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acetabulum is seriously involved, that in many cases no operation could be of benefit.

(3.) Those in which an attempt has been made to save the limb after injury, and this operation becomes the only hope of the patient.

(4.) Those in which the desperate character of an injury recently inflicted renders death inevitable, unless this slender chance is afforded.

Even in the most favourable cases of the first of the above mentioned classes, amputation at the hip-joint is not to be lightly undertaken. I do not even consider it, as asserted by some writers, one of the easier amputations to perform. The necessity should be stringent, the weighing of the chances careful, the decision conscientiously arrived at. But it does seein to me that the degree of success attained in the recorded cases is such as to make it the imperative duty of the surgeon to perform the operation under the circumstances indicated. In other words, it is not a matter of choice for him whether he will seek to exhibit his prowess with the knife or avoid the risk of failure. He is not only justifiable in operating, but he would be unjustifiable in not doing so.

Should the result be unfavourable, he may, it is true, have painful doubts as to the propriety of the course he was led according to his best judgment to adopt. Probably all honest and conscientious surgeons have known what it is to be so troubled—some, from their mental peculiarities, more than others. And such doubts would be more likely to arise when operative interference had been resorted to than when it had been decided against, Still, this is one of the elements of the responsibility assumed by the surgeon, and can not be evaded.

Before concluding these remarks, it may be proper to observe that, in regard to all operations, a larger proportion of the successes are apt to be placed on record than of the failures. And such may be the case with amputations of the hip after previous removal of the same thigh at a lower point. But when we consider the very extensive discussion of the general subject of coxo-femoral disarticulation, and the fact that an operation of such magnitude is not apt to be confined to the knowledge of a few persons only, we may fairly suppose that the known cases of the kind just spoken of afford at least as correct a basis for the estimate of a patient's chances as we have for our guidance in regard to any other surgical procedure.- New York Medical Journal.

CANCER OF THE PYLORUS.

who was

A few weeks ago I was called to see a man,

49 years of

age, suffering from what was supposed to be dyspepsia for the last twenty

five years, but more severely during the past year. Last fall he fractured his leg, and the confinement aggravated his dyspepsia. He had been under the care of different physicians, but they failed to give him any relief. I thought, from the history of the case, that it was an aggravated case of dyspepsia, and might be relieved by simple treatment and attention to diet. He vomited nearly everything-it would stay down about half an hour, but would then be ejected, and as a consequence he was much emaciated. He said he also had a feeling that nothing passed through him; he used injections, but they only relieved the lower bowels. I gave him bismuth, and milk and lime water, and also a pill composed of blue mass, ext. colocynth, co. and ext. belladon, to relieve the pain. The next day the stools were blackened, which seemed to prove that the bismuth had passed through. He grew worse, and I examined his abdomen, and found a tumor near the umbilicus, which made the case more grave than I first thought it. Prof. Wiltenberger was then called in consultation, and we agreed that nothing could be done but give relief, as the tumour was probably carcinomatous. He had had vomiting of blood, which is often connected with cancer of the stomach, He died a day or two ago, and here is his stomach. You see here a scirrhus tumour occupying the pyloric orifice and allowing little if any matter to pass The small intestines were congested, which nearly always occurs in persons who die of starvation, as this man did. The liver, spleen, and pancreas appeared to be healthy. His case has been one of gradual starvation. A person will live longer with pyloric cancer than cardiac, for the former will allow some small portion to be absorbed before it is ejected, while the latter will allow nothing to enter the stomach.-Med. Clinic of Prof. McSherry, in Phil. Med. Reporter.

3

DESTRUCTION OF THE NOSE AND LIPS: NARROWING OF THE OPENING OF THE MOUTH BY CONTRACTED CICATRICES : SUCCESSFUL

OPERATION. The following remarkable case occurred in the practice of Professor von Balassa of Pesth. A lad, aged 16, named Karl Szatmary, of pale cachectic appearance, came into the hospital there with a terrible distigurement of his face. This had been produced a year previously, as far as could be ascertained, by some febrile disease (perhaps pernicious intermittent or typhus); after which the nose, lips, external ear, and a part of the toes, had become gangrenous. The process of cicatrisation which followed this extensive destruction, had left in the place of the nose and

uneven cicatrix, firmly adherent to the suface of the jawbone, and

a

The upper

narrowing the nostrils to a small longitudinal cleft, and the mouth to a roundish hole of the size of a bean, of which two-thirds were occupied by the middle incisor teeth, so that there remained only an opening of the size of a crowquill, with rigid walls. Respiration and nutrition were necessarily greatly impeded; fluids only could be administered in scanty quantity. Speech was difficult ; and saliva flowed almost constantly from the mouth.

It was evident, that the impaired constitution of the patient would not allow the immediate performance of a plastic operation ; the indication was therefore to improve his health, and to remedy the defects by operarations ; performed at intervals of time.

The patient having been well nourished for some months, and his health having improved, the formation of an upper lip was undertaken on May 5, 1862. The cicatrical tissue occupying the place of the upper lip was first removed by two vertical semilunar incisions, joined by a horizontal one parallel to the lower edge of the orifice of the nose. This being done, semi-elliptical incisions, about an inch apart, were made from the ends of the semilunar cuts, nearly as far as the ears. incisions were somewhat longer than the lower, and had their convexity directed upwards ; the lower were convex downwards. The transplantation of the flaps was favoured by their curved edges allowing them to be drawn in the proper direction ; but it was also necessary to make incisions into them, dividing also the mucous membrane. Hæmorrhage having been arrested, the flaps were united in the middle line below the nasal orifice with figure-of-8 sutures, as in the operation for hare-lip; and their upper edges, and the outer third of the lower, were also united in the same way with the corresponding edges of the incision in the face. Ordinary silk sutures, both deep and superficial, were applied in the intervals between the pins. Sutures were also applied to the free edges of the flaps, so as to form the upper lip, the angles of the mouth, and a part of the lower lip. Union rapidly took place; and, when cicatrisation was complete, the patient had not only an upper lip with its red mucuous membrane, bui also a mouth-opening of sufficient size, and capable of being enlarged by the now free movements of the lower jaw.

