cess of the peritoneum. Usually this sac closes in its upper portion, leaving nothing but the cord, but sometimes it remains open, and, upon some violent effort, the gut comes down suddenly through this canal into the scrotum, distending the canal and tearing away the adhesions, if there be any. This is the "congenital" hernia, and may occur at birth or at a later period of life, in which event it is called the "congenital form" of hernia. An acquired hernia, on the contrary, comes down slowly, and gradually insinuates itself through the canal and rings into the scrotum, acquiring for itself a sac by the pounching of the peri

toneum.

Many operations have been devised for the radical cure of rupture, and last year I showed you Wood's operation. The instrument which I now hold in my hand is Wurtzer's. The scrotum is invaginated, and this cylindrical piece of wood is carried up into the external ring; then this needle, which runs through the centre of the cylinder, is made to pierce the surface of the abdomen. A concave piece of wood, with a hole through one end, is placed upon the abdomen, and the projecting end of the needle is passed through it. Then the two pieces of wood are clamped together and allowed to remain for several days, the intention being to set up adhesive inflammation by the presence of the needle.

I have used the instrument a number of times, with varying results, sometimes pretty good and sometimes bad, but never with complete satisfaction. I show the instrument to you because, in a few years, it will be a curiosity-at least I hope so.

The great disadvantage of all operations heretofore performed for the radical cure of hernia is that the patient is always obliged to wear a truss after the operation, and if such be the case, I cannot see that much benefit is derived from the procedure. The Heatonian method is nothing more nor less than the injection of the fluid extract of Quercus alba or white oak bark into and around the external ring and the canal. It is said that Dr. Heaton kept both his method and the preparation he used a secret for a long time, on account of becoming incensed at the profession, and it was finally made public by Dr. Warren, who was Dr. Heaton's assistant. The instrument used by Dr. Heaton was simply a hypodermic syringe [show ing the instrument] with a needle which is chisel shaped, with the orifices at the sides. The piston works like a screw in order that the amount of liquid injected might be more accurately regulated.

Dr. Warren's instrument, which I now show you, is much more complicated. It is self-acting, the piston working by a spring. The needle is flat and twisted like a screw, and the flow of the fluid is controlled by means of a valve, which is opened or closed by pressing on the lever on top of the instrument.

instrument round and bathe the pillars and the canal. I have lately employed this method twice in my private practice, and so far with perfect success. When you introduce the needle you must be very careful not to pass it into the cord or the artery, for necessarily bad results would be likely to follow. Warren's directions for preparing the fluid are as follows: Take Quercus alba, the fluid extract, and evap orate it to the consistency of glycerine; add an equal amount of Absolute alcohol; and to each half ounce of this mixture add 7 Ss. of Sulphuric ether, and gr. ij. of Morph, sulph.

The patient must not be allowed to rise from the recumbent position for twelve days after the operation, until the adhesions have had time to become fully established.

Of course, this operation is only applicable in cases of reducible hernia.

[A patient is brought in, and the operation performed as described above.]

The method, gentlemen, which you have seen me employ is different from that advised by Heaton; he guided the instrument by the left fore finger, pressing the abdominal walls into the ring. His directions are: to invaginate the scrotum with the fore-finger of the right hand just into the ring; then placing the left forefinger so that you can feel the finger that is in the ring, withdraw the latter, and, introducing the needle, inject the fluid, at the point where the finger is invaginated, into the ring. But the trouble with this method is that with a very fat person it is difficult to do this, and I think the better method is the one I have described. About ten minims are injected.

The next important point is the application of the bandage, and I assure you that the after treatment is quite as important as any part of the operation. [Applies compress over the ring and puts on a body bandage, with a tail piece coming up inside the thigh.] The rule for putting on the bandage is that when the patient stands up the perpendicular portion of the bandage falls over the great trochanter.

The history of this case will be that the patient will experience some soreness and may have peritoneal inflammation over the entire abdomen; sometimes suppuration ensues. It takes from ten to fourteen days to see the result of the procedure, and during that time the patient must not be allowed to raise himself from his back. [Second case brought in and operated as before. Unfortunately the stretcher broke while the attendants were lifting the patient from the table, and he fell to the floor. Prof. Helmuth would not allow him to raise himself, but he was placed upon another stretcher, and the gut which had come down was immediately returned to the abdominal cavity.]

