Dupuytren's #8 ...

Five weeks post-op ...

Now, this is looking better.

 

It took the wound in the centre of St. Anley's palm 4 weeks to heal.

He has been attending a hand clinic on a weekly basis for some aggressive physiotherapy.

The physiotherapist has a charming demeanour and a pretty face that disguise an expertise for inflicting excruciating pain.
"Pain is good!" says she as tears appear on St. Anley's cheek.

Then, along comes an occupational therapist who carefully fabricates a splint from some thermo-plastic material ...

"You need to wear this only at night."

After two nights of sleepless discomfort and Anglo-Saxon expletives St. Anley is quite impressed ...

Look, my little finger
is almost straight!

"Fine," Mrs. St. Anley says, "Now you can get on with some chores!"

Dupuytren's #7

Post-op Day 9:

Blood!

Phone hospital ...
"There is blood seeping through my dressing."
Nurse enquires, "Have you contacted your GP?"
"You are in his care until we see you next Tuesday."
"No," replies St. Anley.
"Shall I go to A & E?"
"Ooh, no!" she says, "Don't you know that there's a national crisis in hospital emergency departments!"

Phone GP surgery ...
Tracey answers.
I explain the situation.
"Well, Dr *** is away on study leave. You can see another doctor if you like."
"I like ..." I say.
"Fine," says Tracey, " Come along next Friday at 2.40pm."
"That's too long," I protest. "I'm due back in out-patients on Tuesday. Can't I see the practice nurse?"
"No," says Tracey, "... not until you've seen the doctor."

St. Anley explores bathroom cabinet in hopes of finding a new, clean bandage.

Found it!

Now, in Mrs St. A's absence, this could be tricky!

Dupuytren's #6

Post-op day 8 …

St. Anley attends the ‘dressing clinic’ at his local infirmary in hopes of being relieved of a very heavy splint and having his stitches removed.
This time only the volunteer in reception asks me for my personal details. Everyone else knows who I am.
Was my earlier behaviour that memorable?

I wait patiently in a waiting area occupied by unfortunate people whose trauma is clearly much greater than my own.
Mrs. St. A. accompanies me … because she is concerned for my wellbeing?
No, I just want her take take some photographs!

Nurse F**** appears. She crosses herself and genuflects whilst calling out, “Saint Anley!”
“May my wife come too?” I ask.
“Of course,” replies Nurse, “But will she be OK with the sight of blood?”

Nurse gently cuts away the outer bandaging and removes the plaster slab. “That’s a weight off my arm,” announces St. Anley. Beneath this is some dressing material impregnated with something that looks like boiling pitch.

This is pulled away to reveal …

Now, that's what I call a Z-plasty.

“Oh, it’s not healed yet,” exclaims Nurse.
“I’ll get the doctor to take a look.”

Pretty lady-doctor appears who, to St. A’s disappointment, doesn’t want to know his phone number.

• “No, it’s not completely healed,” she agrees.
• “Can you make a fist?”
• “Ouch!”
• “Now spread your fingers.”
• “More ouch!”

She proceeds to evaluate my sensation and concludes that my pinkie is completely numb, and there is a patch of my palm that has no sensation.
“That’s fine,” she says, “That will recover.”

Mrs. St. A. summarily takes another photo because she has to depart; she has better things to do.




Goodbye, dear!

The stitches are left in place.
Nurse applies a new, clean dressing ...

“Come back on Tuesday to see the hand-therapist.”

Dupuytren's #5

Concerning recovery from regional blockade of the brachial plexus ...

Yesterday I wrote about regional anaesthesia involving an injection of local anaesthetic in the area of the brachial plexus. The anaesthetist told me that the effects would last for about 16 hours.
I described the surreal, dismembering experience of its onset and effects.
What follows is an account of the recovery.


My anaesthetist favoured the supraclavicular approach.

The operation lasted about 1 hour and 45 minutes, whereupon St. Anley is wheeled to a recovery area.
The staff here are different to those he met earlier, so, here we go again:
“Please tell me your full name.”
Etcetera, etcetera …

“Would you like a cup of tea?”
“Ooh, yes please; milk, no sugar.”
Tea duly arrives with two biscuits on the saucer.

St. A. is right-handed, so he has no difficulty in manoeuvring the cup to his lips to partake of the gloriously refreshing liquid.
Now, the biscuits: they are securely encased in a cellophane wrapping, but the nurse who brought them has gone elsewhere.
St. A. holds the packet in his right hand and vainly tries to bite through the cellophane.
Another nurse notices the struggle and asks, “Would you like some help?”
“Yes, please.”
Whilst unwrapping the digestives she enquires, “What’s your full name, DOB, address, telephone number … ?!”

