noted in passing that I was led in each of these cases to examine abdomen externally because of inability to reach the presenting part through the vagina, and one of the women complained that "the child was coming out through the side"; I case was of a face presentation-chin posterior; the other death of child was in a case of turning after unsuccessful use of forceps.

If after a reasonable time I find the os dilated or easily dilatable, with failure to engage from nearly any cause, if the hand slips readily by the head of the child, I usually deliver at once by podalic version. I prefer to have an assistant to give chloroform and to aid occasionally by pressing upward, externally, on the head. If the woman objects to chloroform, I do it without. A single recent case will illustrate sufficiently:

Mrs. B. had had three large children previously, all of whom I had delivered with forceps after prolonged traction; all living at birth, but the third died soon after-probably from injury to the cord, as the canal was somewhat narrowed by an overhanging promontory causing the head to engage transversely. I concluded not to wait long the fourth time, and as there seemed to be little evidence of progress, I sent for a neighboring physician to give chloroform, and finding the head easily pushed aside, I seized a foot, and, turning readily, was surprised at the ease of delivery, although the child was fully as large as the others. Further, the mother, in place of being exhausted as in former labors, had a normal getting up in every way.

Version is indicated in eclampsia, placenta previa, concealed hemorrhage, prolapse of cord that cannot be readily replaced, transverse presentation, some cases of face presentation with chin posterior, occasionally in occipito posterior; in anteroposterior flattening of the pelvis (said to be oftener found in women of foreign birth or parentage than in America), and in general when the head fails to engage unless the forceps are easily applied.

Turning differs from forceps cases in that while in general cases demanding forceps get more favorable by waiting, the head becoming molded so long as the mother is not exhausted, the conditions calling for turning grow less favorable the longer we wait,—that is after dilatation has taken place.

It is my practice to seize one foot (the first I reach), leaving the other flexed on the body to prepare the way for the after coming head which I deliver as rapidly as possible.

There is nothing new in this. Long ago Barnes in his "Obstetric Operations" said: "If we were restricted to one operation in mid

wifery as our sole resource, I think the choice must fall upon turning. Probably no other operation is capable of extricating patient and practitioner from so many and varied difficulties." This being the case we may well give it more consideration in labor, than I think has been customary.

Two points I have desired to emphasize:

Ist. The value of turning to the accoucheur.

2d. In case turning is advisable, the importance of doing it That expedition should go hand in hand with gentleness, goes without saying.

The New York Homeopathic Medical College. The Fortythird annual announcement of the New York college contains a full outline of the work purposed to be accomplished by the recently reorganized faculty. It certainly must be a matter of pride that so thorough a course of medical instruction is offered in an institution under homeopathic management, and we feel sure that all the alumni will have added interest in their alma mater's welfare when they see what provision has been made for prospective students. There has been a tendency among some critics of the New York college to fail to take into account some incidents in its history. When the college moved into its present location, it became practically a new institution, with clinical facilities to be worked up, and it is only within the past year or two that such facilities have been adequate for an up-to-date college. With such hospital alliances as the catalogue announces, there is no homeopathic college that can offer better; and the faculty shows its determination to use its advantages to the full. Perhaps critics should be reminded, too, that the size of the graduating class is no criterion of the standing of the college. It must be borne in mind that the requirements for the medical student's certificate in New York State are in advance of those under which other homeopathic colleges operate; and these latter institutions receive quite a number of students who cannot meet these high requirements.

The newer therapeutics is to receive full attention in the New York college: Electro-therapeutics, suggestive therapeutics, hydro-therapeutics, mechano-therapeutics, the Roentgen and actinic. ray-all are to receive adequate attention from the faculty.

PRELIMINARY LIGATION OF ARTERIES IN THE REMOVAL OF MALIGNANT GROWTHS.*

BY WM. FRANCIS HONAN, M.D.,

Surgeon to Metropolitan and Hahnemann Hospitals.

NY procedure which may be in the least helpful, or any experi

A ence which sheds whatsoever little light upon that dread

scourge of mankind known as cancer, will, I am sure, be welcomed by the medical profession, notwithstanding the many promising hopes which have been held out for its cure or eradication. In spite of the inspirations of earnest workers in the domain of modern pathology who oftentimes find the solution of the vexed problem almost within their grasp, nevertheless, cancer is today the worst plague of civilized life. While preventative medicine, quarantine, and a better understanding of the laws of health have done so much to mitigate disease and rob it of some of its terrors, statistics show that, notwithstanding advanced science and higher thought, cancer is on the increase.

Modern medicine is confounded, watches weakly at its progress and destruction, but lives in the hope that the next decade at least will bring forth relief. So it is that drugs, serums, therapeutic applications, application of bacteria or their modified products-organo-therapy-each in its turn has had its day, some possessing apparent defects, but all, more or less, soon to be relegated to past and unprofitable experience. In the long list, only the knife and caustic agents hold out any promise of a cure.