Case 3. James S., aged 45. Has an irreducible femoral hernia. It appeared four months ago; he does not know whether it came suddenly or not. He has been cut once in this locality for psoas abscess. He was then a patient in another hospital. No pus followed the incision.

There are two other cases of rupture waiting to be

CHEILOPLASTY.

The next case is the man upon whom I made a cheiloplastic operation at a former clinic. You remember how horribly his face was disfigured by the large epithelioma which occupied the whole of the left side of the chin and part of the cheek. You also remember how large a flap was "jumped" from the side of his face and transplanted to the surface from which the epithelioma was removed. You see now how wonderfully the raw surface has filled with granulation tissue, and how slight the scar appears even in this strong light. There is still a notch left in the lower lip, which I propose to close with harelip pins, after having pared the edges. There are also some adhesions between the new lip and the gum, which I will cut away. [Does this.] Now you see that although his mouth is drawn somewhat over to one side, the result is quite satisfactory. The lips may be stretched to a great degree, yet return to their normal position. My greatest apprehension in this case was that the extensive epithelioma, existing as it had for so long a time, might have so infiltrated the surrounding structures that the process of repair would be interrupted, and "the last state of that man be worse than the first." This, I am most happy to state, has not happened, and the new chin is soft and plia ble. He will, however, have to keep himself well shaven, otherwise he will show a beard on but one

side of his chin.

STRETCHING THE SCIATIC.

I shall next proceed to stretch the great sciatic nerve of the patient for whom we broke up the adhesions in an anchylosed hip-joint, at a former clinic. Although motion has been in a measure restored to the joint, she has suffered such severe sciatic pain, and requires such large doses of narcotics to give her any relief whatsoever, that I am in hopes of allaying the agony, at least in some measure, by stretching the

nerve.

You see by this [referring to a large chart] that the great sciatic nerve issues from the pelvis through the great sacro-sciatic foramen just below the pyriformis muscle. This muscle is triangular in shape, and arising from the front of the sacrum, and passing out of the pelvis through the great sacro-sciatic notch, is attached to the upper border of the great trochanter in conjunction with the obturator internus. The obturator internus also arises within the pelvis from its anterior and external wall around the inner border of the thyroid foramen, and also from the rami of the pubes, and the body of the ischium, and the obturator membrane; it emerges from the pelvis through the lesser sacro-sciatic notch, and after receiving fibres from the gemelli muscles it is inserted into the upper porder of the great trochanter with the pyriformis or Just anterior to it. The great sciatic nerve crosses over this muscle and the gemelli. It is overlaid in its upper part by the great glutei muscles and passes down upon the posterior surface of the external rotator muscles of the thigh, nearly midway between the tuber ischii and the great trochanter, but a little nearer the tuberosity. In other words, if a line were drawn from the great trochanter to the tuberosity, the course of the nerve lies about one centimetre to the inside of the middle

of this line.

The nerve then passes down the thigh to the middle of the popliteal space, being overlaid by the long head of the biceps, which arises from the tuber ischii and is attached to the external condyle of the femur, and sometimes by the tendon of the semi-membranosus, which also arises from the tuberosity, and is inserted into the internal condyle of the thigh bone. The tendon of the semi-membranosus lies near the nerve and

may be mistaken for it. But it will be known by the fact that the tendon is shiny, while the nerve is not. The object of nerve stretching is to relieve the pain caused by inflammatory adhesions or contractions around the nerve.

The first experiments in this operation were made Valentin and Paul Vogt. In 1869 Bilroth stretched by Harless and Haber in 1858; they were followed by the sciatic. In 1872 Von Nussbaum stretched the brachial plexus, while Gartner, Patruban, and others have performed the operation upon different nerves, This will make my seventh operation of nerve stretching; the fourth time I have stretched the great sciatic. On one occasion I stretched the inferior dental for intense facial neuralgia of eleven years' standing, and ou another the ulnar, with epileptiform convulsions, intense neuralgia, and paralysis of the arm, arising from traumatism, All these operations have resulted, if not in complete cures, in great relief to the patients. In this case, as you will see, I first draw a line from the great trochanter to the tuber ischii [marking in ink]. Next I measure the distance, and finding the middle point of the line, I measure one centimetre inward, and from this point strike a line which runs at right angles with the first. The course of the nerve will be along this line and to the middle of the popliteal space. Now I take a knife, and commencing the incision just below the gluteal fold, I make it about five inches in length, and down through the skin and fascia [cutting]. I push aside the long head of the biceps, and you see this [elevating a bundle of white fibres]. Well, that isn't the nerve. It is the tendon of the semi-membranosus, which, you see, is glistening. I can feel it contract on my finger. I hold this aside, and opening the sheath, expose the nerve. [Does so, and raises it upon the handle of the scalpel.] Now I take the nerve upon my two fore-fingers, and stretch it until I feel the adhesions begin to give way [stretches until the patient's leg is raised from the table; stretches five times] and let the nerve drop back into its sheath.

