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WESTMINSTER HOSPITAL.

DISLOCATION OF THE HEAD, AND COMPOUND FRACTURE OF THE

SHAFT, OF THE HUMERUS ABOVE THE ELBOW-JOINT, FOL-LOWED BY MORTIFICATION; AMPUTATION AT THE SHOULDER-JOINT; DEATH.

(Under the care of Mr. HOLTHOUSE.)IN compound fractures, the question of amputation is of

course decided upon according to the extent of the injury sus-tained, and the estimate formed of the restorative powers ofthe patient. In the following case, there was a double injuryto deal with-a dislocation of the head of the humerus into theaxilla, and a compound fracture of the same bone near theelbow, and implicating the joint. These were fully considered,and as everything was otherwise apparently favourable, it wasdeemed prudent to reduce the dislocation, which was done,and to put up the arm in an angular splint. On the fourthday, gangrene commenced all around the elbow-joint; but asthe inflammation was not spreading, removal of the limb wasdeferred. On the seventh day, the mortification had not onlyspread, but the man was very low, and amputation of the limbat the shoulder was accomplished, to afford a chance of life,but the result was a fatal one. We are advocates to the fullestextent for conservative measures in all cases holding out achance of success, but in the following, with a compound frac-ture into a joint, with inflammation existing all around it, andthe almost certainty of its spreading, taken with the conditionof his arm on admission, we think that amputation would haveafforded a better chance for life if it had been done when thissphacelated condition first made its appearance. The mortifica-tion was local in its being caused by the compound fracture, andthis is laid down by many high authorities as a reason for notwaiting for a line of demarcation to be formed, when the gangrenewas spreading, which it was not when first seen. The case isone of extreme interest, and contains some points of value inestimating the question of removal of the limb under the cir-cumstances which are detailed.James P-, aged forty-nine, omnibus driver, of temperate

habits, while driving, was run into by a cab, and thrown from Ithe box, the wheel of the omnibus passing over the right arm;was admitted May 31st, at nine P. M., about twenty minutesafter the accident. The head of the humerus was dislocatedinto the axilla, and there was a compound fracture of the samebone just above the elbow-joint. A wound existed at theouter side, from which considerable venous hemorrhage wastaking place; and on putting the finger into this, at about aninch and a quarter from the surface, bare bone was felt.Another wound of a more superficial character existed on theinner side of the joint. The soft parts around were bruisedand discoloured, and felt puffy. The temperature of the handand of the whole limb was natural, but no pulse could be feltat the wrist. When seen by Mr. Holthouse, an hour after hisadmission, the whole of the arm was somewhat swollen, had abrawny feel, but was not discoloured; the skin about and im-mediately above and below the elbow was ecchymosed, andhad a soft, puffy feel; and venous blood was running freelyfrom the wound on the outer side of the elbow. Though nopulse could be felt at the wrist, the hand and the whole limbwas warm. The dislocation had been reduced, and the limbplaced on an angular splint, and bandaged to near the elbow.A compress dipped in alum lotion was applied to the wound.June 4th.-The lower part of the arm and upper portion of

the forearm is in a state of commencing sphacelus, having adecidedly gangrenous odour. The cuticle has become detachedin some parts, and in others is raised from the cutis by a bloody-coloured serum. Emphysematous crepitus is also feltin these parts, which are insensible to touch. Pulse was felt indistinctly yesterday by the house-surgeon (?), but none cannow be felt, though the bandages somewhat impede the attempt.The hand and arm are warm, and have so continued from thecommencement. Slept well last night, from an opiate, andcontinues drowsy at present. Pulse 94, full and strong; tonguea little dry in the centre; bowels acted the day before yester-day, but not since. To have an effervescing draught, a breadpoultice to the arm, and the anodyne repeated. He was seen

by Mr. Holt between one and two, and on the report that themortification was spreading, considered that the arm had" better come off;" but on again examining the injured partsin company with Mr. Holthouse, and learning from him thatthe gangrene was not spreading, it was agreed that amputationshould not be resorted to. A pencil of caustic was run alongthe margin of the inflamed skin by Mr. Holthouse, to markthe limits of the inflammation. -

5th.-There is now a breadth of three inches of sound,healthy-looking skin, between the line made by the causticand the mortified parts, and the patient is in a satisfactorystate. The pupils are somewhat contracted, and he is drowsy,as if still under the influence of a morphia draught which wasgiven him last night. Pulse 94, not wanting in power. Tocontinue the mixture; brandy, six ounces, as occasion requires.

