tonitis I have no doubt. Intense pain, even tenderness on pressure, rapid small pulse, accelerated and impeded breathing, suggest the diagnosis of peritonitis; but if at this stage the patient die and is examined, probably no trace of peritonitis, as revealed by redness or effusion, is discovered. Peritonitis may come on the day following the operation. It may be met by fomentations to the abdomen, by opiate suppositories; and the prostration soon ensuing must be combated with wine, brandy, beef-tea, chicken-broth. Salines are often useful, especially at first.

5. If the patient escapes the preceding dangers, there is still the risk of septic infection, of septicamic puerperal fever. The source of this is the absorption of septic matter from the cavity of the wound, or from the edges of the wound; or it may arise from general blood-dyscrasia resulting from the accumulation in the circulation of effete matters which the excreting organs are unable to dispose of.

6. In addition to the dangers incident to the operation and to the puerperal state, there is the danger inherent to the disease which rendered the operation necessary, liable in some cases, as in cancer, to be aggravated by the operation, which may accelerate the fatal issue.-Med. Times and Gazette, Dec. 26, 1868, p. 717.

97.-ON VESICO-VAGINAL FISTULA.

By Dr. MAURICE H. COLLIS, Surgeon to the Meath Hospital and County Dublin Infirmary; Examiner in Surgery to the Royal College of Surgeons in Ireland; Chairman Irish Medical Association. The first branch of plastic surgery to which I wish to draw attention, is that which deals with fistulæ connected with the vagina and the bladder or rectum. These have been treated by cautery, by suture, and by transplantation of flaps. To the various methods I have contributed one, which has proved not unsuccessful in my hands, and in those of others who have taken pains to master the details. I got the idea from Pancoast, an American surgeon, and author of a work on Operative Surgery. He describes a plan by which he treated a vesico-vaginal fistula successfully. It is briefly as follows. He pares one side of the fistula so as to make it wedge-shaped, stripping it of its mucous membrane, both on vesical and vaginal surfaces.

Fig. 1.

The opposite side or margin of the fistula is split so as to form two flaps, one vesical and the other vaginal; the raw surfaces, when undisturbed, lying in contact. Between these two flaps, the raw wedge-shaped margin on the opposite side of the fistula is pushed and held by sutures. This sort of dovetailing of the flaps seemed to me an ingenious and happy method of increasing the amount of raw surface, and so, of increasing the chances of union.

I had not been long acquainted with this method, when I chanced to meet a case of vesico-vaginal fistula which seemed to me capable of cure. It was the first I had seen; for at this date (1856), they were looked upon in Dublin as inourable. At least, the success was so slight, that men had given up trying any plastic operation for their cure. If a touch of the cautery would close them, well and good; but if the size were too great for that, they were dismissed as incurable.

The method I adopted in my first case has since become known in foreign parts as Collis's method. It is, however, simply a modification and improvement on Pancoast's. I split the margins of the fistula all round to an extent of at least half an inch. This incision of the margins must always pass well through any tough cicatricial tissue, and reach sound areolar tisIf this point be not attended to with great care, the operation will fail. Having split the margins, I now insert a sufficient number of quilled su

sue.

tures (Fig. 2), and, on tying the loose ends with a moderate degree of tightness, the flaps open up, and a very large amount of raw surface is made available for union.

FIG. 2.-Inner dark line shows margin of fistula.

Dotted line shows extent of dissection.

Fig. 3 shows the position of the quills and margin on the stitched or vaginal aspect.

Fig. 4 is a sectional view, showing not only the position of the parts depicted in the previous figure (3), but also the mode in which the vesical flaps adapt themselves to one another; also, the position of the quills and sutures. This mode of treatment has succeeded well in my hands, and in those of Dr. Kidd and other friends. The result in my own practice is thirteen cases and nine cures.

The advantages of this method are-1. There is no loss of tissue, as in paring operations. 2. There is a very large amount of raw surface compared to any paring operation. 3. The flaps towards the bladder will often unite, while the vaginal flaps may fail to unite, either from suppuration or ulceration. Even when the vaginal flaps have been allowed to slough off from undue tightening of the sutures, union of the vesical portion has taken place. 4. These flaps act also as valves to prevent the access of urine in the wound.

I would only add that the length of time I leave the sutures uncut depends on the extent and toughness of the flap. It will vary from the third to the sixth day. I keep the bowels quiet with moderate doses of opium. I keep a catheter in the bladder for forty-eight hours: and I generally place a piece of soft sponge in the vagina to support the sutures, just enough to assist in making a moderate pressure on the bladder, and keep it from much movement. I may add, that I have often resorted with success to this method when other methods had failed.--British Medical Journal, Nov. 14, 1868, p. 518.

98.-ON THE DIFFERENT MODES OF PREPARING THE SPONGE TENT, WITH DIRECTIONS FOR MAKING IT ANTISEPTIC, &c. By Dr. GEORGE SYNG BRYANT (late of St. Louis), Lexington, Ky.