I have absolutely no control over my left arm which has been suspended from a drip-stand by a pillow case.
“You may get dressed now,” says a third nurse.
Clearly, I should have come in with elastic-waisted trousers, and why, oh why, did I feel the need to wear a tie?

Nurse helps me by putting ‘bad’ arm into my shirt first.
I successfully manipulate my trousers onto my legs, but, with some embarrassment, I have to ask, “Please, can you do up my flies?”
All this takes some time, and St. A. begins to understand that the next few hours are going to present some significant challenges.
Eventually made decent and having discarded the tie, a triangular sling to support useless arm is constructed.

The first nurse returns.
We seem to be making progress as she doesn‘t need to ask my name!
Various bits of paperwork are completed and post-operative instructions passed on.
“Will Mrs. Saint Anley be collecting you?”
“Would you like us to give her a ring?
“What’s the telephone number?
“Oh, it’s alright, I’ve got it here!”

Mrs. St. A. duly arrives and transports me to our home, whereafter she diligently attends to my every need.
I still have no sensation in my left arm, so I have to be careful not to injure it by bumping into obstacles.
 
By the middle of the evening comes the very faintest notion that my motor facilities are returning.
First, my arm begins to move from the shoulder joint.
It does so with no cerebration on my part, and to no purpose.
It twitches, it gyrates vigorously, it abducts quite spontaneously.
I know it’s doing all these things because I can see it. However, my sense of its position in space has not returned, so, with my eyes closed, I don’t know where it is.

Then, I seem to be able to flex at the elbow, and the arm, totally unbidden, assumes a near-robotic waving motion.
"Have you seen someone you know?" enquires my wife!

By bedtime I still have no sensation, so I retire to a single bed since Mrs. St. A. wants to avoid being struck by a spontaneously moving plaster-clad arm in the middle of the night.
As instructed, I support the ‘bad’ arm on a pillow alongside me. ‘Bad’ arm, however, has other ideas and launches itself fitfully into the nearby wall.
No matter … I feel no pain.
The wall will polyfill and repaint!

I sleep surprisingly well until about 3.00am when I am awoken by that pleasant, warm, tingling sensation I described at the onset of anaesthesia.
“Ah, it’s wearing off,” I say to myself.

After that comes itching. I try scratching, but still with no real sensation, that makes no difference.

Eventually, all the chorea-form involuntary movements cease, and I can accurately identify the position of my arm in space.
I practise touching the tip of my nose with my index finger … YES!

By daybreak, I can feel light touch at my finger-tips.

What is demonstrated by this experience is that there are various modalities of sensation that recover at different rates, all somewhat later than motor function ...

• First comes tingling and temperature sensation.
• Nobody seems to know what the sensation of itch is all about, or why scratching alleviates it.
• Then comes joint-position sense.
• Light touch apparently takes a long time.

 
Pain comes last of all.

Now I know why I was prescribed those strong analgesics to take home from the hospital!
　

　


　

Dupuytren's #4

 

There has been a cancellation at my local hospital.
“Can you come in on Tuesday next week?” the admissions secretary had asked on the phone.
Saint Anley had enthusiastically agreed.

 
“Hello,” says the pretty receptionist who doesn’t look a bit like Tracey.
“Please give me your full name.”
“Saint Anley the Incandescent,” I reply.
“ … and what’s your date of birth?”
I confess to advancing years.
“ … and is your address still …?”
“ … and your telephone number ends … ?”
“ … and Dr *** is your GP?”

“Yes, yes ... and I think so,” responds St. A.
“Please have a seat there,” instructs the lady who doesn’t remind me of Tracey.

After a few minutes a nurse approaches: “Hello, what’s your full name?
She checks with my records to make sure I have answered correctly.

“ … and your date of birth?

“ … and your post-code is?

“ … does your telephone number end … ?

“ … and Dr *** is your GP?”

St. A. thinks, “She knows all this already.”

St. A. is directed to a cubicle and commanded to undress and don one of those anonymous looking hospital gowns that tie at the back.

Nobody told this patient that
he may keep his underpants on!

Then, along comes my surgeon, Mr ***. I remember him and we perpetuate our earlier conversation about the postage stamps of Papua New Guinea.

“Oh,” he says, referring to his clip-board, “I suppose I’d better ask you all these questions:

“What’s your full name?”
(You know what’s coming next.)

“Now, here’s your anaesthetist.”
He introduces me to a charming woman who looks like she’s just left school.

She goes through the same questions to establish my identity.
“Allergies?”
“None,” say I.
“Medications?”
“Nope.”

