169
May 1st.-Slept badly last night; feels thirsty and
feverish;appetite bad; pulse 124, full and sharp; tongue furred;
woundvery languid, and suppurating, as we thought, unhealthily.
Abread-and-meal poultice to the wound, and low diet ordered.2nd to
7th.-The wrist gradually improved between these
dates, the only marked event being an attack of erysipelas,
,which at one time spread rapidly, but was soon subdued. Onthe 7th
he was better than at any time since the operation.The wound is
dressed with zinc lotion, and the patient istaking bark, ammonia,
two pints of beef-tea, and ten ouncesof wine daily.15th.-Stated
that he had been in the habit of taking
cod-liver oil; is going on well on much lower but moderatediet,
which seems to suit him better than too much stimula-tion.21st.-The
wound so far improved that his arm was placed
upon a splint, well padded with cotton wool, &c., with
ribsreaching as far as the elbow. He is allowed to sit up, his
armresting on a pillow, slightly bent; flexion to be brought to
aright angle gradually.24th.-Doing very well; wound dressed every
other day.
The patient feels very weak.June 3rd to 29th.-The wound looked
alternately better and
worse, now displaying a disposition to slough, now
granulatingwith tolerable vigour. The dressings were varied
constantlyto suit the varying aspect of the wound. Lotions of
chlorinatedsoda and zinc and poultices were in turn tried, and
blacklotion was applied, but without benefit.30th.-Looks languid,
and as if it would not heal.
Sulphate of copper lotion (three grains to the ounce)
ordered;the hand was enveloped in a flannel roller, and placed in
asling and a splint. Under this treatment the arm improvedup to the
middle of July, from which time to the beginning ofAugust it
continued to look languid.August 5th.-No improvement. The arm was
ordered to
be kept midway between pronation and supination, betweentwo pads
of lint placed from the elbow to the second joint ofthe fingers,
fixed by a flannel roller and unconfined by splints.Ordered half an
ounce of cod-liver oil three times a day.20th. -Wound looks very
languid and flabby, and displays a
disposition to slough at the innominata. The
exuberantgranulations were lightly touched with nitrate of silver;
and alotion containing dilute nitric acid, half a drachm; tincture
ofopium, one drachm; tincture of myrrh, two drachms; water,half a
pint, was applied to the wound. There is still muchdoubt whether
the hand will eventually be saved.
GUYS HOSPITAL.
EXCISION OF THE HEAD OF THE HUMERUS; RECOVERY.
(Under the care of Mr. BIRKETT.)
The third case to which we wish to draw attention is that ofa
man who was admitted July 10th into Guys, wasting andsickly, and
complaining of very bad general health, the result,as it
subsequently proved, of old-standing disease of theshoulder-joint;
the latter, on examination, was found to bepartially anchylosed or
motionless, swollen and painful. Afterbeing a short time under
treatment in hospital, the case ap-peared to Mr. Birkett as one
likely to be improved by resec-tion of the diseased head of the
bone. This operation, appa-rently so formidable, has been proved by
statistics to be one ofthe least dangeious of its kind. It has been
performed alreadyabout twenty times in the Crimean war, and the
mortality hasbeen less than that from amputation above the elbow.
Theoperation, though engaging such a large articulation, appearedto
us much easier of performance than either of the twoalready
mentioned-viz., excision of the astragalus, or excisionof the bones
of the carpus. The usual shaped large triangularflap having been
first made by long incisions down the ex-ternal side of the
shoulder, through the deltoid muscle, thehead of the bone was
easily dislocated backwards by throwingthe arm and forearm
forewards. This was at once seen to bequite denuded of cartilage,
and at one point had arrived at astate of necrosis, which there was
too much reason to fearwould not have yielded to any operation less
severe than thatof total removal. This was easily affected by the
new Dublinsaw, which has the very great advantage of not getting
lockedin the bone, and which may be so used as to cut round
anglesor make even, cup-like incisions in large bones. The head
ofthe humerus having been taken away, it was found, on inci-sion,
to be very much diseased, but it fortunately appeared asif all the
diseased parts had been effectually removed. Thecase is very worthy
of notice, as the man began at once to im-prove in general health,
and has since left the hospital quite
well. It is hoped, judging from the twenty cases on thefield of
battle, just cited, that he will have very effective useof his arm
and shoulder. Some of the soldiers who had lostthe " ball and
socket" movement of the glenoid cavity andhead of the humerus by
these operations had obtained a veryeffectual gynglimoid use of the
arm.
