SOLUBLE RELIABLE PERMANENT WM. R. WARNER & CO.'S SOLUBLE COATED GRANULES PREPARED ESPECIALLY FOR PRESCRIBING. The Coating of the following Granules will Dissolve in 1 Minutes. INGLUVIN From the Ventriculus Callosus Gallinaceus. A powder, prescribed in the same manner, doses and combination as Pepsin; prescribed in all cases where Pepsin is required, with superior advantage. A SPECIFIC FOR VOMITING IN PREGNANCY. Preparations Supplied upon Physicians' Prescription by all Leading Druggists. IN DOSES OF 10 TO 20 GRAINS. SURGERY. THE ELASTIC LIGATURE IN THE TREATMENT OF RECTAL FISTULÆ.(Edward P. Crowell, M. D., in Brooklyn Med. Jour.) From the time that the thread with a weight attached was used to cut through the tissue which forms the bridge between the rectal and external openings of these troublesome fistulæ, many devices have been presented to the profession, all of which have had for their object the removal of the trouble with as little pain and inconvenience to the patient as possible. The thread and button have been used, but this method necessitates the tightening of the ligature every day or two, and this causes considerable pain to the patient. Then, too, the ligature cuts very slowly, unless it is frequently tightened. There is quite a good deal of unnecessary suffering attending this method, and considerable inflammation is set up in the vicinity of the fistula. The patient often prefers his old fistula to the pain and suffering of the ever-present ligature. It was with the purpose of removing the fistula with as little disturb ance to the patient as possible, that I turned my attention to the use of the elastic ligature. Various kinds have been tried and have been discarded as useless. The one that has given the best satisfaction is the pure gum ligature, which is furnished by Tiemann, of New York. There are two sizes, of which the smaller is to be preferred. In the selection of the cases which would be benefited by the treatment with the elastic ligature, the circumstances and the general health of the patient are our best guide. Many cannot be away from their daily business; many whose constitutions are not very rugged cannot stand the thought or the shock of the operation in which we employ the knife. There are others whose fistulæ extend far up the bowel, whose chances of recovery are better with the ligature than with the knife. In some the fistulæ are entirely without the bowel, and which have become fistula by the bridging over of the two edges of an old fissure. In all these cases the ligature offers decided advantages over the knife. Before the method of employing the ligature is briefly outlined, a word must be said concerning preparatory treatment. Previous to the passage of the ligature much can be done to render its operation less painful, if the sphincters of the rectum are stretched a little, so that the action of the external sphincter is temporarily paralyzed. This will quiet the spasmodic contractions of the muscle, and the patient will endure the ligature with far less pain. To accomplish this a dilator or the rectal bougies may be used. This preliminary measure renders the work of the ligature nearly painless. The introduction of the ligature may be effected by either of the methods that are commonly employed. The canula and concealed hook is a good instrument, but the whalebone guide, with an end adapted to receive the ligature, is equally good. After the sphincters have been carefully dilated, the ligature is passed up the bowel on the forefinger of the left hand, and is easily attached to the guide which has been previously introduced to receive the ligature. The guide is then withdrawn, and the ligature passes from within the bowel out through the external opening in the buttock. The ends are now threaded through a soft silver ring. One end is taken in each hand, and the ligature is gradually stretched till the greatest tension that it will stand is obtained. Then the ring is closed with a strong forceps, the ends are clipped, a piece of absorbent cotton is placed between the buttocks, and the work is done. An opium or cocaine suppository, if frequently introduced, will quiet any undue stinging sensation that an over-sensitive person may experience. The time that is required for the ligature to cut through depends upon the time that the fistula has existed, the thickness of the tissue through which it has to pass, and the amount of tension which the operator is able to obtain; for the finer the rubber can be drawn the greater is the pressure obtained, and the quicker does the ligature cut, Three days are quite sufficient for the ligature to cut through in some cases, while others require longer time. In the use of the elastic ligature care must be taken to have it so placed that it will cut at right angles to the muscular fibres, and to the folds of the anus. The ligature must be stretched to its greatest tension; this will insure rapid work, and it will be less painful than it will be if it is only partially stretched. As the ligature contracts the pain lessens, and this encouragement can be held out to patients, that each day, even if there is considerable pain, is one day nearer the end of the trouble. The treatment by the ligature is not a painless operation, but has these advantages. 