the Eupatoriam perfoliatum ; still the medicine and remedies externally had no evident action, save to lessen the pain in the side from the application of a heated dough cake that I had directed to be used in the intervals of bathing. I told the patient that if she did not expectorate soon she would die. At the desire of her father, another physician was called in to consult; we determined to apply blister plasters to the inferior extremities and sinapisms to the superior, and to the diaphragmatic region of the lung and liver of the right side, continuing the use of the bath. No change was produced for the better. A saline enema was ordered, which resulted in a watery evacuation, indicating a suspension of secretion from the liver. The case was again placed under my sole care.

It occurred to me that the application of a sinapism to the epigastric region would rouse the dormant nerves of the stomach, and I was gratified to find after the application that that organ responded to the remedies used. A table spoonful of tartar emetic water, (tar. em. grs. vi., water ziv.,) was given every fifteen minutes for a short time; it lessened the febrile excitement a little, but did not produce expectoration. A mixture of oxymel of squills and Coxe's hive syrup was used next, till it produced an emetic effect-the lady ejected from the larynx and bronchial tubes, a handful of vitiated mucous, a great part of which was of the consistence of old cheese, and of a purulent cast. The consulting physician, upon first examination, thought the principal seat of the disease in the liver, but when I directed his attention to the mucous râle in the throat and bronchial tubes, it produced a change in his views. The diet was strictly vegetable and consequently antiphlogistic, except during the brief period of the consultation. The consulting physician wished that chicken water with red pepper should be given, to which I objected, sig. nifying that the inflammation was too high in the lungs, and that there might be gastritis, as the point of the tongue was red, though there was no tenderness on pressure in the epigastric region. I agreed to make trial of plain chicken water, a table spoonful every three or four hours; but it increased the febrile excitement, and was abandoned,

An expectorant of oxymel of squills and hive syrup, with a diaphoretic ptisan of Eupatorium perfoliatum and horehound, with an occasional pill of blue mass, were the chief remedies used during her convalescence.

Case 2. Aun B., a little girl aged 4 years; had two attacks, both ushered in by the same general coldness and rigors, with pain in the frontal portion of the head. She appeared to have recovered from the first, which was a light attack, and to have been in good health for about three weeks, when symptoms of a

return of the disease made their appearance, followed by spasms and signs of apoplexy. The warm saline bath, cold applications to the head, and sinapisms to the extremities, removed the apoplexy, and restored the circulation of the fluids nearly to their healthy action. The tongue thickened and enlarged transversely during the high inflammatory excitement. The mucous tissue of the throat was irritated or inflamed, as has been the case with all the other cases. Thinking that the tendency to apoplexy was produced by worms, I directed a vermifuge to be given, followed by a mercurial purgative; it caused the expulsion of many ascarides. There was considerable pain in the diaphragmatic region. of the right lung and liver. The application of the heated dough cake to the side, the use of nauseants, diaphoretics, expectorants, and the occasional use of the blue pill, with diet similar to that in case 1, soon removed the complaint.

Case 3. C. B., a young man 19 years of age, was taken with coldness and rigors, sore throat and pain in the frontal region of the head; tongue pale, with a scarcely perceptible thin coat of white fur, and pain in the diaphragmatic region of the lungs and liver. As the congestion, irritation and inflammation increased in the liver and lungs, the tongue became swollen, the fur became thick, yellowish, and finally brown. Although this was a severe case, I had no difficulty with it, as the stomach and general system responded to the remedies given. As soon as expectoration became free and continued, the disease subsided.

Case 4. Eliza, a negress, aged 25; had the usual precursors, general coldness, and rigors, sore throat, pain in the frontal part of the head, in the diaphragmatic region of the lungs and liver, pain in the renal region of the back, with apparent congestion in the superficial veins and arteries. There was also general prostration and relaxation that seemed to affect the superficial vessels of the body, numbness of the arms and hands; tongue pale, with a very thin coat of white fur. This is the case referred to in which the pulse did not rise to the healthy standard till convalescence was nearly perfected. The system responded to the remedies taken internally, nauseants produced almost immediate secretion from the lungs, and as expectoration increased she improved, and under the application of sinapisms to the extremities, the heated dough cake to the side, a stimulating liniment to the back, and a tepid saline bath to the feet, with a continued use of nauseants, diaphoretics, ptisans, a mercurial whenever the bilious secretion appeared to be impeded, and expectorants, she recovered. A sinapism applied to the spinal column commencing at the inferior part of the neck and ending at the middle of the back, soon removed the numbness from the arms and hands.

Case 5. Columbus, a negro boy, four years old; indicating

symptoms, sore throat, general coldness and rigors, pain in front part of the head, in the diaphragmatic region of the lungs and liver, in the abdominal region, apparently in the large intestines. The tongue was covered with a thick coat of white fur, and as the disease advanced, this organ enlarged and reddened at the sides and point, the fur assuming a brownish cast. The arterial action was much increased, with evident superficial venous congestion. The warm saline bath was used, cold applications to the head. An aqueous solution of sulphate magnesia and tartar emetic (3i. of salts, iv. of water, I gr. tartar emetic) was administered in doses of one teaspoonful every fifteen minutes, until it acted on the bowels three times. The lips commenced healing under this treatment, and with the use of the Eupatorium perfoliatum as a diaphoretic, and the oxymel of squills with hive syrup as an expectorant, and an occasional blue pill to stimulate the liver to proper action, the patient recovered. The diet was the same as in the other cases.

