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Under both the above terms are comprised a large number oftrifling injuries. Very seldom any of a serious character aremet with.

38. Ambustio.-Cases treated, 16; average per year, 31;deaths, none.

These were scalds and superficial burns, which happen some-times during ball-firing.

(To be concluded in our next.)

ILLUSTRATIONS OF DIFFICULT PARTURITION.BY J. HALL DAVIS, M.D. Lond., L.R.C.P.

PHYSICIAN TO THE ROYAL MATERNITY CHARITY, AND TO THESAINT PANCRAS INFIRMARY.

(Continued from p. 5.)

An arm-presentation labour, with prolapse of the funis.Turning attempted one hour after the discharge of theliquor amnii, as also at a later period, unsuccessfully;Delivery by perforation of the chest, &c. Convalescence

good.DECEMBER 5th, 1850, at half-past ten, P.M., I was requested by

the surgeon in attendance to come to his assistance, in a case ofdifficult labour. E. N- , aged thirty-two. Seventh child.Previous labours had been easy. The membranes had given wayafter two strong pains, at half past six P.1B!., discharging a largequantity of liquor amnii; the pains continued severe for half anhour, when they ceased. A midwife in attendance sent for myfriend at half-past seven, who finding the arm and funis present-ing, tried to turn, but without success, although he managed tobring a foot to the pelvic brim ; he was alike unsuccessful on re-peating his attempt to turn, when the patient had been placedunder the influence of a full dose of opium.At my visit, at half past ten, I found an arm and foot at the

brim of the pelvis, with coils of the funis without pulsation; the

patient not feverish nor plethoric. Thinking that there mightyet be a remote chance of saving the child, the cord having onlyrecently ceased to pulsate, and finding turning impracticable atpresent, I administered chloroform as far as I deemed it judiciousto venture, one ounce of the fluid being disposed of, but withoutthe desired effect of relaxing the rigidly contracted uterus. I maysay that the specimen of that medicine, judging from its effectsupon myself, seemed to be good. I now perforated the axilla,my friend, at my request, keeping the presenting arm on thestretch ; I removed the viscera of the thorax through the openingthus made, and by a puncture with my finger and a crotchet,gradually brought the child through the brim, pelvic cavity, andoutlet. The pelvis appeared to me deeper than a standard pelvis,which made the axilla less accessible than otherwise it wouldhave been, and rendered the operation a little more difficult. Theplacenta was quickly thrown off into the vagina, and thence re-moved within ten minutes after the birth of the child. The childwas of average side ; full term. The pulse after delivery was 90,of moderate strength. The uterus was left favourably contracted.The patient’s puerperium was passed through without a singlebad symptom.Remarks.-Had my friend been called to this patient before, or

immediately after the discharge of the waters, in all probabilityhis attempts to turn would have been successful, and the child’s lifewould have been saved. Of the three remedies for the subductionof inordinate uterine action-bleeding, opium, chloroform-thefirst was contra-indicated by the patient’s freedom from pyrexiaand plethora, her condition rather below than above par; thesecond and third sedatives were tried, but without responding inany degree to our wishes. The only resource left for the reliefand security of the patient, was delivery by embryotomy, after themanner indicated for a transverse presentation. In the instancesof labours with large children presenting transversely, it is, as Ihave already illustrated, necessary to decapitate before we cansucceed in extraction, but the average dimensions of the child inthis instance rendered unnecessary that part of the operation.Another arm-presentation labour, with funis prolapsing, and

partial placenta prcevia, attended by much flooding during apart of the labour; a third labour ; previous labours pro-tracted, and children still-born patient’s age twenty-eight ;deformity by rickets. Opium failed as a sedative of spasmodicaction; chloroform succeeded, and rendered turning prac-ticable.Feb. 12th, 1850.-Nine P.M.: I was requested to visit, in a

parochial infirmary, a poor woman, deformed by rickets, of shortstature and spare habit, aged twenty-eight, in labour of her third

child, at full term. I was informed that her previous labours hadbeen protracted, and terminated by still-births. The membraneshad broken at midday; there had been much hoemorrbage, which,on examination, appeared to have been determined by a partialpresentation of the placenta. Attempts at version had been made,on two different occasions, without success, even after the patienthad been subjected to the influence of a full dose of opium.My attempts were alike fruitless, until I had placed the patient

under the influence of chloroform, of which six drachms weredisposed of, in separate portions, upon a handkerchief, looselyheld over the nostrils and mouth. The child was then turnedwith perfect ease. In performing the operation, I employed thetape-noose to fix the foot at the brim, while with the fingers ofthe other hand I pressed up the presenting part. The patientwas very restless and unmanageable before the exhibition ofchloroform ; calm afterwards, and during a part of the time thatwrs devoted to the operation, unconscious. The child was still-born, as was to be feared after so long delay and pressure on itscirculation. The after-birth followed in less than ten minutes,without hsemorrhage. No inconvenience followed the use of thechloroform, beyond vomiting three or four times, what had beenpreviously taken. The patient was left with a well-contracteduterus, and a good pulse.

