Selections from American and Foreign Journals.

Secondary hemorrhage after amputations-comparative advantages of circular and flap amputations. In a discussion in the Royal Medico-Chirurgical Society, May 11, 1841, "Mr. RUTHERFORD ALCOCK said that the question of amputations generally, and of the different modes of performing them, and of the effects of different circumstances upon the results of the cases, had engaged much of his attention for several years. Many of the results which he had attained were already before the public, and he would now limit himself to observations on the principal topics of the present paper, and especially to the question of the comparative advantages of the flap and circular modes of operation, and the results of each with reference to the ultimate terminations of the cases, and the several accidents that supervene on amputations. With respect to the occurrence of secondary hemorrhage, he quite agreed with Mr. Liston that the oblique division of the femoral artery was not a matter of importance. But he was not sure that the oblique division of the smaller arteries had not some influence in bringing on or permitting that accident. He had often thought that, in flap amputations, the small vessels retracted only partially, which, in circular amputations, would have retracted completely; or that the vessels in the former case were overlooked, which, in the latter, bleeding distinctly, would have been secured. Nothing, however, had convinced him more of the necessity of having accurate records of series of cases, and of not trusting to general impressions, than the results of amputations. In these questions, more than in any others, general impressions were apt to be erroneous, from the circumstance of the strength of the impression which single events, deemed at the time remarkable or important, make upon the mind. With respect to this very

question of secondary hemorrhage, for instance, he had himself gained a very wrong impression from two cases, which was not corrected until he had accurately ascertained the results of the whole series of those that had fallen under his observation. The two cases were these: In an epidemic from which the troops under his charge suffered at Vittoria, the legs in several cases became gangrenous, and required amputation. In the first two instances he amputated in each patient one leg by the flap, and the other by the circular operation; and in both these cases the flap operation was followed by secondary hemorrhage; but after the circular none supervened. The circumstance made such an impression on him that he entertained no doubt that flap amputations were more obnoxious to secondary hemorrhage than circular, till he came to sum up the results of all his cases, or, at least, of all those of which he had a regular and well-kept series. The result of this examination was, that in 115 cases, of which 90 were circular amputations, and 25 flap amputations, the proportion of secondary hemorrhages was somewhat greater in the former than in the latter. In the second place, with regard to the liability to necrosis of the sawn bone in the two classes of cases, he did not think that any difference could be found between them; and it was the same with regard to the conical form of the stump, an event which he believed could only very rarely occur after either kind of amputation, if dexterously performed by a surgeon practised in the operation. As in the 115 cases alluded to it had occurred only twice, he could not draw any conclusion respecting its frequency in one or the other operation. With reference to the main question of the comparative mortalities of each mode of operation, he has found that his results were by a fraction disadvantageous to the flap amputations. He was not, therefore, prepared to agree in what was said to be the growing opinion that this operation would in time completely supersede the other. It was true that the flap amputation was a more rapid mode of operating than the circular, and to this full weight must be allowed; for pain is in itself an absorbent of life, and is always followed by a reaction and a febrile disturbance, that may have an important influence on the recovery of the patient. At the same time he thought that the difference in this respect between the two modes of operation had been overrated. Eighty or ninety seconds were ordinarily sufficient for the performance of the circular operation; and if the flap amputation were done in fifty or sixty, the difference of the times during which the patient was in each exposed to pain was really not so great that much

much importance could be attributed to it. It did not appear to him, therefore, that on this ground there could be any justreason for discarding the circular mode of operation. A more important point seemed to him to be involved in the question of the after treatment of the stump. There was nothing of which he was more certain than that the idea of the advantages of union by the first intention, which was so commonly held in this country, was greatly exaggerated, and he would go so far as to say that, in some cases, such a union was not only of no advantage, but was actually mischievous, and dangerous to the life of the patient. For patients, after immediate union of the wound, would often, as he had himself seen, die of the very diseases which were said to result from the wound remaining open. In a primary amputation, after an accident in a healthy man, it was no doubt most natural to desire that the wound should be healed as quickly as possible; and, probably, in these cases, it was best to try to obtain a union by the first intention. But in secondary amputations, and in those performed for diseases of the limbs, when the incisions were made through diseased tissues, there was no use whatever, but, he believed, a disadvantage, in bringing them together. They would almost invariably open again, and place themselves in the position in which they had been left from the first. This was especially the case when limbs were amputated for diseases which had been connected with a considerable discharge. In all these it was dangerous to stop the discharge too suddenly, and it had been proposed to make an issue near the end of the stump, to keep up an artificial drain to replace that which had been cut off. But this method, he thought, would be very inconvenient, and such indeed as could scarcely be put in practice; another, which he had sometimes adopted, and which seemed to fulfil all the intention, consisted in passing a skein of silk through the lower part of the wound, and thus maintaining, for a time, a constant irritation and a discharge of matter, which afterwards might be gradually reduced."-Am. Jour. Med. Sci., from London Med. Gaz., May, 1841.