I will sew up the wound, putting in three deep sutures, and the rest through the depth of the skin and fat, leaving the lower end open for drainage. The wound will be dressed with carbolized lint and Calendula, and I shall endeavor to report to you the result of the case

The calcium light was used at this, with the same brilliant results as at the former clinics.

SCROFULOSIS AND ITS TREATMENT.

PART II.

BY SARAH J. WHITE, M.D., NEW YORK. After reading the opinions of the learned authors from whose works I have quoted, and studying the disease in our own private practice, we are naturally led to inquire what remedies meet and counteract so dread a poison, and how can we prevent its further progress? In the old school we find a number used upon homeopathic principles, as well as many used empirically; among them Antimony, Mercury, Baryta, Muriate of lime, Bark, Iron, Hemlock, Cod Liver oil, lodine, Chloride of barium, Sea bathing, and many other hygienic measures are recommended, as well as local applications. Taking up our own materia medica, we find from actual experience that there are many from whose use we may derive much benefit, and heading the list is one employed by the old school as a topical application-Acetic acid. This is said to act principally upon the blood, dissolving the fibrin, and upon the cerebro-spinal system, causing paralysis and convulsions. Watching its effect very closely upon several members of the family previously mentioned, we may at least conclude that the following symptoms

many others, mark this as a fine remedy to add to our list. In the Imponderabilia we have agents whose power has been little studied in this connection, and although some few have had success with both Electricity and Galvanism, others have thrown much discredit on their use. I would suggest that not only they be thoroughly studied as we know them in our remedies, but as applications direct from our batteries in connection with the different metals. I have found them of great use in white swelling, infantile paralysis, chronic glandular swellings, and as a hygienic means of giving tone and strength to the lax muscular system, thereby curing spinal curvature and remedying many faults attributable to this disease. Iodine and its compounds, especially the Iodide of Mercury, acted charmingly in two cases of hepatization after pneumonia, in connection with Animal magnetism. In one case the patient regained the use of the lung, and in both the cough was very much better, almost entirely cured in the case of the first. Both were cases of several years' standing. This group is well worth study. In the Kalium group we find a simili mum for many scrofulous ailments. The affections of the skin and mucous membranes with their character istic discharges are all worthy of our notice, as we may cure with some one of this group many a symptom of this dread disease. Kreasotum is another one of the remedies whose action is very marked in subjets of this disease, especially when combined with syphilis. The diarrhoeas of these children whose teeth decay as rapidly as they protrude from the gum, are very often cured by this remedy. The leucorrhoeas of scrofulous females-both mild and corrosive-are also met with under Kreasote.

Lycopodium for many chronic symptoms, dyspepsia, cough, incipient phthisis, chronic catarrhs, etc., etc., will repay much research. Much dependence has been placed upon the various compounds of Mercury, by all the writers upon this subject. Glandular swellings, open ulcers, chronic abscesses, caries of bones, lencorrhoeas, coughs, and a legion of other diseases have been met with them. One has only to study the literature of scrofula to see that the old school made them their chief reliance. Muriatic acid also meets various stages of the disorder; will bear thought and attention. The Natrum group do as good service very frequently here. I would call attention to the catarrhal, the rheumatic and eye symptoms, particularly of Natrum muriaticum. The diarrhoeas of both the Carb. and Mur. of soda are worthy of study in scrofula. The symptoms of the female generative system are very marked and may furnish us a hint. Some of the heart symptoms of the Muriaticum are met with in patients of this class. Nitric acid in scrofulo-syphilitic diseases is very useful, Its symptoms are well given and do not need repetition. Petroleum is a remedy little studied, and yet gives us some fine results with scrofulous constitutions, particularly with young girls who become almost chlorotic, looking pale, much emaciated, suffering much at each menstrual period, the flow being pale and watery, a profuse leucorrhoea, little or no appetite, great weakness. Petroleum cured one such case for me. Phos. and Phos, acid present pictures well worthy our attention. The whole group of eye symptoms, in fact, all the symptoms require our study, for we may meet here our cure for the almost anæmic condition of the whole nervous system that we so often find among this class of patients. The diarrhoea of dentition, and some of the stages of cholera infantum, call for one or the other of these remedies. In Puls. we find a long tried friend, and as a remedy for some of the diseases of the eye of children it has no equal. Its action over the ear is quite as well marked, and often relieves at once the purulent discharges from this organ. The weakness so often met with in children, nocturnal incontinence of urine, I have cured with Puls., and as a remedy