..B6MMM-Z;s.ŇAn earlier resort to the exhibition of chloroformwould, in all probability, besides shortening the patient’s suspenseand suffering. have saved the child’s life. Abstaining, as I do, fromchloroform from choice, in natural labour, I deem a case of thiskind, in the absence of any organic disease or peculiarity to contra-indicate its exhibition, admirably adapted for its employment.That agent, it was seen, succeeded in diminishing the spasmodicaction of the uterus, opposing the efforts to turn, where a corre-sponding quantity of opium had entirely failed. In one of myformer illustrations, I related a case of placenta prsevia, in whichI had been consulted, attended by much hsemorrhage, where theuterine spasm was so great that turning was quite impracticable.Opium was inadmissible on account of a peculiarity of thepatient’s constitution, in reference to that drug. Chloroformwas administered at my suggestion to the production of its seda-tive effect: the operation of turning then becameeasy,and was com-pleted in time to save the child, which was living and vigorous onthe following day, and for aught I know to the contrary, is so at thepresent time. I have not, in the few cases, nineteen in number, inwhich I have given this agent, observed any increased tendency tohaemorrhage from its use. I have not found it in that experienceto diminish strictly parturient action. It has appeared to methat its sedative effects on the uterus have been limited to thesubduction of irregular or spasmodic action of the muscular fibresof that organ, which, I take it, is the kind of resistance opposed toour manual proceedings in cases of difficult or impracticableturning.

Russell-place, 1852.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, tum aliorum proprias, collectas habere et inter secomparare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14, Proœmium.

KING’S COLLEGE HOSPITAL

Cases of Cleft Palate; Staphyloraphy ; Perfect Union.(Under the care of Mr. FERGUSSON.)

IT will be readily understood by all those practitioners whoare acquainted with the various papers which have from timeto time appeared upon improved methods of staphyloraphyfrom the pen of Mr. Fergusson, that we watch his operationsfor cleft palate with peculiar interest. Indeed it happenedlast summer that, by a strange coincidence, one of theseoperations assumed a more than usually important character,as M. Sdd:llot, the professor of surgery at Strasburg, and Mr.Avery, were present. Our readers are aware that both these

gentlemen have laboured very successfully in the subdivisionof operative surgery which we are this day considering.Some misapprehension at one time existed as to the relative

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merits of M. Sédi110t and Mr. Fergusson touching the im- large vessel. Further back than this, there might be a riskprovements introduced in the method of operating; but it was of the point passing out at the side of the upper part of theacknowledged by the French surgeon that the changes intro- pharynx, and doing serious mischief," (loc. cit.) The marginsduced by him referred principally to the forms of the instru- of the soft fissure having been pared, the threads were passedments in use. by means of a needle set in a handle, with the eye at the

It will be recollected that llr. Fergusson pointed out some extremity, the threads being, as usual, of different colours.years since that the well-known approximation, during deglu- It requires much coolness and patience,-whilst the mouthtition, of the soft margins of the fissure, is owing to the con- fills with blood and saliva, and the patient, perhaps, in-traction of the superior constrictor of the pharynx and the voluntarily coughs,-to seize, by means of the forceps, theupper portion of the middle constrictor; and that the palato- thread which appears with the point of the needle in the

pharyngei and levatores-palati muscles tend to separate the fissure. This thread was drawn for several inches out ofgap of the velum. Hence Mr. Fergusson inferred, that "if the mouth, and made to lie, being double, of course, over thethe chief muscular action affecting the soft palate could be commissure and chin. The same is done on the other side ofdone away with,-either for a short time or permanently,- the gap; and the two inner ends of the four, which are hang-there would be a greater probability than ever of union taking ing out of the mouth, are then tied. The outer end on theplace in the mesial line when the parts were united by the pro- patient’s left is now drawn outwards, and naturally carries thecessofstaphyloraphy." As a preliminary step, therefore, to the thread lying on the patient’s right across the fissure throughordinary operation,the division of the levator palati on each side the second aperture, and finally out of the mouth. Thus waswas suggested, and also, if it seemed needful, of the posterior there now one thread ready for tying.pillars of the fauces, whereby large portions of the pa.ato- This latter process of tying, Mr. Fergusson manages in apharyngei might be cut across. Mr. Fergusson also thought very neat manner. He makes a loose loop with thethat the anterior pillars, each containing the palato-glossus, end of the thread lying on the patient’s left, the end of tliemight possibly require division. other thread, on the right, is passed through the loop, and that

