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They suggest the question a,s to the origin of the disease. Mr.Pollock inclined to the belief that the stumps of the decayedteeth were the original cause of the mischief, and this seemsquite probable when the somewhat passive nature of the in-flammation is considered, which fortunately was not accom-panied with that destructive influence on the deep areolarstructures as is witnessed in erysipelas.Frank A--, aged forty-three. a butcher, was admitted on

June 18t.h, 1863. There was very considerable swelling on theright side of the neck, from the jaw to the clavicle, extendingbackwards to near the spines of the cervical vertebrae, and infront two or three inches to the left of the median line. Theswelling passed over the lower jaw, and implicated the rightside of the face. The integument over the whole swelling wasof a dark-red colour, very brawny in consistence, and unyield-ing when pressed upon. There was no great pain on pressure,and. no evidence of fluid locked up under the deep cervicalfascia. All the tissues appeared thickened and hardened byfibrinous exudation, with a tendency towards suppuration.The patient stated that he had suffered from a swollen face andneck. for the last three weeks, and that the swelling came onfrom no apparent cause.

Soon afr.er admission there was great distress experiencedfrom a feeling of suffocation. The house surgeon, withoutsending for Mr. Pollock, ordered twelve leeches to be applied,which bled freely; but the relief was only temporary, and hepassed a night of much discomfort, not being able to lie down.The following day he was seen by Mr. Pollock. The tongue

was then moist, but furred ; pulse quick, countenance dis-tressed, and breathing rather quick. There was difficulty in

opening the mouth ; no great pain. The parts were brawnyand hard. No sense of fluctuation; but the neck was threetimes its natural size, the greater portion of the swelling beingconfined to the right side. The movements of the larynx couldnot be observed in consequence of the amount of effusion be-neath the deep fascia. A free incision was at once made in themedian line from the symphysis of the jaw to the sternum.The parts cut through were infiltrated with lymph, but no pusescaped ; the wound gaped considerably from the retraction ofits edges. A second free- and deep incision was made on theright side midway between the symphysis and angle, and fromthis a small quantity of pus escaped.There were found on the right side in the lower jaw several

stumps of decayed teeth. The patient had not experiencedany inconvenience from them that he was aware of, but itappeared to Mr. Pollock that they were the exciting cause ofthe mischief. The mouth could not be opened yet sufficientlyto have them removed. The relief from the incisions was im-mediate and very great; he at once felt that he could breathemore comfortably, and was better able to move the lower jaw.The following day he appeared better, but perspired very

profusely ; he sat up in bed, and breathed without difficulty.The swelling of the neck was somewhat diminished, and thewounds discharging; but the swelling itself continued amaz-ingly hard and brawny. He was ordered twelve ounces ofbrandy, with beef-tea, &c.On the 2lst he appeared better, but the pulse was weak and

120, and he had no appetite; the swelling had not much sub-sided. He was ordered half a drachm of the tincture of ses-quichloride of iron every four hours.On the 23rd he was found by Mr. Pollock sitting up in bed,

with great distress of countenance; only able to speak in awhisper ; bathed in perspiration ; and complaining of a greatsense of suffocation. He was not able to swallow fluids, andurged that something should be done, or he should die of suffo-cation. It was at once decided to perform laryngotomy. Theoperation occupied nearly an hour. The difficulties attendingits performance in this case were numerous. The wound pre-viously made in the median line had almost exposed the surfaceof the larynx and trachea, but those parts were now coveredwith spongy granulations, and the cellular tissue and muscleswere matted together with lymph. The larynx and tracheawere pushed considerably to the left side, and so fixedand implicated, by the mass of effused fibrin, with the super-jacent soft parts, that it was impossible to distinguish whatwas the situation of the crico-thyroid membrane, until theright ala of the thyroid cartilage was ultimately exposed,and found lying immediately in the median line. The greatestinconvenience was experienced from the condition of thewound in: this operation. With the slightest touch of theknife the granulations bled freely, and it was necessary to waitpatiently till this tendency had entirely subsided, before themembrane could be safely opened. As soon as this was done,the double silver tube was introduced, and the patient expressed