during the irregularities of the menstrual function I need say nothing--it is too well known. Rhus tox. is very highly spoken of by Hartman and Teste, in their works on diseases of children, and, judging from the number of symptoms mentioned in our works on materia medica, we may study it in this connection with advantage. I had forgotten to call attention to one of our so-called isopathic remedies, Psorinum, but it has served me too well to be now neglected. I do not know a form of scrofula in which we may not find its use of benefit at times; and often in acute diseases of such patients a dose of Pso. will accelerate the action of other remedies when they have seemed to fail us, though well indicated. In Sepia we have a remedy much used and well known to the profession, yet under every group of symptoms we find something to newly awaken interest every time we read it overunder those of the skin, eyes, stool, genital organs, extremities-all have something of interest in connec tion with the disease, scrofula. In the hands of some practitioners it does more for the gynæcological dig. eases than any other one remedy. Its urinary range is extensive, and I have had some fine results with it in the troublesome wetting of the bed of children, where Puls. did not seem indicated.

In several cases of hysteria, depending upon misplacement of the uterus, I have had fine success in curing when there was a marked feeling of stiffness in the left ovarian region. Silicea is useful in many forms of this disease. The rheumatic headaches of scrofulous patients, commencing in the occiput and extending upward, with the great desire to have the head well covered, the spinal curvatures, the symptoms of abdomen, stool, genital organs, all claim our attention, and we may perform marked cures in some diseases of the extremities. One case of frost bitten feet, toes badly ulcerated, and whole feet badly swollen, rationt an old woman of sixty years, was entirely cured with Sil. 200th; patient decidedly scrofulous. With Spongia we might expect to find relief from some of the skin diseases, but in scrofulosis, I think, its more proper sphere is in diseases of the larynx and chest; the hoarseness, cough, and coryza, both of children and adults; the croup of children; the cough which seems to come from a deep spot in the chest, when he feels as if the spot had become sore and bleeding from the cough;" all point to Spongia as a remedy.

Staphysagria seems to cover many hysterical symp toms of this class of patients. It has also many glandular affections. The diseases of the skin, head, face, nose, mouth, and digestive organs are quite marked, and the aching pains in the larger points of the extremities are worth our while to study in relation to the rheumatic conditions of the extremities of our scrofulous patients. Sulphur is like a long tried friend, from whom we may expect sympathy in all our troubles. Its adaptation to the lymphatic and leucophlegmatic constitutions, glandular swellings, stiffness of joints, curvature of bones, unsteady gai, inclination to take cold, the whole range of skin diseases, symptoms during sleep, of the head, eyes, ears, nose, face; its gastric troubles, with those of the abdomenare all characteristic of scrofula. Its stools, urine, diseases of the generative system, larynx, chest, back, and extremities, may all be met in cases of the above disease. Often when other remedies seem indicated in acute cases of disease, we sometimes find their ac tion more marked and rapid by giving Sul. first. How perfect the cure in some cases of eczema of the head and face! How marked its action in some cases of threatening abortion, when every known remedy fails! I am sure it saved the lives of one mother and child for me, where Sabina, China, Secale, and Electricity had been given, with no avail. Although the severity of the flow and the regular pains had ceased, still there was constant slight flooding for some days, and Sulphur cured my case and carried the child to term. In

the scrofulous ophthalmia of infants it is one of our finest remedies.

