It was during this stage of the dissection that the hemorrhage was most alarming. The anterior œsophageal wall was sacrificed to the extent of nearly an inch. Fifteen ligatures were required to control hemorrhage, and ten sutures to approximate the edges of the wound. Trachea was plugged with a carbolized sponge above the canula, and the rubber chemise left dilated to prevent oozing into the trachea. The skin wound was now brought together just above the free border of the air tube, and midway between this point and the hyoid bone the œsophagus was made fast to the skin with four sutures, sufficient space being left to admit of the introduction of a good sized tube, through which to nourish what little was left of the sufferer.

Notwithstanding the fact that a little more than four hours had been occupied in the disseetion, and much blood lost, a good radial pulse was to be felt at the completion of the work. Canula was covered with carbolized gauze and patient put to bed in a warm room. At 6:30 P. M., three hours after the operation, pulse 118, temperature 103.2, and respiration 24. Some oozing of blood from the wound. Expresses his wants to his attendants with pencil and paper. Asks frequently for water and to see his friends. Thirst was relieved by bits of cracked ice placed in the mouth. Pain controlled by one-fourth grain morphia suppositories. At 10:30 P. M., pulse was steady at 118; says he feels pretty well except when coughing attacks come on. These attacks were the cause of a great deal of suffering for the first forty-eight hours immediately succeeding the operation, and were produced, I think, by oozing into the pharynx.

September 6th, A. M., pulse 130, temperature 103, respiration 26. Passed a comparatively comfortable night. Slept some. There was quite a copious discharge of seropurulent fluid from the wound this morning. Much fluid of the same character was discharged from the tracheal opening. There was an attempt to vomit, about mid

night, which produced a sense of suffocation, but was only transient. He was much alarmed by it. I ordered a continuance of the suppositories and enemas of brandy and beef tea every two hours.

At 2 P. M. he was comfortable, and had retained nourishment; 6 P. M. pulse 130, temperature 10234, respiration 26; was inclined to be restless and sweated profusely. Discharge from the wound is about the same in character; enemas continued. The least manipulation about the wound produced great discomfort and induced the attack of coughing, so I delayed feeding by the stomach and removal of the tracheal sponge. September 7th, pulse 120, temperature 13 respiration 30 had a very restless night, and is evidently Cake,Complained of hunger and asked for food. By means of a fountain syringe and a gum elastic brandy, ii of beef tea and gr. x of quinine. It was passed into the stomach without obstruction or discomfort. The same dose was repeated in three hours, with the addition of gr. x of carbonate of ammonia. Tracheal sponge

BRAgave by the oesophagus 3 i of

A

was changed, and an attempt made to change the canula, but the largest trachea tube at hand was found too short, necessitating the reintroduction of the original instrument, this being cleansed and the chemise removed. Has suffered two or three attacks of difficult breathing, which seemingly result from spasm of the diaphragm. Evening, pulse 144, temperature 105; is failing rapidly. Has taken carbonate of ammonia, quinine, brandy and beef tea in generous quantities, by the stomach, but apparently all to no purpose. Says he is not as well to-night, but "isn't September 8th, morning; pulse 150, temperature 105 5. I was with him during most of the night. He was perfectly rational, asked frequently for ice; seemed to be much troubled by tenacious mucous, which he raised from the throat with difficulty, and often at the expense of a hard paroxysm of coughing. Has taken liquid nourishment by the stomach since yesterday, and has re

going to die."

༥

tained it without discomfort. He continued to sink rapidly, and died from exhaustion at 10:30 A. M., three days after the operation.

I have ventured to report this case thus fully in detail from the fact of the rarity of the operation. One feature of special interest to me was the rapid progress of the laryngeal deposit after the removal of the rectal growth That there was commencing trouble in the larynx which was overlooked at the time of the first operation, I have not a doubt, and that the sufferer's existence was abbreviated by the excision of the rectum I am also convinced. It is, of course, impossible to say how long he could have survived without interference of any kind, but the rapid and decided improvement in the general health after the first operation, led me to believe that my patient had received opportune aid in combating his frightful malady.

