Elements of Surgery. Robert Liston

spots beyond it, on the outer side of the arm; on the inner side, where the disease has extended a little higher up than the outer, suppuration has already commenced. The integuments in the immediate neighbourhood of the diseased parts are slightly reddened and tumefied, and it is there only that she complains of some slight pain. The hand and wrist are dry and shrivelled, but above this the parts are soft and flaccid. Below the line of demarcation, the extremity is of a dark colour, resembling the skin of a negro, and completely deprived of the power of motion and sensation; but she complains of a disagreeable tingling, referred to the fingers. The discoloured parts are quite cold, and the pulse cannot be felt, even in the axilla. Though she complains much of debility, the system seems to be but little affected. The appetite is very good; the skin is moderately warm; the pulse is 98, and of good strength; the tongue is moist and clean. She sleeps little. ℞. Haust. c. Sol. M. Morph. gtt. xxv. M. Vini Rub. ℥iv. Water-dressing to the arm at the line of separation.

      “27. She continues much the same as yesterday; slept little, bowels moved twice; tongue clean and moist; appetite very good; pulse as before; heat of skin natural; intellect clear; no expression of anxiety in the countenance. ℞. Haust. Con. Vin. Full diet.

      “28. The suppuration on the inner side of the arm is more copious, and the discharge is more fetid. The livid spots on the outer side of the arm have not extended, and there is some slight redness around them. Pulse 104, of good strength; tongue clean and moist; heat of skin still natural; appetite good; bowels moved once since the last report. Continue. A little Sol. Chlor. Calcis to be added to the dressing.

      “29. The dry and shrivelled state of the extremity has extended as high as the middle of the forearm. The discharge is much the same as before in quantity, but is more fetid. The separation between the gangrenous and the sound parts, which had begun on the outer side of the arm when she was admitted, is extending a little, both towards the inner and the outer side. Pulse 90, of moderate strength; skin natural; tongue clean and moist; bowels open; appetite excellent.

      “30. Much the same as yesterday; sleeps a little better.

      “31. The suppuration is more copious; the discharge extremely fetid. The dead parts on the inner side of the humerus are gradually becoming more detached. No change in the appearance of the livid spots beyond the line of separation; pulse 102, of pretty good strength; bowels continue regular, and the appetite is good. Cont. vinum et haust.

      “Feb. 2. The separation of the gangrenous parts on the inner side of the arm has advanced a little more since last referred to. The livid spots have disappeared, with the exception of the largest, where a small superficial slough has formed. The diseased parts were removed to-day, the line of separation being fairly established, and suppuration having taken place in a great part of its extent. The soft parts were divided by means of a pair of scissors, cutting as near to the living parts as could be done with safety; the bone was then denuded as high up as possible, by passing a bistoury round it, and it was then divided by the saw. There was no bleeding from the soft parts, and only slight oozing from the bone, which was found to be alive where it was divided. Cont. vinum et haust.

      “3. Continues in much the same state as yesterday; pulse 104, of good strength; tongue clean and moist; bowels moved once; skin natural; appetite good; suppuration very free. Cont.

      “5. Suppuration copious; a portion of the dead parts left have separated, and left a healthy florid granulating surface. Continues much the same.

      “6. Discharge copious, and much less fetid; bowels regular; pulse 100, of good strength; tongue clean; appetite good; wishes for more food. To have an additional chop. Cont. alia.

      “8. The greater part of the sloughs have separated, and have left a healthy florid granulating surface; no change in the general symptoms. Continue.

      “9. The stump looks well, and the posterior part of the cut end of the bone is covered by healthy granulations.

      “In some notes of this case, kindly furnished me by the late Professor Fergus of King’s College, who had an opportunity of watching the appearances for some time before the admission of the patient here, it is mentioned that the flow of blood in the veins was exceedingly slow, and that hard knotty tumours could be felt in the parts before they became sphacelated. These swellings all along preceded the mortification. It is mentioned, besides, that the patient had a sort of fit, but that it could not exactly be ascertained whether or not she lost consciousness. Her left arm is said to have been motionless from and after that time. There is considerable discrepancy in the accounts of the mode of invasion, and of the duration of the disease, before the line of separation became apparent. A period of six weeks is stated in our case-book to have elapsed from the attack to the admission of the patient into this hospital. It would appear, however, from the other history, that not more than three weeks had passed over. The old lady is not very distinct in her account; at one time she makes a statement with great minuteness, and very soon after contradicts herself on almost every point. When pressed on the subject, she states that she got disgusted with her condition, became despondent and careless about everything, and that her recollection is not now very good.”

      “S.W., aged 16, was admitted March 12, under the care of Mr. LISTON. She is a servant girl, of sanguine temperament and good constitution. On Friday, March 9, she was cleaning the outside of a parlour window, and stood on the sill. The window-sash, upon which she was depending for support, being suddenly drawn down by a person inside, she was precipitated into an area, a distance of fifteen feet. She was immediately picked up, and conveyed to the hospital. The house-surgeon detected a compound fracture of the ulna, and a fracture of the radius, both fractures being a little above the wrist-joint of the right arm. The fracture was adjusted, and the wound, which was inferiorly to, and behind, the wrist, dressed in the usual manner. A dose of house-medicine was administered; suitable directions were given in case of the occurrence of pain or swelling; she was sent home, and desired to remain quiet. The following morning (Saturday) she was visited by the house-surgeon, who found her comfortable, but she had passed a sleepless night. On Sunday morning the affected part became so intolerably painful that she tore off the splints and bandages, which one of the dressers of the hospital had a short time before readjusted; in the evening she was in great pain, and the arm was much swollen.

      “12. To-day (Monday) she was admitted into the hospital; water-dressing was applied to the wound. The bandages were reapplied, and an anodyne administered in the evening, with the effect of producing some rest.

      “13. The pain and swelling were so great during the night that the house-surgeon was called up to see her, and ordered the application of fomentations; this morning she is much more comfortable.

      “14. On removing the whole of the apparatus this morning early, mortification was found to have taken place in the limb; at the time of Mr. Liston’s visit in the middle of the day, the limb was very swollen, the fingers were of a black colour, the forearm livid, there were vesications near the elbow with fetid discharge. There was a good deal of fever with slight delirium; pulse irregular, quick. Mr. Liston considered the only chance the patient had was the immediate amputation of the limb at the shoulder. The patient’s consent having been readily obtained, Mr. Liston proceeded at once to the

      “Operation.—He first introduced a long double-pointed knife under the acromion, and brought the point out at the lower and posterior border of the axilla, by this means the joint was laid open; the flap thus formed of a portion of the deltoid was raised, and the head of the bone separated from its attachments. The other flap was formed from the integuments and muscles in front. The axillary, and one other vessel, required ligature. The edges of the wound were drawn together by three points of suture, and cold water-dressing applied. One grain of muriate of morphia was given. In the evening, several strips of isinglass plaster were applied, and the edges approximated. The delirium ceased after a short but refreshing sleep.

      “15. Passed a good night; has had little pain; feels very comfortable this morning; she is cheerful, and has little fever; pulse 86, regular. The wound looks healthy.

      “April 2. Since the above date, the patient has