[Extracted from the American Journal of the Medical Sciences for October, 1874.] 
CASE OF OSTEOPHTTIC INFLAMMATION OF THE RIGHT RADIOS: 
RESECTION; PRESERVATION OF A USEFUL HAND. 
B. J. D. IRWIN, M.D., 
SURGEON AND BREVET COLONEL U. S. ARMY. 
While on duty at Fort Riley, Kansas, I was called in consultation, July 
25th, 1873, to see Mrs. H , aged 27, born in New Orleans, a tall, 
well-developed physique, fair complexion, blue eyes, light-brown hair, and 
of nervous temperament. 
History.—Until recently has been a professional actress—was married 
and gave birth to her first child during the thirteenth year of her age. Is 
free from constitutional taint, but has been a sufferer from oft-repeated 
attacks of articular rheumatism of an inflammatory character, for several 
years, resulting in considerable enlargement of the knee-joints; the func- 
tions of the right knee having become gradually and seriously impaired. 
About nine months ago had a violent and protracted attack of the malady ; 
the knee and wrist-joints suffering the brunt of the disease, which, after 
some weeks, assumed a subacute or chronic type. 
Some three months subsequently the character assumed by the disease, 
involving the right wrist, would indicate that at about that period symp- 
toms of periosteal inflammation were manifest, and shortly thereafter the 
soft parts situated over the inner and dorsal aspect of the distal half of 
the radius suppurated, leaving a foul intractable ulcer, which has con- 
tinued since then to enlarge and suppurate profusely. 
The system appears to have interposed but feeble resistance to the 
destructive tendency of the disease, as, within the last few days, two gan- 
grenous sloughs, each about an inch in diameter, have destroyed the tegu- 
mentary and muscular tissues in the line of the long axis of the radius. 
During the progress of the disease the general health of the patient was 
seriously depressed, and the constant pain induced a resort to the excessive 
use of opiates, which caused considerable disturbance to the organs of 
digestion. Sleep was seldom obtained except by the aid of narcotics. 
Upon making an examination, I perceived at a glance that the disease 
had involved the oseous structures and that necrosis had taken place, 
which conditions were verified on introducing a probe to the bottom of the 
ulcer. The patient stated that hitherto no exploration had been made, and 
that she was then en route to an eastern city for the purpose of having 
the arm amputated, in accordance with the advice of her former medical 
attendant. The result of my examination convinced me that such an 
extreme measure was unnecessary ; and as the woman was naturally very 
anxious to save the hand if possible, I advised resection of such portions 
of diseased bone as might be found involved, as a means to meet the 
desirable result, believing that the ulna and the contracted cicatrix would 
ultimately form a good support for the hand. 
Having been requested by the attending surgeon to perform the neces- 
sary operation, directions were given to prepare the patient by a few days’ 
rest, aided by a generous diet and a moderate amount of wine; and to 
facilitate the separation of the sloughs, charcoal and yeast epithems were 
applied twice a day. 
1 2 
July 31,11 o’clock A. M. Having satisfied myself that the heart was 
free from organic disease, anaesthesia was readily induced by the adminis- 
tration of a mixture of equal volumes, in measure, of sulphuric ether and 
chloroform. I then made an incision about five inches long, extending 
through the diseased tissues down to the bone, from the proximal end of 
the scaphoid bone to a point about five inches on the inner aspect of the 
radial bone of the forearm. Upon carrying the finger to the bottom of 
the incision, from three to four inches of the radius were found denuded of 
periosteum, and the substance of the bone enlarged by ostitis and osteo- 
phytic deposits. 'By using the handle of the scalpel and the finger, the soft 
parts were carefully pushed aside and protected from injury by a pair of 
metallic retractors. The curved end of one of the retractors having been 
passed under and round it, the bone was divided about a line or two above 
the diseased part by the convex edge of a Hey’s saw, and by manipulating 
the free end as a lever, it was easily detached from its articulation. The 
ulna and carpal bones were found free from disease. By this procedure 
the division or injury of vessels or tendons was avoided. I was assisted 
in the operation by her attending physician, Dr. T. G. Horn, and also by 
Dr. Jones, of Junction City, the former of whom was assiduous in his 
attentions and efforts to consummate the object of the operation. The upper 
portion of the wound was reunited by silver sutures, and the granulated 
surfaces approximated by means of adhesive strips passed from behind 
and made to decussate over the line of the incision. The wound was then 
dressed with carbolized glycerine and the limb supported on a suitable 
splint. Potassium bromide was ordered as a substitute for the narcotics 
hitherto in use. Beef essence, poached eggs, milk and light wine ordered 
as diet. 