She explains the process of a regional block of the brachial plexus.

“You’re first on Mr ***’s list. We’ll have you in theatre shortly.

In the anaesthetic room, Micky, the theatre technician introduces himself before proceeding, once again, to ensure that I am who I think I am.

Anaesthetist returns and, accompanied by another nurse who insists on asking all the same questions again, proceeds to insert a large needle in the region of my left collar bone. Through this needle she infuses some local anaesthetic, not without some discomfort.

“That’ll take about 20 minutes to work.”

St. A. lies quietly and observes that he is slowly losing all motor function of his left arm.
This is followed by a warm, tingling sensation extending down the arm from his left shoulder. That’s quite pleasant.

Anaesthetist returns and pinches St. A’s left forearm.
“Can you feel that?
“Ouch!”
“Not long now,” she declares.

Indeed, within another few moments the limb seems completely disembodied. It no longer belongs to me and is completely at the direction of these various attendants.

The theatre door opens and I am greeted by a cheery theatre manager: “You must be Saint Anley?”
At last the message is getting through!

It's very bright in here.

I am linked to by a monitor that records my pulse and blood pressure. While my surgeon is scrubbing up I experiment with a variety of self-hypnotic techniques to see if I can reduce my pulse and blood pressure as a matter of will.

I CAN!

Now we’re ready.

My arm, which is now totally alien to me, is carefully placed, palm upwards, on an extension to the operating table. Mr *** paints the limb with some red solution, a tourniquet is applied and he carefully draws some hieroglyphics on the palm of my hand.
I can’t see precisely what is going on, so I ask, “Are you doing anything that might be painful?”

“No,” says my surgeon, “I’m just doodling!”

The anaesthetist light-heartedly fakes offence: “Of course you’ll feel no pain!”

Surgeon asks for scalpel and forceps.
St. Anley doesn’t want to look, but engages in conversation with the nurse who is supervising the aforementioned monitor.
"That's a bit worrying: why does is say 'apnoea'?"
"Oh, that's alright. We can see that you're breathing."

The surgeon patiently explains what he’s doing and, encouraged by feeling no pain whatsoever, St. A. turns his head to sneak a peek.

“Oh, you’d like to look?

“ Nurse, please get Saint Anley another pillow.”

Now I have full view of the internal mechanics of the palm of a hand that looks and feels like it belongs to someone else.

This is a really weird, dream-like experience, and I realise that this is not minor surgery: it is seriously intricate stuff.

No, this is not the hand of Saint Anley.
I wasn't permitted to take my camera into theatre.

Although the major deformity is to my little finger, Mr *** has noticed that Baron Dupuytren is threatening to attack the ring and middle fingers, so a surprising amount of diseased tissue is painstakingly, (and painlessly,) scraped away to reveal some glistening white tendons.

“Look at all this rubbish,” announces the surgeon with considerable satisfaction.

Now it’s time to be sewn up.
“5-0 silk, please, Nurse.”

Then we have a dressing and a plaster of Paris splint that I must wear for a week or so.

My hand, (yes, it is mine!) now appears thus …



Is it a duck?

... and by now, the entire staff of my local infirmary have my name, address, DOB, the last three digits of my telephone number and the name of my GP permanently committed to corporate memory.
Next time I'll take my passport and two recent utility bills.

By the way, my mother's maiden name was ... !

Dupuytren #3

 

 

Finally ... Saint Anley attends the Out-Patient department of his local hospital.

The consultant arrives ... late.

He looks ever so young!

 

He shakes St. Anley’s good hand very firmly as he introduces himself.

•  “So, you’ve got Dupuytren’s disease!” he announces ecstatically.
• “Show me ...”

St. Anley extends his left hand - all except the little finger which remains stubbornly in flexion.

Surgeon gently takes the deformed hand in his own, prods, pokes, pulls and measures things with a protractor.

• “That’s quite advanced."
• "With that degree of deformity, you could qualify to become a Freemason.”

(St. Anley begins to wonder anxiously, “Is this an invitation?”)

• “Now, what do you know about this condition?” he enquires.

St. Anley impresses the consultant with the fruits of his recent research:

• “I know that Baron Guillaume Dupuytren is said to have treated Napoleon’s piles.”
• “Well, I never! I didn’t know that!” says the surgeon.

St. Anley then confides about his previous occupation within the medical profession.

(That was before he became a bicycle maintenance person, tender of live-stock or purveyor of incandescence.)

• “So, you’ll know all about it, then,” says Doctor. 

