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Another incision of about two inches in extent was madeto pass from the convexity of this directly forwards or

quite the outer part of the sole, over the calcaneo-cuboidarticulation. A flap was then dissected from the heel, thetendo-Achillis divided, and the whole back part of the calcieexposed. Lateral flaps were next dissected back, the arteryand nerve being carefully preserved while making the innerone. Thus the plantar, external, and internal surfaces of thebone were exposed. The bone was next grasped in order tosteady and use it as a lever, while a stout, narrow-bladedknife, made for the purpose by Messrs. Ferguson, was intro-duced between the calcis and astragalus, to divide the inter-osseous ligament; this done, the anterior connexions of thebone were divided in a similar manner, and the excisioncompleted. Very little blood was lost, and no ligature wasrequired.Three hours after the operation, all oozing having ceased,

the flaps were brought together with two sutures and a fewstrips of isinglass plaster, a compress was placed over theheel, and secured by a roller which extended to the knee.On the fourth day the dressings were removed, and almostcomplete union was found to have taken place between thecut surfaces.

Remarks.-In performing the above operation, I adopted theplan recommended by Mr. Guthrie in a lecture recorded in arecent number of THE LANCET, excepting that I commencedmy incision further back, and exposed the calcaneo-cuboidarticulation by means of a second cut. I was induced to dothis by the situation of sinuses which I wished to include,and still more by my desire to preserve the posterior tibialartery; for though doubtless the foot would have received a suf-ficient supply of blood from other sources, there could be nodisadvantage in attempting the preservation of this vessel; itsdivision during the operation would materially delay its per-formance ; and further, its preservation would allow of morepressure being subsequently made with the bandage withoutfear of sloughing. In order to expose the anterior part of thecalcaneum, a second incision was carried forwards from thefirst, quite in the outer part of the sole, to avoid the externalplantar artery; this rendered it unnecessary to have so largea posterior flap, which was, in consequence, more easily dis-sected back. The second incision was also useful in allowingthe parts to adapt themselves more -perfectly to the hollowcaused by the removal of the bone.Margate, August, 1852.

A CONTRIBUTION TO CLINICAL MIDWIFERY.

BY N. J. HIGHMORE, M.D., M.R.C.S., Bradford.A. B--, aged thirty-six, sent for me at seven o’clock on the

morningofthe29thof January, she being in labour with her firstchild. She stated that her pains had commenced at niidnight,andcontinued gradually increasing infrequency and severity. Theynow occur at intervals of about five minutes; the bowels havebeen twice purged, and the urine is passed frequently andwithout difficulty. On examination, I felt the head of the childdistinctly through the uterine parietes; and after a short timeI left.At half-past nine I was again summoned; the pains were

then rather more frequent, but I found that I was unable todetect the os or cervix uteri, although the vagina was relaxed,and the uterus descended low down with each pain, feeling likea smooth, globular mass, bounded all around by the vaginalcul-de-sac.

’I again called at half-past one, when the symptoms remain-ing as before, I informed one of the persons present of thenature of the case, gave a dose of laudanum, to allay excessiveuterine action and favour relaxation, and again left, thinkingthat if agglutination existed, the continuous pain would

develop the os. ’

At half-past four I again visited my patient, and found that I

although the pains were almost constant, and very severe,not the sligldest trace of the uteuioae orifice existed. I thereforestated the nature of the difficulty to the family, and requestedthat my friend Dr. Morgan might be called in to consult withme.

At his arrival, shortly after six o’clock, on examination,the occluded os uteri was found to have yielded, and was dilatedalmost to the size of a half-crown; and so rapidly did thelabour progress, that she was delivered at ten minutes beforeseven, of a living female child. The placenta was adherent,and had to be removed; it was very soft and friable, breakingupon the slightest pressure, and having precisely the feeling

and consistence of clotted blood. The mother made a goodrecovery, and both she and the infant are now well.Remarks.-The patient whose case I have narrated, has,

since her marriage and during gestation, enjoyed good health,but, previously, was for years in a very delicate state, sufferingfrom aummia, general debility, dyspepsia, pain in the back,scanty, painful menstruation, and leucorrhcea; the connexionbetween which symptoms and the history of her labour,forming, I think, a very perfect and interesting illustration ofone branch of uterine pathology.i Bradford. Wilts. 1852.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. BARTHOLOMEW’S HOSPITAL.

Epidemic of Carbuncular Inflammation of the Lip.(Cases under the care of Mr. STANLEY

and Mr. LLOYD.)

I Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, tum aliorum proprias, collectas habere et interseIcomparare.-MoRGAGNI. De Sed. et Caus. Morb., lib. 14. Proremium.