ST. MARYLEBONE INFIRMARY.
EXTENSIVE CARIES OF THE TARSUS; SYMES OPERATION ATTHE
ANKLE-JOINT.
(Under the care of Mr. HENRY THOMPSON.)L. 0-, aged ten, admitted
into Marylebone Infirmary in
May. Her condition is unhealthy; several abscesses existabout
the body in the glandular and cellular tissues; the rightfoot is
greatly swollen, and its form distorted; several openingsexist,
through two of which, the probe, when introduced, meetswith carious
bone in the direction of the os calcis and astragalus,and,
probably, in the scaphoid also; the ankle-joint is quitefree from
disease. Care is taken of her general health, andthis having
considerably improved in the course of a month ortwo, Mr. Thompson
decided to remove the foot at the ankle-joint. The disease is of
four years standing, and she has beentreated at Margate for a long
period, with the view of savingthe member, but without success.
July 4th. -Operation under chloroform. The incisions weremade in
the usual way, care being taken especially to attendto the
following points :-
1. To commence the incision on the heel at a point
situated.rather nearer to the posterior than to the anterior border
of theexternal malleolus, and to carry it round beneath the foot to
acorresponding point at the inner malleolus, so as to make theheel
flap rather smaller than it is sometimes made. In thismanner it is
easier to dissect cleanly out the os calcis than whenthe flap is
cut large, and the wound is also in better conditionfor uniting
subsequently, because the hollow of the flap doesnot present so
large a cavity in which to lodge the results ofsuppuration. In
short, better approximation of the cut surfacesis effected, and
union by first intention is consequently en-couraged.
2. Care was taken especially to keep the point of the knifeclose
to the bone in dissecting out the os calcis, in order not to"
score" the flap, and thus impair its vitality. (See Mr.
SymesClinical Lecture on this operation, THE LANCET, March
24th,1855.) The parts came well together, and good apposition
wasmade without exerting undue pressure upon them.10th.-The patient
is going on admirably in every respect.
A considerable amount of union has taken place by first
inten-tion.
12th. -All the ligatures have come away.16th.-The wound is
extremely healthy.August 23rd.-A perfect and well-formed stump.
Dismissed
quite cured. ,The astragalus and scaphoid were found to be
largely carious
at their articulating surfaces. The os calcis and cuboid werein
the same condition.
Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.
TUESDAY, MAY 1ST, 1855.MR. ARNOTT, PRESIDENT, IN THE CHAIR.
DR. OGLE exhibited a specimen ofEXTRAVASATION OF BLOOD INTO THE
WHITE MATTER OF THE
BRAIN, ABOVE THE LEFT LATERAL VENTRICLE.It was about equal in
size to a walnut, and was in closeproximity to the grey matter, but
not affecting it. The brain-tissue around the clot wits of a
chocolate colour, and presentedone or two specks of ecchymosis.
There were two cysts, lined.by a distinct membrane, in the left
corpus striatum, evidentlythe result of old extravasation. The
ventricles were enor-mously enlarged, as if by former distension.
The vessels,large and small, of the brain were very atheromatous.
Thepatient was brought into St. Georges Hospital in a semi-comatose
state; it was said he had had a fit the day previous.Shortly after
admission he had a fit, during which the pupilswere extremely
contracted, and which, lasting about a quarterof an hour, left him
hemiplegic on the right side. He wascupped, blistered, and purged,
but died comatose in about a
