thorax. No other tumour presented in any region of the body, and as to the normal ganglia, they were imperceptible.

In consideration of the fact that the existence of the boy was compromised by the presence of the neoplasm, we decided on its extirpation. The opportunity for the operation had come, and in presence of the danger of death from asphyxia or inanition, consequent on the mechanical action of the enormous neoplasm, all hesitation vanished. We did not enter on the discussion as to its malignity or the contrary, its reproduction or not, or its deadly action by cachectic poisoning. There we saw a body which compromised the trachea, the œsophagus, the superficial and the deep veins, and very probably the recurrent nerve; all circumstances calling for prompt surgical intervention. It is certain that an operation of this character, in the depths of a region so delicate, could not be exempt from great dangers.

On the 3rd of November the boy was placed on the operating table, anesthesia was produced, and in the presence of the distinguished alumni of our school, Drs. Ugarteche, Jorge, Aveleira, Knoglang. and others whom I do not recollect, the operation proceeded in the following manner : A curved incision of the skin was made below the clavicle, extending from the acromion to the sterno-clavicular articulation; a fold of the skin and the cutaneous muscle was dissected as far as the parotid region and the anterior border of the trapezius. The ex. ternal jugular was divided between two hemostatic clips. The tumour was then grasped with a strong forceps, and upward traction was made; its anterior border and its base were dissected from their attachments, care being always taken to carry the cutting instrument clear of the surface of the neoplasm. It was separated from the posterior part of the clavicle and the subclavian vein, a strong adherance of the scalenus was destroyed, avoiding to touch the phrenic nerve; it was separated from the brachial plexus and the subclavian artery, and the dissection was carried backward as far as the

We took every precaution for the avoidance, or the provocation, of immediate and consecutive accidents. We felt sure as to the commanding of arterial or venous hemorrhage, but we had to take subscapular fossa. Here the tumour was mounted into account the capillary hemorrhage. Our pa- as a saddle, over the cervical border of the scapula, tient, according to his stature and weight, could requiring its separation from the supra-spinatus, the not contain more than three kilograms of blood great serratus, and the sub-scapularis muscles. (6lbs. 10 ozs.), and the loss of two pounds of this Passing to the anterior internal part, the clavicular fluid might seriously endanger his life. An opera- portion of the sterno-mastoid muscle was cut, and tion of this nature, with so vast a traumatic super-changing the position of the forceps, a new traction ficies, and lasting more than an hour, might cause of the tumour was made, separating it from the the loss of this quantity of blood by mere exhala-carotid, the internal jugular, the oesophagus, and tion (oozing). We left out all thoughts of the use the recurrent nerve; it was dissected from the of the galvanic cautery, since the cperation was trachea and the thyroid body, in effecting which it one in which, above all things, we must clearly see was found necessary to separate with the hook the where the vulnerant instrument reached, and might sterno-hyoideus and the thyro-hyoideus muscles, as by contact, or by simple radiation of caloric, cau- the neoplasm penetrated into the right region of terize the wall of a tube, a vessel, or an important the neck. New tractions were made on the supenerve. We considered the great inconvenience pre-rior part, and it was separated from contact with sented by the perchloride of iron in the cauterizing the parotid and sub-maxillary glands, drawing out of so large a surface, and putting it into worse conditions for speedy cicatrization. It was imperative to keep in view that a copious suppuration might terminate the life of a boy already much debilitated. It was necessary that we should find a special hæmostatic, which would place the traumatic sur- We had now spent an hour in this laborious disfaces in such conditions as would secure healing section, and when we supposed our task ended, we without suppuration, and we gave the preference perceived that there yet remained large masses be-' to an alcoholic solution of salicylic acid, with the hind the top of the sternum, which insinuated them-` double object of obtaining both its hæmostatic and | selves over the mediastinum, and others between its antiseptic action.

a part insinuated between the bellies of the digastric muscle, and separating the tumour from the hypoglossal nerve and the two carotids, as at the height of the thyroid cartilage it penetrated the ganglionar mass as far as the walls of the pharynx.

the scaleni, and many more between the transverse rapidly that twelve days after the operation the boy processes of the cervical vertebræ and the posterior muscles of the neck. We were delayed half an hour in this delicate part of the operation, having finally eliminated the tumour without any accident. It was truly impressive to contemplate this vast fuming surface in whose depths were seen the nerve plexuses and the large injected veins, whilst the silence was broken by the vibrations of the carotids and the subclavian.

not only quit his bed, but walked about the courts of the hospital. The lips of the wound, however, suffered a contre-temps, due most probably to an epidemic of diphtheria then prevailing in the establishment. There remained only one little spot for cicatrization, when suddenly it took on an ulcerating character, which had to be combated by iodoform, and about a month was required for complete healing. The boy now enjoys excellent health, and the cicatrix below the clavicle can hardly be distinguished.