himself greatly relieved. The operation was borne with extreme.fortitude, though it lasted nearly an hour; but the man subse-quently stated that, feeling be should die unless the operationsucceeded, he had made up his mind to submit to any amountof pain it was requisite for him to endure.On the following day the breathing was rather laborious, but

more comfortable. He was able to swallow fluids soon afterthe operation, and has been constantly supplied with nourish-ment and wine and brandy. He perspires freely, and is muchreduced. There is no irritation from the presence of the tube;his countenance is much improved.

Subsequent to this he continued to improve, though he was:attacked with erysipelas a few days after the operation, theredness and swelling running up and involving the face andscalp ; and during this attack he was taking twelve ounces ofbrandy, the same quantity of wine, two pints of porter,! andthree pints of beef-tea.On the 27th he was breathing so comfortably, and evidently

through the glottis without any difficulty, that the tube wasremoved from the opening in the throat-now four days sinceits introduction. The wound of the larynx was left uncovered,and was merely to be kept clean without any dressing or appli-cation to touch it. He breathed quite comfortably on its with.drawal, and could articulate clearly when the point of a fingerwas applied over the wound. He continued to improve steadilyfrom this time, and left the hospital shortly afterwards. The.wound in the larynx was not quite closed, nor the hardness ofthe side of the neck much reduced. He called at the hospitalon the 2 st of August. The wound of the larynx has closed,but a superficial narrow ulcer still discharges ; the superficial.and deeper tissues in the neck on the right side are almost car-.tilaginous in hardness, but much less swollen. The stumps inthe lower jaw (which possibly were the original cause of themischief) were removed a few days after the operation, andevidently added to the patient’s comfort.

ST. BARTHOLOMEW’S HOSPITAL.ERYSIPELATOUS LARYNGITIS THROUGH THE EXTENSION

OF ERYSIPELAS FROM THE HEAD AND NECK, TRACHEO-TOMY AFFORDING BUT TEMPORARY RELIEF.

(Under the care of Mr. WORMALD.)ERYSIPELAS of the windpipe is an affection of the gravest

character ; for it is almost invariably fatal, from the intensity ofthe inflammation, and the rapidity with which it runs its course,on to the diffuse suppurative stage. It is not uncommon to see-

some amount of sore-throat associated with erysipelas of the face.and head, and it is generally coincident when erysipelas attacksor originates in the neck. Now and then, but more rarely, tha:disease arises in the fauces and larynx, without any externalappearance of the disease. In this form either relief is obtained

by the extension of the disease externally, and so relieving thethroat, or death ensues from exhaustion, in which case the

symptoms are essentially typhoid.In the case which we now record the laryngitis occurred by

the extension of the erysipelas from the head and face. The-

intensity of the inflammation was such that the trachea and-neighbouring structures were soon infiltrated with pus. Erysi-pelatous laryngitis is an affection always to be feared andguarded against in the presence of the disease in the vicinity,and recourse should be had to tracheotomy on the first occur-rence of decided dyspnœa.For the following notes we are- indebted to Mr. W. Vernon,

house-surgeon.F. F-, a stout large-built man, aged thirty-one, applied-

at the hospital on the 17th of March, on account of’ erysipelasof the face and scalp, resulting from a contused wound of aweek’s date. After his admission the erysipelas involved thewhole head and face so as to render his features undistinguish.able, and spread to some distance down the neck. Under the-liberal use of stimuli and nourishment the swelling began- to:diminish, and he appeared to be progressing well. Suddenlyon the evening of March 21st the mischief spread to the nos-.trils, and thence to the fauces and larynx. He could notswallow ; and when Mr. Vernon, the house-surgeon, came to-him, he found the dyspnoea so extreme that.he decided at onceto open the trachea. The trachea was situated at an unusualdepth, and could only be reached through much infiltrated