, t

t AN epidemic of carbuncular inflammation of the upper lip- has been reigning for some time past, and the disease has proved) in some instances extremely severe, and even fatal. Cases of

: this affection have occurred in various hospitals, but it would! appear that by far the larger portion have been admitted intoG this institution. It is worthy of remark that the number of cases! of common carbuncle is not in the least diminished by the

l above-mentioned epidemic-indeed, they seem to have greatly, increased. The size of the sores is here and there enormous. (as large as a dessert-plate), and the fact obtrudes itself upon

the observer, that there is now reigning one and the same’

epidemic, attacking either the nape of the neck or the

upper lip.It is particularly to the latter affection that we wish

to draw attention, for we are not aware that it has beendescribed by surgical writers. Indeed, when it was first ob-served at St. Bartholomew’s Hospital, the general impressionwas, that it depended on some local irritation, or was theresult of some noxious influence connected with the patient’strade. (See THE LANCET, vol. ii. 1851, p. 104). But no suchidea can now be entertained, for the numerous cases whichpresent themselves all point to a generally-diffused epidemicaction. Of what nature the poison may be, is, however, some.what difficult to discover; but one fact should nevertheless benoticed-viz., the recurrence of the epidemic at the hot seasonof the year, and also the circumstance that the cases havebeen far more numerous this very hot summer than they werelast year, when the temperature was uniformly lower.

It would be interesting to ascertain whether cases of thiskind have been at all observed in private practice among themiddle and higher classes of society, in order to determinewhether the great heat, combined with the effects of unhealthydwellings or trades, is the chief agent in the production ofthe pathological phenomena to which we are alluding.We know of one case, in which the subject was a surgeon,

whose symptoms were very severe. The patient was underthe care of Mr. Wormald, and recovered completely. Freeincisions and stimulants formed the principal features of thetreatment.The cases have been so numerous at this hospital, that we

shall not attempt to particularize them,-indeed, the symptomswere very much of the same nature in all instances, thedifference lying principally in the more or less intensity. Theprincipal phenomenon presented is an enormous swelling ofthe upper lip, arising gradually from a pustule, which springsup at some part of the upper lip. The heat, pain, and rednessdo not keep pace with the oedema, which latter is the-moststriking symptom. This is generally carried so far, that thewhole face becomes frightfully swollen, as is seen in the worstcases of erysipelas. Such distention and infiltration mustnecessarily be followed by sloughing of the cellular tissue;and this change is made very evident by the aspect of theparts after the incisions which are generally made through the

175

edema.tous textures. The fever which accompanies thesesevere local symptoms is generally of the typhoid type, and somuch so that support is clearly indicated. We shall justsketch a few of the cases which have come under ourcognizance :-Henry F-, aged nineteen years, a robust young man of

fair complexion, and a copper-founder by trade, was admittedinto Darker ward, June 17th, 1852. The patient has alwaysbeen very moderate in his habits; and being suddenly seizedwith pain and swelling in the upper lip, he presented himselfto Mr. Wormald as an out-patient, three days before his ad-mission into the hospital. Mr. Wormald made a free incisioninto the already considerably swollen parts, which procedurewas followed by a good deal of bleeding. The affection hadbegun by a small boil in the lower part of the groove of theupper lip. As the pain and swelling went on increasing, theboy was taken into the hospital. ,

The whole of the upper lip was at that period enormouslyswollen, as well as the right side of the face, the whole beingbrawny and hard; the eye was closed, and the patient couldhardly speak. The thickness of the tissues about the lip andface is certainly increased fourfold, and the aspect of thecountenance is frightful. The tongue cannot be protruded,the pulse is small and frequent, the skin hot, the secretionsscanty, and no sleep can be obtained.Mr. Stanley made several incisions in various directions,

and gave exit to some purulent matter and blood; Dover’spowder was given at night, acetate of ammonia in the day,and several ounces of wine.

In spite, however, of repeated incisions, and plentifulsupport, the patient became daily worse, and died four daysafter admission. On a post-mortem examination, purulentdeposits were found in the lungs, and extensive adhesions ofthe pleura.

Second Case.-Illustrating the mild va1’iety. IJames P-, aged nineteen years, of fair complexion, a

stay-cutter by trade, and who has lived rather freely, was ad-mitted into Colston ward, June 17th, 1852, under the care ofMr. Lloyd. Two days before admission, the patient noticeda pustular elevation upon the upper lip, on the right side, andthe whole of that half of the face swelled considerably in thespace of three hours. He did not experience much pain, butthe tension of the parts was very disagreeable. As the sizeof the lip and face, as well as the pain, went on increasing, theyoung man applied to the hospital.On examination, the whole of the right side of the face was

found cedematous, hard, pale-red, and glossy; the lip everted,and increased to about three times its natural size. Thepatient does not experience very much pain, except when theparts are pressed. The constitutional disturbance is not sogreat as in the preceding case; the tongue is clean, and thepulse 90, with tolerable power. Leeches, fomentations, andpoultices were used in this case. Internally the patient tookthe acetate-of-ammonia mixture, and mild purgatives. The

symptoms were gradually subdued by the further use oileeches. Wine was allowed, and in the course of a fortnighithe patient had quite recovered.

