ST. MARYLEBONE INFIRMARY

1856 The Lancet  
432 August, 1855. Sixteen months before, she sprained her right z , wrist by pulling at a towel when in labour, which was followed next day by pain and swelling over the back of the wrist. In -ie e course of four or five months, suppuration occurred, and matter was let out with relief. Six weeks before admission, an abscess formed over the styloid process of the ulna, which burst, and a slough came away. An abscess formed also at the inner side of the elbow, which is now nearly healed up. The
more » ... ly healed up. The parts around the wrist and hand are very much swollen, and dead bone can be detected in several places; both carpus and metacarpus, and the wrist-joint, seem to be involved. She has no signs of disease elsewhere. On the 6th of October, Mr. Fergusson removed the greater part of the third metacarpal bone. She remained in hospital some weeks after, and went out in November, much relieved. On the 21st of May, 1856, she was re-admitted, with several small sinuses on the under surface of the hand and wrist, and a much larger one on the back of the hand. All these discharged at times freely, but did not look so healthy as when she last left the hospital. On the 31st of May, Mr. Fergusson intended to amputate the hand, but at the earnest solicitation of the patient he excised the wrist as follows :-A lateral cut in the direction and situation of the old ones was made on each side of the wrist and hand; through the inner aperture, the blades of a bone forceps were introduced, and three-quarters of an inch of the lower extremity of the ulna, and an inch of the radius, were cut off; diseased portions of the carpal bones were then cut off, and extracted. The sinuses were stuffed with wet lint, and the arm bandaged again on to a splint. The lower ends of the radius and ulna which were removed were found to be much diseased, and the small portions of the carpal bones which were removed were also in the same condition. There was some swelling and much discharge a few days after the operation, but the wounds commenced to granulate in a healthy manner. By the lst of July, a small sinus only was present, leading from the inner side of the wrist for about three inches up the arm. This sinus had disappeared by the 8th, and the wounds on the hand were healing fast; she could flex the fingers to a slight extent. On the 10th of August, she was discharged cured, with a very useful hand, and a tolerable amount of flexion and extension. WE are indebted to the kindness of Mr. B. Rewle for the abstract of the following case, partly from the notes of Mr. Workman, one of Mr. Fergusson's dressers. J. G---, aged thirty-six, admitted on the 2nd of April, is a brewer's man. Sixteen months ago, without any previous injury, he first experienced pain in the back of the wrist. He continued to work for some weeks, until the pain became so great, followed by swelling of the joint, as to compel him to discontinue work, and he became an out-patient at the Middlesex, then at Bartholomew's Hospital for three months, where he was blistered &c. without relief. At Christmas, he came as an out-patient, under Mr. Bowman's care, who applied two issues, which discharged freely and relieved the pain; but as no permanent benefit ensued, he was admitted under Mr. Fergusson's care, in April, 1856. The whole of the joint was then much swollen, with considerable fluctuation on the outer part, where also was the most pain. The movement of the joint was considerably impaired. There was no redness of the skin, and the swelling was confined to the joint. April 3rd.-Mr. Fergusson made a puncture on the outer side of the wrist, which gave exit to between one and two ounces of bloody serum. The arm was rested on a splint, and water-dressing applied. 12th. —There being little change in tte appearance of the joint, Mr. Fergusson performed excision, considering there was too much disease for other treatment. He first made an incision, two or three inches long, along the outer and inner borders of the wrist, and through these, by means of the forceps and elevator, removed the carpal bones, and then cut off the articular ends of the ulna and radius with the cutting forceps ; and also removed some gelatinous-looking tissue from the soft parts. Only the radial artery required a ligature. The arm was placed on a straight splint, and wet lint applied. The carpal bones were extensively carious, and the cartilage had also been absorbed from some parts of the radius and ulna. 432 15th.