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ration was difficult and tedious, and during the time it occu-pied, the patient was kept under the influence of chloroform.Very little blood was lost; but four vessels required to be tied.An opiate was given shortly after the operation, and in theevening he was calm and free from pain. There had been onlytwo small evacuations from the wound.29th.-The patient had slept little, and had lost all appetite.

No faeces had passed, but there was no tenderness in the abdo-men, or in the wound. In the evening he was much troubledwith nausea and occasional vomiting.On the 30th, learning that no faeces escaped, I passed my

finger into the ascending colon, which I found loaded with softfeculent matter. He had taken very little nourishment sincethe operation, and his pulse was weak. The bowels were wellrelieved next day by a mild aperient draught, but the irri-tability of the stomach continued to distress him, and he tookscarcely any food. Effervescing ammonia draughts, ice to

suck, brandy, hydrocyanic acid, chloric ether, counter-irri-tation over the stomach, all failed in quieting the organ. Hegradually grew weaker and more emaciated, and on the 6th ofOctober, the eighth day after the operation, some bleedingtook place from the wound. He lost between three or fourounces of blood before assistance could be had, but the hæmor-rhage was readily stopped by a little pressure. The bleeding,which occurred with the urine, soon ceased after the operation,but nearly all his water passed by the anus, rendering himconstantly wet and uncomfortable. His stomach at lengthbecame quieter, but he still took scarcely any nourishment,and no animal food. The evacuations took place readily, andwithout pain; but the wound made no progress in healing.He got weaker from day to day, and died on the 13th, havingsurvived the operation fifteen days. Permission to make anautopsy was refused.

In both these operations I was disappointed in not findingthe colon distended, a condition which greatly assists the sur-geon in his endeavours to open the bowel without injury tothe peritoneum. In the first case, after a month’s obstructionat the rectum, not only was the colon contracted, but it wasactually compressed against the spine and put out of the wayby the distended small intestines, so that it was really impos-sible to reach the bowel without opening the peritoneum. Noinflammation or unfavourable symptom resulted, which mustbe attributed in a great measure to the free use of opium,coupled with good nourishment and support. In the secondcase the operation was resorted to on the tenth day of obstruc-tion, and the patient had been able to take food so well that aloaded colon might have been fairly looked for. The bowelwas not indeed compressed and displaced, as in the first case,but it was not distended sufficiently to facilitate the operation;and the patient being a stout man, I found it no easy task toreach the colon and to open it behind the peritoneum. Thesedifficulties are mentioned, not with the view of disparagingthe lumbar operation, but to invite attention to obstacles whichmay arise in its performance. My own opinion leans favourablyto this operation, in preference to the inguinal, in cases of ob-struction from disease of the rectum. In a spare subject, withthe colon moderately distended, the operation is not very diffi-cult, nor one attended with any great risk to life; and afterthe wound has healed around the opening of the bowel, somesuch contrivance as that used in the first case will greatly ob-viate the inconveuiences of the anus in the loin.* Even if theperitoneum be wounded, it may be questioned whether, underjudicious treatment, the dangers of the operation are muchincreased thereby. In the second case the operation can

scarcely be said to have prolonged life, for without it the

patient, by careful management, would probably have lastedas long. The prime object of the operation was accomplishedin enabling him to relieve his bowels freely; and I attributethe unfortunate result chiefly to the unfavourable influence ofchloroform in this instance. That chloroform does occasionallygive rise to an irritable state of the stomach, of some duration,is well known. Mr. S- inhaled an unusually large quantityof it, and was kept under its influence nearly three-quarters ofan hour, in consequence of the difficulties of the operation. Hewas well able to take food previously, but afterwards lost allappetite, and became troubled with nausea and vomiting, whichlasted some days, even after the bowels had been well relieved.The inability to take nourishment, especially animal food, wasthe chief cause of his sinking: for no Deritonitis ensued. and

* I was greatly struck with the moderate inconveniences consequent on anartificial anus in the loin in the case of a gentleman successfully operated onby Mr. Pennell, in Rio Janeiro, in 1849. This gentleman was afterwards muchengaged in business, and in 1854 came over to this country, when, throughthe kindness of Mr. Clendon of Albemarle-street, I had an opportunity ofseeiD? him. I am informed that he is still living.

the wound assumed no unfavourable condition until his powersbecame reduced by want of nutrition.Having recorded these cases chiefly with the view of afford.

ing information in reference to the results of an important ope-ration, I shall not dwell on other points which might claim somenotice. I must, however, allude to one circumstance in the firstcase of great practical interest,-viz., the advance of a formid-able disease in the rectum to such a point as to produce completeobstruction, and its sudden occurrence, without any symptomto raise a suspicion of the existence of an impediment in thepassage, much less of a cancer. This shows the importance ofmaking an examination of the rectum in all such cases. Weknow that a strangulated hernia is occasionally overlooked; anobstruction in the rectum is still more liable to escape observa.tion. The advantage of sn early recognition of serious diseasein this part, even of a cancerous character, will be shown insubsequent communications.