bth, Half-past One P.M.-Much worse; in a half-comatosestate, and seemingly scarcely conscious when roused. Pulse116, more feeble. Inflammation has attacked the arm abovethe parts sphacelated, and extended to the upper part of theshoulder, towards which the gangrene is extending, especiallybehind the limb and on its outer side. The sister reports thatthis change for the worse took place last night between eightand ten o’clock, when he became exceedingly restless, com-plained of great pain in the part, and tore off the poultices.An anodyne being afterwards given by the clinical assistant,he became quieter.-Three P.M.: Although the man seemedmoribund, it was decided in consultation with Drs. Bird, Rad-cliffe, and Reynolds, who were the only officers in the hospitalat the time, that, as amputation might give him a chance, itshould be done. Accordingly the limb was removed by Mr.Holthouse at the shoulder-joint, with comparatively little

haemorrhage, none apparently from the axillary artery. Theflaps were necessarily short. About four ounces of brandywere given during and immediately after the operation, andno chloroform. One suture only was applied, lest haemorrhageshould supervene, and no dressing but wet lint. Pulse about130, feeble; respiration gasping.-Eight P.M.: Has rallied some-what ; more conscious ; pulse less feeble, and responds to stimu-lants-after a draught of ginger-beer and brandy only 108.The edges of the flaps were brought nearer together, and re-tained so by lint and strapping.7th.-Continued in a satisfactory state until three A.M.,

when his pulse became more frequent and feeble. Hiccoughwas brought on after each imbibition of the brandy, and hisurine passed away unconsciously. A draught of twenty minimsof sedative solution of opium in an ounce of camphor mixturewas given him at eleven o’clock last night, and he took abouttwenty ounces of brandy, with eggs and ginger-beer, but sankthis morning at ten minutes past ten A.M.An examination of the limb detected no cause for the want

of pulsation in the radial artery. The humerus was fracturedinto the elbow-joint, the fracture extending obliquely down-wards, from an inch and a half above the outer condyle to thecentre of the articulation, separating the articulation of theradius from that of the ulna. A small fragment of bone wasalso detached from the outer part of the olecranon process ofthe ulna. The extremity of the inner condyle was dark-coloured and necrosed. In addition to these effects of the

recent accident, the lower end of the humerus bore marks of aprevious oblique fracture immediately above the condyles :this his wife stated took place two years ago.

CLINICAL RECORDS.

TWENTY CALCULI IN ONE BLADDER.

A VERY interesting case of stone was submitted to Allarton’soperation by Mr. Cock, at Guy’s Hospital, on the 16th of June,which was very nearly proving fatal from loss of blood, thegreat depression being supposed at one moment to depend uponthe chloroform. The patient was a pale, worn-out lookingman, twenty-four years of age, who had been under one of thephysicians at Guy’s Hospital two years before with somekidney affection. In March, 1856, Mr. Cock sounded him forstone, but detected none at that time. Latterly there was nodifficulty in the matter, as he was passing small calculi fromthe bladder, and about half a pint of pus daily, with constantdribbling of urine. Moreover, a stone could be felt throughthe perinæum, and thiough the rectum, in a sort of pouch atthe neck of the bladder. When the operation in the medianline was performed, Mr. Cock removed a number of calculiwith his fingers alone, without the aid of the forceps, and takenaltogether they numbered about twenty. One of these wasthe size of a pigeon’s egg, but irregular in shape, with a numberof facets upon its surface; the others varied in size, some beingas small as grains of rice. There was a good deal of haemor-rhage--more than a pint, which reduced the patient very much,he became pale and faint, so that at one time he was almostgone. This was supposed to be due to the chloroform. Itmay, of course, have caused much depression, conjointly withthe effects of loss of blood. He. however, after a little while.

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under the use of stimulants, such as wine, ammonia to the nose,&c., revived, and was removed to the ward. He was verylow and weak for a few days, but made a good recovery, not-withstanding the unfavourable condition he was in at the timeof the operation. One of the supposed advantages of Allar-ton’s operation is, as we have heard Mr. Cock say, the savingthe blood of the patient. There is no difficulty in opening theprostate, but there is in getting the stone out afterwards. Ina stone of small size it is easy enough. We saw him performit on a child, on January 27th; also, the week before that, ona boy aged fifteen, the stone having been half in the bladderand half in the prostate for some years. The stones were re-moved with ease, particularly in the last case. In these andothers there was but little bleeding; but in the first-mentionedcase it was excessive, and tells much against this form ofoperation.

AMPUTATION T THE SHOULDER-JOINT OF A LAD.

