2. SUCCESSFUL AMPUTATION FOR TRAUMATIC Gangrene.

Aug. 31, 1837.-The patient was a youth 17 years of age, of good constitution, but probably at the time of the injury, somewhat under the influence of malaria, as he came from a sickly district on the eastern shore of Maryland. Being on board a bay craft he suffered a fracture of the leg near the knee, by the fall of a bag of merchandize which was being removed from the vessel.

Dr. Smith saw him on the fifth day from that of the injury. The limb was then reposing on pillows, in the semiflexed position, not having been placed in splints. The whole foot and leg, to within three inches of the knee, were in a state of complete mortification, the parts being tumid, crepitous when pressed, covered with dark vesications, cold and completely insensible. A belt of gangrenous inflammation existed below the knee; but nothing like a line of demarcation existed between the dead and living parts. There was considerable tumefaction at the place of fracture; but the action above the knee was neither excessive nor unhealthy. His pulse was firm and good, (about 100), the nervous system but little disturbed, and the stomach performing its offices as well as in ordinary cases of fracture.

The consultants came to the conclusion that the mortification must have resulted from some local cause; probably some lesion inflicted upon the great vessels and nerve, and they determined to amputate above the fracture. In less than two hours, Dr. S. performed the operation, and the boy recovered rapidly.

The fracture was within about two inches and a quarter of the extremity of the bone, and perfectly transverse. The upper fragment was thrust into the ham, and lodged directly behind the lower fragment, which it overlapped for about three-fourths of an inch. In the midst of effused blood and serum were found the femoral artery and vien thrust backward, and tensely drawn across the sharp posterior margin of the superior fragment, in such a manner that it was perfectly obvious that the circulation in both vessels must have been completely interrupted.

Of course, in such a case, the chances of success from an operation are much greater than in an ordinary instance of traumatic gangrene.

MASSACHUSETTS GENERAL HOSPITAL.

CASES OF PNEUMO-THORAX, and ExperimENTS TO DETERMINE THE CAUSES OF "METALLIC TINKLING.' By J. BIGELOW, M.D.*

Dr. Bigelow relates three cases of pneumo-thorax, and has instituted six experiments, for the purpose of determining the vexata quæstio-the cause of the the "metallic tinkling." It is not necessary to enter on the cases, but we shall present our readers with Dr. Bigelow's account of the experiments, and his conclusions.

Experiment 1.-Previously to the autopsies of the patients who were the subjects of Cases 1 and 2, a glass cylinder, open at both ends, was pressed into close contact with the chest, so as to hold water. Some ounces of that fluid were poured in, and a perforation was made through it, into the cavity of the chest on the distended side. Immediately a large volume of air escaped from the chest,

* American Journ. of Med. Sciences, Nov. 1838.

bubbling upwards through the water. In the third case, no cylinder being at hand, a superficial cavity was made out of the dissected integuments of the chest, and filled with water. Through this water a perforation of the chest was made on the left anterior surface. The air rushed out, producing strong ebullition, as in the former cases. The experiment was then repeated on the right side, and the perforation made through water as before. No air in this instance escaped, but the water was immediately sucked into the chest by the atmospheric pressure.

Experiment 2.-Artificial respiration was produced in the body of the subject of Case 2, by inflating the lungs through the trachea, and expelling the air by pressure on the abdomen. At each inflation, a most distinct, clear and abundant metallic tinkling was produced, accompanied with more or less amphoric sound, and could be sustained ad libitum by repeating the inflation.

Experiment 3.-Through an aperture in the anterior part of the chest in the subject of Case 2, a catheter was introduced and air blown through it into the cavity of the left pleura. While the end of the catheter was above the level of the fluid, a strong amphoric buzzing was communicated to the ear of an observer in contact with the chest. But when the end of the instrument was pushed below the surface of the liquid, and the latter made to bubble by continuing the inflation, an exquisite metallic tinkling was heard at the explosion of each bubble, resembling, as it had done in life, the sound of a little bell or musical wire. In the subject of Case 3, this experiment was repeated, and varied by pouring into the chest different quantities of water. When a few ounces only were present, metallic tinkling was uniformly produced, but when two quarts or more were introduced, a bubbling only was heard, without metallic resonance. Similar results were also obtained by pouring a small stream, or letting fall drops of water from above, upon the liquid in the chest.

Experiment 4.-Succussion and percussion were both found to produce the same metallic sounds in the dead body as during life in Case 2. Metallic sounds elicited by percussion somewhat resemble those occasionally yielded by the heart, and, as has been observed by Bouillaud, these may be imitated by percussing the back of the hand pressed closely upon the ear, or by closing both ears with the palms of the hands, and walking on a carpet in a still room.