From this time the patient improved in health and appearance, and was able to take food in the ordinary way. The furrows also, which were produced by the contraction of the cicatrices along the edges of the flaps, gradually disappeared ; so that, at the end of February, 1863, scarcely any difference in the level of the skin could be distinguished. On March 8th, rhinoplasty was performed; the flap being taken from the forehead, a portion of the scalp also being used to form the septum. The

flaps of cicatrised tissue on each side of the nose were not extirpated, but were brought together towards the middle line and held there by threads so as to form a bridge for the new nose. Knotted sutures were not ereployed, as they would have interfered with the application of the flap from the forehead. In perforwing the last mentioned part of the operation, a portion of the frontal periosteum was removed with the flap. Union took place readily by the first intention, not only between the nasal flap and the sound skin, but also between the septum and the upper lip. The portion that had been used to form the bridge of the nose also became united from within outwards to the flap taken from the forehead. A considerable time was occupied in the after treatment, in preventing the septum from becoming united with the alæ nasi ; and the patient was therefore kept in hospital until the end of July. This delay, however, gave an opportunity of observing that there was no sinking in of the new nose, but that it had retained the form given it is the operation. The consistence of the bridge of the nose had not underyone the least change ; and, as there was no trace of bone having been formed by the transplanted periosteum, this retention of shape must, sars Dr. von Balassa, be attributed to the retention of the cicatrical tissue of the nose, so as to form a support for the flap. To prevent the nostrils from becoming closed, a special proceeding was required. This consister in passing a leaden wire through the part of the septum which la5 beneath the point of the nose, and was united at the upper part with the alæ. The wire having been introduced by a lancet shaped needle, its end was again brought through the septum at a distance of about two lines; and the two ends were then drawn out through the right nostril and twisted together.

It was necessary to leave these leaden loops until the newly formed nostrils were fully cicatrised. The small bridges of skin between the leaden wire and the alæ nasi were not at first cut away; and it was not until the end of some weeks, when the nasal openings had fully cicatrised, that a horizontal incision was made on each side from the nostril into the alæ ; and, after these were healed, the vertical bridges of skin which extended outwards from the leaden loops were divided. The patient remained in hospital a month after the completion of the operaration, during which period the cicatrisation of the septum and alæ pursued a favourable course, and the nostrils appeared to be certain of retaining a proper size. He went home in October, and returned in 1864, when the leaden ring was removed, and a slight plastic operation was performed for the improvement of the lower lip. There was not the least trace of the formation of bone by the transplanted periosteum ; but the nose retained its proper shape, and the nostrils remained quite pervious. (Berliner Klin. Wochenschr., August 14, 1865.

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TUMOUR, INVOLVING THE PNEUMOGASTRIC ; PERIPHERAL AND

REFLEX PAINS.

CLINIC AT THE DISPENSARY OF MEDICAL COLLEGE OF OHIO.

Reported by H. M. HITTNER, Chief Clinical Assistant. History.—Mrs. Spellman, aged fifty years, a native of Alabama, presented herself to the Dispensary of the Medical College of Ohio for treatment. She stated that a tumour appeared about two years ago on the left side of the neck, about an inch below the angle of the inferior maxilla, which gave her much annoyance, and did not yield to the remedies suggested by various physicians. The tumour was first noticed in October, 1863; although at that time rather small, it gradually increased. In six months it had acquired a size about two and a half inches in diameter. Without any local application it broke and discharged a sero-sanguineous fluid, less in quantity than any one would have anticipated from the size of the tumour. From that time until the patient came to the Dispensary, the tumour closed and broke, at intervals; when open, always discharging a small quantity of sero-sanguineous fluid. But this swelling was not the only annoyance to the patient. She complained of shooting pains along the left side, extending almost over the entire thoracic region, and to the stomach. For two years she was troubled with nausea and vomiting, and the different medicines directed to the stomach by physicians, did not relieve her in the slightest. Other symptoms also presented themselves. Dimness of sight and

. partial loss of hearing; this was more marked on the left than on the right side. The special sense of smell was also impaired; but the most marked of all the symptoms was a neuralgic pain in the head.

Symptoms.-A tumour presents itself near the angle of the jaw on the inder margin of the sterno-cloido-mastoideus. This tumour appears to be produced by an inflammation of the alveolar tissue, and a deposit of fibrin, which involves the sheath of the vessels. There are pains in the side, extending over the chest with slight difficulty of breathing ; pain in the epigastric region with nausea, and pain radiating over the organs of the abdominal cavity. Her senses of sight, smell and hearing are inore or less impaired, especially on the left side, and she has violent neuralgic pains in the distribution of the fifth pair.

Diagnosis.—The symptoms in this case are undoubtedly due to the presence of this tumour. The mode in which it acts to produce the phenomena observed may be explained by either of the following theories :

1. The tumour impinges upon the pneumogastric nerve, which, passing down from the jugular foramen, is contained in the same sheath witb.

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