WE saw a little boy in the London Hospital in July, whowas admitted on the 9th of that month, with his right armmost extensively crushed by a brush-making machine. Thebone was fractured almost up to the shoulder in a comminutedform, and the soft parts were greatly injured. The arm wastaken off at the joint by Mr. Curling, who had scarcely anymaterial to form flaps. However, we found the lad on the30th of July almost well ; the wounds had healed, and thestump, such as it was, looked very well, considering that butthree weeks had elapsed since the injury. The old rule holds

good here, that the most surprising recoveries ensue in theyoung, where the health has been good. This boy looked fatand plump, and nobody would suspect he had sustained anyinjury or undergone any operation in looking at him. Wehave noticed that the sufferers from machinery accidents aremost generally boys.

CONVALESCENCE IN TWO CASES OF CANCER OF THE BREAST.

THE other day we saw two cases in the wards of St. Bartho-lomew’s liospital, in which the breast had been removed forscirrhus by Mr. Coote. Both did well in a short space of time,as we have so frequently seen, showing the advantage of re-moval under chloroform as compared with the lengthenedmisery arising from the use of caustics.One of these patients was a pale, delicate person, of good

family, and well brought up, the mother of one child. Thefollowing is an outline of her case :-Esther G-, aged thirty-four, admitted on June 6th, with

scirrhus of the left mammary gland. She was ordered meatdiet, and a pint of porter daily.June 8th.-Operation was performed. Ordered eight ounces

of brandy, to be given at discretion; she took two ounces inhot water at bedtime.10th.-Ordered four ounces of brandy daily, soda-water,

beef-tea, &o.13th.-The pulse small; the wound sluggish; perspirations

at night. To have half a drachm of liquor of cinchona andtwenty minims of aromatic spirit of ammonia thrice a day inwater.20th.-She has had one quart of brandy at intervals since

the operation. The pulse has been small but regular; skincool; tongue clean; bowels regular. Omit the brandy; fourounces of port wine daily; continue the liquor cinchona.29th.-Ordered a pint of porter daily; four ounces of wine

as before.July 8th.-Discharged well.We may remark that Mr. Coote adopts the very judicious

plan of supporting his patients with stimulants from the timeof operating, and, where this is done, excellent recoveries lakeplace. The practice is becoming more general than it used to be.

AMPUTATION OF THE BREAST; HEALED IN A WEEK.

WHAT is the essential difference between the removal of acancerous breast by the knife and by the application of caustics ?So far as the constitutional results are concerned, there is none;but a cancerous breast can be got rid of by means of the knifewithout any pain or consciousness, under the influence ofchloroform, and the wound will have healed up in seven days.We say this without any exaggeration, for we have manytimes witnessed it.On the 30th of July we saw a female, aged forty-three, in

the London Hospital, who had had a scirrhous breast for a yearand a half, especially troublesome since last Christmas. Thetumour formed by the disease was not large. It was removed,

on the 23rd of July, by Mr. Curling, and on the 30th it wasperfectly healed up, and the woman looking well in everyrespect. If it had been desired to remove this by caustics, itcould only have been accomplished at an expense of sufferingof weeks’, perhaps months’ duration, with the system left,most probably, in a very irritable and worn-out condition.The difference, then, between the two modes of extirpation is:that by one, the cancer is removed without the knowledge of £the patient, and she is well in a few days at farthest, withouthaving suffered the least pain; whereas, by the other, fromfirst to last, it is nothing but a constant agony, with the pro.bability, in our opinion, of a more rapid recurrence, from theirritation of the nervous system.

UNUXITED FRACTURE OF THE TIBIA.

Tins was the case of a boy who fractured his left tibia at itslower third, about four years ago, in the country. He wasseen by a surgeon, who looked upon it as a sort of bruise, kepthim quiet for a little while, and then allowed him to go about..The consequence was that a false joint formed, with deformity ofthe leg. Two years ago, Mr. Lawrence applied a seton to theboy’s leg, in St. Bartholomew’s Hospital, without any benefit;and after that he was under Mr. Tamplin’s care at the RoyalOrthopaedic Hospital, where he was treated by mechanicalappliances which restored the limb to its straight position.He, however, became as bad as ever, living as a poor parishboy, and his friends were anxious to have his foot taken off,for he was a great incumbrance and charge, upon them in hispresent condition. On the 20th of June, it was accordinglyamputated by Mr. Lawrence. From the nature of the case,more especially in its long standing, we doubt whether anymeasure except that adopted would have been of service.Sawing off the ends of the bones would hardly have answeredhere. We intend shortly to give, in our ’’ Mirror," a case underMr. Thomas Wakley’s care, at the Royal Free Hospital,.wherein this proceeding was to a certain extent successful.

