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or thread with it, and thus avoiding the difficulty of catchingthe thread. The following are the notes of the case :-

Sophia S--, aged thirteen, was born with a single hare-lip,and a cleft in the hard and soft palate continuous with it. Thelip was operated upon successfully when she was an infant, butthere being a very unsightly notch still present, I cut out theold cicatrix, and having pared the lip, brought the edges toge- I,ther, with great improvement in her appearance. The lipbeing perfectly healed, I proceeded to operate on the soft

palate on the 15th October, 1858. Having divided the levatorespalati, and pared the edges of the fissure, I proceeded to passa single freshly-annealed silver wire with the needle I havedescribed; this was easily drawn out of the mouth with thehead, and detached through the slit in the eye, and I thenpassed a double loop of silk in the same manner on the oppositeside. The end of the wire was now closely bent into the loopof the silk, and was thus readily drawn through the oppositeside of the cleft (Fig. 2). Two other sutures being introducedin the same way, the ends of each of the wires were simplytwisted together, and held the edges of the palate in admirableaDDOsition.It may be thought there would be a danger of the head of

the needle becoming detached, and so dropping into the

patient’s fauces; but it is effectually retained by the thread orwire being held tightly by the operator’s fingers, and as theslit in the eye is on the convexity of the needle, there is nodanger of the thread escaping through it prematurely. The useof the freshly-annealed wire was suggested to me at the time ofthe operation by my friend Mr. Barclay, and it is certainlypreferable, from its greater pliability, to the hardened wire incommon use. I need hardly say that it is prepared by heatingthe ordinary wire to redness and allowing it to cool slowly.The after-progress of the case was most satisfactory. The

sutures were removed on the fourth and fifth days, when unionwas quite perfect. A little unhealthy action came on aboutthe anterior part of the wound a day or two after, but this wasreadily checked by a dilute hydrochloric acid lotion.A fortnight after the operation, the parts were perfectly

sound and painless, and the articulation was already very con-siderably improved by the operation.

Gordon-square, December, 1858.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

KING’S COLLEGE HOSPITAL.

TWO CASES OF EXCISION OF THE KNEE-JOINT ; FATAIRESULT IN ONE FROM PHTHISIS AND PNEUMONIA, INTHE OTHER FROM ISCHURIA RENALIS.

(Under the care of Mr. FERGUSSON.)

Nulla est alia pro certo noscendi via, nisi quam piurimaset morborum etdissectionum historias, tam aliorum preprias-collectas habere et inter se com-p&ra.re.—MoMAQNi. De Sed.et Oaus. M01’/;.lib.14. Prooemium.

APART from the success attending the operation of excision of the knee-joint in the hands of many surgeons, there occa- Isionally follow results which are far from satisfactory; and,provided the untoward termination of these cases be not tho-roughly investigated and placed in a. correct light, the advance-ment of surgery is arrested; whilst a laudable attempt to com-bat disease in a manner most beneficial to the sufferer ischecked.The particulars of the two following cases, in which excision

of the knee-joint was performed by Mr. Fergusson at King’sCollege Hospital, are deeply interesting, and demand a fullrecital :-CASE 1.-Jane T-, aged thirty-five, married, and the

mother of a healthy child, residing at Battersea, was admittedon the 20th of October. 185S. suffering from extensive disor-

ganization of the right knee-joint. The following descriptionof the patient’s condition is borrowed from the notes of Mr.Lever :-

Eighteen months prior to admission into the hospital, a con-tinuous pain was experienced at the back part of the knee,which was supposed to arise from an undue exposure to cold.The pain gradually increased, and with its accession the jointcommenced to swell. Six months afterwards the hip articula-tion of the same side became affected, and, both joints beingnow included, she entered the Middlesex Hospital. After aresidence of two months, and the use of counter-irritants, somerelief was gained, and for another two months she was enabledto remain at home. In the course of time the disease, whichhad remained in abeyance, appears to have been re-ignited;for pain, and the formation of an abscess, again compelled herto seek hospital relief.

On her admittance into King’s College Hospital, the kneeappeared much swollen, very painful, and rigid, the leg beingbent at nearly a right angle to the thigh. The general healthwas very bad; there was considerable emaciation, no appetite, andlittle or no sleep could be obtained at night. On a closer examina-tion of the joint, an abscess was detected within the articulation,which was opened, and about half a pint of foetid, discolouredpus discharged. There was little doubt as to very consider-able mischief existing within the articulation. In all proba-bility the cartilages and ends of the bones, besides the synovial,membrane, were extensively involved. For the next fortnightthe patient suffered severely all the symptoms of acute ulcera-tion of the articular cartilages, and experienced all the depres-sing symptoms of this painful affection, with diarrhoea,

night-sweats, loss of appetite, and diminution in strength andspirits. The constitutional disturbance arising from the con-stant agony and distress of the local affection called loudly forrelief ; and although the general condition of the patient pro-hibited any very sanguine anticipation in the result of a capitaloperation, yet her own entreaties, combined with a desire to dowhat was deemed best for the unfortunate sufferer, inducedMr. Fergusson to recommend that proceeding fraught with theleast danger to life, and which, if successful, would insurethe prospect of the retention of a useful limb.On November 6th, while the patient was under the influence

