RAPHY.

Although the congenital fissure of the palate does not necessarily affect the health of the individual, it is a malady which causes him much distress, and often destroys the comfort of his existence. Every act of swallowing is a punishment; for the food, especially if fluid, is apt to pass through the cleft into the nasal passages, and be rejected by the nose; and the speech is usually so indistinct, that the unfortunate patient can with difficulty make himself understood.

It is therefore, surprising that surgeons had never made any attempts to remedy this defect, until MM. Graefe and Roux, nearly about the same time, proposed and practised the operation which has been called staphyloraphy. It must be confessed that the operation is one of very considerable difficulty and uncertainty, in consequence of the peculiar susceptibility and disposition of the parts involved. All the manipulations are performed within a contracted cavity, the walls of which, on the slightest irritation, are thrown into irregular and involuntary movements, accompanied with irrepressible efforts of vomiting and cough. The only method of overcoming these, is by endeavouring to accustom the throat, step by step, to the contact of foreign bodies. Even when this has been accomplished, the surgeon may find himself much embarrassed in his attempts to make the section of the cleft palate neat, regular or uniform, and to pass the needles and ligatures through the two sides at the wished-for points, so as to approximate them smoothly and equably. Any feasible proposal to faciliate these desirable ends must be received most gratefully by whoever undertakes the delicate operation of staphyloraphy. M. Berard, of Paris, suggests the following hints, the adoption of which, he believes, contributed essentially to his

success in one case. The operation, he says, consists of three stages, viz. the passing of the threads, the paring of the edges, and the tying of the ligatures. The points of the suture, on either side, ought to be exactly opposite to each other; the spaces between them must be equal, or nearly so, and sufficient thickness of substance must be included between any two opposite sutures, to prevent the ulceration of the interstitial parts before the adhesive union has taken place. The contrary error, that of including too great a thickness of substance, may, indeed be committed, and its effects are nearly quite as injurious, causing a most painful dragging of the velum and soft palate, and inducing a troublesome inflammation in these parts. It is, however, to be well kept in mind, that the failure of staphyloraphy is more often attributable to the former than to the latter of these errors.

M. B. strongly recommends that the sutures be made progressively from before backwards, and not in the opposite direction, as some surgeons have proposed and practised. In the second stage or period of the operation, the section ought to commence at the upper border of the velum; for this curtain, being fixed by its adherent edge to the point of the osseous palate, may be kept stretched by the pressure of the bistoury alone: some surgeons prefer scissors to a scalpel for paring the edges-it is, however, to be observed that, with the former, we are more apt to cut the threads than with the latter. When the incisions have been duly made, the next step is to approximate the edges, and to retain them in apposition by tying the ligatures. The most convenient of all " serrenœuds" are the fore-fingers of the operator, which may generally be conveyed to the requisite depth; in some cases, indeed, considerable difficulty is experienced at this step of the operation, in consequence of the nausea and efforts

to retch whenever the fingers touch the palate or velum; also from the surgeon not being able to see distinctly the parts on which he is operating. M. Guyot has recently invented an ingenious instrument, by means of which he thinks that the surgeon will be enabled to tie the ligatures, without the introduction of the fingers into the mouth. Even after the operation has been satisfactorily concluded, the anxiety of the surgeon is not over, for he knows well the extreme difficulty of keeping the parts quiet and motionless; and, without this favourable condition, he cannot expect a serviceable union. Every effort of swallowing is necessarily attended with some movements of the palate; and although we may endeavour to nourish the system for a few days with beef-tea, enemata, and so forth, the thirst of the patient forces him to be taking every now and then a mouthful of drink, and even sometimes the urgency of his hunger is so intolerable, that he cannot abstain from wishing for food by the mouth.