. HARE-LIP 1-’-T AN ADULT.

CERTAIN affections in certain stages are getting less commonyear by year. A very large tumour is now a curiosity, because

’ such morbid growths that should, be removed are so treatedearly. Thanks to chloroform and the onward march of surgicaleducation, a hare-lip in an adult is certainly very rare in thiscountry. One was operated on by Mr. Haynes Walton, at St.Mary’s Hospital, during the previous month, and about whichwe will say a few words. The man was forty years of age.The lip only was involved, but it was cleft in its entire depth,the fissure passing into the nostril. There was a very consider-able separation of parts when the facial muscles were moved,and several teeth were exposed when they were quiescent, butMr. Walton considered that this was inseparable from theaffection in the fnll-grown Ltce, where the many muscles thatact on the angle of the mouth are fnlly developed, and he spokeof the deformity as being very favourable for operation. Theposition he selected for its execution was perhaps that mostadapted for all the desired purposes. He sat at the edge ofthe operating-table, placed the patient on a stool before him,and secured his head, which was thrown well back, betweenhis knees. The entire operation was done with a small, narrowscalpel-the kind of instrument That Mr. Walton always nsesfor this and similar proceedings. The lip on each side wastransfixed, and pared from above downwards, and the freeedae of the tissue taken off in one continuous piece. Mr.Walton lays much stress on the surfaces being cut in a curve,so that when they are brought together the line of the mouthis maintained. Without this, there is apt to be a retiringangle. Moreover, he detaches the surfaces on each side freelyfrom the maxillary bones, to prevent any straining on the pinsand sutures. He inwardly adjusts the edges from belowupwards, on account of the greater accuracy that this commands.Ee begins, as a rule, to remove the fastenings about forty-eighthours after, a pin is taken out, next day, an upper suture, onthe fourth day another pin or suture, and so each day, till allare taken away. Plasters are generally employed from thecommencement of this process. We saw this patient a weekafter the operation was done, and found the parts perfectlyunited, without any trace of deformity. The operation hadbeen most successful. The advantages of early operation inhare-lip are now so well known, that it is really an uncommonthing at the present day to see adults with the deformity, andwhen we do, they turn out to be country people.

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REMOVAL OF THE MALE ORGAN.

MR. LISTON says, in his " Practical Surgery," "One othermutilation, sometimes rendered absolutely necessary on accountof intractable and malignant disease, remains to be considered :this is, removal of the male organ. It must be done in sound

parts, and at as early a stage as possible, before the lymphaticsystem has been contaminated." (p. 389.) This rule we see everywhere pretty rigidly adhered to; and on the 23rd of July,it was again carried out at St. George’s Hospital, upon anelderly man, by Mr. Tatum, who amputated the penis, thoughhealthy structure, for cancer of the organ of some years’ dura-tion. It was severed by a single stroke of a long knife as onewould divide a carrot. Several vessels were tied, as is usual.If the lymphatics are in any way implicated, experience toosurely shows the return of the disease in them, and the speedytermination of life. A remarkable instance of the kind wasrelated by Mr. Tatum to the pupils present.

Reviews and Notices of Books.On Mineral Waters: their Physical and Medicinal Properties,

with Descriptions of the different Mineral Waters of GreatBritain and the Conti)7eitt, and Di2-ectioiis for their Adrrci-nistratioo. By ROBERT MORTIMER GLOVER, M. D., F. R. S. E.,M.R.C.P., &c. pp.375. London: Renshaw. 1857.

"Water! water! everywhere;"’We cannot go on to say

" But not a drop to drink," for all the water here is to drink, or to be absorbed in someway; to be rubbed in, sat in, bathed in, or plunged in. A- chatty volume on mineral waters has really been a great de-sideratum for some time past. Dr. Glover has given one to theworld which contains a great mass of information, told in aneasy way. Before plunging into the Waters, there are somegeneral remarks, which, while they are appreciable to the publicat large, are by no means valueless to the medical practitioner.One idea in particular strikes us as being capable of a practicalexpansion of no small extent. The sea, Dr. Glover remarks, isthe chief mineral water. Now this is one of those simple butvery important suggestions, which originate only in thoughtfulminds. If any mineral water possesses alterative or deob-struent properties, sea-water, above all, should possess them,developed to the highest degree. The application of this ideais well worth the energies of an enterprising physician. One

thing is certain-viz., that the supply would exceed the de-mand, with the additional advantage of nothing to pay.