The cause, whatever it be, of malignant bilious pneumonia, 1 conceive to be inhaled into the mouth and nostrils, and by producing its action on the Schneiderian tissue of the nose, and the mucous membrane of the mouth and fauces, it creates the cold plague. That the mucous tissue, pleura and parenchyma of the lungs are involved in this disease, I think no one will deny.

On the Cure of Vesico-Vaginal Fistula. By JOSEPH PANCOAST, M. D., Professor of Anatomy in Jefferson Medical College.

To Professor Huston.

Dear Sir,-At your request I send you a brief notice of a new mode of operation for the cure of urethro and vesico-vaginal fisula, which I have successfully employed in two cases, a more detailed account of which I propose hereafter to present you with. The two operations above alluded to, were respectively on patients of Professor Meigs, and Dr. Condie. In one case, there was a complete destruction of a cross section of the whole urethral structure, at its juncture with the neck of the bladder; in the other there was an elongated orifice in the bas fond of the bladder, which would more than admit the end of the finger.

"The peculiarity of the operation, consists virtually in attaching the two sides of the anormal opening firmly together, on the principle of the tongue and groove, so as to get four raw surfaces in contact, and thus increase the probabilities of union by first intention. For this purpose it is necessary that the margins

of the fistula should have considerable thickness; and when not found in this state, they are to be thickened by repeated applications of lunar caustic, or, better still, of the actual cautery.

"Having exposed the fistulous orifice as thoroughly as possible with a Charriére's speculum from which the sliding blade has been removed, an assistant at the same time drawing the vestibulum well up towards the front of the pubis, my first object in the operation is to split the most posterior margin of the fistula to the depth of half an inch, with a sharp-pointed sabre-shaped bistoury. I next pare off the edges of the other lip of the fistula, so as to bring it into a wedge-shape; first reverting it as much as possible with a small blunt hook, and trimming off the mucous membrane on the side next the bladder with the curved scissors or scalpel, and then detaching in like manner, the vaginal mucous membrane, to the breadth of threequarters of an inch, along the whole extent of the lip. This is a very difficult but most important part of the process; and great care should be taken to obtain a sufficient extent of raw surface, at the two angles of the fissure, where the lips will rest merely in apposition. Having checked the bleeding by the use of astringent applications, my next object is to insert the raw wedge or tongue into which one of the lips of the fistula has been converted, into the groove which has been cut in the other, and hold them in close connection. This I accomplish, by the means of a peculiar suture that might be called the plastic, and in the same way that I have described its application in reference to some plastic operations, in my Operative Surgery, and in the American Journal of the Medical Sciences, for October, 1842. The suture threads are to be passed with short, sharp, curved needles, held in Physick's artery forceps with the handles made of twice the ordinary length.

"When the sutures are knotted firmly, the tongue or wedge will be found immovably imbedded in the groove. The sutures I leave for two weeks or more, or until they become loose. A gum catheter should be kept in the bladder to prevent the accumulation of urine. To keep the inflammation from running to a destructive height, a bladder of cold water should be applied for thirty-six hours to the vulva.

"On the second day I direct the frequent injection of a solution of Zinci. Sulph. into the vagina, in order to increase the tone of the parts. On the third or fourth day I apply to the line of union a solution of lunar caustic with a camel's hair pencil. This application should be made twice in the twenty-four hours, the solution being gradually increased in its strength. Union by first intention may be expected to take place under this treat

ment to a considerable extent; at such points as it should fail to occur, union by second intention is to be promoted by the use of lunar caustic in substance, so as to raise a bed of granulation on the raw surfaces of the lips, while they are held in contact by the plastic suture. Occasionally, where the fissure is large, it will become necessary to repeat the process after a partial succcess has been obtained by the first operation. Philadelphia, April 8, 1847.

Case of traumatic Tetanus, successfully treated. By O. H. COSTILL, M. D. of Frankfort, Pennsylvania.

Feb. 18th, 1847. I was called about 10, A. M. to Margaret a coloured woman, said to be in a fit. I found her lying on a settee, her arms, legs, and whole frame perfectly rigid. Her eyelids were drawn down so tightly as scarcely to be lifted, and her jaws were firmly set. Upon inquiry I found that two days previous she had received a carpet tack in the bottom of her right foot. It was withdrawn, and nothing more was thought of it till the evening previous, when she complained of pain in the foot and stiffness in the leg and back. She had, however, risen in the morning and resumed her usual occupation, until seized as above described. As the surface of her body was cold, I had her placed in bed and her clothes loosened, (though owing to the ri gidity of her limbs they could not be removed,) and warm applications to the feet. After some time the spasmi subsided. She opened her eyes, could move her limbs and converse. She complained of extreme tenderness in the anterior part of the sole of the foot; could scarcely bear it touched, though I could find no point where the nail had entered. The pain extended up the leg and back to the neck and jaws, and there was stiffness about the root of the tongue. I directed a lye poultice to the foot and a mixture of castor oil and turpentine to be given every hour and a half, until the bowels should be freely moved, intending after that to commence with opiates should the tetanic symptoms continue.

I saw her again at 12 o'clock. She was much more comfortable but had had one very severe spasm. Medicine had not operated. During the afternoon she became much worse. An urgent message was sent for me, and as I was absent from home my friend Dr. Taylor, at the request of my family, was on his way to visit her for me when I returned. He was so kind as to accompany me, and at my request attended the case with me subsequently. It was about six in the evening when we saw her. She had had more than a dozen spasms during the afternoon, and one occurred while we were with her. Her breathing was difficult, as