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Reports of Medical and Surgical Practice in the Hospitals and Asylums of Great Britain and Ireland

1880 BMJ (Clinical Research Edition)  
Under the care of Mr. GOLDING-BIRD.) [From the report of Mr. J. WV. LONG.] W. A., AGED 2I, a grocer's assistant, was admitted into Guy's Hospital, under Mr. Golding-Bird, on February 6th, 1878. An abstract of his case is as follows. He was a pale, fair-haired, thin, and excitable lad, in a bad state of health, and was then suffering from an inflamed bursa under the tendon of the left sartorius, over the inner tuberosity of the tibia. On March Ist, the bursa was opened under the spray; but the
more » ... he spray; but the incision was very slow to heal, and had barely closed by May ist, when he was discharged on crutches. There was then some evident thickening of the synovial membrane of the left knee, and limited movement in the joint. In spite of treatment, he wvent from bad to worse till November 27th, I878, when, having been readmitted, the left kneejoint was excised. In three weeks, the wound had healed, when suddenly ostitis appeared in the ends of both the bones. On January 2ISt, 1879, a sequestrum was removed from the femur; and on the 26th amputation through the lower third of the thigh was performed; anteroposterior flaps-skin and muscle-were made. The stump healed by primary uinion; but ostitis set in again on February gth, with so severe and conistant pain, that the lad was nearly worn out. In the stump, though very carefuilly examined, no special spot of pain could be found; but any pressure on the thickened end of the bone aggravated his suffering: the pain was referred generally to the foot. He was now sent to the seaside until June 27th, being treated during that time with tonics and unguentum hydrargyri; and, on an examination of the stump at this last date, the bone was found reduced in size, and the pain could be increased only by pressure upon two spots in the posterior flap, one on either side of the median line. The lad was in constant paini, but it was worse when he was sitting than standing. On July 2nd, these two spots were explored, and about two inches of each popliteal neri xe were removed. The pieces of nerve were not bulbous, but ended in cicatricial tissue. On July 15th, the wounds had quite healed, but the pain was just the same, still referred to the foot, and following exactly the final tlistribution there of the great sciatic nerve. The patient's general health was now suffering from the constant pain and loss of rest, in spite of injections of morphia; and therefore reamputation was performed somewhat above the middle of the thigh. The stump healed by primary union, and on August i6th the lad was discharged to Bognor, as unrelieved as ever. He was readmitted into Guy's on September 29th, 1879, with his general health much improved, but the pain as severe as before, though slightly altered in character; it was now more paroxysmal, and confined to these spots-viz., across the heads of the metatarsal bones, between the great and second toes, on the outer side of the ankle, and in the heel. On firm pressure being made over the great sciatic nerve, in the buttock, the pain was at once intensified. It was therefore decided to stretch the trunkof the great sciatic nerve; and this was done on October 3rd. The nerve was cut down lupon (under the spray) betweeni the tuber ischii and great trochanter; the forefinger vas slipped around it, and the nerve forcibly tugged several times, till it rose from the wound like the handle of a bucket. It was then seize(d between the thumb and finger, and forcibly pulled in the direction of both its central and peripheral attachments. It was then returned to its place, and the wound closed. On October 4th, the pain was much less intense, though still referred to the same spots in the foot. Morning temperature 98.8°. Later in the day the pain shifted, and, leaving the heel entirely, was confined to the front of the foot. On the evening of the 5th, the patient described the pain as more severe, and as proceeding from the spine, and passing along the line of the incision in the buttock to the stump and foot. On the 7th, the pain was increasing in severity, and worse in the evening and night, augmenting from about 5 P.M. Its character was again changed: the pain on the outer side of the foot and between the great and second toes was numb; that across the heads of the metatarsal bones was intermittent; but that in the heel as intense as ever. The patient remained thus a fortnight, and on October 2Ist he desired that some-thing further might be done to relieve him of the pain in the heel, which was unbearable. The stump was very canefully examined, and a small spot was found in the middle of the cicatrix at the edge of the posterior flap, on the pressing of which, all the pain in the foot was much increased: the stump had frequentlv been examined for any tender spot before, but this was the first time that one was found. It was now excised; and, though examined with the aid of osmic acid, no trace of nerve-structure could be found.
doi:10.1136/bmj.1.1017.969 fatcat:6rddor3apneh5jv2y3jyuzypqq