Perhaps the Spa proprietors might find the competition toostrong, except in the case of chalybeate springs, and " the sadsea waves" might recover their tone of spirits by reason of in-creased prosperity, and an influx of good company. The intro-

, ductory part of the volume relates to the value of mineralwaters, and here Dr. Glover appears to be a judicious eclecticto the mode of their discovery; their nature as regards contentsand thermality ; their medicinal action and modes of exhibition;and finally, some general advice is given as to the detection ofa mineral water, and the adjuvants of climate, diet, andregimen.The main portion of the work is divided into five parts,

which treat successively of Mineral Waters North of the Trent,and Mineral Waters South of the Trent; of the Waters of Bel-gium and France; of the Waters of Germany, Switzerland,Savoy, and Italy; of the Mineral Waters of Ireland and Scot-land, and of some miscellaneous matters.Some idea of Dr. Glover’s diligence may be formed, when WE

state that his work contains an account of no less than 15(

spas. We miss, however, a spring well known to ourselvesand frequented at one time, for a long time, and as far as mknow now, by many thousands of visitors in a season. Ou:North Country friends will know the picturesque " Whittle-leWoods," not very far from Houghton Tower, where Kin;Jamie created that most ubiquitous, long-lived, and ever-to-b

cherished knight, Sir-loin. We fear that Whittle-le-Woodswill feel itself aggrieved, albeit that it is not aristocratic. The

springs there are chalybeate and saline, and will vie in realtherapeutic merit with many others more successful in attain-ing to the dignity which surrounds those at fashionable water-ing-places.One is naturally anxious to know what an expert on such

matters thinks of the Kreuznach waters. We iind our own

opinion very strongly echoed by Dr. Glover. He evidentlytotally disbelieves all the nonsense that has been talked aboutfibroid tumours disappearing under a course of Kreuznach

waters, although he does not directly refer to the subject.With regard to the bromine in the Elizabeth Quelle at Krenz-nach, Dr. Glover says,"I know abundance of brine springs in England, and espe-

cially the brine springs about Birtley, in the county of Durham,from which bromine could be obtained as readily as from thewaters of Kreuznach."

So much for the amount of bromine in these be-puffed springs.Now for the general utility of these waters.

" According to the analysis of Mialhe and Fiquier, a pint ofsea water contains nearly a grain of bromide of sodium, [theKreuznach contains a quarter of a grain in the same quantity,]so that the advocates of the efficacy of the water of Kreuznachrelying upon the existence of its bromine, must admit that sea-water is likely to be more beneficial."

Again :" A brine spring like Kreuznach is valuable in the treatment

of diseases to those who live in an inland country; but there isnothing which it can accomplish but what the sea will do aswell, or better, especially as there is the sea air as well. Icould easily quote case.-, from my own experience, and cite fromthe works of others quite sufficient to prove this."The last part contains an enumeration of the diseases in which

mineral waters are beneficial. There is no attempt to exaltthe virtues of mineral waters in general, or still better, of anyparticular springs. Perhaps some readers would say that Dr.Glover was not an enthusiast upon his subject. We beg, how-

ever, to recommend the work most heartily, as containing fullvalue for the money expended in buying it, and for the timeand attention expended in reading it. It is a very useful and

agreeable book, and is a complete repertorium of knowledgecompressed into a, very moderate compass.

Hydropathy ; or, the ivatit)-al System of Medical Treatment.An Explanatory Essay. By EDWARD W. LANE, M.A.,M.D.Edin. London: Churchill.

HYDROPATHIC establishments being brick and mortar ma-chines to make money with, every proprietor of such a place ispretty sure to write a book ptiffiiiop his own wares. Dr. Laneis the superintendent of a house at Farnham. His book is notwell written, and contains nothing particularly new or clever,if we except the rather startling assumption on the title-page,that hydropathy (with its elaborate machinery of sheets andbaths and attendants) is a "natural system of medical treat-ment." This is new. The ingenious way in which the author’stremendous experience is implied is rather clever. There is no

doubt that the judicious application of water treatment is avaluable adjunct, but the book descriptive of its value and itsuses has yet to be written by a far different man from Wilson,Gully, or Lane.

Burning the Dead, or Urn Sepulture, Religiously, Socially,and Generally Considered. London: Philip and Son,Fleet-street.

! THE subject treated of in this pamphlet is at least worthy of’ discussion at the present time; and, however startling, or even. repulsive, a direct proposition to substitute burning for burying; may appear at first sight, mature consideration might leadmany to the conclusion that the former would be by far the