The tumour weighed 1250 grammes (234 lbs.); and consisted of 78 lobules, the largest about the size of a hen's egg, the smallest, of a chick pea. Some were soft, contrasting with the cartilaginous hardness of others. All were united by a lax connective tissue, and formed various groups surrounded by an incomplete fibrous capsule.

CATED WITH EMPYEMA.

BY J. H. RYAN, M.D., SUSSEX, N.B.

With a hope that the history of the following case may be of some practical interest to the readers of the LANCET, I beg to contribute it towards the literature on this subject.

Sixteen hæmostatic pincettes were applied on the arterioles and small veins, and torsion was made on a branch of the transverse cervical, which was the chief nutrient artery of the neoplasm. The capillary hemorrhage was controlled by continually applying compresses soaked in the alcoholic solution of salicylic acid, on the cut surfaces, as they became gradually exposed. Furthermore, many hemorrhagic accidents were averted by the use of an instrument much overlooked by surgeons, and which is always present in their cases. We allude to the spatula, which in our operation performed CASE OF PLEURO-PNEUMONIA, COMPLIthe principal role in the dissection, and which we shall in future recommend especially for the extirpation of large, tnmours. By its obtuse point, its fine non-cutting edges, and its curvature, it seems as if expressly made for insinuation into the lax connective tissue, without injury to the partitions and walls of important organs. It possesses a marked superiority over the handle of the scalpel. Half an hour after concluding the operation, all the hæmostatic pincettes were removed, and the traumatic surface was perfectly washed with the salicylic alcohol, and when it was quite dry, exact apposition of the cut parts was made, and three Chassaignac tubes were left in, one leading from behind the sternum, another crossing the whole region and coming out by a contra aperture by the spinal border of the scapula, and the third from between the scaleni, coming out at the external angle of the incision. The edges of the wound were united by twelve stitches, and the Listerian occlus-lung with pleurisy. The pulse was beating tumultion was made, compression having previously been made over the supra-scapular hollow, in order to prevent the existence of any sac.

On the evening of the 12th May, 1878, I was summoned to attend J-O-, a native of N. B., a farmer, single and æt. 25. He was of a ro bust constitution, and had always enjoyed good health, but he was addicted to the vice of intemperance and often suffered in consequence from exposure. It was in this way that he contracted the above disease.

His present illness commenced twenty-four hours previous to my visit, with pain in his right side, cough and dyspnoea. On physical exploration of the chest there were revealed engorgement of right

uously at 122 per minute, and the inspirations 33; temperature, 104.5°; the skin was perspiring freely; and the tongue was furred. Fomentations were The progress of the case was very satisfactory. ordered to be applied over the right lung, and an There was febrile reaction for three days, but the aperient administered. A mixture containing cartemperature scarcely exceeded 39°C. (102.2°F). | bonate of ammonia and vin. ipecac. was directed to The cough, dyspnoea and dysphagia completely dis- be given at regular intervals, and a Dover's powder appeared, and the deep cicatrization took place so to be taken at bedtime.

May 13.-No improvement, but felt easier in the the axillary line, and withdrew 30 ounces of puruafternoon. lent lymph. The patient felt much relieved after May 14.-Pain more intense, crepitant and sub-the operation, and the inspirations fell to 24 per crepitant rales audible over the right lung; pulse, minute; pulse, 98; and temperature, 101.1°. A 94; inspirations 25 per minute; and temperature morphine powder was ordered to be taken at bedin the axilla, 102.6o.

May 15.-Delirium ; pulse, 86; inspirations, 34; lower half of right lung solidified. A small quantity of brandy allowed, and supporting remedies in moderation.

May 16.-Feels better; pulse, 86; temperature, 102.5°; complains of pain along the crest of the right ilium.

May 19.-Spent a restless night, and complained much of dyspnoea and pain in different parts of the body; pulse, 80; inspirations, 30; temperature, 100.4°; cough insignificant, and appetite tolerably good. Physical signs of this date reveal the left lung and upper lobe of the right normal, and the vesicular murmur and resonance more pronounced at the base of diseased lung, and the general symptoms denote improvement.

May 23.-Pulse, 75; inspirations, 30; temperature, 100.7°. A specimen of urine examined gave a faint acid reaction; no albumen; the chlorides increasing, and sp. grav. 1010. The dulness was greater and more pronounced at the base of right lung than when examined four days previously. By changing the position of the patient I was able to detect fluid in the right pleural cavity in small quantity. Elaterium and buchu were prescribed with a view to hasten the absorption of the effusion.

time

June 8.-Perceptible improvement. The bowels. being constipated senna was administered. Some bulging yet noticeable on the diseased side, which on measurement being made was 18 inches from spine to sternum, one inch greater than the corresponding side, but an inch less than it was previous to the operation. Right lung comes down lower in front, but still dulness exists at the base. His diet since yesterday has been a little too much, consisting of 3 oz. brandy, 1 pints of milk, a dozen oysters, some tender broiled beef and biscuit. June 9 and 10.-Feels not so well to-day; pulse, 96; and tongue becoming coated. Physical examination of the chest reveals left lung normal, heart normal, but right pleural cavity becoming more distended with fluid, though no increase in measurement.