Experiment 5.-In the body of a person recently dead from accident, having no pneumothorax, a repetition was made of several of the foregoing trials. Air and water were forced into the chest, the former so as to distend the cavity and render percussion quite resonant. Ebullition of the fluid was then produced by blowing through a tube inserted between the ribs and pushed below the surface. The only result was a bubbling noise, having not the slightest metallic character. It will be observed that this was nearly a repetition of Magendie's experiment, and it probably failed to produce metallic sound for the same reason as in that case, viz. that the patient was not pneumothoracic.

Experiment 6.-A bladder, and afterwards a stomach, each containing a few ounces of water, were inflated until thoroughly distended. Whenever the inflating tube was pushed below the surface of the liquid, and the inflation continued so as to produce bubbles, a sharp tinkling was heard upon the explosion of every bubble, by the ear applied as in auscultating to the outside of the bladder. In this experiment the sound becomes more exquisitely metallic, in proportion as the tension of the bladder is increased by farther inflation. Succussion of the bladder produces a similar effect. It is necessary that a recent bladder should be used, the texture and elasticity of which are not altered by

drying. When the orifice of the tube is above the surface of the water, also when no water is present in the bladder, an intense amphoric sound is produced during inflation; and if saliva or other liquid, in small quantities, is blown through the inflating tube, a more feeble, or sub-metallic tinkling is produced.

From these experiments, and from the cases to which they are pendents, Dr. Bigelow concludes that the following agencies are concerned in producing metallic sounds of the chest.

1. "There must be a cavity, the walls of which are preternaturally susceptible of vibration. This takes place when the pleura is pathologically distended, so as to overcome the obtuse or muffling effect of the contiguous soft organs, such as the lung, diaphragm and intercostal muscles. Some time is probably necessary to prepare the parts for this pathological resonance, since it fails to appear post-mortem in healthy chests submitted to experiment. It should be added that when metallic sounds appear in simple phthisis, there are cavities of the lungs, the walls of which are in a state of tubercular induration.

2. The immediate or exciting cause of metallic tinkling, is a forcible or sudden disturbance of the liquid in a vibrating cavity like that described. The explosion of bubbles of air from beneath the surface of the liquid, appears to be the most common cause of such a disturbance; but it may also take place when a part of the liquid is thrown upward in the act of coughing and falls back upon the remainder. The same occurs in succussion of the chest.

3. The vibrations which yield metallic tinkling are transmitted from the liquid to the solid parietes, and thence directly to the ear, without any necessary agency of an echo, or a reverberation of air in the cavity. This is shown particularly by the experiment of the bowl.

4. A minor, or submetallic tinkling, having no musical resonance, may be produced by slight impulses given to the air in the cavity, such as the breaking of bubbles of mucus at orifices above the surface of the liquid.

5. Amphoric resonance is produced by reverberations of the air in a vibrating cavity, without sonific impulse of the liquid. The same is true of metallic modifications of the voice, and of the cough when there is no tinkling. Metallic percussion seems also to depend upon the vibrations of air independently of liquid, and may be produced in some other cases when we strike upon a tense cavity in which a certain quantity of air is confined."

CLINICAL REPORTS FROM THE PENNSYLVANIA HOSPITAL.*

I-DISLOCATION OF THE HUMERUS, REDUCED AT THE END OF
TWENTY-ONE DAYS.

Eliz. B. a servant, aged 22, had laboured under an unreduced dislocation into the axilla for twenty-one days, when reduction was effected in the hospital, by Dr. Norris. The following, not unusual, method was pursued.

The patient having taken a grain and a half of tartar-emetic, in divided doses, Dr. Norris proceeded at once to the reduction. A folded sheet was firmly applied by wet rollers to the arm, just above the elbow, to effect extension with the use of the pullies; another sheet was passed around the chest, and secured to a staple, for counter-extension; and in order firmly to fix the scapula, a third band was applied over the acromion process, and given to assistants, who were directed to apply their force in a line obliquely downwards towards the opposite

Medical Examiner, Philadelphia.

side. The apparatus being adjusted, a vein was opened, and extension kept up by two assistants, for the space of about fifteen minutes, at the end of which time all extension being suddenly removed, the bone was found to be reduced.

II. DISLOCATION OF THE HEAD OF THE RADIUS BACKWARDS, REDUced.

"Mr. John B. W—, clerk, aged 23 years, whilst riding in the city, on the afternoon of the 12th of May, accidentally fell from his horse and dislocated the left radius backwards. He stated that he fell on his left hand whilst it was turned inwards, and immediately felt a sharp pain in the elbow, which induced him to think he had broken his arm.' He came at once to the hospital; the arm was semiflexed; he was unable to supinate the hand, or to bend the elbow or straighten it, without intense pain. The head of the radius was distinctly felt behind the external condyle of the humerus, resting against the olecranon process. On partially pronating and supinating the hand, the head revolved distinctly, and owing to the little swelling, and the slight development of his muscles, the button shape of the radius was distinctly seen revolving against the olecranon. The patient, to use his own expression, had always been very 'loose-jointed,' but had never before dislocated any of his bones. After a close examination of the case, he was placed on a bed; an assistant was directed to seize the humerus near the condyles, place his thumbs against the head of the bone, and force it downwards and forwards. At the same time, I made extension at the wrist, suddenly straightened the arm, and supinated the hand, when the bone readily slipped into its place. The arm was then placed in a carved angular splint, loosely bandaged, and cold lotions applied to it. The next day, the patient could bend the arm, and perform the usual motions of the hand, but, of course, was not allowed to do so. Little inflammation followed, and on the 14th of May, still wearing the splint, he returned to Mullaga Hill, N. J. where he resided."

