belief that passive motion in fractures near the joints, before firm union of the bones has occurred, is as a rule pernicious. In old persons after the first week I liberate the fingers in treating a Colles' fracture. This it is well to do in all cases after ten days or three weeks for all the muscles of the fingers may be put in action without disturbing the fracture or material motion of the wrist so long as the metacarpus is steadied by a splint and bandage. Passive motion where it has been most used and most strongly advocated, viz., in fractures of the elbow is a most dangerous expedient and to me seems irrational on theoretical grounds.] RUPTURE OF PERINEUM. A In Vol. VI. International Encyclopedia of Surgery, I find described an operation for perineoplasty which I have for the past four years practiced where the rupture involved the rectal wall, with considerable satisfaction but which I supposed was original. I am pleased to find that it is given by the author of this article, Prof. Theophilus Parvin, M.D., as the method of Hildebrandt, and also of Hegar and Kaltenbach, an old method to which attention is again called. The butterfly denudation is first made and approximation is effected by three sets of sutures. superficial line of sutures along the rectal surface, another along the vaginal surface and a third passed more deeply along the skin surface of the perineum. When I first followed the plan it was a tedious operation, for the interrupted suture with fine silk was used. For the past two years I have used one or two deep sutures of wire or silk and in all the others along the three surfaces, vaginal, rectal and perineal, the continuous cat gut suture. The deep sutures can also be made with large cat gut. The parts can thus be very perfectly approximated and without the tension on the deep sutures that is necessary where there is only one line of sutures. In approximating the rectal and posterior perineal line of denudation we can be giving attention to "Emmet's pits," secure very complete apposition Approved antiseptic methods have, I think, effected a marked advance in the success at tending operative procedures for the radical cure of hernia. They have enabled us to inspect the parts, remove or treat directly the sac, and more accurately and firmly approximate the pillars of the ring, than by the subcutaneous methods heretofore practiced. The ready union of the parts without marked inflammation, excited in my mind the fear that the adhesion would not be firm enough to resist the pull of the tissues and the strain of the impulse from within. There is an article in the Annals of Surgery, August, 1886, by Wm. MacEwen, M. D., of Glasgow, under the title "On the Radical Cure of Oblique Inguinal Hernia by Internal Abdominal Peritoneal Pad and the Restoration of the Valved Form of the Inguinal Canal", in which he gives the results of his method of operating primarily for the radical cure, or in its use after the operation for the relief of strangulation. Under the head of results he says: "There have been thirty-three cases in which the operation has been performed for radical cure of inguinal hernia, and fourteen have been subjected to it subsequently to the relief of strangulation; making in all fortyseven cases of inguinal hernia in which this method has been performed. In nine others, the principles of it were carried out in femoral hernia, after the relief of strangulation. In both of the latter classes of cases the operation was not performed where gangrene of bowel was pronounced, or even where there was a distinct approach to this condition. In a number of femoral hernia it could not be performed owing to the firm adhesions of the sac, especially when they were to the outer side next to the femoral vein. he felt a "want" when there was no bandage over the part. It was more a force of habit than a need. The parts were firm. Among the fourteen who had been subjected to radical cure after the relief of strangulated inguinal hernia, three subsequently wore a pad and bandage as a precautionary measure. One of these was of very lax habit, and was advised to continue the use of a support; one was a case of direct inguinal hernia with a very the third did so, as his occupation (engineer) often demanded considerable exertion. After the femoral hernias no truss has been worn." [This is certainly a most excellent showing. The details of his operations must be ob tained from the article. The method of dealing with the sac is peculiar. It is first dissected so as to separate it from the scrotal tissue and loosened by the handle of the scalpel and the fingers from the inguinal canal and from the wall immediately surrounding the internal abdominal ring. A needle is then carried through the fundus and the sac folded upon itself so that the needle traverses its walls a number of times before it reaches the neck, when, guided by the finger, it is made to traverse the abdominal wall above the site of the internal ring. This catgut suture is drawn snugly and tied, and the folded hernial sac is thus fas tened to the inner surface of the abdominal wall, and the peritoneal pad formed presents a convex surface toward the cavity. The author claims that this gives additional resisting power. here appended, from which it will be seen that there have been no deaths from the operation. In a few cases suppuration has ensued and that to a very slight extent, with the exception of a femoral hernia in which there was a prolonged dissection necessary. All the patients before leaving the ward were thoroughly inspected, and firm occlusion was obtained in each, so that the primary result was highly satisfa c-wide opening in the