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tissue. Free bleeding occurred, so that, owing to this circum-- ..’stance and to the extreme depth of the trachea, the knife was’ Very sparingly used in the latter part of the operation. ’When’the windpipe was reached and opened, a long bivalve tube wasintroduced; the relief to his distress was very manifest, and

’the bleeding was speedily controlled without the use of liga-tures. Considerable emphysema occurred in the surroundingtissues, and it became evident that a longer tube would be re--quired. The longest that could be procured was then insertedwithout much difficulty; but it still became necessary to fit a- second tube into the upper aperture of the inner tube, so as’to increase its length and permit it to be secured in the wound.

Wrapped in blankets, and breathing steam, the patient hada comfortable night, and in the morning could swallow without:much trouble beyond occasional cough. His progress for sometime was satisfactory, the erysipelas’steadily subsiding. Forthe next forty-eight hours he was sensible, could take’abun-dance of fluid nourishment, and slept-fairly with the assistance

- of morphia injected beneath the skin.On the morning of the 24th, a densely foggy one, he flagged;

had much cough, with a considerable increase of thick mucusdischarged’ through the tube. During a fit of coughing, somebleeding.occurred from the wound ; its source was not evident,and, as he was breathing to some extent -through the larynx,the tubes were removed. For a time he rallied and improved,but again failed, and in spite of nourishment; which he tookseagerly and without difficulty, he slowly sank, dying appa-rently from mere exhaustion, just one hundred hours-after theoperation.

Having lost his left arm five years’since by a machineryaccident, throughout his illness he invariably lay on his rightside; but up to the last, as far as could be ascertained, hislungs remained sound.Autopsy twenty six hours after death.-The wound looked

sloughy and discoloured. The surrounding parts were infil-trated with a dirty, puriform fluid, which had completelyencircled the trachea, separating it from the eesophagus, andhad then made its way down .into the posterior mediastinum,almost to the roots of the lnngs. The upper lobe of the rightlung was tightly bound down by old adhesions; the posteriorportion of this lobe was congested, but, with this exception,the lungs were throughout sound. There was no distinct evi-dence of the recent congestion about the fauces or larynx. Theknife had divided the fourth; fifth, and sixth tracheal cartilages.The edges of the aperture were irregular and ulcerated. Theentire length of the trachea was of a vivid red colour, from in-tense inflammation. Immediately below the incision were somesmall patches of inflammation, clearly due to the pressure of.the end of the tube.

GUY’S HOSPITAL.

ABSCESS OF THYROID GLAND, WITH ŒDEMA OF ONE SIDEOF THE GLOTTIS, IN A CASE OF BRIGHT’S DISEASE OFTHE KIDNEYS; TRACHEOTOMY; FATAL RESULT.

(Under the care of Dr. REES.)

JOHN B-, aged twenty-one, was admitted into Job wardon the 30th May, 1862, for albuminuria &c. On the morningof the 15th June he was taken with difficulty of breathing,accompanied by a stridulous noise. This increased until the

evening, when the noise made on inspiration was much greater,and the voice nearly gone. At the same time he was some-what drowsy, as if under the influence of uraemia. Althoughthe breathing was quick, the air appeared to enter the lungsfreely. It might thus have been a question as to the proprietyof tracheotomy; but as the man was sinking fast, and it ap-peared to hold out a faint chance, it was performed about teno’clock P.M. It was thought that he rallied somewhat, but heafterwards sank into a lethargic condition, and died at half-past three r.M. on the 16th.