[The use of sponge tents in uterine disease is so necessary and frequent, that any suggestions as to their improvement are of value.]

The great objection to the sponge tent has been its retention of the secretions, allowing them to decompose in the uterus, and in some instances producing pyæmia. This absorbing quality of the sponge made it desirable to find a substitute for it as a uterine tent. The sea-tangle-"laminaria

digitata"-was proposed by Dr. Sloan, of Scotland, for this purpose, and greatly improved by Dr. Greenhalgh. But this article is far inferior to the sponge except in the single quality of cleanliness. Some surgeons prefer the sea-tangle when the os is very small, not admitting even the most diminutive sponge tent. The usual plan of treating these very narrow constrictions has been with metallic stilettes, or wooden stems, until the os or canal was sufficiently large to admit a small sized sponge tent. But this slow process of dilatation I have long since abandoned, and am in the habit of resorting at Fig. 3.

once to the knife, opening up the os and cervix sufficiently to receive a small carbolized sponge tent; after which there is no further trouble in effecting dilatation to almost any desirable degree.

For opening the os and cervix I have added another blade, with a probe point, to Dr. Sims' blunt-pointed ball-and-socket knife. With this blade the nicking operation is perfectly safe; for the probe point can only find its way along the canal, and the cutting edge can do no more than follow the probe point, simply nicking the mucous membrane to the extent of the width of the blade, which should not exceed one-eighth of an inch.

If the objection to the sponge as a nidus for putrid secretions can be obviated it is evidently the best material yet known for dilating the os and cervix uteri. In the American Journal of Medical Sciences of July, 1867, will be found a formula for making the sponge tent antiseptic, by Dr. J. C. Nott, now of New York. He prepares the sponge in the usual way, then saturates it with an antiseptic paste, composed of alum, acetate of lead, wheat flour, and gum-water, heated to the boiling point, and wraps it with gold-beater's skin. It is then punctured freely with the point of a small knife-blade.

Mr. Robert Ellis describes (see Amer. Journ. Med. Science, January, 1868, p. 276) a method of carbolizing the sponge tent by passing threads saturated with carbolic acid through the centre of the sponge longitudinally, which is then rolled into shape and covered with cocoa butter, to which is added a little glacial carbolic acid.

For more than eighteen months past I have been in the habit of using ten or twelve grains of crystallized carbolic acid to one ounce of thick gum muoilage, prepared for saturating the sponge tent before being wrapped with cord. This mode of mine for making the sponge tent antiseptic is well known in St. Louis, and to many of the profession in Louisville and elsewhere. The carbolic acid not only renders the sponge antiseptic, but its styptic qualities add much to the efficiency of the sponge in many diseased conditions of the mucous membrane. In preparing the tent moderately coarse, elastic sponge should be selected. Cleanse it well, cut while wet into the exact shape and size preferred; saturate it with gum mucilage, prepared as before described, and wrap it on an awl, with a strong, coarse, well-twisted cord. The tent should be fusiform in shape, and wrapped from the small end, as directed by Dr. Sims, taking care to keep the layers of the cord as they are carried around the sponge with perfect regularity, in close proximity to each other. By leaving the screw threads-not cutting them down with sand paper-the tent can be much more easily introduced; giving it a

turn, as to an ordinary screw, in the act of inserting it. When made in this way the tent does not slip out, as a smooth one is apt to do; and it should not project more than one-eighth or one-fourth of an inch out of the os. The best instrument I have found for introducing the tent is a pair of small, straight forceps, with an attachment to the handles to make fast the blades. The tent, firmly fixed in the forceps, is inserted as above directed, the uterus being held by a volsella or hook. The tent should always be slightly soaped, more particularly at the small extremity, to enable it to pass in with less friction.-American Journal of Medical Science, Oct. 1868, p. 410.

99.-ON THE THERAPEUTICAL USE OF MEDICATED

PESSARIES.

By Dr. ALFRED MEADOWS, Physician to the Hospital for Women and to the General Lying-in
Hospital.

[The medicated pessary in common use has for its basis the cocoa butter, and ordinarily weighs about a drachm and a half. The uncertainty of their action, however, has led Dr. Meadows to question the propriety of using any greasy substance as a vehicle for a drug, as such substances tend to shield the drug from the absorptive action of the vaginal wall.]

I have made some pessaries in which the basis is the neutral soft soap of the British Pharmacopoeia, made into a proper consistence with white wax, or powdered althæa root. I have also reduced the size one-half, or even less, as the others appear to me to be needlessly large: these made with the althæa are very nice when properly prepared; they are agreeable in use, and have a pleasant emollient action, which is very grateful where an anodyne effect is also required. There is, however, one slight objection to this base, viz., that it is apt to become very hard if kept long and exposed to the air. This is avoided if only half-a-dozen are made at a time for present use. portion which is found to answer best is three parts of soft soap to one part of powdered althæa. Where the emollient action is a matter of indifference, the white wax may be used in place of the althæa, in the proportion of three parts of soft soap to one part of white wax. This mass melts gradually, and forms, with the vaginal mucus, a kind of emulsion holding the drug in solution, which is readily absorbed.

