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though applied in the most dexterous manner. The objection,however, which has been made to congelation in amputation,that even if its anaesthetic action were rendered complete bycombining pressure with it, the peculiar nature of such woundsmight prevent their healing favourably after its use, does notappear to be well founded. M. Robert, of the Hotel Dieu inParis, states in the Voniteur des Hôpitaux of the 7th Aprillast, that " he has often recourse to congelation in amputationof the fingers and toes, and that he has never seen any trouble-some consequences." No objection can be made to the use ofcold for rendering the outer or more sensitive textures pain-less. Were its action limited to these, a great advantage wouldbe gained; for with its anaesthetic there is combined a power-ful antiphlogistic virtue. The swelling of the part from effu-sion of serum in its looser textures, caused by a deeper con-gelation, might oppose union by the first intention, unless carebe taken to have a redundancy of skin; and the subsequentdressing of the wound must then be suitably modified. Whencongelation is properly used, under common circumstances, itgreatly promotes the healing process: its improper use mayhave the opposite effect.

York-street, Portman-square, July, 1859.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

WESTMINSTER HOSPITAL.

FRACTURE OF THE BASE OF THE SKULL AND OF THE

PELVIS, WITH COMPOUND FRACTURE OF THE LEG;AMPUTATION; RECOVERY.

(Under the care of Mr. HOLTHOUSE.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdisseetionum historias, tam aliornm pioprias, collectas habere 6t inter se com-parare.—MoBaAGJ’n:. De Sed. et Cazcs, lib, 14. Prooemium.

FRACTURES of the pelvis are generally accidents of so seriousa nature, from the violence required to produce them, thatthey are almost necessarily fatal. Such injuries as ensued inthe two cases which we place upon record to-day were quitesufficient to destroy life, and the prognosis from the first wasserious. Nevertheless, a recovery ensued in both instances.With regard to the first case, besides fracture of the pelvis,there was a fracture of the base of the skull, and a compoundone of the leg, which necessitated amputation, the patient re-maining in a maniacal condition for some time. An exampleof such severity as this proved to be, rarely recovers in ourhospitals; either of the three lesions from which he sufferedwas sufficient to destroy the patient. Although not mentionedin the notes, we may observe that there were great sorenessand threatened sloughing of the skin over the sacrum, whichlatter was obviated by removal to a water bed, upon which helay for many weeks. Since his convalescence he has had a fallon the stump of the amputated limb, and two or three smallpieces of bone have come away; nevertheless, he possesses anexcellent cushion of skin and fat over the ends of the bones.As the injury to the pelvis was not only remarkable, but

rare, we would draw special attention to it. The head of theright thigh-bone was driven through the acetabulum into thepelvis, producing the appearance as if the neck of the femurwere broken, for the leg was shortened and everted. It is

essential, therefore, that the diagnosis should be clear uponsuch an important point. The records of medical science fur-nish but few instances indeed of this form of fracture of thepelvis, with remaining integrity of the thigh-bone. Exampleshave been described by Earle, Sir Astley Cooper, Dupuytren,M’Tyer, Gibb, and some others, and these are quoted in manyof the standard works of the day. In our own pages there isrecorded a case of the kind, under Mr. Moore’s care at the

Middlesex Hospital, which was brought before the Medioo-Chirurgical Society, (THE LANCET, vol. i. 1851, p. 379.)In the diagnosis between fracture through the acetabulum

and that through the neck of the femur, we have the nature ofthe accident to guide us in the former; the limb also cannot bedrawn downwards to an equal length with its fellow, nor in-verted ; it can be drawn freely outwards without much pain,as contrasted with a broken thigh-bone ; on rotation, the tro-chanter moves in the segment of a smaller sphere than in theother leg; and, what is perhaps of still greater value than allthese, is the remembrance that a co-existing fracture of theneck of the femur and of the acetabulum is one of the rarestsurgical injuries known. But one instance is mentioned by SirAstley Cooper, and in that the fracture extended through thetrochanter. If, then, a patient sustains an extensive breakageof the pelvis, with an everted and shortened limb, it is almosta certainty that the head of the thigh-bone has been driventhrough the cotyloid cavity. In the event of recovery, thelimb remains permanently shortened.Edmund C-, aged twenty-eight, was carried into the

Westminster Hospital, on the 13th of last May, having fallenfrom a height of 60 or 70 feet from the giving away of somescaffolding at the Westminster Palace Hotel. When first ad.mitted, he was unconscious; there were bleeding from the leftear, and dilatation of the left pupil; subsequently slight ptosisof the upper lid of the same side was observed; there was alsoa fracture of the pelvis of the right side, the right lower limbwas shortened and everted, simulating a fracture of the neckof the femur, and a compound fracture of the left tibia, withlaceration of the posterior tibial artery, existed. Besides theptosis and dilatation of the pupil, there were no other para-lytic symptoms.For the first few days the patient seemed scarcely recovered