abdominal muscles, while tory. But it is just in cases of this kind that the permanent result so often differs from the primary, and as the former is the true test of the efficiency of the operation, the patients have been kept under observation as long as possible. In judging of the permanent results, two must be excluded from table number one, as having been so recently operated on. The remainder in table No. I have been kept under observation as follows: Four from four to six months after, four from eight to ten months, two for one year after, three for about one year and a half, five for two years, five for three years, one for four years and one for five years. So that eight have been kept under observation for less than a year, and seventeen from one to five years. Table No. II. gives: one for eight months, three for one year after, three eighteen months after, four two years after, two three years after, and one four years after. Table No. III. gives: One not seen after dismissal, two seen eight months after, two one year after, one eighteen months after, one two and a half years after, two three years after. In table No. II.. one has been kept under observation for less than a year, and thirteen from one to four years after. In table No. III two have been kept under observation for less than one year, and six from one to three years after, while one was not seen after dismissal from the wards. In all of them when last examined the rings remained firm. Out of the thirty-three cases in which this operation has been performed for radical cure, one only has been found subsequently to wear a pad and bandage. In this instance patient said that he had been wearing a truss so long previously to the operation that The well known disposition of the adhe sions formed by serous surfaces to stretch and elongate should be remembered in according to this pad such a function. If it will remain as a knob to fill the pit or depression natu rally found at this point it will be a great help in the avoidance of a recurrence of the her nia. Dr. Macewen does not state that the size of the sac influences him in the selection of his cases, but it must necessarily limit the number of cases fitted for this operation. The extent of the freshened surface thus carried into the abdominal cavity must more fre quently determine suppuration than in those procedures where the sac is removed and the for the radical cure of hernia are growing in pillars approximated. Operative procedures favor, and have promise of a useful future.] ORIGINAL ARTICLES. ERYSIPELAS COMPLICATING PAR TURITION. BY I. N. LOVE, M. D. Mrs. K., æt. 33, a woman of good constitution, of high social position, living in the most healthful part of the city, with a thoroughly intelligent appreciation of the necessity of domestic sanitation, and living in an ideal home, looking forward cheerfully and hopefully to her fifth confinement (which event was anticipated within one week), felt slight chilliness on the evening of Aug. 3, '86 -bad what she considered were symptoms of "a cold." The following day felt feverish, "achy," and uncomfortable. On the evening of this day I saw patient for the first time. Examination revealed a large, heavily-coated tongue. Pulse full and heavy, 90 beats to the minute: temperature, 102° Fahrenheit; a general soreness of muscles, marked enlargement of lymphatic glands in cervical region anteriorly and posteriorly, as well as parotid glands. Ordered ten grains each of quinine and blue mass (to be followed in morning by large dose of castor oil), a hot mustard foot bath and a hot brandy toddy. solution of corrosive sublimate (one part to 1000 of water) for the hands of the attendants, and had vaginal injections of same used on patient. Under the administration of chloroform, patient was delivered of a good sized child, about five hours after beginning of labor. Administered two drachms of Squibb's ergot, which is my habit, as the head pressed upon the perineum. Womb contracted promptly and thoroughly. Directed external genitals to be bathed with bi-chloride solution, and a cloth wet in same solution to be kept constantly in close contact with their surfaces. Mother never having been able to nurse any of former children, concluded to take no chances (new-born infants being peculiarly susceptible to erysipelas), and ordered child immediately removed to an adjoining room and thoroughly isolated from mother. At my next visit (10 A. M. Aug. 5), erysipelas had rapidly extended, covering head and face, neck and down upon the shoulder of the right side. Both eyes were closed, patient was dull and heavy, pulse 108, temp. 1044°, and everything establishing a violent case of erysipelas. Skin generally dry and hot, urine scanty and high colored, mouth and tongue dry, glandular system thoroughly torpid. To Discontinued quinine. Ordered a continuuance of iron, and as a stimulant to the secretory system directed one-sixteenth grain of muriate of pilocarpine every hour until a decided effect should be produced. guard against depressing effects directed nurse to sandwich in between the doses, a half ounce of whisky made into a toddy, also ten grains of benzoate of soda every two hours. Six hours later a thorough salivation and sweating had been secured; temperature was 101°, pulse 96, directed continuance of pilocarpine every two to four hours, as might be necessary in order to keep up the effect secured, and great care to be observed to prevent drafts striking patient. Instructed nurse to devote most of her attention to the upper extremity of her patient, and leave her genitals alone except to bathe them once a day under the severest antiseptic precautions; removing