and then suspended. Of the present number being operated, six are eclectic, twelve are homeopathic, two are physiopathic, and about seventy assume to be "regular," although how one college, incorporated according to legal statutes made and provided, can be more regular than another, or "the only regular school," is a problem which no fair-minded man can solve. Common-sense people naturally hold all "equal before the law," differing only where any fail to fulfill what the law dictates should be done by organization under it.

In the many discussions which I have read, no class or kind. accuses any others of being special experts at rapidity and cheapness in manufacturing doctors. Not long ago, all were included under this great sin against our profession and the people. Nor can any sect elevate clean hands as a rule. "A А general awakening" upon this important subject appears to have recently occurred, and, as usual, great reformers are rising and inveighing cogently against this great evil in our country. There appears to be a spirit abroad looking to a radical reform; better preliminary qualification to begin medical study; longer terms of study and lectures; a graded course and graduation on real acquirement or merit. Shall we yield our voluntary influence in the right direction, or wait until compelled? Plain indications point to a near future of medical education upon a much higher and better plane, and it is hoped and believed that we, as a fraternity, will be neither last nor least in contributing to this very desirable end.

[Continued in next journal, in which a brief history of Eclecticism will be given.]

VIBURNUM PRUNIFOLIUM (Black Haw).

[From Frof. Goss' New Medicines.]

This little tree, or shrub, belongs to the genus Viburnum, the same that furnishes the cranberry and sheep-berry. It is an erect, tree-like shrub, growing from twelve to fifteen feet in height. It has dense clusters of snow-white blossoms in early

spring. It grows all over Georgia; and most of the Southern States, bearing an abundance of black berries, which are edible, being of a sweetish taste. It grows mostly in dry copses, and open woodlands, near streams.

Medical Properties.-This humble little shrub furnishes one of our positive remedial agents. No remedy in the materia medica is more positive in action than the Viburnum Prunifolium. It does not have a very wide range of action, being confined to the uterus. Dr. Pharis, of Newtonia, Miss., in the year 1866, wrote an article on the uses of Viburnum, which was first published in the Atlanta Medical Journal, which then called the attention of the profession to it, but I was familiar with its use long before that period, and had used it in several cases of threatened abortion successfully. I have used it for several years in cases where there was considerable dilation of the os uteri, and it has always checked it. I usually give the fluid extract in doses of one drachm. The earliest mention of the Viburnum Prunifolium as a medical shrub is in a work written by James W. Mahoney, who obtained his information from a half-breed Cherokee, whose name was Richard Foreman. Mahoney mentions it as being the safest diaphoretic for pregnant females. He also says that it is tonic and anti-periodic. I have never used it for any purpose except to prevent abortion, and I have never found any article as efficient and prompt as this shrub. In the year 1863 or 1864, I was called to a female who had miscarried, and a lady friend who was nursing her, and was also in a pregnant state, becoming sick from the smell of blood, was attacked with labor, and I had her to use a tea of the rootbark of the black haw freely, which arrested the labor at once. In a short time after this, I was called to attend a young lady who was in hard labor at the fifth month of pregnancy. gave her the infusion of the bark of the root of black haw freely, and it checked the labor, and she went her time. I was recently called in consultation with another physician, to a lady in hard labor at the sixth month, and we gave 13 of the fluid ex. of the black haw, which arrested the labor at once.

I

SELECTED.

A Case of Fistula in Ano, with a Few Practical Remarks Regarding the Surgical Operations for Its Relief, as also the Action of the Sphincter Tertius Described by Hyrtl.

BY T. G. COMSTOCK, M. D., ST. LOUIS, MO.

Cases of fistula in ano, or more correctly. fistula in recto, occur so frequently in surgical practice, that I shall take occasion to call the attention of the profession to particulars regarding the surgical anatomy of the sphincter muscles.

