Upon examination, eighteen hours after death, it was found that the internal table of the fractured portion of bone had been driven under the sound bone, and had become firmly adherent to it; and that an abscess occupying the greatest portion of the anterior and middle lobes of the brain, existed on the right side of the head, communicating with the external wound and lateral ventricle.

As Dr. Norris observes, this case shews the necessity of caution in prognosis and in treatment after injuries of the head.

MASSACHUSETTS GENERAL HOSPITAL.

STATISTICS OF THE AMPUTATIONS OF LARGE LIMBS.*

The report from which we draw the following particulars is from the pen of Dr. Hayward, one of the surgeons to the hospital.

Dr. Hayward well observes, that the fatality of amputations has taken people by surprise. More than one-half of the amputated die in the Parisian hospitals; and of fifty-five so operated on in the Pennsylvania Hospital, twenty-one died. Amputation is, therefore, a serious evil, and should not be lightly had

recourse to.

The results at the Massachusetts Hospital were somewhat more favourable than those at the Paris, and Pennsylvania Hospitals above referred to. In a large proportion of the following cases, the amputation was done by the circular incision; the flap operation was adopted occasionally, whenever there was reason to believe that a better stump could be made by it than by the other method. The dressings were always of a light and simple kind; consisting of two or three strips of adhesive plaster and a small compress and roller; and yet there are some surgeons of the present day, who would perhaps regard these as more cumbersome than was necessary.

If the bleeding was slight, the dressings were applied before the patient left the operating room; but if there was any thing more than an oozing from the veins, it was deferred till a few hours after.

Secondary hæmorrhage was not frequent, though it sometimes occurred; pressure was generally sufficient to arrest it, but occasionally it was found necessary to open the stump, and tie one or more vessels. In one case where hæmorrhage occurred twelve days after the operation, from a diseased state of the posterior tibial artery, the femoral artery was tied. No one who had secondary hæmorrhage died, and though it sometimes debilitated the patient, in no case was there any permanently injurious effect from it.

In all the cases it was attempted to heal the wound by the first intention, and in a few instances it was completely successful, but in by far the greater number it was only partially so.

It has not been the usual practice at the Massachusetts Hospital to administer an opiate before an operation, though in a few instances it has been done. In one case where amputation was performed on a patient with delirium tremens, twelve grains of opium were given shortly before the operation; he became drowsy soon after and recovered.

Dr. Hayward subjoins a table of the amputations performed in the hospital. This is too long for insertion, and we may content ourselves with presenting the summary.

* Amer. Med. Journ. May, 1840.

There were seventy operations on sixty-seven patients; three patients having two limbs removed. In one of these three cases, one operation was above and the other below the knee, and in the other two, both operations were below; the first patient died, and the other two did well.

Of the whole number operated on, fifteen died and the remainder recovered, at least so far as to be able to leave the hospital; though it is probable that in some instances the disease may have returned.

There were thirty-four patients who had the thigh amputated, and one of these had the other leg taken off at the same time below the knee; of this number, nine died. Of twenty-three patients whose legs were amputated below the knee, two having both legs removed, five died; and of the ten who had an arm amputated, six below and four above the elbow, one died.

This goes to confirm the prevailing opinion among surgeons, that amputation of the lower extremities is more often followed by fatal consequences that that of the upper, and that death takes place more frequently after amputation of the thigh, than after that of the leg. More than a quarter of those whose thighs were amputated died, while there was but little more than one death in five among those whose legs were removed below the knee, and only one of the ten whose arms were amputated. This patient too died of delirium tremens. The operation to be sure did not arrest the disease, but apparently contributed nothing to the fatal result.

This table tends also to support the opinions, that patients who undergo amputation for chronic diseases are much more likely to recover than those in whom it is performed in consequence of recent accidents. Of the first class, there were forty-five patients afflicted with various diseases, and of this number all recovered but six; and of the remaining twenty-two, whose limbs were removed on account of recent injuries, no less than ten died; being nearly half of the latter and less than one in seven in the former.

This fact certainly gives support to the opinion, that a state of high health is not favourable to surgical operations; and it also tends to show that death after amputation is not by any means attributable in all cases to the operation alone; for if it were, the proportion of deaths should be as large among one class of patients as among the other.

Dr. Hayward thinks that the result is affected, not only by age and constitution, but by the period at which the operation is performed. He thinks that, in recent cases, it is often done where it might have been avoided-and, in chronic cases, avoided or deferred where it ought to have been done, the patient being allowed to sink into an irremediable condition. He is against operating while the system is under the influence of shock-reaction should occur. With regard to the ages of the patients operated on, it appears that there

Spirit of the British and American Periodicals, &c.