-The wound is looking healthy; suppuration is commencing. Water-dressing to be continued. 18th.-The wound is healthy, but the ulna slightly projecting, to remedy which a pad was bandaged over it. Patient slightly feverish. 20th. -He has a slight shivering attack and loss of appetite; some erythema of the forearm exists, and the fingers are swollen. The wound is dry; a poultice to be applied to it. To have six ounces of brandy. 29th. -Better. The wound discharges very little. Not, much pain; but the erythema still remains. General health good. May Ist.-Erythema of the arm has disappeared, and the wound is healthy. Water-dressing and bandage. 6th.—Wound healthy. Bandage and splint still applied. 27th.-The ulna-side wound is healed up; that on the radial side granulating freely, and no appearance of sinus. A shorter splint applied, so as to allow movement of the fingers. June 12th.-Wound nearly healed. There is still some thickening of the tissues about the wrist. 25th.-Wound nearly healed. Mr. Fergusson passed a No. 1 catheter to relieve a stricture from which he had been suffering. July 1st.—Nos. 3 and 4 were passed with tolerable facility, and on the 3rd, No. 5; at this time the patient had pain in his. chest, with expectoration. 15th.-Mr. Goodall, the house-surgeon, examined his chest, and found evident symptoms of phthisis in both lungs. The wound in the wrist discharges rather more than it did, and does not look quite so healthy. He was discharged to go into the country, and readmitted on the 2nd October, with considerable tenderness and inflammation of the arm. The arm was put in a splint, and fomentations applied, which rapidly subdued the latter. He has now (October l3th) increased power in his hand, and is continually exercising his fingers, which he can bend to a considerable angle by the aid of his other hand; but he has, as yet, very little muscular movement in the fingers themselves. ST. MARYLEBONE INFIRMARY. SPONTANEOUS GANGRENE IN THE UPPER AND LOWER EXTREMI-TIES; TWO CASES, OCCURRING IN OLD PEOPLE; RECOVERY. (Under the care of Mr. HENRY THOMPSON.) Up to the time of Pott, a case of spontaneous gangrene was treated, more particularly when occurring in an elderly subject, as in the great majority of instances would be the case, (senile gangrene,) according to an established routine, based on a certain theory, " of warming, invigorating, stimulating, and resisting putrefaction;" and the way in which this theory was carried out was, to apply locally spirit washes and stimulating dressings, and to give bark largely by the mouth. Furthermore, it was the habit to cut or scarify the diseased parts with a lancet pretty freely, in order to enable the stimulating dressings to permeate the tissues. Pott's experience led him to follow and recommend a widely different course. He tells us that in the course of his practice he met with an obstinate patient who could not be persuaded to take the bark in any form. All Pott's arguments were insufficient to overcome the patient's antipathy; so, in order to relieve the pain, which was exceedingly severe, opium was administered by itself, and in pretty large doses. Under this treatment the diseased parts soon greatly improved, and the patient ultimately did remarkably well. The result made an impression on Pott's mind; he " soothed his patients in future. Instead of stimulating: applications, he soaked the part in warm milk, and applied linseed poultices to a large portion of the affected limb; he gave opium, with occasional enemata to keep the bowels open, and avoided all scarifications; and, lastly, he declined, as a rule, to interfere in removing the mortified parts by the knife, preferring, for the most part, to leave the process to the hands of Nature. Such still appears, on the whole, to be the most approved method of treating the spontaneous gangrene of elderly people at the present day. But without adopting any one method as altogether applicable to every case, it must certainly be regarded as necessary to estimate the powers and constitution of the individual patient. In London, subjects of senile gangrene ! are frequently weak and emaciated, and exhibit the ill effects either of want of nourishment and other necessaries of life, or ! of malnutrition, as the result chiefly of an inordinate use of . alcoholic stimulant, and improper rather than deficient food. In both classes of cases, an indication appears rather to support
doi:10.1016/s0140-6736(02)34666-x fatcat:iw6c7rn75jeyrcrwlh4nrrjd24