It has been proposed to introduce food into the stomach by means of an elastic tube, conveyed down the œsophagus: if we intend adopting this method, it will be prudent to accustom the parts to the contact of the tube for several days previous to the operation. It may be useful to detail briefly the history of the case in which M. Berard performed the operation with success. The patient was a man, 27 years of age he had the scar of the operation for hare-lip his voice was hoarse, indistinct, and his speech very inarticulate. Upon examining the throat, the velum palati was found to be cleft in its middle-the fissure extended from the uvula to within two or three lines of its adherence to the palate bones; it was about an inch and a quarter in length, and had a triangular shape, the apex of the triangle being uppermost. The palate itself, the soft as well as the hard, was quite entire. When the parts were in a state of repose, the breadth of the fissure was not more than three or four lines, but no sooner were they thrown into action, than the two halves were immediately drawn so

much asunder and upwards, that they could scarcely be perceived. For several days, M. Berard endeavoured to accustom the parts to the contact of foreign bodies, by repeatedly introducing his fingers into the mouth, and touching the parts which were to be the seat of the operation. Three sutures were employed, and great care was employed to insert each of them at about three lines, distance from the loose edges of the fissure. Fortunately, this patient was able to abstain from swallowing any food for five days, nourishing injections being exhibited two or three times daily. The ligatures were removed on the sixth day; by this time, the lower half of the fissure was well cicatrized-the upper portion also adhered, but between these there was a gap, about half an inch long and a quarter broad. The edges of this gap were touched every second or third day with nitrate of silver: they gradually became approximated, and, finally, were firmly agglutinated; but not until two months from the date of the operation. The deglutition and speech of this patient have become much more easy and distinct than they were formerly.-Archives Générales.

ON THE CURATIVE EFFECTS OF ABSTINENCE, AND OF A VERY RIGID DIET, IN CERTAIN DISEASES.

The Sangrado treatment has been several times tried and recommended in Italy, France, England, and Sweden, and now our German brethren have adopted it, and are extolling its salutiferous blessings. Rust assures us that he employs it extensively at the Charité Hospital at Berlin, with great good effects; and his disciple, M. Rolfs, has communicated the history of a case, the cure of which was altogether attributable to a "diète méthodique!" The case was one of spinal deformity, accompanied with paralysis of the lower limbs, and occurring in a lad 14 years of age.

There was also caries of the ischium, and a fistula in the perineum. Confinement to the horizontal posture for a length of time, and the use of va

rious remedies, had been tried, without any good effects. Issues had been kept open for several months; but notwithstanding their use, paraplegia had increased so much, that the patient could with difficulty lift either of his legs from the bed.

The "diète méthodique" was then commenced, and the young patient voluntarily submitted to its exactions with great fortitude. One ounce of food was withdrawn each day-no animal meat nor bread was allowed. In the course of three weeks, the whole quantity of food taken in 24 hours was only eight ounces of fresh vegetables, two small cups of milk, and half a pound of grapes. The pulse had fallen from 80 to 48 beats. After other six days, it was found that he had considerably more use of his limbs, and that not only could he raise them, but also that he could stand erect for a few minutes on his feet; nevertheless, they had become considerably emaciated. The hunger was now so ravenous, that he felt almost inclined to catch and devour the flies which settled on his clothes. From this period, the amelioration of all the symptoms was very rapid and striking, for not only could he walk about his chamber, but soon he was able to go out, and in the course of a few months he became an apprentice to a baker. The perineal fistula had quite healed.

Remarks. It is not stated what appearances the spine presented after the cure had been affected; but our readers will doubtless agree with us in believing, that there had, in all probability, never been any considerable disease of the bones, and that the paraplegia might be owing to a slight compression of the spinal cord, from the existence of a serous or other fluid within the vertebral canal. The rapidity of the cure is inconsistent with the presumption of any serious mischief of the osseous structure. One of the most important physiological effects, says M. R. of the "diète" is, that the patient draws a portion of his nourishment from his own flesh and blood, and thus the universal interstitial absorption goes on increas