Perhaps some of our readers will be glad to be reminded of end being gently drawn away from the patient, the loop slidesMr. Fergusson’s reasons for recommending the division of the inwards towards the fissure, the two margins of which itabove-mentioned muscles. We subjoin them from a paper pub- nicely and securely brings together; a common knot is after-lished in the London Journal of Medicine:" An examination wards added, and the threads cut short.of the course of the fibres of these muscles in the cleft state The bystanders cannot minutely follow all the stages of theof the palate will show, beyond a doubt, that one of their operation within the mouth, but by seeing the proceedings re-actions will be to pull the edges asunder; in this state of the peatedly, as it is the case with ourselves, all the steps of itparts the anterior or upper extremity of each muscle is become familiar, though its difficulties grow more and moreattached to the posterior margin of the osseous palate, and striking. Three stitches were applied in the manner abovethe fibres in their progress downwards, towards the sides of described, and the boy, who had behaved extremely well, re-the pharynx, form a convexity upon the margins of the soft turned to the ward.flap, (in fact, it is this convex part which constitutes the most The parts were lax and thick, and therefore favourable forbulky part of the flap;) thus the action of each muscle tends the operation. The patient was kept on liquid food, thoughtowards the straight line, the parts are drawn asunder at such not starved, as was formerly the custom, and strictly prohibiteda time, and consequently the gap is enlarged. In the ordinary from talkiug. Mr. Fergusson did not disturb the parts forcondition of the palate these muscles have their fixed points eleven days; after which time, he removed the three stitches,above, in the mesial line of the soft palate, and acting towards and union was found perfect. The boy was now allowed tothat line, they must necessarily close or cause the posterior speak. Some difference .was at once noticed in his intonation.pillars to approximate, in accordance with their supposed He was discharged on the fourteenth day after his admission;functions. Perhaps during deglutition in the cleft state, the and it may be presumed, that, by careful practice and training,upper margin of the superior constrictor forms for the instant the voice will become natural.a fixed point, which permits the lower portion of the palato- It will be perceived that the stitches were allowed to remainpharangei to act in the normal manner; but during the for eleven days, and the result has certainly been very satisfHoc-quiescent state of the constrictor muscles the palato-pharangei, tory. Formerly the threads were taken out very early; butwhen exerted to action, must tend to enlarge the fissure in Mr. Fergusson has now found that it is better to leave thethe mesial line. The tensor (or circumflex) palati seemed to stitches a pretty long time, for fear of breaking adhesions.me to possess so little muscularity, and besides to have such a CASE 2.-Thomas P-, aged twenty-six, was admitted,limited sphere of action, that I deemed its influence upon the CASE 2—Thomas P—, aged twenty-six, was admittedmovements of the palate as of little consequence, and I enter- Jan. 7, 1852, under the care of Mr. Fergusson, with congenitaltained similar views with regard to both the palato-glossus

fissure of the soft and hard palate-a peculiarity in the ap-and the azygos uvulae"

i & pearance e of the gap being a delicate band running across from

We shall now glance at a few of the later cases which have one margin to the other, just at the complicated of the velumbeen under Mr. Fergusson’s care at King’s College Hospital. to the bone. Here, voice very a complicated malformation° ° & f which affected the voice very considerably. Mr. F ergussonCASE 1.—Edward P-, aged seventeen, was admitted determined to lessen the evil, in closing the soft palate,

December, 1851, with congenital fissure of the soft palate. leaving the proceedings to be attempted upon the hard portionFor some days previous to the operation, the patient was for a later period. The patient, who was thoroughly resolvedallowed an alum gargle, to allay the vascularity of the part, to assist the surgeon with all his power, was prepared with theand astringe the tissues; he also made frequent use of a alum gargle and the feather, as had been done in the first case,feather, slightly to irritate the back of the mouth, so that the and the operation was performed three days after admission.irritability natural to that region should be, as far as possible, The young man displayed admirable fortitude ; thegradually diminished. muscles were divided, and the three stitches applied in theMr. Fergusson is in the habit of advising this kind of manner described above, with comparative ease, owing to the

