earnest and conscientious research, and the profession owe to the author a debt of gratitude for its production. In this, the third edition of the work, the author has added considerable material from published observations recorded since the appearance of the second edition. He has also taken advantage of observations made by himself at the Bellevue and Charity Hospitals, New York. In this labour he acknowledges the able assistance of "that zealous student and thorough scholar, Dr. John Winslow" of New York.

In the chapter on "gun-shot injuries" the author has added many interesting and valuabls statistics obtained from the published records of the United States and Confederate armies. The work is amply illustrated by 294 illustrations, two hundred and thirteen of which are devoted to the subject of fracture. The author has selected some of the illustrations from Gray's treatise on anatomy, descriptive and surgical. These chiefly illustrate the centres of ossification and subsequent development of bone. Furthermore he has borrowed from the same author several illustrations of fractures; these are duly accredited in the text. We regard this as one of the most valuable and interesting works which have issued from the American press. It forms a handsome volume of seven hundred and seventy-seven pages, printed on excellent paper and of superior finish. It is to be had of Dawson Bros., Great St. James Street.

PERISCOPIC DEPARTMENT.

Surgery.

CASE OF PARACENTESIS PERICARDII-RECOVERY-CLINICAL

REMARKS.

(Under the care of DR. CLIFFORD ALLBUTT)

This rare operation was lately performed at the Leeds Infirmary in a case of acute rheumatic pericarditis, and with perfect success.

Dr. Allbutt, in his remarks upon this case, compared the operation as performed with a canula by Mr. Wheelhouse to that with a bistoury as recommended by Trousseau and others. He expressed a very decided opinion in favour of the canula. He also pointed out that in the present case one tapping was found to be sufficient, and that irritant injections were not required. He added that, had it been found necessary to repeat the operation, he should have advised the injection of an iodised solution.

Dr. Allbutt, in concluding his remarks, pointed out how strong an instance was to be seen in this case of the unity of the Medical Art in all its aspects. He said that no case could show more clearly how necessary it is for a physician to have a useful knowledge of the resources of the surgeon, and for the surgeon to be able at once to perceive the wants of a physician. Nothing, in his opinion, was more to be regretted than the unfortunate division of these two great departments of the healing art, by which a mere arrangement of convenience has been placed on the level of a real distinction, thereby encouraging at the very outset of a student's career a narrowness of thought and an incompleteness of education, which is most mischievous to the best interests of the profession. For the notes of the following case we are indebted to Mr. George Thompson, clinical clerk :

C. S., aged 26, gas-pipe layer, was admitted into No. 4 ward, under the care of Dr. Allbutt, on September the 18th, 1866. On admission he was suffering from very acute rheumatism, both muscular and arthritic, and there was considerable dyspnoea and oppression. On examination the pericardium was found to be much distended with fluid, and there was acute pain in the region of the heart. A blister over the heart was ordered, and full alkaline and opiate treatment.

On September 19, about 11. 30 p.m., Dr. Allbutt was hastily summoned to see the patient, who was found sitting up in bed, with his elbows on his knees, struggling for breath. He was covered with a cold copious sweat. The area of pericardial dulness was found to be considerably increased, occupying nearly the whole of the left chest in front. There was perfect resonance all over the left lung behind. The patient was clearly at the point of death, and Dr. Allbutt determined at once to ask Mr. Wheelhouse to tap the pericardium. Mr. Wheelhouse was, therefore, called in to see the patient.

The extent of the pericardial dulness was now accurately defined, and the probable position of the apex of the left ventricle and of the auricle was as far as possible ascertained. Mr. Wheelhouse determined to open the sac half an inch from the sternum on the left side and opposite the upper margin of the costal cartilage of the fifth rib. He passed in a fine trocar, inclining it slightly upwards and inwards, so as to enter, if possible, opposite the centre of the left ventricle. He pushed it onwards until he could distinctly feel the movements of the heart with the instrument; and then, sheathing the point, he pushed the canula well up to the heart until he could both feel and see the impulse. The trocar was then wholly withdrawn, and the fluid allowed to escape. This it did in a steady stream at first, which soon subsided into a saltatory flow coincident with

the heart's contractions.

serum.

The fluid consisted of a pale-pink coagulable

On the whole, about two and a half or three ounces escaped During the operation the patient gradually obtained relief, and after the canula was withdrawn, the bed rest was removed, and he was able to lie down. The breathing was now only 36 per minute, and he was able to speak a few words, and express that he felt relieved. The pulse had lost its rapid and struggling character, and could easily be connted, its number being about 110. The area of dulness was very decidedly lessened, but it was not thought well to tease the patient again with a minute examination. Mr. Coleman was good enough to sit up all night with the patient, who passed it in tolerable comfort, though there were several threatnings of syncope, which were warded off by large and repeated doses of brandy; all other medicines were omitted.

Next day the cardiac dulness had not increased. On the evening of this day (September the 26th) the breathing again came more laboured, and considerable delirium came on. Another large blister was placed over the region of the heart, and half a drachm of liquor morphia was given ten drops were ordered to be repeated every six hours. fortable night was thus passed.

