, the parts Avere first properly prepared by the paring and vivi- fying process, together with lateral incisions, when the strain on the suture was sufficient to Avarrant their being made. Du- parcque also states, " Xo union in a proper sense can occur un- aided." Chelius is among the number who advocates the use of the suture; also Wutzer, M. Verhaeghe and Kilian. Velpeau recommends the suture and Dieffenbach's lateral incisions. Chelius, in his work, Vol. II, page 38, while he favors an operation, thinks the consequences are very uncertain; and on page 39 of same volume, the editor, Mr. South, records a suc- cessful issue in an operation made by Dr. Davidson; extracted from the pages of the London Lancet, 1838-39, Vol. II. In this instance the quilled sutures Avere used, and Avith a view to counteract the tendency to eversion of the edges, the gum cylinders Avere draAvn tighter and closer together, by means of a piece of tape. In order to counteract this defect, Roux in- serted a feAV interrupted and superficial sutures, as before inti- mated. In Burns' edition of "The Principles of MidAvifery," Vol, I, page 58, 1820, the sutures are strongly recommended, when 62 PERINEORRHAPHY. union cannot be effected by any other means, and yet the American editor, Prof. James, in a foot note on the subject, and embodied on the same page, states, " the sutures should rarely be had recourse to, as they give rise to great irritation." I. Baker Brown states incorrectly, that " Burns makes no mention of the accident." In 1829, Dieffenbach gave deep thought and much attention to rupture of the perineum; and after a thorough and matured contemplation of the entire subject, concluded that "these ac- cidents should not be left solely to nature." The substance of his remarks, and conclusions arrived at, may be summed up briefly as follows: "Immediate operation:" the use of the twisted and interrupted sutures. Secondary operation: the edges being previously well pared, semi-lunar 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 sev- eral days; also the removal of the urine by the use of the cathe- ter, as the occasion may require. M. Montain made a success- ful operation, in a case thirty-six days after delivery; and oth- ers have succeeded after the elapse of a much longer period of time. Nevermann, in a German translation of Duparcque, having noticed that stone-masons receiving lime into the eye, in twenty- four hours had the lids and eye-ball adherent, from this cir- cumstance concludes and suggests, that the margin of a lacera- tion should be subjected to a similar treatment, viz., by apply- ing quicklime to the parts, and then securing the limbs to- gether. 'Tis almost needless to add, such an unscientific pro- position and process as this, could never be popular nor suc- cessful. Langenbeck, renowned for his ingenuity, presented a method, which he terms perineo synthesis, a description of which will be found in a "Memoir sur un nouveau proce'de' operatoire pour le Guerison des Ruptures. Completes du Pe'rine'e. Brux- elles, 1852, by M. Verhaeghe, of Ostend. This monograph is not in my possession, nor can a copy of it be obtained. The following points embraced in the essay are gathered from the able treatise of I. Baker Brown, on "Rupture of the Perin- PERINEORRHAPHY. 63 eum." The first stage in the operation consisted in freshening the edges, or free borders, or the recto-vaginal septum, then 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 vaginal discharges. After Fig. l. this, the edges of the laceration are then pared, extending for- ward to the posterior commissure of the vulva, avoiding the mucous membrane of the vagina. The following is the method of the approximation, after the paring process is completed: After the bleeding has ceased, and every particle of intervening clot or string of coagulum has been remo\Ted, the rectum is first closed by suture, inserted by means of Wutzer's curved needles; after Avhich the perineum is then approximated by means of interrupted sutures, known as the twisted variety. Finally, the anterior portion of the septum is closed in like manner. To 64 PERINEORRHAPHY. overcome any unusual tension, he resorts to the lateral curved incisions, suggested and adopted by Dieffenbach. The limbs being approximated and secured in the usual manner, the after treatment may consist of vaginal injections of infusion of chamomile, catheterism, low diet, etc. The bowels may be kept in a state of quiescence, by means of internal administra- tion of opium, until after the sutures have been removed. Bernard and Huettes' " Operative Surgery," page 454, recom- mends position, if the case be a recent one. If old or deferred, revivifying the edges, then uniting them by means of the quilled suture, the same as that used by Roux, and also Dieffen- bach's lateral incisions, if required. They add, " the sutures should be permitted to remain until cicatrization is complete, union by first intention not being expected," we might add, exceptionally realized. Guerin, " Chirurgie Ope'ratoire," page 578, approves and ad- A'ises Roux's operation, with Dieffenbach's incisions. PERINEORRHAPHY. 65 Sedillot, Vol. II, page 441, recommends the last described method. Vidal, "Pathologie Externe," tome 5, page 755, also speaks favorably of Roux's and Dieffenbach's methods ; and also does Duger£, "Des Dechirures du Pe'rine'e," 1856. Dr. C. Clay, referring to the subject, in 1856, advises quilled sutures; use of catheter for a period of twelve to fifteen days; rest and cleanliness. He adds, the sutures should be removed on the seA'enth day. Miller, in his practice of surgery, regards the subject very briefly, and is rather adA'erse to the operation, in recent cases, regarding the use of sutures as improper. Skey, on operative surgery, 1858, does not seem to regard the question with any amount of favor, and recommends the operation of I. Baker Brown. M. Jobert, "De la Reunion en Chirurgie," 1804, advocates a method of suture Avhich he terms serpentine, which is made of silk thread, inserted Avith curved needles. His description is not concise nor clear. Sir J. Y. Simpson, in his able wrork on " Obstetrics and Gy- naecology," edited by J. Watt Black, A.M., M.D., American edi- tion, 1871, page 65, mentions three varieties of ruptured perin- eum, viz., longitudinal, oblique and central. In the slight forms. or partial ruptures, he recommends approximation of the limbs, cleanliness and quiet, In the more severe and com- plete forms, he directs that the patient be placed so that the discharges, etc., do not run into the wound; the use of metallic sutures, attention to the bladder by use of the catheter, and opiates to control the bowels. Should these means fail, he then recommends revivification and sutures. The following is a method he advises, in order to prevent central perineal lacera- tion, pages 594 and 595. First, "manual support of the per- ineum, so as to save excess of pressure upon it, AA'hile at the same time Ave push the child's head forward to the vaginal open- ing, a means, Avhich in the practice of Denman and Lachapelle succeeded in preventing it from passing through the perineum, after its central structures were split and burst." Second.—"Delivery of the head and its proper guidance 5 66 PERINEORRHAPHY. through the vulva by the forceps, as has been effected by D' Outrepont, Hiiter and Braun, in cases in which this accident was impending." Third.—"Lateral incisions, if absolutely necessary, of the in- terior edge of the perineum—for in this, as in the more com- mon longitudinal forms of ruptured perineum, it is necessary, I believe, better practice, to make one or two slight cuts on either side of the fourchette, so as to regulate the site and di- rection of the laceration that must occur, rather than leave their form and their character to mere chance alone. It is al- Avays a more infinitely important matter to save the sphincter of the anus than the sphincter of the vagina." There is one name among British surgeons more promi- nently associated than any other with this specialty, viz., I. Baker Brown, whose name we haA'e mentioned on several occasions in the course of our remarks. His experience in rup- ture of the perineum has undoubtedly been far greater and more prominent than any other authority of late years. From 1853 to the present time, his cases have accumulated, until they noAV number, according to the last edition of his work, pub- lished in 1866, one hundred and twelve cases; one hundred and four of which were successful. We may, then, add, so com- plete has the operation of perineorrhaphy been vindicated, that there is scarcely a treatise of surgery published now-a-days that fails to contain a chapter on this subject. Of late years great strides have been made in this operation by Verneuil, Langier, Demarque, in France; Langenbeck, Simon, of Germany; Sims, Emmet, Bozeman, Agnew, Thompson, Thomas, of the United States. ToAvering above all those just named, or any that has preceded him, is the name of I. Baker Brown, of England; and probably no one before him, in the list of those known, or ever reported, equalled that of M. Roux, of Paris, France, in point of numbers and successes of his operations of perineor- rhaphy. The precise number of his cases are not on record, as far as I have been able to learn ; but it is generally admitted by those who are famiriar with the history of this surgical proced- ure of those times, that Roux's fame and skill exceeded that of any other surgeon in this special department. PERINEORRHAPHY. 67 One of the leading features of Brown's operation is, extensive paring and denudation of the implicated parts. He also uses the quilled and interrupted sutures, dividing the sphincters on each side, and keeping the bowels quiet with opium. In concluding this portion of our essay, we will take occa- sion to add, that very little attention has been given to this subject by the old American surgeons and writers. Dorsey, Warren, McClellan, Gibson, Mutter, who were cotemporaneous with most of those just mentioned, make no allusion what- ever to the condition nor the operation. The most promi- nent mention, and as far as my knowledge extends, the first operation made in our own country, is one reported in Churchill's " System of Midwifery," 1853, and transcribed from the " American Journal of the Medical Sciences," October, 1850. This operation was made by Dr. Win. H. Horner, Professor of Anatomy in the University of Pennsylvania. The rupture oc- curred in. a primipara case of a young married lady. It was not until after the birth of her second child that the case came under the observation of Dr. Horner. The laceration extended from vulva to anus; the parts were cicatrized over an inch in depth, and but one fissure was apparent from near the os coc- cyx to the clitoris. The patient had suffered very much from frequent diarrhoeas, only to be restrained by opiates, constantly used. Her life was unavoidably passed in seclusion from soci- ety ; much of the faeces passed forward through the rim of the vulva, which added much to her distress. He pared each peri- neal margin of the cicatrix, also the rectal and vaginal edges of the rupture; used interrupted sutures, along the rectal and vagi- nal margins, the sphincter ani muscles being divided on each side of the anus; a procedure which the doctor then deemed ne- cessary in old cases of this kind. Unfortunately, the menstrual flow came on prematurely, and with the natural discharges of the vagina, loosened everything up in the way of adhesions. This operation AA'as a failure. Fifteen months subsequently a second operation was made. Additional difficulties had now to be met. Owing to a loss of material, and a consequent in- crease in the Avidth of the rupture, he selected another method of overcoming the trouble. Tavo flaps were taken from the 68 PERINEORRHAPHY. perineum and adjoining parts of the vulva, one on either side. By placing the base of the right flap beloAV, and the base of the left flap above, upon crossing the two flaps, a partition Avas formed between the rectum and vulva; the free side of the right flap forming the upper part of the rectum, and the free side of the left the lower part of the vagina. Interrupted sutures Avere again used. This operation was only a partial success, but the patient's condition was considerably improved. For full par- ticulars see Churchill, pages 467 and 408. Edition of 1853. Among those of the modern school of American surgeons, who all, more or less, have had some experience in this depart- ment of surgery, and who also refer to the subject in their re- spective works on surgery, may be mentioned as follows : Sims, Gross, Smith, Agnew, Hamilton, Helmuth, Franklin, Thomas, all of whom describe and advocate the operation. In the "American Journal of Medical Science," Vol. XIII, page 113, 1833, may be found a remarkable and successful case, reported by Dr. Mettaurer, of ATirginia, in which the rent extended three inches up into the rectum. After revivifying the edges, he closed the rupture by means of leaden Avire sutures. These were introduced and the parts were approximated by twisting their ends. Prof. Gross adopts, and agrees with the plan of I. Baker Brown's method of operating, excepting in one par- ticular, viz.: the dividing of the sphincter muscle. He states, " I have never found it necessary." A case operated on by Dr. Lewis, is reported in the " New York Medical Journal," 1865, in which sutures were used, and stitches were taken very deep. In this instance the sphincter muscle was not divided; the re- sult proved a success. In the " Columbia Hospital Reports for Women," 1873; Ly- ing-in ward, and presided over by J. Harry Thompson, A.M., M.D.; up to this date, 34 successful cases are reported by him. Next in order we will consider briefly the causes that oper- ate in producing this sad disaster. The tabulated reports from the various American and Euro- pean hospitals, do not furnish any data from which to form an estimate or even judge of the relative frequency with which this accident occurs, to the entire number of Avomen confined and PERINEORRHAPHY. 69 delivered. This silence may be due to a neglect to examine properly the parts after delivery, or from intention to keep si- lence, from the mistaken notion that a ruptured perineum ne- cessarily reflects discredit upon the attending accoucheur. It certainly is by no means an uncommon accident, and oc- curs in both private practice and in public institutions, and under the care of accomplished obstetricians. Its frequency may be accounted for in a measure, when we consider the A'arious causes, either combinedly or singly, that may produce the lesion. I, Baker Brown suggests four princi- pal causes. 1. The dimension of the child's head being too large, abso- lutely and relatively, for the capaciousness and expansibility of the maternal outlet. 2. An unnatural rigidity of the perineal tissue, or extreme width of the same. 3. Unskilful use of instruments. 4. Parturition for the first time at a very early or late age. Churchill gives thirteen causes: 1. Sacrum too perpendicular. 2. Arch of the pubes too acute. 3. Thickened state of urethra and adjacent parts (infiltrated probably). 4. Too rapid passage of the child's head. 5. Exostosis in any part of the pelvic cavity. 6. Excessive breadth of the perineum. 7. Rigidity of the perineum. 8. Tissues of the perineum weakened by disease. 9. Occlusion of the lower outlet of the hymen. 10. Malposition of child's head. 11. Malpresentation. 12. Exercise of too much force by the patient. 13. Want of care Avhen instruments are used. Tyler Smith only alludes to one, corresponding to the 7th of Churchill, viz.: Rigidity of the perineum. Thomas gives four causes, viz.: Parturition, forceps, manual delivery, craniotomy. Hewitt simply refers to difficult labor. 70 PERINEORRHAPHY. Thompson, five causes: 1. Violent expulsive force by the patient. 2. Unusual width of child's shoulders in proportion to the size of child's head. 3. Excessive width of perineum. 4. Inelasticity of the perineum, occasioned by fatty degenera- tion of its tissues. 5. Unskillful use of the forceps. (The fourth cause occurs most frequently after 30 years of age.) Agnew states as to causes, "these may be arranged under three heads." 1. Such as relate to the mother. 2. To the child; and 3. To instruments. Under the first heading may be included powerful expulsive uterine contractions, forcing forwards the foetus before the ma- ternal parts are sufficiently dilated; or to an unyielding rigid perineum, the tissues having undergone some structural change, possibly fatty degeneration; or where the muscular structure is lacking in tone and unequal to cope or react against the great pressure of the advancing foetal head; also where the uterine contractions are suspended, and at a period when the perineum is put upon tension, and then without premonitory warning, recommences with unusual force and power. Under any one, or a combination of several of these conditions, laceration may occur in one of two modes: either by the muscles con- tracting powerfully, or else by their being much enfeebled by protracted extension, as to be unable to assist, the parts becom- ing then ruptured. The form and proportions of the perin- eum should be noted. There are congenital departures and peculiarities which, when present, serve to complicate the mechanism of labor. These may be due to a redundancy of tis- sue, associated with an unusually straight sacrum; in conse- quence of which the presenting part of the foetus tends to direct protrusion, instead of the usual manner in being deflected in the axis of what otherwise should be a normal pelvis Avith pro- per curves or straits. An abnormally narrow arch may pre- dispose to the accident, by preventing the usual extension. PERINEORRHAPHY. 71 Under the second head, or such as relate to the child, may be mentioned unusual size of the head or breadth of the shoulders, either from natural or morbid causes, demanding extraordi- nary dilatation of the vaginal outlet; or an abnormal position of the foetus. It is a mooted question, by no means clear, as yet, whether the passage of the shoulders does not often pro- duce the damage ascribed to the head. The third heading embraces lacerations from the unskilful use of instruments, and these come in for a full share of blame, in many cases. When judiciously and carefully used, they sel- dom, if ever, cause any such trouble. If a child is dragged through the maternal passage without regard to the pelvic straits, or curve, on the plan of a lever, damage will almost inevitably result; or if the acoucheur, before he has the blades of the forceps properly placed and adjusted, permits himself to be surprised by the sudden expulsion of the child's head, to- gether with the instruments, the result to the parts may be very disastrous to the patient, and no doubt humiliating and damag- ing to the attending physician. Various are the degrees of rupture of the perineum. First. When the laceration extends from the posterior fourchette or commissure of the vagina toward, but not into the perineal body. Second. Where the laceration extends from the pos- terior commissure of the vagina to the verge of the anus, but only involves the integument and subcutaneous cellular tissue. Third. When the laceration extends from the fourchette to the rectum, dividing the integument, fascia, sphincter vagina and sphincter ani externus; and in some cases involving the recto- vaginal septum, including the sphincter ani internus. Fourth. In rare cases, when the head is forced through the perineal body, or triangle, leaving the sphincter ani and vagina unsev- ered, the point of exit being through the integument midway between the two muscles. The discomforts arising from the first and second class, or par- tial ruptures, are by no means trivial; still are more remote and tolerable than those that accompany and follow the more com- plete forms. In time the consequences of these two forms will become aggravated, to say nothing of the liability of an increase 72 PERINEORRHAPHY. of the rupture, at each period of delivery succeeding the first mishap. When rupture of the perineal body and integument only occur, there is always prolapsus more or less of the uterus singly. When there is complete rupture, im'olving the vaginal and rectal sphincters, and especially Avhen the internal sphincter ani and recto-vaginal septum are included in the laceration, there always exists prolapsus of uterus, bladder, rectum, and vagina as instanced in case VI of our report. Incontinence of urine and of fceces exist, and rectal gases escape; strangury and marked physical prostration are present, together Avith con- comitant conditions and symptoms to such an extent as to render the patient's life unbearable to herself and an object of loathing and disgust alike to both family and friends. In addition to this there is imposed upon the patient a seclu- sion of life from all its enjoyments, worse than death itself. To rescue a human life from so terrible and life-long an or- deal, as this condition entails, deserA7edly ranks among the noblest achievements of modern surgery. It not only exchanges misery and suffering indescribable for a life of comfort and ease, but it also reflects to the honor and credit of the surgeon ; who goes on his way rejoicing in the happy consciousness of having been the humble instrument, in the hands of an all-see- ing God, of performing an act pleasing to Him, and to his felloAV man. Truly has it been said, "these are the threads of gold which run through the complex mechanism of professional effort and toil, and inspirit the heart (and we add, enliven the soul) amid so much calculated to weary and depress." The consequences, then, of all forms and degrees of lacerated perineum, varying only in degree and severity according to its extent, may be enumerated as follows: 1. Prolapsus uteri. 2. Pro- lapsus of the vaginal walls and uterus, Avith more or less subinvo- lution of both. 3. Prolapsus of vagina, with rectocele and cysto- cele. 4. Prolapsus recti, with incontinence of fceces and fcecal gases, together with incontinence of urine.. The following classification, to our mind, is the most feasible, concise, and as comprehensive as any. The varieties of perineal rupture may be classed under two distinct heads, viz.: partial PERINEORRHAPHY. 73 and complete rupture. The folloAving includes and embraces the stages of destruction. 1. Superficial laceration of the posterior fourchette and peri- neum, in which the sphincters are not involved. 2. Deep ruptures, moving the superficial structures and sphincters vagina, perineal triangle or body too, but not involv- ing the sphincter ani. 3. Rupture through all the last-named, involving and in- cluding the sphincter ani. 4. Complete laceration of all the foregoing structures involv- ing the internal sphincter ani and recto-vaginal septum, to a greater or less degree. I do not regard anything short of this fourth A^ariety as truly complete. The first three named, and referred to as consequences, may result from both forms of rupture, Avhile the last named, the fourth, attends chiefly the form of complete laceration. Prominent among the causes that operate to produce rupture of the perineum, Ave will mention, in the order of their impor- tance and frequency: • 1. Instrumental delivery. 2. Manual delivery. 3. Parturi- tion. 4. Craniotomy. 5. Extirpation and removal of large tumors. 6. Injuries from fall or severe blows. Subinvolution is not regarded by authors generally as a con- sequence of this disaster. I have noted but one author who mentioned it, viz., T. Gaillard Thomas, M.D. I have Avitnessed this condition in three instances out of the number embraced in this report. According to Savage, the muscular walls of the A'agina are not separable into coats or layers. Two-thirds of the thickness of the vagina, varying from tAvo to three lines above, to fiAre or six beloAV, is made up of this muscular portion; the inner third consists of a dense, cellular lining membrane, inseparably united to it. The contractile elastic elements or structures of this passage then, are identical in structure with those of the uterus while under the process of gestation. A re- trograde metamorphosis likewise influences them subsequent to parturition. This process is not unfrequently interrupted in the uterus in consequence of rupture of the cervix; it is then fair to presume, that the same condition or change may accom- 74 PERINEORRHAPHY. pany or follow rupture of the perineum in the vaginal Avails. Nor is this justly and only attributable to instrumental delivery, which may produce both these conditions. A close and care- ful examination into these cases will prove our assertion to be correct, and that the result herein alluded to has often occurred in labors that have been rapid and unaided. Again, it may be urged that prolapse of the vagina, when a consequence of rupture, excites excessive growths in its Avails; but the two states co-exist when perineal laceration has not occurred in vaginal prolapse quite as frequently as when it has. Prevention. It has been truly and often remarked, that "an ounce of prevention is worth a pound of cure," and we will add, that there is not a more striking application of the axiom than in the question here at issue. Every Avriter on obstetrics devotes a passage in his work to the process of labor and the support of the perineum. This is a very natural and commendable feature, but there appears to be much discrepency of opinion as to the manner of performing this manipulation. There are not a few who deny entirely the necessity of such a precaution. Prominent among the Ger- mans who do, are Sarcombe, Wiegand, Faust among the senior class; and V. Siebold Mende; the former takes occasion to con- trovert and refute these views at some length; the latter de- clares that Nature provides all remedies against its injury. In France Pinel Grand-champ and Danyan express them- selves opposed to support, asserting it to be positively injurious. Thompson, of England, 1824, expresses the same opinion. Late in the fourteenth century, Eros, or Trotula, in the twentieth chapter of his book, page 50, 1597, argues in favor of support. In Germany, Roder and Stein virtually agree with him, and advise the insertion of two fingers into the rectum, with the view to guide the fcetal head in the proper direction. Schaffler, 1802, recommends one hand placed upon the sacrum and drawn, while pressing softly the perineum, in order to gain more skin for the latter, at the same time with the palm of the hand to press the head in an upper direction, thus easing the downward pressure. Wiegand also advises rubbing the skin upward from the PERINEORRHAPHY. 75 thighs toward the genitals. Manipulations like these can be of no use. Stark, sen. and jun., and Nedel counsel proper support, with the hand; also Niemeyer, who advises leaving one inch of the perineum back of the posterior commissure free, Avhile pressure be made in the axis of the inferior strait of the pelvis. Barlow advises support until the perineum is well distended, then, he says, it will provide for itself. Nedel only places his thumb across the fourchette. Magdeberg, 1806, appears to simply provide support at the point where the rent begins. Hohl advises a peculiar method, viz., the placing of four fin- gers on the fcetal head, close to the posterior commissure, and the thumb on the opposite side of the head, near the arch of the pubes, thus both restraining and guiding the delivery. Little, if any, support is furnished by this plan, but its chief value, if any, is in preventing too sudden expulsion of the child before the parts are properly prepared. Heine and Miil- ler advise the side position to prevent laceration. English authorities, such as Denman, retard the head partly by pressure made directly against, and partly by the hand planted or pressed upon the perineum. The object being to detain the head until the parts are ready for its passage. Burn's mode is uniform pressure applied over the entire peri- neum, until the head passes; and particularly to the posterior commissure, charging the patient not to bear doAvn during the presence of pain. Mr. B. evidently did not properly compre- hend nor understand the mechanism of the parts, nor yet the principle of labor, when he gave such advice. Busch advises the fingers being planted against the child's head, to prevent its being forced out too suddenly; and when not likely to occur to support the parts by placing the ball of the hand on the posterior commissure, the palm on the peri- neum, the fingers alongside of the anus; supporting only dur- ing the presence of a pain, and never to strongly oppose the advance of the foetus. During the exit of the head and retrac- tion of the perineum, the supporting hand should follow the head carefully. He is unfavorable to using the uncovered hand. Hamilton uses the hand to such part as sustains the greatest 76 PERINEORRHAPHY. pressure. During intervals of pain he rubs the perineum Avith lard; Avhen the head is emerging, lays the fingers against the posterior parts of the vulva, then presses the perineum to- Avard the pubes. Cams states, that it is only necessary to give the posterior commissure sufficient background by pressure. He no doubt had the old maxim in his mind, " obsta principiis." Siebold, during the intervals between the pains, only rubs the skin of the thighs toward the perineum, and during pains gives very gentle support. He does not agree Avith Busch, Avho insists upon uniform pressure. Pinel Grand-champ says: Support is not only useless, but injurious. Mende", of Gbttingen, published the same opinion. Messnard thought it only necessary to hold the coccyx back- Avard, or to place two fingers between the head and perineum. Hodge, of Philadelphia, Pa., enforces pressure, especially at the posterior commissure. Meigs and DeAveese advises the same, using a napkin sup- ported by the hand. Ramsbotham, of England, uses a napkin as a matter of deli- cacy, maintained against the perineum with the hand. Velpeau uses a napkin, but places the hand transversely, the cubital edge toAvard the coccyx. Cazeaux employs the hand alone. A few remarks at this stage of the question would not be remiss, touching upon the great and abnormal size of the foetal head, or some peculiarity of the perineum that may produce laceration. Michaelis recommends in such instances incisions in the perineum. Siebold, in discussing this feature, insists the incisions should be made where there is least pressure or tension. Ritgen endorses a similar view, but likewise confesses such a repugnance to it in civil practice, that he declined to do it; —nor yet has he performed it in hospital service. Blundell simply recommends, and practices only slight inci- sions made laterally, during a pain. M. Paul Dubois also advises oblique incisions. Chailly Honor6 concurs in the same method, believing that PERINEORRHAPHY. 