confound the novice in homoeopathy with an embarrassment of riches. To all such this little volume of Dr. Clarke will prove a veritable boon, for it was to meet just such a difficulty, a difficulty which the author had experienced himself, that the book was written. It gives compactly under the headings of the different diseases or conditions the medicines most commonly indicated in such condition, with the guiding symptoms. To the experienced homoeopathic practitioner such a work will present but slight claims for attention, but to the student, and the practitioner of other schools, who desires to honestly test homœopathy, it will prove invaluable. AMMONIA Applications in Malignant Pustule-.Dr. Leonidas Avendaño, of Peru, who has previously written (The Lancet) in favor of the local treatment of anthrax by ammonia, now publishes in a Lima medical journal an account of a recent case of undoubted malignant pustule, in which he successfully adopted this treatment. The patient was a married woman, aged thirty-four, who two days after being stung by some insect in the forearm, began to experience the symptoms of acute inflammation in the spot. Thinking an ordinary boil was forming, she applied poultices. The next day, when seen by the writer, the pulse was 105; there was a great deal of oedema and redness about the arm, and there was a papule, which was blackish at the centre and surmounted by a circle of vesicles. The etiology, the rapid development, and the local symptoms, all pointed to the malignant nature of the case. A crucial incision was made, and a brush saturated with the ordinary solution of ammonia was applied to the cut surfaces. An acetate of ammonia and aconite mixture was ordered, and in a few days the patient was well. Dr. Avendaño thinks that other caustics which have been employed in anthrax-as nitric acid, chloride of antimony and Vienna paste-only partially and incompletely destroy the bacillus anthracis, but that ammonia has a much more powerful effect. This makes the fifth case in which he has seen remarkably successful results follow its employment. REPORT of Progress in Orthopedic Surgery. By E. H. BRADFORD, M.D., and R. W. LOVETT, M.D.-Flat Foot.-Humphreys* contributes a paper upon the "Mechanism and Pathological Condition in acquired. Flat-Foot." The astragalus is the key stone of the arch of the foot, the posterior pillar the os calcis; the anterior is formed by the scaphoid, cuneiforms, and the three inner metatarsals. The anterior pillar is, by its structure, more elastic and weaker, because it contains the astralago-scaphoid joint. This joint, in addition to its ligaments, is strengthened by the tendons of the tibialis posticus and peronei muscles. Now, in long standing, the muscles become fatigued, fail to afford the necessary support to this joint, the ligaments stretch, in time, and an extension of this astragaloscaphoid joint takes place. In consequence of this altered relation of the pillars of the arch, the astralagus is changed in position, and, by * Lancet, 1886, I., 329. virtue of its shape, it rotates inward, so that it falls inside of the plane of action of the tendo-achillis, and the foot is thereby weakened, and the muscles whose function it is to raise the ankle and heel on the fulcrum of the ball of the foot can not do so. "It is a persistent overextended and incurved condition of the chief joint of the tarsus." Moreover, the muscles on the tibial and flexor side of the foot become relaxed and enfeebled, and fail to afford the proper support, and, therefore, the extensors and peronei not being extended and used, become irritable and contracted, and add to the discomfort. * Flat-Foot Treated by Ogston's Method.-Franks and Stokes report cases treated by astragaloid osteotomy. Franks performed Ogston's operation, refreshing of the astragalo-scaphoid articulation, and nailing the bones in a corrected position, and some stiffness in gait followed, perhaps on account of the fixed gypsum bandage, which was worn for four months. Stokes considers Ogston's operation too severe, and prefers moving a wedge from the inner side of the neck of the astragalus, thus avoiding an anchylosis at the Chopart's articulation. The case was a successful one. Knee-Joint Disease.-Dr. Judson comes forward with a new and very simple splint for the treatment of tumor albus in children. After insisting on the importance of absolute rest in this disease, he proceeds to describe his new splint, which consists of a strip of malleable iron, about an inch wide, which runs the length of the leg and thigh in the middle line behind, being somewhat longer than the ordinary ham-splint. At the top and bottom of this, and at two equi-distant points, are riveted semi-circle steel bands, transversely bent, to fit the leg and thigh. It is, in fact, a skeleton ham-splint. It is bent to fit the outline of the leg, and secured by straps and buckles. Dr. Judson claims that a plaster or ham-splint holds the femur as if it were imbedded in a mass of jelly, and, therefore, fails to afford definite support, while in this splint the transverse steel arms approach much more nearly to the bone, and therefore holds it more firmly The apparatus is very inexpensive, and could be made by any blacksmith. Clutton describes a bilateral chronic synovitis occurring in children from eight to fifteen years old, which affects only the knees, and is clearly syphilitic in origin. He has seen and recorded eleven cases of this sort, in all of which the condition of the patients was such that there was no doubt of the existence of constitutional syphilis. The synovitis is painless, does not give rise to muscular spasm, and the affection is extremely chronic. It does not tend to go on to destructive changes, but it is, nevertheless, not very amenable to constitutional treatment. Loose Cartilage.