preliminary schooling, and it is very probable that in the firmness of the patient. The subsequent restrictions were thepresent case it aided materially, combined with the patient’s same as were enforced in the first case; and just one weekcourage, to make him bear the operation with as much resolu- after the operation, Mr. Fergusson presented this patient totion as its painful nature can allow. Staphyloraphy is, of the pupils, subsequently to an operation of a somewhatcourse, one of the few operative proceedings where chloroform similar kind which we shall relate below, and the fissure wascannot be used. found perfectly united.Mr. Fergusson operated December 20th, 1851, and began Mr. Fergusson said that it was very satisfactory to see such

by dividing the levator palati and palato-pharyngei muscles complete union after so short a time. He had not cut awaywith a bistoury, the cutting portion of which forms a small the isthmus or band, (which we described above,) for it provedtriangle, and is placed at right angles with the stem. The very useful, by assuming more thickness between the stitcheshaemorrhage after this preliminary myotomic step was not on either side of it, and it had now become almost a quarter ofconsiderable,-indeed, Mr. Fergusson has generally found it an inch broad. Nor was that band useless in another point oftrifling, provided the incision be kept within the proper view, as it caused the circulation through the uniting parts tobounds. The following are the operator’s directions:- be more plentiful. The stitches had been removed only the

" There might be imminent danger if the knife were carried previous day, Mr. Fergusson never thinking, at present, offar back above the palate, but so long as it is limited in its taking them off before eight or ten days are passed. Theaction between the posterior nares and the posterior border parts for the first two or three days had looked rather sioughy,of the levator palati, there is no possibility of reaching any yet Mr. Fergusson was not so much alarmed at this circum-

119

stance as he formerly might have been: he did not removethe stitches, a myrrh lotion was used, and union had satisfac-torily taken place. One of the stitches, as sometimes happens,had fallen out spontaneously.As to the hard palate, the gap had already become smaller

by the contraction of the velum below it. Mr. Fergussonpurposes, after a little while, to endeavour to close the greaterportion of the hard palate, by bringing the mucous membranetogether, and, with a mechanical contrivance, speech will pro-bably be much improved.As to mechanical contrivances, we would just cursorily re-

mark that we saw, last summer, a very neat obturator,brought to London, by M. Liier, of Paris. It consists merelyof two strong cylindrical caoutchouc rings loosely superposed,one being double the siza of the other; the larger one is intro-duced into the fissure which the lesser one immediatelycloses, the neck between the two rings being caught in thefissure. None but actual force and lateral pulling can dis-place this obturator. We lately noticed a case at the RoyalFree Hospital, under the charge of Mr. Gay, which not onlypresented a fissure of the velum, but a complete separationof the hard palate even to the incisors, with double harelip.The operations were here performed upon those various de-fects separately, and the final result, especially as to theapproximation of the bony parts, has been very satisfactory.The girl will probably, with the aid of an obturator, regain anatural voice, and her appearance is of course vastly im-proved. The details of this case, where Mr. Fergusson’smethod was fully carried out, will soon be brought before ourreaders, and no doubt prove extremely interesting.CASE 3.-In this instance, the subject is a woman, about

twenty-five years of age, of a very nervous and excitable tem-perament. The deficiency in the velum is not congenital, buthas resulted from a sloughing process which took place in thepart. The perforation which had ensued was large enough toadmit the tip of the index finger, and this state of things hadthe usual effect on the articulation of words.The first steps of the operation, which took place on the

17th of January, 1852, were the same as in the above Cases-viz. the division of the lavatores palati, and the anterior fibresof the palato-pharyngeus muscles. But besides these measures,Mr. Fergusson thought it likewise necessary to detach theupper part of the velum from the bone, herein followingthe advice given by Dr. Warren, of the United States ofAmerica. By these incisions the velum lost much of its ten-sion, and the aperture in it looked smaller. The fits of cough-ing and spasmodic contortions of the patient were very dis-tressing, and put the patience of the operator to a severe test;but the stitches were applied in the manner described above,the parts not offering much resistance, as they were com-pletely relaxed.Mr. Fergusson stated that he entertained some doubts as to

union in this exceptional case; but he still preferred theproceeding to which he had resorted to certain measures ofplastic surgery which had been recommended. Mr. Fergus-son had had no ocular demonstration of their good effects, hehad only seen prints and books regarding this kind of opera-tions, and on these he could not put implicit reliance. Afterthis patient had retired, Mr. Fergusson removed a piece ofnecrosed bone from a young man; under circumstances of pe.culiar interest.

Necrosis of Portion of t7te Ilium.(Under the care of Mr. FERGUSSON.)