(Actually, St. Anley knows just a bit about lubricating bicycles. He has rudimentary experience of chicken farming. He knows all about the wholesale price of incandescent light bulbs. His recall of the history of the London & South Western Railway is encyclopedic. However, all he knows about Dupuytren’s contracture is that it is that he’s got it. It is often hereditary, that it’s vigorously progressive, can recur after treatment. The association with consumption of gin-and-tonic is purely anecdotal, and it has nothing to do with haemorrhoids.)

•  “ … and what does it stop you doing?” asks Doctor. 

Here, St. Anley has to admit that he is an amateur musician who plays a number of instruments rather badly.

• “What instruments?"

St. Anley includes in the list a mandocello and a bowed psaltery.“I have never heard of those,” says the consultant.

There follows a lengthy dissertation on the mandolin-family of instruments.

The bowed psaltery is impossible to describe in words alone.

The consultant seems to be utterly engaged.

This takes a very long time.

• “Would you like to hear about my collection of stamps from Papua New Guinea?” asks the doctor.
• “Oh, yes.” replies St. Anley with feigned enthusiasm, “I’ve been there.”
• “Did you know that the German colonists constructed a railway there late in the 19^th century?”
• “Oh, tell me more …”

... and this prolonged, competitive exchange of inconsequential trivia becomes somewhat tedious. 

• “So, what about my hand?” enquires St. Anley, patiently.
• “Oh, yes, I almost forgot! We’ll get you in for surgery: day-case, regional anaesthesia; you know what I mean… OK?”
• "My secretary will contact you."

(St. Anley imagines that said secretary is named Tracey!)

• “When?”
• “When I can find the time!” responds the consultant.
• “Good afternoon. I’ll see you next on the operating table.”

As he departs St. Anley sheepishly asks, “Will I be able to play my mandocello?”

• “NOT WHILE I’M OPERATING!”

 

  

Dupuytren's progress report ...

Last week St. Anley received a letter from the local hospital.
It reads: "I am writing to invite you to telephone our appointments office as soon as possible to agree a convenient appointment ..."

St. Anley phones.
You know who answers ...




Hello, my name is Tracey.
How may I help?



"I've received this letter, ref. ..." says St. Anley.

• "Ah, let me check," replies Tracey.
• "What's your hospital number?"
• "Please confirm your date of birth."
• "... and what's your post-code?"

"Please hold ..."

St. Anley luxuriates in a recording of the spring movement from Vivaldi's 'Four Seasons'. That's one of his favoutites.

Eventually ...

• "Are you still there?" asks Tracey.
• "Yes, I'm really enjoying the music."
• "Now, I am sorry to tell you that we have no available appointments to offer you right now."
• "Oh," says St. Anley, "Then why have I received this letter?"
• "We're just keeping in touch to make sure that you still want an appointment," replies Tracey.
• "Is there anything else I can do?" she asks.

"Yes, can you play some Beethoven, please, next time I phone?"

Clearly, Tracey is not a fan of LVB ...
The line goes dead!

Regarding Baron Guillaume Dupuytren ...

 

Baron Guillaume Dupuytren
(1777 -1835)

 This French anatomist and surgeon is best remembered for having treated Napoleon's haemorrhoids.

He also described this condition, known eponymously as Dupuytren's contracture ...

 

 

In some cultures this could be perceived as a rude gesture.

Above, you see St. Anley's ageing left hand, with the characteristic deformity of fixed flexion of the little finger.  This has become rapidly more apparent since the beginning of the year. There is also some thickening involving the flexor tendons of his ring and middle finger.

St. Anley, having trawled earlier medical knowledge, and after consulting wikipedia, knows what it is. It will only get worse.

"Please may I have an appointment to see my GP?" asks St. Anley on the telephone.

"Of course," replies Tracey, (now a medical receptionist.)
"Come along at 7.30 in the morning."
(Gosh, these doctors work long hours these days.)

My GP's surgery just after sunrise.

The consultation proceeds thus:

• Doctor: "You have a Dupuytren's contracture."
• St. Anley: "I know."
• Doctor: "It will only get worse."
• St. Anley: "I know. What can be done?"
• Doctor, becoming animated: "Surgery!"
• St. Anley, anxiously: "Will it hurt?"
• Doctor, with considerable glee: "Undoubtedly!!"
• St. Anley, with furrowed brow: "Is it life threatening?"
• Doctor, becoming impatient: "There is the highly regrettable risk that you will survive!!!" (I think this doctor doesn't like me.)
• St. Anley: "What's the recovery time?"
• Doctor: "Oh, about three months."
• St. Anley, dejectedly: "How will I be able to play my musical instruments?"
• Doctor: "Badly!"

... No change there, then!