from the shock, his pulse was exceedingly feeble, and his deathwas expected daily. The head was shaved, wet lint appliedto it, a Liston’s splint was placed on the outer side of the limbwith a cradle over the leg, and a pledget of wet lint to thewound in front, which communicated with the fractured tibia.His diet was strong beef-tea and brandy. A new set of symp-toms now appeared ; the patient became violently delirious, orrather maniacal, shouting and screaming, and tearing off hisbandages, which he said gave him so much pain that he couldnot bear them. Nothing could be kept on his head, which ap-peared very tender on pressure. Haemorrhage also, to a smallextent, took place from the wound in the leg, which was easilyrepressed by pressure, but it continued to recur at intervalstill the 7th of June, when the posterior tibial artery, fromwhich the blood was found to proceed, was tied. Up to thistime the outbursts had always been arrested by pressure overthis vessel, and the patient was altogether in so feeble acondition as not to admit of the operation being performedearlier.On the 9th, at nine P.M., haemorrhage again took place from

the original wound in front of the leg; and the house-surgeon,supposing that the ligatures round the vessel had given way,reopened the wound which had been made to secure the vessel,but found everything in its place, and no blood between itslips: the haemorrhage was therefore assumed to come from theanterior tibial or perineal arteries. A tourniquet having beenapplied, and local pressure made, the bleeding was stopped;but as a good deal of foetid, unhealthy pus escaped from bothwounds on pressure, Mr. Holthouse considered that the patientwould have a better chance of recovery if his leg were removed,than if another operation were performed in search of the bleed-ing vessel. Taking advantage, therefore, of the incision whichhad been made previously to secure the posterior tibial artery,another was made parallel with it on the outer side of the limb,and the two connected by a transverse incision below: a verygood and abundant anterior flap was thus formed of skin only,while a short flap posteriorly completed the operation, accord-ing to Teale’s method. The patient lost but little blood, andrallied well from the operation. It was observed at the timethat a portion of the skin forming one of the lower angles ofthe anterior flap was thickened, indurated, and unhealthy-looking ; and on the 14th, this was found to be in a state ofslough; the patient’s pulse also was very frequent and feeble:he was therefore ordered three grains of quinine every threehours, and the brandy, of which he had previously taken four-teen ounces daily, was increased to twenty-four ounces. Seve-ral of the wire sutures were removed, and a yeast poulticeapplied to the stump.i June 15th.---The sloughing process was arrested; the appear-ance of the patient had much improved; the pulse had fallento 92 and was stronger.

137

17th.-Slough separating; pulse 88; his general appearancemuch improved. He will have a good stump, the slough nothaving extended to that portion of the skin which covers theends of the bones.19th.-Slough quite separated, and its place occupied by

healthy granulations.24th.-Stump nearly healed; pulse 66; tongue clean; appetite

good. He was yesterday placed on full diet, and has twentyounces of brandy and a pint of porter daily. Convalescent as

regards his general condition, but he is not yet co7opos ment’ís,being still unable to converse in a rational, consecutive manner.He will answer the first question put to him rationally, butwill then diverge into some topic altogether irrelevant. Hehas no memory of anything that has happened; he cannot evenremember events occurring only a few hours since, and willlose his temper with the nurses or his wife, whom he chargeswith neglecting him, and not coming near him, notwithstand-ing their attentions have been most assiduous, and he has neverbeen left alone.

July 18th.-A few days after the last note was made, hisintellectual faculties returned, and for the last fortnight he hasbeen going about the ward on crutches, and is gaining strength iand flesh. He recollects nothing of the accident, beyond the Ifact that he was wheeling a barrow on the scaffolding at the ’,moment it gave way; but from that time till the 26th of June,when he was removed from a private ward in which he hadbeen placed into the general ward, his existence was a blank.He has no recollection of either of the operations, and was sur-prised to find he had lost his leg.

ST. THOMAS’S HOSPITAL.

FRACTURE OF THE RAMUS OF THE ISCHIUM OF THE

RIGHT SIDE, WITH RUPTURE OF THE

URETHRA; RECOVERY.

(Under the care of Mr. LE GROS CLARK.)OF the fatal complications which are often associated with

injuries to the pelvis, laceration and rupture of the bladder,urethra, or rectum, are not the least important. Now andthen some of the larger bloodvessels are torn across. In the

following case the urethra was ruptured, and the patient couldnot pass any urine. With some difficulty a catheter was in-troduced into the bladder, and the urine drawn off, thus

showing this viscus to be intact. The instrument was re-tained until a recovery took place.On the present occasion we may refer to an instance of frac-

ture of the pelvis, with rupture of the bladder and urethra,under Mr. Fergusson’s care, at King’s College Hospital, whichended in death (THE LANCET, vol. i., 1852, p. 302); the reportof a case of fracture of the pelvis, by Dr. Bradshaw, of Read-ing, in which death ensued from injury to the spinal nervoussystem (vol. ii., 1853, p. 571); a case of fracture of the pelvis,with laceration of the urethra, in Professor Syme’s Lectures onClinical Surgery (vol. i., 1855, p. 174); another, with ruptureof the bladder, &c., under Mr. Ure’s care, at St. Mary’s Hos- ’,pital, death ensuing on the fourth day (vol. i., 1857, p. 315);an instance, under the care of Mr. Holthouse, at the West- ’,minster Hospital, with laceration of the abdominal muscles, Iand death from pysemia, (ibid., p. 316); another, with rupture IIof the bladder, and recovery, under Mr. Featherstonhaugh’scare, at the Gateshead Dispensary (ibid., p. 350); and, lastly,the notice of a case of compound and comminuted fracture ofthe pelvis, in which recovery ensued, under Mr. Holt’s care,at the Westminster Hospital.For the notes of the following case, we are indebted to Mr.