Some years ago, when a pupil at the University of Vienna, while attending the lectures of Prof. Hyrtl, I first learned the existence of a sphincter tertius. It is remarkable that this sphincter is not mentioned by Gray or other English anatomists. That such a muscle (whose action is really that of a sphincter) does exist, is to me a matter of no doubt; and if such were not the case, the radical operation for fistula (dividing the lower sphincters), would be followed by very unpleasant consequences-in other words, we should have as a result, involuntary fæcal evacuations. That such an untoward result fortunately does not often occur, every experienced surgeon knows, but the reason for this we shall give by quoting the following, which we have translated from Hyrtl's Anatomy.*

"The older surgeons were astonished, after having divided the sphincter muscles in operations for fistula, that no involuntary discharges of fæces followed. Faget found, after removing the lower end of the rectum from a patient, that he could retain his fæces and flatus, and he explained this upon the hypothesis that a new sphincter must have subsequently formed. Houston was not disinclined to believe that the lower portion of the rectum, where a fold occurs as it passes through the pelvic fascia, was surrounded with a development of circular fibers. Lisfranc, who many times extirpated the terminal portion of the rectum, noticed that such patients

*Handburch der topographischen Anatomie, Von Josef Hyrtl, Zweiter, Band, p. 141, 5te Aufiage, Wien 1865.

were not deprived of the power of holding back their stools, and declared it as his opinion that, as a positive necessity, a superior sphincter must exist. Likewise, every unprejudiced observer must allow of the existence of such a muscle, for the reason that in prolapsus ani, where both the external sphincters are paralyzed, no involuntary stools occur.

66

“In rupture of the perineum and congenital opening of the rectum into the vagina (cloaca) the same thing happens. Ricord cites the case of a woman aged twenty-two, where the rectum opened into the vagina, yet the bowels acted regularly, and, what is more remarkable, the husband, after having been married three years, had no conception of this abnornal condition of his wife.

"When the index finger is introduced into the rectum of a patient who has had no action from the bowels for a few days, as a rule, just above the anus, no fæces will be found, and yet the column of fæces would naturally sink down to this point if not held back by an opposing circular muscle. Kohlrausch opposed this view, which presupposes the existence of a third sphincter, because he found upon dead subjects, as well as in patients, hard scybala in the lower portion of the rectum; but I take occasion to mention that the existence of fæces in the rectum upon subjects simply proves that the sphincter tertius no longer acts, and the same thing in the living (in patients), may be the result of diseased conditions, and which affords an example of an exception to the rule. Enemata which are not introduced high enough into the rectum, are liable to come away immediately; on the contrary, if the canule (extremity) of the syringe is pushed up sufficiently high, the injection will be retained a longer time. Dr. O'Beirn called attention to the fact that an elastic tube can be introduced quite a distance into the rectum, before any flatus is given off, and then the discharge comes suddenly. All these observations make it probable, a priori, that at a certain distance above the internal sphincter ani, a third sphincter must exist. Nelaton and Velpeau have demonstrated the existence of it, as a thickened band of muscular fibers, four inches above the anus. This muscular development is not always easy to find. To find it

upon the cadaver, care should be taken that the rectum is not forcibly distended with air.

"In order to demonstrate it well, the rectum should be cut upward longitudinally, and stretched upon a board, and the several layers carefully dissected off until the muscular layer is reached, when the sphincter tertius, if present, will be seen as a broad bundle of thickly conglomerated muscular fibers. Not unfrequently this investigation will be fruitless of a result, but the physiological fact that there are developed muscular fibers encircling the rectum at this point is not to be doubted. In one instance I have publicly demonstrated the existence of the fibers of the sphincter tertius taking their origin from the

sacrum.

This third sphincter does not permit the excrements (fæces) which are in the sigmoid flexure and are pressing down, to reach the lower rectum. Only when the desire for an evacuation exists, does it relax and allow the fæcal column. to come down on the lower sphincters. These latter can voluntarily keep back the stools for a long time, and are assisted in their efforts by the levator ani muscle, as likewise by the buttocks (nates) firmly pressed together, so that when one is unfortunately in such a critical situation (for obvious reasons), he takes care not to take long steps or to run. At last, these muscles, from having such an unusual strain upon them, become paralyzed, and then follows what, under such circumstances, is, of course, unavoidable. When the lower end of the rectum is removed, or the sphincters are divided, as in the operation of rectal fistula, then the patient will not be afflicted with the most hopeless and disgusting of all ailments, viz., involuntary stools; for when the slightest desire for a stool is experienced, and the upper sphincter is relaxed, the evacuation below is being accomplished, because simultaneously the two lower sphincters will involuntarily be relaxed."

I should perhaps mention that Dr. James R. Chadwick, of Boston, in a very elaborate article,* regards the sphincter tertius as "a collection of constricting bands, and a part of the general circular layer of muscles whose function is to dilate

*Transactions of the American Gynecological Society, Vol. II, p. 43. Boston, 1878.