77 even should the incision become a laceration, its course would be such as to incur the disastrous consequences Avhich usually ensue in a laceration into the raphe. Simpson, of Edinburg, also advocates this practice. Penrose, Professor of Obstetrics in the University of Pennsyl- vania, teaches the propriety of incisions in cases of extreme nature. E. Wilson, of Philadelphia, Pa., a teacher of obstetrics in the Nurses' Home, opposes the practice as unnecessary. Dr. Wallace, Professor of Obstetrics, Jefferson Medical Col- lege, Philadelphia, Pa., thinks the necessity for such a remedy can scarcely occur. D'Outrepont, objects upon the ground that the cut once made may soon be converted into a rent, extending even to the anus. Busch thinks the incisions should be confined to cases of or- ganic anomalies only. In conclusion, on this point, we will add, that cases demand- ing such a measure are rare; the greatest danger of inculcating the theory is, that it is likely to be abused by practitioners of limited experience becoming unnecessarily alarmed, and then prematurely resorting to the knife. The wiser plan, in our judgment, of avoiding this accident, is by preA^enting it by a judicious and timely use of the forceps; a practice that will, we think, commend itself to most intelligent practitioners. Careful use of ether or chloroform Avill contribute to the preservation of the perineal structures; and Avith the action of the parts wrill serve to relax them, by rendering the patient somewhat insensible to acute sufferings; Avhich seems to be the cause that provokes violent and sudden contractions of the perineal muscles. We do not propose to ignore a proper support to the perineum as a precautionary measure, and made by the bare hand, as it communicates to the mind A'aluable in- formation Avhich could never Avell be received through any interposing substances, as a napkin, for instance; nor should the support be applied too soon or before the foetal head is engaged in the loAver strait and is pressing out the perineal structures. The pressure should be properly graduated and 78 PERINEORRHAPHY. applied, according to the demands of the case; likewise exerted only during a pain and in the proper direction, so as to prolong the natural curve, which, of course, should correspond Avith the axis of the straits. The palm of the hand should be applied against the perineum, the balls of the thumb and little finger resting in front of the anus, and the fingers upon the posterior fourchette of the vulva. The hand thus adjusted, the pressure should be at first somewhat firm posteriorly, and thus deflect the head toward the pubic arch, during the exit, well and securely applied to the posterior margin of the vulva. A careful observance of these last named rules, we think, will be found the safest and most efficient method yet recom- mended. Period of Operation. We propose to divide the operation for the cure of lacerated perineum into Avhat may be termed Primary and Secondary. By primary is understood the early employment of the su- ture at the time or while the surfaces of the laceration are still raw; and the earlier they are used the better for both patient and physician. Attempts should be made even when the parts are cedematous, tumefied, inflamed; and when in addition there are threatenings in form of suppuration, sloughing, or gangrene; it is better to give the patient the benefit of the doubt. By some it is thought best to avoid sutures, but for my own part I do not see any just reason why operative efforts at restoration should not be made, and especially when silver wire sutures are used, as they are much less likely to induce suppuration than any other kind. Should even only a few points of adhesion be secured, it is a positive gain; the remainder may granulate up and thus close in. Those who object to primary or immediate operation, allege as a reason that: 1. There is danger of vaginitis or metritis. 2. The lochial discharges diffusing themselves over the parts prevent healing. 3. Cases make a good recovery when proper position is maintained and the process left to nature. As regards the first objection, this is simply imaginary, for as already intimated, silver sutures, when used, cause less irri- PERINEORRHAPHY. 79 tation than when the part is left to itself, because the raw sur- faces are protected by being maintained in apposition; there is consequently much less suppuration. For the same reason the second objection can be disposed of; inasmuch as a partial and accurate adjustment precludes in a marked degree any prejudicial effects from the lochial flow. The third and last objection simply rests upon a peradventure, and places the ex- ception before the rule. Nature, when unaided in such straits as these, makes but a sorry and incomplete restoration, in a large majority of cases. This is a well-known fact to operat- ing surgeons. The retraction which the torn muscles neces- sarily undergo, before and during the slow process of granu- lations and cicatrizations, diminishes very much the perform- ance and completion of their proper functions'; hence the value of the immediate introduction of the sutures. By the secondary is designated any period later, Avhen the knife is required to revivify or freshen the margins of the lacerations; especially after cicatrization has set in. Presuming secondary operation becomes necessary, the ques- tion then arises: when should it be made? As a rule, we should decide, whenever the patient's general health and condition will admit, and the parts are thoroughly healed, sound and free from all inflammatory or suppurative action. It is, in fact, imperative that that should be the case, otherwise the necessary tension brought to bear upon the stitches will not be borne by the tissues. A period of at least three to four months should be allowed to intervene, and if necessary, a year, before a sec- ondary operation, in our judgment, would be justifiable. To undertake an operation during gestation, is another question to be considered. Most surgeons, until recently, have indulged in the opinion that during this period the attactive forces concentrated with- in and about the uterus and its associate organs, would most likely defeat the healing process in the perineum, in the event of operation. This view is not sustained by facts. The operation may therefore be undertaken during the early months of pregnancy at least; prior to the third or fourth month. This opinion is endorsed by some very competent 80 PERINEORRHAPHY. minds ; prominent among the number is I. Baker BroAvn, AAdio states: "In no instance in Avhich I have operated have there arisen any symptoms threatening miscarriage." Beyond the last named period, there are two reasons, that may be urged why it is improper to undertake an operation. 1. The reflex influences tending to uterine contraction, and thus endangering the safety of the embryo. 2. The period is too brief to secure, for the perineal parts, the requisite physical and vital properties of elasticity and contractility, so as to obviate the risk of a second laceration. The menstrual flow constitutes another contra- indicative influence. The third or fourth day after the cessa- tion is the most favorable period under ordinary circumstances. The presence of a catarrhal invasion, accompanied with cough- ing or sneezing, is also a sufficient barrier to defer any opera- tion ; as the antagonism that exists between the diaphragm and perineum, would be the means of greatly disturbing the stitches and dressings. Some authors, among whom may be men- tioned M. Roux, opposes operative procedures while the mother is nursing. The same counsel he also offers in cases of vesico-vaginal fistula, under the belief that an additional com- plication, A'iz., pyaemia, may supervene. AVith neither of these views do we coincide; having never learned of nor witnessed any such unpleasant results. Preparation of the Patient. The first point to be considered by the surgeon when he as- sumes the management of a case of this character, is to care- fully note the condition of the different organs. Not unfre- quently he will observe the patient suffering with diarrhoea; more or less disturbance of the digestive apparatus, together Avith a train of distressing nervous symptoms. To correct these disorders—rest, composure of both mind and body, a proper se- lected, regulated and nourishing diet, pure, fresh air, and the application of appropriate remedies, according to the indica- tions present, are required. Not unusually the patient contracts the habit of resorting to the internal administration of opiates or other narcotics, for the two-fold purpose of obtaining rest PERINEORRHAPHY. 81 and binding the bowels. This should, of course, be done away Avith, as it soon leads to indigestion, nervousness, head- ache and other ill effects, and a contrary course be recom- mended and substituted. The articles of diet best suited to the case, and for the chief reason that they do not create stool, are good strong animal broths, free from fat, containing no seasoning, only a moderate amount of salt; stale bread one day old; milk toast and a moderate amount of vegetable diet, avoid- ing such articles as produce flatulence; plain pudding, and soft boiled eggs, fresh. These will as a rule effect the desired result and should be given at least for one week or longer prior to the operation. At least forty-eight hours before the operation is attempted, the lower boAvel should be thoroughly freed from stool by use of enemas, aided, if necessary, with a dose or two of castor oil. A suppository composed of cacao butter and opium in a small quantity may be passed well up into the rec- tum ; this will materially contribute to keeping the bowels quiet. The patient should take a very moderate meal on the morning of the day set for operation, so that the anaesthetic may not be interfered Avith. The bed assigned the patient for operation should be a firm hair mattress, over AA'hich a sheet of gum cloth should be spread, this in turn covered Avith a folded sheet. A bright sunny day should be selected, also a morn- ing hour, and thus allow ample latitude for the operation. Operation. The usual complement of assistants is four, distributed as folloAvs: One to take charge of and to administer the anaesthetic, and to do nothing else but give his Avhole attention to it. Two to hold in position and support the loAver extremities, and the fourth to attend to the sponges, instruments, etc., which are required by the operator. Three different attitudes have been suggested. First on the side, with the nates brought over the side of the conch, Avith both thighs strongly flexed on the trunk. This is the position recommended by Busch and Moser. They claim for it complete relaxation of the perineal structures, and less risk of the patient taking cold, as there is very little 6 82 PERINEORRHAPHY. of the perineum exposed. Second, the kneeling position, Avith the body well bent forAvard; the abdomen supported by means of a small feather bed rolled up in a sheet in such manner as to rest and support the abdomen; the body enveloped in a sheet. Third, the dorsal position, the patient reclining on the back, hips projecting over the edge of the bed; the legs flexed upon the thighs and the thighs upon the abdomen; much the same position as Avhen lithotomy is to be performed. The one most suitable and frequently resorted to is the last described, because it offers the most complete con- Fig. 3. Fig. 4. Fig. 5. trol in eyery partiCular. The following constitute the instru- ments, which are feAV and sim- ple: a straight scalpel, sharp- pointed, Avith long handle (Fig. 3); one pair curved spring rat- tooth forceps, (Fig. 4); compres- sor, (Fig. 6); suitable curved needles, with a porte aguile (Fig. 7), or needle holder, Avhich Avill ansAver for both deep and intermediate sutures; or, a long needle, Avith a moderate curve, and eye near the point, set in a handle, will do as well (Fig. 5), one tenaculum, one pair artery forceps, sponges, dressings, sil- ver wire, etc. Sutures. Three different kinds of sutures have been suggested and used, all more or less adapt- ed to this purpose, viz., the in- terrupted, the twisted, and the quilled suture. Osiander, Dief- fenbach and others succeeded with the first named, or inter- rupted. Duparcque states the successes with this form haA'e PERINEORRHAPHY. S3 been equal to the failures. Both Alcock and Bayer treated their cases successfully in this manner. The objection to this suture is the lips of the wound is not closed completely by its use, and union is only partial. Fig. 6. Fig. 7. The same objection may be urged against the tAvisted, al- though Morlaune and Dieffenbach and others commend it. The quilled and interrupted sutures combined seem to be the most successful, and better adapted for the purpose in most cases. In the event of I. Baker BroAvn's method of operation being adopted, there may be added a blunt or probe-pointed bistouri, with Avhich to divide the sphincter muscles, AATith likeAvise some pieces of cane or elastic bougie, together with silver Avire, both 84 PERINEORRHAPHY. heavy and light sizes, of Avhich to form the quilled sutures. Silver annealed wire is the best material for the purpose. Immediate or Primary Operation. As soon as the accident is discoA'ered, it should be promptly met and the torn parts brought in apposition, then secured with the sutures. I need hardly add, that the advantages of such a course Avill be apparent, when it is considered that the perineal tissues are flaccid because of the extreme tension to Avhich they have been previously subjected, and consequently there Avill be little strain upon the sutures. Again, there is a natural tendency of the parts to heal when thus immediately adjusted. It may now be said, this truly is the accepted time. The number of sutures will vary according to the extent of laceration. The method of introducing and securing the sut- ures Avill be explained under the head of the secondary method of operation, and also the mode of dressings, with a A'ieAV to avoid repetition. The parts must be kept perfectly clean, frequently bathed, or sprayed Avith a Avarm and weak solution of carbolized water, or permanganate of potash prepared in same manner. Secondary Operation. The patient having been placed in the position described un- der the third method—lithotomy position—and the parts care- fully shaven, the patient being duly and thoroughly anaesthe- tized, an assistant makes the requisite tension upon the lateral sides of the laceration, wmile the surgeon pares aAvay at least a quarter of an inch external to the torn edges, and sufficiently deep to reflect inwards the mucous membrane. The edges of the recto-vaginal septum must also be carefully freshened. The next step is the division of the sphincter ani on both sides, about a fourth of an inch in front of its coccygeal attachment. This should be done Avith the blunt-pointed bistouri, guided Avith the operator's finger placed within the anal margin, and then pressed through the tissues to the extent of one or two inches PERI n eorrh a ph y. So external to the anal opening, and embracing the superficial fasciculi of the muscle, leaving the deeper portion intact. Some operators paralyse the sphincter by means of extreme tension or dilatation; for instance, Van Buren. The third stage in this procedure embraces the insertion of the sutures. The point of the needle is passed through one side, entering at least one inch external to the pared margin, and dipping deep, so as to embrace the fissure and cause the point to emerge at a location precisely opposite the point of en- trance, and the same distance from a point opposite on the pared margin. Each deep suture should be inserted in same manner, the one nearest the anus always the first. The ligatures Avhen passed and ready to close, present looped ends on one side and free ends at the other side. This is ac- complished by first introducing the curved needle, properly armed Avith an ordinary thickness of wire, then seizing the ex- posed end of the Avire as it emerges at an opposite point; Avith- draw the needle simultaneously, unwrapping the Avire, until the needle is Avithdrawn from the flaps, then excise the Avire close to the point of the needle, alloAving some latitude for play. You now have but a single strand of Avire in situ. To double the suture you haA'c but to cut some strands of wire sufficiently heaA'y and long, that when doubled or looped to alloAv for the breadth of the gap. Now fasten one end of the inserted Avire at the looped end of the double Avire, pressing its sides Avell to- gether. Xoav make traction on the single Avire, and thus draw the looped end of the double Avire through and through until it emerges at the opposite side, or opening, then detach the single Avire from its attachment at the loop; it may be removed and used thus again, and so on until all the double sutures are placed in position. Two pieces of elastic bougie, or ivory rounded for the purpose, are next placed in their respective positions, one on each side; one piece passed through the wire loops, and then secured by traction made on the free ends at the opposite side. The second piece is laid in the same direc- tion, both parallel Avith the rent. The approximation of the pared surfaces are hoav effected by the equal pressure of the assistant's hands from both sides; the pared sides of the flap 86 PERINEORRHAPHY. are thus pressed together; then the free ends of the wire are twisted over the pieces of iA-ory that lay between them. The edges are thus secured in apposition. As an additional precaution, and to prevent gaping or ever- sion of the edges, (a common accident), interrupted or inter- vening single superficial silver Avire sutures should be inserted and secured by twisting, between the quilled form. Some operators employ the hare-lip suture, for this additional se- curity. Before proceeding to close in the operation, one finger should be introduced into the rectum and another into the vagina, in order to test the accuracy of the co-aptation, and adjustment of the pared and secured surfaces. This being now satisfactorily performed, cleanse the parts thoroughly, being sure that there are no intervening coagula at any point, and that all oozing has ceased. Place a compress suitably propor- tioned, made of patent lint or other soft material, saturated Avith arnicated water, 1 part to 20, used Avarm; over this a soft folded napkin, and the Avhole of this dressing secured with a T bandage. The thighs being also secured Avith a roller bandage, a folded napkin being placed betAveen the knees, to prevent the ill effects of friction. The patient should now be placed upon a soft hair mattress and spring bed, properly protected Avith gum cloth and sheet covering. The gum catheter should be introduced, and so ar- ranged that a competent nurse can draAv the urine about once every six to eight hours, and for a period of four to five days. A soft elastic catheter may be used, and I prefer it to any other. A caoutchouc bag may be used as a receiver for the urine, and the outer end of the catheter may be secured to the same. The boAvels should be kept bound for the first five or six days; the diet to consist of boiled milk, arrowroot, beef tea, mutton broth, a small portion of tender, broiled meat, and if occasion require, some pure Avine may be alloAved. All things being equal, and everything looking favorable, in from forty-five to fifty hours following the operation, some of the most favorable looking of the deep sutures may be removed; and the superficial ones on about the seventh day. It is generally conceded best to keep the boAvels bound for from fourteen to twenty-one days; but PERINEORRHAPHY. 87 Ave do not think it necessary, nor advisable, as Ave have fre- quently found union sufficiently firm on the ninth day, to admit of a gentle movement. After the parts haA'e united, they may be moA^ed Avith Avarm Avater enemas, composed of a little castor oil and some common table salt, say a dessert or tablespoonful of the former, and an e\7en teaspoonful of the latter, to one quart of Avarm Avater, aelministered warm. Fruit and a feAv vegetables may be added to the patient's diet, as soon as circumstances will permit. The operation I have herein detailed is knoAvn as Brown's method. On reviewing all the features throughout, there is really nothing new in it. The quilled sutures have been in use many years by Roux, Davidson and others. The incisions of the skin and subcutaneous tissues had been used by Dieffen- bach; of the sphincters, by Saucerotte; and the use of opium to constipate the boAvels, also by Dieffenbach and others. The particular points at Avhich the sphincter muscle of the anus is divided is hoAvever original with I. Baker Brown, and also the combining of all the peculiarities mentioned in the various steps of the operation, into one method. He has illustrated their great value Avith a record of many successful cases, larger in point of success and numbers, than any other specialist, and certainly has contributed a noble A\rork to the science of sur- gery, and justly gained a Avorld Avide reputation thereby. The folloAving is Avhat Ave will term the American method, and the only one; (with the exception of the operation attempted by Prof. Horner, referred to in a former portion of our remarks). It Avas first practiced and introduced by D. Hayes AgneAv, M.D., Professor of Surgery in the University of Pennsylvania. The preparatory treatment and positions are the same as that last described; it will not therefore be necessary to repeat. Agnew's Operation. The following remarks apply to deferred cases especially; as witnessed by the writer. The professor commenced the revivifying process from be- . hind forward, including a slight portion of the labium; the 88 perineorrhaphy. breadth of Avhich should extend inward, so as to include a small portion of the vaginal mucous membrane, and outAvard toAvard the buttocks. The paring was made superficial, so as to abrade the surface, and about one inch Avide Avlien completed. Both sides of the rupture were thus prepared, precisely alike. The assistants supporting the limbs, now compressed the sides and made traction so as to render the recto A'aginal septum tense. When in this condition the edges may be readily freshened to the extent of f of an inch; or the operator may, if he so elect, in- sert his finger into the rectum and by making the part tense, resort to the scissors for freshening this portion. Great care should be exercised so as not to omit a single point in the par- ing process. The bleeding was rather free, but Avas easily arrested; there Avas no necessity, hoAvever, for ligatures. Ice Avater applied by means of an ordinary syringe, Avas the method used in arresting the hemorrhage, and the author states that this rarely fails. Should it fail, hoAvever, he then proceeds, notwithstanding, to introduce the sutures, relying on the ad- justment. Suture*. The approximation was made by the use of the inter- rupted sutures; one series was placed deep and a second series superficial. The material used Avas iron Avire silverplated. He places much reliance upon the introduction of the first stitch and prefers the iron Avire because of its strength. It is not so liable to break as the silver wire. He introduced the deep sutures first commencing Avith the most posterior one; next to the rectum. From three to four is the usual number used. The superficial sutures he introduced, intermediate or between the deep ones. The needle was entered £ of an inch from the pared margin, below its lowest point at the anterior-portion of the ischio rectal fossa, then carried upwards and forwards until it appeared at the middle of the septum, just above the line of denudation. The wire was" then draAvn through the eye of the needle and the latter AvithdraAvn; then made to pass unarmed through the corresponding parts at the opposite side emerging on the septum, close to the first puncture. The Avire was again passed through its eye, and as the needle AA'as AvithdraAA'n, made the perineorrhaphy. 89 complete circuit of the wound, so that Avhen it was tightened, the parts closed together like the mouth of a purse. At three Fig. 8. equidistant points deep sutures Avere inserted, then followed the approximation. Adjustment. Carefully removing and sponging the parts and nates, the latter Avere pressed together by aid of the assistants, and the ends of the sutures in the order of their introduction (the one nearest the anus first) Avere passed through the hole in the adjuster at the end of the forceps and then being strongly draAvn upon as the latter Avas being carried down, the parts were brought in apposition with accuracy. To maintain and secure this adjustment, he resorted to perforated shot, run down over the projecting ends of the Avires, these Avere firmly clamped by means of suitable compressing forceps. After securing the remainder of the deep sutures in same manner, he proceeded to insert the superficial ones. An ordi- nary cuiwed surgical needle Avas used, armed at the heel Avith 90 perineorrhaphy. the same kind of Avire. These Avere entered f of an inch from the edge on one side; were made to penetrate the skin and cel- lular tissue, then to emerge at an equal distance from the edge opposite. These were secured by simply twisting the ends. The protruding ends were then all trimmed away, the super- ficial ones at the twist, the deep ones near the compressed shot. Fig. 9. The dressing consisted of a strip, 21 inches Avide of adhesive plaster, 12 to 14 inches long, was placed across the nates to give additional support, the limbs were bound together and the patient was put to bed in the usual manner; a pre- cautionary measure in shape of a napkin placed betAveen the knees to prevent excoriation of the surfaces. Patient Avas permitted to lie on either side, and also on the back. The author of the operation, at last report, had made fourteen successful and satisfactory operations by this method, one being a case of complete procidentia. There is much in the Avay of simplicity, and no small amount PERINEORRHAPHY. 91 of originality, to commend in this plan. It is certainly worthy of imitation. REPORT OF CASES, OPERATIONS AND TREATMENT. In our own field of practice, Ave have fifteen cases of operation to report, six of Avhich Avere recent, complete and incomplete; the balance, or nine, Avere delayed or secondary, and most of them complete ruptures of the perineum. Case 1.—March 4th, 1859, Avhile a resident of Canada, and practicing there, I encountered my first case of ruptured peri- neum. The mishap occurred Avhile the patient Avas in other hands; in fact I found the case an abandoned one as far as her former professional advisers Avere concerned. Her last medi- cal attendant had left the patient on the fourth day after con- finement, Avith the assurance that he could do no more for her, stating that her case Avould "come out all right." I Avas called on the fifth day, and found the patient in a sad plight. The parts were sAvollen and inflamed considerably; and suppu- ration was established. The presence of fceces, and urine, in and about the Avound, served to complicate and irritate the lacerated surfaces and surrounding parts very much. The patient Avas a primipara, nineteen years of age, of English birth, had much fever and headache, much thirst, no appetite; otherwise her general condition Avas good. Labor had been tedious, child Avas large, weighing fourteen pounds. I reluctantly accepted the responsibility of the case, and pro- ceeded Avith proper materials to cleanse the parts Avith Avarm carbolized Avater; draAving off the urine, emptying the loAver boAvel Avith enema, etc. Having nothing else at hand for sutures, I Avas obliged to use silk ligatures; stimulating the raw surfaces Avith a mild application of Argent, nit., grs. x to aqua f. Si. I Avill here take occasion to state that the rupture invoh'ed the entire perineum, also the external sphincter ani muscle. Introduced first deep perineal sutures, four in number, and three intermediate superficial ones. The ordinary curved 92 perineorrhaphy. surgical needles Avere used and Avere entered three-fourths of an inch from the lacerated margins, dipping down rather deep, introducing the one at the ruptured sphincter first. After draAving and tying these ligatures, the parts being now in apposition, a compress, moistened Avith carbolized oil, to- gether with a roller bandage, Avas applied; a compress being laid betAveen the knees to avoid excoriation; gave Aconite30, and ordered a nourishing diet. Called on the folloAving day, found the patient rather more comfortable; continued treatment and diet. On the fourth day after the operation, called, removed the dressings; Avas surprised to find good union; then removed all the stitches. Re-applied dressings; used suppositories composed of cacao butter and opium, gr. J, to quiet the bowels and gaA'e due at- tention to the urine. There being hoav no special indications for any internal remedy, nothing remained but to pay proper attention to the dressings until the fourteenth day, Avhen the parts had healed; my services in the case then ceased. The patient took my advice and remained quiet, resting herself for a month. After this she reported herself entirely restored, and I had the satisfaction of having it practically demon- strated, as I was called upon two years later to attend the patient in her second confinement, and can testify to her hav- ing passed " the rubicon " in safety. Everything in connection with this confinement period, passed over without any draw- back. Case 2.—Occurred April, 1860. Patient a colored woman, aet. 47, fifth labor. This was a secondary or delayed case, both in point of laceration and operation. Patient had been afflicted in a former labor with partial rupture, and was treated « as far as I learned, on the expectant plan; simply had the limbs bandaged together. On the occasion in question, the labor was a case of twins, one a very large child and the other rather small. The large one was born first; the laceration occurred during this period of the labor, the case being under the supervision of a colored midwife. I was not called until the woman conceived for the sixth time, when I found gestation had advanced to the third PERINEORRHAPHY. 