Grosvenor-street, Jan. 1858.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

CHARING-CROSS HOSPITAL.

EXCISION OF A PART OF THE PELVIS,TOGETHER WITH THE HEAD OF THE FEMUR AND FLOOR OF

THE ACETABULUM.

(Under the care of Mr. HANCOCK.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter se com-parare.-MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proœmium.

A FEw weeks earlier than this period of last year, we wit-nessed the memorable operation of removing the floor cf theacetabulum and head of the thigh-bone from a boy fourteenyears of age, the subject of pelvic abscess and caries of thepelvis, by Mr. Hancock, at this hospital. The sequel was anexcellent recovery. (The " Mirror," in vol. i. of THE LANCETfor 1857, p. 141.) During the past year, we gave a series ofcases of excision of the head of the femur, in our " Mirror," inseveral of which the acetabulum, and even the pelvis, wasdiseased, and good recoveries were made notwithstanding.The objection to this operation, then, which at one time wasso strong, from the presence of disease of any portion of thepelvis, has now passed away, and we trust to see broughtforward for the future an argument in favour of the operationwhich was formerly used as an objection against it.On this day fortnight, an operation was performed by Mr.

Hancock on a female twenty-six years of age. The details ofthe case, as we gathered them from Mr. Hancock’s observa-tions, were to the effect, that the patient, who had a flushedcountenance, and very delicate health, has been an inmate ofthe hospital for the last few weeks. She fell down twentyyears ago, and hurt her right hip. This was followed by in-flammation, suppuration, and other effects, as are witnessed inthe usual course of disease of the hip-joint. The limb assumeda faulty position, and was anchylosed. About three weeks

ago, a large abscess formed over the buttock, which burst, anddischarged a good deal of matter. Matter had formed fromtime to time before that, and had caused considerable mischief.There were the remains of an old abscess near the anterior

spinous process of the ilium; two large fistulous openings werepresent over the prominence of the hip, and through two ofthese a probe could be passed its entire length, which enteredthe pelvis through the great ischiatic notch. There could beno doubt the patient would die if not relieved. The diseasecommenced in the hip-joint, and the pelvic abscess wassecondary to this disease, and unless that was removed theconsequences would surely be what was stated. He accord-

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ingly consulted with his colleagues, Mr. Canton, Mr. Hird,and Mr. Barwell, and they agreed with him that the onlything to be done was to remove the head of the bone and thediseased parts of the pelvis, and with their assistance the z,

operation was performed, the patient being under the influenceof chloroform. ’

A longitudinal incision, eight or nine inches long, in thecourse of the two larger fistulous openings, was made, over theouter side of the joint, and the trochanters exposed. A

quantity of plastic matter surrounded the diseased parts, whichwas removed with the finger.. The head of the bone was nowdetached by sawing the femur below the trochanters; but sofirmly was it anchylosed to the acetabulum, that it was re-moved partly through the aid of the saw and the cutting-forceps, the anchylosis existing especially round the brim. Thefloor of the acetabulum was extensively carious and penetratedwith small openings. The greater part of this was removed,together with its entire back part. The spine of the ischium,together with a considerable portion of the tuberosity, werealso taken away for disease, and complete denudation of peri-osteum, and the fingers could be passed into the pelvis throughthe ischiatic notches. Every portion of diseased bone wascarefully removed. The head of the bone was found to be

rough and carious, flattened in shape, and not dislocated, asalready stated. The wound remaining was very large anddeep. It was closed by deep sutures, and the poor girl wasremoved.

In some remarks which he made upon the operation, Mr.Hancock observed that where there had been disease of thepelvic fascia, as in this case, there is a certainty of there beingdisease of the pelvic bones. He thought even where therewas a distinct pelvic abscess in any case, the best means ofcure would be to open it through the acetabulum, because itwould form the best drain for the matter to come away.In this case, then, there were removed the head and neck of

the femur, the posterior part and floor of the acetabulum, thespine of the ischium, and the same bone down to its tuberosity.We doubt very much whether so much of the pelvis has everbeen before removed under such circumstances. Her pro-gress was excellent up to the eighth day, when erysipelasattacked the wound, and, we very much regret to state, shesank the same night. There was a point of considerable in-terest in her case. She had not been regular for some twoyears, and had not menstruated for six months. On the thirdday her catamenia came on, and continued naturally until thesixth day, the discharge from the wound being free and healthy.

UNIVERSITY COLLEGE HOSPITAL.

PSORIASIS OF THE MATRICES OF THE NAILS.

