A MIRROR OF HOSPITAL PRACTICE.
Treated
CASES by Surgeon-Major F. Odevaine, F.R.C.S., Bhopal Battalion. (Continued from page 292.)
RAPIDLY SPREADING TRAUMATIC GANGRENE OF THE LEFT ARM AND FOREARM : AMPUTATION THROUGH THE SHOULDER JOINT. A youi^g Mahomedan Sowar fell from the roof of a house at and sustained a compound fracture of both radius and ulna on the left side, at about two inches above the wrist joint. When admitted into the dispensary, very soon after the accident, the lower end of the upper portion of the radius projected through a jagged horizontal wound at site of fracture. There was very little haemorrhage, and the limb was put up in angular splints ; the protruding bone having been returned, the wound was dressed with carbolized oil. On the day following the accident, swelling of the hand and forearm, with vesication here and there, gave indications of gangrene, which necessitated the removal of the splints ; and on the following morning, mortification had extended to witbin four inches of the acromion on the external aspect of the arm, not being, however, quite so far advanced on its inner side. The entire limb was much swollen, in a state of vesication, the cuticle peeling off the forearm, and exuding a thin foetid
night time,
discharge. Taking
?
into consideration the rapidity of advance of gangrene, I felt that the only hope of saving this man's life was immediate amputation, but feared that even this would not arrest the progress of the mortification, which had extended so quickly that crepitation existed in the cellular tissue about the pectorals and above the clavicle. The patient readily assented to my proposal to have the limb removed at the joint, and having been brought under the influence of chloroform, it was amputated by external and internal flaps, the former by transfixion, and the latter by a sweep of the knife placed behind the bone. Compression had been made over the sub-clavian as it passes the first rib ; and for this purpose, I found the small hard pad of a field tourniquet of great use, as it can be firmly pressed by both thumbs of an assistant into the space behind the clavicle. There was very little loss of blood, and the arteries having been well secured, the flaps were brought together by several points of interrupted suture, and the stump dressed with carbolized oil, which was kept constantly applied. Besides the injury to the bones of the forearm, the man sustained a severe contusion over the lumbar region and upper part of sacrum, which caused him much pain, and probably injured more or less the cauda equina, as he could not pass urine, and required the employment of a catheter twice a day to relieve the bladder. He has both sensation and motion of both lower limbs, but on being questioned, says he feels some formication of the feet and legs. Subsequently, the sphincter vesicae became paralyzed, so that the urine dribbled away, and soon became ammoniacal, depositing phosphates and mucus?sure indications of catarrh. He had sinapisms and fomentations applied to the lower part of the spinal column, and was given bromide of potassium in ten-grain doses three times a day ; afterwards, he was ordered a combination of ergot, buchu, and nitric acid, and a small blister was applied over the painful part of the spine. His appetite was small, bowels regular, and is unable to sit up; complains of hyperasthesia of skin of lower limbs, which he is however able to move freely, and says there is no formication
latterly.
For the mixture last ordered, which he had continued to take for about three weeks with but little benefit, a combination of liquor strychnise, with tincture of iron, was substituted. The wound resulting from the amputation was perfectly healed in a month, and the patient left the dispensary for his home on the 2nd of July, being fifty-three days from the date of his ad-
mission.
In a case, very similar to the above, I amputated at the shoulder joint with success, but the gangrene in this instance had not made such rapid progress as in the one which is another example of the necessity and
now
reported,
advantage
of
318
THE INDIAN MEDICAL GAZETTE.
immediate operative interference in cases of traumatic gangrene, no matter how quickly the disease may be extending. On dissection of the limb after removal, the ulna was found comminuted, and the radial artery torn across, most probably by the upper broken extremity of the radius, which, as has been previously stated, was at the time of the accident protruding through the wound.
[December 1, 1877.
Treated
CASES by Surgeon-Major F. Odevaine, F.R.C.S., Bhopal Battalion. (Continued from page 292.)
RAPIDLY SPREADING TRAUMATIC GANGRENE OF THE LEFT ARM AND FOREARM : AMPUTATION THROUGH THE SHOULDER JOINT. A youi^g Mahomedan Sowar fell from the roof of a house at and sustained a compound fracture of both radius and ulna on the left side, at about two inches above the wrist joint. When admitted into the dispensary, very soon after the accident, the lower end of the upper portion of the radius projected through a jagged horizontal wound at site of fracture. There was very little haemorrhage, and the limb was put up in angular splints ; the protruding bone having been returned, the wound was dressed with carbolized oil. On the day following the accident, swelling of the hand and forearm, with vesication here and there, gave indications of gangrene, which necessitated the removal of the splints ; and on the following morning, mortification had extended to witbin four inches of the acromion on the external aspect of the arm, not being, however, quite so far advanced on its inner side. The entire limb was much swollen, in a state of vesication, the cuticle peeling off the forearm, and exuding a thin foetid
night time,
discharge. Taking
?
into consideration the rapidity of advance of gangrene, I felt that the only hope of saving this man's life was immediate amputation, but feared that even this would not arrest the progress of the mortification, which had extended so quickly that crepitation existed in the cellular tissue about the pectorals and above the clavicle. The patient readily assented to my proposal to have the limb removed at the joint, and having been brought under the influence of chloroform, it was amputated by external and internal flaps, the former by transfixion, and the latter by a sweep of the knife placed behind the bone. Compression had been made over the sub-clavian as it passes the first rib ; and for this purpose, I found the small hard pad of a field tourniquet of great use, as it can be firmly pressed by both thumbs of an assistant into the space behind the clavicle. There was very little loss of blood, and the arteries having been well secured, the flaps were brought together by several points of interrupted suture, and the stump dressed with carbolized oil, which was kept constantly applied. Besides the injury to the bones of the forearm, the man sustained a severe contusion over the lumbar region and upper part of sacrum, which caused him much pain, and probably injured more or less the cauda equina, as he could not pass urine, and required the employment of a catheter twice a day to relieve the bladder. He has both sensation and motion of both lower limbs, but on being questioned, says he feels some formication of the feet and legs. Subsequently, the sphincter vesicae became paralyzed, so that the urine dribbled away, and soon became ammoniacal, depositing phosphates and mucus?sure indications of catarrh. He had sinapisms and fomentations applied to the lower part of the spinal column, and was given bromide of potassium in ten-grain doses three times a day ; afterwards, he was ordered a combination of ergot, buchu, and nitric acid, and a small blister was applied over the painful part of the spine. His appetite was small, bowels regular, and is unable to sit up; complains of hyperasthesia of skin of lower limbs, which he is however able to move freely, and says there is no formication
latterly.
For the mixture last ordered, which he had continued to take for about three weeks with but little benefit, a combination of liquor strychnise, with tincture of iron, was substituted. The wound resulting from the amputation was perfectly healed in a month, and the patient left the dispensary for his home on the 2nd of July, being fifty-three days from the date of his ad-
mission.
In a case, very similar to the above, I amputated at the shoulder joint with success, but the gangrene in this instance had not made such rapid progress as in the one which is another example of the necessity and
now
reported,
advantage
of
318
THE INDIAN MEDICAL GAZETTE.
immediate operative interference in cases of traumatic gangrene, no matter how quickly the disease may be extending. On dissection of the limb after removal, the ulna was found comminuted, and the radial artery torn across, most probably by the upper broken extremity of the radius, which, as has been previously stated, was at the time of the accident protruding through the wound.
[December 1, 1877.
