William Pirrie
1859 The Lancet  
505 intact to admit of amputation at the wrist-joint. I made two flaps, a dorsal and a palmar, by detaching the soft parts from before backwards, the latter flap being larger than the former. Ligatures were applied to the radial and ulnar arteries, and the borders of the flaps approximated in the usual manner. The stump was redressed on the fifth day, and the boy went out on the twentieth day after the operation. The power of pronation and supination was perfect. CASE 3.-A man, aged thirty-six,
more » ... n, aged thirty-six, was admitted, under the care of Mr. Luke, for orchitis. His hand had been amputated by Mr. Luke at the wrist-joint by the double-flap operation six years previously. An excellent stump had resulted, and the patient had the power of rotating the radius on the ulna to the .extent of about twenty-five degrees. CASE 4.-A labourer, aged thirty-five, was admitted in consequence of having received an injury to the hip. Amputation of the hand had been performed eleven years previously. The forearm was fixed in a state of pronation. The ends of the radius and ulna were anchylosed, so that no rotatory move. ment of the former on the latter could occur. A cicatrix existed three or four inches above the lower surface of the stump, just internal to the tendon of the supinator longus. This indicated the position of an abscess, which the man said had been opened three or four days after the operation. The styloid processes of the radius and ulna could not be felt, so that it is probable that removal of the lower ends of the radius and ulna had formed part of the operation. Remarks.--In irremediable injuries of the hand, amputation at the wrist-joint is unquestionably preferable to the removal of the mutilated part by an operation performed at the lowest part of the forearm,-a practice still recommended by some surgeons of the present day. In the former proceeding, if the steps necessary during its performance are carefully attended to, the inter-articular fibro-cartilage and sacciform synovial membrane between it, the radius, and the ulna, are left uninjured ; and when the stump has healed, the rotatory movement of the one bone on the other is more or less preserved, and consequently a more extended range of movement allowed to any mechanical appliance made use of as a substitute for the deficient portion of the limb, than if amputation had been had recourse to through the lower part of the radius and the ulna, in which instance anchylosis between them would result, as shown in Case 4. Amputation at the wrist-joint is best performed by making a dorsal and palmar semi-elliptical flap. The apices of the styloid processes being taken as the guide for the limits of the incisions, the first incision is made over the back of the hand when in a state of flexion, its most prominent part being about three-quarters of an inch from the carpal surface of the radius. The skin and soft tissues beneath it are then dissected from before backwards, and the joint is opened by a division of the dorsal ligaments. The hand is then placed in a state of supi-.nation, and extended, in order to render tense the flexor tendons ; and a similar flap, but more extensive (the prominent part of its border being on a line with the lower third of the carpus), is made from the palm, by dissecting the soft tissues in a similar manner from before backwards. The first part of this flap is to be made of skin and connective tissue only, the flexor tendons being divided about a quarter of an inch below the joint. The palmar and lateral ligaments are then cut through, and the operation is finished. By this method of operating two neat flaps are made, and the border of one can be brought into accurate apposition with that of the other. This cannot be effected by the ordinary method of proceeding, which consists in first making a dorsal flap, then entering the joint, passing the knife between the carpus and bones of the forearm, and finishing the operation by carrying the instrument from behind forwards through the palm, and so making the anterior flap. The objections to this method apply only to the second part of the operation. The hand being then in a state of flexion on the forearm, in order to admit of the easy insinuation of the blade of the scalpel above the upper row of carpal bones, the inter-articular fibrocartilage is apt to be injured by the edge of the cutting instrument. The tendons of the flexor muscles, being in a state of relaxation, are also apt to be drawn before the scalpel, and after having been cut through to require subsequent shortening ; and, in consequence of the prominence of the pisiform, unciform, and trapezium bones, the resulting cutaneous flap would be more or less angular and jagged, and probably here and there button-holed, thus interfering with and retarding the reparative process. LATE ASSISTANT-SURGEON IN H.M. 71ST HIGHLAND LIGHT INFANTRY. As so many of our fellow-countrymen have of late died from the effects of sun-stroke, the following remarks, based on the observations of one who had opportunities of seeing many such cases during Sir Hugh Rose's summer campaign of 1858 in Central India, may not be unacceptable to those in this country who have never witnessed the direful results of direct exposure to a tropical sun. Everyone knows the influence of high atmospheric temperature in stimulating the organic, and, if continued for some time, in depressing the animal, functions; yet many who have not had opportunities of personal observation may not be aware of the distressing effects of heat when it acts as an exciting cause of sudden attacks of illness. Exposure to the influence of a tropical sun may give rise to various minor forms of illness of a febrile and more or less lingering character, but on these affections it is not my purpose to write. The terms Insolatio, Sun-stroke, or Coup-de-soleil, are applicable to those cases only in which an individual is seized with sudden, alarming illness, and in which life is placed in immediate jeopardy, the patient exhibiting some one or other of the combinations of symptoms to be afterwards described. The object I have in view may, perhaps, be best accomplished by classifying the following remarks under the successive heads of, 1st. The various forms which the attack may assume; or, in other words, the different degrees of intensity of the affection; and the symptoms characteristic of each form. 2nd. The predisposing causes of this affection. 3rd. The post-mortem appearances, and the conclusions deducible from them as to the nature of the disease. 4th. The treatment most successfully adopted in these cases. Amongst the many cases of sun-stroke which came under my observation, three different forms of attack were observable :-In the first and speedily fatal form, the individual has no premonitory warning of the impending evil, or, if he has any, it is of momentary duration, for he immediately falls down insensible, quite unconscious of all outward impressions, makes a few hurried, gasping respirations, and instantly expires. The examples I had opportunity of seeing of this most rapidly fatal form of the disease, occurred during direct exposure to the rays of the sun. The redness and heat of the surface of the body, the perfect unconsciousness, and the gasping respiration, are striking features in this sudden and fatal form of seizure. In the second form of attack the sufferer has an unusual and an extremely painful feeling in his head; a distressing sense of bursting and burning in his eyes, accompanied with giddiness and confusion of vision; a most overpowering sensation of constriction in the chest, with greatly oppressed respiration; great heat of the surface of the body; a dark red, almost livid, colour of the skin, and an alarming sense of general oppression and exhaustion. On looking at the patient, the impression formed was, that the chief suffering was in the chest, and patients labouring under this form complained most of the symptoms referable to the chest and the breathing, and in many instances described them as almost insupportable. If proper means be instantly adopted and zealously pursued, consciousness may not be lost, and the symptoms may be removed, and leave the patient to all appearance comparatively well; or they may increase in severity, and merge into those of the third form, the phenomena of which are the following :-The sufferer complains of violent pain in the head and eyes, of giddiness and confusion of sight, of a most painful feeling of suffocation and constriction in the chest, of extreme debility, especially in the back and limbs, of intense thirst, and of heat in the epigastrium, all which symptoms rapidly increase in severity until the supervention of insensibility, which too often most rapidly ensues. If called in early, the medical attendant usually finds his patient in a state of extreme prostration, and affected with convulsions, vomiting, a burning hot skin, a very contracted pupil, an excessively suffused conjunctiva, and a rapid and feeble pulse. In many cases, shortly after the seizure. priapism and emission of semen take place. The re-
doi:10.1016/s0140-6736(02)45702-9 fatcat:6cpxowdtwzbzjfouwqdyoxrnle