-Poulet and Valliard § have endeavored, in a long series of pathological and experimental investigations, to learn under *Trans. of the Acad. of Med. of Ireland, 1885. Lancet, 1886, I., 391. Centralblatt f. Chirurgie, September 18, 1886, p. 642. what conditions loose cartilages are most frequently developed. They report that a foreign bony or cartilaginous substance in the joint is developed out of bone corpuscular elements, and originates either from traumatic causes, peri-articular osteophytes, from loosened fragments of the joint cartilage of separated pieces of fragments from the ends of the joints. Dry or deforming arthritis shows the most favorable condition for the development of loose cartilage, and should be regarded as a symptom of the disease. Beside this most frequent form of dry arthritis, there is also a variety seen chiefly in youth, attacking only one joint, and only at one point of this joint. A peculiar affection of an insidious course, which is otherwise little known, exists, and is active in separating pieces of cartilage from the ends of the joints. In such cases, the resulting foreign substance is held in a depressed symmetrical spot in each of the bones, forming the joint. Every bony, foreign body may undergo changes in shape and structure, differing as the body may be free or pedunculated. The latter are inclined to a a fibrous change, while the free bodies may undergo a cartilaginous change on the periphery, so that a substance originally bony may become partly cartilaginous, and further, this cartilage may proliferate. A Case of Old Dislocation of the Knee Backward.*-Karewski reports a most unusual case of this rare deformity. A woman thirtytwo years old, presented herself with an old deformity of the knee, resulting from a severe injury received when sixteen years of age. A complete dislocation of the knee-joint had taken place backward which from the presence and size of a scar, it was evident that the dislocation had been a compound one. The condyles of the femur were remarkably prominent in front, covered by a cushion of fat on the under-joint surface. The patella is dislocated downwards. The edge of the tibia projects backwards, and in a measure the upperjoint surface can be felt. Motion at the joint was perfect and the woman had been able to earn a livelihood as a serving-maid. Some arrest of growth of the tibia had been caused by the accident. The affected tibia was 3 cm. shorter than the other, in addition to the shortening due to the luxation. According to the history the patient had remained several months in bed after the accident and gradually learned to walk without using crutches. She complained of lateral laxity of the joint, and suffered from one attack of hydrops articuli in consequence. Lateral Curvature.-Landerer considers that scoliosis is to be regarded as a deformity resulting from superincumbent weight, as genu valgum is, and that all treatment shall be based on that fact. The chief factor in determining the attitude is the muscular system. In a new-born child the spinal column is straight, if the child is made to sit up, the head and spine bends forward, and a total kyphosis is presented; if, however, the child is held sideways the spinal column with the head falls side-ways and a single lateral curve involving the whole spine is presented. In a child, when it becomes necessary to hold the head erect, in a similar position a double curve S-shaped Deutsche Zeitschrift f. Chirurgie, Bd. xxxiii., p. 535. would present itself, the force causing the upper curve being the muscular system. Heavy superincumbent weight alone is not sufficient to cause a lateral curvature if the muscular system is strong enough to hold the spine in a vertical position. The spine in beginning lateral curvature is usually quite flexible and the erect position is to be maintained chiefly by strength of the muscles. Massage, the writer claims to be a ready means of developing the muscular strength. As a new exercise the writer advises that in suitable cases the patient carry a basket upon the head for five or ten minutes daily, steadying the basket with the hand of the depressed shoulder.† CASE of Pyometra. By FANCOURT BARNES, M.D., British Gynæcological Society.