541

II-CARIES OF THE HIP JOINT ; EXCISION OF THE HEAD OF THEFEMUR AND PART OF THE ACETABULUM ; GOOD RECOVERY.

Harry P-, aged eight years, a thin emaciated boy, wasadmitted Sept. 16th, 1861, suffering from disease of the lefthip-joint. His mother stated that about two years previouslyhe had a fall on his side, which caused him for a few days towalk lame, but from which, in the course of a week, he appa-rently recovered. Soon afterwards, however, he was observedto limp while walking, and he complained of pain in the left

hip joint and knee, but more particularly in the latter; and thelimb appeared shortened. He was taken to St. George’s Hos-pital, where he was under treatment for two months, withoutmanifest improvement.Upon admission he was exceedingly emaciated ; his counte-

nance pale and cachec’ic; pulse quick and feeble; tongue foul;bowels irregular and secretions unhealthy; appetite indifferentand capricious. He had likewise a troublesome cough andnight-sweats. There was considerable flattening of the leftnates. Three sinuses existed over the hip joint, leading tocarious bone, from which there was a constant discharge ofpus. There was much angularity of the pelvis; the thigh wasflexed on the abdomen and the leg upon the thigh, the limbbeing adducted, and the knee embedded on the opposite thigh.Any movement of the limb caused him great pain, both at thehip and at the knee. He was placed in bed, and as nutritiousa diet as he could take, with three ounces of wine daily, wereadministered. Poppy fomentations were applied to the hip,and he was ordered to take henbane with carbonate and acetateof ammonia three times a day. Under this treatment his healthsomewhat improved, and the soft parts in the vicinity of thecarious and necrosed bone became less inflamed.

1Blr. Holt determined on enlarging the existing openings andremoving the carious head of the femur, as well as any otherparts affected. The boy having been carefully placed underthe influence of chloroform on October 1st, an incision was imade through the sinuses over the great trochanter down tothe bone; and, having detached the connecting tissues, Mr.Holt was enabled, by rotating the limb inwards, to disengagethe head of the femur from the cotyloid cavity, and to removeit by the aid of a saw. The acetabulum was now examined,and the whole of that portion which was found to be cariouswas removed. The limb, being now perfectly under command,was extended and placed on an uninterrupted splint, andwater-dressing applied to the wound. Notwithstanding themagnitude of the operation, comparatively little blood was lost;and the depression produced by the proceeding was soon re-covered from after the administration of hot wine-and-water.

October 2nd.-He had some sleep during the night, and,although very low, says he is comfortable. He is able to takea fair quantity of strong beef-tea, and three ounces of wine daily.4th.-Improving in every respect. The wound having sup-

purated freely, the dressings were removed for the first timesince the operation ; there is a free discharge of healthy pusfrom the wound, and the parts around look healthy; appetiteimproving. The limb is in good position.

6th.—Discharge from the wound rather offensive, and theskin around looks red. To have a poultice applied, and a solu-tion of nitrate of silver to the surrounding skin.

12th.—Very much improved ; the limb is in a good posi-tion, and the wounds look healthy and are granulating;appetite much improved. To take middle diet and half a pintof porter daily.Nov. 2nd.-Continues to improve ; the wound is nearly

healed; the limb is in a perfectly straight position, and he isfree from pain.30th.-His strength has so much improved (all the sores

about the hip being entirely healed) that he was allowed a pairof crutches, which enable him to move about pretty freely.

Dec. 10th.- Very much improved in health and strength.He can move the limb freely in every direction, and bear onit without pain. The limb is shortened to the extent of twoinches and a half. He has had a high-heeled shoe made, withwhich, and the aid of one crutch, he walked out of the hospitalto-day to go into the country.III-HIP-DISEASE ; DISLOCATION OF HEAD OF BONE ON TO THE

DORSUM ILII; EXCISION ; SATISFACTORY PROGRESS.

