ly aided me in the operation which it was evident could no longer be deferred. The insertion of the canula gave immediate and complete relief. The following day, on closing the tube with my finger, I found that there was absolutely no passage for air through the larynx. Forty-eight hours after the operation there was rather sudden and very copious expectoration of muco-purulent matter from the mouth, followed at once by partial relief of the laryngeal obstruction. This relief became every day more decided, until on the eighth day the tube was removed. As the wound closed it was observed that the voice had undergone a singular and yet welcome modification. Before the operation it had always been peculiarly shrill and harsh; it was now soft and pleasant, without having lost any of its distinctness or flexibility.

Soon after her recovery it was noticed that the patient manifested a slight difficulty of respiration after severe exertion. About six weeks after the operation this developed, in the space of a few days, into a marked stridor whenever the breathing was a little hurried, and during sleep. At one time it seemed that the necessity for a second operation might occur at any moment.

The patient now submitted very readily to a laryngoscopic examination, and, after repeated and patient trials, a view below the cords was at last obtained. This revealed a growth, having the appearance and dimensions of a currant of medium. size, attached apparently to the left side of the cicatrix, resulting from the operation. The growth which I saw was not large enough to occasion the degree of dyspnoea present, and probably it concealed another growth lower down.

The aspect of the case was now not of the most pleasant. The difficulty of breathing had been steadily increasing for two or three days, and it seemed probable that the growth or growths would become still larger as time went on. Tracheotomy, if called for suddenly and performed hastily, might present very awkward complications, inasmuch as any disturbance of these vascular growths would lead to abundant hæmorrhage directly into the air-passages. I therefore determined to keep the patient under close observation, and, in case there should be any considerable increase of dyspnoea, to

operate without waiting for an emergency to arise, opening the windpipe with the thermo-cautery and exposing and removing the growths. Meantime I ordered an inhalation. three times a day of an atomized solution of perchloride of iron, as strong as it could be borne. This was with the hope that enough of the astringent might be absorbed through the delicate investing membrane of the growths to at least impose some check upon the rapidity of development.

The next day the mother reported that there were streaks of blood in the expectorated mucus. The following morning, on waking, the patient coughed up a clot of dark blood of considerable size, and it was noticed that the breathing was easier. Three or four hours afterward I made an examination with the mirror, and found that the growth which I had seen forty-eight hours before was entirely gone. From this time. the improvement in the breathing was very rapid, and in a day or two more every trace of obstruction had disappeared. A subsequent examination showed only a slight general thickening of the mucous membrane on the anterior wall of the trachea, concealing the tracheal rings, and in which the cicatrix could not be distinguished.

Whether the detachment of the growth or growths was wholly spontaneous, or whether it was influenced in some degree by the astringent inhalations, I am unable to decide. The spray provoked coughing, and the mechanical effect of this may have been favorable.

III.—Multiple Fracture of both Thighs with Compound Fracture of Leg; Amputation; Gypsum Bandage; Recovery. BY LEROY J. BROOKS, M. D., Norwich, New York.

JOHN ALLEN, aged eight years, a healthy boy of Irish parentage, was seen October 3, 1878. He climbed into a wagon in motion, and in his efforts to get into the box threw his limbs across the back axle. While in this position his feet became entangled between the spokes of the wheel. The springs holding the body from being thrown forward, the legs were carried around the axle, producing the following inju

ries: 1. A compound comminuted fracture of the left tibia and fibula, a little below the middle of the leg; 2. A simple fracture of the corresponding thigh, just above and extending into the knee-joint; 3. A simple fracture two and one half inches above, and (4) a compound fracture at the extreme upper third of the shaft of the same thigh. The fracture at this point was oblique and the opening small; 5. The right thigh received a fracture (simple) at the upper third, and one at (6) the lower third of the shaft. Both limbs were apparently greatly shortened and were considerably deformed, but measurements, of course, were of no value. The patient was suffering from shock, and he was placed upon a pillow and stimulants were administered with opiates. Two hours after, the patient having sufficiently rallied, with the assistance of Dr. Bellows I amputated the left leg a little above the middle, making lateral skin-flaps. Wishing to save all that was possible, I risked cutting through a considerable amount of contused muscle and cellular tissue. Not wishing to continue the anesthesia longer, the fractures were supported with thin board splints; he was bound upon a large pillow as before and one eighth grain of morphia administered. Two hours after the operation he was sleeping quietly, and had thoroughly rallied from shock.

October 4th.-A. M., pulse 140; temperature 101°. P. M., pulse 140; temperature 103°. We have kept him pretty well under the influence of morphia, but he complains bitterly when moved at all, and has frequent spasms of the muscles of both thighs.

5th.-A. M., pulse 136; temperature 102°. P. M., pulse 140; temperature 1034°.

6th.A. A. M., pulse 120; temperature 102°. Suffered greatly last night from the muscular spasms and from frequent startings," which produced great pain at the seat of the fractures. At 10 A. M. (again with the assistance of Dr. Bellows), I etherized our patient, extended the right thigh as strongly as possible, the left also being kept in position by an assistant, removed the board splints, and applied a gypsum splint in the usual way, extending from right ankle to pelvis on the right side, and from knee to pelvis on the left, thus

making one solid splint. The drawing shows the splint, and I have indicated the points of fracture. We dressed the stump at the same time. There was no union, and the skin and cellular tissue had sloughed for a distance of a quarter of an inch. The stump was dressed with oakum and carbolic acid.

7th.-A. M., pulse 100; temperature 99°. A small fenestra made over opening in thigh. This opening was sealed with collodion on day of accident, and seems now to be nearly closed. Had no muscular spasms since the application of the splint, and slept quietly last night without morphia.

20th. Since the last note, patient has progressed finely. The pulse has at no time been higher than 100, and his temperature has averaged 99°. To-day the last ligature

was removed from the stump, which is entirely healed, except where the ligatures made their exit. The splint has not been disturbed, and the patient has not suffered any particular pain or discomfort from it.

November 2d.-The splint becoming a little loosened on the left side, I cut it up on the anterior surface and applied a bandage on the outside.

9th.-Removed the splint entirely to-day, and applied an ordinary bandage. There is considerable thickening of the bone at the region of the compound fracture in the left thigh, and slight curving outward. In the right thighwith the exception of some thickening of the bone at the seat of fractures-there is no apparent deformity. The stump is entirely healed. There is some motion in the right knee-joint. Passive motion has been made in the left knee-joint since the first week, and we have succeeded in preventing anchylosis.

December 1st.-No stiffness of either knee-joint. Patient about on crutches.

Notes of Hospital Practice.

CHARITY HOSPITAL.

Transfusion. Dr. Joseph W. Howe has recently performed in this hospital nine cases of transfusion, on patients suffering from phthisis and syphilis.

CASE I.-A woman, aged twenty-four, was admitted, suffering from syphilis, and phthisis in the stage of excavation. On November 9th three and a half ounces of milk were transfused. During the operation alarming symptoms developed, but rapidly passed away. Following the operation there was marked improvement in the general symptoms, but at the end of a month she was in much the same condition as before.

CASE II.-A man, aged twenty-six, entered hospital suffering from syphilis and phthisis. He had ulcerations of the