For the purpose of keeping the mouth open and pressing down the tongue, artificial means, as the introduction of cork between the back teeth, SUCHET'S katagoglos (a), as well as the introduction of a blunt hook at the corner of the mouth, are superfluous: and the depression of the tongue with a spatula is so much the more dangerous, as thereby choking is only more provoked. The fixed purpose of the patient is fully sufficient. It must, however, be remarked, that during the operation the patient is to be often allowed rest and the mouth rinsed with cold water, partly to stanch the bleeding. and partly for the removal of the mucus hanging about. The refreshing of the edges of the cleft from below upwards in the way proposed, is more certain than from above downwards, because the flowing of the blood does not interfere with the direction of the knife.

According to GRAEFE's original proposal, the edges of the cleft should be brought into a suitable condition for union, by removal with a chisel-like instrument, furnished with a counter-hold, or by touching them with muriatic, or sulphuric acid, caustie potash, tincture of cantharides, and the like. Subsequently, when this operation had been performed by others in a more simple manner, GRAEFE also employed for the removal of the edge of the cleft, a pair of curved forceps and a narrow knife, which he carried from above downwards. Roux, who commenced with the introduction of the threads, then laid hold of the lower part of one edge of the cleft with a pair of forceps, drew it out, and cut it off with a straight button-ended bistoury, sawing it from belów upwards. EBEL (b) also and KRIMER (c) use a pair of forceps and a simple knife, directing it from below upwards. DIEFFENBACH (d) freshens the edges of the cleft with a bistoury, laying hold of the edge of the cleft with a hook, and cuts off a straw`s breadth with the bistoury, directed from below upwards. BÉRARD (e) makes his incision from below upwards. ALCOCK (f) used the fine scissors, which Roux also partially employed, in a bent form, in his later operations.

735. For the purpose of uniting the raw edges, a thread is to be used, on which two straight needles are threaded; each needle is to be held with a needle-holder, and thrust through, the edge of the cleft being fixed with a pair of forceps, from behind forward, at three and a half to four lines distance from the edge; the point of the needle is now to be taken hold of with the forceps which had hitherto held the edge of the cleft, and drawn out together with the thread. The other edge of the cleft is to be similarly treated. The number of stitches which are thus to be introduced, differs according to the size of the cleft. If the uvula be completely cleft, then from three to four stitches are necessary, and the upper must always be first put in. After the patient has been allowed a little rest, and cleared his mouth with water from blood and mucus, the threads must be tied together by means of the extended forefinger against the wound, first with a surgical, and afterwards with a common knot, and cut off close to the knots.

Various modes of treatment have been recommended for bringing the cleft together. GRAEFE'S hook-like needles, and the threading of the two ends of the suture into the lateral openings of a canula placed on the palate, and when the threads have been sufficiently tightened, is closed by means of a screw. Subsequently he employed nearly straight needles, and tied the threads (which were black and soaked with oil) in a surgical and afterwards in a simple knot (g). Roux used needles of a small curve and a needle-holder, and tied the threads together in two simple knots, in which the first is held with forceps till the second is looped, so that it may not meanwhile give way. EBEL (h) employs for the sewing, short, straight, double-edged needles, and a needle. DONIGES proposes a long needle, like an aneurismal needle, with a very sudden curve, a sharp point having an eye immediately behind it and the stem fixed in a handle bent down, for convenience, like the handle of a gorget. The needle threaded, is passed from behind through either edge of the cleft, and the end of the thread on the inside of the

66

needle curve, being caught with a hook or forceps, is drawn forwards and completely through; the needle itself still unthreaded, is then drawn back, its point carried behind the other edge, and having been thrust through, the thread on the outside of the needle curve is drawn forwards out of the needle-eye, which being thus set at liberty the needle is withdrawn entirely, the threads passed through each other and tied, by thrusting down between them a little plate six lines long, with a notch at each end for the threads to run in, two lines broad, and fixed on a stem four inches long, with a handle. WARREN (a) proceeded in a similar manner, not only in the case he describes, but also in another on which he operated some years previously. The principal difficulty he met with in this operation was in disentangling the ligature from the hook after it had perforated the palate, and he therefore proposed a curved needle with a movable point, which after having been passed through the soft palate, can be separated from the stem, unthreaded, and having been refixed and rethreaded with the hinder end of the thread, is passed through the other edge of the palate, and separated from the stem as before. As to the objections to this treatment, see SCHMIDT (b). WERNECKE used a needle with an eye in front, and a whalebone handle. LESENBERG'S (c) needle is similar to that of DONIGES, but its point can be covered with a guard. KRIMER (d) also uses a similar needle, which can be closed.

