the left side I effected it with much more ease than on the right; but here also, on the division of one of the thyroid veins, I distinctly heard the gurgitation of air. To guard against its repetition during the remainder of the operation, I was careful, whenever I divided any fascicules which might be supposed to contain veins, to grasp it firmly with the finger and thumb below the incision, and if blood flowed from the upper portion, to secure the lower with the ligature. I should have remarked that I found it necessary to divide the tendon of the omo-hyoid muscle on each side. As I progressed with the dissection of the tumour from the deep-seated parts, I found it necessary to proceed with extreme caution. The sheath of the great vessels on each side lay in immediate contact with the tumour, and, indeed was to some extent incorporated with it. I also found that the fascia covering the thyroid and cricoid cartilages was thickened, and adherent to the tumour. Its separation from these connections was the most tedious and difficult part of the operation. The separation of the tumour from the parts immediately above the border of the sternum, where I was prepared to expect great difficulty and danger, was effected with infinitely more ease than I had anticipated. The vessels in this region appeared, by the traction of the tumour, to have been elongated, and to some extent obliterated. The thyroid artery, particularly on the right side, presented the appearance of a long, loose, hard cord, pulsated but feebly, and was secured without any difficulty, being drawn out with the tumour. On the left side I secured nothing but branches. The veins of this region were neither numerous nor large, they having no doubt been diminished by the pressure of the parts upon the sternum. At length I succeeded in effecting the complete removal of the tumour. There was now left a frightful chasm in the throat, the larynx being dissected quite bare, especially on the right side, and the trachea exposed as low as the border of the sternum. The great vessels on each side were also seen throbbing in their sheaths. The recurrent laryngeal nerve was distinctly seen on the right. The last point from which I detached the tumour was a portion of the thickened tissue covering the thyroid cartilage, and its attachment here was very firm. When I had severed it, two or three minute arteries sprung, one of which I immediately secured; but as the hemorrhage then appeared to cease, I did not take up the others. The operation was necessarily painful and protracted, its execution occupying an hour; the patient, however, endured her sufferings with wonderful fortitude, and at no time did there take place any alarming sinking of the powers of life. Twice or thrice, at her desire, I had delayed a few minutes to allow her a moment of comparative repose, but neither then, nor after the operation, did there appear to have been inflicted any serious shock. I now directed the administration of tinct. opii. gtt. L. closed the wound with the interrupted suture and adhesive strips, and placed my patient in bed, leaving her in a more comfortable state than could have been expected. She swallowed liquids without difficulty; her voice was but little altered, and her breathing not difficult. I found her doing equally well in the evening. In the morning, on visiting Mrs. Wells, I was alarmed at finding the dressings bathed in blood which was still flowing from the wound, and evidently of the arterial hue. I immediately cut the stitches, opened the wound, turned out a mass of coagulated blood, and found the bleeding to have occurred from a minute artery seated where the last attachment of the tumour had been cut away. I secured the vessel with the ligature, and as there was a disposition to hemorrhage from minute vessels, I applied to the part a small compress of lint dusted with alum powder. I should here remark, that on opening the wound for the purpose of arresting the hemorrhage, I found it to a considerable extent united by the first intention. By this bleeding, and by the irritation resulting from the coagula and the opening of the wound, my patient was much prostrated. She complained of a sense of extreme faintness, suffered much from urgent thirst, and once or twice vomited. These unpleasant symptoms soon, however, disappeared, and again the case presented a favourable aspect. There remained but little pain in the wound; she swallowed with effort, but yet without great difficulty; there occurred an occasional paroxysm of coughing; but it was not distressing; her stomach received food kindly, and her bowels responded. Indeed, for the four subsequent days, I had every reason to expect a favourable termination of the case. On the fifth day, however, there occurred a severe rigor, followed by fever, sonorous and embarrassed breathing, cough, and irritability of the stomach. It passed off with a sweating stage, precisely as a paroxysm of intermittent fever. The wound, which had suppurated kindly, now began to exhibit a flabby appearance, and to discharge an unhealthy secretion. It is not necessary that I should relate the subsequent progress of the case; suffice it to say, that the rigors recurred every day, notwithstanding our endeavours to parry them, and that the patient expired on the 13th day. The chills were evidently of malarious origin, and my patient undoubtedly came to me predisposed to intermittent fever. To this, in part, I think I may with propriety ascribe the fatal result. From the brief account which I have given of the steps of the operation, it is manifest that the large arteries which are thought to present the most important difficulties in the operation, are by no means so much to be dreaded, as has been believed. It also appears, so far as a single case goes, that the ingress of air into the veins is the source of greatest danger during the operation; as I believe it to be in all operations upon the throat. This, however, is the third instance in which I have witnessed the introduction of a small quantity of air