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and more remote. Inasmuch as we are supposed to be ac- Iquainted with the nature, and therefore can form a tolerablyaccurate idea of the size, of the foreign body, we can in somemeasure judge of the magnitude of the opening required for itsescape. I am not aware of any great increase of danger ordifficulty created by the division of a greater over a lessnumber of rings, or, in other words, in making a large openinginstead of a small one."The success of an operation of this kind is much dependent

on the skilful co-operation of the assistant. In the above case,the edges of the wound in the trachea were held widely asun-der by Mr. Savory; and when we consider the peculiar struc-ture of the trachea, the importance of this duty must be Iobvious. In the recorded case of Mr. Paget, the same part ofthe operation devolved on me, and at the moment of escape of Ithe foreign body, I was engaged in the act of dilating the open-ing in the trachea to the fullest extent it was susceptible of. z,I felt myself indebted to Mr. Savory for his very efficient co- Ioperation, upon which the success of the operation so largely ’,depended. "July 15th.-The boy has passed an extremely good night; If,

skin pungently hot, and dry; respiration, 40 per minute ; in-

spiration seems to take place entirely through the larynx, butexpiration partly through the wound and partly through thelarynx; pulse 140; tongue coated with a moist, whitish fur;the subcutaneous tissue over the right pectoral muscle is em-physematous ; no morbid sounds in the chest. To have one-twelfth of a grain of tartar emetic, with half a drachm ofsimple syrup, in a drachm and a half of water, every secondhour.16th.--The child is much better; the skin moist, and cooler

than it was; respiration only 24 per minute, and no air passesthrough the wound, except when the child breathes very deeplyor coughs; pulse 140; wound looking healthy; no morbidsounds in the chest; the emphysema has not extended; thebowels acted last night. To leave off the antimonial draught,and to have half an ounce of the tartrate of soda mixture everyfour hours.17th.-The child is now sitting up in bed, playing with his

toys; the wound is granulating up. To have a couple of eggs,milk, and beef-tea; also, twenty minims of the liquor of cin-chona, and ten minims of the aromatic spirits of ammonia, inhalf an ounce of water, three times a day.

ST. MARY’S HOSPITAL.

THE VALUE OF EARLY CONSERVATIVE MEASURES IN STRU-

MOUS DISEASE OF THE KNEE ; GOOD EFFECTS OF THEIODIDE OF SODIUM.

(Under the care of Mr. URE.)THE following case (for which we are indebted to Mr. Achille

Vintras, house-surgeon to the hospital) is instructive from atwofold point of view. In the first place, the morbid processwas arrested by early surgical interference in the complete re-moval of the carious bone. Had the destructive process beenallowed to go on, in a short time the knee-joint would havebeen so much involved (the patient being of strumous habit) asto have been amenable to no treatment short of amputation.In the second place, great advantage was derived from theiodide of sodium, and it had the unexpected effect of com-pletely clearing the hazy cornea, without any topical measures,and thus affords an additional proof of the value of thisremedy.

Jane C-, aged twelve years, was admitted on Oct. 22nd,1858. She was of strumous habit, thin, worn, and wasted bysuffering. The cornea of the left eye was nebulous. Over theinner side of the head of the left tibia was an extensive ulce-rated surface, about four inches in diameter, presenting large,flabby, unhealthy granulations; and, in the centre, a depres-sion, in which the bare surface of the tibia, about the size of afourpenny piece, was seen exposed, and of a dark-grey colour.The secretion of pus was abundant. It was stated that aboutthree weeks before her admission, an inflammatory swelling,like a large boil, had made its appearance in the above situa-tion, which, after the lapse of a week, burst, and was followedby rapid ulcerative destruction of the textures down to thebone. She has suffered from pain in the shin-bone ever sinceshe can remember, and also complains of pain referred to thepatella, but not in the sore. She lies with her leg completelybent upon the thigh, and screams whenever any attempt is

made to straighten the limb. The tongue clean, but pale andflabby; the appetite pretty good; pulse 80. A mixture, con-taining bark, and an opiate at night, was ordered for her; apoultice to be kept constantly on the knee.

Oct. 27th.-Slept well; appetite good; pulse 78. It wasdetermined in consultation to examine the patient, under theinfluence of chloroform, in order to ascertain the extent of thedisease, and, in the event of the knee-joint being implicated,either to amputate the limb, or perform excision of the joint;otherwise to remove simply the diseased portion of bone, andtrust to appropriate constitutional treatment for the recoveryof the patient.On careful exploration, it was found that the upper end of

the tibia was separated from the epiphysis, stripped of perios-teum, and diseased to the extent of more than an inch. Thismorbid portion was removed with bone-forceps, some of theadjoining unhealthy granulations snipped off with scissors, and,while the patient was still insensible, the limb was graduallyextended and- attached to a Macintyre splint. The block of ·

bone thus removed was somewhat rectangular in shape, mea-suring from side to side fully an inch and a half, and fromabove downwards rather more than half an inch. The surfacepresented the eroded, worm-eaten appearance characteristic ofscrofulous caries.28th.-Nausea from the effects of the chloroform; skin cool;