the cloth saturated with the bi-chloride solution once every six hours and immepiately replacing with another. The following morning bowels had moved well, temperature was not quite so high, but patient felt very uncomfortable, having spent a very restless night. Glandular soreness was even more marked; small kernels about neck and head being numerous and well de fined, but swelling not great. Ordered five grains each of quinine and Dover's powder every three hours. In the evening (Aug. 4) patient was much more comfortable, having passed a very pleasant day under the influence of the remedies. Temperature, 102°, pulse, 88; condition of glands about the same, which, coupled with a redness and soreness of skin of right ear and temple, established a diagnosis of facial erysipelas. At once ordered the proper remedies. Internally, quinine five grains every three hours, and muriated tincture of iron,dram doses well diluted with water, every three hours. Locally, equal parts of lime water and olive oil, with five drops of kreasote to each ounce of the mixture. Had monthly nurse sent for, and left with her instructions to use freely of disinfectants about Whenever the pilocarpine was withdrawn the room. Felt great anxiety for my patient for too long a time and the secretions became on account of close proximity of her confine- less active, the patient was not so comfortment, which was daily expected. At mid- able, and other sym toms connected with night I was summoned and labor had com- the inflammatory condition of the skin indimenced. Used every antiseptic precaution,cated the propriety of its resumption. From this time on up to August 11, the severity of the symptoms varied, there being three days and nights when active delirium was present, and the administration of the ever reliable remedy for the delirium of erysipelas was necessitated, viz., carbonate of ammonia. Several times a distressing laryngeal cough and irritation of pharynx suggested possibility of laryngeal erysipelas as a very unusual complication and first reported in a most interesting manner by Dr. William Porter, of St. Louis, (Archives of Laryngology, 1880). This condition invariably yielded to the administration of the pilocarpine and a free spraying with dilute solution of eucalyptol, thymol and boracic acid. At one time violent pain occurred in the right ear, and an examination with speculum revealed an extension of inflammation into the external auditory canal. The same application which was applied to the face with a few drops of muriate of cocaine secured relief whenever applied. The ear required attention for several days. After August 11, the symptoms all become milder, and within a few days all signs of erysipelas, save a few breaks in the skin upon the cheeks, had disappeared, and my patient was convalescent. In addition to the remedies which I have enumerated I had my patient take large quantities of peptonized milk (from a quart to a quart and a half in twenty-four hours), which was given to her almost ice cold, and relieved her thirst materially. The activity of the excretory organs and the intensely hot weather (the thermometer ranging from 95° to 100° each day), having produced a great demand for liquids. This case of erysipelas was interesting on account of its being synchronous with parturition. Most writers and observers recognize the dangers of erysipelas and others of the exanthemata in connection with the puerperal state; during the prevalence of such diseases, septic complications in connection with surgical injuries and obstetric practice are frequent. All careful physicians are so impressed with this danger that they would not be willing (nor should they) to accept a confinement case while they had under their care a case of exanthematous fever, and particularly erysipelas cr scarlet fever. Impressed with these views, I was gravely anxious as to the outcome of my case, and instituted from the very beginning the most thorough antiseptic measures-guarding the uterine outlet against infectious intrusion and fighting the diseased surfaces of the upper extremity with antiseptic germicide remedies. Apropos to point here made, since writing the above notes of case, I have received the August number of Dr. Leartus Connor's able and admirable American Lancet containing an epitome of the views of M. Hervieux of the French Academy of Medicine (from Ľ Union Mèdicale) regarding erysipelas and septicemia, viz: 1. That identity evidently exists between erysipelas and septicemia, whether the latter be puerperal or surgical. 2. That erysipelas being only an expres ion of septicemia, may on occasion produce the latter, just as septicemia may produce ery. sipelas. 3. That erysipelas demands, therefore, from the surgeon the same remedial measures as are required in septicemia. M. Trèlat, in discussing the views above quoted, said that the identity of the two diseases, as yet, is not a recognized scientific fact, and that science has not yet determined the nature of the agent or microbe which produces erysipelas. Whatever may be the dif ference or analogies which exist between the agents producing erysipelas and septicemia, the fact remains that erysipelas does not ordinarily pursue the course of septicemia, but, nevertheless, though the question is still undecided, it is true that all antiseptic precautions are also precautions against erysipelas. The result of the case, there being at no time the least inclination towards a puerperal complication, and the rapid convalescence of my patient, she being at the end of two weeks from delivery in a better condition than at the same time of any of her four previous confinements, was very