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split; the longitudinal extended downwards into, and openedthe ankle-joint, which contained a little blood. The fibula wasbroken into three or four small pieces.

This case having thus terminated favourably, the questionarises-What would have been the chance of recovery withoutthe operation ? I think such chance would have been small,for even if the collateral circulation had been established, stillthere would have been a great drain upon the system for manymonths, with so large a portion of bone exposed and the ankle-joint opened, which it is not likely the patient, whose powersof life were getting enfeebled by age, could have withstood;and even if secondary amputation had been waited for, afavourable period for its performance might never have arrived.So that, on the whole results of the case (the termination andpathological condition of the injured parts), I think the manowes his life to the early amputation.

St. John’s. Fulham. 1865.

ON A CASEOF

CONGENITAL TALIPES CALCANEUS SUC-CESSFULLY TREATED WITHOUT DIVI-SION OF TENDONS.

BY W. WHALLEY, ESQ., M.R.C.S.

Oif the 12th of December, 1863, I attended Mrs. W- inher second confinement, who gave birth to a very large, healthy,female child. The right foot presented a rather singular aspect:the heel was depressed ; the toes and anterior part of the footwere elevated, the dorsum being in close proximity with thefront of the leg. An attempt being made to depress the foot,the tendons of the anterior muscles of the leg became tenseand prominent. The tendo-Achillis was elongated, but notvery tense. The integument covering the annular ligamentwas of a bluish colour, and almost transparent. The foot was

involuntarily flexed, both when awake and asleep, as is repre-sented by Fig. 1.The mother believes this deformity to have arisen from hei

having worn during pregnancy a new boot which pinched her.She expressed her great aversion to any surgical interferencewith the child’s foot. I therefore decided to apply a boot, witha view of gradually extending it. A small leather boot wasspecially made, having brass lace-holes in front; the sole olthe boot was firm, being nearly a quarter of an inch in thick.ness ; beneath the boot-lace a small piece cif leather was placed,nearly one-eighth of an inch in thickness. The foot was wrappedin flannel, and the boot put on the ninth day after birth, ten.sion being made every day upon the boot-lace, which depressedthe foot; so that at the expiration of fourteen days it was re-stored to its natural position. But at this period, when thfboot was removed, it again became involuntarily flexed. Itwas, therefore, allowed to be worn a fortnight longer, at thfend of which time the extensor muscles exhibited no signs ojabnormal contraction ; but to obviate a recurrence of contrac-tion, the boot was worn a week longer, so that in the aggregatefiTe weeks only were occupied in remedying this rare deformity.

FIG. 1. FIG. 2.

Fig. 2 shows the appearance of the foot at the age of twelvemonths. The child is now in the enjoyment of excellent health,and the right foot does not exhibit any sign or symptom of theoriginal deformity. The feet are perfectly symmetrical, andthe child can walk as well as any other child of the same age.

Bradford, Sept. 1865.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

UNIVERSITY COLLEGE HOSPITAL.CONCUSSION (?) OF THE SPINE FROM A FALL FROM A

SCAFFOLD.

(Under the care of Mr. ERICHSEN.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, turn aliorum, tum proprias collectas habere, et interse comparare.—MORGAGNI De Sed. et Caxs. Morb., lib. iv. Proaemium.

A FEW days since, as we entered the hospital, a patient wasleaving it. He was a man between thirty and forty years ofage. Brought up to the door upon a wheeled chair, fromwhich he was helped with some trouble to rise, he traversedon foot the short distance from this point to a cab, supportinghimself by a hand placed upon each shoulder of the porter, andlifting his legs evidently with the greatest difficulty. Wemade some inquiry about him, and this is what Mr. Mason,one of the house-surgeons, told us :-More than three months ago this man, W. R- by name,

a painter, fell thirty feet from a scaffold upon the flat of hisback. On being carried to the hospital, it was found that nobones were broken, and no injury was to be seen. He com-plained of intense pain in the loins, which was increased bymovement. There was no palsy of the bladder or sphincter;and when he lay in bed he could move his legs fairly, but onattempting to get up he was quite unable to stand. There wasno loss of sensation. By degrees he managed to move aboutthe ward leaning upon a chair or assisted by a bystander. Asregards his treatment, he had an opiate for the first three orfour nights; and on the lOth of July he had commenced takingbichloride of mercury-one-sixteenth of a grain three timesdaily. He was now leaving the hospital for the House ofCharity, Soho, improved to some extent, but crippled as wehave described.