W. Allingham, surgical registrar to the hospital:-Thomas S-, aged twenty-eight, a guard on the South-

Eastern Railway, was admitted into Henry’s ward on theevening of the 14th of April last. It appears that this manWas crossing part of the rails at London-bridge, when he wasstruck by an engine, which was coming up to the station atthe rate of about nine miles an hour. The first blow he re-ceived was upon his right hip, and as he was trying to scrambleout of the way, he was again struck just above the right eye,and fortunately knocked off the rail, so that the engine passedwithout running over him. When brought to the hospital, heWas in a state of considerable prostration, complained of greatpain in the right groin and perinarum, and was unable to passhis urine. Some stimulant was administered, and the house-surgeon on duty passed a catheter, which seemed to enter the

bladder, but no urine escaped. On examination, a contusedwound was observed on the right hip, and fracture of theramus of the ischium was detected. Mr. Le Gros Clark sawhim at ten P. M., and found that the urethra was ruptured; hewith some difficulty introduced a catheter into the bladder,and drew off his urine, which was coloured by blood. Thepatient’s sufferings were greatly aggravated by a troublesomecough, which he has had for some time past. The catheterwas retained in the bladder, and twenty minims of Battley’ssedative solution were ordered.

April 15th.-He slept at intervals during the night, and isnot in any great pain, except when he coughs; there is ex-treme tenderness on pressure all over the abdomen; the urineis only slightly tinged with blood; the pulse is quick, andskin hot; bowels are confined, and some castor oil has beenordered. To continue the opiate.16th.-He slept pretty well last night, but his cough is

troublesome, and he can feel the grating of the fractured bonewhen he coughs; he takes his food pretty well, and seemscheerful; bowels not yet acted.

17th. -Much the same. Mr. Clark ordered a calomel andcolocynth pill, and, as his cough was very troublesome, thefollowing draught every four hours: half a drachm of com-pound tincture of camphor, and two drachms of the liquor ofthe acetate of ammonia, in water.

18th.-His cough kept him awake very much last night; hehas less pain in the groin and perinseum, and the abdominaltenderness has subsided; the urine is now clear; bowels open;skin cool; tongue clean; pulse quiet. Ordered, half a grainof morphia at bed-time.I 20th.-His cough is much better; countenance cheerful;urine slightly tinged with blood this morning; he has no head-ache nor shivering, and no pain unless he moves-he then,however, feels the bone grate. Mr. Clark removed the cathe-ter to-day for the purpose of having it cleaned, and he replacedit without much trouble. The patient was ordered to be placedon a water bed yesterday, and finds it very comfortable.27th.-He is going on exceedingly well; has not had any

shivering, nor any unfavourable symptom; when he moves, heno longer feels crepitus; his appetite is good.May 2nd.-The catheter was taken out to-day, and not re-

placed, and he finds that he can pass his urine tolerably com-fortably and freely; his cough does not trouble him, and he isexceedingly cheerful.16tb.-He sits up in bed now, has no pain on moving, and

passes his urine with ease; he is very anxious to get up.24th.-He is now able to walk about the ward on crutches,

and, although weak, feels quite well; he is going into thecountry to recruit his strength.

"DREADNOUGHT" HOSPITAL SHIP.

CHOLERA AND CHOLEROID DIARRHŒA.

(Under the care of Dr. BARNES.)THE record of the earliest cases of a cholera epidemy is

always replete with interest. In addition to their individual

pathological features, it is upon these cases that the most im-portant questions as to origin and mode of propagation mustmainly depend for illustration. Whether the following cases,(for the histories of which we are indebted to Dr. Barnes’ case-book, and to Mr. Bedford, the physicians’ assistant,) mark thebeginning of an epidemy, or whether-as we cannot but hope-they will remain isolated instances, they possess value as a.

chapter in the history of that formidable disease which nowseems to become a periodical scourge to this country.

’ Down to the 28th of July, the general health of the Dread-

, nought had been excellent. Notwithstanding the offensiveemanations from the river, there had been no particular dispo-sition to diarrhoea, certainly not so much as has been remarkedat a distance from the Thames; and during the last fortnightthe state of the river had so much improved, that it had com-paratively ceased to be annoying. On the 28th and 30th of

July five remarkable cases were admitted.CASE l.-C. W-, aged thirty-six, from Sydney, left his

ship on the 15th. in the London Docks, and lodged in theneighbourhood. He went to Euston-square Station on the23rd, where he was taken ill with purging, vomiting, andcramps; he was taken to Universitv College Hospital. but left