Cancer is a growth originating in epithelium and characterized by continuous and more or less rapid growth, which, invading the lymphatics, spreads to neighboring organs. Under certain favorable. circumstances the growth is very rapid, the involvement considerable and tasermia an early symptom. When recurrence takes place after operation it is due perhaps to some cells left behind, insufficient eradication of the primary focus and of adjacent infected areas.

* Presented at meeting of the Homeopathic Medical Society of the State of New York.

recurrences.

More careful and radical surgery which contemplates extensive dissection into healthy tissue, shows fewer or, at least, longer deferred The actual cautery, chemical caustics, and X-ray show oftentimes good results, for the reason that if infiltration has not taken place beyond the point of primary focus, the mouths of the lymphatics are sealed by the eschar, which, when it separates, leaves a clean and often uninfected base of granulating tissue. The itinerant or advertising "Cancer Specialist" has by such means often accomplished more than his scientific medical brother. From the standpoint of general surgery, the early and complete removal of the part affected, including, where possible, an amount of healthy tissue, and the rendering of the remaining adjacent parts unfit for a recurrence of the growth, is our present purpose. Some years ago the writer became convinced that nature had many resources for gradual restoration of circulation in parts where main blood channels had been ligated. This was shown in a case of recurrent carcinoma of the breast. The recurrence was mainly in the axilla. It became necessary not only to ligate the lower large arterial branches, but also resect the axillary vein, which became very intimately involved. in the secondary process. The condition of pronounced edema which followed was somewhat alarming; but equilibrium of circulation was re-established, the patient made a good recovery and lived some years afterwards.

Some time after that a case of epithehoma of the tongue came into my service at the Metropolitan Hospital. The growth occupied principally the left side and anterior portion of the tongue. In this case it was decided to do a preliminary trachectomy, a useful procedure at times, no doubt, but unnecessary and unsurgical in my opinion. It was further decided to ligate the lingual arteries, assuming that would sufficiently control the circulation, then through a Whitehead gag the tongue could be cut off with a scissors, a few stitches placed in the stump to approximate the cut edges, and the operation would be complete. The linguals were ligated easily enough; they were recognized by several members of the attending staff who happened to be present. The tongue was removed as per programme with practically no loss of blood at the time. All went well until the patient began to recover from the anesthetic, when a severe vomiting spell produced a hemorrhage through the mouth. The house surgeon and his assistants were unable to control the flow of blood and the patient succumbed. Post mortem examination showed proper ligation of the linguals; but an accessory branch at the root of the tongue, evidently from another source, produced the

fatal hemorrhage. This case very thoroughly impressed me with the idea that ligation of linguals was not a certain procedure, and reference to medical literature showed that this unfortunate accident, as above described, had happened in several instances. The next case of this character was one of sarcoma of the left superior maxilla involving the eye and the hard palate on that side. The patient was a man, age about 50 years, who had been affected about one year. External examination showed that the disease was deepseated, and to accomplish anything of value, the operation must be decidedly radical. One of the troublesome features of such a case is, of course, hemorrhage, which not only obscures the field of operation, but endangers the life of the patient by strangulation if the blood enters the trachea, or, if he escapes that calamity, leaves him to run great risk from the subsequent development of an aspiration pneumonia from the septic clots. Accordingly, the common carotid artery of the affected side was ligated. An incision was made from near the external angular process of the orbit to the inner canthus of the eye, thence along the nose around the nostril through the furrow of the upper lip. This flap was dissected back and the bony growth exposed. With a chisel and heavy forceps the articulations were severed, leaving the division of hard and soft palates until the last. There was very little hemorrhage, some oozing was promptly stopped by the application of the actual cautery, and the wound packed with gauze. Great care was exercised lest any blood should enter the larynx. This was avoided by the use of the Trendelenburg position and careful sponging. Partial anesthesia is the rule in such cases. There is a nice point between loss of pain and the continued presence of sufficient reflex to enable the patient to cough. This is the sanctioned surgical procedure in operations about the face, tongue and jaws.

This patient did well, the large cavernous wound granulated nicely; but as the disease had involved the brain through the base of the skull, we were unable to determine whether his death some months later was due to shutting off the circulation by ligation of the common carotid, or to the effect of the primary disease. This vessel has been frequently ligated, and, so far as is known, without bad results; but there is a strong probability of cerebral softening following the interruption of the blood current. Crile (Annals of Surgery) reports 19 operations about the face, tongue, jaws, neck, where in a majority of instances both common carotids were temporarily ligated for 48 hours. This is accomplished by a small clip with parallel blades covered with rubber tubing, regulated by a set screw.