The plan which I now follow is to administer the Fiebre amar. alone, in any stage of the disease when there is not a well-marked, characteristic indication calling for another remedy. In case other remedies are indicated, I use them alternately with the Fiebre amar., and the result is so satisfactory that, although I am in general opposed to alternation, I would not feel justified in treating a case of yellow fever without using Fiebre amar.

It is greatly to be regretted that we are not acquainted with the Cuban plant from which the remedy is extracted, for these reasons: firstly, those who have never experienced its efficacy might have scruples in using an unknown substance in the treatment of so critical a disease; and secondly, those who are convinced of its value must anticipate the advent of a time when the existing supply will have been exhausted,

On this latter point I may remark that I have reasons to suppose that the secret is known by one of the relatives of Dr. Iturralde in Spain. I can assure my colleagues that my utmost endeavors shall be exerted to ascertain the name of the plant, in order to make it known to the profession.

CLINIQUE,

SURGICAL CLINIC AT THE HOMEOPATHIC
HOSPITAL ON WARD'S ISLAND.

BY PROF. WM. TOD HELMUTH., M. D.

Reported by Sidney F. Wilcox.

Spurious Anchylosis of the Hip-Operation-Cheiloplasty and
Removal of an Extensive Epithelioma-Adaptation of
Calcium Light for Clinical Purposes.
GENTLEMEN: The first case which I show to you
to-day is one of spurious anchylosis of the hip joint.
I say spurious, because anchylosis is divided into two
varieties: the false or fibrous, and the true or bony.
The first variety is where, from some inflammatory
process, either rheumatic or traumatic, an effusion of
fibrous material is poured out either around or into the
capsule of the joint, forming fibrous bands which pre-
vent motion.

If this be allowed to remain, cartilage is formed, and within its cells will be deposited osseous material, until finally we have the true variety of anchylosis or synostosis. There are other divisions of anchylosis made by some authors in reference to position, as the straight and angular varieties. In olden time it was considered impossible to diagnose between true and false anchylosis. This was due to the inability to move the joint on account of the pain it occasioned to the patient, who always involuntarily contracted the muscles of the part, and thereby rendered the joint immovable.

Since the discovery of Anasthesia, however, this difficulty has been overcome; for when the patient is fully under the influence of the anesthetic, the muscles are relaxed, and motion, if there be any, may be discovered. The diagnostic point between the two varieties is, that when the patient is etherized, the joint remains perfectly rigid in the true, while in the false there is some mobility. One thing I wish to impress firmly upon your minds, gentlemen, and that is never pronounce a case of anchylosis bony until you have proved that it is not false. Put the patient under ether, and make a thorough trial. If, after the complete relaxation of all the muscles of the part, there can be perceived the least motion, it is of the false variety, but if it remains rigid, you may pronounce it true synostosis. Brodhurst

also declares that, if the muscles in the vicinity of a joint can be rendered tense by voluntary action, then synostosis does not exist.

Now, as to treatment. In the false variety it may be broken up by what is known as brisement force, as I shall show you when the patient is brought in. One thing should always be remembered when applying force for the rupture of adhesions, and that is, always to flex the limb before extending it; as, in the latter case, there is danger of rupturing the vessels of the part when the adhesions give way.

After the adhesions have been broken up, passive motion should be made every two or three days, and extension put upon the limb, to keep the roughened surfaces from rubbing together. Indeed, much may be done to prevent anchylosis in a joint by applying extension and continuing it until the inflammation has subsided; thus friction may be prevented.

In the treatment of true anchylosis, much may be accomplished by subcutaneously dividing the bone, or removing a V-shaped portion from just above or below the joint, as was first performed by Dr. J. Rhea Barton, of Philadelphia.

A curious fact has often struck me in this connection, which you will pardon me if I allude to here. It is this: that often the very contact of a great man may render the thing or person he touches almost immortal. Coyle was a common sailor, and died of phthisis after having abandoned himself to drunkenness and dissipation, and yet by Barton's touch his name descends to posterity. So with St. Martin and Michael Bateman and many others.