-M., aged 36, married eleven years, one child nine years ago, was admitted into the Chelsea Hospital for Women, April 8, 1884. Her history was as follows:-Her labor was a difficult one; she was delivered of a dead child by craniotomy, and was laid up for a long time afterwards. She was sent to me by Dr. Delépine, of Camberwell. On admission there was found to be a rounded tumor, apparently uterine, which rose in the abdomen one inch above the umbilicus. It was elastic and very tender to the touch. She had menstruated regularly until two years ago, when menstruation became irregular for six months and finally ceased. At the time of admission she had not menstruated for eighteen months. There was pain, however, recurring regularly each month. On attempting a vaginal examination it was found that the vagina was completely occluded from the vulva upwards. On April 10 I therefore dissected up the occluded vagina to a distance of two and a half inches, when the uterus was reached and eighteen ounces of thick yellow pus escaped in a full stream. The vagina was then allowed to collapse, so that the pus which remained in the uterus might gradually ooze away. She passed a good night, the temperature next morning being 101°. The vagina was syringed daily with a carbolic solution. During the first three weeks after the operation, the temperature varied from 100° to 103°. The vagina was prevented. from closing again by frequent digital examinations. She left the hospital on August 30, cured. I have not been able to find any similar case recorded. There had evidently been a cicatricial closure of the vagina from the vulva to within half an inch of the os uteri, the sound passing the normal length. Succeeding menstrual periods gradually filled the uterine cavity, which became distended with the retained blood. The hæmatometra thus created ended in suppuration. The cases usually described under the title of pyometra are those in which there is a free opening to the vulva. When the patient was admitted into the hospital she was in a state of septicemia with emaciation, and evidently had not long to live. Dr. Mansell-Moullin thought the case related by Dr. Fancourt Barnes was unique. There were one or two points, however, on which he wished to have further details. He was hardly prepared to accept Dr. F. Barnes's explanation. Hæmatometra under such circumstances was Deutsche Zeitschrift f. Chir. Bd., xxiii., p. 557. rare; it usually occurred in cases where the occlusion was congenital or had taken place from injury prior to the advent of menstruation. When the injury took place subsequently to that period, the menses generally managed to maintain a passage for their escape, however minute it might be. The tarry fluid found in the uterus in cases of retention would scarcely have disappeared completely and given place. to the pus which was evacuated at the time of the operation. Absence of menstruation was easily explained by the exhausted condition of the patient. He supposed that after making a way through the great depth of cicatricial tissue Dr. Barnes did not experience any difficulty in determining the cervix and upper part of the vagina. Dr. Bantock said the case narrated by Dr. Fancourt Barnes reminded him of the case of a married but sterile woman who came under his care some years ago in the out-patient department of the Samaritan Free Hospital. The vagina was not more than an inch in length, and terminated in a minute opening just capable of admitting a fine surgical probe. On dilating this opening by means of tangle tents, he found a collection of muco-pus in the upper part of the vagina. The case was cured by bilateral division followed by continuous dilatation. The difference between the two cases was, that while there was only incomplete atresia in his case with partial accumulation not sufficient to distend the uterus, in the case under discussion these conditions were complete. In another case, which was one of true pyometra, occurring in a married woman who had had three pregnancies terminating respectively at eight, six, and five months, there was great contraction of the cervical canal, and in dilating it quite an ounce of pus escaped. In this case the canal was kept open by means of a strip of lint saturated with glycerine, and within eighteen months the patient had another child at full time. In the impression which he had formed of the case from the title of the paper he was a little disappointed to find that the case was not, as he understood it, a case of pure pyometra, for he regarded a case of pyometra as one in which the pus was wholly contained in the uterus. Such a case was that of a lady upon whom he had operated about two months ago on account of ovarian and tubal disease. On one occasion a few years ago she had passed from the uterine cavity a pint at least of the most horribly offensive purulent matter. At the time of the operation the chief symptom was menorrhagia, and the uterus was considerably enlarged. Dr. Walter had listened with much pleasure to the account of Dr. Fancourt Barnes's interesting and rare case of pyometra, and failed to see any reason why an objection to the term pyometra should be raised in this particular case. Even supposing it were true that pus first accumulated in the vagina and subsequently filled the uterus, it would simply be a parallel condition to what occurred in retained menses from imperforate hymen, when the fluid first accumulating in the vagina afterwards distended the uterus into a hæmotometra, and it made no difference whether the hæmatometra or the hæmatocolpos occurred first; so long as the uterus was distended with blood it was a hæmatometra, or if with pus a pyometra. If it so happened that the vagina also contained an accumulation of pus, we had a pyocolpos in addition to the pyometra. |