of chloroform, a single transverse incision exposed the interiorof the joint, which had undergone total destruction. As wassurmised, the synovial membrane, inter-articular and investingcartilages, were extensively included, while the bones hadsuffered from ulceration. The articulating extremities of thefemur and tibia were removed by the saw, together with thepatella. There was little or no bleeding, and the operationwas promptly performed. The flaps were accurately adjusted,and retained by sutures of silver wire. A few hours after theoperation, the patient rallied, and expressed considerable relief.At a week from this time, the report says, that the patientsleeps much better, takes her food remarkably well, and makesno complaint of pain in the wound." The confinement to bedin one position caused a bed-sore to form over the sacrum, andon the 20th, fourteen days after the operation, she commencedto complain of sickness, restlessness, and weariness. Two

days subsequently, diarrhoea accompanied the vomiting, butwas allayed with brandy and medicines composed of ammonia.

and chloric ether. On the seventeenth day after the operation,difficulty of breathing and some pain in the chest were com-plained of. Crepitation became distinct over the left lung, the

nulse rose. the annetite failed. and an anxious expression crentover the countenance. Rapid exhaustion set in, and all theendeavours of Mr. Walters, the house-surgeon, failed to rallythe sinking patient. Death took place at ten o’clock the fol-lowing morning.At the post-mortem examination, the wound, which had

united, was re-opened, and the bones found denuded of theirperiosteal covering to the extent of about a quarter of an inch.-A coating of lymph covered the ends of both bones. Anabscess had formed at the back part of the wound, and ex-tended for some little distance behind the tibia. On openingthe chest, both lungs were adherent at their apex, but the rightthrough its entire surface. In the apex of the left lung thereexisted a cavity containing pus and a large amount of broken-down tubercular deposit. The upper lobe was solid, the lower

I gorged with blood and infiltrated with recent tubercle. The

right lung was even more diseased, and bore the same strikingevidence of old mischief. The apex was included in tubercular

deposit, and the lower lobe greatly congested, and nearly solid.

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Scattered tubercles were found infiltrating the entire lung-tissue. The heart and kidneys were normal; the liver fattyand enlarged. No secondary deposits or abscesses were dis-covered.

CASE 2.-Alexander G-, aged twenty-one, unmarried,born at Sheffield, and following the occupation of a clerk, wasadmitted into hospital on the 27th of October last. Severalyears ago he was attacked with rheumatic fever. The left

knee-joint appears to have suffered very considerably, for hewas admitted on account of rectangular anchylosis of the joint,the leg being flexed at a right angle with the thigh. Threeyears ago he was under Mr. Fergusson’s care, and at that timeboth he and his mother were most desirous that somethingshould be done to remedy the deformity. The lower end ofthe femur at that time appears to have been affected with dis-ease, for a small piece of bone was removed. After quittingthe hospital, he remained at his employment for three years,but had returned, determined either to lose the limb or

have the deformity rectified. In this determination he wasseconded by his mother. An examination of the joint showedthe tibia to be bound to the femur by bony material; the unionwas firm and unyielding; the patella likewise immovably fixed.The lad had an anaemic aspect, but expressed himself to be inexcellent health. The nature of the operation of removing theanchylosed joint was fully explained to him, and a decidedwish expressed that it might be resorted to in preference toamputation through the thigh.On Nov. 13th, the following operation was performed:—A

single transverse incision was carried across the front of thejoint, and the integuments reflected back far enough to enablethe saw to be applied to the ends of the femur and tibia. Bothbones were found firmly bound together by osseous material,solid and compact, and therefore considerable difficulty wasexperienced in removing the anchylosed joint entire. Althougha considerable amount of bone was sawn away, still it wasnecessary to remove another slice from the end of either shaft.The cut surface of the femur was perfectly healthy, but thebone denser and firmer than usual. In the head of the tibia asmall cavity was detected filled with a cheesy-looking matter,which was duly cleansed by the gouge. The patella wasfirmly tied to the block of bone which was removed. Thehamstrings, although offering some resistance, were not divided,and, with a moderate amount of force, the parts were broughtinto excellent apposition. The haemorrhage was trivial, andthe flaps of skin were retained by the silver-wire suture. Thelimb was placed on a splint-such as is invariably used-beforethe patient was removed from the operating table. A tolerable

night was passed, and the next morning he expressed himselffree from pain.On the 16th, after a comfortable night, pain in the site of

the wound was complained of, while the discharge was thinand unhealthy. A poultice was applied. For four days heconsiderably progressed, and the purulent discharge becamemore healthy, and increased in quantity; the appetite im-proved, and his sleep was refreshing. In the middle of theday, however, he had a shivering fit, which recurred onthe 24th, when the tongue became furred and dry, and thepulse rose to 120.25th.-He experienced another shivering fit; the tongue

remained furred, and the appetite declined. The wound,however, looked healthy and discharged freely. In the even-

ing, about nine o’clock, it was discovered that he had onlypassed about an ounce of urine. A catheter was introducedinto the bladder, but failed to draw off any fluid. A large mustard plaster was applied to the loins, and a full dose of ’’,compound jalap powder administered. Subsequently, a hot-air bath was given, but the kidneys refused to secrete. Mr.

