ment, or from a large ascending pharyngeal artery. Never, I believe, does the blood spring from the internal carotid if the incision be prudently devised. Before making an incision I have been in the habit of placing the index finger of the disengaged hand in the throat and endeavoring to introduce the tip between the tonsil and the posterior wall of the pharynx. The knife should be thrust toward the finger-tip. This manipulation protects the ascending pharyngeal artery and gives freedom to the operator, who, in any event, may dread wounding the pharyngeal wall. That this is no timid precaution is evident. I have notes of peculiarities in three persons, and have knowledge of a fourth, in whom a vessel as large as the radial artery is seen pulsating on the posterior wall of the pharynx. I have advised these persons that in the event of tonsillar incision being proposed that they should inform the physician in attendance that an abnormally large artery lies just beneath the surface of the throat-passage directly back of the tonsil. CHRONIC ABSCESS.-Retention of pus for an indefinite period is unusual, and I invite attention to a few remarks on the subject. A gentleman, aged fifty-six years, had had for ten years an excessively irritable pharynx. In this period, two acute attacks of inflammation were reported, the first of which was severe. The patient was rheumatic, although there was no history of acute rheumatic fever. Distress was referred to the left side of the throat; the membranes here were more injected than on the right side. A mild form of pharyngeal catarrh was present with laryngitis. The tonsils were small. After the patient had been under treatment for a month without relief, I determined to remove a portion of the left upper tonsil; with this object in view, I cut away a portion about the size of a split pea. Pus to the amount of four or five drops escaped; at the next visit, two or three days after, the parts were greatly improved, and in a short time all signs of the trouble ceased. A second case illustrating chronic pus-retention was that of a medical student, nineteen years of age. He was suffering from laryngitis, and had always had irritable tonsils. He had suffered from repeated attacks of diphtheria when a child. The present distress ensued upon a rather severe form of tonsillitis. Believing that much of the condition of the larynx was due to irritation excited by the tonsils, I removed a portion of the main mass on the right side with the knife, when there escaped fully a half-drachm of pus. The tonsils were of great thickness, and the pus lay fully three lines from the surface. The patient made a satisfactory recovery. The laryngitis spontaneously disappeared, showing that it had been caused by the irritative effects of pus in the tonsil. J. Garel (Annales des Maladies de l'Oreille et du Larynx, 1889, p. 1) narrates three cases of chronic abscess of the tonsils. The first of these was a man forty-six years of age, who reported January, 1885; he developed an acute tonsillitis on December 7, 1884, which was opened on the 10th, and again on January 31st, so it will be observed that the duration of the case, including the date at which pus was supposed to have formed, was but seven weeks. The second case was that of a woman, aged twenty-eight years, who had had her tonsils removed by tonsillotomy in infancy; she had subsequently repeated attacks of quinsy with attendant suppuration on the left side. In January, 1885, quinsy, resulting in suppuration on the right side; after the escape of pus, however, the pain did not subside, and the patient could not report. The neck was found to be tumefied; dysphagia intense. The case passed from observation, but it was ascertained that a month afterward, namely, at the end of February, an abscess opened spontaneously, and the inflammatory condition rapidly subsided. The entire duration of this case appears to have been about one month. In the third observation, that of the young man, aged thirty-six years, who reported September 21, 1888, the patient was subject to repeated attacks of tonsillitis, and at the twelfth year had an attack in which both tonsils suppurated. In 1883 acute abscess developed in the right tonsil, which demanded surgical interference. In August, 1888, tonsillitis developed on the left side; the physician opened the collection of pus on the seventh day, but the cure was not completed; three weeks afterward pus could be still detected oozing from the tonsil. The opening in it was enlarged by Dr. Garel by the galvano-cautery, As a result of treatment by this agent, the case was cured by the 20th of October; this case, therefore, had a duration of two months. M. Noquet (Revue de Laryngologie, d' Otologie, et de Rhinologie, 1888, No. 7, p. 393) reports a case of a person, twenty years old, who suffered for six months with acute pain in swallowing at the level of the left tonsil. Many times a day the