The instruments for drawing the knot have also been varied by the above-mentioned practitioners. WERNECKE carried the knot up to the palate with two small grooved probes, and cuts off the ends of the thread. EBEL used small tubes, and DoNIGES the special knot-tier, already mentioned.

DIEFFENBACH by means of a nearly straight needle, into the hinder hollow part of which a leaden thread has been introduced, unites the cleft by drawing the wire together; cuts it off a few lines distant from the soft palate, and turns the twisted ends upwards, so as not to irritate the root of the tongue. The lead wire allows loosening and much tightening. DIEFFENBACH also proposes to effect the union with a pair of peculiar forceps.

HRUBY's palate-holder, is similar to BEINL's lip-holder (e).

SCHWERDT's cleft needle for the introduction of the thread (ƒ).

BÉRARD (h) thrusts in the needle from before backwards.-SMITH's needle (g) is long lance-shaped, and furnished with a notch for the reception of the ligature. [But MÜTTER objects to it, "first, as being mounted on a straight handle, which renders it more difficult to introduce its point at the proper places; and secondly, the difficulty of disengaging the thread, which may be drawn back along with the needle in the attempts of the Surgeon to disengage the latter from the margin of the palate." (p. 9.)] ALCOCK (i) operated at intervals, so that he made raw, and united only one part of the cleft; in one case he only effected perfect union after five operations: in the first four he used the interrupted, and in the last the twisted suture.

HARTIG (k) effects the union by means of a palate-cramp (fibula seu retinaculum palati.)

[LISTON (1) introduces a double ligature on a curved needle fixed in a handle, through the front of the palate curtain, "the noose of which is caught by a blunt hook and pulled out into the mouth whilst the instrument is withdrawn. A second and smaller ligature is carried through opposite to this, and by means of this second thread the first and double one is brought through" (p. 503) MÜTTER uses a much curved “needle half an inch in length and mounted on a cylindrical neck, a portion of which is held in the grasp of the porte, (SCHWERDT's,) and the other part, made rough, is intended to be grasped by the forceps of an assistant. The cutting edge of the needle being wider than the diameter of its neck, will make an opening large enough for the easy transmission of the ligature. The forceps too may be improved, by causing them to close with a spring instead of a catch." (p. 9.)]

FERGUSSON, of King's College Hospital, has proposed a new mode of staphyloraphy, and has successfully treated two cases by it. "The principle of this new proposal is to divide those muscles of the palate which have the effect of drawing the flaps from each other, and widening the gap between them when they contract; so that the stretched

(a) American Jour. of Med. Sciences, 1828. Nov. (b) VON GRAËFE and VON WALTHER'S Journal, vol. v. pt. ii. p. 338.

(c) Dissert. de Staphyloraphia quædam. Rostochii, 1827.

(d) VON GRAEFE and VON WALTHER'S Journal, vol x. p. 622.

(e) In VON GRAEFE and VON WALTHER'S Journal, vol. ix. p. 323, pl. iii. f. 2.

(f) Above cited, pl. iv. f. 7
(g) Above cited.

(h) North American Archives of Medical and Chirurgical Science, October, 1834.

(i) Above cited.

(k) Beschreibung eines neuen Apparates zur. Vereinizung des gespaltenen Gaumens ohne Naht. Braunschweig, 1841.

(4) Practical Surgery, London. 1837. 8vo.

velum may be in a state of repose, and the pared edges may not be pulled asunder by any convulsive action of the parts during the process of union. In other words, he advises, as an important accessory to the operation of staphyloraphy the division of the levator palati and palato-pharyngeus muscles, and, if requisite, the palato-glossus (a),

736. If in very large cleft, the closure be difficult and only to be effected with great stretching, in consequence of which severe inflammation and tearing of the sutures are to be dreaded, the satisfactory result of stitching the palate is rendered most certain, according to DIEFFENBACH (b), by making an incision with a bistoury down to the bone on each side of the closed cleft of the palate, and half an inch distant from the lower edge of its arch. This immediately produces relief from all tension, the united edges hang loosely in the middle, unite together and the threads neither cut in nor through; the patient breathes freely through the holes, as otherwise the great swelling of the palate renders breathing very difficult. In the previous tension of the palate there is also great increase of substance as the lateral openings are closed by granulation in from ten to fourteen days. When at the same time there is a cleft in the hard palate and considerable separation of the edges of the cleft, it may be necessary for effecting the union to separate the soft palate, to some extent from the hard palate, by two horizontal incisions.