August 1, 12 M. Patient passed a comfortable night; did not sleep 
much, but feels tranquil and much relieved in having passed through the 
trying ordeal, the fear of which had caused severe mental anxiety prior to 
the operation. 
Wound looks well. Where it was practicable to use the sutures, union 
has taken place. A slight erythematous blush extends half way up to the 
forearm. Removed sutures ; ordered a small piece of ice applied on the 
outside of the dressing, and continued previous treatment. 
2d. Feels much better, having enjoyed a fair amount of sleep. The 
erythema has disappeared ; pulse 90. 
3d. Continued improvement. Wound granulating nicely. Tendency 
to diarrhoea during the night, owing, doubtless, to the ill-effects of the 
effluvia from the wound, which, despite the carbolized dressing applied 
morning and evening, rapidly became very offensive, owing to the high 
atmospheric temperature—Bs° to 95° F. 
ith. Is better; bowels regular. Wound looks favourable. Continue 
treatment. 
blh. Continued improvement. Has a return of her former appetite, and 
relishes her food. 
6Hi. Does not feel quite so well to-day. Through the misconception of 
her attendant, the patient has had potassium bromide administered to her 
at frequent intervals, so that she took one ounce of the remedy since I saw 
her yesterday. The amount ordered was fifteen grains at bedtime ,to be 
repeated twice during the night, if necessary. The quantity given has pro- 
duced an extreme degree of lassitude and weariness of the whole body. The 
patient appears haggard and fatigued, the mouth is dry and the pulse 100, 
but without any marked increase of the normal temperature. Wound 
granulating rapidly and looking healthy. Some slight tumefaction on the 
back of the hand ; a piece of ice was ordered kept on the outside of the 3 
dressing. Ordered egg-nog and milk-punch in addition to other remedies 
and extract of conium or hyoscyamus as a substitute for potassium bromide. 
Her brother, a physician, came to visit and remain with her yesterday, and 
promises to watch the case carefully hereafter, she having missed certain 
minor attentions which are not ordinarily obtainable in a hotel or boarding 
house. 
*]th. Condition much better. The conium induced a night of refreshing 
sleep, the best, she says, that she has enjoyed in six months. Tumefac- 
tion disappeared from dorsum of hand. Wound discharging freely and 
granulations looking healthy. Appetite better; pulse 96. 
9th. Continued improvement. Put on citrate of iron and quinia and 
aromatic extract of cinchona. 
12th. Patient is able to sit up in bed and hold the disabled arm with 
the other hand. The wound continues to granulate satisfactorily, and all 
traces of the old sloughs have disappeared. Appetite good ; sleeps well, 
and is cheerful. Ordered a bandage of mosquito netting applied, so as to 
crowd the tissue during the formation of the cicatrix. 
20th. Has continued to improve. Wound nearly healed. A small 
superficial slough formed and separated four days ago. The felt splint, 
applied to support the arm while suspended in a sling around the patient’s 
neck, has become limp and soft by moisture, allowing the hand to tilt too 
much to the radial side, causing the ulna to partially slip from its carpal 
articulation. To remedy this defect the hand was again placed on a light 
flat splint supported by a handkerchief bandage. The wound continues 
to diminish, and the patient is now able to get about the house and sit in 
the open air. 