patient would raise pus which could be traced to the tonsil. This patient had had the right tonsil removed at the sixth year, and the left six months subsequently to the time at which the case came under notice. Dr. Noquet detected in the left tonsil a fistulous track which led to a pocket which contained pus, which, being opened, led to complete recovery. In the discussion which followed, M. Moure cited an analogous case, namely, one with abscess of the tonsil, lasting several years, finally cured with the galvano-cautery. Heryng names two cases in which abscess was detected during operation by tonsillotomy. Grynfellt (Gaz. hebd. des. Sci. Méd. de Montpellier, No. 34, 23 Aôut, 1884) reports a case of chronic abscess of the tonsil which occurred in a man seventeen years of age, the result of acute tonsillitis. FOREIGN BODIES.-The practitioner is frequently called upon to remove foreign bodies from the pharynx. When these are large the most casual inspection reveals their presence. Frequently, however, examinations carefully conducted fail to detect them. The conclusion is arrived at that the objects have been either swallowed or ejected, and the symptoms complained of are referred to the effects of congestion or to the anxiety of the patient. It must not be forgotten that small fish-bones may be lodged within the tonsil and be out of sight when the throat is inspected, but may protrude during the acts of swallowing and speech. A gentleman once reported to me with the complaint that a fish-bone was fixed in his throat. The history was consistent, and a careful but futile examination had been made by the family physician. I was equally unfortunate in not finding the offending bone. I ventured to say that it had disappeared, and that the distress could be controlled by the use of a soothing gargle. But in this I was mistaken. The patient reported after an absence of several hours and persisted in his belief that the bone remained in the throat. Finding the right tonsil rather large, I grasped it with a pair of forceps and drew it forward, thinking that the bone might be found between the gland and the palato-pharyngeal fold. Directly, I saw (as a result of compression) projecting from the gland the end of an exceedingly slender needle-like fish-bone, which was readily lifted from its bed by a pair of forceps held in the disengaged hand. The bone was fully an inch in length, and would have remained undiscovered had I not fortunately by the seizure of the gland forced it slightly out of its bed. On another occasion I removed a thin scale of an oyster-shell, which had been in the throat forty-eight hours, from the interval between the upper and the main tonsil. The object was readily seen by drawing the palato-glossal fold forward. REMARKS.-In conclusion it may be said: That the existence of a large pocket or crypt at the lower part of the tonsil is common; that a mass lies above the thickened cryptose tissue above the opening of the main pocket, and forms the velar tonsil; that the varieties of tonsil-form, as above expressed, constitute the best guide to clinical study of the region; that the treatment of the affections of the tonsil should be based upon structure; that, this structure being of the character of recessions of mucous membrane from the general pharyngeal surface, attempts to restore such parts to their normal condition should be always borne in mind, and all canals or fistulous passages in the tonsil that are abnormal should be slit up; that closed tonsils should be opened; that incisions for the reduction of enlarged tonsils should be in directions which harmonize with the plan of the region; and that, when such hints for the treatment of the tonsil are acted upon, the majority of the diseases of these glands are remediable. RETRO-PERITONEAL TUMORS: THEIR ANATOMICAL RELA- BY ALBERT VANDER VEER, M.D., CONSULTING SURGEON TO ST. PETER'S HOSPITAL; ATTENDING SURGEON, ALBANY HOSPITAL, ALBANY, N. Y.; As our experience in abdominal surgery increases, we find there are yet many problems that confront us, and of these problems there is 1 Read before the American Surgical Association, at the Washington Congress, September 22-25, 1891. none which, to my mind, requires at our hands more careful research and is capable of greater improvement, both in operative management and prognosis, than new-growths arising from the retro-peritoneal space. The exact diagnosis as to the true nature of these growths may not be so necessary, but a clearer investigation at the post-mortem table and pathological laboratory to determine anatomical relations and physical changes cannot be denied. In order to bring this subject more fully to your attention, allow me to report to you the histories of a few cases which have come under my observation : CASE I.