pulse natural; no complaint of any pain.Nov. 2nd.-The patient is doing well; the bottom of the

wound is covered with granulations.20th.-The wound is nearly filled up; the patient looks

better and stronger; appetite very good.Jan. 3rd, 1859.-The patient has been improving rapidly

since the last report.18th.-The sore had almost cicatrized under the use of

a weak solution of nitrate of silver; but towards the margins *

there remained two or three circumscribed patches of super-ficial ulceration, which seemed spreading and indisposed toheal. The girl looked sickly. She was ordered five grains ofiodide of sodium in an ounce of cod-liver oil mixture thricedaily.28th.-A speedy improvement has followed the use of the

iodide of sodium; the complexion has regained a healthy hue;the appetite is excellent. The little patient feels stronger, andthe sores look much healthier.

Feb. 10th.-The splint has been removed, and the patientcan now sit up in a chair, and move the knee-joint a littlewithout complaining of any pain; the sores have all healed.A curious circumstance is, that thé haziness of the cornea of

the right eye, which heretofore had prevented her from dis-tinguishing objects, has so far dispersed as to enable her to re-cognise persons. This nebulous cornea was, no doubt, thesequel of previous scrofulous corneitis-a condition which oftenyields to the use of alterative medicines.

12th. -Discharged cured.

GREAT NORTHERN HOSPITAL.

LITHOTOMY ; SECOND PERFORMANCE OF THE OPERATIONAFTER THE LAPSE OF THIRTEEN MONTHS; RECOVERY.

(Under the care of Mr. PRICE. )A SECOND operation for stone in the bladder is sometimes

necessary, but instances are rarely seen in which, a secondstone having formed during a few months, the repetition of acutting operation is required. Mr. Price, on the 25th of July,at the above hospital, removed a calculus from the bladder ofa man sixty-four years of age. The patient appeared muchharassed by continual suffering. The operator stated that,thirteen months before, he had removed a phosphatic calculusof considerable size by the lateral operation; the nucleus ofthe stone being a portion of effused blood. A rapid recoveryfrom the operation took place. With regard to the presentoperation, Mr. Price said he could see no reason why the variousoperative steps should in any way differ from those employedat the first operation, and had therefore carried his incisionsinto the bladder in the direct line of the former wound. Hadhe not been aware that the patient had been already operatedupon, it would have been impossible to surmise the fact fromany indication met with in the passage of the finger and knifealong the urethral track. The external incision was madedirectly through the old cicatrix. The stone was not large,and had the urethra and bladder been less irritable, a crushinginstead of a cutting operation would have been adopted.

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llr. Price stated that about two or three years since, he hadremoved a full-sized lithic acid stone from the bladder cf aman aged sixty-four; and in about eighteen months afterwardshis patient again sought his advice for the relief of similar dis-tressing symptoms affecting his urinary organs. The existenceof calculi being proved, the man again submitted to lithotomy,and five stones were removed. In this instance the incisionswere made on the same side of the perinseum, and the sametissues were divided, as in the first operation. The patientmade as rapid a recovery from the second operation as fromthe first.The patient now in the hospital has gone on uninterruptedly

without a single untoward symptom.

PARTIALLY ENCYSTED CALCULUS ; REMOVAL BY

LITHOTOMY ; RECOVERY.

(Under the care of Mr. LAWSON.)THE following case will be found not less interesting and

important than the preceding :-John M-, aged sixty-five, late a corporal in the 16th

Hussars, was admitted into the above hospital on July 23rd, ilabouring under all the usual symptoms of stone in the bladder.He dates the first symptoms as far back as 1819, when hesuffered intense pain in the loins, for which he was under treat-ment in the Bristol Military Hospital. He was subsequentlydischarged, unrelieved, and admitted into the old York Hos-pital, Chelsea. After having been there some time, he gainedrelief; but on attempting one day to micturate, a small cal-culus passed from the bladder into the urethra, where it be-came impacted, and was removed by the surgeon. In 1820 hewas invalided from the army. Since that period, he has con-tinued to suffer more or less from pain in the loins, and has atvarious times passed by the urethra gravel and small calculi.His urine, so far as he can remember, has, ever since his firstattack, deposited a tenacious, ropy sediment. The presenturgent symptoms commenced about eighteen months since, andhave continued to increase in severity.The condition of the patient on admission was that of ex-

treme emaciation and debility. He had an almost incessantdesire to pass his urine, and complained of a heavy, draggingpain in the loins. His urine deposited a large amount ofmucus, and some pus. No casts were detected under themicroscope. On examining the bladder with a sound, Mr.Lawson detected a stone, evidently of large size, and lyingclose to the prostate.On the 29th of July, the usual operation for lithotomy was

performed by Mr. Lawson, and a large lithic acid calculus re-moved. Some little trouble was experienced in catching holdof the stone, in consequence of its lying in a pouch of thebladder close to the prostate, from which it was with difficultydislodged. The stone presented an appearance very charac-teristic of its having remained for some time partially encysted.A clear margin around its long circumference marked thedepth of its seat in a pouch of the bladder; while above thisline there was a copious reddish deposit, evidently of morerecent date than that which formed the bulk of the calculus.The patient has progressed most satisfactorily since the opera-tion.