The literature of extirpation of the larynx is so limited I have been unable to gather much general information on the subject, or of the views of the older surgeons with reference to the advisability of the operation. Dr. Mackenzie, of London, tells us that up to last May, (1880), nineteen cases had been operated upon: One in Glasgow, Scotland, and eighteen on the continent.

To quote

directly from his work, we learn that "of the nineteen cases operated upon, one patient died six weeks after the operation from pericarditis, resulting from the passage into the mediastinum of a bongie, used for dilatation of the œsophagus which had undergone cicatricial contraction as a result of the operation; eight patients died from collapse or pneumonia within a fortnight-in other words, directly after the operation, viz., one on the second day, one on the third day, one on the fourth day, two on the fifth day, one within a few days,' one on the eleventh day, and one within fourteen days. In seven instances recurrence took place within a few months after the operation, viz., once in three months, once in four months, twice in six months and once each in seven months, nine months and

ten months, respectively. Three cases were cured, one of which was an example of carcinoma, and two of sarcoma.' "In these three cases the disease was absolutely confined to the larynx, whilst in many of the others the neighboring tissues were also involved. It has already been shown that, owing to the arrangement of the lymphatic system in the larynx, disease of that part does not quickly infect the constitution. This fact favors the prospects of extirpation of the larynx, when the neoplasm is confined to its cavity. In any case the rescue of three patients out of nineteen (15.7 per cent.) from certain death must be regarded as one of the greatest triumphs of modern surgery.

CASE II.

Hemorrhage from a Femoral Aneurism, Treated by Ligation of the External Iliac Artery.

John O'Brien, a native of Ireland, 35 years of age, a sailor by occupation, and a man of dissolute habits, entered St. Joseph Hospital in the month of May, 1880, suffering from secondary syphilis. He had contracted the primary sore about six months before in New Orleans. In conjunction with the primary lesion there was much induration of the lymphatics in the right groin. This thickening resulted in suppuration, and finally phagedenic ulceration took place, uncovering nearly the upper half of Scarpa's triangle. Under specific treatment the ulcer healed and our patient was nearly convalescent, when, by exercising too much, a fresh deposit was induced; rapid filling of the whole of Scarpa's triangle took place. Knee became contracted to a right angle: pain along the distribution of the anterior crural nerve became excruciating. Leg was cold; pulsation in the terminal superficial vessels was hardly perceptible, and general edema from the middle of the thigh to the foot existed. This condition of things continued till fears were entertained that gangrene would

Iodide of pot

Cod liver oil,

supervene, and end the patient's suffering. ash and mercury in large doses were given. whisky, sulphite of calcium, and iron and quinine were freely exhibited, but made little impression on the deposit, or change in the case. Finally a small ulcer appeared in the old cicatrix, and a short sinus developed which discharged an unhealthy pus, frequently tinged with bright blood. Palpation gave a distinct femoral pulsation within the boundaries of Scorpa's space. No aneurismal omit

Iwas heard at this time.

On Monday evening, August 12th, I was summoned to the hospital in great haste and found my patient lying on the bath room floor, in a pool of blood, where he had fallen while on his way to the watercloset. He had lost by actual measurement, 11⁄2 quarts of blood. Inquiry developed the fact that during the afternoon he had been exploring the sinus in his groin with a toothpick, and had succeeded in introducing it about two inches. Examining the case closely, I inferred that the femoral had been injured by the improvised probe and the sanguinary flow excited by the fall. A spica bandage with compress controlled the hemorrhage and gr. ii of opium made him comfortable for the night. Ausculting the thigh the next morning, a well marked aneurismal souffle was apparent. There now seemed to be nothing to do but to choose be'tween probable death from hemorrhage without operation, and probable death from gangrene with it. In consultation with Drs. Stewart, Stone and Owens, it was decided that passive treatment of the case would inevitably lead to a fatal issue, and euthanasia demanded the scalpel and the ligature. At 4 P. M., August 13th, in the presence of the before mentioned physicians and Drs. Horst, Davenport and Jones, I tied the right external iliac artery. The incision was begun an inch above and anterior to the ant. sup. spine of right ilium, and continued obliquely downward and forward parallel with Poupart's ligament to the outer border of the external ring. The incision was