A com

On the whole, the patient may be said to have steadily improved from this time, and on October the 13th he was discharged cured. The pericardial dulness on his discharge was little, if any, beyond the normal extent. There was a loud blowing systolic murmur heard over the apex. -Medical Times & Gazette.

ON REMOVAL OF THE ENTIRE TONGUE.

By THOMAS NUNNELEY, Esq., Leeds.

THE operation for the removal of the entire tongue may, without hesitation, be declared one of modern surgery; so modern, indeed, that I believe it belongs to the latter half of the nineteenth century. Though portions, larger or smaller, of the tongue have, from time immemorial, been in various ways removed, the idea of its being feasible to remove the whole of the organ does not appear to have been entertained, or, if ever entertained, ever to have been put in practice. So strong in all ages has been the popular idea for the necessary presence of at least some portion of the tongue, that, when the historian of the introduction of Christianity into the Roman Empire recorded, amongst other gross barbarities to which the converts were subjected, that one of the martyrs who had the tongue torn out not only survived, but afterwards spoke, he thought it necessary to call in the aid of direct miraculous intervention as the only explanation of so astounding a fact. Referring to this statement, Gib

bon, who, as is well known, had no belief in miracles, sneers at the credulity of those who can believe in the possibility of such a mutilation being recovered from, and regards the whole statement as a romance. So also accounts have from time to time reached the western world, of the barbarous chiefs of some of the tribes in Central Asia, as an extreme measure of political vengeance rather than of criminal punishment (for which it appears to have been considered too horrible), ordering the tongue to be torn out, and the occasional surviving of the victim. Though the evidence in support of the truth of the stories, obtained by one of our ambassadors at the Persian Court. and by other persons in the East, would have been considered in many matters of inquiry sufficient to justify the belief in the statement, still so opposed was the general opinion to the possibility of any one living and speaking after such mntilation, that most commonly it was thought the well known tendency to exaggeration and mystification in these regions had imposed upon the credulity of those who related the tales. This opinion was rather confirmed than not by the fatal result which followed in the first two cases in which the operation was performed by a British surgeon, and by the very discouraging conclusions which he arrived at on a consideration of the operations. Mr. Syme says: "I think there should be no hesitation in deciding against the repetition of this procedure. In promoting the progress of surgery, it is hardly of more consequence to determine what is expedient than to ascertain what is not expedient; and I venture to hope that the experience now related may not prove useless, by saving others from the disappointment which I have myself experienced." (Lancet, Aug. 14th, 1858, p. 169.)

The reasons which mainly have weighed with surgeons in deterring them from attempting to remove the entire tongue, are—

it.

1. The difficulty of reaching the base of the tongue so as to cut through

2. The difficulty in arresting hæmorrhage in a part so deeply seated

so elastic in texture, and supplied with large arteries in immediate continuity with the carotids.

3. The immediate danger to life from other important organs becoming involved.

4. Even though the immediate danger be escaped, the improbability of life being maintained for any lengthened period, owing to the difficulty in deglutition and the loss of the sense of taste.

5. The miserable condition to which it was supposed the sufferer must be reduced by condemnation to perpetual dumbness, from the loss of what has been universally regarded as the necessary instrument of speech.

Yet, in practice, it has been found that none of these reasons possess nearly the same importance which has been assigned to them. The entire tongue may be removed without any very great difficulty. The hæmorrhage is not necessarily severe; in some cases there has literally been none; and in no case has its arrest been difficult. The immediate danger to life has not proved great. Instead of deglutition being rendered impossible by the ablation of the whole tongue, on the contrary, after the first soreness caused by the operation has passed off, the patient is found, as compared with his previous condition, to be able to swallow both solids and liquids with facility. Indeed, no one who has not watched a person wholly without tongue, would be prepared to see him drink off half a pint of beer without stopping, as I have repeatedly seen more than one person do. The sense of taste is not lost, but remains in a considerable degree; and, so far from emaciation following the operation, in every case which I have seen, the patient has rapidly improved in flesh and strength, which may partly, no doubt, be attributed to loss of the pain and want of sleep he has suffered, but to which the improved facility of deglutition mainly contributed. So far from dumbness ensuing, the loss of the diseased organ is speedily followed by greatly improved articulation; and the power of speaking and reading aloud with sufficient dis tinctness to be easily understood is surprising. Indeed, one of my patients, who was fond of exhibiting his power, when in company often took part in the conversation, and contrived to lead it towards the subject in which he was so interested, frequently had to exhibit his empty mouth before his incredulous companions would believe him to be without a tongue.

I have now operated five times. In four of the cases the entire tongue was removed; in the other, more than two-thirds of it. In two of the patients, no constituted disturbance whatever followed; one did not even require an opiate; and in two others, the disturbance was very slight and temporary. In the first case only were there any dangerous symptoms; and even this man, on the separation of the tongue, immediately recovered. Much of the trouble and suffering in this case arose from its being a first operation, and the unfortunate contretemps of the chain of the écraseur breaking, and thus necessitating a different and far more tedious proceeding than that originally intended. Hence I think I am justified in saying that, as compared with other important operations, the removal of the entire tongue is not a very dangerous one. It would be difficult to point out one new capital operation, in which, in the hands of one surgeon, all the cases-five in number-have recovered.

I allude now only to my own cases, because, while I would desire to