rather more than can be said of any operation upon the small intestine in which the suture is employed. The obstacles to success are evident; but we should not hesitate, in wounds involving the continuity of the small intestine, to enlarge the wound in the abdominal wall and close the one in the bowel, upon the principle that a mortal peril demands an extreme remedy. (XXVI.] LARYNGOLOGY. BY PROF. MILTON JAY, OF CHICAGO. No part of the human system is more complex in its anatomical structure than the regions of the throat, embracing the larynx, trachea, pharynx and oesophagus. To become thoroughly and practically acquainted with the minute anatomical structure of these parts, demands the most careful and diligent microscopical dissections, with comparisons made of inferior animals as well as man. It is in this region that some of the organic structures are not only complicated, but their physiological functions are not thoroughly and satisfactorily understood. There undoubtedly is a duty to be performed and an office to be filled by each and every organic structure in the body, yet what that office is, and what that duty may be, is not always so easy of interpretation. Although we may not understand the physiological office of the tonsils (if they have any), or the use of the uvula, yet there are so many important functions to be performed in this region that it is very essential to have a thorough and practical knowledge of the workings of this complex machine. We have to live and breathe on what travels this road, as well as to enjoy the harmonious sounds that emanate from this region. Though delicate in structure, and extremely liable to get out of repair, yet how very essential to life and happiness. Occupying and guarding the front door to the citadel, to be faithful sentinel, no disease should abide here. Physicians and surgeons generally understand that these parts are subject to the same irritations, inflammations and ulcerations as other passages of the body lined by similar structures or mucous membranes. It is more difficult to treat these affections of the throat than similar affections in most other parts, because complete rest cannot be had; we must breathe. As a general rule, physicians do not treat irritation or inflammation of the throat with the same tenderness and care as like structures in other parts. Delicate and gentle handling, mild treatment and rest, should never be overlooked in treating these parts when already inflamed and delicately sensitive. It is not my intention to discuss the pathology or treatment of chronic inflammation and ulceration of the air passages, or, as it is generally termed, catarrh. I will only pause to say, that, like all other chronic blood affections, they need and must have constitutional treatment in order to be permanently benefited. But I will only mention, briefly, some of the many affections of the throat that demand surgical interference or aid. One very frequent affection is chronic tonsillitis, where the tonsils have become permanently enlarged, producing great obstruction and difficulty of breathing, as well as of swallowing. In these cases, I believe excision (which is not a difficult operation) to be the best and only certain course to be adopted. No harm or bad results need be feared from this procedure, but permanent relief is generally the result. I have excised one or both of the tonsils in scores of cases, without one single unfavorable result. Abscesses of the pharynx or larynx, when they can be seen by the aid of the laryngoscope, or diagnosed in the œsophagus or trachea, should be punctured and their contents allowed to escape. Nothing can be gained, but much may be lost, by delay. This procedure is often attended with both difficulty and danger, and the utmost care should always be taken; and here a knowledge of the minute anatomy of the parts is very essential to safety. Again, in cases of aphonia, where the vocal chords are thickened, and cannot vibrate with "musical harmony," and loss of voice or speech is the result, how often do we hear physicians talk about using the probang to swab the larynx and make heir applications direct to the vocal chords. Every intelligent surgeon knows how very difficult this would be, if even possible. This may do to blind the ignorant. By inhalation the remedy may be brought in direct contact with the larynx and vocal chords, but not certainly in any other way. But in most cases, loss of voice depends upon or arises from some constitutional disease, and not until that has been eradicated will speech return. Direct surgical interference is, in most cases, of little or no avail. Those cases that demand prompt and energetic action on the part of the surgeon, and in which there is no time for delay, are when it becomes necessary, in order to save life, to open the air passage, or the gullet, in some part of their course, to prevent suffocation from disease or to remove some foreign body. This procedure is always attended with danger, yet the existing conditions that demand the operation are generally fatal without the operation, and may be with it. It is not the operation, generally, that causes death, but the condition existing, for the relief of which the operation is performed. This fact is very plainly demonstrable in the comparison of cases operated