after that date. The swelling and redness in the upper arm subsided gradually, but the region of the elbow remained swollen and red and tender. Consequently, on August 15 the elbow was aspirated and it was found that most of the swelling was in the subcutaneous tissues, only a few cubic centimeters of serosanguineous fluid being obtained. Cultures of this yielded no growth.The improvement continued, but there was persistent swelling and tenderness over the dorsum of the forearm and on August 21 a probe was introduced beneath the skin and it was found that there was a cavity extending up almost to the elbow. Under local anesthesia the skin over this cavity was incised and the skin edges were folded back. It was found at this time that the grayish white necrosis of the subcutaneous tissue extended well over the dorsum of the forearm and almost up to the elbow ( fig. 2). The wound was dressed with sulfanil¬ amide powder every other day.In the meantime the extensive area of necrosis on the dorsum of the hand had been excised with a knife. Under it was found a similar gray necrosis of the subcutaneous tissue. The necrosis of the subcutaneous tissue extended beyond that of the skin, so that it involved the tissues on either side to the border of the hand and down to the knuckles. The veins were thrombosed and necrosed. Apparently the necrosis did not extend through the tendon sheaths, nor did it involve the wrist joint. This is partly accounted for by the fact that from the time the patient was admitted to the hospital the hand and wrist were immobilized, first in a large wet dressing, then on a splint and finally in a plaster of paris mold.On August 17 the patient had urticaria and complained of a sore throat, and on examination the tongue and pharynx were bright red. This was believed to be due to the sulfa¬ thiazole, which she was still taking. The sulfathiazole was discontinued, and the urticaria and sore throat cleared up promptly. The wet dressings were discontinued on August 14.After the incision of the skin over the extensive subcutaneous abscess the wound was dressed daily with sulfathiazole powder and the necrotic tissue was excised or separated. The infection subsided and the convalescence was uneventful.On September 25 Dr. J. B. Brown operated on the patient and drew the skin together over the forearm and sutured this part of the wound, while that part over the wrist and dorsum of the hand from which the skin and subcutaneous tissue had been lost by necrosis was covered with a split skin graft. This was of necessity applied directly over the sheaths of the extensor tendons. The graft was successful and the patient left the hospital on October 4, fifty-seven days after admission.At present (Oct. 28, 1941) there is marked disability of the hand, as the fingers are quite stiff and the extensor tendons are adherent to the adjacent tissues.COMMENT 2 This case is reported because it is felt that the medical profession should be warned against the injection of material which is not known to be sterile. I believe t...