Catherine Louisa H-, aged eight years, was admitted intoHolland ward on the 4th of February, 1862, with abscessesabout the right hip, the result of disease of the hip-joint. Threeyears ago the child had a fall upon some stone steps, which gaverise to pain about the hip and haunches, for which she was undermedical treatment for some time ; and eighteen months ago she

was admitted under Mr. Holt’s care with an abscess on the

right hip-joint. This was opened at the time, and, under propertreatment, the child’s health improved and the abscess healed,re-opening again, however, after she had left the hospitalOn admission there were several sinuses about the right

buttock, through which carious bone could be felt, and which keptup a constant discharge. The head of the femur was evidentlydislocated upon, and apparently fixed to, the dorsum ilii ; andthe limb was strongly flexed upon the pelvis. A compensatorycurve in the spine had been established. The child’s healthhad suffered from the suppuration and irritation, and she waspale and feeble.

Feb. 12th. -The patient was ordered a drachm of steel winethree times a day. There being a good deal of inflammatoryredness about the skin in the neighbourhood of the part, a lotionof nitrate of silver was applied with good results, and the child’shealth gradually improved.

April 15th.- t he child having been placed under the influenceof chloroform, Mr. Holt laid open the sinuses, and carried anincision down to the head of the femur, which was found to be.dislocated and in a carious condition. The saw was appliedbelow the trochanter and the bone divided, and the adhesionsformed between the head and the pelvis having been severed, thediseased portion was removed. With the gouge some cariousspots of bone in the pelvis were removed ; and the limb wasthen straightened and brought to nearly the same length as theother, being confined by an interrupted long splint and peri-neal bandage in the usual way.

After the operation the child made the most satisfactory pro-gress, healthy action being rapidly established in the wound,and the pain previously complained of being entirely relieved.May 13th (some weeks after the operation).-The greater part

of the wound is healed, and the discharge but trifling. Thelimb is but slightly shorter than that on the sound side, andthe child’s health has materially improved since the operation.IV. -OLD HIP-DISEASE, WITH CONTRACTION OF THE THIGH UPON

THE PELVIS, IN A CHILD; FORCIBLE EXTENSION UNDER CHLO-ROFORM.

Bridget M-, aged six years and three quarters, was admitted into Holland ward, under Mr. Holt, 7th April, 1862,with contraction of left femur, the result of old hip-disease.Three and a half years ago she had acute inflammation of theleft hip-joint, which gave rise to abscesses on the outer side ofthe limb; but these were healed up two years ago, since whichtime the thigh has been forcibly flexed upon the abdomen, andthe child has only been able to get about with a crutch.

April 16th. -The child having been placed under chloroform,Mr. Holt proceeded to extend the limb forcibly, the pelvisbeing firmly held by an assistant. The adhesions were evi-dently of a fibrous character, and yielded to the force applied,with a slight cracking sound. The limb was fully extended,but could not be brought to quite the same length as the oppo-site one, on account of the curvature of the spine, consequentupon the distortion. The skin in the groin was softened andtender, owing to the long-continued application of the two sur-faces. A long splint was applied before the patient left thetheatre, to prevent recontraction of the limb.Two days subsequently the splint was removed, and a weight

was attached to the foot, with strips of plaster applied up theside of the limb, which mode possesses the great advantage ofnot exercising injurious pressure on the foot. The weight beingallowed to hang over the end of the bed, kept up extension,whilst counter extension was provided for by the use of a peri-neal bandage passed through the groin of the sound side, andattached to the head of the bed. Ordered syrup of iodide ofiron, half a drachm; water half a drachm: three times a day.May 13th (one month after the operation).=The limb is

perfectly straight, and there is some degree of motion in thejoint, which is increasing under the use of passive exercise.The spinal curvature is much diminished, and the child is welland strong.

KING’S COLLEGE HOSPITAL.

DISEASE OF THE HIP-JOINT; ABSORPTION OF THE HEADOF THE FEMUR; ACETABULUM MUCH INVOLVED;REMOVAL OF CARIOUS FRAGMENTS; RECOVERY.