25th. Is almost well, and anxious to return to her family, in the 
southern portion of the State. The wound has almost completely healed, 
and the prospects are that the hand in time will be a very useful one and 
free from any deformity. As she is now able to be about, her brother 
returned to his home some days ago, and at my 
visit on the 30th, I found that she had followed 
his example, but, in the hurry and anxiety to 
reach the home circle, had forgotten to dis- 
charge even the claims of gratitude to her medi- 
cal benefactor. 
The wood-cut showing the condition and 
extent of bone removed, is taken from a photo- 
graph of the specimen, deposited in the Army 
Medical Museum. 
In excision of the wrist-joint the extremity of 
the radius was excised as early as 1158 by 
Cooper of Bungay, and subsequently by Moreau 
in 1794. (Ash-hurst’s Principles and Practice 
of Surgery, 1871, page 602.) But the removal 
of any considerable portion of the distal end of 
the shaft of the bone does not appear to have 
been recorded prior to the early part of the sixth 
decade of the current century. The removal of 
the articular surface or extreme distal extremity 
of the bones of the forearm, necessary in exci- 
sion of the wrist-joint, as performed by Cooper 
and subsequent operators, leaving a sufficient 
or suitable base upon which to cdapt and sup- 4 
port the carpal bones, is a measure of almost a totally different character 
in extent and magnitude. In 1853, Dr. Compton, of New Orleans, 
resected the bone of the forearm, removing both bones “ with the excep- 
tion of the inferior extremity of the radius;” and Erichsen, of London, 
states that he resected the whole radius “ with the exception of its articular 
head, which was sound,” but I am unable to give the date of his operation, 
as it is not alluded to in the copy of Erichsen’s work before me. The 
entire exsection of the radius in 1854 by Dr. Carnochan, of New York, 
demonstrated the feasibility of preserving a useful hand after the removal 
of the principal supporting base thereof; and, as a sequence to the ex- 
perience gained by his major operation, we find that, in 1857, the same 
surgeon excised, “ the lower four-fifths of the bone” from a female patient, 
aged 31, who made an excellent recovery, the functions of the hand—the 
left—being so little impaired that she was able to perform her household 
duties nearly as well as before the operation. (Vide American Journal of 
Medical Sciences, vol. xxxvi. p. 89, et seq.) 
Professor Gross, of Philadelphia, excised “ somewhat more than the 
upper third of the bone” in 1857, and in 1859 Prof. Choppin, of New 
Orleans, “resected all hut the inferior articular extremity of the boue.” I 
have seen it stated that West, of Birmingham, resected a considerable part 
of the distal extremity of the radius with success, but I am unable to 
state the exact time and character of his particular operation. 
While the whole of the ulna has been removed, with successful results, 
by Carnochan, Jones, and Williams, and segments thereof, more or less 
extensive or important, according to the situation and nature of the ope- 
ration performed, by several other American and European surgeons, I 
am unable to discover that any extensive portion of the lower extremity of 
the radius, beyond that immediately engaged in the formation of the 
wrist-joint or in close proximity thereto, had been removed prior to the 
operation of Dr. Carnochan in 1854, and, although extensive portions of 
the upper part of the bone have been removed in several instances, the 
exsection of any extensive part of the lower extremity of the radius does 
not appear to have been performed except in the instances already men- 
tioned. 
Since the foregoing was written, I have learned from Dr. Horn that 
he had seen the patient in February last, at which time she was able to 
flex and extend the fingers of the hand separately and pronate the arm. 
Her health he describes as excellent, and states that she used a broom in 
sweeping the floor to show how well she could use the limb. The wound 
made by the operation had cicatrized satisfactorily, but the disease mani- 
fests some disposition to reappear in the carpus. After her hurried flight, 
he says, she was allowed to follow the bent of her wayward disposition, and 
the carpo-ulnar articulation had not been properly maintained in position. 
U. S. Military Academy, West Point, New York, May, 1874.