The pro

With these ingredients I have had much better, more certain and uniform effects than with those made of cocoa butter; I have, therefore, found it necessary to use smaller doses, if I may so call them, of drugs; for instance, with one grain of extract of belladonna I have had more marked effects than with two and even three before. There is, however, one drawback to be noted. In two cases which have come under my notice, the soap appeared to cause some little irritation to the vagina; in one of these the patient was cbliged to get up in the night and use cold water freely to allay it. I can only explain this as an idiosyncrasy, just as there are some skins which can rever bear soap of any kind. In the case in question, however, I found that the althea with belladonna was borne very well.

There is one other form of pessary quite recently introduced by Dr. Sansom. It consists of a hollow cone of white wax, containing a watery solution of the ingredient used; the apex of the cone is filled over with cocoa butter, and as this melts much sooner than the wax the liquid flows out, and is then absorbed. I have not yet been able to test these efficiently, but the idea is ingeniously carried out by a chemist at Islington, and may, I conceive, prove successful; the preference which, as yet, I feel disposed to give to those I have employed arises partly from my fear lest the watery solution in these latter forms might escape too quickly for complete absorption, and so the dose become untrustworthy.

A few words now as to the remedies which may be used with most benefit. As anodynes I do not think there is anything comparable with the extract of belladonna in about 1 gr. doses, or its alkaloid, atropine, in gr. I have

long been in the habit of using this, and can endorse at that Dr. Anstie has urged in its favour as a special anodyne to the female pelvic organs. Conium I have also used, and, though it is strongly recommended by French authorities, I have not found any great benefit from it. Henbane is better (5 to 8 grs. of the extract), and morphia (togr. of the acetate) is exceedingly valuable. By any of these, used in the way I have suggested, we may easily, if we wish, affect the whole system.-Practitioner, Jan. 1869, p. 12.

100.-ON A NEW DUCK-BILL SPECULUM FOR PRIVATE

PRACTICE.

By Dr. J. C. NOTT, New York

[This speculum is peculiarly suitable to the requirements of the private practitioner.]

No one who has worked much in uterine surgery, and tested fairly the lever speculum of Sims, and the various forms of valvular and cylindrical specula, can deny that the former possesses important advantages over all others. I believe I may safely say that there is scarcely anything that can be done with others, that cannot be equally well done with the instrument of Sims, while the latter has many applications peculiar to itself.

The leading advantages of Sims' speculum are briefly these: It enables us to explore the vagina more satisfactorily than any other, as it covers but a small portion of the canal, and its position is quickly changed. Where the vagina itself is diseased, or sensitive, it is greatly preferable, as it presses on but one side, and leaves the atmospheric pressure to complete the dilatation. During operations the position and direction of the instrument can be changed by the assistant, at a moment's warning, to suit the wishes of the operator. It obstructs less the view and manipulations than any other speculum heretofore used. Not putting the vagina on the stretch longitudinally, it allows the uterus, by slight traction with a tenaculum, to be brought near the vulva, and thereby greatly facilitates cauterizing, probing, and all cutting operations on the cervix, introduction of tents, &c. Nothing need be said about its triumph in vesico-vaginal fistula.

It would be a waste of time to enumerate the objections, now so generally admitted, which may be made against the cylindrical and common valvular specula; suffice it to say that their utility is limited to but few conditionsthat they act on principles the reverse of the instrument of Sims-they dilate the vagina simply by mechanical force-they cover the whole vagina from view--they push the uterus away from the operator, and are of little service beyond affording an excellent view of the os and lips of the uterus, and of allowing the easy application of caustics or other remedies to these parts. Where flexions or versions of the uterus exist, they do not even admit the introduction of a sound without unjustifiable violence, and from the length and narrowness of the channel through which we hope to manipulate, they are utterly useless in all cutting operations. The ingenious instruments of Drs. Emmet, T. Gaillard Thomas, and Bozeman, have been fully described by their representative inventors, and any fair comments upon their respective and acknowledged merits would far transcend the limits here allowed me. 1 would remark, in passing, that I do not think either one well suited to the wants of the private practitioner. To get at the cervix uteri they all require either the semi-prone position or that on the knees; they consequently require an elevated table, and a light horizontal with the table, to give a good view, all of which conditions are inconvenient in private houses. Dr. Thomas' modification of Sims' speculum requires to be held by one hand, and therefore leaves but one free. Dr. Emmet (whose operations are all performed in hospitals, private or public) frankly said to me that Sims' speculum is superior to all others, and that he rarely uses any other. His object in contriving a new instrumeut was not for his own convenience, but for that of others; and the profession is certainly