Besides the interest which must ever attach to obscure lesionsof nervous substance, we have a special motive for recordingthis case. It is, unfortunately, not uncommon for a railwaypassenger to receive a shock to the spine which leaves no markof injury to the tissues, and yet, by the patient’s own account,disables him as this man is disabled. It may be taken as cer-tain that this poor fellow’s impairment is genuine. He canhave no reason for exaggerating the amount of damage whichhe has received. He has no claim for compensation like thatwhich often throws such suspicion upon the feeble movementsof a passenger who has been injured in a railway collision. Hiswhole anxiety has been to get about again to his work, forwhilst he lay in hospital his home was broken up and his familydriven to destitution. Here, then, is a case which is full ofinterest in reference to the question so frequently arising inour law courts of obscure injury to the spinal cord. It is quitecertain that were this man the plaintiff in an action against arailway company the fact of the bladder and sphincter func-tions being perfectly performed, and the entire absence ofpalsy of sensation, might tend to throw great doubt over thegenuineness of the partial palsy of motion with which he isaffected. It seemed to us, as we watched him, that his diffi-culty lay in using the muscles in front of the thigh, indicatingsome injury to that part of the cord from which the second,third, and fourth lumbar nerves issue ; and this would corre-spond to the seat of the pain which he experienced. Withoutattempting to explain the exact nature of this injury-whetherit arise from concussion of the spine (supposing that there beany such lesion, the possibility of which is doubted by many),or from haemorrhage upon the surface of the cord compressingthe motor roots of the affected nerves,-we can only point tothe case as one which shows the necessity of great caution inthe diagnosis of injuries alleged to be produced by railwayaccidents. The whole subject of injury to the cord is involvedat present in much obscurity. It is one of the weak points in

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our hospital system that we cannot follow up these cases andlearn the length of time which elapses before the injury isremedied, or whether it is ever repaired. And yet this is all-important in relation to forensic medicine. We should be gladto receive from those who have had the opportunity of watchingsuch cases accurate, but concise, records bearing upon thispoint. There is a man, thirty-one years of age, now lying in King’s

College Hospital, under the care of Mr. Partridge, whose case

may be usefully compared with the above. On the 25th of

August he slipped upon the pavement and fell, striking hissacrum. On admission, he was found to have lost the use ofhis legs. There was no external injury, and an examinationby the rectum detected no fracture. Three hours after admis-sion he had a sort of fit and lost the power of perfect expres-sion, saying half a word and not completing it, and in themiddle of a sentence forgetting what he was about to say.This difficulty passed off, but on the morning of Sept. 2nd heentirely lost his speech. When we saw him on that day, helay on his back, with an imbecile expression of face. Whenaddressed, he nodded or shook his head, but could make nosound whatever. He seemed, however, perfectly intelligent,and wrote well, using this means to reply to our inquiries.There was absolute paralysis of motion and sensation through-out the lower extremities. Tickling the soles of the feet pro-duced only very slight muscular vibration about the upperpart of the thighs. The functions of the bladder and sphincterhave been perfect throughout. The pupils were equal in size,perhaps slightly dilated and somewhat sluggish. His sightand hearing were unaffected. He described a sort of ticklingsensation shooting up the whole length of the spine, and painover the back of the head and across the eyes. It seems thatfifteen years since he had a fall on his back and partially lostthe use of his legs, five years elapsing before he perfectly re-covered. Since that accident he has occasionally suffered from"fits," which have been liable to be brought on by trouble, ofwhich he has had a full measure. His last attack of this kindtook place two years ago. He denies (shaking his head vehe-mently) that his recent fall on the pavement was in conse-quence of any such seizure.On a future occasion we may be able to report the progress

of this patient. The case is complicated materially by theprevious injury, and still more, we are inclined to think, bythe occurrence of fits, which were probably of an epileptic character. It is very possible that the substance of the cordhas been degenerating slowly for some time past, and, in spite of the patient’s denial, one cannot lose sight of the probabilitythat an epileptic seizure preceded, and indeed caused, his fall Iupon the pavement.

ST. MARY’S HOSPITAL.TWO CASES OF LACERATION OF THE PERINEUM:

OPERATION ; CURE.

