CASES OF AMPUTATION AT THE HIP-JOINT. By De. Eaillie,

Surgeon,

Calcutta Native

Hospital.

I.?AMPUTATION" BY THE CIRCULAR METHOD FOB INJURY ; CARBOLIC ACID NOT USED : DEATH ON THE TWENTIETH DAY FROM HAEMORRHAGE. Nogendronath

boy aged 7, admitted 22nd August, a high house, and sustained compound comminuted fracture of the right thigh bone at its upper third, which protruded nearly two inches from the wound, the surrounding soft parts being much bruised. After waiting a few hours till re-action had set in, amputation at the joint was performed under chloroform; the operation was well-borne, and progress good till the fifth day, when diarrhoea occurred, and the stump opened out; however, this in a few days became filled with healthy granulations, which were guarded by warm dressing. The pulse, however, which was very rapid on admission, never fell below 150, although he was well supported and had tonics. After this he went on fairly, the wound granulating and contracting till 9th September. Diarrhoea with fever then set in, and continued more or less till 11th September, at 4j a.m., when, whilst straining at stool, arterial haemorrhage occurred from the bottom of the wound, but not in a jet; the bleeding was speedily arrested, not more than four ounces of blood having escaped ; the little patient, however, rapidly sunk, and died a little before six o'clock the same morning. No postDutt,

a

1867, having fallen from the roof of

mortem examination could be obtained. Remarks.?The injury to the muscles surrounding the joint was so great in this instance, that I was induced to adopt the circular in preference to the flap operation, so as to enable more of the muscular structure, and less of the integument to-be removed ; had this alternative not been called for, probably the boy's chances of recovery would have been greater; and they wouid also have been still more increased, had carbolic apid been applied at the time of the operation, as I believe thereby adhesion might have followed, and the long suppurating process been averted.

II.?AMPUTATION BY

ANTERIOH AND POSTERIOR FLAPS FOR DISEASE ; CARBOLIC ACID FliEELY USED ; STUMP HEALED IN SIX WEEKS ; DEATH FUOM EXHAUSTION, THREE DAYS AFTER A SLIGHT ATTACK OF CHOLERA.

Becharam Bagh, an emaciated Hindoo lad, aged 16, was brought to the hospital on 12th August, 1869, by his mother, who immediately afterwards decamped, thinking probably that his case was hopeless; and certainly the poor boy's appearance justified her fears. He was suffering from a large osseous tumour of the left leg, its greatest circumference just below the knee being 26 inches; the entire thigh also was much increased in size; the plate taken from a photograph by Mr. Rust, of the Calcutta Photographic Company, hardly gives a fair idea of its

dimensions, the part having been out of focus ; it was hard, and large distended veins were seen meandering tortuously over its surface, giving it a most malignant aspect; and, indeed, the history and period of the growth (scarcely eight months), tended to confirm the view of its malignancy; the accident that originated the disease was a slight one. Whilst walking the left foot got into a hole, and he fell upon his left side, the limb being tightly twisted under him; soon after he felt a severe pain about

THE INDIAN MEDICAL GAZETTE.

262

the head of the fibula, where a tumour formed) which rapidly increased downwards and upwards, till the thigh, nearly to the groin, became involved in the disease; and his strength and general health failed so much, as to make it manifest that unless the affected parts were soon and entirely removed, he could not long survive. Accordingly with his consent, on the 18th August, amputation at the hip-joint by double flaps, was performed, Dr. Macnamara, Surgeon to the Opthalmic Hospital of this city, kindly assisting; the arteries having been secured with but little loss of blood, a solution of carbolic acid, 1 part to 24 of water, was freely applied to every portion of the wound, which was then brought together by iron wire sutures, and the whole stump covered with lint soaked in carbolic oil. An hour after the operation he was very low: pulse could not be counted, but this was the case before the operation, so reduced was the patient; his respiration was also very hurried. 19th.?Pulse and breathing still very rapid, but aspect improved; towards the afternoon he rallied a little, and a few of the sutures were removed; and a considerable quantity of sanious discharge, evidently mixed with carbolic acid, escaped, causing a burning sensation to such parts of the hand with which it came in contact; the line of incision was supported by straps of adhesive plaster, and air excluded by application of warm dressing mixed with carbolic oil.

20th.?Progressing well; pulse 132; respiration 26; stump healthy looking. From this date there is nothing to chronicle, save that the patient gradually, from day to day, gained strength and improved with no drawback, except occasional slight attacks of dysenteric diarrhoea, which were easily checked by small doses of rhubarb and ipecacuanha with bitter extract; he had afterwards at different times, pepsine, syrup of lactate of iron, and opium : the latter alone seemed to suit him very well. On the 30th September, being the day of the quarterly meeting of the governors of the hospital, the patient was seen by Dr. John Murray, the Inspector-General; the stump was then quite solid, and healed, save a small sinus (at the outer extremity of the line of cicatrization), which could but just admit an ordinary probe, and from which about half a drachm of healthy pus escaped daily. Pulse 84, at which figure it had been for

the past three weeks. On 3rd October, all having gone on well previously, he had several copious conjee-like stools, but unaccompanied by cramps or vomiting; this purging was checked in the after part of the day, and in the course of the next two days, the stools, although still watery, became smaller in quantity, and began to assume a yellow tinge, and I hoped he had got over the attack, but during the night of the 5th, without any increase of diarrhoea, he became very faint and gradually sank, dying early on the morning of the 6th October, just seven weeks from the date of the operation. A post-mortem examination was made the same morning; all the viscera were in a healthy condition; the stomach, however, was much distended with a grumous fluid, and the gall bladder ?with bile, but the examination disclosed positively nothing to^ account for death; the stump was cut into, and found solid throughout, even the acetabulum was quite filled in, and the little sinus mentioned above, which admitted only the small blow-pipe usually seen in dissecting cases, was traced to the back of its outer edge. The whole of the amputated parts were sent to the Medical College Museum for examination, but owing to a misadventure, the soft structures were unfortunately not examined, so that Professor Ewart could but report upon the osseous part of the growth, which he considered to be of the nature of osteosarcoma.

nothing short of the removal of the I believe, have offered a chance of to recovery, and the correctness of this opinion may be said have been confirmed by the result of the operation; for so far as the wound of the amputation was concerned, nothing could exceed the steady progress of the healing process, unattended as it was by a single contretemps" during its whole period, no fever, haemorrhage or other adverse incident having occurred. Then as to the death, there can be but little doubt that in consequence of the low state of the boy's health, to which his disease had brought him, combined with the demands upon his strength, had expended so much of the vital force, as to leave an insufficient amount of it, to enable his system to rally from the shock it sustained from the attack of cholera, slight though it was. It is singular that in this, as in the successful cases of hipjoint amputation, reported by Drs. Fayrer and Partridge, the age of the patient was 16, Remarks.?In this

limb at the

case

joint would,

"

[December 1,

1869.

Cases of Amputation at the Hip-Joint.

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