ing, just in proportion to the absorption from the surface of the intestines decreases. The superfluous blood is removed, the fat of the body is taken up, and every organ supplies its quota of nourishment to the support of the whole. Although a general emaciation is the consequence of all this, and, although the organs of digestion be comparatively inactive, and the circulation become languid, it is observed that the functions of the nervous system are not depressed in proportion, and that very often they even seem to be exalted. The diseases in which the "diète" is most useful, are threatened miscarriage, hæmorrhages, dairrhoea, and ephidrosis. It is also highly efficacious, we are told, in arresting seminal pollutions, . especially if the patient, at the same time, engages in some serious pursuits during the day, and sleeps on a hard bed at night! Syphilis and many cutaneous diseases are often singularly benefited, and sometimes quite banished, by the penance of fasting. Gonorrhoa, too, may very generally be got rid of, in the course of one week, by restricting the patient to the use of mere barley water, and an occasional dose of the powder of cubebs. Some physicians have recommended that small doses of ipecacuan, or of tartaremetic, be given frequently, with the view of exciting nausea, and thus suspending the desire for food; but Dr. R. assures us that this practice cannot supersede the one which he recommends; for that in order to be of service, the feeling of hunger must be experienced, and that it is this very feeling which is often so extraordinarily efficacious in curing disease, by the state of general excitement which it induces. In conclusion, adds our starving author, it is necessary to animate and support the courage of our patients by painting, in the most glowing colours, the hope of a speedy cure, and by appealing to their honour and fortitude to assist us in the noble object they, as well as ourselves, have in view!! -Archives Générales.

We have great doubts that the praises of the "diète méthodique” will ever be sung, or at least will ever be listened

to, with so warm an enthusiasm on this side of the Channel, as in Germany or France. It has the mighty disadvantage of being in direct antagonism (to use a new medical word) with all the inbred notion of our countrymen.-REV.

thumb and fore-finger of his right hand into the vagina, ruptured the membranes of the foetus, and discharged a large quantity of the inclosed waters. The operation had by this time lasted for an hour and a quarter; and as uterine pains began to come on, the wounds were dressed, and the patient put to bed, and a large opiate was administered. The

GALBIATI.

A rachitic female, about thirty years of age, was admitted into the Hospital of Incurables at Naples, pregnant with her first child, and near the end of her gestation. She was exceedingly deformed, very low in stature, and all the limbs, especially the lower ones, were bent into the most irregular shapes. On examination of the pelvis, it was found that the sacro-pubic diameter did not exceed one inch and a quarter. A consultation was held, to determine on the practice to be followed. Signor G. proposed the operation of pelviotomy, modified in the following respects from the original Sigaultian method: the two ossa pubis to be divided with strong curved scissors or nippers, at about three fingers' breadth from the symphysis; then the ossa ischii, at the posterior part, to be similarly divided; and, lastly, the symphysis pubis to be cut across and separated laterally. "By means of this quintuple section," we are told, "sufficient space may be obtained for the easy expulsion of a fœtus from a pelvis so deformed, that the Cæsarian operation would be deemed quite necessary."

The following are the steps of the operation, as performed by Sig. Galbiati. An incision was made through the soft parts over the right os pubis, and over the region of the posterior, or lower portion of the ischium; these bones were then divided across with pliers-a manœuvre not very easily done, but which, after some delay, was satisfactorily accomplished; a small intermuscular artery required a ligature; the pudic and obturator vessels were quite safe. The next step was to divide the symphysis pubis;-this being accomplished, Signor G. introduced the

the night, and occasionally she was delirious. On the following day, the sacro-pubic diameter of the pelvis was found to have stretched at least a third of an inch since the operation; the os uteri had become dilated, and the head of the fœtus had advanced somewhat, squeezed like a wedge between the ossa pubis, and the vast protuberance of the

sacrum.