James R-, aged twenty-six, noticed, about two yearsprevious to his admission into Canterbury ward, a swelling justbelow the vertebral column, in the right iliac region. It gra-dually increased in size, but did not cause much pain, norprevent him from attending to his work. About six monthsprevious to his applying here, two abscesses, in the lumbarand sacral regions, were opened at St. George’s Hospital, andhe left that institution much relieved. On examination he wasnow found to present a large, diffuse, reddish swelling aboveand behind the right hip, where two openings, respectivelyleading iuto sinuses, were also noticed. One of these wassituated over the sacrum; the other over the posterior portionof the ilium. The probe introduced along these fistuloustracts, did not detect dead bone very distinctly, but strongsuspicions were entertained that such was existing at the backof the ilium or upper part of the sacrum. Mr. Fergussondirected soothing applications to the part, and tonics inter-nally, and on the 17th of January, 1852, the young man wasbrought into the theatre, as it was clear that no benefit could

be expected unless the source of irritation, probably necrosedbone, was removed.When the patient was under the influence of chloroform,

(which agent caused at first so much excitement as to requirethe assistance of six persons,) Mr. Fergusson made an incisionfrom three to four inches in length, unconnected with eitherof the fistulous apertures, being, in fact, a kind of counteropening. This incision over the supposed site of the necrosedbone was preferred to largely laying open the sinuses, as thusthe wound was less extensive. By introducing the finger, apiece of dead bone was now felt, the pointed gouge was intro-duced, the bone raised, and by the forceps a piece of necrosedbone, about the size of a small orange, was extracted.Mr. Fergusson remarked that a good deal of uncertainty had

existed in this case, and that the present result showed howuseful and proper it is thoroughly to investigate the state ofthe parts, and assist nature in the process of extrusion. Heconsidered that twenty years might have been necessary forunassisted nature to accomplish what he had done in about asmany minutes. Recoveries, in cases like the present, werevery rapid, and the patient had now every favourable chanceon his side.

CHARING-CROSS HOSPITAL.Cases of Acute Rheumatism; Treatment by Lemon-juice;

Rapid Cure.(Under the charge of Mr. HANCOCK.)

MR. HANCOCK has lately been trying the lemon-juice inacute rheumatism, with two patients, according to Dr. OwenRees’s plan, and both recovered in about a week. The firstpatient is a servant girl, of twenty-three years, who was ad-mitted, Dec. 30, 1851, with acute rheumatic pain in the rightwrist, which flew, two days afterwards, to the left, the jointsin both cases being red and swollen. The shoulders weresubsequently involved, and the perspiration was profuse. Thepatient took, at first, calomel and Dover’s powder, and coolingalkaline draughts. On the second day, she was ordered oneounce of lemon-juice every fourth hour, and went on takingthese doses, with an occasional anodyne at night, for ten days,when all the above-mentioned symptoms had disappeared.Mr. Hancock now prescribed quinine and quassia, the patientonly complaining of weakness and want of appetite.The second case refers to a man of forty years, who was

admitted, Jan. 6,1852, with a non-rheumatic affection of theknee. Whilst under treatment, lie was suddenly attackedwith pain, swelling, and redness of the left wrist. Mr.Hancock ordered half an ounce of lemon-juice, three times aday. This dose was taken for a week, when we were kindlyshown the patient, who had regained the full use of the wrist.There were no heart complications in either case.

MIDDLESEX HOSPITAL.Case qf A neurism of the A rte1’ia I nntYffitinata.

(Under the charge of Mr. SHAw.) )THERE is now in Percy ward, a man, sixty years of age, and

a bricklayer by trade, who is suffering from aneurism of thearteria innominata. The disease has been noticed by thepatient for the last two years, and has now reached the sizeof a turkey’s egg. It lies behind the two sterno-claviculararticulations, beats very strongly, and sinks somewhat intothe chest behind the upper bone of the sternum. The manhas always enjoyed good health, but is now affected with asevere cough, which is probably owing to pressure on thetrachea, or on the recurrent nerve. Surgery cannot do muchin such a case, as the only plans that could be adopted aremore hazardous than the disease-viz. the tying of the inno-minata between the heart of the tumour; tying both the sub-clavian and carotid on the distal side of the tumour, (Brasdor;)or coagulating the blood in the sac by an electro-galvanic current,(Petrequin of Lyons.) Soothing measures are meanwhile em-

ployed, both externally and internally.

GUY’S HOSPITAL.Removal of a .N aeVU8 by the Platinuoi Wire, heated by a Galvanic

Current.

(Under the charge of Mr. HILTON.)Oun readers probably remember the cases of fistula in ano

and hsemorrhoids successfully treated by Mr. Marshall, at