A utopsy, twenty -four hours after deat7t.-The body wasslightly œdematous at the lower part. On examining the

larynx, the first thing noticeable was suppuration of the thy-roid body and neighbouring glands. The left lobe was full ofsmall abscesses, so that, when cut through, fluid purulentmatter flowed out. In the right lobe there were scatteredyellow deposits of lymph, in the midst of which was purulentmatter. These deposit? appeared somewhat like tubercle, buton close examination showed merely lymph and pus. Some

lymphatic glands near also contained lymph, and in one or twothis was softening. The pharynx was healthy, also the tonsilsand epiglottis. The glottis on the left side was cedematous,but not sufficiently so, as then seen, to cause much impedimentto respiration. The opening made at the operation was in theusual position. Both above and below it the membrane wasacutely inflamed, the surface having mucus upon it and alsoflakes of lymph. (It was a question whether or not all thishad arisen since and in consequence of the operation.) Theinflammation extended down the bronchial tubes; these.beingfull of dirty purulent mucus. The lungs were full of air, andin parts highly congested ; the blood having burst through thetissue, producing an apoplectic condition. The kidneys wereof usual size, quite white, and full of deposit of advanceddisease.

WESTMINSTER HOSPITAL.

CASE OF SUCCESSFUL REMOVAL OF A LARGE STONE FROM

THE TRACHEA, WITHOUT ANY OPERATION.

(Under the care of Mr. HENRY POWER.)THE details of the following most interesting case tell-their

own story; but we may remark, that it is rare indeed thatsuch a large foreign body is removed,or ejected’spontaneouslyfrom the trachea without the usual operation :-Henry.N-, aged forty-five, a robust Irish labourer, was

in the habit of sucking a small stone whilst he was at work tokeep his mouth moist. On Thursday, the 23rd of July, atfive P.M., whilst stooping,.he made a sudden inspiration, andimmediately felt that the stone had passed into his windpipe.It gave him little or no uneasiness; but he was sufficientlyalarmed to apply to several medical practitioners at Dartford.’By one of these gentlemen he was inverted, and an- emetic-wasordered for him. On inversion, which he also several timestried, by himself, violent coughing came-on, and he felt thestone rise up to a certain point, and then fall back. Fearingsuffocation, he came to town, and applied at Guy’s Hospital.He was here again inverted, though with an unsuccessful result.An operation was suggested, and he was told to return. Heapplied amongst the out-patients of the Westminster Hospitalon the 25th of July, when he was breathing quite naturally,and-at once said he wished the windpipe to be opened.On auscultation, the respiratory sounds were natural, except

that on coughing, which was of a spasmodic character, thesharp blow of a hard body was distinctly perceived by thestethoscope pressed on the trachea in the interclavicular depres-sion. This sound was clearly heard both by Mr. Power andDr. Wallis. There were no bronchitic symptoms. Mr. Powerlaid him on his belly on a couch, with his head and chest de-pendent, directed him to take a full breath, and then to cough.At the moment of coughing, a sharp blow was struck on theback, when, to the infinite joy of the patient, who expressedhis gratitude with truly national fervour, the large stone, ofwhich the annexed woodcut is an exact copy, was projected

with considerable force upon the floor, after having been lodgedfor forty-five hours in his trachea. Its dimensions are-length,nineteen-twentieths of an inch; breadth, fifteen-twentieths ofan inch; thicknecs, five-twentieths of an inch : thus almostexactly equalling a shilling in circumference, but with aboutone-fifth chipped off, which was probably the circumstance thatprevented suffocation ; whilst its thickness is rather greaterthan five shillings placed one upon the other. It is a perfectlysmooth water-worn pebble. It is somewhat surprising that astone whose diameter cannot have been far short of that of theman’s trachea should have produced so little embarrassment ofthe breathing. It probably rested, during the greater part ofthe time, on the bifurcation of the trachea, and only partiallyoccluded each of the bronchi.

In conclusion, it may be observed, that in similar cases whereinversion is tried, it is wise to have the insfruments for tracheo-tomy at hand in case of the impaction of the foreign body in

! the-rima glottidis.