(Under the care of Dr. HARE.)AN interesting case, both as presenting an abnormal variety

of a well-known disease, and as exhibiting the influence oftreatment in the cure of psoriasis, is at present under care atthe above hospital. It is by no means uncommon to find theupper surface of the nails variously pitted, and presenting anotherwise abnormal appearance, when the fingers are affectedwith psoriasis,-this state of course depending upon the poste-rior part of the matrix, where it is bounded by the crescenticgroove, being affected, by continuity, with the same diseasewhich implicates the adjoining portion of the skin. But in thecase under consideration, the disease is entirely confined to theanterior two-thirds of the matrices of the nails; so that the

posterior portion and upper surface present nothing abnormal,and there is no psoriasis of any other part of the body. The

following particulars of the case have been kindly furnished byMr. Frederick B. White, who clinically reported the case.The patient is a female, aged forty-seven. She first became

affected by the disease about four years since, when it made itsappearance first on the matrices of the toe-nails, and afterwardson those of the fingers. It had not, however, caused her muchinconvenience till about six months ago, since which time ithas been getting gradually worse, and she has been incapaci-tated from following her occupation (that of a sempstress) inconsequence. In each instance it was the anterior portion ofthe matrix which first became affected, the disease then gra-dually extending backwards to within about a line of thecrescentic groove, when it ceased, the nail being separatedand raised up, owing to successive depositions of the scales.

On admission, the fingers and toes presented the appearancesdescribed above, and the patient complained much of pain attheir extremities. Dr. Hare referred to the close analogy, intheir nature and structure, between the matrix secreting thenail, and the corium which secretes the cuticle, and the proba-bility of the two being liable to similar diseased conditions:the case in question was an example of the generation of cellsin excessive quantity, and of a diseased character, bv thatportion of the corium which forms the matrix of the nail.Taking this view of the disease, he treated the case on the planhe ordinarily adopts in cases of psoriasis, -viz., with fiveminims of the arseniated liquor of potash, and about thirtyminims of liquor of potash in water, three times a day; besidesthese, no other remedies (except aperients occasionally) wereemployed. Marked improvement, almost from the first, tookplace; she was soon able to sew as usual, and now but slighttraces of the affection remain.

It is, perhaps, worthy of remark that the matrices of thenails on the middle finger of each hand, and the correspondingtoe of each foot, have been throughout entirely exempt fromthe disease.

THE "DREADNOUGHT" AND METROPOLITANFREE HOSPITALS.

PHOSPHATE OF ZINC IN EPILEPSY.

DURING the last two years Dr. Barnes has extensively testedthe restorative and curative powers of phosphate of zinc-anew remedy introduced by him in the treatment of epilepsyand other nervous affections resulting from cerebral exhaustion.This physician was led thus to combine phosphorus and zincby reasoning upon the known efficacy of zinc in epilepsy, andthe fact that in exhausting nervous diseases there appears tobe a waste of phosphorus in the brain-matter. The import-ance of phosphorus as an element of the organization is furtherexemplified in the richness of the more nutritious cereal grainsin this substance. It therefore seemed a reasonable indicationto administer the two elements in combination. Experiencelias fully justified this idea. In convalescence from fevers,which induce great wasting of tissues, and notably of brain-matter, to the extent, not unfrequently, of leading to insanity,Dr. Barnes has exhibited the phosphate of zinc with quinineand other remedies with the most satisfactory results. In-combination with conium, it is frequently exhibited with ad-vantage in phthisis in preference to the sulphate of zinc. Butit is especially at the obstetric clinique at the MetropolitanFree Hospital that the good effects of this remedy havebeen illustrated. The following case is a type of a large-number:-A woman, aged twenty-three, the mother of fourchildren, was first seized with an epileptic fit at twelve yearsold, after a fright. Similar fits occurred frequently since, butwere more frequent and severe during suckling, remitting some-what during pregnancy. She never had convulsions duringlabour. She usually, whilst suckling, menstruates about fivemonths after delivery, and becomes pregnant. She was suck-ling, and the fits were frequent, when she was ordered phos-phate of zinc, four grains; dilute phosphoric acid, twentyminims; tincture of bark, half a drachm, three time a day.After taking this for a fortnight, the patient’s account was thatthe fits were " backened" by the medicine. She had had

headache, slight vertigines, but only one fit. She continued forthree months improving much in health, and had no return ofepileptic seizures. In the menstrual form of epilepsy, whenaccompanied by exhaustion and ansemia, the remedy has beenof equal service. In one case of insanity following on exhaus-tion produced by lactation for eight months, the phosphate of-zinc, judiciously combined with other remedies, completely re-stored the patient to physical and mental health in threemonths. Dr. Barnes often refers to the readiness with whichthe phosphate of zinc adapts itself to the peculiarities of diffe-rent cases by the facility of combination with various otherremedies. He prescribes the dilute phosphoric acid as the

proper solvent. With this basis, he combines tincture of vale-rian, tincture of cinchona, calumba, quinine, or iron, accordingto the indication present. It is less liable to cause vomitingthan the sulphate. The experience of Dr. Barnes is certainlydecisive enough to recommend the phosphate of zinc to theattention of the profession.