TRANSFIXION OF THE BASE OF THE TONGUE BY A NEEDLE; DIAGNOSIS AND REMOVAL WITH THE AID OF THE LARYNGOSCOPE:

The following case, admitted into Westminster Hospital under Dr. Gibb, strikingly illustrates the valuable aid afforded by the laryngoscope in discovering foreign bodies lodged in the throat:

"Mrs Annie D., aged seventy-six years, was admitted as an out-patient on May 19th, under Mr Power, with the impression that she had a pin in her throat. He transferred her to Dr. Gibb for examination by the laryngoscope. She stated that she resided at Dulwich with her daughter, and that two weeks ago she swallowed a pin with some pudding. She felt it prick the throat right across, followed by severe pain, particularly on the left side, and dysphagia. Every now and then she had a choking sensation, with a disposition to retch. On the 13th (Sunday) she became nearly frantic with suffering, and the next day she retched continuously for nearly an hour. She had lived upon slops since the accident, and could only get them down by sipping small quantities. Her sufferings had been so severe that she had become exceedingly weak and feeble, and she was nearly suffocated on her way to town.

The neck was thin and all
There was some tenderness

"Nothing could be detected externally. the structures were easily distinguished. across the hyoid bone especially on the left side, where indeed there was a little tumefaction. In that situation the neck had been much swollen shortly after the foreign body was lodged, but this had subsided to a great extent. The voice was quite natural.

"In the fauces nothing was seen with the unaided eye, but on the tongue being held out and the laryngeal mirror introduced, the black point of a needle was seen emerging from the base of the tongue on its left side, near the lateral edge of the epiglottis, and occasionally coming in contact with it to the extent of about two lines. The needle had evidently penetrated the left side of the sac of the pharynx, transfixed the tongue's base in that situation, been driven through its structure, and emerged in the situation described.

"Any attempt at removal, without some guiding point, would have been futile. Dr. Gibb, therefore, made the patient protrude her tongue out of her mouth with firmness and resolution. He then introduced the mirror with his left hand, and with the right inserted a pair of curved forceps capable of holding the minutest body with unusual tenacity, and succeeded in getting hold of the point of the needle, which he pulled outwards towards the right side, and brought out of the mouth. On examination, it was found perfect, quite black, and an inch and a half long. All

symptoms of discomfort immediately subsided, and the patient left for her home, expressing herself in terms of gratitude and thankfulness for relief, after what she described as such 'horrid suffering and misery.'

"In some clinical remarks whieh Dr. Gibb offered upon this case, he observed that it might be taken as an invariable rule that pins were seldom discoloured, whereas needles were always black-an important point in the diagnosis when a portion only of the foreign body was seen with the laryngoscope. The patient's voice and breathing were natural; and although there were occasional attacks of dyspnoea and retching, yet beforehand it could be seen that the larynx was not in any way involved. The dyspnoea, and perhaps the retching, were due to the occasional contact with the edge of the epiglottis. He had recorded several cases in his own experience of the removal of pins and other substances, both from the larynx and fauces. In one case a pin had become lodged within the larynx of a gentlemnn, the head of which was situated in the hollow of the anterior angle of the thyroid cartilage. Symtoms of the most violent strangulation were present, and suffocation was imminent; until removal was accomplished, when they vanished, as it were, by magic. He doubted whether the patient in that instance would have been saved by even opening the trachea, unless the pin had been removed at the same time. In the generality of cases perfection of voice and breathing pointed to freedom of the larynx; but when the body could not be felt by the finger, and then removed, the employment of the laryngoscope afforded great assistance in diagnosis."-Lancet, June 30, 1866.

REMOVAL OF ENTIRE HUMERUS AND HEADS OF ULNA AND RADIUS AFTER GUN-SHOT INJURY. GOOD USE OF ARM

BY AID OF AN APPARATUS.

BY JAMES B. CUTTER, M. D. (American Journal of Medical Sciences, Jan 1865.)

A Minie ball passed through the shoulder joint, Nov. 27, 1863, fracturing the head and neck of the os humeri, which were removed, with three inches of the shaft, three days afterwards. Ten days subsequently an abscess formed at the elbow joint, which was opened and gave exit to a large quantity of pus. July 21, 1864, an operation was performed for the removal of entire bone, including the heads of ulna and radius. Continued the incision made in the first operation down the ulna line of the arm to the forearm; removed the bone with very little injury to the surrounding parts. No ligatures were required, as the bleeding was completely arrested by the use of cold water. It is proper to state

that the tubercle of the radius was left, leaving the insertion of the biceps muscle. The lips of the wound were brought together with silver sutures and adhesive plaster, and comfortably supported at a right angle with splints. Succeeded in getting union by first intention almost throughout the entire length of incision. Three weeks after operation, wound healed completely, and patient moving about.

The carpal, metacarpal, and digital muscles were left powerfully subservient to the will for grasping, holding and pulling, though there is some paresis of the extensor-carpi digitorum. The arm, forearm, and hand are daily regaining a healthy tone; biceps and deltoid muscles contract strongly, zigzag, for lack of fixedness; the entire arm and hand are somewhat atrophied. The arm is shortened one and a half inches, is extremely flexible and ungovernable.