93 month, with the following symptoms and conditions. There Avas more or less prolapsus of the uterus and bladder. Patients limbs were anasarcous, and swollen from the knees doAvnwards, including the feet. Constant desire to urinate, with urging, accompanied Avith frequent and only slight passages of urine. Severe sacral pains, Avith urging to stool; this condition AA'as aggravated very much by the displacement—doAA'.nward—of the uterine organs. The only relief that could be obtained, was by lying on the back, Avith head low and hips Avell built up Avith pillows; patient Avas also much prostrated. The period that had elapsed between the first partial and second, or complete rupture, Avas twenty-three months; that between the second rupture and the time I saw the patient, Avas seventeen months; total, forty months, or three years and four months from date of first mishap. Confinement to bed Avas ordered, freedom from labor and all exertion. After a preparatory course of treatment consisting of manipulation by means of persistent taxis, I succeeded in replacing the uterus and bladder in their normal positions. This treatment Avas supplemented by means of a proper support consisting of a compress to the perineum, sup- ported with a T bandage, and the decubitus position, as Avell as a good generous liquid diet; also mild soothing applications to the external parts, Avhich Avere somewhat inflamed and sensi- ti\'e. These manipulations consumed about six Aveeks time, repeated every two to four days. The patient being chloro- formed, operation Avas then made, revivifying by paring the cicatrized surfaces of the perineal body or triangle, Avhich in this instance Avere very dense. In this case the silver wire Avas used for sutures. Four deep seated and five intermediate superficial sutures Avere required to secure the parts in situ. The usual dressings Avere applied. On the third day the deep sutures were all removed; the superficial ones on the eighth day, the patient making a very favorable recovery, Avith no untoAvard symptoms, resulting in firm union of the lacerated parts. Case 3.—Was a young girl, aet, 16, born in England, who conceived on board ship, carrying her child to full term, May, 94 PERINEORRHAPHY. I860. She stated that her delivery was made with forceps. The perineum gaA'e way, just as the shoulders passed. Efforts Avere made to overcome the ill-effects by the expectant plan, ?'. e., simply bandaging the limbs and trusting to spontaneous recovery; her physician informed her, Avhen his services ceased, that her case was cured. I saAv the case nearly a year after the occurrence of the rupture, and found the patient much reduced from ovenvork and fatigue, in consequence of her hav- ing to do housework and nurse her child, who Avas a large, fine bouncing boy, requiring much attention. An examination revealed a rupture of the sphincter ani, involving the perineal triangle, two-thirds of its extent. There was partial prolapsus of the rectum and bladder, accompanied with the usual distress- ing symptoms. I ordered the recumbent position, with head and shoulders low; the hips somewhat elevated, and a generous diet. She was then Avithih two Aveeks of her monthly period. After attending to the usual preparatory steps, I made the operation freshening the cicatrized parts, and using quilled and superficial sutures, the latter being of carbolized cat-gut. Due and daily attention AA'as given to the patient. Dressed this case, in the usual manner. On the fifth day after remov- ing the dressings, cleansed the parts well and not feeling Avar- ranted in removing any of the sutures, redressed the case. On the eighth day remoAred all the deep sutures, five in number, leaATing the superficial ones in situ, then redressed the case and allowed these to remain until the eleventh day, when all the superficial ones were removed. The patient was not allowed to go about or be upon her feet for a period of three weeks. The result was a fine and satis- factory recovery, with entire freedom from her former com- plications. Case 4.—Patient unmarried, aet. 27. The rupture followed a breech presentation and occurred during her second con- finement. Stated her first labor was very severe and tedious, lasting five days and nights; the first child was still born, was delivered October, 1863; being also premature, caused, from her own account, by taking medicines to produce mis- carriage. PERINEORRHAPHY. 95 In September, 1805, she Avas again taken Avith labor-pains, a breech presentation, and during two days the child had advanced only as far as the umbilicus. Labor Avas completed on the morning of the third day. Its limbs Avere much dis- colored from long continued presence in the pelvic cavity. There Avas also some delay in getting the head through; the chin becoming locked betAveen the symphysis pubis and sacral eminence. SeA'ere hemorrhage followed, Avhich ceased as soon as the placenta Avas remo\Ted, which was facilitated by knead- ing and friction over the hypogastrium. The child weighed ten pounds, eight ounces. During the passage of the breech and while forceps were being used, she stated that she felt some tearing and giving aAvay. She then fainted, but soon recovered, and then real- ized, to use her oavii Avords, "she had been torn." During the month of April of the following year, 1866, I was called upon to give an opinion of her case. Examination, while standing erect, revealed a displacement of the uterus; bladder and rectum, protruding Avithout the vulva, and Avhile in that position, it Avas impossible to return them. Requesting the patient to recline, lying Avith head and shoulders 1oaat, with hips eleArated, by making taxis over the abdomen Avith one hand, and the other grasping the extrud- ing organs, I succeeded, after some difficulty and pressure, pushing upwards and backAvards, in replacing these organs. I then examined the perineal structures, and found them torn through, including the sphincter ani muscle, up into the recto vaginal septum, and thoroughly cicatrized. Enjoined rest and the recumbent posture, like-Avise a preparatory course of treatment. The operation was made by first freshening and revivifying both sides of the perineal triangle, then introducing the sutures, Avhich Avere metal—silver wire. The first stitch Avas taken in the sphincter ani muscle. Four deep sutures Avere inserted, also, and one at the apex of the triangle. The sutures Avere now drawn, commencing at the sphincter stitch, then the recto vaginal stitch, afterAA'ards the intermediate ones, and finally the superficial stitches were inserted, after twisting the deep seated 96 PERINEORRHAPHY. sutures, Avhen the entire rent Avas accurately approximated. The operation being hoav completed, the parts Avere dressed as usual, the proper precaution being used, to proAride for the urine and faeces, some soft cotton was Avrapt about the protruding ends of the silver-Avire ligatures, and thus prevent any prick- ing or irritation to the surrounding parts. A nourishing and slightly stimulating diet Avas ordered. This patient had several seA'ere chills during her illness succeeding the operation, also much prostration. Ars. alb.30 Avas administered until relieved. The dressings were removed on the sixth day; the sutures were not removed. Reapplied similar dressings for three days longer, each day, again made an examination, finding it Avar- ranted, I removed the deep sutures, allowing the superficial ones to remain. On the twelfth day after the removal of the dressings, found good union has ensued. Kept the patient confined to her bed for three or four weeks, she was then allowed to move about cautiously, the case resulted in a good recovery. Case 5.—Was a primipara, aet. 18. Was called November, 1807, after the child Avas born, and found a case of laceration, complete. Was informed that the case had been a rapid labor and patient was alone during delivery, the medical attendant, Avho had been summoned, failed to appear. Child Avas born about 3 a.m., the mother stated. Patient has lost considerable blood before her condition was discovered. Was summoned at 11 a.m., the following morning, found the patient very weak; too much so for an operation. Administered China30 and ordered nutritious diet. She re- cuperated rather promptly, so that on the fourth day I pro- ceeded to readjust the lacerated parts. The patient Avas placed under the influence of chloroform, having first evacuated the bowels and bladder. Before introducing the sutures I scarified and revivified the torn surfaces. As soon as the oozing of blood ceased, I pro- ceeded to close the parts with double tAAristed sutures and per- forated shot, to the number of four deep ones; also inserted superficial intermediate sutures. The usual precautions of re- lieving the patient of urine, and binding the boAvels, with cathe- PERINEORRHAPHY. 97 ter and suppositories, were used. Applied warm carbolized lotion, and the usual dressings daily. On the second day pulse ran high; skin Avas hot, especially over the abdomen; temperature ranged to 104°; symptoms of delirium, Avith slight subsultus and restlessness; pulse 140, quick and full; pupils dilated. Gave Bellad.30 December 3d. On the following day there AA'as increased tenderness, delirium and subsultus milder. Prostration and thirst, with desire to drink but little at a time; also some chills; for Avhich class of symptoms gave Ars. alb.200, repeated every two hours. The spinal hot water bag of Dr. Chapman was applied, and the hot water was ordered to be reneAved every half hour. Visited the patient at midnight and found her in a Avarm gloAV and sweat; also more composed, Avith a loAver temperature, viz., 102°. Pulse diminished in force and frequency, viz., 110. Ordered light and mild diet, drink of cold, Aveak tea. On the fourth day patient Avas better. Tympanitic condi- tion lessened and abdomen soft. Prescription continued. Fifth day.—Patient improved; gaAre Hepar sulph.30 every three to four hours to promote cicatrization. Otherwise con- tinued treatment same as before. Sixth day.—Temperature 99°, pulse 95; still improving. Made no change, except the dressing, which Avas renewed. Seventh day.—Better; temperature 98°, pulse 92. Treat- ment and diet continued. Dressings changed. Eighth day.—Better; ordered more generous diet. Dressed the parts/and removed the upper and loAver deep sutures, the parts being healed. Replaced dressing as before, and discon- tinued spinal hot water bag. Ninth day.—Still improving. Patient had a slight stool, rather loose. No disturbance of the adhesion of the sphincter muscle. No untoAA-ard symptoms. Patient passed to a steady recovery. By the tAvelfth day all the sutures had been removed. Patient Avas confined to her bed, as a precautionary measure, three Aveeks longer, with limbs bandaged. Result, complete recovery; the child, an eighteen pound baby, was sent to the foundlings home. Case 6.—Feb., 1868, was consulted by a.Avoman, ret. 47, Avho 7 98 PERINEORRHAPHY. stated she had borne nine children. Was married in her eighteenth year. When her seventh child Avas born, partial laceration of the perineum occurred; she was then in her thirty-second year. The doctor in attendance resorted to the expectant plan, using simply a bandage, and trusting the case to nature. She always complained afterwards of bearing down pains, Avith more or less desire to urinate; frequent difficulty of making stool, Avith almost constant pain in the sacral region, Avhich always Avas relieved for aAvhile by pressure with the hand, and on lying down. At times, and especially when affected with diarrhoea, these pains Avere much aggravated. She stated that the mouth of the womb could be felt at that time just within the opening, or vulva, Avhen at stool, or when moving about much on her feet. Patient Avas of an active, energetic disposition, and was in the habit of carrying home heavy baskets of marketing, three times a Aveek, for a considerable distance. At each successiA^e labor, viz., the eighth and ninth, the parts were torn each time, until the recto-vaginal septum was invohred for an inch and a half beyond the limit of the perineal triangle. Fifteen years after the first rupture, and nine years after her last child was born, I saw and examined the case. She pre- sented the following condition : The patient could not stand erect and walked in a position much inclined forward, looking like an aged person seventy or more years of age; was haggard and pale, also very weak, having been more or less confined to her house and bed for seven years prior to the period I Avas called. Pulse was feeble; respiration short, labored ; her favor- ite position being on the back, with lower limbs flexed and spread Avide apart. Digestion Avas remarkable, considering the nature of the case. Was obliged to live chiefly on fluid diet, on account of the great distress she experienced when having stool formed from a solid diet. She described these occasions as being as severe as any labor, and seemed to dread them as much; in fact she Avas obliged to use enemas to obtain a stool, and then in insufficient quantity. The urine had to be draAA'n for seA'eral years prior with the catheter. The catamenia had ceased in her forty-fifth year. PERINEORRHAPHY. 99 An examination of the parts involved revealed the following appearance: Prolapsus of the uterus and bladder complete, Avith partial prolapsus of rectum. There were extensive adhe- sions at and completely encircling the vulva, and subinvolution of the vaginal walls. The entire surface of the protruding mass had lost its identity, having been completely changed from a mucous to a tegumentary covering. (Fig. 10.) Here Avas a condition of parts such as I had never witnessed before and had not even heard of. I was much puzzled, and took time to look up authorities on the subject, but found no comfort in shape of information anywhere I applied. The case had been pronounced hopeless, by various medical men who had been applied to, on former occasions. NeArertheless I treated the patient for several weeks by means of repeated taxis, keeping her in a recumbent position of decubitus, with head and shoul- ders low, and hips elevated; prescribing for her a fluid, nourish- ing and somewhat stimulating diet. After much delibera- Fig. 10. tion I then figured out a plan, and submitted it to the patient, and her daughter, the only one living with her. They both consented to place the entire management of the case in my hands, and allow me to use my own judgment. I should here remark, that a few remedies had been given as symptoms pre- sented themselves during the period above referred to; but 100 PERINEORRHAPHY. I rather think the abatement of her physical ailments was due more to quietness, rest, position, good nursing and a proper diet. After vainly seeking for professional assistance, I succeeded in obtaining only the aid of my associate in the practice at this time, although he did much to discountenance the operation. Operation. First evacuating the boAvels and bladder, the latter being very much atrophied and of A'ery limited capacity, the patient was aetherized. I should have stated that the patient had been very carefully examined several times during the pre- paratory course of treatment, and although there was some functional disturbance of the heart and circulation, still not sufficient to contraindicate an operation, and the use of anresthe- sia. I then proceeded to dissect up carefully the adhesions around the vulva, and found them very dense and extensive. It seemed as though the upper limit never would be reached below the limit of the abdomen. Finally, by means of slow and persistent efforts, I at last succeeded in detaching them, having to make considerable tension upon the protruding mass to enable me to complete entirely their free dissection. This being accomplished, the parts were bathed freely Avith hot water and annointed Avith simple cosmoline, and then en- veloped Avith a soft towel; by means of persevering and con- tinued taxis of more than one hour in duration, they finally yielded and were passed up into the cavity of the pelvis. Hav- ing gained this much, and feeling greatly encouraged, I de- termined to be content for the present, delaying the final oper- ation for the time, as the operator and patient both needed rest. With the usual dressings for operations of these parts, together with the care required of both bowels and bladder, the patient was put to bed, being placed in the same position as heretofore described. Diet consisted of broths, milk toast, etc., no solid food being given. After the expiration of six weeks, due at- tention having been paid to the wants of the case in all respects, and no untoward symptoms occurring, the second operation Avas made. PERINEORRHAPHY. 101 The relaxed organs were nicely healed, keeping their posi- tion ; and the functions of the bladder and rectum had im- proved, the patient having more control over both the organs. The decubitus position, Avith hip Avell raised, had been main- tained throughout the six Aveeks referred to. Second Operation. I noAV made efforts to repair the perineal structures. It will be remembered that an interval of fifteen years had elapsed between the first rupture and the time when I first saw the patient. Therefore it may be readily imagined that the parts Avere not in a favorable condition for an operation. I found it extremely difficult to limit what were its former and natural boundaries; nevertheless I succeeded by careful measurements; and then outlining the remnants of the parts involved in the rupture, Avith pen and ink, proceeded Avith suitable knife and forceps to incise these lines, dissecting out both triangular por- tions of what was now cicatricial structure. This step in the operation Avas after the manner of a rhinorraphy operation, only rejecting the dissected portions. This proved somewhat difficult and protracted, on account of the profuse bleeding, the parts being very A'ascular; still it Avas effectually accomplished. Xext freshened the margins of the recto-A'aginal septum; this Avas done Avith properly con- structed scissors and rat-tooth forceps. Now introduced recto- vaginal sutures first, these were four in number; next in order the sphincter ani stitch. Here let me add, that I haA^e in\Tariably, from the first opera- tion I ever made, AA'here this muscle AA'as involved, introduced the needle Avithin the limits of the torn ends of this muscle and not Avithout, as I have seen performed in some cases by other operators, Avith incomplete, unsatisfactory results. The main features in an operation for complete rupture are PRIMARILY THE ENTIRE RESTORATION OF THE SPHINCTER ANI MUSCLE TO ALL ITS NORMAL FUNCTIONS AND RELATIONS TO THESE PARTS; THOSE OF THE RECTAL OPENING AND PERINEAL BODY ARE BOTH SECONDARY. WHEREAS, IN PARTIAL RUPTURES, AND WHEN 102 PERINEORRHAPHY. THE SPHINCTER IS NOT INVOLVED, THE PRIMARY FEATURE THEN BECOMES THE RESTORATION OF THE PERINEAL BODY. In this instance the sphincter and adjoining structures had become so shrunken that I was obliged to make what is known as Dieffenbach's operation, AA'hich consists of the lateral incisions, for the purpose of relieving tension of the parts Avhen the sutures are drawn. The sutures used in this case were the double silver quilled variety, and Avere taken A^ery deep; nine deep penetrating sutures, together Avith four intervening super- ficial ones; total, thirteen stitches. A finer grade of Avire Avas used for the last named. The usual dressings, such as already described, and same procedure, Avere resorted to. The patient bore the operation and its effects nobly, and rested well the night following. On the following day, little or no fever; pulse 95; tempera- ture 99°; and feeling comparatively comfortable, judging from her appearance and symptoms. Took some nourishing food, and relished it. Attention Avas paid to the urine at stated and regular intervals. To abbreviate the history of this case, and thus avoid lengthy details, we will state, that the patient pro- gressed to a good recovery, without any unfavorable symp- toms. Dressings were renewed from time to time, as the case demanded, and much the same applications were used; also daily deodorizing the patient's bed with carbolized spray. The first stitches removed were some of the deep ones, three in number, on the fifth day. On the eighth day all the re- maining sutures, including the sphincter and recto-vaginal, were removed, and the parts were nicely healed. The patient was kept closely confined to bed, in a recumbent position, for a period of seven weeks, when she Avas allowed to move about. But the long contracted habit of stooping and bending for- ward, to which she had been addicted for years, could not be overcome unaided. Therefore a Banning's spinal and abdomi- nal supporter was applied, which aided her very materially in standing erect. She wore the apparatus for a period of tAvo years, and then laid it aside, feeling fully able to support her- self erect Avithout its aid. No return of the trouble ever re- curred. Some seven months ago I heard of the case, and she PERINEORRHAPHY. 103 was then in the enjoyment of good health with no return of any of her former troubles. This case demonstrated the practicability of overcoming a condition of affairs that had been for years pronounced by numbers of physicians, also some eminent surgeons, as " be- yond THE PALE OF SURGERY." Case 7.—Was called April, 1868, to attend what Avas stated to me to be a case of confinement, and upon arriving and entering the room of the patient, found the child was born, the mother lying unconscious, having fainted as it appeared from loss of blood. Turning aside the bed-clothing, found a large mass of coagulated blood in the midst of AA'hich the placenta was imbedded. The hemorrhage had evidently ceased spontaneously, Avhen syncope set in. A further examination plainly indicated rupture of the peri- neum, involving the parts through the sphincter ani. I ex- amined the os uteri and finding it contracting, though tardily, aroused the patient Avith an application to the nostrils, of aqua ammonia. As soon as she could swallow, gave China30, repeating frequently, and ordered it to be continued afterwards every hour, until she had regained some strength. The ac- count received Avas that the patient had been, more or less, in pains for three days, Avhich were supposed to be only false pains. Early on the morning of the fourth day, at 3 a.m., severe and strong pains set in. Her husband was sent with a message to call me, but failed to deliver the call unti HI a.m. following day. Having no proper assistant at hand, I merely applied and secured a compress, moistened with arnica Avater, to the vulva, and bound the limbs together. Called the eA^ening of same day, at 10 p.m., and found the patient dozing quietly; she had had no further hemorrhage during my absence. On the following da}' I called Avith assistance, and proceeded at once to repair the breach. Found the torn parts needed no other inter- ference than simply the introduction of stitches. First exam- ined the rectum, finding it unoccupied as far as the finger could reach. Relieved the bladder; administered anaesthesia. Intro- duced double silver Avire sutures, first securing the torn ends of the sphincter muscle. Three other deep stitches AA'ere also 104 PERINEORRHAPHY. taken, in the order, from below upAvards to the fourchette. The margins Avere now approximated, then the ends of the sut- ures twisted in the order of their introduction. Superficial stitches were also used, two in number; these were of a finer grade of Avire, and taken in the intervening spaces betAveen the deep ones. Dressings were noAv applied as usual; quiet- ness and rest were enjoined; the remedy, China30, Avas con- tinued at intervals of three to four hours during waking hours. Visited the patient daily, giving attention to the usual de- mands of such cases, already herein referred to. On the second day examined the parts; found adhesions ap- parently starting in; reapplied dressings. On the fourth day removed dressings; found union suffi- cient to warrant the removal of the two central sutures. Re- dressed parts; as usual, patient had improved much, was gain- ing strength. Had slight fever, hoAvever, pulse a little rapid, 95, temperature 99°. On fifth day patient had some thirst, Avith sensitiveness OA'er the abdomen, which was tympanitic, pulse rose to 102, tem- perature 102°, skin was hot and dry; frequent desire to make water; tongue coated, headache, no appetite. Diet: AA'ine aahey, crackers and milk, weak tea, etc. Sixth day.—Called and found patient had had a restless night; was somewhat flighty and restless, pupils dilated. Pulse full and bounding, 120, temperature 107°. Abdomen more swollen and sensitive, also more tympanitic. Removed dressings and found parts somewhat tumefied, red blush in and around the margins of wound, which Avas very tender to the touch, or by eA'en slight movement of the body; sutures, excepting cut ends, buried out of sight. Erysipelatous complication had devel- oped. Applied locally hot applications of sulphite of soda in solution, grs. xx to aqua f^i, adding a little glycerine to pre- vent rapid evaporation. This Avas ordered to be frequently reneAved, by means of a syringe, and throAvn on to the dressing 0ATer the wound and inflamed parts. Gave same remedy in- ternally every two hours, proportion of one grain at a dose. Applied one of Chapman's spinal hot water bags to the back; ordered renewal of hot water every forty minutes and thus PERINEORRHAPHY. • 105 kept up. Diet light and nourishing, with toast and milk, Aveak tea, milk punch, beef tea, etc. Srrcnth day.—Called and found the patient easier, all the unfavorable symptoms abating, inclination to urinate less fre- quent. Pulse softer, 105, temperature 102°. Wound not so swollen; abdomen not so sensitive; cystic irritation diminished. Patient remained quiet as long as the spinal bag was kept hot— Avhen it got cool she became restless and desired the hot water to be renewed. Renewed same dressings, after removing the old, bathing the parts freely with hot water. Prescription re- neAved. Eighth day.—Patient still improving; pulse 104, temperature 99.5°. Removed dressings; parts operated on were much better in every respect, redness and swelling had all disappeared, marked diminution of sensitiveness. Continued prescription and dressings same as previous day; likewise diet same as before. Ninth day.—Patient passed a comfortable night, no restless- ness, little fever, skin inclined to be moist, less thirst, counte- nance more cheerful, pulse 98, temperature 99°. Examination of parts operated on presented a more promising appearance. Sutures were now clearly defined, all of which were removed at this A'isit. Redressed the Avound same as before, still using same application. No motion from bowels since confinement, neither any desire. Some slight suppuration apparent where the sutures were draAvn from, but union appeared firm. Hepar sulph.30 AA'as given three to four times daily. Diet of strong broths, milk, eggs, etc. The Avound healed kindly, and the patient fully recovered. Case 8.—Was consulted August, 1868, to give an opinion in a case of seven years' standing; the patient a mother of seven children; was forty-nine years of age, formerly of Vir- ginia. Accident occurred during her last confinement, which was an instrumental delivery. Patient was much broken doAvn in body and in spirits, also was emaciated. She could scarcely move about Avithout becoming, very weak and short of breath. Syuiptoms.—Much bearing down, upon assuming an erect 106 PERINEORRHAPHY. position, and feeling as if everything inside of her would fall out through the vagina. Pain and severe aching in small of back, over the sacrum and as high up as kidneys. Constant urging to urinate, passing small quantities at a time. Invol- untary passages of flatus; with the stool there Avas much urg- ing in both organs. Had passed the turn of life, having suf- fered during this term very much from weakness, losing much blood; appetite was poor, could not enjoy her food at all; had sour stomach and water-brash. Palpitation of the heart, Avith difficult respiration. Feet and ankles up to knees, would swell very much, and become cedematous, especially Avhen upon the feet. These symptoms and conditions would be alleviated, some- what, when recumbent and at rest. Examination of the gen- ital, rectal, and urinary organs, presented the following condi- tions. Protrusion of the cervix uteri, and a large portion of the body of the womb; the bladder and rectum also prolapsed. All these parts were more or less flabby and relaxed, at the time herein referred to. Patient stated that at times, when on her feet, or moving about, these organs would swell, and be- come red and somewhat painful. These symptoms would sub- side, after a few days rest, by lying on the back with hips eleA^ated, head and shoulders low. There were some adhesions formed around the vulva here, as in the case already reported, (Case No. 7), but no such changes of the mucous surfaces of the protruding mass, still it was not as moist as natural. Patient stated that when they protruded, became swollen and hot, they were then much drier than usual, which was intensified by the friction from her garments. I gave my opinion in favor of an operation, recommending first, a preparatory course of treatment. Both 'husband and patient acquiesced; and forthwith the case was placed under my supervision and care. To curtail this statement, I will simply say much of the course of treatment was resorted to in this instance as in Case 7, the only variation being in the selection of the remedies. The symptoms and temperament indicated Nux vom. Accordingly the 200th was administered. The gastric symptoms gradually subsided under the use of this PERINEORRHAPHY. 107 remedy. Much Avas accomplished in other directions, by means of quietness and rest, patient using the raised hip position. A carefully selected diet was observed, principally of milk, wine- Avhey, egg custard, broths, free from fat; also a moderate amount of fruit, and as a beverage milk, as Avater disagreed with her, and tea and coffee were restricted. After some eight or nine weeks careful nursing, the patient improved physi- cally, most of her distress having subsided, and she now was quite desirous of having the operation made. Operation.