BONFILS (c), after paring the edges, separates a V-shaped piece of skin from the palate, corresponding to the cleft, and unites it by the interrupted suture.

In a case in which the cleft of the soft was connected with that of the hard palate, and the distance of the edges was great, for the purpose of bringing them into contact, Roux, after putting in the stitches, and paring the edges, made two horizontal ents, which divides the soft from the hard palate, and extended from the edge of the cleft somewhat above the perpendicular of the ligatures on both sides. The edges of the cleft may in this way be easily united.

In one case, in which with a cleft of the soft palate there was also a very considerable wolf's jaw, and the union of the soft palate thereby rendered impossible, KRIMER (₫) made on both sides two longitudinal incisions, four lines distant from the edge of the cleft, which joined together at an obtuse angle in front, and terminated behind at the still projecting portion of the soft palate; the soft parts were then divided by these cuts towards the edge of the palate, that a pair of wedge-like flaps were formed with their bases behind. After the bleeding had been stanched with sage-water and alum, the flaps were turned inwards, so that their palatine surface was level with the floor of the nostrils, and the sewing together of the palate was then effected with the needle-holder in the ordinary way. DIEFFENBACH (e) proceeds more simply; after closing the cleft in the soft palate, he separates the soft parts on the hard palate, shaves the bone, and draws together the edges with lead wire.

[MÜTTER mentions that WARREN of Boston, U. S., had succeeded in closing a deficiency in the upper part of a palatine cleft, or that portion which extended into the hard palate, by detaching the mucous membrane, and sliding it from each side to the median line, uniting the flaps by two or three sutures." (p. 20.)]

737. After the operation, the patient may neither speak, nor take food, nor swallow his spittle, but must have it removed from his lips with a cloth, or carefully allowed to flow into a vessel, and everything must be avoided which may excite coughing, sneezing, or laughing. At the end of the third the upper, and at the end of the fourth day the lower stitch may be removed, the knots being held with a pair of forceps and the thread cut by its side with a pair of scissors and drawn out in the contrary direction. Nourishing broths may be taken at first in small quantity and with great caution, and when the union has become firm, more solid food may be allowed.

(a) Medical Gazette, N. S., vol. i. p. 389. 1844-45. (b) In RUST's Magazin, vol. xxix. p. 491.

(c) Journal de Medecine, 1830, December, p. 297.

(d) VON GRAEFE und VON WALTHER'S Journal, vol. x. p. 625.

(c) RUST's Magazin, vol. xxx. p. 288,

According to GRAEFE, if the spittle be collected in the throat in quantity, we should attempt its removal by injecting, or by brushing off with a brush made with charpie or linen. A solution of from one to two grains of extract of belladonna may be at once given in a little water, by which the patient is much relieved. On the first days also he permits strong wine, with yolk of egg, given with a spoon, and nourishing clysters. The living activity in the edge of the wound may be increased by pencilling with muriatic acid, naphtha, equal parts of tincture of euphorbium, cantharides, and myrrh, or in torpid persons, with tincture of cayenne pepper or capsicum. The stitches should only be removed when they entirely or partially fall out of themselves. DIEFFENBACH also says that the patient may take fluid food without fear.

[Although the operation of staphyloraphy is generally unattended with danger, yet, in a few instances it has been fatal from the inflammation spreading along the windpipe to the lungs, as happened in the case of an English nobleman's daughter, who was operated on by Roux; the only one, of sixty cases on which he operated, which he lost. BÉRARD (a) also mentions that he lost one case from pneumonia, originating in the same cause; and that, in another instance, the face was attacked with erysipelas, from which, however, the patient recovered.]

738. If the union be only partially effected, the mouth may be washed gently with red wine, and the open parts pencilled with honey of roses, tincture of myrrh and borax, only strong fluid nourishment is to be permitted; and the patient not allowed to speak. If an opening of two or three lines remain, it may be frequently closed by touching with muriatic acid; but if this be not effectual, these parts, three or four weeks after the completion of the scar, must be again stitched up. If the cleft do not unite at all, the edges soon scar with using red wine as a gargle and the pencilling just mentioned. The cleft is generally smaller.

DIEFFENBACH (a) endeavours to close such apertures in a peculiar manner. He makes on each side of the opening penetrating but parallel incisions, at the distance of a line from the edge, by which the tension is relieved, and an approach of the edges effected, which DIEFFENBACH still favours by introducing into the incision charpie soaked in almond oil. After the scarring of the latter he makes two similar incisions, though in contrary directions, which are held together in the same way.