The second day after the operation, it was a question among the surgeons, whether the section of the bones on the left side should now be performed; and it was urged in favour of this step, that sufficient space might be thereby obtained for the introduction of the forceps, and the mechanical extraction of the child, of whose death there were now well-grounded suspicions. The condition of the patient was, indeed, far from being favorable; nevertheless Sig. Galbiati resolved to complete the operation, as he had proposed at first. Having, therefore, cut across the rami of the pubis and ischium on the left side, as he had done the day before on the right, he then introduced the forceps, and extracted, but not without considerable difficulty, a well-formed male foetus, whose appearance indicated that life had ceased for about 24 hours. A belt was applied round the pelvis, and warm fomentations kept to the abdomen. On the morning after the second operation, the patient was found to be in a highly irritable and nervous state; the symptoms became gradually more alarming, the pulse fell, the body became cold, and the poor woman passed "a miglior vita" on the morning of the fourth day after the first operation, and thirty hours after the second.

Dissection. The three first wounds were in a sloughy gangrenous state, bedewed with sanies; the other two

wounds were dry. On dividing the abdominal parietes, all the viscera appeared healthy; the uterus and its appendages presented no morbid signs; when cut through its internal surface was, in every respect, such as might have been expected after a recent delivery. The sacro-iliac synchondroses were in a normal state; the ossa pubis and ischii on the right side were found to have been smoothly cut in their perimeters, or surfaces, and broken through rather irregularly in their substance; but none of the spicula or fragments had injured the surrounding soft parts; the bones on the left side had been more smoothly divided throughout.The lowest lumbar vertebræ and the sacrum were greatly enlarged, and projected forwards, like a huge round mass, into the cavity of the pelvis, so that the conjugate diameter was exceedingly small.-Giornale di Ghirurgia, Napoli.

Such is a brief history of this remarkable case ;-remarkable only for the unjustifiable and barbarous boldness of the medical attendants. Really, some of our continental brethren in Italy, and, we may add, in Germany also, seem to regard the body of a parturient woman as a block of wood, on which they may cut, and carve, and chisel, with the utmost coolness. The narrator of the preceding case seems to have been quite puzzled how to account for the death of the patient! He attributes it to "a nervous affection, the result of an imagination over-excited by all the circumstances which preceded and followed the operation!!" He speaks somewhat more like a rational being, when he advises that the operation be completed at once; and that it was highly reprehensible to allow two days to intervene, before the section of the pelvic bones of the left side was performed. But the operation, however modified, ought to be denounced as murder.-REV.

REMOVAL OF CALCULI FROM THE

PERINEUM.

tal at Naples, presented on examination a prominent swelling of the scrotum; several hard bodies, like calculi, were felt under the integuments. Professor de Horatiis made an incision over the part, and extracted three calculi, of the size of coffee-beans, and a quantity of gravelly matter-the wound speedily healed. It is to be observed, that this boy had previously suffered severe pains in the region of the kidneys; the calculi were therefore probably of renal origin, and being driven along by the current of the urine, had become impacted in the urethra, through the parietes of which they had forced their way.-Ib.

A middle-aged man was lately admitted into the Hotel Dieu. The symptoms were feverishness, great debility, confusion of head, and inability to use his limbs, at least freely. There was no abdominal or pectoral distress. When he was put to bed, it was observed that the head was in a state of continual rotation, even when resting upon the pillow; it was not bent forwards or backwards, but only rolled about from side to side: the muscles of the face were occasionally convulsed, but the mouth was not distorted, nor was the tongue drawn either to the right or left side, although constantly moving with a tremulous agitation. Both forearms exhibited a prolonged convulsive.movement along their radial sides, so that the thumbs and forefingers were kept bent; the soles of the feet were turned inwards and upwards; the tendons of the tibiales autici muscles were very prominent, and permanently stiff. The patient seemed to have a complete control over the flexors and extensors of the head; when assisted, he could raise himself up and sit in bed. The movements of the thoracic and abdominal muscles were healthy. The voluntary movements of the extremities were very imperfect; he could not raise his left