—The usual preliminary steps Avere observed, such as the evacuation of the bladder and bowels, and the patient Avas put under anaesthesia; there being no contraindications for its use. She was placed in the usual position, same as for lithotomy; chloroform was used, and the patient passed under its influence Arery kindly. I was assisted by my professional associate and the lady's husband. The first step Avas to loosen up the vaginal adhesions, which were somewhat extensive, by means of taxis, and kneading the abdomen, raising up Avell the hips, at the same time pressing Avell upward. After some exertion, I succeeded in crowding back the extruding organs to Avhich in this condition a compress was suitably adjusted and kept moistened Avith hot arnicated water, one part to forty, then binding the limbs together, placing them in a flexed position, the patient was put upon her side. This constituted the first stage of the operation. Diet and after-treatment in this case Avere much the same as in first operation of case No. 7. Made daily visits until the close of the third week, at which time the cut surfaces had sufficiently healed so as to permit further procedure. Second operation.—Prepared patient same as before, and when anaesthesia Avas complete, I proceeded to mark out on each side, Avhat should constitute the perineal triangles. Dissected out the cicatrized tegumentary surfaces, bringing into view the ends of the torn sphincter muscle; freshened the margins of the recto-A'aginal septum. As soon as the hemorrhage had ceased, I introduced four deep silver wire sutures, heavy double Avire. This accomplished, the sphincter ani suture was first secured, after the intermediate deep ones were placed in situ, 108 PERINEORRHAPHY. and the remainder Avere secured afterAA'ards. Intermediate superficial sutures were also used, between the deep perineal stitches. The quilled or lateral supports were used in securing the deep ones; all the remainder Avere twisted single Avire sutures. Five deep ones wrere used in securing the sphincter ani and perineum, besides three superficial ones. Four single wire sutures were used in the torn portion of the recto-vaginal septum. The margins were now nicely approximated; but the tension was more than I felt warranted in trusting, I therefore made the lateral incisions which had the effect of taking off the tension. The parts were now adjusted to my satisfaction. The usual after-treatment was adopted here. The dressing being completed and the patient put to bed, she soon reacted nicely, some little sickness of the stomach was all she com- plained of. Nux vom.200 relieved this condition. Patient soon after fell asleep. Observed the usual precautions in regard to the bladder and bowels. On the following morning called and found the patient had passed a comfortable night. Water had to be drawn twice during the night. Pulse 95. Temp. 99°. skin warm, no dryness. Second day.—Patients condition favorable, no untoward symptoms whatever. Pulse and temperature same as day before. Ordered the patient's room to be deodorized with Bromine. Third day.—Some uneasiness about the parts operated on, but subsided after dressings were renewed. Fourth day.—Patient wras uneasy and restless, did not rest Avell during the night. Skin hot and dry. Parts about the perineum hot, burning and throbbing, urine hot, slight chills and creepings, pulse 110, temperature 102J°. Headache, anx- iety and fears of death. Gave Aeon. 200th, repeated every two hours; called the eATening of same day and found patient easier. Fifth day.—Increase of heat, and a burning in the region operated on. Patient seemed to dose at intervals through the night, but would wake up and start, complaining of pain and throbbing in the parts operated on. Tongue Avas coated, dry hot and feverish; headache. Pulse 115, temperature 104|°. PERINEORRHAPHY. 109 Noav removed the dressings, sprayed the parts as before, with carbolized water. Some swelling was apparent and redness of the wound. Slight pressure left a transient white spot, showing an erysipelatous condition, involving both of the lateral incisions, and Avound as well. Removed the two re- maining sutures. Applied sulphate of soda solution, in pro- portion of grs. xx. to aqua f§ 1, hot; this was ordered to be used freely; the parts and dressing not being allowed to get dry. Dressed as in the usual manner. The same remedy was given internally and repeated in grain doses every 2 hours. The patient gradually improved each succeeding day, passing on to speedy recovery, the operation being a complete success. A feAv months later she had gained a condition of health and degree of comfort, that she had long been a stranger to. One year later heard from the patient, who stated that she Avas then in robust health. Case 9.—Was called to see this case October, 1869. .The patient was of Irish birth, aet. 27, and had just been de- livered of a hale, hearty child. She had been attended through her various confinements by a midwife, Avho was pres- ent Avhen I called. The latter stated that the patient Avas in labor some nineteen hours, and had vigorous pains through- out the period named. Examination of the case showed, a partial rupture of the perineum, extending to the sphincter ani muscle; also involving nearly three inches of the posterior wall of the vagina. The after-birth had not yet come away, the patient had lost considerable blood, and the hemorrhage was still actiA'e on my arrival. The patient being of robust and sturdy health, however, did not seem to feel any marked Aveakness. By means of kneading the abdomen with one hand, and passing the other hand well up into the cavity of the womb, I found the placenta partially adherent to the left Avail of the womb. Detaching the remaining portion and making conjoined manipulation Avith the hand that was in- troduced and the other outside upon the abdomen, I succeeded in removing what Avas the half detached placenta, and excited contraction of the uterine Avails, when the hemorrhage ceased. After caring for the child, preparations were made for an 110 PERINEORRHAPHY. operation, to secure and restore the lacerated parts. Placing the patient in the usual attitude, heretofore described as in lithotomy, she was chloroformed; this accomplished, I pro- ceeded to introduce the sutures. Passed in first three single wire sutures through the vaginal rent, afterwards three deep perineal double sutures, of silver wire. Closed the vaginal stitches by first tAvisting these, and bending the protruding ends flat wise, protecting the vaginal surface from irritation with carbolized cotton. The deep perineal sutures Avere se- cured ; commencing at the posterior fourchette, thence towards the anus, using the quilled lateral supports. The margins were nicely coaptated Avhen all the sutures were in situ. The ordinary dressings were used, and the usual requirements of such cases met, A'iz.: carbolized lotions; attention to urine and bowels, also purifying the atmosphere of the patients room; proper diet, mostly fluids. Prescribed China off.30, a dose every three hours, except during sleeping hours. Without going into any further details, we will simply state that after the lapse of the second day, the case was seen and properly attended to daily, until the fifth day, when all the sutures were removed; the parts having healed more rapidly than usual in such cases. The patient passed on to a speedy and complete recovery, leaving her bed to resume her duties on the nineteenth day; and no further trouble was experi- enced from this mishap, as I learned five years later. Case 10.—Was summoned, early in November, 1869, to at- tend a case of labor, at 3 a.m. Found the patient a young girl, aet. 16. She was attended by a friend, who stated that she called upon her casually on the previous afternoon, and was surprised, to find her alone, in labor. The patient persistently refused to have a physician; though her pains were very strong and seemed to convulse her. The attendant delayed, but find- ing after the lapse of some nine or ten hours, that the patient gave evidence of swooning, she started off at once, and being the nearest physician at hand, I was called. On my arrival, I found her in convulsions, with head thrown back, teeth clinched, sudden starting of the limbs and entire body. Pupils were dilated, breathing labored and stertorous; during PERINEORRHAPHY. Ill the intervals betAveen the paroxysms there was subsultus ten- dinum. For this condition Bellad.30 was given every fifteen minutes, until the spasms greAV less in force and frequency, Avhich Avas Avithin an hour. A further examination revealed the head and shoulders of the child, Avhich had just emerged through the vulva. I also discovered by SAveeping the finger over the perineal margin, that a partial rupture of the peri- neum, through the raphe, two-thirds its extent, had taken place. During the next pain the child was born and Avas of unusually large proportions. Considerable hemorrhage fol- lowed. The same process was adopted here for its arrest as in Case IX, which AA'as successful; the placenta being removed and the parts cleansed, I at once proceeded to insert the stitches. The patient, a primipara, Avas chloroformed, and Avith the assistance of her friend, I introduced three deep peri- neal sutures. Finding that the parts coaptated nicely, the ends Avere twisted and properly protected and turned doAvn lengthwise with the raphe; a compress was applied and the usual bandage. This case was treated much the same, as here- tofore described; daily attention was given to the case, and it progressed favorably to a successful issue. There is nothing worthy of note, except to state that the stitches in this case Avere removed on the fourth day, the parts having nicely healed. The patient Avas confined to bed fourteen days, Avhen she arose of her own accord. We will also state, in conclu- sion, that the child, in this instance, Aveighed over sixteen pounds. Case 11.—Late in November, 1869, was called in consulta- tion by my former preceptor, Dr. J. G. Houard, to see a lady, aet. 40, rather large in Aveight and stature, who had fallen early in the seventh month of pregnancy, striking the perineal re- gion over the sharp edge of a large wash-tub; haA'ing fallen backAvards in her descent some seven feet. On my arrival at the patient's residence, I found her lying in a state of semi- consciousness, pulse weak and rapid, skin cold, SAA'eat over the face and forehead, respirations somewhat labored and long, with sighing. I recognized the condition as one of traumatism, and accordingly suggested Arnica mont., 30th 112 PERINEORRHAPHY. trit. This remedy was given every fifteen minutes, and so continued until the fourth dose, Avhen she presented symp- toms of recovery from the shock. Examination of the peri- neum reA'ealed an extensive ecchymosis and laceration of that region, from the posterior fourchette to the sphincter ani mus- cle; also partially detatching and otherAvise injuring the os coccyx and sacral bones, the symphysis-pubes, mons veneris and urethra. The extent of the laceration involved two-thirds of the perineal body, implicating the posterior vaginal Avail to a like extent. Some apprehension Avas felt that premature labor might occur as a result of the injury; nevertheless it was thought best to close the Avound Avithout delay. Bathing the parts freely with warm arnicated Avater—proportions one part of the tincture to thirty of Avater—three deep sutures were taken at equidistant points. The parts were iioav approxi- mated and sutures secured by twisting them; and the usual means of protecting the exposed ends and dressings were ap- plied. Patient was then put to bed to wait the issue, with orders to notify the doctor in the event of any uterine pains setting in. On the day following we both visited the patient, finding her as comfortable as could be expected, having passed a more favorable night than was anticipated, complaining only of a bruised and sore feeling throughout her whole body. There AA'as slight fever and thirst, pulse 112, temperature 99°. Arnica Avas continued, the 30th internally, and the same strength of lotion locally as used the day before. There is nothing of note to report of the case, excepting that the pa- tient passed on to a favorable recovery; carrying her child to full term; when she was delivered of a still-born child which was not fully developed. The patient stated that after the effects of the shock had passed off the movements of the foetus in utero had ceased. Case 12.—Early in December, 1869, my attention was called to a case of what had been pronounced and treated, for several years by a number of practitioners as a case of "falling of the womb." Examination revealed the presence of the os and cervix uteri protruding outside of the vulva; the measure- ment of this portion was half a finger's length, Avhile the PERINEORRHAPHY. 113 patient was in an erect position. Placing the patient in a de- cubitus position, with hips elevated, head and shoulders low, now making pressure in the line of the straits of the pel- vis, displaced organ passed up into position, and, while the. patient lay as described, it remained there. Sweeping the index-finger around the margin of the vulva, immediately I suspected there had been a laceration of the perineum at some remote period. Making now an ocular examination, I ascer- tained that my suspicions were correct. The case proved tQ be a partial laceration, which was confirmed by the statement of the patient, upon being interrogated. She said about fifteen years prior to this time, and after her second delivery, of a, large child, she felt a tearing sensation during the passage of the child into the world. The doctor in attendance, on the occasion in question, admitted that a partial rupture had occurred, but comforted the patient by telling her that "it would come all right." The expectant plan, was adopted. At the close of the first Aveek the parts were examined by the doctor and pronounced "all right." But there was a conditio^ of affairs that not unfrequently occurs after this method of treatment. When the doctor was asked to account for the womb falling down so far, he remarked, "Oh! it was a commoi^ thing among women." The patient being convinced now of the true state of affairs, an operation was advised as the only remedy for a permanent cure, to which she consented; her gen- eral health being fair enough to warrant an operation. The fol- lowing was the method adopted: First, marking out the limits of the original perineal boundaries, as in Case 6, re-vivifying both sides of the lost portion of what was formerly the perineal body, (the patient being properly chloroformed) three deep perineal double wire sutures were introduced and the quill supports placed in position. The freshened surfaces were now co-aptated and secured; the parts coming together nicely into their former position. No ill effects followed the opera- tion ; the usual attentions and dressings were given and used in the after treatment of the case. On the sixth day union Avas sufficiently advanced to remove all the sutures. The patient remained in bed seventeen days and then arose, taking 8 114 PERINEORRHAPHY. gentle exercise. Three years later the patient reported herself completely relieved of all her former trouble; having regained the usual good health she enjoyed prior to the time of the acci- dent, which for fifteen years had caused her much distress. Case 13.—AVas called in consultation, early in the sum- mer of 1879, by Prof. N. Schneider, M.D., of Cleveland, Ohio, to see a case which had twice been operated on before we saw the case, both of which attempts had proved failures. The parts implicated in the laceration involved the sphincter ani muscle, and the perineal structures. These had been so changed by the fruitless attempts to close them that it was difficult to recognize anything of the former boundaries. The patient being anxious to have the parts restored, and ex- pressing her willingness to undergo one or more operations, if necessary, we concluded to give her the opportunity. A prepa- ratory operation was necessary; and, for obvious reasons, the parts had to be prepared for the final closing up. This accom- plished, the usual operation for re-vivifying the cicatrized parts was made; first marking out the former limits of the perineal boundaries. The first operation fulfilled all that was expected; the second one likewise; five deep silver-wire sutures of the quilled variety were used. The one through the sphincter was closed first; the stitch at the posterior fourchette next, and the intervening deep sutures in the same point of order. Four intervening superficial stitches were likewise taken, when the parts Avere nicely coaptated and secured; the superficial ones were single wire, and were secured by twisting. The usual carbolized dressings, with prepared oakum, were used, and the patient was visited daily, attention being given to all the re- quired details in all such cases. On the fifth day tAvo of the intervening deep sutures were removed. The case promised favorable termination; but some difficulty was experienced from inability to retain the stools, which delayed the union of the sphincter ani; this point had to be stimulated Avith Argent, nitr. On the seventh day the remaining deep sutures were likewise removed, as well as the superficial ones. The patient was confined to her bed, after the final operation, nearly three weeks, when all seemed to be well. Shortly after PERINEORRHAPHY. 115 this time she returned to her home, which was some distance away. As far as can be learned, through a second party, the operation Avas a success. Case 14.—Early in September, 1878, was called by Dr Moses Pardee, of South Norwalk, Conn., to repair a case of perineal laceration. The case was a primipara, set. 19. The following is the history. During the month of April, preced- ing, while in the act of hanging up clothes to dry, standing on a stool, she fell upon her seat, striking a stone violently that Avas jutting out of the ground. She suffered for a while very severely, but made no mention of it to any of her family. After which all thoughts of the accident, passed from her mind, nor did she ever examine the parts. When the doctor was called to deliver her, labor had progressed somewhat, AA'hich not being tedious, the child was soon born. She did not complain, as far as the writer knows, of any tearing sensa- tion during labor; but the doctor in attendance noticed some- thing unusual, at a subsequent visit; the perineal structures looking unusually dark and tumefied, which, upon further ex- amination, he judged to be laceration of the perineum. Three days after the accident, I examined the case, giving a very unfavorable prognosis, and for the following reasons: The patient was of a pale, flabby, leuco-phlegmatic temperament; the Aveather quite warm, the rent commenced at the posterior fourchette, thence extending along the raphe to and involving a portion of the sphincter ani muscle; the second tear ex- tended from a point two-thirds of the way of the right side of the raphe, toAvard the gluteal region, obliquely. A space as large as the palm of an adult's hand, full size, was ecchymosed and tumefied, looking as if it were a recent bruise. This, be it remarked, Avas the condition, no doubt, which followed in the wake of the accident that she met Avith in the preceding month of April. There Avas also laceration of the posterior vaginal Avail, nearly three inches into the septum. Operation was made in the following manner, assisted by Drs. Emily and M. Pardee. Placing the patient in the usual position, same as in lithotomy, chloroform was administered. Trimming away some suppurating shreds from the lacerated surfaces, and 116 PERINEORRHAPHY. as much of the tumefied and ecchymosed tissues as could be spared; five deep perineal double silver-Avire sutures and three single stitches were introduced into the ruptured vaginal Avails, also four superficial stitches in the perineum. The quilled lateral supports were used for the walls; the vaginal stitches were twisted and turned down, being properly protected to prevent irritation. Carbolized dressings, and the usual ban- daging with prepared oakum, were used in this case; and a proper diet enforced. Daily visits and dressings were made by the doctor in attendance. I called, in company with the doc- tor, on the fourth day, and removed two of the deep perineal sutures; suppuration was threatening between the prepared surfaces, for which a moderately strong solution of carbolic acid and warm water was used. Leaving the case in the hands of the doctor in attendance, I did not see the patient again for about two weeks or more, when I visited her and found during this interim the parts had healed effectually; the ecchymosed and tumefied conditions had all disappeared, the parts having resumed their normal condition. In conclusion, will add that the patient had, in addition to this trouble, a malarial condi- tion of system, which was met and relieved with the indi- cated remedies. The result obtained in this case far exceeded my expectations. At last accounts, the patient had regained her usual health and strength. This case is a striking illus- tration of what may be accomplished, under a very unpromis- ing and adverse state of affairs. Case 15.—Was also called to another case, early in Septem- ber, 1878; which was, like the preceding one, a primipara case, aet 27. Nothing AA'orthy of note occurred during the pro- cess of labor; but, shortly after its conclusion, the doctor, who was the same attending physician as in Case 14, noticed a partial rupture of the perineum, which extended from the pos- terior fourchette and along the raphe to a point midway to the sphincter ani. I saw the case on the day after its occur- rence. The patient was chloroformed, and three deep perineal sutures, single wire, were inserted; likewise two intervening superficial ones. Finding now that the parts co-aptated PERINEORRHAPHY. 117 nicely, the deep ones were drawn and twisted; also the super- ficial ones. The usual wants of the patient were attended to, and dress- ings applied; after which the patient received daily attention from her attending physician. On the sixth day the centre and posterior deep stitches were removed, and two or three days afterwards the remainder. The patient fully recovered from the effects of her mishap, with the exception of a single point near the posterior four- chette, which was probably due to a greater freedom of motion on the part of the patient, and from not observing the proper care. An offer was made to her to remedy the defect, but she persistently declined. Otherwise, our record of cases in this department of Surgery stands without a blemish or failure. In concluding this Essay, we will take occasion to mention that all of the cases herein reported, excepting three, were in- strumental deliveries. AVhether due to an improper use of the instruments or not, is not within our power to judge; but we can state, without any hesitation, that in an active experi- ence of a quarter of a century no such mishap as a ruptured perineum has ever occurred in our field of labor, from this cause. From casual observations made, however, and from information obtained from a large number of sources, we are inclined to the belief that these accidents are often due to the too free and too early use of the forceps. Another point noted is, that perineal ruptures are of much more frequent and common occurrence now-a-days than in former years, within our recollection. The result of our report is substantially as follows: Primipara class, six (6); Multipara, nine (9); Recent cases, eight (8); Delayed cases, nine (9); Complete lacerations, eleven (11); Incomplete lacerations, four (4); Complicated, five (5); Instrumental cases, twelve (12); Natural deliveries, three (3), Complete recoveries, fourteen (14). Partial recovery, one (1). HOSPITAL GANGRENE AND ITS KINDRED DISEASES IN RELATION TO THEIR TREATMENT WITH BROMINE AND THE SULPHITE OF SODA, GANGRENE. Authors usually divide gangrene, or mortification, into two divisions, parts, or stages; naming the first the incipient stage, or gangrene attended by sudden diminution of sensation, or feeling, in the part invaded. A livid discoloration sooner or later ensues, Avith detachment of the cuticle, under which a tur- bid fluid collects, and, upon manipulation, is felt a crackling sensation, due to the generation of gaseous products in the sub- cutaneous cellular tissue, accompanied by a more or less boggy feeling in the part, communicable to the sense of touch, and pressure. The word gangrene is derived from the Latin, " gangrsena," to gnaAv, to eat—meaning a partial destruction of living tis- sues; a partial death, so to speak; and entitled by some writers "local asphyxia." AVhatever may be the kind of gangrene, its causes are Ararious—viz.: violent inflammation, asthenic in type; severe contusions, burns, scalds, and the application of a ligature to an important arterial trunk; strangulation of a part from tight bandaging; the obstruction of a flow of arterial blood to a part, from disease of the coats of the vessels them- selves, and termed arteritis; or, by the return flow of blood through the principal veins of a part being cut off; specific poisoning of various kinds; the infiltration of an acrid and irri- tating fluid in apart; and a diseased state of the heart. Again, gangrene may be constitutional or local. Either condition, Avhen caused by a specific inflammation of the part, from obstruction of the blood vessels, or heart dis- 122 GANGRENE. ease, or from the action of specific poisons or drugs that are operating in the system, calomel, for instance, when adminis- tered in frequent or massive doses—and these are not uncom- mon cases—produces gangrene of the face, mouth and throat, resulting in, and technically known as " gangraenopsis." Gangrene often arises from causes inappreciable to us; for instance, when it occurs as an epidemic. The works of Seig- bert, an ancient writer, as early as the eleventh century, re- veal to us epidemics, termed in those days " pestilences," which appeared in the western part of Lorraine, in France. To use the writer's own words: "Many persons became putrid and died in consequence of their inward parts being consumed by St. Anthony's fire," as it was styled then, but now known as erysipelas. The writer continues: " others lost their limbs and recovered, and still others were afflicted with permanent contraction of their sinews." Various epidemics have visited France and Germany, from A.D. 1500 to the present century, traced to the free use of ergot, or spurred rye, eaten in the bread, which the people of the lat- ter-named country partake of largely. As an additional and almost inappreciable cause of gangrene, may be mentioned the transfixion of an important arterial trunk by a spicula of bone in case of fracture. During the war of the late rebellion, (1861 to 1864,) investigations were instituted in some of the Gov- ernment military hospitals relative to the treatment of hospital gangrene, and likewise other affections that appeared in con- junction with, and may be denominated as kindred to gan- grene. These kindred diseases are erysipelas ichorrhsemia, thrombus, metastatic abscesses, (pyaemia,) diphtheria, and scarla- tina gangrenosa. The principal object in view was to ascertain the exciting causes, the manner of their operation in the pro- duction of these most formidable affections, especially when allied with gangrene; also the nature of the process, or means, set in motion, together with the prophylactic agents best adapted for the arresting and curing of these maladies. Vast, and almost innumerable, were the opportunities offered in our military hospitals for the study of the diseases referred to; more especially was this the case in regard to gangrene, pyaemia, or erysipelas. GANGRENE. 123 Diphtheria and scarlatina were isolated and few in number, and Avere only occasionally found as accidental complications. Sufficient, however, was observed to Avarrant the belief finally arrived at, and, I believe, concurred in by all who took an ac- tive part in these investigations, viz:— That hospital gangrene, erysipelas, pyaemia, gangrenous diphtheria, and scarlatina maligna, viewed as local diseases, present, on close observation and careful analogy, many points of resemblance; and that they likewise bear a close similarity in their constitutional aspects. These similes are very strik- ing, and will be seen as we proceed. For instance: In diphtheria the transformation of the mem- branous formation, or exudation, into diffluent pulp; the irri- tating effect of the erosive sero purulent fluid upon contigu- ous and neighboring structures, abrading and excoriating wherever it touches the skin, and mucous membrane alike. In scarlatina, sloughing, or ulceration, a constant accom- paniment, which also exudes or throws off sero-purulent dis- charges ; and a disgusting and offensive foetid odor. Now hospital gangrene invariably evolves a pungent, putrid odor, exudes thin, acrid, sero-purulent pus, likewise corroding and searing over the tegumental surfaces, wherever it overflows the boundaries of the slough. Need I add that when erysipelas runs on to destruction of the cellular tissue, it is attended with similar phenomena. Erysipelas and hospital gangrene are likewise allied in many of their clinical aspects; apparently they may be dissimilar, but, by a careful comparison, there will be found points of similarity, as well as those of dissimilarity. The attentive ob- server cannot fail to be convinced of this. Let us now proceed to compare the two diseases. ERYSIPELAS. GANGRENE. 1. Invades skin, cellular planes 1. Attacks the integuments and cell- (known as succulent tissues). ular planes likewise (succulent tissues). 2. Does not readily involve tendons, 2. Will not readily attack tendons, bone, fascia, etc. (dry tissues). bone, fascia, etc., and, I might add, blood-vessels. 3. Attacks and extends along the skin 3. Attacks and extends along the 124 GANGRENE. ERYSIPELAS. and cellular planes, seeming to possess a strong affinity for such tissues. 4. In the cellular form, presents ne- crosies, or death of cellular substance, in the form of diffluent sloughs. 