into the veins without an immediately fatal result. I should remark that I now have the tumour preserved, and an examination of it clearly shews that the entire gland was removed. Professor Geddings, on examining it after its removal, pronounced the diseased gland to be entire. It is rare that a case occurs which will justify the attempt to remove the thyroid gland; but the above case appears to me to warrant the belief that it may be undertaken with hope of success. Instances in which the operation has been successfully accomplished are, no doubt, fresh in the mind of the reader. ARTICLE VI. Remarks on Malignant Cholera. By RICHARD SEXTON, M.D. of Baltimore. ALTHOUGH many volumes have been written of late years on the subject of malignant cholera, yet, investigations relative to its nature and treatment are certainly still appropriate. We would, therefore, essay to condense a few practical remarks and inferences, suggested from observation of this epidemic during its existence in the city of Baltimore in the years 1832 and 1834. In the former year, the cholera made its first attacks in North America. Whether or not to the world in general a 'nova pestis,' with the European race on this continent the malady certainly bore that extraordinary character. Its progress, in previous years, westwardly through Europe, had been observed with anxiety by the inhabitants of the United States; but as long as the broad bosom of the Atlantic separated us from the theatre of the pestilence, a hope of immunity was reasonably entertained by those best acquainted with the history of its mysterious movements. However, the irruption of the epidemic at Quebec and Montreal in June, 1832, disclosed the alarming truth, that what had been acted to the terrour of foreign nations was about to be repeated in our own country. Progressing southward and westward, the disease broke forth in Baltimore at the beginning of August, and realized, in some degree, the apprehensions of danger which had been previously conceived. The deaths were not proportionably so numerous as some other American cities were doomed to exhibit, but the destruction of life was sufficiently great to impress on the minds of all the gloomy certainty of imminent individual peril. The disorder existed three months. In the western states it raged a second time, in 1833, proving at certain places excessively malignant; but it did not appear east of the mountains, except sporadically, and in that manner only to a small amount of cases. Here, however, the population, far and wide, breathed an air inquinated with matter, causing irritability of the alimentary canal, as was demonstrated by the frequency of diarrhea and colic, and the increase of sufferers with dyspepsia. In the first part of the summer of 1834, an irruption of cholera occurred almost simultaneously in several of the seaports and inland towns of the United States, and in the cities of Canada. At Baltimore a few cases were observed from July to October, in which latter month they increased in number to an epidemic, but did not occur so frequently as to generate much alarm among the citizens. The Board of Health reported only about seventy deaths. Cold weather has heretofore exerted sovereign power over the pestilence, in the United States,-of which assertion its sudden cessation in Baltimore, at the middle of November, 1834, offers a fine exemplification. On the 16th day of that month a vicissitude in weather occurred, accompanied with a slight fall of snow, and a temperature below freezing. Attacks had been numerous daily up to this period, but in three or four days there after, although revisited by the ordinary autumnal mildness, a new case could not be found in any part of the city. During each visitation to the city of Baltimore, malignant cholera was observed under two forms:— 1st. In its proper type; 2d. Mingled with the endemial fevers. In its first form the disease verified the description given by authors of its most malignant development. There were recognized the characteristic watery discharges, the peculiar and most remarkable cold stage, the distinctive spasm, and that intractability when subjected to remedial restraint, which has rendered the disorder an object of dread throughout the world. The second, or modified form, was a frequent type of cholera, in both seasons of its prevalence. This pestilence appears to possess a propensity for blending itself with other epidemic affections, though its disposition thus to amalgamate has received but very slight notice, and those instances in which it has been observed complicated with a fever of a known type, have been adduced by authors, with the view of proving, that the disease is in essence but a fever of a malignant character. There is, however, an original form of cholera, which is marked with but little of the nature of fever. Authors have accurately pictured three stages, the premonition, the cold stage, and the reaction, of which the first and second have rarely, if ever, been considered as caused or accompanied by inflammation of tissue. But in the last stage the phenomena have varied in different portions of the world. In India the original form of the disease is the prevailing one; and in this type the reaction is simple, not being coexistent with any inflammatory or febrile symptoms. To confirm this statement, numerous authorities at once occur to the medical reader; but none offers such a mass of testimony on the point, as the "Report of the Madras Medical Board,"* in which are given the individual histories of cholera, drawn up in different years by sixty-five physicians and surgeons, but eight of whom mention any disorder consecutive to the reaction. In Europe and the United States the reaction is almost always a stage attended with inflammation and congestion; although, perhaps in most of the places in these countries where cholera has raged, cases are not wanting where there was as much freedom from fever and inflammation as is customary in India. The well * See Medico Chirurgical Review for April, 1832, |