SOME PATHOLOGICAL FACTS.

IN our Dublin contemporary we have a full report of the Proceedings of the Pathological Society of Dublin—a very excellent society, whose meetings are attended by distinguished men, and enriched by valuable facts. Of the latter we shall cull the more important.

1. Precautions in Operating for Empyema.-Speaking of a case of empyema, Dr. Corrigan observed that the phenomena which attend the formation of matter externally are very apt to prove deceptive. The opening by which the fluid in the cavity of the pleura escapes in the first instance, is often very small, so small indeed, that it will barely admit the introduction of a probe, while the matter in the cellular tissue beneath the skin is often in very considerable quantity. The fluid which escapes from the pleural sac creates and keeps up irritation, and hence the quantity of pus in the external abscess is sometimes much greater than one would expect. When an incision is made, a large quantity of matter flows out, and the operator thinks he has made a sufficiently large opening. The lapse of four-and-twenty hours is sufficient to convince him of his mistake; the matter now either trickles out very slowly, or perhaps stops altogether, and continues so until a fresh opening is made. Dr. Corrigan said he mentioned this as a practical fact. In all cases of this kind, it is necessary to open, not only the external abscess, but also to take care, that the matter of the empyema has a ready mode of exit.

2. Traumatic Emphysema without Laceration of the Pleura, or Fracture of the Ribs.-A strong man was run over by the mail. On admission into the Richmond Hospital he had intense dyspnoea, with the usual symptoms which accompany internal hæmorrhage; there was also slight cough, but he did not spit any blood. All the muscles of the chest, abdomen, and neck were thrown into the most violent action, and the dyspnoea under which he laboured was frightful. His pulse was about 96, weak, and failing; his face pale and livid; his extremities cold. At the root of the neck there was a large tumor, which was found to be produced by effusion of air into the cellular substance, constituting subcutaneous emphysema; the whole of the anterior, lateral, and posterior parts of the chest became subsequently inflated. He died about three-quarters of an hour after admission. On dissection, the right lung was found as compressed as in an old emphysema, by an enormous quantity of air in the cavity of the pleura. There was a large quantity of extravasated blood lying about the roots of the great vessels and primary branches of the aorta. There were three different lacerations in the substance of the lung on the right side, but not on the left; the lung of the left side presenting nothing except a considerable degree of sanguineous engorgement. The pleuræ on both sides were quite uninjured, and there was no fracture of the ribs. The chief alterations consequent on the injury were emphysema of the neck and trunk, effusion of air into the right cavity of the pleura, causing very remarkable compression of the lung, laceration of the right lung, with extravasation of blood about the roots of the great vessels, and congestion of the left lung. The most singular circumstance connected with

* Dublin Journal, September, 1840.

the case was the occurrence of such extensive laceration of the lung without rupture of the pleura, or fracture of the ribs. These parts were examined with great care, but no solution of continuity could be discovered. The effused air had first passed into the mediastinum, and subsequently into the cellular tissue of the neck and trunk. This was the fourth case of rupture of the lung, without fracture of the rib, which Mr. Smith had witnessed. The first case was that of a woman who had met with a severe accident, and in whom this condition was discovered after death. The next case was that of a dog which was killed near the Richmond Hospital, by a car passing over its body. Mr. Smith examined the body shortly after the accident, and found that, although there was not a single rib fractured, the pericardium was torn in various directions, and the lung extensively lacerated. The last case was that of a man brought into Jervisstreet Hospital, who had general emphysema and rupture of the lung, without any injury of the ribs or pleura.

3. Softening of both Lobes of the Cerebellum-Symptoms.-Our readers are aware of the uncertainty that obtains in reference to the functions of the cerebellum. It is thought to be a regulator of motion, and to be connected with the venereal passion. The following facts do not seem to lend much confirmation to either notion.

:

The subject of the case was a young woman, æt. 26, unmarried, and who enjoyed perfect health until three months before her death, when she was attacked with intense headache, not referred to any particular part of the head, and accompanied by sickness of the stomach in the morning. When she applied at St. Vincent's Hospital, she was almost completely amaurotic, and had double vision, which continued until her death: her headache was intense, but intermitting she suffered greatly from globus hystericus. Previous to her admission into the hospital, she had undergone a course of mercury; and while in hospital, she was again salivated with temporary benefit: under the use of mercury her pulse fell from about 90 to 72; and for some time her febrile symptoms underwent a marked improvement. She had no paralysis during the whole course of the disease; the prominent symptoms were intense, but not constant headache, globus hystericus, double vision, amaurosis, and strabismus. She died rather suddenly about three months after the first appearance of her symptoms. Upon examination after death, the anatomical characters of chronic inflammation of the membranes of the brain were found, and both lobes of the cerebellum were softened nearly throughout their whole extent, and of a pale rose colour.

