THE BRITISH MEDICAL ASSOCIATION 195 



sinuses/ may sometimes be performed with great advantage when suppuration 

 has not occurred, or when the pus has been evacuated antisepticalty. An 

 instance of this occurred in my practice last spring, in a man fifty-seven years 

 of age, with an obstinate and painful disease of the wrist affecting the whole 

 articulation, but especially the end of the ulna, which was extremely thickened. 

 I cut down under the spray and nipped off the end of the ulna with bone pliers, 

 and found the cartilage rough and eroded, though without suppuration. The 

 wound was left open at its central part, with a drain of lint soaked with an oily 

 solution maintaining a free communication with the joint, yet healing took 

 place without the formation of a drop of pus. The man was discharged with 

 a strong, useful hand, but came back a few weeks afterwards, not on account 

 of recurrence of the disease, but because he had fallen from a haystack when 

 he was at work and broken the radius of the same arm. 



Senile gangrene is, I suspect, a disease the treatment of which must undergo 

 a complete change through the antiseptic system. Amputation in such cases 

 is now generally prohibited on account of the great probability of sloughing 

 of the stump. But wliat is the reason of this risk of sloughing ? The cause of 

 the original gangrene is generally interference with the arterial circulation. 

 But that interference is only sufficient to produce actual death at one spot 

 where the disease begins, and it generally spreads by inflammation. Xow 

 dead tissues do not cause inflammation of themselves, any more than a bit of 

 catgut does. Inflammation occurs because the dead part putrefies, and the 

 parts in the vicinity, being weak, die from inflammatory mortification. If that 

 be true, supposing we were to amputate and avoid putrefaction in the stump, 

 who is to say but that sloughing, instead of being the rule, might prove the 

 exception ? while even such sloughs as might occur, if kept from putrefying, 

 should be limited to the extent to which the operation might interfere with the 

 vascular supply. Having long entertained these views, I was prepared to put 

 them in practice in the following case. 



A year ago, a woman above sixty 3^ears of age came into the hospital with 

 her little toe affected with black discoloration, which had connnenced at its tip 

 and gradually extended to its base, and she was suffering constant acute agony. 

 After carefully washing the surrounding skin with an antiseptic lotion — for 

 that is absolutely essential in such a case — I amputated the toe within an eiglith 

 of an inch of the black part and dressed antiseptically. The result was that 

 the wound healed without the slightest inflannnatory disturbance ; but the 



' When an operation is performed in a part affected with sinuses, the presence of putrefaction 

 in such tracks renders the case unsuitable, of course, for antiseptic management, as described in the 

 text. For a special mode of dealing with such cases, the reader is referred to tlic article on Amputation 

 (sec p. 378 of this volume). 