In bony anchylosis it is worse than useless to attempt to break up the adhesions, as it would only result in breaking the bone, and perhaps doing great injury. [Patient brought in etherized.] This patient, Maggie Stevens, aged twenty-three, was a trapeze performer, and received an injury by falling from a trapeze and striking forcibly on the hip. This is the story she tells the nurse, while she informs the house physician that she received the injury by falling while crossing a railroad track. But it makes little difference, gentlemen, which way she received the injury. A trapeze and a railroad track are the same thing to us, as far as the treatment of the case is concerned. You see now, while the patient is under the anaesthetic, I can make but little motion in the joint, although the pelvis moves somewhat. Now, I shall ask Professor Thompson and Dr. Moffat to hold down the pelvis firmly; I will attempt to flex the thigh upon the abdomen, and when the adhesions give way, you will probably hear a snap. [Flexes the thigh forcibly upon the abdomen.] There [adhesions break with loud report], you hear it. I now flex the limb a little more, and now you see the thigh is completely bent, and motion is restored. You saw that it required all my strength and assistance from Professor Thompson to complete the flexion. Compresses of cold water will be applied to the part, and Dr. Moffat will see that passive motion is made every alternate day after two days.

Case II. The next case, gentlemen, is one of epithelioma of the lower lip and chin, upon which I intend to perform a cheiloplastic operation.

You know, as I have told you in my lectures, that epithelioma or cancroid is the least malignant of all the varieties of cancer, and that it is the least liable to return after extirpation. It has less tendency to infiltrate the surrounding tissues, and for this reason has often been confounded with lupus.

The microscopic difference between this and encephaloid and scirrhus is that its substance more nearly resembles the normal epithelial structures of the human body. It is more common in men than in women, and, as a rule, does not appear before the age of thirty-five.

The causes of epithelioma are obscure; but in certain constitutions the constant irritation of the mucous

membrane, as from a pipe in the mouth, seems to induce the growth. It may appear as a wart, a crack, a scab which peels off, leaving underneath a moist surface, and which is quickly replaced; a hard lump which feels like a shot under the skin; or, as chocolate-colored spots, generally more than one appearing at a time; this latter variety is the slowest to develop. In whichever form it begins, the epithelioma gradually spreads by infiltration, and throws out a fungous papillary growth, which also has caused it to be mistaken for lupus.

The case before us to-day is a man named McNulty, aged fifty-eight, and he tells us that this appeared ten months ago. It was removed by the actual cautery, but now has returned. You see it involves the whole of the left side of the lower lip, the left side of the chin, and a part of the cheek, descending into the neck. The operation which I propose to perform is called cheiloplastic, and means the making of a new lip. There are six methods of performing plastic operations. 1. Sliding in a direct line. 2. Sliding in a curved line. 3. Jumping (or the Indian method). 4. Inversion or eversion. 5. Taliacotian (where the flap is obtained from a distance). 6. Grafting.

As a rule, it may be said that the sliding method, having previously cut under the flap, and the torsion method are the ones giving the best results.

Sometimes, in the operation of rhinoplasty, the flap is taken from over the deltoid muscle, a regular apparatus being used to keep the arm in place. This is the proper Taliacotian method, receiving its name from Tagliacozzi, its originator. In making a plastic operation, you should always be careful to provide abundance of flap to allow for cicatricial contraction; and to leave a large enough bridge to supply sufficient nutrition to the part. Great care also should be taken to avoid twisting the pedicle too much, lest the circulation be cut off. Another point should be borne in mind, viz.: as few ligatures as possible should be put under the flap; for, although it is now known that silk ligatures may become absorbed, yet the constricted end of the vessel will slough, and thereby make a suppurating surface as well as a sinus. In this case, I propose to jump a flap from one side of the face, and also to slide one by cutting under, from the opposite side of the lower lip, so that I shall leave as much mucous membrane in the mouth as possible.

Now, gentlemen, if Professor Deschere will give us the light from his apparatus, and you will give me the light of your countenances, we will begin. I shall dissect up the flap, for which I have previously prepared a pattern, from the face, and stop the bleeding there, before I remove the epithelioma.

First I will place the pattern, cut from a piece of moleskin plaster, upon the patient's cheek, and with this stylographic pen, mark around it in ink, the size and shape of the flap [marking], which occupies the entire cheek. Now I will make an incision in this line which I have drawn [cutting], and will dissect up the flap [dissecting].

We will stop the bleeding and ascertain if this flap fits. You see the diseased part is well covered.

Next I will remove the epithelioma. First I take this pair of forceps, which has tortoise shell blades, and is self-closing, and place them in such a manner that they will constrict the coronary artery of the opposite side. There will probably be considerable bleeding from the left facial, which I will have to cut.

Now I make an incision, beginning at the middle of the lower lip and going nearly around the growth and through the lip, but as vet avoiding the facial artery, which I wish to leave until the last. Next I take a pair of strong scissors, with long handles, and inserting the blades at the angle of the mouth, complete the incision. Thus the epithelioma is removed, and we will stop the bleeding. [Ligates and twists the vessels.]