5. When attended with necrosis of the cellular tissues, exudes an acrid, corrosive fluid, peculiar to the phleg- monous variety, which contains no pus, nor other cells. The constituents of this fluid seem to be fine granular debris, or granular matter, the residue of what was formerly tissue (inelastic fibrous tissue). 6. In the cellular form there are putrid odors emitted. 7. Is both infectious and contagious. 8. Is frequently complicated with thrombus and blood clots. 9. Leads occasionally to ichorrha- mia, or blood poisoning. 10. Is producible by inoculation, with putrefying animal matter. 11. It arises spontaneously in over- crowded and illy-ventilated Hospital wards. 12. Attacks generally vitiated and depressed constitutions; and in these are most destructive in its tendency. 13. The treatment required, stimu- lating, both local and constitutional, with generous diet. 14. When death ensues the animal tissues pass rapidly and generally into a state of putrefaction. GANGRENE. tegumentary and cellular planes rapidly. 4. In all the structures which it at- tacks, presents constantly diffluent sloughs, except in bone. 5. Exudes corrosive, thin, sero-puru- lent fluid, excoriating the integument contiguous to it, or where it overflows. The yellowish fluid which can be pressed out of gangrenous sloughs and ulcers, contains no pus or organized cells. The constituents seem to be fine debris, or granular matter, the debris of connective tissue, and a few inelastic fibrous shreds. 6. Likewise emits putrid odors. 7. Likewise infectious and conta- gious. 8. Is frequently accompanied with thrombus. 9. Leads almost invariably to ichor- rhsemia, unless promptly arrested. 10. Is producible by inoculation, with putrefying animal matter, as well as by some of the gaseous products of putrefaction. 11. Arises from the profluvia of illy- ventilated, over-crowded apartments of Hospitals. 12. Occurs mostly in broken down and depressed constitutions, in which it proves most destructive in its ten- dency. 13. Treatment required—Stimulat- ing, both constitutional and local, with a generous diet. 14. Passes into a state of rapid pu- trefaction even before death is com- plete, or the body grows cold. In the present state of medical knowledge, we are disposed to regard the local evidences of erysipelas, of scarlatina, and diphtheria, to be preceded by, and depending on, certain blood conditions—i. e., " blood poisoning." In this respect, there is GANGRENE. 125 some noticeable resemblance. All three of these diseases ap- pear to have the same characteristic location—viz., the tegu- mentary surfaces, or planes. Erysipelas is not unfrequently a complication of diphtheria and scarlatina. Both of these diseases are adynamic, or prostrating diseases, and present to chemical examination analogous changes in the blood. As to the causes that operate to produce erysipelas, thus far we knoAv: Erysipelas is often the product or result of dissect- ing Avounds—of wounds received in killing and dressing dis- eased cattle, or the putrefying carcasses of those killed by vio- lence or accident. It is also knoAvn to occur in the form of puer- peral fever, (peritonitis,) from infection conveyed through the hand of the midwife, as is well knoAvn in Europe and America. Often is it associated Avith severe and crushing injuries of the joints, and diseases of bone;, especially is this the case in re- gard to caries, or ulceration, and necrosis, or death of the bone —diseases remarkable for the persistent and foetid odor, Avhich accompanies all such discharges. In fact, all that is known thus far, and can be said, with re- gard to the artificial production of erysipelas, may be summed up in a few words—viz.: It is the agency or product of putrefying and decomposed animal matter. Erysipelas, likewise, seems to be engendered in crowded and ill-ventilated apartments, reeking Avith the foul effluvia emanating from the human body; in hospital wards, poisoned with the exhalations from imperfect drains and cess-pools, especially from the former. It may also be traced to the miasm emanating from the bodies of those afflicted Avith the disease. The bodies of those Avho are afflicted with erysipelas in some of its worst forms, (malignant,) and especially Avhen epidemic, it is a Avell-known fact, emit offensive and putrid odors. The remains of those Avho die from it, as before remarked, pass speedily into a state of putrefaction. Search then as closely as we may, we will find the entire weight of the testimony goes to prove, most conclusiArely, that erysipelatous diseases are, more or less, intimately connected with putrefactive processes; and while it may not be possible, in our present state of medical knowledge, to establish the precise 126 GANGRENE. relationship between erysipelas and gangrene, enough is known to make it certain that a most intimate connection exists be- tween the two. Of the causes that operate to originate and produce hospital gangrene, so far we know: It arises in overcrowded Avards, where the wounded are collected, and where the apartments are poisoned and the air impregnated Avith the stench of pro- fluvia from traumatic causes, and probably where the impuri- ties of cellars and sewers pervade the air. It is also producible by inoculation; and there are very strong reasons for asserting that gangrene can be produced by keeping the putrid flesh of animals, that died in health, in proximity to the surface of an open and healthy wound. The poison spreads rapidly through the medium of the air, and adheres with great tenacity to fomites—such as bedding and clothing of a woolen nature. But little is yet accurately known as to the precise method by which the agents originate and produce erysipelas and hos- pital gangrene. Waiving all considerations as to its identity and personality, it seems to—and, indeed, does—operate through the medium of the atmosphere. According to traditional views, it gains access to the system or blood by being " breathed in." This, although a popular and received theory by many, yet needs a closer investigation, for there are some facts (which will be obserAred as we proceed) that seem to militate against this much-received view of the question. The facts in the case are simply these: It Avill be noted, by such as are careful observers, that those who are recovering from erysipelas, say, for instance, of the face, or the scalp, are, after desquamation of the part attacked, peculiarly liable to fresh attacks, when re-exposed to the effluvia or miasm in af- fected wards of hospitals, or apartments; and that this liability to the malady can be prevented by coating over the part with tincture of iodine, which process, as is well known, detaches the epithelial layer of skin. The same immunity may be in- duced by repeated embrocations with glycerine, and keeping the parts, more or less, continually moistened during the ex- posure. Castor oil, collodion and cerate, or most any oleagi- GANGRENE. 127 nous material, will do the same, so long as the pores of the skin are kept sealed Avith it. Moreover if the accepted theory is correct that erysipelas acts from, and through, the medium of the blood; it is very difficult to comprehend why it so constantly selects the face and backs of the hands as the points of original invasion; and yet having commenced on the face, extends to the neck, hairy scalp, underneath the beard, and over the shoulders and thorax. Any part of the tegumentary surface exposed to the atmosphere, and not protected by hair, may be invaded by erysipelas; while those parts covered Avith clothing are at- tacked only in case there is an ulcer, wound or abrasion, located there, and exposed, at some time, to the influence. If a man has caries, necrosis, or hospital gangrene—in fact, any disease commonly associated or akin to erysipelas—the latter attacks the skin at the site of the original disease. A morbific agent, operating in the blood, is said to attack those tissues, or parts, of the body which have a supposed af- finity for the poison—a susceptibility or sensitiveness to it. As an instance, let us regard these facts;—secale cornutum im- presses the uterus; phosphorus the lower jaw; mercury the gums, teeth and bones of the face, and liver; nitrate of silver the skin and»kidneys; belladonna and opium the brain; but it is not positively known that any producible disease or condition of these organs renders them any more sensitive to the matter circulating in the blood. The precipitation of the silver upon the skin, or particular tissue, seems to depend upon original and physiological endowments of the parts; and this same re- mark applies to the other remedies named. Let us now consider how it is with the virus, or poison, of erysipelas. The theory runs thus: The virus, miasm, infection, or whatever it may be termed, enters the blood through the medium of the air breathed in, and by a sort of process which Ave Avill term "elective affinity;" it attacks the skin of the face, and respects the skin of all other portions of the body, meaning, of course, as points of original invasion. True it is that, beginning in the face, it may spread to other parts, by continuity of surface, but idiopathic erysipelas rarely 128 GANGRENE. begins at any other point, except under certain conditions which will noAv be mentioned. Let a woman give birth to a child, and, while in the parturi- ent state, bring her in contact, or let her be exposed to the in- fection, and forthAvith she Avill get puerperal peritonitis. Now the question may be asked, " AVhat is the pathological condition of the parturient woman, precisely co-eval Avith the period in which she is liable to the iiiA'asion of erysipelas ?" The ansAver is simply this: The interior of her uterus, may be likened unto a surface of skin stripped of its epithelial cover- ing. AVhen reproduced, (and it is not until the close of the second month after delivery that this occurs,) and the parts are restored again, she is no longer any more liable to the in- vasion of erysipelas than she was before becoming pregnant. But suppose a hundred, or tAvo, of men are exposed to the infection of erysipelas, those who take the disease will al- most invariably have erysipelas of the face; the disease will locate on the eye-lids, alae of the nose, and even behind the ears—the integument in these localities, let it be noted here, being very thin and tender. It does not readily attack the surfaces of the upper or lower extremities, as already stated, unless, indeed, the person be suffering Avith injury, or an abra- sion of some kind, which part is exposed to the same influence. This process may, as a rule, be taken as a guide. But it is likewise true that wounded men are, at times, attacked in the face with erysipelas, while the abraded or Avounded parts may escape; and, after the malady has run its course in the face, the injured parts have become subsequently involved. The accepted theory then, is that in idiopathic erysipelas the disease begins on the face, and the only exception is in the case of parturient women and young children and infants. These latter are attacked Avith erysipelas on the extremities quite as often as on the face; but this liability is confined only to the period of early childhood, and for obvious reasons—the skin of the entire body being very tender at that period. It is Avell known, and among the profession particularly, that those AA'ho have had erysipelas on the face are exceed- ingly liable to fresh attacks during the period of desquama- GANGRENE. 129 tion, and how readily these attacks may be averted by re- peated applications of some simple unguent, tinct. of iodine, etc. Again, how common a circumstance it is (and no doubt ex- perienced in the circuit of every surgeon), in cases of severe injuries of a crushing nature, particularly when an important joint is involved, for erysipelas to develop in the injured part, and this, too, when no endemic, or epidemic, influences are at hand. Let us go a step further in our argument. It is a noted fact that all the known blood-poisons, all foreign substances that tend to precipitation in certain parts of the body, or eli- mination by certain organs, Avill seek—if the habitual destiny of the substance is interfered with—vicarious locations. Uric acid, for instance, in gout, tends to certain parts—for example, the joints. Now if the deposition of uric acid, or its compounds, at the joints, is interfered Avith, forthwith the acid seeks another locality. If the agent that produces rheumatism is forced from its resting-place, it at once seeks another locality. If bone earths, re-dissolving in certain diseases, fail in being eliminated, or thrown off, by and through the kidneys, they are then deposited in other localities or organs—for instance, in the lung substance and coats of the stomach. No local treatment for gout or rheumatism dislodges or cures the dis- ease; the utmost hope of topical, or local, applications is pallia- tion of pain, or, it might be, of the local, pathological condition. The agents herein acting, and that have been referred to, are known and recognized as "blood-poisons." The local affection persists, because of the continuous and persistent action of the morbific agents operating from within, and thus producing these affections. AVith the drying-up of the fountain-head )the sources from which these poisons emanate and flow (the local diseases Avill be in the same ratio removed—in fact, cured—and all remedial measures should, therefore, be applied Avith a strict regard to the accomplishment of this end. On the other hand, the records of our military and civil hospitals, as well as the experience of numbers of private prac- titioners, show conclusively that erysipelas may be checked, or interrupted, at any point or stage in its proceedings or devel- 9 130 GANGRENE. opments, and that such interference does not produce any metastasis. Neither are the constitutional statis, nor symptoms, aggravated thereby; but, on the contrary, it will be found that, in the ratio with which the local symptoms are dispelled, the constitutional symptoms will vanish with it. This same remark holds good in regard to gangrene, as can be proved in hundreds of instances. It has also been asserted, and with a considerable appearance of truth, that the same rule holds good, in erysipelas and gan- grene, as in what are known as inoculable diseases: vaccina- tion, hydrophobia, etc.—Avhen the virus has been aborted. In vaccination, we find a period of incubation of some four days; at the expiration of this time, there is some appearance ,of an elevation of the skin, but no redness: this is the period known as infiltration. After the fourth or fifth day inflam- mation sets in, and, co-incidentally, the accompanying symp- tomatic fever. We will suppose now, that, at this precise period, the vaccinia is aborted, or interrupted—it may be by an accidental brush of the hand or clothing, or a scratch of the finger-nail—the constitutional state falls, and is destroyed; nor is the protective agency of the vaccination yet developed. May it not then be possible that the virus of erysipelas acts in the same way ?—that there properly belongs to erysipelas a period of local incubation—zymosis, so to speak, (a passing from with- out inwards)—corresponding to the period of infiltration in vaccination? Following this point, redness and inflammation are developed. The constitutional infection may be produced at any period intervening between the first contact of the infec- tious material, and the development of the local process, full as well as after inflammatory symptoms are developed. If the ancient dogma is founded and based on truth, and if the virus of erysipelas finds its way into the blood, and, by virtue of hypothetical affinities, forces and precipitates itself upon the skin of the face—as nitrate of silver does upon the (entire surface of the body, as ergot does upon the uterus, or belladonna upon the brain—we have to assume (in order to make this theory coherent) that wounds endow the skin of the extremities with another and new order of affinities; that GANGRENE. 131 the puerperal state of the uterus endows it and the perito- neum Avith an entirely new order of sensibilities; that the skin of the legs of infants has affinities that disappear with age; that the coating of the skin of the face with grease, iodine, glycerine, etc., destroys its affinities; and all this in the face of the fact that Avounds—the puerperal state—age and protection are not knoAvn to have influences upon these affinities, or local sensibilities, in connection with measles, scarlatina, small- pox, or any other infectious disease of the skin. Do not these facts make it appear that the contagion of erysipelas is rather by direct contact with the skin ?—that the virus, or miasm, floating in the air attacks the skin of the face, because that is the part most exposed and uncovered; that this is the part most frequently invaded, because of its epithelium being thinner; even more so than that covering the back of the hands? Then, too, the vessels of the face lie more super- ficial; the alae of the nose, the eye-lids and back of the ears, are more susceptible than the cheeks, etc., for the reasons al- ready stated; and it avoids those parts of the hands and feet, on which the epithelium is much thicker and denser. AVho ever heard of erysipelas primarily attacking the unwounded palm of the hand, or sole of the foot ? Is it not reasonable to assume that desquamation of the skin, or its division by a Avound or ulceration, and the exfoliation of the maternal surface of the womb, opens up the parts to the in- fluences of the contagion, and thus renders these surfaces more susceptible; just as the same condition would open the parts to the action of medicinal local applications ? And is it not reasonable to assume that the constant exposure of the child's legs to the open air—or possibly the fact that, in the child's body, there are not yet developed those differences in the thickness and susceptibility of the epidermis, which are obtained later in life—permits the contagion to act with equal force upon different parts of the body?—that the protection (with the agents named) of the tender and delicately-covered skin, just recovering from erysipelas of the face, may prevent the action of the contagion, and thus impart to, or bestow upon the patient immunity from relapses ? 132 GANGRENE. "En passant," let me add, that parts once in\raded with thi^ malady scarce ever escape a relapse, unless protected in some way. In all that the writer has herein adAranced, he does not claim the complete overthrow and doAvnfall of the old dogma of the breathing into the blood the poison, or miasm; but he is of the opinion that the considerations herein urged, as Avell as the records of the past few years, present sufficient grounds to Stimulate thinking minds in the profession to a close re- investigation of the old, (but to his mind,) unscientific and per- haps' mistaken theory. These observations—supported as they are by records obtained practically during the AVar of the Rebellion of 1861 to '84, as well as other statistics—show plainly that the increasing gravamen of many diseases, supposed to originate in blood infections, is due rather to retro-active influ- ences of the parts locally, than to an increasing quantity or in- tensity, or to a growing development of the original blood poisons. Pyemia is the next in order of importance, as a kindred affection to gangrene. The word is derived from the Greek, pyo, pus; and ema, blood—signifying pus in blood, an altera- tion and poisoning of the blood. Like many other medical terms, this one may be classed among the misnomers. Pus, in substance, never reaches the blood, but ichor may; there- fore, the term ichorrhaemia, or even septicaemia, would be more appropriate—the former, as its name indicates, implying the presence of ichor in the blood, and the latter a septic poisoning of the blood. These two terms are from the Greek, and may be said to be synonomous. AVriters have divided pyaemia into two stages or conditions; 1st: A state which they designate ichorrhous infection, or ichor- rhaemia—the condition pronounced commonly when fully de- veloped, and will be recognized by frequent rigors or chills, feeble pulse., loss of appetite, colliquative and exhaustive sweats, local in their nature; a fermentive and sweet odor of the breath, palor of the lips and face, and marked physical and nervous prostration. 2d .stage; Metastatic abscesses and inflammations, produced by the softening of thrombi, or blood cysts, previously formed. GANGRENE. 133 The first of these conditions, or ichorrhaemia, is the constitu- tional state, and develops with the most surprising rapidity, and quickly leads to fatal results; frequently a result of gan- grene, with extensive injuries, especially those involving bone. The state termed "thrombus" is often associated Avith ichor- rhaemia, both of Avhich processes—the ichorrhaemic and throm- bic (otherwise termed pyaemic)—are connected occasionally— in fact, it might be added, frequently—with the more serious local effects of erysipelas, such, for instance, as abscesses and sloughing of the cellular tissue. On the other hand, erysipelas and hospital gangrene are not necessarily followed by ichorrhaemia; still there are feAV cases, that are fully adAranced and developed, in which there is not more or less of it. This ichorous infection appears to be de- pendent on the presence of putrid substances or fluids in the wound; in suppurating cavities and sloughing wounds, as well as upon gangrenous surfaces. A majority of a given num- ber of cases Avill shoAv that constant correspondence, or relation- ship, exists between foetid discharges and ichorous infections. In a large number of cases, carefully recorded, it has been ob- served that the discharges were foetid prior to the development of the first symptoms of ichorous infection, or constitutional disturbance. Ichorous infection, it was noticed, does not al- Avays folloAv upon the presence of foetor in the discharges, but ichorous infection of the blood never occurs where the dis- charges are not foetid; in other words, the latter could not pos- sibly exist Avithout the former having preceded it. Not only is this the case, but, furthermore, it will be invariably noticed, that, as soon as the foetor is corrected in the wounds or slough itself, the constitutional symptoms of ichorous infection, or poisoning, begin to disappear, and that, too, Avith a rapidity that is astonishing. Again, it Avill be seen, that relapses take place; and that these are ahvays co-incident Avith a return of foetor in the Avound. The constant co-relation that is invariably found to exist be- tween the product of infection and the ulcerating and sloughing part, and the constant precedence of the latter in point of time; the constant disappearance of the former upon the correction 134 GANGRENE. of the latter, establishes unequivocally the intimate connection between the two; i. e., the presence of foetor, in the Avound, and the symptoms of poisoning of the constitution. What the peculiar substance is that forces its Avay into the blood, and gives rise, either directly or indirectly, to the ichor- ous poisoning, as yet Ave do not know definitely. One point, however, we are well and thoroughly acquainted Avith, viz., that it is developed only during the putrefactive process, or decom- position of animal matter or tissue. This is made to appear from facts collated from practical experience. Furthermore that the discharge is not pus, in its cells, that finds its way into the blood, but rather that it is a fluid, or dissolved in a fluid, of a foetid ichorous character. Ichorrhaemia then, as already stated, occurs only in cases in which the process of foetor, or ichor, is going on; the power of the agent, or active principle—if such a term is allowable— disappears upon the arrest of putrefaction in the wound; the influence of the same agent is destroyed by, and succumbs to, the material or substance that possesses the power of neutral- izing and arresting putrefaction. Much empiricism has been resorted to in the endeavor to arrest these maladies, and all we know of this treatment may be summed up as follows: 1st. In erysipelas, the topical applications hitherto and mostly used have been iodine, (in the form of tincture,) creosote, sul- phur, argent nitricum, muriated tincture of iron, etc. These substances, as regards their active properties, are A^ery diverse. Wherein, let me ask, does creosote resemble iron or iodine? They agree only in that they are anti-septics—i. e., possessing the poAver to arrest putrefaction. 2d. Hospital gangrene: The local remedies most commonly used, after long years of disheartening experience, are acid nitrate of mercury, chlorate of soda, arsenical solutions, ni- tric acid, and the actual cautery. These are all anti-septics, at least so-called, and they agree in so far that they break up, or arrest, the putrefactive action, directly or otherAvise. 3d. Pysemia: The agents found to be most useful in this most formidable of all these maladies, are free openings, and -complete drainage, at most dependent points, together Avith GANGRENE. 135 great cleanliness and care. Some use has been made of chlori- nated water and hyposulphite of soda, (in the form of injections,) and of iodine, upon the parts most affected. These look in the same direction: on the one hand, cleanliness, and depending openings, and drainage tubes, look to an easy, free and rapid removal of the discharges; and on the other hand, iodine, and chlorinated water, and the sulphites, to the arrest of putrefac- tion in animal matter. Does it not seem singular that in the slow and gradual growth of empirical medicine, that one rem- edy after another, selected by guess-work, or by purely experi- mental processes, and not under the domination of any theory as to the disease in question, should be found side by side, and in common use; and that those remedies, however diverse in other respects, should be found to agree Avith perfect uniformity in one common quality, unless that one quality had some re- lation to the special nature of the diseases, or the causes of their production ? It may be that the putrid process (or, at least, some of its associate products) exercises a counteracting or antidotal in- fluence in the production of the local processes, and that the putrid fluids, passing into the circulation, exercise a direct and controlling poisonous influence, or possibly set up in the blood similar processes as are going on in the wounded or putrefying cavity. It is probable—for the results thus far obtained point in this direction—that peculiar alkaloids are produced in putrefactive decomposition, and that one or more of these are the active agents. AVhatever these agents are, they exist more or less in all kinds of animal matter undergoing putresence. Early in the fall of 1872, a series of investigations were in- stituted in some of our Government military hospitals, having in view the discovery, if any existed, of the essential agent which causes these diseases. After careful, patient and extended investigation, and a general summing-up of results by such as were engaged in the arduous task of determining the agent, or force, directly concerned in the production of blood poisoning, the following are some of the principal points and deductions arrived at. 1st. That the force or agent here at work is not the final 136 GANGRENE. product of putrefactive fermentation; the final product of pu- trefactive fermentation differs from the initial and mediate products. Again, in like manner—according to the conditions of moisture, heat and access of air—Ave ha\-e, as a result, putre- faction setting in, Avith different phenomena and products. AVho has failed to observe the differing results from the decomposition which takes place in the ordinary process of maceration, in the cadavar, enclosed in a metallic coffin, and from one that is openly exposed to the hot rays of the sun. 2d. That the agent producing this affection will be found to be generated most freely in the incipient stage of putrefaction. This point can be readily tested by the results obtained in the experimental injection of putrescent animal matter into the veins of live and healthy animals. Solutions of putrid pus Avhich do not evolve ammoniacal odors, or products, freely and commonly give rise to, and pro- duce, a group of symptoms allied to ichorhaemia; while so- lutions of highly-poisoned and ammoniacal matter commonly produce death in a very brief space of time, engendering gan- grene, putrid diarrhoea, and a condition allied to ammoniaemia. This term is applied, and the theory borne out, by no less a writer than the celebrated pathologist Virchow. The discharges and gangrenous pulp noticed as connected with ichorrhaemia, had an acid reaction, always becoming evolved, or thrown off, and disappearing, on keeping the sjDecimen until ammonia was freely developed. The differ- ence in the terminal symptoms seemed to have some relation to the physical character of the putrefied substance; thus, the more readily did the constitutional symptoms seem to be pro- duced; the more coherent—i. e., the drier the product—in the same ratio did the effects appear in local processes. In regard to the directly appreciable effects of the gangren- ous substance—by some denominated "putrilage" of hospital gangrene—the following results were obtained: The first effect of the virus, or poison, is to coagulate the blood in its vessels on, or adjacent to, the point or surface to Avhich •it Avas applied. This power of coagulation manifests itself sometimes in the blood of large and thin-walled veins—seldom in the GANGRENE. 