CLINICAL RECORDS.

EXTENSIVE FRACTURES OF THE SCAPULA ANDNINE RIBS; DEATH.

THE injuries were too extensive and serious, in the followingcase, to permit of recovery. The wonder is that the patient’ssufferings were not more acute, when we consider that manyof the ribs were broken in two places. We avail ourselves ofthe following notes, clinically reported by Mr. J. E. Davey,one of the pupils of the hospital.

Francis A-, aged sixty-seven, traveller, was admittedinto the accident ward of Guy’s Hospital on the 8th of June,1859, under the care of Mr. Cock. The patient, a strong,healthy-looking man, of temperate habits, was attempting tocross the road in the Borough, when he was knocked down bya Hansom cab, the wheel passing over his shoulders from theleft to the right side. He was picked up and conveyed to thehospital. On admission, he was very much prostrated, butperfectly sensible. On the left side, several ribs were diagnosedto be fractured; and tinding he had no use in the left arm, andthe clavicle not being fractured, an examination was made inthe region of the scapula. Crepitus could be distinctly felt and

heard by the stethoscope, and Mr. Cock detected emphysema.There being such severe injury, and so many ribs fractured, aflannel bandage, just tight enough to support the parts, wasapplied. At first he could only lay flat on his back, with theshoulders slightly raised. He had no cough, but after a dayor two he suffered from a kind of bronchitis (which he frequentlyhad in winter). He never expectorated anything but a white,frothy mucus, and there was not the slightest stain of blood.The lung on the left side did not seem to be doing its work,and on the right side puerile breathing was very audible. ’1 hepatient was too ill to allow of proper examination of the chest.June 9th.-At times quite delirious; great difficulty of

breathing; bowels opened; tongue slightly furred; pulse 94.! 10th.-Still very ill; has passed a very bad night; greatdifficulty of breathing. Ordered, half a drachm of tincture ofopium. At eight P.M., being very much more oppressed, hewas ordered two ounces of brandy, and an antimonial pill withopium every four hours.llth.-Much the same.12th.-He has passed a rather better night, but is still very

much oppressed and very restless; has no pain, but complainsof great difficulty of breathing.13th.-Died this morning, an hour previous to his death

suffering from extreme dyspnoea.Post-mortem examination, twenty-two laovcrs rifte2,wards.-

No signs of decomposition. Rigor mortis present. Bodytolerably healthy for an old man, but considerable excess offat. Head not examined. All the upper ribs of the left sidewere fractured, and most of them in more than one place. Thefirst nine were fractured in their middle, and all these, exceptthe first two, at their angles also; the broken ends projectedinwards; but the pleura was only slightly injured. Scapulafractured transversely immediately below the spine, the fissurerunning through the neck, but not quite penetrating the gle-noid cavity. From this spot another short fissure came down-wards and inwards into the middle of the bone; and besidesthis fracture, another longitudinal one existed, running downthe back of the bone at a distance of not quite half an inchfrom the edge: a rim of bone was thus completely broken off.On opening the chest, the left lung was found collapsed; abouteight ounces of blood in the chest. There was no lymph onthe pleura, except at a spot on the posterior surface and upperpart of lower lobe of the lung. On scraping off the exudation,a laceration an inch in length, but quite superficial, was seen.The right lung was healthy. Pericardium healthy. A con.siderable excess of fat on the surface of the heart; valves andlining membrane healthy; peritoneum, jejunum, ileum, andca3cum healthy. Liver excessively fatty. Prostate slightlyenlarged, especially the middle portion, which projected intothe bladder, and must have caused some impediment. Bladderalso hypertrophied.

SIMPLE EXTENSION IN CONTRACTION FROMBURNS.

WE lately had the opportunity of observing the treatmentof a case of deformity arising from an old burn in a little boy,nine years of age, under Mr. Coote’s care at St. Bartholomew’sHospital, which is worthy of notice. [t is a plan in use, webelieve, at the Orthopaedic Hospital, and consists in the properapplication of simple extension, perseveringly carried out. Theboy was admitted on the 7th of April, with his lips and mouthdrawn downwards from a burn in the neck when an infant.The cicatrix possessed the usual characters of hardness andthickening. By suitable appliances the head and chin werekept extended, with the effect of bringing back the lower lipsand jaw to their natural position, and getting rid of the ex’treme deformity which had heretofore existed. The mouthcan now be closed.The effect of extension is to cause the absorption of the ad.

ventitious material present in the cicatrix, and thus permitthe latter not only to become soft and extended, but perma-nentlv to rpmain Sn

A VITREOUS FOREIGN BODY SUCCESSFULLYREMOVED.

A POPULAR notion prevails that wounds produced by con-tact with glass are of a very festering character, and that whenportions of that substance remain lodged the danger becomesvery much increased. In small wounds of the fingers andbands, wherein minute fragments of vitreous substances some-times get forced in, much swelling and inflammation will occa-sionally ensue from the irritation which they cause; but, as a