Now I will slide the flaps from the opposite side so

227

as to cover as much of the denuded surface with mucous membrane as possible. [This is done.] By bringing the two flaps together, you see we have the gap filled up.

now have the part cleaned off and then secure the The bleeding having in a measure ceased, I will flaps with hare-lip pins and sutures. [This is done.] better than he did before we commenced the operation, You see, gentlemen, we have a man who looks much and is in less danger of dying from cancer.

a calcium light. The amphitheatre not being well [The second operation was performed with the aid of lighted, it has been difficult to see the details of operations heretofore performed, especially on dark, cloudy days.

arranged with Professor Deschere, our microscopist, to To obviate this difficulty, Professor Helmuth had have a strong calcium light thrown by the means of a large reflector directly upon the patient.

appreciated by the class, who were thus enabled to see The effect was startling and brilliant and highly every point demonstrated with perfect clearness.

The result having proved so satisfactory on this occause of this valuable aid in his future clinics, whenever sion, Professor Helmuth has decided to always make the occasion demands.]

EARTH TREATMENT OF UTERINE
FIBROIDS.

BY J. G. BALDWIN, M.D., New York. presented, not because I consider it a cure, but to The following case of fibroid tumor of the uterus is show the results thus far of a peculiar treatment in an apparently desperate case:

years.
Mrs. B. is 37 years old, and has been married twelve
been an unusually healthy woman, having none of the
She has never been pregnant, and has always
uterine weaknesses so common to the sex.

unusual hardness in the lower part of the abdomen, a In May, 1877, while in Europe, she discovered an little to the right of the median line. I saw her soon after her return in October, 1877. I found a fibroid tumor attached to the posterior wall of the uterus, filling the concavity of the sacrum, and extending through the abdominal walls it seemed about the size above the pubes a little to the right. Examined of a large orange, round and smooth, and not at all sensitive. Vaginal examination showed it to be somewhat flattened and nodulated, but not tender. It had increased in size somewhat since she first discovThere was no pain or discomfort of any kind. I preered it in May. Menstruation was perfectly normal. scribed Muriate of ammonia, 10 grains three times a day. This was continued about three months, but the tumor grew steadily though slowly.

confirmed the diagnosis. He advised the hypodermic In January, 1878, Dr. Helmuth examined her, and be equal to 4 grs. of Ergot. This was done weekly, injection of Ergot in doses of 5 minims, each minim to 5 to 10 drops of the fluid extract of Secale were taken with few omissions, until July, and at the same time three times a day. During this time the tumor continued growing, increasing more to the left, nearly filling the left side of the abdomen as high as the navel, and becoming more nodulated or uneven above as well as below, and at times tender in some parts.

my request, consulted Dr. Atlee, who confirmed the In May, 1878, Mrs. B. went to Philadelphia, and, at previous diagnoses, and approved the treatment by Ergot, but advised a modification, so that it should be used only at the menstrual period, and the Muriate of ammonia given as before during the intervals. In July the Ergot was omitted, and the muriate was taken city at that time I found to my astonishment the tuthree times daily until October. On my return to the

mor had more than doubled in size. It was very hard, very uneven, and very tender to the touch in different parts, especially during the second week be fore menstruation, which was still perfectly normal.

I at once recommended the administration of the Ergot, both internally and hypodermically, but the growth of the tumor was not checked. It increased steadily until, in February, 1879, it completely filled the abdominal cavity, and extended three inches above the umbilicus. It was still very hard, and more distinctly lobulated, and in some parts was so painful and tender as to cause grave apprehensions of malignancy. The general health began to suffer; the appetite failed; the patient became emaciated, and suffered much from the size and weight of the tumor, as well as from the pain and tenderness. She could not lie down, and at night was obliged to sleep sitting in a chair.

office, on the day of my arrival, to welcome me home. She had gained much flesh and color. Her appetite is good, and bowels are regular. Her general health seems to be perfectly restored, but she has not menstruated since March last, when she had the attack of peritonitis.*

On a subsequent examination I found the tumor reduced to less than half the size it was when I saw her last. It extends only as high as the navel, and lies mostly on the left side-where it developed firstthe right side of the abdomen being entirely free from it. It is not tender anywhere, and is quite soft-very different from the solid, hard tumor which filled the abdominal cavity six months ago.