137 large arterial branches. A feAv instances have been observed in which the saphena and femoral veins, and their branches, have been implicated in the progress of gangrenous under- minings and chasms; but in all such cases, it was noticed, that the process Avas tardy, and that the first change occurring Avas the coagulation of the blood in the vessel. Again—in a few cases—though the sheath of the vein Avas destroyed, and the latter exposed, yet the vein itself was not destroyed. To the sense of touch and feeling, in every case, it was found to be hard and \vhip-cord like; the induration was found to com- mence, and was firmest at the distal end of the vessel, as it lay exposed in the chasm. This condition Avas traceable be- yond the cardiac end, in view, and thus a considerable sec- tion of the vessel was embraced, as it were, in the destruction process. The Avriter once observed this condition in a case of extensive gangrene of the inner, or femoral, side of the right thigh, in which some seven inches of the femoral vein was thus implicated; the section afterward sloughing out, leav- ing the parts to be sustained by collateral circulation. The hemorrhages that accompany this disease are invariably arte- rial, the coagulating power of the virus being noticed in thin- walled and deep-seated veins, more than elsewhere. In the small veins, it was noted, that coagulation Avas complete, Avhile in the larger veins the blood presented the appearance of in- creasing thrombus. Further—the thrombi, which Avere found to be formed in the large veins, seemed to originate at the point where the gangrenous cavities came nearest in contact Avith the vein, and the thrombus appeared to start a little toward the heart. Observations, however, have not been sufficiently nu- merous on this point to Avarrant the promulgation of this fea- ture as an established and accepted fact, but they certainly tend that Avay. The fluid parts of the putrid and poisoning properties appear to flow into the cellular planes; seeming to possess an affinity, as it Avere, for this tissue where it engenders a sort of gangrenous liquefaction. This Avas noted, in repeated instances, in which large acreage of integument, embracing many square inches of surfaces, was in this condition of liquefaction, while the over- 138 GANGRENE. lying tegumentary structures gave forth no indication of the havoc transpiring beneath. The extent of this destruction could only be determined by free and bold incisions, in some cases, to the extent of ten to twelve inches, in a direct line. The affected parts thus bared, the muscles, tendons, vessels, etc., could be clearly discerned,—dissected out, as it were—as if done by the anatomist's knife, for demonstration. The writer can call to mind Avhole groups of muscles and contiguous struc- tures, in the femoral and cervical regions, thus undermined, and only exposed to view by free incisions. In such cases, the cellular planes, throughout great districts, were noticed to take on a yellowish appearance, losing its co- herency, and, in the more advanced stages, breaking down into a putrid, yellowish fluid. Under the microscope, this fluid presents the appearance of fine granular debris, entirely devoid of any cell structure, and contains threads and shreds of in- elastic fibrous tissue. This change in the cellular tissue, when finally completed, accumulates in such quantities as to flow from one region to another; leaving the tegumentary struc- tures, as before noted, undermined and shelving; emitting, (as it Avill then appear,) upon manipulation, a kind of gurgling sound. As this condition advances still further, the skin turns pale, and does not become thickened and indurated, as in facial erysipelas. Next, a livid condition is apparent at different points, and finally the skin becomes necrotic, or carious—i. e., dies, or ulcerates. The ravages of the disease now extend in every conceivable direction, but principally downwards and between the muscles. In exceptional cases, and where the recuperative powers are good, small, flocculent sloughs are thrown out, yet of the same offensive, putrid, serous-looking nature already spoken of. Accompanying this condition of affairs, the following symptoms will be noted: chills, small and frequent pulse (ranging as high as 140 to 150 pulsations to the minute); dry, pungent and hot skin, of a dark yellow, or dusky hue; red and dry tongue; unquenchable thirst; frequent, la- bored and superficial respirations (50 to 60 to the minute); hebitude; hacking cough at times; singultus; sopar and de- GANGRENE. 139 lirium; emaciation; occasional subsultus; and death closes the scene. These symptoms also answer to the so-called phlegmo- nous erysipelas, and differ from the circumscribed abscesses so common in the eye-lids of facial erysipelas. In addition to the influences exerted by the virus upon the blood contained in the vessels, it also starts in the tissues (with which it comes in contact) the putrefying process; no transi- tional state of the tissues touched has yet been observed. The gangrenous and living parts are so shaded and blended, one with the other, and so identified do they become, that it is often difficult to determine where the living tissue begins, and the dead ends. The invaded tissue melts and breaks down into a state of deliquescence, as it were; but this step is not progressive, as the older portions of the sloughs do not appear to be any softer than those newly or primarily forming. Some of the elements of this broken-down tissue seems to furnish a dirty, yellowish fluid, which can be readily pressed out from the adhering por- tions, and contains no corpuscles, or other organizable material; is not separable; has not serum, as in the other case, floating on the surface; nor does it gather any sediment upon being left to stand. In fact, it has not any of the properties of pus, except its fluidity and color. Pus corpuscles, or any other organized material, haA^e never yet been discovered in the dis- charges of a gangrenous slough, unless taken from some point where granulation was going on. From all that can be gath- ered and seen, the parts are destroyed pretty much, in fact, in the same manner or form as occurs from poisonous vi- rus, or miasm, developed in the course of a series of pathologico- chemical actions, which may be expressed in the generic term of "putrefaction." (Here we will take occasion to remark, that the experience of the past fifteen years has strengthened and confirmed the foregoing observations.) Stimulated with these ideas, the minds of several in the medical department of our army (the writer among the num- ber) became engaged in special efforts,—during the Civil AVar of the Southern Rebellion,—having for their object the dis- covery of an agent possessing the power of arresting putre- 140 GANGRENE. faction, and also of destroying its products in whatsoeA'er form they might present themsehres—whether of gaseous fluid, or a solid nature. The extreme paucity at the time of any accurate knoAvledge of the putrefactive processes, proved a great barrier to the at- tainment of our Avishcs; and although the results arrived at were of marked practical value, still very little light Avas af- forded, pathologically speaking. As we glance over the list of agents that has been in use in gangrenous affections, Ave will find that the actual cautery and corrosive acids have been the most potent weapons used to arrest the destructive tendency of this direful scourge, that decimated our ranks. In their use, these involve a large amount of living tissue, and are therefore only applicable upon superficial and open surfaces. The operation is lim- ited to the charring over of the parts. None of these last-named agents can be introduced with safety into deep gangrenous sloughs, or chasms. Suffice it to say, that one and all of these remedies have failed to answer the desired purpose fully. Much attention, at the time referred to, was being attracted toward the Halogenous remedies—remedies that contain iodine, chlorine, fluorine and bromine: these are well-known halogens, These substances are all very similar, and act very much alike. differing mainly in intensity and degree. They, however, dif- fer in their physical properties. Fluorine cannot be used as an isolated remedy, or material, on account of its violent and ra- venous activity. Chlorine cannot well be obtained pure, except in form of a gas, or as fluid only under considerable pressure; independent of all this, solutions of chlorine are too feeble in their action. Iodine cannot be had in a state of gas, at an or- dinary temperature, and cannot be employed either in a solid or fluid state (unless much diluted) to possess the necessary force. Bromine can be obtained in a fluid form, vaporable at any ordinary temperature, and, unlike chlorine, is respirable in this condition, without injury or much inconvenience. Researches had been (prior to this period) made by the late Prof. Brainard, of Chicago, that went to prove that iodine mixed GANGRENE. 141 with the virus of the rattlesnake neutralizes and destroys its power; and also showed it to possess the same poAver over other animal poisons. These experiments afforded valuable hints, and appeared to promise some results, and accordingly Avere acted upon. Reasoning from these hints derived from Prof. Brainard's experiments, that there is an antagonism ex- isting between the halogens and the poison of reptiles and of animals—the inference Avas reasonable that such a remedy in the form of gas would be a direct antagonist to animal poisons, in the form of vapor. The same rule, it is well known, holds good in relation to chlorine; but the great objection to this agent is, that even minute quantities of this article render the surrounding air irrespirable, and even suffocating, which, of course, Avould pre- clude the possibility of its use in the sick chamber, or even hospital wards. Bromine A\-as then settled upon, and selected for trial. The first case it Avas applied to Avas one of gangrenous erysipelas, and it here met the most sanguine expectations of such as were testing it. Subsequent reports and records, from every point at which this remedy Avas tested, proved its unquestioned supe- riority and efficacy (as far as results were concerned) over any other knoAvn substance; and the death rates were most won- derfully reduced. Investigations Avere also made in regard to its value in pyaemia; not only as a therapeutic, but also a pre- ventive or prophylactic agent; and here again equally satis- factory results ensued. More important, in fact, were the experiments, in this instance, on account of the greater fre- quency and insidiousness of this peculiar malady. Hospital Gangrene presents more or less constancy in many of its characteristics, and has a tendency, usually, to assume more or less of a circular form, being only interrupted or al- tered by the varying effect of the remedy locally used. AY hen the integument is not undermined, the disease is gen- erally arrested; the remaining ulcer presents then the same form; but if it so happens, through want of thorough appli- cation of the agent or other cause, that the disease is arrested at one point and not at another, this circular form is de- 142 GANGRENE. parted from. There Avere many instances observed in Avhich the gangrene attacked penetration gun-shot wounds; in which event the part would present itself as a sloughing core, of a pulpy nature, Avhich would protrude at both entrance and exit of the wound. Gangrene is influenced in its ravages by the succulent nature of the tissue—seeking out (as it always appears to do,) the cellular tissue; and this it will do, Avith unerring certainty, particularly if there exists an abrasion or solution of continuity of the tegumentary structures. If not arrested here, the muscular structures become next involved. Dense fascia and tendons resist its influences even longer than bone. Gan- grenous sloughs vary in consistency; Avhile some are tolerably firm, others again are pulpy and soft—depending much upon the tissue involved. For example, cellular tissue, under its ravages, becomes rapidly soft and flocculent, yielding in abund- ant quantities a dirty, yellow fluid, of a peculiar, pungent, foetid odor. In some cases in which the ravages Avere sloAver, the skin, cellular tissue and muscles, appeared to become si- multaneously invoWed; these seemed to break doAvn—melt, as it were—into diffluent matter; the product of each of these several structures being one and the same; no one tissue being recognizable in the destruction and debris left. The odor of gangrene is very peculiar, better imagined than described; • when once experienced, never forgotten. It is exceedingly pungent and intolerable; so marked is its former quality that the lining membrane of the nose and the conjunctival mem- brane of the eyes of the operator, are irritated and reddened to such a degree as to oblige him to desist, at times, from his duty. Under the microscope the gangrenous products, dis- charges and sloughs, are found to consist chiefly of granular matter containing shreds of inelastic fibrous tissue; other struc- tures, undergoing metamorphosis, are gradually lost. Gangrene may invade any point in the body Avhere a partial or complete solution of continuity of surface exists. Instances were noted in which it has attacked wounds almost entirely healed. One of the most extensive and destructive instance of gangrene that came under the writer's observation, during GANGRENE. 143 the war, was that of a large, robust looking, muscular man, who had a slight abrasion, from a glance shot of a musket ball, near the left nipple. Gangrene invaded it in less than thirty- six hours after his entry into the Hospital. (Satterlee General Hospital, located at AVest Philadelphia.) It invaded and sloughed out the entire left breast, involving the pectoral mus- cles (which in this case Avere very large) before it could be ar- rested. The cellular tissue was also very abundant here; up- wards of seven ribs were exposed when the mass separated; it weighed over three pounds. The patient, however, made a good recovery. The state of the constitution at the time of invasion, or, in fact, prior to this period, does not seem to have much influence upon the liability to the disease; for it seems to attack the old and the young—the feeble and the strong—the sick and con- valescent, alike. Neither has it been found to have travelled with any more rapidity in those of depraved habits than those of sound health. The condition of health has, however, much influence in the process of repair. In those of previously vigorous habit of body, the granulations start up more rapidly; and after the disease has been arrested, convalescence then sets in more rapidly. Usually those who are affected express a a disgust and repugnance for food; the nervous system is much disturbed; there follows dullness, despondency and in- somnia—or a great restlessness; great muscular prostration; subsultus tendinum; colliquative sweats and a saccharine odor of the breath; this latter symptom is strongly marked when pyaemia declares itself. The surface of a gangrenous slough is not painful, sensitive, nor yet irritable. None of the applications of the agents mentioned in connec- tion with treatment are painful, unless applied to living tissue. When bromine is used, the patient complains of a sort of gnawing, biting, or stinging pain. This condition of sensi- tiveness may be always regarded as favorable than otherwise. Constitutional remedies, unaided by local means, do not ap- pear to have any marked influence over the local and general condition of the disease. It will be noticed, invariably, that the constitutional symptoms will abate and pass away just in 144 GANGRENE. the same ratio as the local ravages are controlled; convales- cence begins as soon as putrefaction is thoroughly arrested; there appears, in truth, to be a concert of action betAveen the arrest of the local disease and the beginning of convalescence. The appetite, which Avas before entirely dissipated, Avill return after the elapse of a few hours, in many cases; the writer can testify to periods as short as five to six hours after local arrest; and this forms a good index often to the arrest of the disease and the general condition of the patient. Isolated cases Avere noted, in Avhich a patient having two wounds on different limbs, produced by the same missile, the one became gan- grenous, Avhile the other passed on to granulation and cicatri- zation. These cases were idiopathic in their origin. Any one not familiar Avith the action of Bromine on a heal- ing surface, Avould conclude that it was a highly corrosive and irritating agent, but a single practical illustration will convince the most skeptical to the contrary. Bromine coagulates the albumen of the sloughs, and thus it coats over or incrusts the surface of the wound; it cannot then penetrate any further or deeper. This incrustation can be readily removed with spatula or scissors; and thus living tissue may be reached, and the nearer the latter is approached the more effectual will the re- sult be. In other words, the Bromine must be thoroughly mixed with the surface of living tissue. In some cases, Avhere it was found impracticable to entirely remove the sloughs, the hypodermic syringe was brought into use with decided success. METHOD FOR USING THE BROMINE. If the patient is nervous and intolerant of pain, and the gangrenous sloughs are very extensive, partial anesthesia had better be resorted to, unless contra indicated. The appliances necessary are as follows: a good stout one-ounce glass syringe, an ordinary glass or tumbler, an ounce of pure bromine, and an ordinary pocket case of surgical instruments, together Avith a horn spatula and two basins; the patient aetherized, or not, as the surgeon may desire; but if not, administer half an ounce of good whisky, in a half tumbler of water. GANGRENE. 145 Fill the tumbler to contain the bromine three-fourths full of cold water; and then—introducing the neck of the stoppered bottle of bromine into the water, with one hand, remove the glass stopper Avith the other—the mouth and stopper immersed. Immediately the bromine settles to the bottom of the glass, its specific gravity being much heavier and denser than the water. Agitate the contents of the glass Avith the aid of the syringe, and thus the water becomes thoroughly impregnated with the bromine. Various strengths of the bromine may now be ob- tained, depending upon the point at which it is taken. A mild form may be had by drawing, Avith the syringe, from the sur- face ; a medium, or stronger form, from the middle or centre of the column; while the pure bromine, if desired, may be draAvn from the floor of the glass. For a gangrenous slough, the full strength should be applied—being careful to apply it at arm's- length, as the operator, if bending directly over it, will receive the fumes in his mouth and eyes, thus causing him to desist for awhile. The action of the bromine vapor on the nasal res- piratory and conjunctival surfaces, will cause marked irrita- tion. The latter may be almost immediately relieved by a free ablution of cold water to the eyes; snuffing cold water into the nostrils will relieve this organ, and that of the respiratory ap- paratus will subside by a visit to the open air, breathing it in freely. Time and much annoyance may, therefore, be obviated by a careful observance of this rule. The bromine then being in its full strength applied to the slough, the spatula may be used for its removal. If this implement fails to remove effec- tually, forceps and scissors must be brought into use, and the slough thus cut away until a quick or sensitive surface is reached. After this is accomplished, dash over the entire and denuded surface a syringe or tAAro full of the medium strength—taken from the centre of the column in the glass. Trim away care- fully the edges, and leave no fragment, or undershelving point, in which the gangrene may lodge. Every particle must needs be removed to insure a successful issue. The water serves the double purpose of controlling the bro- mine, as well as to enable the operator to obtain the several strengths, as desired. The application is best made by quick, 10 146 GANGRENE. short jerks with the piston-rod—driving it home gradually in this way. Should the first application of strong bromine fail to destroy the slough, another, of the same strength, should be repeated until it is accomplished. When the case to be treated is one of a penetrating gun-shot wound, a long-nozzled, glass (always) syringe should be inserted at one end, and then a se- cond syringe, partly filled, at the other terminus of the wound, and the full strength used. This is forced thus into the wound, and again repeated until the entire slough can be effectually removed. A milder application is now used to the living sur- face, and thus continued daily—once, twice or thrice, as in the judgment of the operator the case may demand. A granulating surface should always be treated with the medium or weaker strengths of the bromine. Usually one part bromine to sixty or eighty of water suffices for this purpose. When bromine is applied too strong to a granulating surface, it here likewise co- agulates the albumen, and thus kills the granulations. To the naked eye, there is very little difference, apparently, between such a surface and one affected by gangrene. In some cases in which the bromine was not properly or thoroughly used, (either through fear or want of proper care,) the result was not so marked and rapid as in others properly and effectually treated. It will be known when the sound tissues are reached, by the patient evincing some sensitiveness; hence it is well that the patient should be allowed to recover from the effect of anesthesia before deciding that point. The immediate effect of bromine to a gangrenous surface is the har- dening or coagulating effect; and the color imparted is of a yellowish white. The foetid odor peculiar to gangrene is cor- rected at once, and effectually, by the bromine, when properly and thoroughly applied. As long as any foetor remains, it is certain that the bromine needs re-applying. If these points are not rigidly observed, the gangrene will nestle in some nook or corner, and from a single point will speedily re-invade the neighboring parts. The best means for dressing purposes, after the bromine has been effectually applied, is a stimulating poultice, composed of pulv. flexseed, 10 to 15 parts, with one part pulv. charcoal, to GANGRENE. 147 which from 6 to 10 tablespoonfuls of yeast (or in the absence of this article use porter or ale, instead of water—which latter article Avould be needed in case yeast were used) to give proper consistency to the poultice. The poultice applied, over all a piece of oil silk, or gum cloth, will retain moisture for a period of 24 hours. If necessary, a loose roller bandage may be placed on, to secure the dressings in position. The dressings must neA'er be allowed to get dry, but prevented by the use of the outer covering of oil silk, or gum cloth, already mentioned. A por- tion of glycerine—say one part to 50 or 60 of the fluid—will materially assist in retaining moisture. A low trituration of bromine should be given internally at the same time. The part affected should be kept in a recumbent, and not a dependent position. As soon as granulations have become firmly established, then dispense with the poulticing, and use instead a Carbolized Oil dressing, of five to ten grains to the ounce of oil, or, what is much more desirable dressing, in the writer's estimation, Carbolized cosmoline, or Petro cerate, of same strength. Another important feature, observed in the use of bromine, in the treatment of gangrene, is its powerful properties in pre- venting the spread of gangrene in hospital wards. Instances were repeatedly observed in which gangrenous cases were ad- mitted, unwittingly, into hospital wards, with numbers of other, wounded men; and, by a careful and thorough fumigation daily of the air of the wards, besides treating thoroughly the in- fected cases with the Bromine, no instance of its spread occurred. After its certainty and success had become known (among those who were testing the Bromine treatment,) all the for- mer dread and fears, that previously held sway throughout the hospitals, in which it had been tested, gave way to a sense of security and confidence, that was mutually participated in by surgeons and patients. None but those who were the happy instruments in this humane effort knew the great peace, of both mind and body, that followed. The feeling was one of deep thankfulness, for it seemed as though some hideous monster had been dethroned in our very midst; and it was regarded as a God-given boon. % 148 GANGRENE. The news of an approaching conflict was never received with anything like the terror that had been inspired, Avhen the cry rang out (among our sick and Avounded) that gangrene—that fell destroying monster!—had invaded our midst. There was no one disease that decimated our ranks, as did this terrible malady. But armed now with Bromine, the feeling of confi- dence that pervaded us was attended with a certainty of suc- cess, that knows no such word as failure. Many Avere the ex- pressions of gratitude toward the late Prof. Brainard, of Chi- cago, for his timely and valuable suggestion, which the writer noticed in a brief article from his pen, in which he classified Bromine as one of the haloginous remedies; though Prof. B. had never tested its value in this class of diseases. From this suggestion alone, the writer was induced to institute the first series of experiments in the treatment of these various dis- eases; which were rewarded with success, and led the way to the marked results finally obtained. Some there are who have undertaken, after a fashion, to test the Bromine remedy but have failed simply because they did not comply strictly with the rules necessary to ensure success. All these failures as far as known Avere attributable to ineffi- ciency and the careless manner in which the Bromine was applied. Those, on the other hand, who have regarded the rules laid down, have never failed to arrest these maladies short of a complete exhaustion of the vital forces. Time and space for- bid the enumeration of cases here; but numbers could be ad- duced and authenticated in which the most marvellous results of success were obtained, and lives were snatched, as it were, from the very jaAvs of death. A few remarks in regard to the character of the diet neces- sary in these cases, are appropriate here. A stimulating, nour- ishing diet, principally of a fluid nature, should be rigidly en- forced in extreme cases for the first few days. Milk punch, prepared as follows: to one pint of sAveet, unskimmed milk add a well-beaten fresh egg; sweeten moderately; and then add four to six tablespoonfuls of good whiskey or pure brandy. This should be given in moderate quantities, say an ounce or GANGRENE. 149 two at a draught—thus taken ad libitum and according to the state of the stomach. Fresh milk in as liberal quantities as can be borne. Beef tea, made after the following formula: to one pound of fresh, lean beef—chopped fine as mince meat, placed and covered in a glazed earthern dish—add one pint cold water, allowing it to macerate for the period of two to three hours. Place now on a brisk fire, and allow it to cook for twenty minutes. Strain through a coarse sieve, salt moder- ately, and administer cold or hot, as the patient may elect, and in such quantities as can be borne, frequently repeated, night and day. As the patient improves, a glass or two of good por- ter may be added daily to this list. Finally, rare beef, mutton, chicken, potatoes, light pudding and the like, may be used. Cleanliness of person, and frequent, warm, sponge and spirit baths, will conduce much to the recovery and benefit of the patient. The writer here takes occasion to add his experience in the use of that most valuable and efficient agent, the "Sulphite of Soda," in the treatment of all forms of erysipelas—except in the gangrenous variety; averring, as he does, that he has never known a failure in any single case since adopting its use. The Sulphite, in the proportion of forty to eighty grains to the ounce, or stronger, if necessary, will abort the most severe at- acks in twenty-four to thirty-six hours, if properly and freely used. Bromine is also a valuable agent in the treatment of uncom- plicated erysipelas; but the method of applying it is somewhat tedious and troublesome. The use of the Sulphite of Soda and the facility and great success Avith which it can be used, leaves nothing to desire; still, I will briefly give the "modus ope- randi " for Bromine. Presuming the face to be the locality affected:—First care- fully wash and rinse the part with moderately hot water, so as thoroughly to soften the epidermis. Pure, white, castile soap may be added and will facilitate this end. Then thoroughly rinse the suds from the parts with hot water. The tar soap, manufactured by Packard & Co., of New York, is a valuable preparation, likewise, for this purpose. Cut now a mask; from 150 GANGRENE. patent lint, to fit the entire face—cutting suitable apertures for nose and mouth, and allowing the margins to overlap freely the diseased surface. A second piece cut in the same manner and then a third one of oiled silk or sheet rubber. Spread one of the lint masks, very lightly, with Petro cerate, cosmo- line, or some other simple unguent, and lay it on the face. Saturate now the second lint mask, with a solution of Bro- mine, one part to forty or fifty of water, and quickly apply over the former; pressing out first the surplus of fluid, to pre- vent dripping. Over all this speedily place the oiled silk, or gum cloth, with apertures cut to accommodate the nose and mouth, and thus the dressing is completed. The outer mask of lint should be renewed, four to five times daily, or as often as the vapor of the Bromine subsides. Two patches of dry lint should be previously placed—one over each eye—for the purpose of protection from the action of the remedy; this pre- caution is necessary for the patient's comfort at least. In all cases in which Bromine is used locally it is advisable to use the same remedy internally. The 30th trituration is a potency which the writer has used with satisfaction. Herewith will be found annexed two tabular statements, Nos. 1 and 2, of eight hundred and forty cases treated, personally, by the writer during the war of the Rebellion. There is also annexed a third, embracing a list of two hundred and forty- three cases of traumatic and hospital gangrene, and gangrenous erysipelas, treated in private and hospital practice; and this is designated as No. 3. By a reference to Table No. 1, it will be observed that Series A consists of a total of seventy-five cases, treated with other rem- edies than bromine; with thirty-five recoveries and forty deaths; the percentage of loss being 53^g-. Series B embraces two hun- dred cases, treated with bromine, in all kinds of ways—i. e., strong, weak and medium. Out of this number, there were one hundred and eighty recoveries and twenty deaths, the per- centage of loss being 10. Here we have a gain of 43j^- per cent, over all other known remedies. Not content with this result, the bromine was still further pushed in the treatment of gangrenous erysipelas; and the remedy was applied in its GANGRENE. 