-Miss S., aged forty-two, consulted me in March, 1882, in relation to a tumor located in the back. She gave a good family history, and, with the exception of this difficulty, had suffered from no important diseases. About fifteen years prior to my first consultation she had noticed a small growth in the back, to the left of the spine, and at the level of the first lumbar vertebra. It grew slowly and gave rise to no particular discomfort until recently, when it caused increased anxiety on account of more rapid growth. Examination revealed a large tumor attached to the left side of the spine and ribs, and extending into the dorsal region as far as the angle of the scapula. It seemed deeply attached to the surrounding tissues, of a smooth contour, and hard to the touch (Case I., Fig. 1). An operation for the removal of the growth was advised, but declined by the patient. I saw her several times in the interval between this time and her death, in November, 1888, and at one visit introduced the fine needle of the aspirator into the tumor, when about two ounces of blood was immediately withdrawn. The tumor continued to increase in size until her death, from other causes. At the autopsy the growth was removed and its origin found in the connective tissue about the left kidney. It was distinctly encapsulated and easily removed; its blood-supply was abundant, chiefly from its lower border. The tumor weighed eight pounds, and upon section showed abundant stroma having the appearance of fibro-myxoma, with here and there an apparent area of lipomatous tissue; there were also cavernous spaces. Undoubtedly the needle of the aspirator had punctured a thrombotic cavity containing an effusion of blood. Microscopical examination revealed the presence of fat and myxomatous tissue, with an abundant small, round-cell infiltration into the stroma of the growth. The growth could have been enucleated by the crucial lumbar incision from the kidney, saving the latter. CASE II-On May 28, 1889, Dr. I. I. Buck bee, of Fonda, N. Y., brought to my office for consultation a patient with the following history: Mr. H. V., aged forty-one, married, a native of United States, and by occupation a farmer. He gave an indifferent family history: grandfather died of dropsy, father of rheumatism, a cousin of phthisis. Until five years ago patient's health had been good. He then injured his back by lifting a hay-press. The pain following this injury had never been relieved, although blisters were applied and medicines were administered for a considerable period. He had also employed many patent nostrums without relief, and two years ago discontinued all treatment. Three months ago he grew worse, the abdomen began to enlarge, the pain was more severe, he lost both appetite and flesh, the ankles became cedematous, and a distressing cough followed. The bowels were constipated, the urine scanty and high-colored, but free from albumin or casts. Physical examination. Abdomen was rather more prominent on right than on left side, and to palpation gave an impression similar to that of a lipomatous tumor. Fluctuation could not be elicited at any point.. Percussion revealed flatness from the right nipple to the crest of the ilium on that side, and extended to the median line, save in a narrow space along the border of the ribs, where there existed a zone of reso nance. Diagnosis. First, the tumor was manifestly not cystic, nor was it connected with the liver, being separable from the liver border by a distinct line of resonance on percussion. Was it a tumor of the abdominal walls, of the omentum, cæcum, the kidney, or of the retro-peritoneal space? Was it a dislocated liver, localized impaction of feces, or hydatids? Hydatids were excluded by the absence of obscure fluctuation, of nodular excrescences, and the hydatid thrill; fecal impaction by the absence of the doughy feeling, and the ability to secure free evacuation of the bowels. The liver could not be dislocated alone, for there was on percussion dulness over its normal area. The tumor was too deeply seated to have its origin in the abdominal walls, did not move with the respiratory act, nor was its mobility affected by the fixation of the abdominal walls. New-growths of the omentum are, unless cystic, usually diffused with nodules and accompanying ascites. Again, the dulness is often relative, rather than absolute. Was it from the kidney? The urine was normal, but scanty, the dulness extending from the kidney, or rather spine, directly around to the median line. The probability of its arising from the kidney was strong. From the conditions present an exploratory abdominal section was clearly demanded, an opinion which was confirmed by Drs. Ward and Townsend in consultation. Operation. An operation was done on June 1, 1889, as follows: An incision five inches long was made over the external border of the right rectus muscle, the centre of the incision being opposite the umbilicus. The dissection was very difficult; the landmarks were hard to determine, and I was not quite sure that I had divided the peritoneum, |