June 14.-The symptoms being unfavourable I concluded to make a free opening of the pleural cavity and insert a drainage tube. Assisted by Dr. B. McMonagle, I made a free opening into the eighth intercostal space in the axillary line, introduced a rubber drainage tube about three inches, and secured it by transfixing the tube with a harelip pin, which was readily passed through strong, adhesive plaster in such a manner as to make a May 25-Area of dulness increasing; pulse, complete and simple appliance for securing it to 105; inspirations, 32; temperature, 98.8°. Urine the chest. About 30 ounces of sanguinolent fluid tested gave the same indications as before, except- escaped through the tube, after which the pleural ing the sp. gr. which was greater. The patient contin- cavity was washed out with a weak solution of carued on in much the same condition; the hydra-bolic acid. The pulse before the operation was gogues and diuretics failing to reduce the effusion 124, after it, 104; respiration, 30 before, and 24 to any perceptible amount. per minute after the evacuation of the liquid. June 15.-On removing a small plug I had inserted into the tube to prevent air from entering, 12 ounces of pus escaped, and the cavity was washed out with a solution of permanganate of

June 3.-The symptoms more aggravated; pain, cough, restlessness, loss of appetite, an anxious countenance, and low delirium. Pulse, 128; and temperature, 102°.

Fune 5.—I indroduced the needle of a hypoder-potash. His diet to be nutritious, and to have pormic syringe into the pleural cavity and withdrew one ter, a wineglassful every two hours. drachm of purulent matter, and informed his Fune 16.-Much improved. The discharge tofriends that it would be necessary to operate and day amounted to one pint. Cavity washed out remove this collection. with carbolic acid solution.

Fune 6.-1 performed the operation of paracen- June 17.-Improving; pulse, 88; respiration, tesis thoracis in the eighth intercostal space, in 24; temperature, 98.7°; and no discharge from I

pleural cavity since yesterday. Injected Condy's and taken charge of the case. I was not called in fluid in half-a-pint of warm water, which returned consultation as I expected to have been, but learned without any increase in quantity. Prescribed a that owing to the disease not progressing favourably mixture of potass. iodidi and tinct. cinchona co. the attendant physician called in consultation anJune 18.-Is not so well to-day. By turning other medical man, and they came to the decision the patient well over on his side so as to bring the the case was one of pneumonia. opening as low as possible, about 9 ounces of very thick pus escaped. Condy's fluid was injected and allowed to remain ten minutes, the patient rolling over so that the wash might be generally distributed over the pleural surface. After it came away the patient went to sleep immediately.

June 19.-Is better; ten ounces of pus escaped. Cavity washed out with carbolic acid solution.

June 20.-About 20 ounces of pus escaped to

day.

A few weeks later passing that way, I was called and asked to step in and see the sick man who was still confined to his bed. I refused to do so, but being assured that he was not under any regular physician's care, I reluctantly consented to see him only. He was much reduced and not able to assist himself in anyway. The physical signs indicated liquid in the pleural cavity. I informed the invalid of the fact, and urged him to have it removed by operation, and that if he did not have

Fuue 22. The tube cut short, and a large hand- it so removed the collection of purulent matter ful of oakum applied with the tube open.

June 23.-Was sent for in haste, as the patient had fainted. His sister, who had been intrusted with the injecting of the fluid, was told to cease the injection, but did not do so-which caused great distress and syncope. From this time forward, however, the case progressed rapidly.

July 1. I ordered the tube to be stopped for 26 hours; on the removal of the plug, only one ounce of thin liquid escaped.

July 7.-The tube was removed, and the patient continued to improve. He convalesced so rapidly that he was able to work in a short time, and cut all the hay on his father's farm without assistance. Remarks. I would urge upon the profession the advisability of early operative interference in empyema. To operate early it is necessary to be well satisfied that fluid exists in the pleural cavity. This is quickly and positively ascertained by introducing a hypodermic needle in one of the intercostal spaces and drawing off some of the fluid if any exists, the nature of which can then readily be determined. There can be no danger, according to late English authorities, should the needle of the syringe accidentally enter the healthy lung, or the liver. This is a valuable aid in the diagnosis of this disease, and may be instrumental in preventing many grievous errors, similar to the following instance: A few years ago I remember having been called to attend a patient, in the absence of the family physician. I diagnosed the case, pleurisy with effusion. I did not see the case again for several weeks, the family physician having returned

would probably make its own way out if he lived so long, but he persistently refused.