(Under the care of Mr. FERGUSSON.)

A PFCULIARITY of the following case was the almost entireabsence of suffering throughout the long period during whichthe disease progressed. At the operation, the head of the

542

thigh bone was found to be absorbed, and the acetabulummost extensively disorganized-so much so, indeed, that, onthe removal of all the affected part, the wound, as in Mr.Holt’s first case, communicated with the cavity of the pelvis.This, although a grave matter, did not produce any serioussymptoms; the healing went on, but slowly, and the boy leftthe hospital ten weeks after the operation.The notes of the case were kindly furnished by Mr. G. For-

tescue, late house-surgeon to the hospital.W. B-, aged thirteen, a native of Preston ; a pale, deli-

cate, strumous-looking youth; admitted October 4th, 1861.About seven years ago it was observed by his parents that thepatiant walked lame, and after a time he himself found thathis right leg became easily tired: Four years ago a swellingappeared on the upper part of the right thigh in front, whichburst, and has continued to discharge pus ever since. Soonthe leg became shorter. He has undergone a variety of medi-cal treatment, with little or no benefit.On admission, the right thigh was found to be much wasted,

and the pelvis "tilted" on the diseased sirle. The thigh wasin advance of the opposite one, and when standing the limbwas everted, the foot turned outwards, and the heel rested alittle above the left inner malleolus. From the anterior supe-rior Sp410US process of the ilium to the outer condyle on theright side the distance was less by rather more than an inchthan on the other. There W,lS considerable swelling about thehip-joint, and a series of sinuses existed along the crest of theos innominatum. There was no pain in the knee, nor has thereever been any; scarcely any tenderness on pressure over thetrochanter. Very little independent movement of the hip-jointremained. Passive motion caused very slight pain, and inaeedan almost complete absence of suffering lias been throughout aprominent feature of this case. On examination, dead bonewas readily detected through one of the larger sinuses.

Oct. 19th.—The patient having been put under the influenceof chloroform, Mr. Fergusson made a crucial incision over thetrochanter major, and examined the condition of the parts.The head of the femur was found to be absorbed, and the ace-tabulum extensively diseased. In the latter locality the gougewas freely used, and a very deep wound resulted, which appa-rentlv communicated with the interior of the pelvis. The cavitywas filled up from the bottom with dry lint, and a strip of lintpassed through the incision above was brought out as a setonthrough the other opening below the trochanter.-21st.-The boy is without pain, and appears to suffer very

little from the operation.Nov. 4th.-Continues to improve; eats and sleeps very fairly.

There is a free discharge from the wound, which looks rathersluggish. The w ounds are syringed out daily with a weak solu-tion of Condy’s fluid (liq. potass. permanganat.), two drachmsto a pint of water, and dressed with a stimulating lotion undera poultice.

llth.-The wound looks more healthy, and is filling up alittle. Its edges are drawn together by strapping.

Dec. 27th.-The boy was discharged somewhat improved incondition. The openings, however, refused to heal, and werestill discharging.

MIDDLESEX HOSPITAL.

CARIES OF THE PELVIS AND FEMUR; EXCISION OF THEHEAD OF THE FEMUR ; RECOVERY ;

CLINICAL REMARKS.

(Under the care of Mr. NUNN.)

THE patient, a female child, aged twelve years, had beensome weeks in the hospital. When admitted, there was a,

fistulous opening at the riht femoral fossa, and a threateningof abscess at the middle third of the thigh. Most of the ordi-

nary symptoms of advanced hip-joint disease were, if not

absent, at least obscure. Mr. Nunn ordered the long straightsplint to be applied, with apparent benefit for some time; butabout ten days since the abscess at the middle third of the

thigh became much inflamed, the region over the trochantermajor assumed a tense aspect, and the painfulness of the hipprevented the continuance of the application of the long splint.Very soon an opening formed in the middle of the thigh, andpermitted the evacuation of much matter of a very fetid nature.Through this opening pus of the same character continued tcescape in large quantities. As there was evidently diseaseeither of the pelvis or head of the femur, Mr. Nunn deter-