Fracture of the tibia, with avulsion of the internal malleolus, and penetrating wound of the ankle-joint; consecutive abscesses; necrosis of the tibia, and resection of its inferior extremity-recovery. By M. CASTELLA.-C. H. J. St. Croix, aged 42, was thrown down on the 22d of May, 1840, under a bag

gage wagon. The right foot was turned forcibly outwards, the internal malleolus was torn from its attachment, and the inferior extremity of the tibia protruded through the skin to a considerable extent.

Considerable inflammation followed the injury, abscesses formed behind the tibia, and amputation being deemed necessary, the patient was conveyed to the hospital at Pourtales, on the 27th of May.

The right foot was found to be very much averted-the fibula was fractured three inches above the external malleolus, which was flattened and crepitated on pressure--and, above which the fibula presented a reentrant obtuse angle. Internally the inferior extremity of the tibia, black and denuded, projected to the extent of two inches, and the internal malleolus was torn off at the level of the articular surface of the tibia. Several fistulous openings existed at the posterior border of the tibia, and yielded a fetid sanious discharge. The foot was cedematous; there was considerable fever, and the patient was very much debilitated.

June 2d.--Before resorting to amputation, it was determined to resect a portion of the necrosed tibia, to replace the foot in its natural position, and to retain it in situ by means of Dupuytren's apparatus for fracture of the fibula.

With this view, an incision was made anteriorly and posteriorly to the tibia, and a slip of lead passed round the external surface of the bone, as high up as possible, to protect the soft parts, and especially the vessels; the bone was then sawed across, and twenty-one lines of its inferior extremity removed.

The foot was now easily drawn inwards, and kept in position, with Dupuytren's bandage; the depression of the fibula disappeared; and the leg being semi-flexed, was placed on its outer surface.

Phlegmonous inflammation followed the operation, requiring several incisions which gave issue to sloughy cellular tissue; but at length granulations covered the inferior extremity, of the tibia; the medullary membrane became rapidly developed, and in proportion as the vacant space between the tibia, fibula, and astragalus became filled with granulations, the heel which had been drawn forcibly upwards by the action of the gastrocnemii and solei muscles, resumed its situation, and the foot ceased to be extended on the leg.

At the expiration of two months the fibula was consolidated, and presented a symmetrical outline; and after a few months, the wound was completely consolidated. The foot had acquired some small degree of motion, and the space resulting from

the resection of the tibia had disappeared, and was filled by a solid bony substance. In October the patient began to walk on crutches; and on the 11th October he left the hospital, being able to walk with the aid of a stick.-Dublin Med. Press, from Gazette Médicale de Paris.

[This case resembles in some respects that of Wm. Smith, which was noticed in the February number of our Journal, p. 141. The mode of treatment adopted is likewise similar to that so successfully pursued in the latter by Dr. Shipman, of Cortlandville, N. Y. We may mention, by the way, that a correspondent writes us that Smith is entirely well, and has walked 30 miles in one day since last winter; his injured limb, save that it is shorter, being equally as serviceable as the other. Dr. Shipman's triumph over his persecutors, or rather we should say, the triumph of science and skill over ignorance and dulness, is therefore complete. Thus may it ever be. We commend the case above quoted to the espécial notice of Professors Hamilton and Webster of the Geneva Medical College, and to all others who can do nothing without "authority from books."-EDS.]

Comparative frequency of tuberculous disease. By J. B. S. JACKSON, M. D., of Boston, Mass. The following is an analysis of dissections made during the last ten years in this city or the immediate vicinity, and tending to confirm the general statement, that in the temperate latitudes about one sixth or more of our race die from some form of tuberculous disease.

The whole number of autopsies I find to be 604.

Of these there were excluded 94 cases of patients dying from disease foreign to the lungs, and in which these organs were not at all, or not sufficiently, examined; also four cases in which there was a question between pneumonia, and tuberculous disease.

Of phthisis there were 93 cases. Amongst these were included some cases of general tuberculous disease in children, and in which some of the other organs may have been as much or more affected than the lungs. One of these last was a child that died of tuberculous disease of the brain, with considerable disease of the bronchial glands and only a trace in the lungs.