739. Although after most of the modes of treatment for effecting the suture of the palate successful results occur, yet is the above-described simple mode of treatment to be considered most preferable, as from my own experience I have proved. That the lead wire has not the many inconveniences attributed to it by GRAËFE and SCHWERDT (b), that by its hardness it presses, by its weight it tears, that cutting-in is not prevented, and that severe traumatic re-action is produced, have been long since disproved by the satisfactory and numerous results of DIEFFENBACH'S practice even in the most difficult cases. To him owe we especially the greatest thanks in reference to his perfection of suture of the palate.

740. Even when the cleft is perfectly closed, the speech only becomes gradually more distinct as the tension of the soft palate subsides. The person operated on must first use himself to utter single letters, and afterwards syllables and so on.

(a) Article-Staphyloraphie; in Dict.de Med., ou, Répert. gén. des Sciences Médic., vol. xxviii. p. 547.

(b) SCHWERDT, above cited.
(c) Above cited, vol. viii. P. 102.

IV. OF THE OLD DIVISION OF THE FEMALE PERINEUM.

NOEL; in Journal Général de Médecine, vol. iv.

SAUCEROTTE, ibid., vol. vii.

MURSINNA; in LODER'S Journal, vol. i. p. 658.

VIET, De Ruptura Perinæi. Goettinge, 1800.

V. FABRICE, C. E., Medicinisch-chirurgische Bemerkungen und Erfahrungen. Nürnberg, 1816. p. 1.

SCHREGER, Annalen des chirurgischen Clinicums auf der Universität zu Erlangen, 1817, p. 73.

Roux, in Journal Hebdomadaire, vol. i. No. iii.

DIEFFENBACH, Chirurgische Erfahrungen, besonders uber die Wiederherstellung zerstörter Theile. Berlin, 1829. No. v. p. 64; and in the Medicinischen Vereinszeitung in Preussen. 1837. No. 52.

DUPARQUE, Histoire complète des Ruptures et Déchirures de l'Utérus, du Vagin, et du Périnée. Paris, 1836. 8vo.

MERCIER; in Journal des Connaissances Medico-chirurgicales, 1839, March, p. 89. 741. Tearing of the perineum may be consequent on difficult labour, when there is disproportion between the size of the child's head and the extensibility of the external organs of generation or artificial narrowing. The tear is often only at the vaginal edge of the perineum, but frequently extends throughout the greater part, more or less following the raphe to the edge of the rectum, or the whole perineum is torn into the rectum. Slight tearings of the perineum are of little consequence and generally heal without assistance, the patient remaining constantly on her side with the thighs kept close together, and proper attention paid to cleanliBut this rarely happens in large tears, as the wound is continually fouled by the lochial discharge, and at every time of going to stool the wound is opened. In complete tearing of the perineum between the vagina and rectum it is quite impossible to retain the stool if the greater part of the sphincter ani be torn. If in a torn perineum union cannot be effected, the two edges of the wound skin over, and the cure is only pos sible by removing the skinned edges and by union with the stitch.

ness.

From what has been said, it follows that in considerable tears of the perineum it is most safe immediately to effect its enclosure by stitching It must not be overlooked. however, that the parts are rarely in a suitable condition for quick union, and that if there be swelling and inflammation of the edges of the wound, union is thereby contraindicated. If the woman herself object to this treatment, if accompanying indisposition, or the circumstances already mentioned forbid it, the position on the side must be per sisted in, with the thighs a little drawn up towards the body and tied together (1), care also being taken for proper cleanliness, for soft motions, and for drawing off the urine from time to time with the catheter. The healing which in this way takes place in small tears of the perineum, does not depend on any union of the edges, but on its shortening backwards, so that the labia pudendi extend back and occupy the place of the former wound. The greater the tear the shorter becomes the perineum, and the longer, on the contrary, the labia and great fissure, the former at the same time losing their fulness, and becoming thinner. If the tear of the perineum extend into the orificium an, the labia are drawn backwards by the scarring, and their hind extremities are held together by whitish callous scar; it seems as if the anus had moved further back, and the labia were drawn with it.

Sometimes there is a central tear of the perineum, and the whole child is thrust through it (a). The cure in this case may be effected by the natural powers; but if the tear extend on the sheath of the rectum, it has never been seen to take place.

Large and recent tears of the perineum can be alone satisfactorily treated with the stitch, as all other remedies proposed for bringing the wounded edges together, either (a) DUPUYTREN, POURCHIER; in Gazette Médicale, vol. iii. First Series, pp. 684, 866.