Three months afterwards, Dr. E. D. Hudson, the othopraxist of New York, made and applied an apparatus, the incipient results of which were, arm and forearm supported, strong, and reliable; arm oscillates at the shoulder; forearm flexes at will, at a right angle with the arm; holds parcels in his hands, lifts a pail of water perpendicularly, pulls strongly on a horizontal line; with practice will regain a highly commendable and gratifying use of his arm and hand, and demonstrate the exceeding utility and propriety of the extreme exsection as a beneficial alteration for an amputation. Dr. Hudson writes under date of November 27, 1865, that he has "since improved and reapplied this apparatus, omitting the wristband, and substituting an elastic strap across the chest from the shoulder pad passing to a soft pad, placed beneath the axilla of the opposite arm; further, that the general principle remains the same; and he is improving in the use of his arm, He was in there a few days ago, took an arm-chair and swung it at an elevatiou of 45°—almost at a right angle with his body."

AMPUTATION THROUGH THE KNEE JOINT.

There seems to be a growing impression in favor of this operation in Great Britain, and of late years it has been quite frequently performed; four times by Mr. Lane, twice by Mr. Coulson, once by Mr. Spencer Smith, once by Mr. James Lane, once by Mr. Pollock, three times by Sir W. Fergusson. The following cases of Mr. Pollock, Mr. T. Holmes, and Mr. Cooper Forster, are recorded in the London Lancet, January 13, 1866.

Mr. Pollock amputated through the knee-joint at St. George's Hospi tal, August 3rd, 1865, in a woman æt. 55, for a large ulcer of the leg from

which she was evidently sinking from exhaustion, by double flap, the anterior being somewhat the larger. Patient hardly rallied. On the 6th, anterior flap looked dark colored, and was about to slough, when she sank and died.

Mr. Timothy Holmes, at the same hospital, exarticulated the leg of a boy æt. 12, September 14th, 1865, for disease of knee joint. A semilunar cut across and below the patella was made, and it was removed. Mr. H.'s purpose was to excise, if the case seemed suitable, but the shaft of the tibia was found extensively diseased. A catlin was substituted for the bistoury, and this was passed transversely between the femur and tibia, was made to cut its way downwards and backwards, forming a posterior flap of the tissues of the calf. A shorter anterior flap was provided by the tissues in which the patella had rested. October 8th, discharged well.

Mr. Cooper Forster's operation at Guy's Hospital was done October 10th, 1865, for a recent compound comminuted fracture of tibia and fibula of the right leg, just below the knee, in a healthy laborer. A circular cut was made around the leg, two inches below the knee, the skin and superficial layers of fat were cut through and dissected back. The tendons of the hamstring muscles were then divided about opposite the middle of the joint, the ligaments cut and the leg freed from the trunk. The patella was dissected out. Discharged November, 18th, 1865.

Medicine.

TONSILLITIS. APHTHOUS AND EDEMATOUS VARIETIES; CAUSTIC; INCISION.

This very common affection may be found worthy of brief commentary, and one of its forms is well illustrated by a case recently treated in Dr, Lyons' Clinique, Richmond Hospital, Dublin.

The patient, a young man, aged about 20, was admitted labouring under considerable dyspnoea, extreme dysphagia, and with a marked amount of pyrexial excitement. He stated that he had not previously laboured under sore throat, and had been attacked a few days previously with rigors, pain in the neck, difficulty of swallowing, pain shooting up to the right ear, and all the usual symptoms which attend the invasion of tonsillitis.

On inspection there was visible swelling externally on the left side, great distress in breathing and on attempts to swallow, and all the evidences of much febrile disturbance of the system.

On opening the mouth, which was accomplished not without difficulty, the left tonsil was found to be enormously engorged, projecting far beyond the mesian line, and carrying the uvula before it. It was also enlarged in a direction forwards, and had thrust the left anterior half-arch of the palate, part of velum palati and contiguous tissues, far forward into the mouth, causing very remarkable swelling of the parts involved, which were thrust forward so as to reach the level of the front molar teeth. The mucous membrane of the palate and inflamed parts was of a deep claret colour, and all the symptoms and appearances indicated the rapid advance of a high degree of erysipelatous inflammation. It might have been for some moments a question of grave debate as to what steps could be best taken for immediate relief of the urgent symptoms which were presented in this case; but relying on his former experience in circumstances very similar, Dr. Lyons at once proceeded by means of an ordinary gum-lancet, or, as he prefers to call it, "his favourite tonsillotome," to make a few bold free incisions through the swollen organ by gently raking the instrument two or three times in a parallel direction from behind forwards, and to the depth of about one-sixteenth to one-eighth of an inch through the tissue of the gland. The result of this procedure is invariably to give exit to a considerable quantity of blood, and to allow the escape of the serum, the infiltration of which had caused the principal amount of the swelling which had produced so much distress, dyspnoea, and dysphagia. After the free incision just mentioned, the patient was directed to freely gargle the throat with warm water. The result was, that in a brief period, partly from the escape of blood, and more particularly by the free exit of the serous fluid infiltrated into the tissues of the gland, marked subsidence of the swelling took place, and therewith relief was procured to all the principal sources of distress of which the patient complained. Convalescence was rapidly established in this case.

In commenting on the features of this particular case, Dr. Lyons took occasion to draw the attention of the class to the distinction which he believes to be so markedly observable between the two forms of tonsillitis which so very commonly come under the notice of the practising physician and surgeon-viz. :—

Aphthous Tonsillitis.—This term Dr. Lyons thinks may be applied very appropriately to one of the two common forms of tonsillitis. In this variety of the affection the tonsil is but little swollen; it is red, irritated, patchy in appearance, and here and there covered with buff-coloured spots or specks of yellowish or aphthous matter-a low form of exudative material. This affection is attended with smart sensation of pain and distress on swallowing, often with sharp fever and marked evidence of a