151 strongest solution, topically, and given likewise internally of the first decimal dilution, four times daily; in addition to which the hospital wards were fumugated with bromine vapor; and here—as it will be perceived by a reference to the table of Series C—one hundred and eighty-five Avere thus treated; and the result obtained was one hundred and eighty recoveries, with but five deaths: percentage of loss, 2iy0—a gain of 41 per cent, over the first series treated Avith other remedies; and of 7t2o9q- per cent, over the second series (B), or those treated with bromine of varied strengths. The tabular statement of hospital gangrene will show up quite as brilliant results. This is designated as No. 2. Table No. 3 embraces (as will be noted by reference thereto) Iavo hundred and forty-three cases, treated during the period of eleven years by the writer, in private and hospital practice. Here, too, the bromine and sulphite of soda treatment shows up very handsome results—the loss being less than three per cent. In conclusion, we challenge a finer exhibit for the same class of diseases. I. Tabular Statement of Cases of Erysipelas treated at Saterlee General Hospital, West Philada., at Fredericksburg and City Point, Va., Summer and Fall of 1863 and 1864. Series A. Treatment with other remedies (Bromine excluded)..... Series B. Treated with Bromine in all sorts of ways ; strong,weak, medium. Series C. Treated with full strength of Bromine, topically and in addi- tion thereto purifying the Hospital Wards with Bromine vapor 35 40 20 RECOVERIES COMPLICATED WITH 65 11 10 10 <* e s 0 !. S - s ^ &< "« * a, rfS s> rfS h Oh DEATHS COMPLICATED WITH 8 °o £8 ^.3 9 Hours Days. 4 Hours 9 Days 1 Hours 12 Days 18 Hours 10 Days. Hours 4 Days 28 Hours 9 Davs 9 Days. Days 2 5 Hours 20 Mortality. Percentage of Loss 53^,. Deaths 20. Percentage of Loss 10. Percentage of Loss TV(,. OX to GANGRENE. 153 II. Tabular Statement of Hospital Gangrene treated in Post Hospital and Field Service during the Summer and Fall of 1863 and 1864, Army of the Potomac. ■e e E«i 00 =0 e C> =0 * eo 0 s. S. «0 « >© •c S g .3 0 t fa; * (=1 ^ Percentage of Loss. Treated with Bromine in all kinds of ways, from weak to strong........ Treated with Bromine in solu- tion, exclusively..... Treated with pure Bromine after the solution had failed . , Treated exclusively with strongest Bromine solution .... Treated with strongest Bromine solution after Nitric Acid had failed........ Treated with strongest Bromine solution after all other remedies had failed....... Treated with Nitric Acid, ex- clusively ....... Treated with other remedies, ex- clusively ...... Total . . 130 84 10 49 23 10 41 33 380 127 82 10 46 22 10 19 333 24 14 Days. Hours, 164 9 6 12 20 2 21 3 m 5 8 8 20 9 16 46 1 2tfo" Percentage of Loss or 97T%% Recoveries out of 100 Cases. 58TVfr Percentage of Loss. 42^% Percentage of Loss. 154 GANGRENE. III. Tabular Statement of Hospital Gangrene and Gangre- nous Erysipelas in Hospital and Private Practice, embraced within a period of eleven years, from 1865 to 1876. "8 e s 1 °0 c e 1 8 St. i e | 0 s 8 s 1 8 ! -a S < «o s v. S e "5 s < =0 "e 3 8 i « Si £ < 8 3 e S ■S g 8 » s s §> 8 s-s> "1 Percentage of Loss. Hospital Gangrene treated with strongest Bromine solution and fumigating the wards with Bromine Gangrenous Erysipelas treated with strongest Bromine solution and fumigations .... Idiopathic Erysipelas treat-ed with Sulphite of Soda. Traumatic Erysipelas treat-ed with Sulphite of Soda. Total . . 27 13 113 90 243 26 13 112 89 240 5 5 9 5 24 2 1 3 2 2 2 2 3 3 ft w 7 20 9 17 6 4 5 7 %tgo Percentage 01 Loss. Grand Total . . «o 1083 =0 0 969 =0 8 114 10f% Percentage of Loss. BOERICKE & TAFEL'S HOMCEOPATHIC PUBLICATIONS. ALLEN, DR. T. F. The Encyclopedia of Pure Materia Medica; a Record of the Positive Effects of Drugs upon the Healthy Human Organism. With contributions from Dr. Eichard Hughes, of England; Dr. C. tiering, of Philadelphia; Dr. Carroll Dunham, of Xcw York; Dr. Adolph Lippe, of Philadelphia, and others. X volumes. Price bound in cloth, 800.00; in half morocco or sheep, . . . $70 00 This is the most complete and extensive work on Materia Medica ever attempted in the history of medicine—a work to which the homoeopathic practitioner may turn with the certainty of finding the whole pathogenetic record of any remedy ever used in homoeopathy, the record of which being. published either in bookform or in journals. The volumes average about 640 pages each. ALLEN, DR. T. F. A General Symptom Register of the Homoe- opathic Materia Medica. By Timothy F. Allen, M.D., Author of the Encyclopaedia of Pure Materia Medica. 1340 pages in one large volume. Price in cloth, $12.00; in sheep or half morocco, . $14 00 This Index to the Encyclopaedia of Materia Medica is at the same time the best arranged and most complete Eepertory ever attempted. Its inge- nious selection and arrangement of different kinds of type greatly facilitate its use. ANGELL, DR. H. 0. A Treatise on Diseases of the Eye; for the Use of Students and Practitioners. By Henry C. Angell, M.D.. Professor of Ophthalmology in the Boston University School of Medicine, etc., etc. Fifth edition, enlarged and illustrated. 313 pages. 12mo, Cloth,............$3 00' • The fifth edition of this standard work has just been issued from the press, and shows that the whole work has been thoroughly revised and brought up to the latest dates in ophthal- mology. Exquisite clear photographic illustrations have been added, and an exposition given of the dioptric or metric system, as applied to lenses for spectacles. BAEHR, DR. B. The Science of Therapeutics according to the Principles Of Homoeopathy. Translated and enriched with numerous additions from Kafka and other sources, by C. J. Hempel, M.D. Two volumes. 1387 pages,. . *......$9 00 . . . " In short Dr. Baehr has presented us with the results of his observations at thd bedside rather than of his researches in the study. It is this which renders his work valuable, and which at the same time accounts for his occasional imperfections. We know; 2 BOERICKE & TAFEL'S of no -work of the kind in homoeopathic literature where the suggestions for the choice of medicines are given in a freslier or clearer manner, or in one better calculated to interest and inform the practitioner. AVe have only to add that the two volumes are highly credit- able to the publishers. The type is good, the paper good, and the binding excellent."— Monthly Homoeopathic Review. BECKER, DR. A. 0. Dentition, according to some of the best and latest German authorities. 82 pages. l2mo. Cloth,. 50 cts. BECKER, DR. A. C. Diseases of the Eye, treated homceopathi- cally. From the German. 77 pages. 12mo. Cloth, . . 50 cts. BELL, DR. JAMES B. The Homoeopathic Therapeutics of Diarrhoea, Dysentery, Cholera, Cholera Morbus, Cholera In- fantum, and all other loose evacuations of the bowels. 168 pages. Bound in Muslin. 12mo. Cloth, . ... . . $1 00 This little book had a very large sale, and but few physicians' offices will be found with- out it. The work was, without exception, very highly commended by the homoeopathic press. BERJEAU, J. PH. The Homoeopathic Treatment of Syphilis, Gonorrhoea, Spermatorrhoea, and Urinary Diseases. Eevised, with numerous additions, by J. H. P. Frost, M.D. 256 pages. 12mo. Cloth,............$1 50 " This work is unmistakably the production of a practical man. It is short, pithy, and contains a vast deal of sound practical instruction. The diseases are briefly described ; the directions for treatment are succinct and summary. It is a book which might with profit be consulted by all practitioners of homoeopathy."—North American Journal. BREYFOGLE, DR. W. L. Epitome of Homoeopathic Medi- cines. 383 pages,.........$1 25 Interleaved with writing paper. Half morocco,. . . . $2 25 We quote from the author's preface: " It has been my aim, throughout, to arrange in as concise form as possible, the leading symptoms of all well-established provings. To accomplish this, I have compared Lippe's Mat. Med.; the Symptomen-Codex ; Jahr's Epitome; Boenninghausen's Therapeutic Pocket- Book, and Hale's Xew Remedies." BRYANT, DR. J. A Pocket Manual, or Repertory of Homoeo- pathic Medicine, Alphabetically and Nosologically arranged, which may be used as the Physicians' Vade-mecum, the Travellers' Medical Com- panion, or the Family Physician. Containing the Principal Eemedies for the most important Diseases; Symptoms, Sensations, Characteristics of Diseases, etc.; with the Principal Pathogenetic Effects of the Medi- cines on the most important Organs and Functions of the Body, together with Diagnosis, Explanation of Technical Terms, Directions for the selec- tion and Exhibition of Eemedies, Eules of Diet, etc. Compiled from the best Homoeopathic authorities. Third edition. 352 pages. 18mo. Cloth, . . . '........ • $1 50 : BUTLER, JOHN. A Text-Book of Electro-Therapeutics and Electro-Surgery, for the Use of Students and General Prac- titioners. By John Butler, M.D., L.E.C.P.E., L.E.C.S.I., etc., etc. Second edition, revised and enlarged. 350 pages. 8vo. Cloth, $3 00 ' ".Butler's work gives with exceptional thoroughness all details of the latest researches on HOMCEOPATHIC PUBLICATIONS. 3 Electricity, which powerful agent has a great future, and rightly demands our most earnest consideration. But Homceapathia especially must hail with delight the advent from out the ranks of her apostles of a writer of John Butler's ability. His book will also find a large circle of non-homoeopathic readers, since it does not conflict with the tenets of any therapeutic sect, and particular care has been bestowed on the technical part of electro- therapeia."—HomozopathischeRundschau. DAKE, DR. WM. C. Pathology and Treatment of Diphtheria. By A\rin. C.Dake, M.D, of Nashville, Tenn. 55 pages. 8vo. Paper, 50 cts. This interesting monograph was enlarged from a paper read at the Third Annual Meeting of the Homoeopathic Society of Tennessee, held at Mem- phis, September 19, 1877. It gives a report of one hundred and seventy-six cases treated during a period of eleven months. It well repays a careful perusal. DUNHAM, CARROLL, A.M., M.D. Homoeopathy the Science of Therapeutics. A collection of papers elucidating and illustrating the principles of homoeopathy. 529 pages. 8vo. Cloth, . . $3 00 Half morocco,..........$4 00 "After reading this work no one will attempt to justify the practice of alternation of remedies. It is simply the lazy man's expedient to escape close thinking or to cover his ignorance. The one remedy alone can be accurate and scientific; a second or third only complicates and spoils the case, and will inevitably ruin a good reputation. But to come to more practical matters, more than one-half of this volume is devoted to a careful analysis of various drug-provings. It teaches us Materia Medica after a new fashion, so that a fool can understand, not only the full measure of usefulness, but also the limitations which surround the drug. . . . We ought to give an illustration of his method of analysis, but space forbids. Wo can only urge the thoughtful and studious to obtain the book, which they will esteem as second only to the Organon in its philosophy and learning."—The American Homceopathist. DUNHAM, CARROLL, A.M., M.D. Lectures on Materia Medica. 858 pages. 8vo. Cloth,........$5 00 Half morocco,..........$6 00 . . . "Vol. I is adorned with a most perfect likeness of Dr. Dunham, upon which stranger and friend will gaze with pleasure. To one skilled in the science of physiognomy there will be seen the unmistakable impress of the great soul that looked so long and stead- fastly out of its fair windows. But our readers will be chiefly concerned with the contents of these two books. They are even better than their embellishments. Thev are chiefly such lectures on Materia Medica as Dr. Dunham alone knew how to write. They are pre- ceded quite naturally by introductory lectures, whicli he was accustomed to deliver to his classes on general therapeutics, on rules which should guide us in studying drugs, and on the therapeutic law. At the close of Vol. II we have several papers of great interest, but the most important fact of all is that we have here over fifty of our leading remedies pre- sented in a method which belonged peculiarly to the author, as one of the most successful teachers our school has yet produced. . . . Blessed will be the library they adorn, and wise the man or woman into whose mind their light shall shine."—Cincinnati Medical Ad- vance. EGGERT, DR. W. The Homoeopathic Therapeutics of Uterine . and Vaginal Discharges. 543 pages. 8vo. Half morocco, $3 50 The author brought here together in an admirable and comprehensive arrangement everything published to date on the subject in the whole homoeopathic literature, besides embodying his own abundant personal ex- perience. The contents, divided into eight parts, are arranged as follows: Part I. Treats on Menstruation and Dysmenorrhea; Part II. Menor- rhagia; Part III. Amenorrhea; Part IV. Abortion and Miscarriage; Part V. 4 BOERICKE et T A FEE'S Metrorrhagia; Part VI. Fluor albus; Part VII. Lochia ; and Part VIII. General Concomitants. No work as complete as this, on the subject, was ever before attempted, and we feel assured that it will meet with great favor by the profession. "The book is a counterpart of Bell on Diarrhoea, and Dunham on Whooping-cough. Synthetics, Diagnosis and Pathology are left out as not coming within the scope of the work. The author in his preface says: Remedies and their symptoms are left out, and thesymp- toms and their remedies have received sole attention—that is what the busy practitioner wants. The work is one of the essentials in a library."—American Observer. " A most exhaustive treatise, admirably arranged, covering all that is known of therapeu- tics in this important department."—Homoeopathic Times. GUERNSEY, DR. H. N. The Application of the Principles and Practice of Homoeopathy to Obstetrics and the Disorders Pe- culiar to Women and Young Children. By Henry N. Guernsey. M.D., Professor of Obstetrics and Diseases of Women and Children in the Homoeopathic Medical College of Pennsylvania, etc., etc. With numerous Illustrations. Third edition, revised, enlarged, and greatly improved. 1004 pages. 8vo. Half morocco,......$8 00 This standard work, with the numerous improvements and additions, is the most com- plete and comprehensible work on the subject in the English language. Of the previous editions almost four thousand copies are in the hands of the profession, and of this third edition a goodly number have already been taken up. There are few other professional tvorks that can boast of a like popularity, and with all new improvements and experiences diligently collected and faithfully'incorporated into each successive edition, this favorite work will retain its hold on the high esteem it is held in by the profession, for years to come. It is superfluous to add that it was and is used from its first appearance as a text-book at the homoeopathic colleges. GUERNSEY, DR. E. Homoeopathic Domestic Practice. With Full Descriptions to the Dose to each single Case. Containing also Chapters on Anatomy, Physiology, Hygiene, and an abridged Materia Medica. Tenth enlarged, revised, and improved edition. 653 pages. Halfleather,.......... $2 50 GUERNSEY, DR. W. E. The Traveller's Medical Repertory and Family Adviser for the Homoeopathic Treatment of Acute Diseases. 36 pages. Cloth,.......30 cts. This little work has been arranged with a view to represent in as compact a manner as possible all the diseases—or rather disorders—which the non-professional would attempt to prescribe for, it being intended only for the treatment of simple or acute diseases, or to allay the suffering' in maladies of a more serious nature until a homoeopathic practitioner can be summoned. HAHNEMANN, DR. S. The Lesser Writings of. Collected and Translated by E. E. Dudgeon, M.D. With a Preface and Notes by E. Marcy. M.D. With a Steel Engraving of Hahnemann from the statue of Steinhauser. 781 pages. Half bound,.....$3 00 This valuable work contains a large number of Essays, of great interest to laymen as well as medical men, upon Diet, the Prevention of Diseases, Ventilation of Dwellings, etc. As many of these papers were written before the discover)' of the homoeopathic theory of cure, the reader will be enabled \r peruse in this volume the ideas of a gigantic intellect when di- rected to subjects of general and practical,interest. HOMCEOPATHIC PUBLICATIONS. 5 HAHNEMANN, DR. S. Organon of the Art of Healing. By Samuel Hahnemann. Aude Sapere. Fifth American edition, translated from the Fifth German edition, by C. Wesselhceft, M.D. 244 pages. 8vo. Cloth,...........$1 75 This fifth edition of " Hahnemann Organon " has a history. So many complaints were made again and again of the incorrectness and cumber- some style of former and existing editions to the publishers, that, yielding to the pressure, they promised to destro}r the plates of the fourth edition, and to bring out an entire re-translation in 1876, the Centennial year. After due consideration, and on the warm recommendation of Dr. Constantine Hering and others, the task of making this re-translation was confided to Dr. C. Wesselhceft, and the result of years of labor is now before the pro- fession, who will be best able themselves to judge how well he succeeded in acquitting himself of the difficult task. " To insure a correct rendition of the text of the author, they (the publishers) selected as his translator Dr. Conrad YVesselhoeft, of Boston, an educated physician in every respect, and from his youth up perfectly familiar with the English and German languages, than whom no better selection could have been made." "That he has made, as he himself de- clares, 'an entirely new and independent translation of the whole work,' a careful compari- son of the various paragraphs, notes, etc., with those contained in previous editions, gives abundant evidence; and while he has, so far as was possible, adhered strictly to the letter of Hahnemann's text, he has at the same time given a pleasantly flowing rendition that avoids the harshness of a strictly literal translation."—Haltnemannian Monthly. HALE, DR. E. M. Lectures on Diseases of the Heart. In Three Parts. Part I. Functional Disorders of the Heart. Part II. Inflamma- tory Affections of the Heart. Part III. Organic Diseases of the Heart. Second enlarged edition printing. HALE, DR. E. M. Materia Medica and Special Therapeutics of the New Remedies. Fourth edition, revised and enlarged. In two Volumes. Vol. I. Special Symptomatology. With new Botanical and Pharmaco- logical Notes. 672 pages. Cloth,......$5 00 Vol. II. Special Therapeutics. With Illustrative Clinical Cases. 900 pages. Second enlarged edition. Cloth, .... $5 00 N. B.—Same in half morocco, per Volume, . . . . $6 00 " Dr. Hale's work on New Remedies is one both well known and much appreciated on this side of the Atlantic. For many medicines of considerable value we are indebted to his re- searches. In the present edition, the symptoms produced by the drug investigated, and those which they have been observed to "cure, are separated from the clinical observations, bv which the former have been confirmed. That this volume contains a very large amount of invaluable information is incontestable, and that every effort has been made to secure both fulness of detail and accuracy of statement, is apparent throughout. For these reasons we can confidently commend Dr. Hale's fourth edition of his well-known work on the New R-medics to our homoeopathic colleagues."—Monthly Homoeopathic Review. " We do not hesitate to say that by these publications Dr. Hale rendered an inestimable service to homoeopathy, and thereby "to the art of medicine. ' The school of Hahnemann in every country owes him hearty thanks for all this; and allopathy is beginning to share our gain.' The author is given credit for having in this fourth edition corrected the mistake for which the third one had been taxed rather severely, by restoring in Vol. II the 'special therapeutics,' instead of the 'characteristics' of the third edition."—British Journal of Ho- moeopathy. 6 BOERICKE & TAFEL'S HALE, DR. E. M. The Medical, Surgical, and Hygienic Treat- ment of Diseases of Women, especially those causing Sterility, the Disorders and Accidents of Pregnancy, and Painful and Difficult Labor. By Edwin M. 11 ale, Ml)., Professor of Materia Medica and Therapeutics in the Chicago Honnoopathic College, etc., etc. Second enlarged edition. 378 pages. 8vo. Cloth, . . . $2 50 " This new work embodies the observations and experience of the author during twenty-five years of active and extensive practice, and is designed to supplement rather than supersede kindred works. The arrangement of the subjects treated is methodical and convenient; the introduction containing an article inserted by permission of Dr. Jackson, of Chicago, the author upon the ovular and ovulatien theory of menstruation, which contains all the obser- vations of practical importance known on this subject to date. The diseases causing sterility are fully described, and the medical, surgical, and hygienic treatment pointed out. The more generally employed medicines are enumerated, but their special or specific indications are unfortunately omitted. The general practitioner will find a great many valuable things for his daily rounds, and cannot afford to do without the book. The great reputation and ability of the author are sufficient to recommend the work, and to guarantee an appreciative reception and large sale."—Hahnemannian Monthly. HAYWARD, DR. JOHN W. Taking Cold (the Cause of half our Diseases): Its Nature, Causes, Prevention and Cure; its frequency as a Cause of other Disease, and the Diseases of which it is the Cause, with their Diagnosis and Treatment. Fifth edition, enlarged and improved. London, 1875. 188 pages. 18mo. Cloth.............50 cts.' We quote from the author's preface: "This Essay was originally published under the conviction that, by attention to the di- rections it contains, persons may not only very frequently avoid taking cold, but may them- selves frequently cure a cold at the onset, and thereby prevent the development of many of those serious diseases that would otherwise follow. The favorable reception it lias met with is a sufficient testimony that it has been found useful." HELMUTH, DR. W. T. A System of Surgery. Illustrated with 568 Engravings on Wood. By Wm. Tod Helmuth, M.D. Third edition. 1000 pages. Sheep,.........$8 50 This third edition of Dr. Helmuth's great work is already in appearance a great Improve- ment over the old edition, it being well printed on fine paper, and well bound. By increas- ing the size of the page, decreasing the size of type, and setting up solid, fully one-half more printed matter is given than in the previous edition, albeit there are over 200 pages less. And while the old edition, bound in sheep, was sold at §11.50 by its publishers, this im- proved third edition is now furnished at §3 less, or for §8.50. The author brought the work fully up to date, and for an enumeration of some of the more important improvements, we cannot do better than to refer to Dr. Helmuth's own Preface. HEMPEL, DR. C. J. The Science of Homoeopathy; or, A Critical and Synthetical Index of the Doctrines of the Homoeopathic School. Second edition. 180 pages. Large 8vo. Cloth, . . . $1 75 HEMPEL, DR. C. J., and DR. J. BEAKLEY. Homoeopathic Theory and Practice. With the Homoeopathic Treatment of Surgi- cal Diseases, designed for Students and Practitioners of Medicine, and as a Guide for an intelligent public generally. Fourth edition. 1100 pages,............$3 00 HOMCEOPATHIC PUBLICATIONS. 7 HERING, DR. C. Condensed Materia Medica. Second edition. More condensed, revised, enlarged, and improved, . . . $7 00 In February, 1877, we were able to announce the completion of Hering's Condensed Ma- teria Medica. The work, as was to be expected, was bought up with aviditv bv the profes- sion, and already in the Fall of 1878 the author set to work perfecting a'second and im- proved edition. By still more condensing many of the remedies, a number of new ones could be added without much increasing the size and the price of the work. This new edition is now ready for the profession, and will be the standard work par excellence for the practitioner's daily reference. HEINIGKE, DR. CARL. Pathogenetic Outlines of Homoeo- pathic Drugs. Translated from the German by Emil Tietze, M.D., of Philadelphia. 576 pages. 8vo. Cloth, . . . . $3 50 This work, but shortly issued, is already meeting with a large sale and an appreciative reception. It differs from most works of its class in these respects: 1. That the symptomatic outlines ofthe various drugs are based exclusively upon the "pathogenetic" results of provings. 2. That the anatomico-physiological arrangement of the symptoms renders easier the understanding and survey of the provings. 3. That the pathogenetic pictures drawn of most of the drugs, gives the reader a clearer idea, and a more exact impression of the action of the various remedies. Each remedy is introduced with a brief account of its preparation, duration of action, and antidotes. HILDEBRANDT, PROF. H. Catarrh of the Female Sexual Organs. Translated with the addition of the Homoeopathic Treatment, by S. Lilienthal, M.D.,........30 cts. HOLCOMBE, DR. W. H. Yellow Fever and its Homoeopathic Treatment,..........10 cts. HOLCOMBE, DR. W. H. What is Homoeopathy? A new expo- sition of great truth. 28 pages. 8v0. Paper cover, per doz., $1.25, 15 cts. " Prove all things, hold fast that which is good."—St. Paul. HOLCOMBE, DR. W. H. How I became a Homoeopath. 28 pages. 8vo. Paper cover, per dozen, 81.25, . . . .15 cts. HOLCOMBE, DR. W. H. Special Report of the Homoeopathic Yellow Fever Commission, ordered by the American Institute of Homoeopathy for presentation to Congress. 32 pages. 8vo. Paper, per 100, $4.00, . . ........5 cts. This Beport, written in Dr. Holcombe's masterly manner, is one of the best campaign documents for homoeopathy. The statistics must convince the most skeptical, and every homoeopathic practitioner should feel in duty bound to aid in securing its widest possible circulation. HOMCEOPATHIC POULTRY PHYSICIAN (Poultry Veterina- rian) ; or, Plain Directions for the Homoeopathic Treatment of the most Common Ailments of Fowls, Ducks, Geese, Turkeys, and Pigeons, based on the author's large experience, and compiled from the most reliable sources, by Dr. Fr. Schroter. Translated from the German. 84 pages. 12mo. Cloth,..........50 Cts. We imported hundreds of copies of this work in the original German for our customers, and as it gave good satisfaction, we thought it advisable to give it an English dress, so as to make it available to the public generally. The little work sells very fast, and our readers will doubtless often have an opportunity to draw the attention of their patrons to it. 8 BOERICKE & TAFEL'S HOMCEOPATHIC COOKERY. Second edition. With additions by a Lady of an American Homoeopathic Physician. Designed chiefly for the Use of such Persons as are under Homoeopathic Treatment. 176 pages,............50 cts. HUGHES, DR. R. Manual of Pharmacodynamics. 500 pages. American reprint out of print. See list of British books. HUGHES, DR. R. Manual of Therapeutics. 540 pages. American reprint out of print. See list of British books. HULL'S JAHR. A New Manual of Homoeopathic Practice, Edited, with Annotations and Additions, by F. G. Snelling, M.D. Sixth American edition. With an Appendix of the New Remedies, by C. J. Hempel, M.D. 2 vols. 2076 pages, «.....$9 00 The first volume, containing the symptomatology, gives the complete pathogenesis of two hundred and eighty-seven remedies, besides a large number of new remedies are added by Dr. Hempel, in the appendix. The second volume contains an admirably arranged Reper- tory. Each chapter is accompanied by copious clinical remarks and the concomitant symp- toms of the chief remedies for the maiady treated of, thus imparting a mass of information, rendering the work indispensable to every student and practitioner of medicine. JAHR, DR. G. H. G. Therapeutic Guide; the most Important Re- sults of more than Forty Years' Practice. With Personal Observations regarding the truly reliable and practically verified Curative Indications in actual cases of disease. Translated, with Notes and New Remedies, by C. J. Hempel, M.D. 546 pages, . . . . . . $3 00 " With this characteristically long title, the veteran and indefatigable Jahr gives us another volume of homoeopathies. Besides the explanation of its purport contained in the title itself, the author's preface still further sets forth its distinctive aim. It is intended, he says, as a ' guide to beginners, where I only indicate the most important and decisive points for the selection of a remedy, and where I do not offer anything but what my own individual experience, during a practice of forty years, has enabled me to verify as absolutely decisive in choosing the proper remedy.' Tlie reader will easily comprehend that, in carrying out this plan, I had rigidly to exclude all cases concerning which I had no experience of my own to offer.....We are bound to say that the book itself is agreeable, chatty, and full of practical observation. It may be read straight through with interest, and referred to in the treatment of particular cases with advantage."—British Journal of Homoeopathy. JAHR, DR. G. H. G. Clinical Guide, or Pocket Repertory for the Treatment of Acute and Chronic Diseases.. Translated by C. J. Hempel, M.D. Second American revised and enlarged edition. From the third German edition, enriched by the addition of the New Remedies. By S. Lilienthal, M.D. 624 pages. 12mo. llalf mo- rocco, ............$2 50 " To those of our readers who have used the old edition, nothing need be said to induce them to procure a copy of the new. To others, however, we feel free to state that as a volume of ready reference to lie on the office desk, or be used at the bedside, it is very valu- able, and will save many tedious and distracting hunts through the symptomen codex. The typographical execution of the book is excellent."