(Under the care of Mr. JAMES LANE.)CASE 1.—M. G——, aged twenty-six, was admitted on the

25th of March, 1865, under Dr. Tyler Smith, but was subse-quently transferred to Mr. James Lane for operation. Shewas married in January, 1863, and was confined in January,1864, when laceration of the perineum took place. The labourwas protracted, but instruments were not used. She had notbeen pregnant since. On examination, there was not a vestigeof perineum to be found, the sphincter had been completelytorn through, and the recto-vaginal septum beyond the isphincter had also given way to a slight extent. She wasquite unable to retain any fæces at all approaching to a fluidconsistence, and felt great discomfort and weakness from the iloss of support to the pelvic viscera. She was in fair health "

and condition. The operation for restoration of the perineum was performed I

by Mr. J. Lane on the 5th of April, 1865. A portion of mucous membrane and skin was dissected off on each side atthe entrance of the vagina, in a position corresponding to theoriginal situation of the perineum. The raw surfaces thusmade were about an inch and a half in length, about an inchin width inferiorly, but tapering to about half an inch in widthsuperiorly. They were made to be continuous with each otherposteriorly, at the point corresponding to the angle where thelaceration had ceased. Four stout silver-wire sutures werethen passed acres? deeply from one side to the other, and by

means of these the deep portions of the denuded surfaces werefirmly held together on the principle of the quill suture. The

quills were represented by two ivory bars, perforated withfour holes, through which the wires were passed and fastened.Four superficial sutures of thin silver wire were then applied tothe anterior edges of the wound, in order to retain them in accu-rate contact. The sphincter was then divided freely in adirection outwards and slightly backwards on the left side.For a week after the operation a grain of opium was given

night and morning, for the purpose of keeping the bowelsquiet ; and the urine was drawn off twice daily with a cathe-ter. Forty-eight hours after the operation the deep sutureswere cut and removed, together with the quills. Some slightosdematous swelling of the parts had taken place, but this soonsubsided after their removal. The superficial sutures were notremoved till the eighth day after the operation. At this periodthe union appeared to be tolerably firm. A free aperient wastherefore given, and the bowels were emptied on the followingday without any injury to the newly-united parts. Afterthis, the tenderness of the parts rapidly subsided, and she wasdischarged from the hospital quite well on the 27th April,twenty-two days after the operation. There was then a firmand thick cushion in the natural situation of the perineum.Control over the motions was restored, and she expressed her-

self as having regained the natural sense of support and secu-rity in the perineal region which she had lost since the acci-dent happened.CASE 2. - A. R——, aged thirty-five, was admitted into

St. Mary’s Hospital on the 24th February, 1865, under thecare of Dr. Tyler Smith, but was afterwards transferred toMr. J. Lane for operation. She had been married six years,and had had three children. The rupture occurred with thesecond child, when she was in labour for thirty-two hours.The head was very large, but instruments were not used. Adetailed description is umiecessary, as the rupture was almostan exact counterpart, as to its extent, of that met with in thefirst case. A similar operation was performed on the sameday (April 5th), with precisely the same after-treatment, andwith a like result. She left the hospital quite well on the28th April, twenty-three days after the operation.Mr. J. Lane, in his clinical remarks, stated that these cases

furnished excellent examples of complete rupture of the peri-neum. When the sphincter was torn through, as in both thesecases, very great care and attention were required to retainthe parts in accurate contact, because the action of the musclewas continually tending towards their separation t the lowerangle of the wound. For this reason it was very desirable toparalyse its action for the time by an incision ; but he believedit was sufficient to divide it on one instead of on both sides, ashad been recommended. It was especially necessary to secureaccurate union at the angle corresponding to the terminationof the rupture, where the two raw surfaces became continuouswith each other, otherwise there was the risk that an aperturemight remain at this spot behind the new perineum; andthough the perineum might be effectually restoi ed, there wouldbe the inconvenience of a recto-vaginal communication behindit, a condition scarcely less annoying to the patient than thatwhich the operation was intended to remedy. Mr. J. Lanesaid that he had used the wire suture and the perforated ivorybars for the last five years, during which time he had operatedon, he believed, about thirty cases of rupture of the perineumof every degree of severity. He had every reason to be satis-fied with the mode of operation, as he had not failed to obtain

complete union in a single instance.

Provincial Hospital Reports.NORFOLK AND NORWICH HOSPITAL.

DISLOCATION OF THE HUMERUS COMPLICATED WITH

FRACTURE OF ITS SURGICAL NECK ; INEFFECTUAL

ATTEMPTS AT REDUCTION ; REMARKS.

(Reported by Mr. CHARLES WILLIAMS.)A FARM-LABOURER, aged forty-eight, was brought to the

hospital in August, 1860. He had been riding on the shafts ofa waggon, fell asleep, and shortly after was thrown off. Oneof the wheels, he thought, passed over his left arm. When

seen, the nature of the accident seemed to be sufficiently ob-vious : it was a case of fracture of the humerus at its surgical