upon suffering from disease, as croup or diphtheria on the one hand, and for the removal of foreign substances on the other. The record is, that about 75 per cent of the cases operated upon for croup or diphtheria prove fatal, while of those operated upon for the removal of foreign bodies, only about 25 per cent prove fatal. Most frequently, in cases of croup or diphtheria, the operation is not performed until the patient is in a moribund state. It is not to be supposed that simply cutting into the windpipe or gullet of a person in a state of health would necessarily prove fatal. I am of the opinion that the percentage of deaths from these operations would be much reduced if the operation was not delayed until the last moment of life. When it has been decided that it must be performed as the only hope of saving life, it should be done, if done at all, without delay. There is no doubt but that in croup, lives are often saved by this operation that otherwise must be sacrificed; but in cases of diphtheria, very seldom, if ever. It generally aggravates the trouble, although this is a question about which there are differences of opinion. It is very different in cases of foreign bodies in the gullet. Generally in those cases it is the pharynx or oesophagus that is to be opened. While the operation is more difficult of execution, the results are more satisfactory. Practice in this department of surgery is very ancient, as from time immemorial the human species have been noted for using the mouth as a reservoir for almost all kinds of substances, both fluids and solids. Substances of value, and messages of vital importance to individuals and to nations, have been placed in the mouth for safekeeping, and rather than lose the treasure in the one case, or be detected and treated as a spy in the other, the individual has been instructed to swallow the valuable or important substance. From this early example of securely depositing substances in the mouth for safe keeping, the human family have improved upon the practice of the ancients, until now not only valuables, but many vile, disagreeable and filthy substances are placed in the mouth and "rolled as a sweet morsel under the tongue." But I need not particularize. Suffice it to say, that a very great variety of substances, of various sizes and shapes, have been found lodged in the passage from the mouth to the stomach. It may be simply a pin, or it may be a portion of a set of teeth; it may be a fragment of an oyster-shell or it may be a diamond ear-ring. No matter what the substance, the practical question is, What shall be done to remove it? The size of the substance is not the question so much as the roughness or smoothness of its surfaces and edges. If it is smooth and oblong in shape, it may be forced into the stomach by pressure from above, gently and continuously exerted with the instrument ordinarily used for dilating the oesophagus. When this can be accomplished, it is far better, as a rule, than to open the tube; but when this cannot be done, and the substance is firmly fixed in the tube, there is no alternative; an operation must be made. It is the only chance for the patient's life. It is not often that solid substances produce trouble after they reach the stomach. It has been recommended that the patient eat articles of food of a doughy consistency, expecting to increase the substance and make its passage through the intestinal canal more easy. I do not think there is much dependence to be placed on this procedure. From the frequency with which cases of foreign bodies lodged in the throat occur, it is very essential that every practitioner have at hand the necessary instruments to give relief, as those are generally cases that demand prompt action. Yet it is notably true that, as a rule, physicians are not prepared for such emergencies. He is more likely to be prepared for amputations, resections, disarticulations, and major operations, than to be ready to give immediate relief in those cases where relief must be had. Read the thousands of curious cases published by authors, and you will see how frequently the address and ingenuity necessary to overcome the difficulties presented in such cases have been wanting, and how useful a knowledge of similar cases may be. Some surgeon has written that, “in order to know how to arrest a hemorrhage, it is necessary to have tied the arteries in animal vivisections." A similar precept is equally applicable to foreign bodies. [XXVII.] GANGRENE FROM THE USE OF ERGOT-REPORT OF A CASE. BY J. Z. VAN DE WALKER, M. D., DAVENPORT, THAYER COUNTY, NEB. Armanus Nott, age 20; temperament, nervo-bilious; school teacher. While attending normal school at Winimac, Ind., was taken sick with typho-malarial fever. Was treated five days by Dr. Thompson; was then brought home to his father's, near Medaryville, Ind., when I was called to take charge of the case. Found patient raving with typho-mania ; pulse, 136; temperature, 1011°; tongue covered with brown crust in center and at the base tip, and edges bright red; teeth covered with sordes; petechia and sudamina well developed. I made the usual prescription to meet the indications, with the following to relieve the cerebral excitement: R. Hydrobromic acid................. Syrup Acacia, qs. ad................ 3i. .388. .ii. .ziv. |