1. It does not confine the patient to the bed. is attended by no loss of blood. 3. It will safely cut through dense tis sues where the knife would seriously impair the health of the patient, especially if he were suffering with a bronchial affection. 4. The tissues heal as the ligature advances through them. The results obtained commend this treatment to the careful consideration of physicians, who by its judicious employment may mitigate the sufferings of those whose lives are made miserable by rectal fistulæ. SURGICAL TREATMENT OF ERYSIPELAS IN CHILDREN.-A. Siebert, M.D., reports in the N. Y. Med. Jour. three cases of erysipelas, all occurring in the lower limbs of children, and treated by the KroskeRedel method. All these cases were rapidly cured. We cite the method as given in case first: Next day I brought a new vaccination lancet with me, and proposed to make the bloody fence with the little harrow attached to it and without the anesthetic. This was consented to. The erysipelas had meanwhile spread upward to about an inch above the knee and downward to the ankle joint. I decided to make a fence only around the thigh. After carefully cleansing the whole thigh with soap, water, ether, and a five per cent. solution of carbolic acid, and covering the erysipelatous region with a carbolized towel, I firmly grasped the leg, and with long strokes of the harrow managed to open the skin around the thigh to the width of about an inch, and about an inch and a half away from the erysipelas. The longitudinal scratches (which were all deep enough to draw blood) were carefully but quickly crossed diagonally with manifold strokes of the harrow, so as to be sure that all of the surface operated upon was opened. A solution of corrosive sublimate (1 to 2000) was then rubbed into the wound, and a layer of absorbent cotton applied and fastened with gauze bandages. This dressing was moistened freely with the same solution every fifteen minutes. The whole operation lasted no more than two minutes. The child's temperature at the time was 105° F., it had vomited all the food for two days, and had been awake and delirious most of the previous night. The fence was made at II P. M. I did not see the child until the next day, when I found it sitting up in bed smiling, with a temperature of 100 5° in the rectum, due to the erysipelatous infiltration remaining in the limb below the "fence." The erysipelas had evidently reached the wounded ring, for on the lower border of the dressing the skin disappeared under it in a red and swollen condition, with a number of blis ters spread over it, while on the other side it was as white and cool as could be, and it remained so until seven days later, when I removed the dressing. The temperature never rose again, the appetite returned, the child had slept well, and the subsiding of the severe symptoms had set in about six hours after the little operation. THE QUESTION AS TO THE RADICAL CURE OF HERNIA IN ITS PRESENT ASPECT.-(Geo. R. Fowler, M. D., Surgeon to the M. E. Hospital and St. Mary's Hospital, Brooklyn.) If the writer may be allowed to express his own views, based upon his personal experience and a knowledge of the work of other surgeons, upon the general subject of the radical cure of inguinal hernia, he would formulate them about as follows: 1. As to the selection of cases in which the radical cure is to be recommended, it may be said that the operation becomes one of neces sity in all young persons with hernia, in the lower walks of life where existence depends upon some form of manual labor. Among these there always exists a demand for a snug or tightly fitting retentive apparatus; this alone will in the course of time so alter the anatomical conditions as to render its next to impossible to retain the hernia in posi tion as well as increasing the difficulties of a radical cure. Again, the expense and want of time to devote to personal needs prohibits most of this class from keeping themselves supplied with the most approved form of truss, and likewise from keeping the same in repair. Hence, always a temptation to either do without it entirely, in ignorance of the dangers of such a course, or to place reliance upon an instrument which may either be inefficient or inapplicable for other reasons. On the other hand, among the better class where ample means exist, and probably always will, to provide the best possible appliances and keep the same in an efficient condition: where the mental calibre of the patient is such as to grasp the situation and appreciate the dangers attending a careless disregard of instructions regarding the use of the truss, the operation may be regarded as one of convenience, and operative measures are to be instituted exactly as in the condition, analogous in this respect, of club foot. The judgment in this class of cases must be largely influenced by the wishes of the patient, or his friends, if he be too young to express his own desires, the probable prognosis as regards immediate and remote success being fully explained, as well as the conditions which may be confidently looked for, and the undeniable |