Fergusson was sent for during the night, and found the patientsinking.26th.-The pulse sank to 44; a small quantity of urine-

about an ounce-was passed; the administration of stimulantsand other medicines was unavailing, and he died at two

o’clock, without any signs of coma or delirium.On the 27th, a post-mortem examination detected the lungs

congested and loaded with mucus, but everywhere crepitant.The right ventricle of the heart was greatly dilated; the wallsthin, but the valves healthy. The liver weighed six poundsthree ounces, and was considerably enlarged and fatty. Thekidneys were more than double the ordinary size, and wereexceedingly fatty, and apparentlv undergoing some strumous

degeneration. Each organ weighed fifteen ounces and a half.The spleen was enlarged, and weighed twenty-two ounces and

,half. No secondary abscesses nor deposits were found.

WESTMINSTER HOSPITAL.PARAPLEGIA FROM FRACTURE OF THE SPINE AND

CRUSHING OF THE LOWER END OF THE

SPINAL CORD.

(Under the care of Mr. HOLTHOUSE.)IN the following case, the body of the first lumbar vertebra.-

was completely crushed between the last dorsal and secondlumbar, so that the opposed articulating surfaces of the twolatter were in contact, the spinal cord above the cauda equinabeing likewise crushed by the fragments of the intermediatebone, to such an extent as to amount to almost a completedivision. With such a severe injury, no extravasation of blood.occurred; but all the symptoms manifested by the patientclearly pointed to the nature of the mischief, and, as was anti-cipated, a fatal result ensued.An instance of fracture of the spinal column, but much

higher up than in Mr. Holthouse’s patient, was recently in thesame hospital, under Mr. Hillman’s care, which we will onlyrefer to at present. The patient was a female, aged thirty-eight, who fell from a third-story window on the 15th of Sept.,and was admitted into the hospital the same day with concus-sion of the brain, and a large scalp wound. The respirationbecame diaphragmatic on the 17th, and she died on the 23rd.At the autopsy there was found a most extensive fracture ofthe skull, with a fracture of the body of the sixth cervical ver-tebra, and softening of the spinal marrow.Hannah H-, aged forty-two, was admitted into Queen

Anne ward, on the 25th of July last. She was in a semi-col-

lapsed state, but was perfectly sensible, and complained ofgreat pain in the abdomen, which was hard and tolerant ofpressure; both ankles were greatly swollen and ecchymosed,and an extensive ecchymosis occupied the buttocks, the rightlabium pudendi, and the right side of the face and eyelids.’ The pulse was 60, small, and very feeble. When she had some-what recovered from the shock, she stated, that while shewas in her bed-room, on the third floor, the wind suddenlyblew to the door, which had no handle on the inside, so thatshe could not get out, and being alone in the house she becamealarmed, got out of the window, and let herself drop into theplayground below, alighting on her feet on a flight of steps,and then slipping down and falling over on her right side, asfar as she can recollect. She was taken up insensible, and atonce brought to the hospital.On the 26th she complained of feeling very ill, and being

very thirsty; her tongue was red and dry, and she had notpassed urine or had an evacuation since her admission. It wasthen discovered that her lower extremities were paralysed, andthe urine was drawn off by a catheter.

! 2Sth.-The urine was still retained, and the faeces passedinvoluntarily and unconsciously; no reflex movements weremanifested on tickling the soles of the feet, nor was she con-scious of their being touched.

29th.--She was cheerful, and her general appearance hadimproved; a slight fulness is perceptible in the lower dorsalregion of the spine, the skin over which is very sensible topressure.31st.-The patient was depressed and exhausted, having

passed a bad night. She complains of a constant sensation offaintness, and a craving for fresh air. She has no appetite. Theabdomen has become somewhat distended and tympanitic ; themotions continue to pass involuntarily, and the urine likewise,which has become highly ammoniacal, and loaded with mucus.Although no movements take place or sensation is felt ontickliug the soles of the feet, there is slight sensation in thecalves of the legs, and in the whole of the limb on the rightside, but not on the left. Two large bullae, which had formedover the sacrum, have burst, and the cuticle has separated,leaving excoriated surfaces, which have a somewhat sloughyaspect. She had been taking some effervescing medicine up tothe present time ; but to-day ten minims of dilute hydrochloricacid were ordered to be taken three times a day in an ounce ofthe decoction of pareira, and eight ounces of wine were pre-scribed daily.

Aug. 2nd.-Passed a bad night; the back discharges a gooddeal, and there are redness and tenderness of the skin over theright gluteal region. Sensation has returned in both legs as faras the ankles; but the feet remain quite insensible to irritation,and no reflex or other movements can be excited.

5th. -She has lost flesh, but is cheerful and comfortable, andcomplains onlv of being thirsts ; the tongue is red and drv.