A few weeks later, curiosity led me to call and see how far my predictions had been verified. At the base of left lung in front, a diffused redness existed with an aperture in the centre from which a thin purulent matter made its escape. On the right side above the right nipple and towards the sternum was a round hole the size of a goose quill, through which air and thin purulent lymph would whistle and flow with every inspiration and expiration. This man lingered on for weeks and even months, and suffered from painful bed-sores. Nature had done her part in making a spontaneous opening, but too late, his life slowly ebbed away, within twelve months from the commencement of the disease.

Correspondence.

PUBLIC PROSECUTOR.

To the Editor of the CANADA LANCET.

SIR, Will you kindly permit me through your valuable space, to call attention to the state of the medical profession in the eastern counties of Ontario. In the May number of the Lancet a correspondent under the signature of "Justice" referred to it, at the same time accusing the public prosecutor of not doing his duty towards the licensed medical men. "Justice" complained most of midwives, but I'do not think any physician could injure himself much by personally prosecut

ing them. I do not myself ask the public prose-titioner whose practice is firmly established, but for cutor to look after them, but I do ask, and believe young men to act as he advises, would be a sure I have a right to ask him, to come down to this means of dispensing with what little practice they section occasionally. "There are larger fish to have. Now I think we have as much need of a catch here than midwives." I have waited patiently visit from detective Smith as any section in to see if the appeal of "Justice" would be re- Ontario; for I venture to assert that there are no sponded to, but I must say I have been dis- two other counties whose unlicensed practitioners appointed.

In two adjacent counties only, (in one of which I have the misfortune to have settled) there are no less than twelve unlicensed medical men, and but six that are licensed, and in almost every case do these unlicensed men hold the best fields, shielded by professional etiquette and the carelessness, or, I believe more truthfully, the laziness of him who is appointed to look after our interests. I believe it is quite useless to write to the present worthy prosecutor, as I have been informed by surrounding medical men that they have done so more than once, but their requests have all passed unheeded. These men who are thus "sponging" upon the courtesy of their qualified brothers, are, with few exceptions the meanest of practitioners, using underhand means to injure those they ought to respect. What would some of your western medical men think of practitioners who would treat an ordinary case of diarrhoea as typhoid fever, colic as peritonitis, follicular tonsillitis as diphtheria, &c., and by the rapid cures that must follow such trifling disorders, to build up their reputation and secure lucrative practices? Some of them systematically make it appear that their patients are much worse than they really are, even when their diagnosis is correct, in order to worm themselves as far as possible into the gratitude of the public. Every physician is aware how much such doings affect an ignorant public. Yet such are the means taken by the unlicensed (and even some of the licensed) men in this section. Not content with usurping the rights of others they stoop to such low, mean practices as the above, to further injure their legally qualified neighbors. I am not writing what others have told me, but what I have observed myself. It has been said and will be again I suppose, that we should prosecute personally, but these men so work upon the sympathy of the public, that it is worse than useless to attempt such a procedure. It is all very well for Dr. Harris of Brantford, in his answer to "Justice" to advocate prosecution of these men personally; he may be an old prac

are as two to one.

Trusting that this may lead to some good, and thanking you for inserting it in your valuable journal. I am yours truly,

Dec. 15th, '79.

FAIR PLAY.

To the Editor of the CANADA LANCET.

SIR, The LANCET for November, 1879, contains an original communication on "Antiseptic Surgery," by Dr. Canniff of Toronto, which I hope will not pass unnoticed. Dr. Canniff refers to Mr. Savory's address. I would refer him to the columns of the Lancet, (London), and British Medical Journal, for various articles, editorial and in correspondence, dealing with Mr. Savory's address, and dealing with it in a very satisfactory manner. Particularly he might read the articles by J. Greig Smith of the Bristol School, and Thompson of Richmond Hospital, Dublin. Dr. Canniff had no necessity to trouble himself, or fill the columns of your paper with cases treated without Lister's method, and doing well, as the majority of cases treated surgically before Lister was known, as well as those now treated by other methods than his, do well. The experience of every surgeon must be sufficient on this point. These cases prove nothing against Lister, but if good, may be better, and if Lister's method insures this, why not follow it? Then Dr. Canniff gives a case from Charing Cross Hospital. He selects one of those cases in which no certainty can be had, that septic matter had not got into the wound, and remained there in spite of treatment. Besides, considering the novelty of Listerism at Charing Cross, is it not fair to ask if the treatment was really Listerian? Three or four days should have decided as to the asepticity of the wound. It were folly to keep on the dressings longer if not aseptic. He refers to Hutchinson's method; it is no doubt excellent, so was that of Callender, but that does not prove Lister's is not "a more excellent way." I think Dr. Canniff shows something like spleen when he speaks