Our readers are aware that this accident is exceedingly uncommon. duction appears to have been effected with precision and dexterity.

The re

III. THREE CASES OF COMPOUND FRACTURE OF THE CRANIUM.

Our surgical readers are aware that some difference of opinion exists on the treatment of "compound fracture with depression of the cranium." While Sir A. Cooper, Sir B. Brodie, and some other surgeons, recommend trephining as a rule in this accident; others, for example, Mr. S. Cooper, do not acquiesce in the general principle on which that advice is founded. We notice the following cases in order to add them to the recorded facts, which form the best data for generalization.

Case 1. Joseph W--, æt. 10 years, was struck on the head by a large block of wood, which fell from a three story dwelling, on the 10th August, 1837. On his entrance, three hours afterwards, he had a wound of three and a half inches in the scalp, bone bare of periosteum for two inches, fractured the length of the cut, and depressed about an eighth of an inch. Patient insensible; pulse strong, corded and slow; pupils dilated, extremities cold. He was trephined immediately by Dr. Norris. On raising the bone consciousness instantly returned. The middle artery of the dura mater was cut by the trephine, but the hæmorrhage was checked by a coagulum, which soon formed. The scalp was drawn partially together by adhesive strips, and the wound poulticed-ordered perfect rest in a dark room, and lowest diet. Evening.-Pulse increased, skin hot and dry-lies quiet, and complains little; ordered V. S. ad fžvi, and mist. sal. fzvi. ant. tart. gr. ss., a table-spoonful every two hours.

On the 31st, there was considerable fever. V. S. ad 3x.-Hyd, Sub. gr. ij. 4tis horis.

This removed the febrile excitement. The wound suppurated, granulated, threatened fungus cerebri, (compresses of lint soaked in lime-water prevented its occurrence), several pieces of bone came away, and on Nov. 5, the patient was discharged cured, the wound having firmly healed and the intellects being unimpaired.

Case 2. This case was too severe, and the issue too rapidly fatal, to admit of conclusions respecting the value of modes of treatment. The injury happened from a man falling head-foremost against a large circular saw, which was revolving 240 times in the minute. A fur cap on his head was torn to tatters, the scalp terribly lacerated, and turned back, leaving the skull bare for a space of four inches long by three wide; the skull was fractured from the lower part of the os frontis to the vertex, in a line a little oblique to the sagittal suture. The saw had penetrated the dura mater, a process of which was hanging out, and entered deeply into the substance of the brain. The patient was sensible, and could sit up in bed. But he became delirious in the night, comatose next day, and died within forty-eight hours after the injury.

Among other lesions, there were-the arachnoid much inflamed and thickened; several drachms of pure pus found on the brain and membranes; vessels injected; brain very soft around the wound; wound in the anterior lobe of left hemisphere of cerebrum, two and a half inches long, and near two inches deep; brain covered with pus, and much softened on that side.

The early occurrence of suppuration is sufficiently striking to induce us to give this brief account of the case.

Case 3, was one of pistol-ball lodged in the brain, which proved fatal on the third day, with such symptoms as might naturally be expected to occur. It is not, we think, necessary to detail the case.

The only instance of the three which bears upon the question of trephining, in cases of compound fracture of the cranium with depression, is the first. In that it will be observed that suppuration occurred, and it is fair to suppose that had the bone not been raised and removed by the trephine, the collection of pus might have produced unpleasant consequences.

IV.-MORTALITY AFTER AMPUTATIONS, IN THE PENNSYLVANIA HOSPITAL.

Dr. Norris, one of the surgeons of the hospital, has made a report on this subject. He says:

66

Contrary to the opinion generally prevalent in this country, amputation, even under favourable circumstances, is frequently followed by fatal results in civil hospitals. In the practice of the Hôtel Dieu, of Paris, it is said that not more than half of the cases prove successful; and I have the authority of M. Hache, a former interne of the hospital of St. Louis, of the same city, for stating, that out of twenty successive amputations made in the year 1833, in that institution, twelve died.

After a tabular view of the operations performed in the Pennsylvania Hospital, for the last seven years, Dr. N. observes:

"Of the above 56 amputations on 55 patients, 24 were primary, of which 14 were cured, and 10 died; 4 of the deaths occurring within the 24 hours immediately following it; 12 were secondary, of which 5 were cured and 7 died; 20* were for the cure of chronic affections, of which 15 were cured, and 4 died;

* One of the patients here included suffered double amputation.