mined to make exploratory incisions; and, in the event of theresult of these incisions justifying it, to excise the head of thethigh-bone.On November 20th, 1S61, the patient being placed under

the influence of chloroform, Mr. Nunn cut down almost imme-diately over the upper fifth of the femur, and, detecting throughan aperture in the capsular ligament caries in the head of thebone, extended the incision upward, and, by opening the cap-sule of the joint, easily everted the head, which was removed,with the neck, by the chain-saw; and subsequently, on theadvice of Mr. Shaw, the trochanter major was also removed.After the patient was again in her bed the straight splint was

reapplied.Mr. Nunn stated to the class that although he could not

hope for a cure, since there evidently existed very considerabledisease of the pelvis, yet he felt sure that the operation wouldafford relief by removing one great cause of the patient’s ex-treme suffering,-namely, the tension on the inflamed partsfrom the anatomical disposition of the structures surroundingthe hip joint.

Nov. 26th. -The progress of this case has been hitherto quitesatisfactory. The patient has slept well, and enjoys her food,and has quite a cheerful look. There are some very largely-dilated veins over the hypogastric and inguinal regions, whichhave an ominous appearance. The relief afforded has been,nevertheless, quite remarkable.May 17th, 1562.-The immediate result of the removal of the

carious head of the femur was, as above stated, a completerelief from pain and distressing constitutional disturbance. Verycopious purulent discharges continuing, every nutritious articleof food and a very liberal supply of wine were supplied. Aboutsix weeks since the patient was placed under the influence ofchloroform, and the sinuses remaining were explored. As nocarious patches and no sequestra about the pelvis could be de-tected, the patient was discharged from the hospital.

Accounts from the child’s home represent her as eating andsleeping well, and free from suffering. Taking into considera-tion the extensive disease of the ischium and pubis, the pro-gress of the case may be considered satisfactory. Should thesinuses heal, and the patient continue to gain strength, it isprobable that the tendons of the adductor longus will requiredivision in order to improve the position of the limb. Thiswould have been done already had not a sinus coursed exactlyover it, and the integument been very much attenuated at the

point most advantageous for division of the tendon under ordi-nary circumstances.

WEST LONDON HOSPITAL.

EXCISION OF THE ELBOW-JOINT FOR SCROFULOUS DIS-

EASE OF TWENTY YEARS’ STANDING ; RECOVERY.

(Under the care of Mr. ERNEST HART.)THE results of excision are not in any joint more satisfactorythan in that of the elbow. Of 149 recorded cases there were

33 deaths, or a little over 22 per cent. Of 470 amputations ofthe humerus 157 proved fatal, or in the ratio of about 33 percent. Thus it will be observed that the resnlts are decidedlyin favour of excision of the elbow-joint. The following caseadds an additional unit to the favourable statistics which are

accumulating in relation to this operation. We are indebtedto Mr. Atkins, house-surgeon, for the notes indicating the pro-gress of the case.

A. H-, aged thirty-three, was admitted into the hospital,having been the subject of scrofulous caries of the elbow-jointfor nearly twenty years. During this long period he had hadrepeated attacks of inflammation in the joint. Pieces of bonehad at various times been removed. On admission, the armwas anchylosed in the bent position. There were one or two

apertures connected with small sinuses, and the patient com-plained of much nocturnal pain. The arm was useless to himin his occupation. Mr. Hart proceeded to excise the diseasedjoint and ends of the bonps on March 12th, employing thesingle posterior incision, On laying open the joint, the dislo-cated and anchylosed process of the ulna projected most pro-minently; Mr. Hart therefore removed this first, then slicedaway the articular ends of the humerus, and cut through thehead of the radius. It was necessary to remove a greater ex-tent of bone than usual, because, owing to the number of yearsthat dislocation and consequent shortening had continued, cor-responding retraction of the soft parts existed; so that it was