Mrs. B. gives the following account of herself in Philadelphia:

"On the 9th of May, 1879, I commenced the appliIcation of the earth poultices under the care of Dr. In February, 1879, she was seen by one of the most Hewson. I was so weak I could not walk alone, or eminent gynecologists of the allopathic school in New even raise my foot to a footstool. I could take no York. He described the tumor as a large multilobular nourishment except beef tea, brandy, and cream. It fibrous tumor of the uterus, projecting posteriorly and was three weeks before I could perceive any effect laterally, bearing the uterus high up behind the sym- upon the size of the tumor, though within twenty. phisis pubis. He thought the prognosis unfavorable four hours after the first application of the earth, all on account of the rapid growth. He did not think an pain left me, and I was able to lie down twenty minoperation should be attempted, as it would involve en-utes, which I had not been able to do for months. tire extirpation of the uterus, and would probably be fatal. He advised the continued use of the Ergot. This treatment was followed until March, 1879, without any improvement.

On the 10th of March Mrs. B. complained of unusual soreness in the tumor, but ascribed it to the approach of the menses, as it was near the time, and to the fatigue consequent upon a long walk she had taken the previous day.

In the afternoon she had a chill, and at the same time agonizing pains came on in the peritoneum. Soon the whole abdomen became exquisitely tender to the touch. The pulse rose to 130, and the skin became dry and hot. The countenance had the peculiar hippocratic appearance indicative of intense suffering.

For three days the inflammation was so severe that it seemed hardly possible she could survive. How ever, with the use of Aconite, Bellad., Bryonia, etc., with anodynes, the peritonitis gradually abated, but the patient did not recover from the shock. The appetite was gone, and the emaciation became very great. The menses did not come. The tumor developed rapidly, and was exceedingly tender. The abdominal walls were stretched to their utmost capacity. The bowels were constipated, and the pressure of the tumor on the rectum was so great that it was with extreme difficulty that a movement could be had. The urine was normal, but was voided with difficulty. The patient became so weak she could not walk without assistance. Having been unable to lie down for many weeks, the lower extremities became very much

swollen.

In April, 1879, a prominent practitioner of the eclectic school was called. After a thorough examination he could suggest nothing new to be done.

Having tested pretty thoroughly the resources of the different schools-the homœopathic, the allopathic, and the eclectic-I proposed a trial of the earth treatment as used by Dr. Hewson, of Philadelphia. Mrs. B. did not think of this treatment with much favor, but, as I was going abroad for five or six months, after much persuasion she consented to give it a trial.

In May, 1879, she was with much difficulty carried to Philadelphia, her friends taking leave of her as if for the last time. None of them expected to see her again alive. Indeed, many of them doubted whether she would live to reach Philadelphia.

Parting with her in this condition, I was exceedingly, but joyfully surprised-though I had heard encouraging reports from her-when she called at my

"I measured, when I began the earth poultices, at the base of the breast bone, 264 inches; at the navel, 35 inches; three inches above the navel, 28 inches; three inches below the navel, 37 inches. Now I measure at base of breast bone, 234 inches; at the navel, 27 inches; three inches above the navel, 244 inches; and three inches below, 29 inches. These measurements make no allowance for the flesh I have gained. I was a mere skeleton; now I weigh nearly my usual weight, 135 lbs.

"I remained under Dr. Hewson's care six months. At the end of this time the dropsy had disappeared from my limbs. My bowels became regular and my appetite excellent. I could sleep all night in bed. I gained 19 lbs. in weight during the month of September. I can walk out alone, and can exercise moderately. I pass more urine than when in perfect health. I perspire so freely that I often change my night dress three or four times in one night, while the pillow and mattress are wet with the perspiration; yet I feel no weakening effect. Dr. Hewson wishes me to continue the earth poultices an entire year."

FRACTURES OF THE FEMUR.

BY W. C. GOODNO, M. D., PHILADELPHIA.

The November issue of the TIMES Contains a reply by Dr. C. H. Von Tagen, to my criticism of his paper on the "Fracture of the Shaft of the Femur," etc., published in the North Am. Jour. of Homeo., for November, 1878.

I feel some hesitancy in replying, as our journals have of late been filled with articles of a controversial character, often teeming with personalities and offensive matter.

I feel impelled to criticise Dr. Von Tagen's original paper. First, because I personally am, with the concurrence of almost the entire profession, opposed, I think upon rational grounds, to the use of the doubleinclined plane in nearly all fractures of the femur. Second, for the reason that it contained statements of results, number of cases treated, methods of gaining extension and counter extension, etc., of so remarkable a character as to demand further explanation. I feel

* In December, since the above was written, the menses have appeared, and in a perfectly normal manner, the poultices being continued all the time.