440 ON EXCISION OF THE WRIST FOR CARIES 



the imperfection of my first mode of operating, the disease recurred, and, after 

 waiting in the vain hope of improvement for about six months, I explored 

 the bones and performed re-excision. A few weeks later — namely, on the 

 28th of February, 1864, a spot of redness appeared on the forearm, about mid- 

 way between the wrist and elbow, and next day he had a severe rigor. I was 

 at once called to see him, and, finding evidence of inflammation of a superficial 

 vein leading upwards from the red spot to the elbow, I thought there might 

 be a chance of arresting the pyaemia in its outset by amputating the arm, which 

 I did about three inches below the shoulder, within an hour and a quarter of 

 the occurrence of the first rigor. On examining the veins, I found a mixture 

 of pus and blood in the vessels of the forearm, while those of the arm appeared 

 quite sound. Sulphite of potash, in ten-grain doses, was now administered 

 every three hours, with the view of counteracting the poisonous effect of any 

 septic matter already introduced into the circulation, and this was continued 

 till the 5th of March. After this time he improved for several days in general 

 health, while the stump was progressing favourably ; but just as I was con- 

 gratulating myself on a cure of pyaemia, pulmonary symptoms appeared, and 

 carried him off on the 23rd of March, twenty-three days after the amputation. 

 Whether the affection of the lung was an aggravated condition of the phthisis 

 under which he laboured, or an unusually remote effect of the pyaemia, 

 I unfortunately had not the opportunity of ascertaining by post mortem 

 examination. 



In no instance have I been troubled with secondary haemorrhage or any 

 other bad symptom immediately referable to the operation, which appears to 

 be a peculiarly safe one. 



A general review of the cases above related may be stated shortly as follows. 

 I have excised the entire articular apparatus of the wrist in fifteen patients. 

 Of these, two have died of causes independent of the operation, and of the 

 remaining thirteen, one is in an unsatisfactory condition, but not hopeless, 

 two afford good hope of a satisfactor}^ termination, which in the remaining ten 

 may be said to have been already arrived at. 



On comparing these results with those of previous practice, bearing in mind 

 that the cases include all varieties of carious disease, sometimes in the most 

 aggravated form ever likely to be presented, and also that they have been treated 

 under the disadvantages of hospital atmosphere, so that I have had to contend 

 in no less than six instances with hospital gangrene and in one with pyaemia 

 it will, I trust, appear that the principles which have guided me are sound, 

 and afford the means of removing one of the greatest opprobria of modern 

 surgery. 