4. Flaccid state of the Heart in Fever.-Dr. Stokes has observed that, in certain cases of typhus, the sounds of the heart are greatly diminished, so that one or both become more or less indistinct. In such cases, he has stated that there is a specific change, or softening of the heart's substance. Dr. Graves exhibited the heart of a man labouring under typhus without maculæ. He was admitted into the Meath Hospital on the fourteenth day of his illness. It would be unnecessary to give any detail of the symptoms, further than to state, that on admission his pulse was strong and dicrotous, continued so for some days, and did not lose this character until five or six days before death. He died on the thirty-third day of fever. During the course of the disease, the chief symptoms were a dry tongue, dicrotous pulse, general bronchitis, with congestion of the lung, and diarrhoea. Some thought that one of the sounds of the heart was inaudible; but this was dubious. The man died on the thirty-third day of the fever. There was a general flaccidity of the heart, but no evident specific softening of its substance.

5. Co-existence of Scirrhus of the Pylorus and Tubercles of the Lungs.-Mr.

Smith presented the recent parts in this case, one of the lungs contained a tubercular cavity, which had evidently existed for a considerable time, and several scattered groups of tubercles were found in both lungs. Along the lesser curvature of the stomach, and completely encircling the pylorus, there was a large cancerous ulcer, the surface and circumference of which presented numerous fungous growths, the mesenteric glands were much enlarged, and filled with a white, cheesy matter, of a scrofulous character.

Similar cases have been mentioned by Bayle.

6. Is Bright's Kidney the cause of Albuminous Urine ?—Dr. Graves exhibited a case of granular kidney, and detailed the particulars of the case. The Reporter states :-A question then arose, whether that state of the kidney termed "Bright's kidney" was the cause of albuminous urine, or whether it was to be looked upon in an opposite point of view, and regarded as the consequence. Dr. Graves said he was inclined to adopt the latter opinion for various reasons. He had seen so many persons cured of albuminous urine under various circumstances, that he should hesitate in ascribing this condition to a permanently disorganized state of the kidneys. A remarkable instance of this occurred in the person of Staff Surgeon Finnie, Surgeon to the Military School at the Park; about six months ago he was attacked with pleuro-pneumonia of the left lung, of a very severe character, and speedily followed by anasarca. About the time the anasarca was making its appearance, his urine became highly albuminous, and continued so for nearly six weeks. About the time when the pectoral symptoms were about to yield to treatment, the anasarca and ascites began to disappear, and at the same time the urine began to lose its albuminous character. In this case the pectoral symptoms were so severe, that for some time Dr. Graves indulged but faint hopes of his recovery. The antiphlogistic treatment pushed to its furthest extent, mercury to salivation, and repeated and powerful vesication succeeded in removing the disease, and with it all trace of albumen in the urine. The case occurred about six months ago, and the gentleman has remained quite well ever since, and without manifesting any symptoms whatever of a return to the albuminous diathesis.

It should be borne in mind, that in the dropsical diathesis there is a tendency to the secretion of water loaded with albumen, not only in the kidney, but also into the cellular membrane and serous cavities. It is rather difficult to conceive, that when the general system takes on this diseased action, the kidneys should be exempt, or that the kidneys should become affected with organic disease, in order to pour out albumen, while other tissues and organs can assume the same function without any structural alteration. Why should the kidneys alone become changed, while other parts retain their organic constitution? Dr. Graves said that he thought a few observations on this point would not be out of place. The Profession were in general aware, that modern discoveries have shown that the cortical portion of the kidney consists of an immense number of very minute tubes convoluted on each other, blending, and lying in apposition with the ultimate ramifications of the the arterial capillaries, through the parietes of which the urine is separated from the blood, making its first appearance in the minute tubes of the cortical substance. Now what are the chief constituents of urine? water, salts, and various acids, as the phosphoric, nitric, &c. Now if the nascent principles of the urine are secreted into these minute tubes in company with nascent albumen, the latter will be inevitably coagulated by some of the abovementioned acids, and if this process be often and continually repeated, it is not surely a very improbable result, that these tubes may ultimately become filled with coagulated albumen, a fact observed by Valentin.

We quite agree with Dr. Graves that albumen in the urine is not necessarily indicative of serious disorganization of the kidneys. Every physician and surgeon must see cases of albuminous urine cured. But, whilst we allow this we