Third Oa8e.-Illu8trating the very simple variety. IEdward B-, aged sixteen years, a healthy, intelligent I

boy, following the occupation of silkmercer’s porter, wasadmitted June 17th, 1852, into Kenton ward, under the careof Mr. Stanley. None of the above-mentioned patients, northis boy, remember any irritating substance coming in con-tact with their lips. Two days before admission this patientnoticed a little pustule on the groove of the upper lip, just abovethe red margin; the part swelled rapidly, and no sleep could beobtained. The pain was not very severe, but great incon-venience was experienced from the aedematous state of thelip and face.When admitted, these parts were about twice their natural

size, hard, red, painful, and brawny. The tongue was clean;the pulse 90, but with no power; the skin rather hot, butsomewhat moist. Mr. Langdon, Mr. Stanley’s house-surgeon,made a transverse incision across the red part of the lip,which yielded about half an ounce of pus, and soon afterwardsthe surfaces of the wound looked sloughy. A poultice wasapplied on the lip and face, and with very simple treatment,composed of light purgatives, broth, &,c., the boy quicklyrecovered, and left the hospital five days after his admission

It will be perceived that these three patients were receivecinto the hospital on the same day; and since that period case:of this kind have been frequently admitted. The fatal issue

has, however, been the exception, and recovery the rule.There is now in Darker ward, under the care of Mr. Stanley,a young man, about twenty-four years of age, presentingexactly the same symptoms as have been described of the

first of the preceding cases; he is being treated in the same

manner, but his recovery is doubtful.ST. THOMAS’S HOSPITAL.

Melanotic Tumour growing from the Heel; Amputationof the Leg.

(Under the care of Mr. LE GROS CLARK.)THERE are certain portions of the body more prone to

become the seat of melanotic tumours than others: the eyeand some of the viscera being the localities most frequentlyattacked. Melanosis has also been observed upon the trunkand upper extremities; but the heel is rather an unusuallocality for this kind of malignant growth. A very strikingcase, in which the tumour was so situated, was lately treatedby Mr. Clark; it is well worthy of being placed upon record,both as regards the pathological alteration itself, and theoperative measures which were had recourse to.

Philip W——, an agriculturist, seventy-one years of age,was admitted into Naples ward, June 24, 1852, under the careof Mr. Clark, with a melanotic tumour growing from the leftheel. Neither the patient’s parents nor any member of hisfamily have ever suffered from malignant disease; his fatherdied at the age of eighty-four, and his mother at eighty. Theman himself has always enjoyed excellent health up to thetime when the ulceration of his heel began to give himuneasiness.

Seven years before admission a vesicle formed upon thelatter, on the left side, from some irritation and pressure ofthe shoe; he opened the vesicle with a needle, and gave exitto a little serum mixed with blood. A small ulcer, the sizeof a shilling, now gradually formed, and interfered to someextent with his comfort as to walking and common fieldlabour. This state of things continued for four years, whenthe patient was obliged to give up work, and applied to asurgeon. The ulcerated spot was then about the size of afive-shilling piece. The principal application used was sulphateof copper; but the part soon began to throw out a fungus,and the patient now experienced much pain in the heel. Thetumour progressed very slowly for about three years; but forthe last three weeks before admission it grew very rapidly,and Mr. Clark, who had been consulted in the country con-cerning the case, advised the patient’s removal to town.On admission, the outer portion of the left heel was found

covered with a globular, fungoid mass, of a dark colour, nodu-lated, discharging a considerable quantity of pus, and of thesize of the clenched fist. The tumour seemed principally con-nected with the skin, was somewhat moveable, and did notappear to have any direct communication with the os calcis.The patient complains of sharp, lancinating pains in thetumour, but his health has not materially suffered, in spite ofthe protracted suffering which he has experienced. -

As it was evident that this tumour was of a malignant kind,Mr. Clark resolved to take off the leg, rather than subjecta man of so advanced an age to a recurrence of the disease inthe cicatrix. The operation was performed on the 3rd’ofJuly, 1852, the patient being under the influence of chloro-form.The tumour was carefully examined by Dr. Bristowe, demon-

strator of morbid anatomy to the hospital, and we have muchpleasure in subjoining the results of this investigation:-The tumour was seated on the outer ankle, and encroached

somewhat on the sole of the foot; it was sessile and mushroom-like-that is, the tumour itself was broader than its base, thediameter of the former being about three inches, that of thelatter about two; its surface was divided by deep fissures intolobes, and these again were more or less perfectly divided intolobules; generally it was of a deep brown-black colour, butsome of the lobules were pearly white, and even where blackestthe surface was divided into irregular islets by bands of asimilar white hue. Many of the lobules were covered by akind of cap of epidermis, which in most instances was com-pletely isolated from the epidermis of the healthy skin. Thiswas easily separated, and found to grow on, and to be adaptedto, overgrown papillae of a pearly-white colour; some of themwere half an inch in length. The epidermis of the skin sur-rounding the tumour was quite healthy, and was prolonged toa variable distance into the tumour.

. On section the tumour was found to be confined entirely :to: the skin; it did not seem to extend at all below the level -of