gratifying, and was, I believe, aided by the antiseptic, eliminative and supportive plan of treatment adopted. During the years 1872-3 4, when assistant physician to the City Hospital of St. Louis, we had several epidemics of erysipelas. As a local application everything which I had seen recommended was in their order used, such as silicate of soda, collodion, iodine, etc., etc., ad infinitum. I finally adopted as in my judg ment the best, the stereotyped application usually made to burns, viz., equal parts of lime water and olive oil, with five drops of kreasote to each ounce, for the reason that it was soothing and emollient, protective against the air and antiseptic; fourteen years experi ence with it has increased my preference for it as a topical application. During the past year I have treated six sporadic cases of erysipelas, located in different sections of the city and widely separated as to time, (there being at no time any signs of an epidemic) the majority of them severe, upon the supporting, germicidal and eliminative plan, the same as I adopt in the treatment of diphtheria and scarlatina, and I have had no reason to regret so doing-to say the least the result has been more satisfactory than under any other plan. I look upon the muriate of pilocarpine as one of the most reliable eliminative remedies in the materia medica. As a stimulant to the glandular sys. tem, it is par excellence that it must be given carefully and guardedly goes without saying the same may be well said of all physic. Dr. R. M. King, of St. Louis, who has recently written a very valuable paper upon this drug, and who has had a very large experience in its use, strongly endorses it. The topical application of the mixture containing kreasote, in conjunction with olive oil and lime water, I prefer for the reason that the mixture is alkaline, antiseptic and antagonistic to the air. A recent writer, whose name I have forgotten, has recommended the aqueous solution of carbolic acid. The objection, I think, to this, is the evaporation of the water, and the consequent chilling of the surface. I concur in the views of Prof. Marcus Beck, of University College Hospital, London, who says regarding the local treatment of erysipelas: "Warmth and avoidance of variations of temperature are essential. Cold is utterly inadmissible; it aggravates the inflammation and tends to cause suppuration and even sloughing." In In the direction of more thorough local antiseptic treatment, Hueter has recommended the subcutaneous injection immediately about the territory of invasion of a 30 per cent solution of carbolic acid, the same as in the treatment of carbuncle. I fancy there might be some risk of carbolic acid poisoning. connection with this procedure the following from the London Lancet is interesting, viz., "In the venereal wards, under the care of Dr. Montes de Oca, in Buenos Ayres, consid erable success has been obtained in cases of erysipelas by the injection of a 30 per cent solution of carbolic acid, as recommended by Hueter, Boeckel, and Sukowenkoff. Care was taken to introduce the carbolic acid as near near as possible to the part attacked. In one case where a patient with syphilitic cachexia had been attacked for the second time, six injections, two being given daily, served to limit the affection to the right ear, which was the part affected, and to entirely prevent its spreading further." I feel that this case and previous observations justify me in arriving at the following conclusions: 1. Erysipelas being an infectious disease like scarlatina, diphtheria, due to a specific germ, etc., should be treated in a somewhat similar manner, upon tonic supporting, antiseptic germicidal and eliminative principles. 2. As tonics and supporters nothing surpasses the good, old-fashioned, ever-reliable, muriated tincture of iron in large doses, well diluted with water and frequently administered together with free quantities of peptonized milk and beef peptones, and quinine should not be given in quantities sufficient to interfere with the secretions or the assimilation of food. 3. As a local antiseptic the kreasote in combination with equal parts of lime water and olive oil meets every indication, and as an internal germicide and controller of fever, the benzoate of soda is a reliable remedy. 4. For the purpose of stimulating the functional activity of the skin and the secretory system in general, and thus aiding in the elimination of the germs of the disease and the waste matters produced by them, there is no remedy equal in efficiency to the muriate of pilocarpine properly administered and properly guarded by stimulants, to overcome its depressing effects. Lindell and Grand Aves. THE EARLY DIAGNOSIS OF UTERINE CANCER. Abstract of a Paper read before the Cincinnati Academy of Medicine June 14, 1886, BY C. D. PALMER, M. D., Professor Gynecology Medical College of Ohio. Cancer is a disease three times more fre quent in the uterus than any other organ of the body. It is occurring with increasing frequency. This increase is largely apparent the result very naturally of improved methods in diagnosis and more frequent examinations. The benign affections which may be confounded with cancer, are chronic inflammation, eversion, granular and cystic degeneration, and ectropium. Nothing can be easier than the diagnosis of most of the benign diseases of the cervix uteri. Nothing can be plainer than the determination of the presence of advanced cancer of this part of the uterus, by far the most common site. As it is of vital importance that we recognize a malignant disease early, if we would do any radical or permanent good, and as mistakes are most generally made in the |