—Hahnemannian Monthly. JAHR, DR. G. H. G. The Homoeopathic Treatment of Diseases of Females and Infants at the Breast. Translated from the French by C. J. Hempel, M.D. 422 pages. Half leather, . . . $2 00 This work deserves the most careful attention on the part of homoeopathic practitioners. The diseases to which the female organism is subject are described with the most minute correctness, and the treatment is likewise indicated with a care that would seem to defy criticism. No one can fail to study this work but with profit and pleasure. HOMCEOPATHIC PUBLICATIONS. 9 JAHR, DR. G. H. G. Diseases of the Skin; or, Alphabetical Reper- tory of the Skin Symptoms, and External Alterations of Substance, to- gether with the Morbid Phenomena observed in the Glandular, Osseous, Mucous, and Circulatory Symptoms. Arranged with Pathological Re- marks on Diseases of the Skin. Edited by C. J. Hempel, M.D. 515 pages. 12mo. Cloth,.........$1 50 JAHR, DR. G. H. G. The Venereal Diseases, their Pathological Nature, Correct Diagnosis, and Homoeopathic Treatment. Prepared in accordance with the author's own, as well as with the expe- rience of other physicians, and accompanied with critical discussions. Translated, with numerous and important additions, from the works of other authors, and from his own experience. By C. J. Hempel, M.D. 428 pages. 8vo. Cloth,...... . . $3 00 This is the most elaborate treatise on the subject in print. The work is divided into four divisions, of which the first treats on Primary Forms of Venereal Diseases, in four chapters: On the Venereal Phenomena in general; the Different Forms of Gonorrhoea; the Various Forms of Chancre; and other Primary Forms of Syphilis. The second division, on Second- ary Forms of Syphilis, treats in three chapters, of Secondary Syphilis generally; Syphilitic Cutaneous Affections, and Intermediate Forms of Syphilis. The third division: General Pathological Observations on Syphilis and its course generally, in three chapters; Patho- logical Nature and Origin of Syphilis; on Venereal Contagia; General Development, Course, and Termination of Syphilis. The fourth division: General Therapeutic Observa- tions on the Treatment of Syphilis; General Diagnostic Remarks; General Therapeutic Observations; Pharmaco-dynamic Observations, and Addenda. INDEX to the first eighteen volumes of the North American Journal of Homoeopathy. Paper,........$2 00 JONES, DR. SAMUEL A. The Grounds of Homoeopathic Faith. Three Lectures, delivered at the request of Matriculates of the Depart- ment of Medicine and Surgery (Old School) of the University of Michi- gan. By Samuel A. Jones, M.D., Professor of Materia Medica, Thera- peutics, and Experimental Pathogenesy in the Homoeopathic Medical College of the University of Michigan, etc., etc. 92 pages. 12mo. Cloth, per dozen, $3; per hundred, 820, . . . . ' . . 30 cts, Lecture first is on The Law of Similar* ; its Claim to be a Science in that it Enables Perver- sion. Lecture second, The Single Remedy a Necessity of Science. Lecture third, The Mini- mum Dose an Inevitable Sequence. A fourth Lecture, on The Dynamization Theory, was to have finished the course, but was prevented by the approach of final examinations, the prepa- ration for which left no time for hearing evening lectures. The Lectures are issued in a con- venient size for the coat-pocket; and as an earnest testimony to the truth, we believe they will find their way into many a* homoeopathic household. JOHNSON, DR. I. D. Therapeutic Key; or Practical Guide for the Homoeopathic Treatment of Acute Diseases. Third edition. 312 pages. Bound in linen,..........$1 50 Bound'in flexible cover, ........$2 00 This has been one of the best selling works on our shelves; more copies heing in circula- tion of this than of "any two other professional works put together. It is safe to say that there are but few homoeopathic practitioners in this country but have one or more copies of this little remembrancer in their possession. JOHNSON, DR. I. D. A Guide to Homoeopathic Practice. De- signed for the use of Families and Private Individuals. 494 pages. Cloth, . ..........$2 00 10 BOERICKE & TAFEL'S This is tlie latest work on Domestic Practice issued, and the well and favorably known author has surpassed himself. In his book fifty-six remedies are introduced for internal ap- plication, and four for external use. The work consists of two parts. Part I is subdivided into seventeen chapters, each being devoted to a special part of the body, or to a peculiar class of disease. Part II contains a short and concise Materia Medica, i. c, gives the symptoms peculiar to each remedy. The whole is carefully written with a view of avoiding technical terms as much as possible, thus insuring its comprehension by any person of ordi- nary intelligence. A complete set of remedies in vials holding over fifty doses each, is fur- nished for s?7, or in vials holding over one hundred doses each for $1(3, or book and ease complete for 89 or $12 respectively. Address orders to Boericke A Tafel's Pharmacies at New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco. JOSLIN, DR. B. F. Principles of Homoeopathy. In a Series of Lectures. 185 pages. 12mo. Cloth, ..... 60 cts. JOSLIN, DR. B. F. Homoeopathic Treatment of Epidemic Cholera. Third edition, with additions. 252 pages. 12mo. Cloth, 75 cts. This work offers the advantage of a threefold arrangement of the principal medicines, viz., with reference, I—to the varieties of cholera; II—to its stages; and III—to its symptoms as arranged in repertories. These last will give the work a permanent value in treating the more frequent complaints of summer. LAURIE AND McCLATCHEY. The Homoeopathic Domestic Medicine. By Joseph Laurie, M.D. JSinth American, from the Twenty- first English edition. Edited and revised, with numerous and important additions, and the introduction of the new remedies. By R. J. McClatciiey, M.D. 1044 pages. # 8vo. Half morocco,.....$5 00 "We do not hesitate to indorse the claims made by the publishers, that this is the most complete, clear, and comprehensive treatise on the domestic homoeopathic treatment of dis- eases extant. This handsome volume of nearly eleven hundred pages is divided into six parts. Part one is introductory, and is almost faultless. It gives the most complete and exact directions for the maintenance of health, and of the method of investigating the con- dition of the sick, and of discriminating between different diseases. It is written in the most lucid style, and is above all things wonderfully free from technicalities. Part two treats of symptoms, character, distinctions, and treatment of general diseases, together with a chap- ter on casualties. Part three takes up diseases peculiar to women. Part four is devoted to the disorders of infancy and childhood. Part five gives the characteristic symptoms of the medicines referred to in the body of the work, while Part six introduces the repertory."— Hahnemannian Monthly. "Of the usefulness of this work in oases where no educated homoeopathic physician is within reach, there can be no question. There is no doubt that domestic homoeopathy has done much to make the science known ; it has also saved lives in emergencies. The prac- tice has never been so well presented to the public as in this excellent volume."—New Eng. Med. Gazette. A complete set of remedies of one hundred and four vials, containing over fifty doses each, is furnished for 812, put up in an elegant mahogany case. A similar set in vials containing over one hundred doses each, is furnished for $18, or book and case complete for $17 or S23 respectively. Address orders to Boericke & Tafel's Pharmacies at New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco. LILIENTHAL, DR. S. Homoeopathic Therapeutics. By S. Lilienthal, M.D., Editor of North American Journal of Homoeopathy, Professor of Clinical Medicine and Psychology in the New York Homoeo- pathic Medical College, and Professor of Theory and Practice in the New York College Hospital for Women, etc. Second edition. 8vo, $5 00 Half morocco,.......... $6 00 " Certainly no one in our ranks is so well qualified for this work as he who has done it, and in considering the work done, we must have a true conception of the proper sphere of HOMCEOPATHIC PUBLICATIONS. 11 such a work. For the fresh graduate, this book will be invaluable, and to all such we un- hesitatingly and very earnestly commend it. To the older one, who says he has no use for tli is book, we have nothing to say. He is a good one to avoid when well, and to dread when ill. We also hope that he is severely an unicum."—Prof. Sam. A. Jones in American Homoe- opathixt. "... It is an extraordinary useful book, and those who add it to their library will never feel regret, for we are not saying too much in pronouncing it the best work on therapeu- tics in homoeopathic (or any other) literature. With this under one elbow, and Hering's or Allen's Materia Medica under the other, the careful homoeopathic practitioner can refute Neimayer's too confident assertion, ' I declare it idle to hope for a time when a medical pre- scription should be the simple resultant of known quantities.' Doctor, by all means buy Lilienthal's Homoeopathic Therapeutics. It contains a mine of wealth."—Prof. Chas. Gatchel in Ibid. LILIENTHAL, DR. S. A Treatise on Diseases of the Skin. A new edition in preparation for the press. LUTZE, DR. A. Manual of Homoeopathic Theory and Practice. designed for the use of Physicians and Families. Translated from the German, with additions by C. J. Hempel, M.D. From the sixtieth thousand of the German edition. 750 pages. 8vo. Half leather, . . . . ■.......$2 50 This work, from the pen .of the late Dr. Lutze, has the largest circulation of any homoeo- pathic work in Germany, no less than sixty thousand copies having been sold. The intro- duction, occupying over fifty passes, contains the question of dose, and rules for examining the patient, and diet; the next sixty pages contain a condensed pathogenesis of the remedies treated of in the work; the description and treatment of diseases occupy four hundred and eighteen pages, and the whole concludes with one hundred and seventy-three pages of reper- tory and a copious index, thus forming a concise and complete work on theory and practice. MALAN, H. Family Guide to the Administration of Homoeo- pathic Remedies. 112 pages. 32mo. Cloth, . . .30 cts. MANUAL OF HOMCEOPATHIC VETERINARY PRACTICE. Designed for all kinds of Domestic Animals and Fowls, prescribing their proper treatment when injured or diseased, and their particular care and general management in health. Second and enlarged edition. 684 pages. 8vo. Half morocco,.........$5 00 " In order to rightly estimate the value and comprehensiveness of this great work, the reader should compare it, as we have done, with the best of those already before the public. In size, fulness, and practical value it is head and shoulders above the very best of them, while in many most important disorders it is far superior to them altogether, containing, as it does, recent forms of disease of which they make no mention."—Hahnemannian Monthly. MARSDEN, DR. J. H. Handbook of Practical Midwifery, with full instructions for the Homoeopathic Treatment of the Dis- eases of Pregnancy, and the Accidents and Diseases incident to Labor and the Puerperal State. By J. H. Marsden, A.M., M.D. 315 pages. Cloth,.........$2 25. " It is seldom we have perused a textbook with such entire satisfaction as this. The author has certainly succeeded in his design of furnishing the student and young practitioner, within as narrow limits as possible, all necessary instruction in practical midwifery. The work shows on every page extended research and thorough practical knowledge. The style is clear, the array of facts unique, and the deductions judicious and practical. AVe are par- ticularly pleased with his discussion of the management of labor, and the management of mother and child immediately after the birth, but much is left open to the common-sense and practical judgment of the attendant in peculiar and individual cases."—Homoeopathic Times. 12 BOERICKE & TAFEL'S MILLARD, DR. H. B. The Climate and Statistics of Consump- tion. Read before the American Geographical and Statistical Society. With extensive additions by the author. 108 pages. Cloth, . 75 cts. MOHR, DR. CHARLES. The Incompatible Remedies of the Homoeopathic Materia Medica. By Charles Moiir, M.D., Lecturer of Homoeopathic Pharmaceutics, Hahnemann Medical College, Philadel- phia. (A paper read before the Homoeopathic Medical Society of the County of Philadelphia) Pamphlet, in paper cover, . . 10 cts. This is an interesting paper, which will well repay perusal and study. It gives a list of fifty-seven remedies and their incompatibles, diligently collated from the best-known sources. MORGAN, DR. W. The Homoeopathic Treatment of Indiges- tion, Constipation, and Haemorrhoids. Edited with Notes and Annotations by A. E. Small, M I). 166 pages 12mo. Cloth, 60 cts. Diseases resulting from irregularity or debility of the digestive organs are so frequent in their occurrence, that scarcely a family can be found in which one or more of its members are not sufferers thereby. The present work gives in a concise manner the hygienic meas- ures as well as the medical treatment that should be observed, calculated not only to obviate the necessity of recourse to dangerous palliatives", but to promote a complete restoration of health. MORGAN, DR. W. The Textbook for Domestic Practice; being plain and concise directions for the Administration of Homoeopathic Medicines in Simple Ailments. 191 pages. 32mo. Cloth, . 50 cts. This is a concise and short treatise on the most common ailments, printed in convenient size for the pocket; a veritable traveller's companion. A complete set of thirty remedies, in vials holding over fifty doses each, is furnished for $4.50, in stout mahogany case; or same set in vials holding over one hundred doses each, for $6.50; or book and case complete for $5 or §7 respectively. Address orders to Boericke & Tafel's Pharmacies, New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco. _. MURE, DR. B. Materia Medica; or, Provings of the Principal Ani- mal and Vegetable Poisons of the Brazilian Empire, and their Application in the Treatment of Diseases. Translated from the French, and arranged according to Hahnemann's Method, by C. J. Hempel, M.D. 220 pages. 12mo. Cloth,..........$1 00 This volume, from the pen of the celebrated Dr. Mure, of Rio Janeiro, contains the patho- genesis of thirty-two remedies, a number of which have been used in general practice ever since the appearance of the work. A faithful wood-cut of the plant or animal treated of ac- companies each pathogenesis. NEIDHARD, DR. C. On the Universality of the Homoeopathic Law of Cure,........ • 30 cts. NEW PROVINGS of Cistus Canadensis, Cobaltum, Zingiber, and Mer- curius Proto-lodatus. 96 pages. Paper, ..... 75 cts. NORTH AMERICAN JOURNAL OF HOMOEOPATHY. Pub- lished quarterly on the first days of August, November, February, and May. Edited by S. Lilienthal, M.D. Vol. X, New Series, commenced in August, 1879. Subscription price per volume, in advance, . $4 00 Complete sets of the first twenty-seven volumes, in half morocco binding, including Index to the first eighteen volumes, . . . $90 00 Index to the first eighteen volumes....... $2 00 HOMCEOPATHIC PUBLICATIONS. 13 OEHME, DR. F. G. Therapeutics of Diphtheritis. A Compilation and Critical Review of the German and American Homoeopathic Litera- ture. Second enlarged edition. 84 pages. Paper, . . . 60 cts. Same, in cloth,..........75 cts. "This pamphlet contains the best compilation of reliable testimony relative to diphtheria that has appeared from the pen of any member of our school."—Ohio Medical and Surgical Reporter. ''Although he claims nothing more for his book than that it is a compilation, with 'criti- cal reviews,' he has done his work so well and thoroughly as to merit all praise."—Hahne- mannian Monddy. " Dr. Oehme's little book will be worth many times its price to any one who has to treat this terrible disease."—British Journal of Homoeopathy. " It is the best monograph we have yet seen on diphtheria."—Cincinnati Medical Advance. PETERS, DR. J. C. A Complete Treatise on Headaches and Diseases of the Head. I. The Nature and Treatment of Headaches. II. The Nature and Treatment of Apoplexy. III. The Nature and Treatment of Mental Derangement. IAr. The Nature and Treatment of Irritation, Congestion, and Inflammation of the Brain and its Membranes. Based on Th. J. Riickert's Clinical Experiences in Homoeopathy. 586 pages. Half leather,.........$2 50 PETERS, DR. J. C. A Treatise on Apoplexy. With an Appendix on Softening of the Brain and Paralysis. Based on Th. J. Riickert's Clinica .Experiences in Homoeopathy. 164 pages. 8vo. Cloth, $1 00 PETERS, DR. J. C. The Diseases of Females and Married Fe- males. Second edition. Two parts in one volume. 356 pages Cloth,............$1 50 PETERS, DR. J. C. The Diseases of Married Females. Disorders of Pregnancy, Parturition, and Lactation. 196 pages. 8vo. Cloth, $1 00 PETERS, DR. J. 0. A Treatise on the Principal Diseases of the Eyes. Based on Th. J. Riickert's Clinical Experiences in Homoeopath}7. 291 pages. 8vo. Cloth,........$1 50 PETERS, DR. J. C. A Treatise on the Inflammatory and Organic Diseases of the Brain. Based on Th. J. Riickert's Clinical Experi- ences in Homoeopathy. 156 pages. 8vo. Cloth, . . . $1 00 PETERS, DR. J. 0. A Treatise on Nervous Derangement and Mental Disorders. Based on Th. J. Riickert's Clinical Experiences in Homoeopathy. 104 pages. 8vo. Cloth,.....$1 00 PHYSICIAN'S VISITING LIST AND POCKET REPERTORY, THE HOMCEOPATHIC. By Robert Faulkner, M.D. Second edition,......., ... $2 00 " Dr. Faulkner's Visiting List is well adapted to render the details of daily work more perfectly recorded than any book prepared for the same purpose with which we have hitherto met. It commences with Almanacs for 1877 and 1878; then follow an obstetric calendar; a list of Poisons and their Antidotes; an account of Marshall Hall's ready method in As- phyxia; a Repertory of between sixty and seventy pages; pages marked for general memo- randa ; Vaccination Records; Record of Deaths; Nurses; Friends and others; Obstetric 14 BOERICKE & TAFEL'S Record, which is especially complete; and finally, pages ruled to keep notes of daily visits, and also spaces marked for name of the medicine ordered on each day. The plan devised is so simple, so efficient, and so clear, that we illustrate it on a scale just half the size of the original there follows illustration). The list is not divided into special months, but its use may he as easily commenced in the middle of the year as at the beginning. We heartily recommend Faulkner's List to our colleagues who may be now making preparations for the duties oi 1878."—Monthly Homoeopathic Review, London. RAUE, DR. C. G. Special Pathology and Diagnosis, with Thera- peutic Hints. 344 pages. 8vo. Half morocco, . . . $5 00 This standard work is used as a textbook in all our colleges, and is found in almost every physician's library. An especially commendable feature is that it contains the application of nearly all the new remedies contained in Dr. Hale's work on Materia Medica. RUDDOCK, DR. Principles, Practice, and Progress of Homoe- opathy, 5 cts.; per hundred, 83; per thousand, . . . $25 00 RUOFF'S REPERTORY OF HOMCEOPATHIC MEDICINE. Nosologically arranged. Translated from the German by A. H. Okie, M.D. With additions and improvements by G. Humphrey-, M.D. 251 pages. 12mo. Cloth,.........$1 50 As a book of reference for the practitioner, the present work far excels every other work, presenting him at a single glance what he might otherwise seek for amidst a confused mass of records and never find. The indefatigable author has drawn his matter from the infallible results of experience, leaving out all guesswork and hypothesis. RUSH, DR. JOHN. Veterinary Surgeon. The Handbook to Vet- erinaiy Homoeopath}^; or, the Homoeopathic Treatment of Horses, Cattle, Sheep, Dogs, and Swine. From the London edition. With numerous additions from the Seventh German edition of Dr. F. E. Gunther's " Ho- moeopathic Veterinary." Translated by J. F. Sheer, M*.D 150 pages. 18mo. Cloth,..........50 Cts. SCHAEFER, J. C. New Manual of Homoeopathic Veterinary Medicine. An easy and comprehensive arrangement of Diseases, adapted to the use of every owner of Domestic Animals, and especially designed for the Farmer living out of the reach of medical advice, and showing him the way of treating his sick Horses, Cattle, Sheep, Swine, and Dogs, in the most simple, expeditious, safe, and cheap manner Translated from the German, with numerous additions from other veteri- nary manuals, by C. J. Hempel, M.D. 321 pages. 8vo. Cloth, $2 00 SCHWABE, DR. WILLMAR. Pharmacopoeia Homoeopathica Polyglottica. Second edition. Cloth, . . . . . $3 00 Of this valuable work, the second edition has just been issued. SHARP'S TRACTS ON HOMCEOPATHY, each, . . 5 cts. Per hundred,...........$3 00 No. 1. What is Homoeopathy? No. 7. The Principles of Homoeopathy. No. 2. The Defence of Homoeopathy. No. 8. Controversy on No. 3. The Truth of " No. 9. Remedies of . No. 4. The Small Doses of " No. 10. Provings of No. 5. The Difficulties of " No. 11. Single Medicines of " Ho. 6. Advantages of " No. 12. Common-sense of " HOMCEOPATHIC PUBLICATIONS. 15 SHARP'S TRACTS, complete set of 12 numbers, ... 50 cts. Bound,...........75 Cts. SMALL, DR. A. E. Manual of Homoeopathic Practice, for the use of Families and Private Individuals. Fifteenth enlarged edition. 831 pages. 8vo. Half leather,.......$2 50 SMALL, DR. A. E.. Manual of Homoeopathic Practice. Trans- lated into German by C. J. Hempel, M.D. Eleventh edition. 643 pages. 8vo. Cloth,..........$2 50 SMALL, DR. A. E. Diseases of the Nervous System, to which is added a Treatise on the Diseases of the Skin, by Dr. C. E. Toothacker. 216 pages. 8vo. Cloth,........$100 This treatise is from the pen of the distinguished author of the well-known and highly popular work entitled, " Small's Domestic Practice." It contains an elaborate description of the diseases of the nervous system, together with a full statement of the remedies which have been used with beneficial effect in the treatment of these disorders. STAPF, DR. E. Additions to the Materia Medica Pura. Trans- lated by C. J. Hempel, M.D. 292 pages. 8vo. Cloth, . . $1 50 This work is an indispensable appendix to Hahnemann's Materia Medica Pura. Every remedy is accompanied with extensive and most interesting clinical remarks, and a variety of cases illustrative of its therapeutical uses. TESSIER, DR. J. P. Clinical Researches concerning the Ho- moeopathic Treatment of Asiatic Cholera. Translated by C. J. Hempel, M.D. 109 pages. 8vo. Cloth,.....75 cts. TESSIER, DR. J. P. Clinical Remarks concerning the Homoeo- pathic Treatment of Pneumonia, preceded by a Retrospective View of the Allopathic Materia Medica, and an Explanation of the Homoeo- pathic Law of Cure. Translated by C. J. Hempel, M.D. 131 pages. 8vo. Cloth,..........75 cts. THOMAS, DR. A. R. Post-Mortem Examination and Morbid Anatomy. 337 pages. 8vo. Cloth,.....$2 50 VERDI, DR. T. S. Maternity; a Popular Treatise for Young Wives and Mothers. By Tullio Suzzara Verdi, A.M., M.D., of Washington, D. C. 450 pages. 12mo. Cloth, . . . $2 00 " No one needs instruction more than a young mother, and the directions given by Dr. Verdi in' this work are such as I should take great pleasure in recommending to all the voung mothers, and some of the old ones, in the range of mv practice."—George E. Shipman, M.D., CJiicago, III. " Dr. Verdi's book is replete with useful suggestions for wives and mothers, and his medi- cal instructions for home use accord with the maxims of my best experience in practice."— John F. Gray, M.D., New York City. VERDI, DR. T. S. Mothers and Daughters: Practical Studies for the Conservation of the Health of Girls. By Tullio Suzzara Verdi, A.M., M.D. 287 pages. 12mo. Cloth,.....$1 50 " The people, and especially the women, need enlightening on many points connected with their physical life, and the time is fast approaching when it will no longer be thought sin- 16 BOERICKE & TAFEL'S HOMCEOPATHIC PUBLICATIONS. gular or 'Yankeeish' that a woman should be instructed in regard to her sexuality, its organs and their functions. . . . Dr. Verdi is doing a good work in writing such books, and we trust he will continue in the course he has adopted of educating the mother and daughters. The book is handsomely presented. It is printed with good type on fiiie paper, and is neatly and substantially bound."—Hahnemannian Monthly. WILLIAMSON, DR. W. Diseases of Females and Children, and their Homoeopathic Treatment. Third enlarged edition. 25t; pages. 12mo. Cloth,....... . . $1 00 This work contains a short treatise on the homoeopathic treatment of the diseases of femab s andchildren, the conduct to be observed during pregnancy, labor, and confinement, and di- rections for the management of new-born infants. JUST PUBLISHED. A Treatise on the Medical and Surgical Diseases of Women, with their Homoeopathic Treatment. By Morton Monroe Eaton, M.D. Fully illustrated. 782 pages. Bound in sheep. Price, $6 50 This treatise represents an immense amount of work, as it is fully brought up to date. The whole medical literature has been laid under contribution, and this, supplemented by the large experience from the author's own extensive practice, resulted in a volume of which the profession may justly feel proud. The fine illustrations are made from original drawings, and both in completeness as to the subjects treated upon as well as in the superiority of its illustrations, the work is far in advance of any similar publication of any school issued so Far. The text proper takes up 782 pages, with 64 plates of illustrations, and over seventy such printed in the text. The work is divided into seventy chapters, and is very carefully indexed. HOMCEOPATHIC JOURNALS. THE NORTH AMERICAN JOURNAL OP HOMOEOPATHY. Samuel A. Lilienthal, M.D., Editor. Boericke & Tafel, Publishers. Quarterly. Subscription price per year, payable in advance, $4 00 This is the oldest Homoeopathic Journal in this country, being now in its twenty-seventh year. The first volume was published in 1851, under the editorship of C. Hering, M.D., of Philadelphia; E. E. Marcy, M.D., and J. W. Metcalfe. M.D., of New York. In 1856, E. E. Marcy and J. C Peters, M.D., of New York; Wm. H. Holcombe, M.D., of Waterproof, ' La., and H. C Preston, M.D., of Providence, E. I., appear as editors. In 1860, Dr. J. C. Peters, with a corps of assistant editors, assumed charge; and from 1861 until 1869 the late Dr. F. W. Hunt virtually edited the Journal, although his name did not always appear as such. In 1870, Dr. S. Lilienthal became associated with Dr. Hunt as co-editor, and since 1871 Dr. Samuel A. Lilienthal took sole charge of the Journal. The Journal had its ups and downs during the long years of its existence, but under the administration of indefatigable Dr. Lilienthal it entered on a career of prosperity such as it never enjoyed before, and it is safe to say that it never before had as many friends, as valu- able original or translated articles, and as large a subscription list. The Twenty-eighth Volume of this Journal commences in August, 1879. Subscriptions please address to the publication office as follows: BOERICKE & TAFEL, 145 Grand Street, New York, HES'-All the Medicines mentioned in this'work can be obtained in their utmost purity and conscientiously prepared at BOERICKE & TAFEL'S myopathic Pharmacies. XJ. W 1 ESTABLISHED IN- 1835. NEW YORK, 145 Grand St. PHILADELPHIA, 635 Arch St, PHILADELPHIA, 125 South Eleventh St, BALTIMORE, 135 West Fayette St, NEW ORLEANS, 130 Canal St, CHICAGO, 35 South CM St, SAN FRANCISCO, 234 Sutter St, NOTICE TO PHYSICIANS. Mother Tinctures. In the preparation of our Mother Tinctures, we make use of none but fresh, green plants, for the proper collection of which wc have un- usual facilities* Most of these are collected by ourselves within a radius of less than twenty miles from Philadelphia. Plants indigenous to the West wc procure through our branch in Chicago; those of the South, through our branch in New Orleans; while plants growing on the Pacific Coast, the Sandwich Islands, etc., are furnished by our branch at San Francisco. Thus saturated tinctures made from fresh plants, gathered when in full vigor, may at all times be relied upon. European Homoeopathic Tinctures we import from the best known sources, i. e. from reputable Homoeopathic Pharmacies. The only exceptions to above rule are tinctures from plants growing in distant countries, as Nux vom., Rheum, Ignatia, etc., which of necessity are made from carefully selected dry material. Triturations. Our Triturations are made with Pure Sugar of Milk in steam triturators with the latest improvements. Having ample facilities, we are enabled to accord to each trituration fully two hours, whereby an unusual degree of excel- lence is obtained. Eemedies such as Sepia, Mercurius v., Graphites, are triturated four hours or longer, until the desired grade of comminution is secured. Dilutions. Our Dilutions are all conscientiously made by hand. We com- menced by running up one hundred remedies to the 30th, retaining all intermediate attenuations and using a separate box for each remedy. Gradually the list has in- creased until to-day we carry in stock over seven hundred remedies, and are able to supply any of them like the 12th, 15th, 24th, etc., as readily as the 3d or 6th. Each of our eight pharmacies carries such a set in stock, and our patrons thus have ab- solute surety of obtaining any intermediate potency called for. Our Pharmacies are devoted exclusively to the sale of Homoeopathic Medi- cines and Books; and as all Branch Establishments are supplied from our Labora- tory in Philadelphia, Medicines of our uniform standard quality, may be obtained alike from either of our several establishments. In conclusion, we beg to assure the profession that, it has ever been our en- deavor to excel in the quality of our preparations; that while furnishing our medi- cines at a moderate advance on cost, we do not intend to compete with establish- ments whose sole claims lie in cheap prices. Our endeavors have met with hearty acknowledgement by the profession, and the generous support accorded to our es- tablishments, bears witness to our ability to give satisfaction to our many patrons. Complete Price List and Illustrated Catalogue sent free to Physicians on application. * NLM005801260