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incise the vein and tie in a Kaliski needle just beforethe tube is ready to be taken from the donor. Onecould then make a metal to metal junction betweenthe full tube of blood and the recipient ; there couldnever be any difficulty about this.

This method of filling a Kimpton tube by means ofa needle is applicable to any case where the donor hasthe veins of the average healthy adult male. As a rulethe tube fills just as quickly as when it is inserteddirectly into the vein. Where the donor’s veins aresmall and indefinite it is advisable to cut down on thevein and fill the tube directly in the ordinary way.

I have used this method of blood transfusion in aconsiderable number of cases in the last 15 months,and can strongly recommend it. I obtained the needleshere illustrated from Messrs. T. G. Hartz, of Toronto,where I was fortunate enough to see the Kaliskineedle employed so skilfully in the syringe method ofblood transfusion by the surgical staffs of the GeneralHospital and the Hospital for Sick Children.

Clinical and Laboratory Notes.AN UNUSUAL CASE OF

ACUTE ABDOMINAL EMERGENCY.

BY O. W. ROBERTS, M.D., B.S. LOND., F.R.C.S. ENG.,ASSISTANT MEDICAL SUPERINTENDENT, ST. GILES’

HOSPITAL, S.E.

THE following case of acute abdominal emergency,which belongs to a class of rare occurrence in thepractice of a London hospital, is of unusual interestfrom a surgical point of view.

L. C. H., a frail boy aged 6 years, was admitted onJan. 16th, 1926, with abdominal pain. The history givenwas that five days previously the boy was playing on a ladderin a garden when he slipped and fell a few feet, injuringthe upper part of the right thigh ; shortly afterwards hevomited and complained of abdominal pain. He was putto bed and three days later had recovered sufficiently to beallowed to get up ; then, however, the abdominal painreturned and two days later his doctor ordered his admissionto hospital. On clinical examination there was a smallabrasion about 2 inches below the inner end of Poupart’sligament on the right side ; the lower half of the abdomenshowed no respiratory movements, and the right side wastender and rigid. Clinically the condition appeared to bedue to an appendix abscess.An anaesthetic was administered and on palpation, prior

to incision, an indefinite lump could be felt nearer themid-line than would be expected from an ordinary appendixabscess. By a right paramedian incision a quantity of freepurulent fluid was found, and the small intestine was seento be distended. On investigation of the cause of thedistension a hard, irregular body was discovered passingacross the right iliac fossa and penetrating the root of themesentery ; when it was manipulated out of the wound itproved to be a twig of a tree, which must have been driveninto the abdominal cavity at the time of the fall. Thistwig had pierced the femoral ring, the parietal peritoneum,and the root of the mesentery, and had come to rest alongsidethe second part of the duodenum. Round the twig therewas an abscess, containing thick, creamy pus and walled bythe tissues of the iliac fossa and by coils of small intestine.About 6 inches of gut near the terminal part of the ileumwas in a condition of doubtful viability, but the patient’sstate did not allow of resection. A large drainage-tube wasinserted into the abscess cavity and the abdomen closed.The track in the thigh was opened up for additional drainage,and as a precaution against possible secondary hemorrhagefrom the femoral vessels a piece of ribbon gauze was passedup the femoral ring.An injection of antitetanus serum was given and the

boy made an uninterrupted recovery.The points of interest in this case are : 1. The

unusual path taken by the foreign body. 2. Theremarkable escape of the femoral and iliac vesselsfrom injury. 3. The healing by first intention of thepath taken by the foreign body. 4. The delayin onset of acute abdominal symptoms. 5. The

uncomp licated recovery.

SERIOUS HÆMORRHAGE FOLLOWINGOPENING OF PERITONSILLAR ABSCESS.

BY NORMAN PATTERSON, M.B., CH.B. EDIN.,F.R.C.S. ENG.,

SURGEON TO THE THROAT, NOSE AND EAR DEPARTMENT,LONDON HOSPITAL, ETC.

THIS complication seems to be sufficientlyuncommon to be worth reporting. Ligature of theexternal carotid appeared to be the only means ofsaving the patient’s life.Woman, aged 31, married. Four years ago attended

Stratford Hospital for menorrhagia ; bleeding continued forthree weeks. History of a sore-throat for ten days accom-panied by swelling on the right side of the neck. Theswelling was diagnosed by her doctor as quinsy and wasincised and pus evacuated. On the following day the quinsywas again incised and the day after the wound wasopened up with forceps. Considerable bleeding followed(six days prior to admission) and it continued until’admission. When seen at 5 A.M. on Jan. 5th, 1926, thepatient was pale, lips colourless, skin cold and clammy,temperature 98° F., pulse 120. Much swelling was present inthe right peritonsillar region. There were two verticalincisions a quarter of an inch long on the anterior surface ofthe swelling ; from the outer one blood was oozing and thepharynx was full of bright blood. The condition improved,but at 11 A.M. the haemorrhage started again. At 12 noonI saw the case and decided to tie the external carotid.The operation was rendered extremely difficult by theglandular enlargement and inflammatory condition of theneck, by the fact that the bifurcation of the common carotidwas situated behind the angle of the jaw about 2 inchesabove the usual site, and by finding a regular plexus of largeveins over the carotid sheath. On account of the friablenature of the tissues some of the ligatures would not holdand the patient was sent back to bed with three pairs ofSpencer Wells forceps controlling the bleeding. These wereremoved on the fifth day. The wound in the neck, whichwas very septic, took a long time to heal.

Eventually the patient made a good recovery.

A CASE OF

GANGRENE OF THE NOSE DUE TODIABETES MELLITUS.

BY K. ARDESHIR, M.R.C.S. ENG.

FROM the inadequate facilities for reference at mydisposal, I am only aware of three cases of gangreneof the nose in diabetic subjects, described by Bowers,and quoted by MacLean in the " Medical Annual

"

for 1925.An Indian female child, aged 8, was brought to me from

a neighbouring village on Jan. 19th, 1926, for a rapidlygrowing boil on the nose. The history given was that itstarted as a small pimple some four days back.On examination I found destruction of the ala nasi on the

right side ; the tissues round about looked definitelygangrenous. A first glance suggested erysipelas, but therose-red rash was conspicuously absent. It was unlikeanything I had seen before. It certainly did not suggestsyphilitic origin. The child was evidently ill and very muchemaciated, temperature 99-5° F., pulse 103, respiration 29.On further examination I noticed dermatitis of both hands,tongue foul, mouth very septic. I could squeeze out pusfrom both tonsils.

Urine examination showed : Reaction acid, sp. gr. 1030.No albumin. No casts. 215 c.cm. of urine was found tocontain 4-2 g. of sugar. Both diacetic acid and acetonewere present.

Local treatment: I removed the slough with a sharpscissors without any anaesthetic. The affected region wascleansed with normal saline, dried, and a dry dressingapplied. The dressing was renewed frequently. The mouthwas kept thoroughly clean and a saline purgative was given.Having no facilities for examining sugar in blood,

I administered 5 units of insulin subcutaneously ; a similardose was given the same evening. Next day 10 units hadto be given. On the third morning the urine was found tobe sugar-free after a total dose of 20 units. On the firstday nothing but coffee and plenty of fluid was given;later on she was put on a restricted diabetic diet, and was