Length of right limb, from anterior superior ...... 351 แ spine of ilium to external malleoli . . . . . . . . . 334 inches. 181 14 แ 114 ... 121 แ (Swollen.) 66 right thigh at its middle.... 13§ "left 66 There are 12 sinuous openings situated over the vicinity of the hip-joint; these all appear to lead toward an indurated mass which seems to surround the whole articulation, and through some of these the probe appears to come in contact with bone. The discharge is at present slight in amount, thin, and somewhat offensive. There is no pain or tenderness over the hip. The lower half of the right leg and the foot are œdematous and red, and on the toes and dorsum of the foot are several sloughy and foetid ulcerations. July 8th.-Wet antiseptic dressings were applied to the foot, and the limb bandaged. 13th. The swelling of foot remains the same, and the sloughing has somewhat increased. The only operation which afforded any prospect of relief was amputation at the hip-joint, the dangers of which he was made acquainted with; yet he was resolute in his deterinination to run any risk, could he only be relieved of his limb-which, indeed, was a great burden to him, and certainly threatened ere long to terminate his life. Amputation was accordingly done July 18th, at 3 P. M., assisted by Drs. Sands, Weir, Allin, Briddon, and Sabine. While the patient was on the table and under ether, I examined the limb to determine if the anchylosis were true or false; using a moderate amount of force, I thought I detected a slight motion in the joint, with crepitus; in a second endeavor to verify the same, the femur fractured in its upper third. Esmarch's bandage was applied, and the aorta was compressed by the same instrument (May's modification of Signoroni's tourniquet) which I used in my other two cases (reported in the NEW YORK MEDICAL JOURNAL for December, 1876). This time, however, a sponge was placed between the pad and the integument, with the aim of lessening the pressure which might be made upon any intestine (an idea, I believe, suggested and put in practice by Mr. Lister). The operation was the same as in my other two cases, with the exception of the outer incision, which this case demanded. The operation was what is usually known as the circular method. The skin being divided with the large knife, it was drawn well up by an assistant and the various muscles divided down to the joint, the soft parts being all the time well retracted. It was now discovered that, though probably there was true anchylosis, a recent fracture had taken place in the joint. Accordingly, the vessels were ligated with silk ligatures, and the compression over the aorta removed, which had been kept up just one hundred seconds. An external incision was now made, to facilitate the removal of the bone. The upper fragment of the femur was seized with the lion-toothed forceps, and removed. The head of the bone had been fractured evidently, I thought, in manipulations to determine the amount of anchylosis that existed, and about one-half of the head of the bone remained in the acetabulum, where it was firmly anchylosed. The hæmorrhage attending the operation was, as in the other cases, very small. Several detached portions of bone were removed from the margin of the acetabulum, and a small sequestrum from the horizontal ramus and body of the pubes. The portion of the head of the bone remaining in the acetabulum, being vascular and apparently healthy, was not disturbed. The wound was thoroughly irrigated with a solution of salicylic acid 1 to 50; a drainage-tube was introduced and wound closed with silk sutures, the ligatures, twelve in number, being brought out at the angle of the wound. The stump was now dressed with Lister's antiseptic dressing, which, with the spray of carbolic acid, was used during the treatment of the case. His pulse remained good throughout the operation. At the moment of severing the limb from the body a hypodermic injection of whiskey (half a drachm) was given. He was not removed from the theatre till pretty well out of the influence of the ether, when a hypodermic injection of twelve minims of Magendie's solution of morphia was given. At 6 P. M. his pulse was 80, and strong; temperature, 9810; 9 P. M., sleeping quietly. Was given one grain of opium when he awoke, at 11 P. M., complaining of pain in his knee. 19th.9 A. M., pulse, 124; temperature, 99°. Wound dressed, and thoroughly irrigated with carbolic acid. Feels weak, and complains of pain, which is referred to the knee. 20th.-Vomited once or twice during the night; with this exception, passed a good night. 9 A. M., pulse, 112; temperature, 984°. 22d.-Edges of the wound have almost entirely united; discharge is thin, and red in color; the drainage-tube was removed. 25th. The sutures have all been removed; the flaps are adherent throughout the greater portion of the wound; at parts where remaining open, healthy granulations are pres ent. Without giving a daily record of the case it may be sufficient to state that everything progressed most satisfactorily, and the patient was up and walking about on his crutches August 14th. August 21st.-Lister's dressing now irritated the integuments of the stump, and was dispensed with, sheet lint. spread with simple cerate and salicylized jute being substituted. September 16th.-Patient left the hospital at this time. The face of the stump was healed, but there remained open one or two of the old sinuses, which were discharging but little; for the treatment of these the patient occasionally reported at the hospital. He has now no cough, has gained considerably in weight, enjoys perfect health, and has attended to his business. daily since leaving the hospital. During the whole time he was under treatment his temperature never rose above 991°. December 15th.-The day this photograph was taken, there remained one small opening, which hardly discharged at all, just below Poupart's ligament, and one on the face of the stump, which the patient states is now fast closing, and gives no trouble. I can add nothing more, with reference to the manner of performing this operation, to what I have previously stated, in the remarks appended to the history of the cases reported in this JOURNAL for December, 1876. With the use of the tourniquet over the aorta, and this carefully applied with a soft sponge intervening between the pad and the abdomen, and permitting this pressure to remain just long enough to secure the anterior vessels, the danger to injury of the intestines or peritoneum is greatly lessened. No more pressure is required than that which would be required from pressure made by the hands of an assistant, while it is more certain, and less liable to be removed from the vessel than digital compression. With this, and Esmarch's bandage, the operation is accomplished with the loss of but a few ounces of blood; and the shock is further diminished by giving a drachm of brandy or whiskey subcutaneously at the moment the limb is severed from the body. From my experience in these three cases my preference is decidedly in favor of the circular method. The vessels are readily secured; the surface of the wound is smaller, and it is far more easily dressed, and with less disturbance to the patient, than would be after the operation by flaps. The stump resulting from the circular method is all that could be desired. Examination of the limb of this patient revealed a diseased condition of a portion of the anterior tibial artery, and in this locality the lumen of the vessel was encroached upon by a deposit upon its inner coat. The femur was atrophied, and its upper five inches are roughened-the result of perios titis. In conclusion, it may be of interest to add the latest statistics that have appeared, as far as I am aware, of amputation at the hip-joint. These are by Dr. August Lüling, and are given in the Deutsche Zeitschrift für Chirurgie, vol. viii., page 327 (June 15, 1877). They are as follows: |