I was called to make physical exploration, so without unnecessary delay, I placed the patient in position, and proceeded with all due care to introduce the index finger into the vagina. As there had been no nervousness connected with the contemplated examination, I was astonished to see my patient writhing in greatest agony, as I had as yet scarcely touched the labi. Of course I ceased any attempt at farther explorationthe suffering continued for a minute or more and the patient fainted. After her restoration I remarked to her mother, who was standing by, that there was something wrong. I then submitted the parts to inspection. The only pathological condition presented was a small tumor (not larger than a rice kernel) at the mouth of the urethra. I could open the hymeneal surfaces freely by placing my thumbs well back from the labiæthe parts relaxing thoroughly; and to all appearances there could be no difficulty in introducing an ordinary speculum. Without attempting this, I oiled a small probe, and the first touch of it within the grasp of the sphincter vagina induced the same train of suffering with its sequela, as had attended the attempt to introduce the finger. I diagnosed Vaginismus. The ques tion then to decide was what caused the vaginismus? The possibility of this little, insignificant excrescence in the mouth of the urethra being the cause of such spasmodic action was hardly to be entertained. With the hope of lessening the irritable state of the tumor, Hydrastis ointment was ordered, and a free application of it was made daily for three or four weeks, but with no relief. At this juncture I called to my aid Dr. John J. Mitchell, of this city.

Among the later remedies we have Tarantula, and, judging from the verified provings, it promises to take a very prominent rank, particularly in all abscesses and glandular swellings. The symptoms here are very marked, and the remedy seems to give almost immediate relief from the terrible pain sometimes endured in these troubles (T. cabensis). It has many skin symptoms-the intolerable itching, pricking sensation and the pimply eruption the most prominent. The chorea and nervous symptoms are well marked, hysteria being very prominent among them. It well repays a thorough study, and a proving, translated by J. A. Terry, M.D., may be found in the North Ameriein Journal of Homeopathy, of February, 1872. The species Tarantula hispanica, and another of Tarantula cabensis, in the Homœopathic Times of March, 1879, the latter only giving a few of the symptoms, by Jose J. Navarro, M.D The Hispanica gives us the extreme irritability we so often find in scrofulous patients, the sensitiveness to cold air, and aggravation of some of the symptoms by use of cold water, reminding us of Calcarea. Then there are retraction of one or more muscles, as we find them in some children during dentition; the sadness, sometimes extreme and with out cause; the absence of mind; headaches; eye affections, and those of the ear; gastric and abdominal, and many of those of the female generative system-all point to Tarantula as a future favorite in scrofula. Those of the chest and extremities also give us hope of good results with it in diseases of these localities. The hygienic measures to be adopted in scrofula are many and very necessary. The food should be of the most nourishing kind, and varied enough to meet the needs of weak digestion and poor assimilation. Rarely cooked beef, well cooked mutton, cream, soups of various kinds, but plainly made, fruits, grains, preparations of malt-all these will aid us much, it taken in quantities suitable, and at the appropriate time. Fresh air and Sunlight are very necessary adjuncts to the cure of this disease; and Exercise, as much as is suite to the strength of the patient. Bathing, both the fresh and sea bath, are absolute luxuries, and absolutely necessary to the full restoration of those af flicted in this way; and last, though not the least in its effects, is the keeping the patient free from the desponding cares which tend to depress the mind. Already is there a tendency to sadness and dejection, and everything should be cheerful, sunny, and bright, and the patient stimulated to read and converse only upon those subjects which strengthen, amuse, and cheer the mind. With children, give them a small barrow, with its accompanying tools, and allow them to roam at will in the yard or in the country. The air, earth, sunlight, will all make them happier and health ier, and certainly keep them denizens of this earth much longer than to confine them indoors, shutting out all the busy life outside. I have only given here a few hints gathered from our best experience as I could call them, and I trust they may be useful to the student as my study has been to me.

A CASE OF CHRONIC VAGINISMUS.

BY E. J. PIERCE, M. D., NEWBURGH, N. Y. In Oct. 18-, I was called to make uterine examination of Miss M, a stout, robust young lady, of about 20 years of age. She stated that she had for some years suffered from dysmenorrhea, yet the difficulty that caused her the greatest suffering was " falling of the womb," as she supposed-however, I failed to recognize in the general appearance of the lady, indications of such a condition, for I had seldom met a lady presenting so fine a physique.