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418 ST. MARY’S HOSPITAL. DISEASE OF THE HIP-JOINT IN A BOY AGED EIGHT YEARS, WITH ABSCESSES, SINUSES, CARIES, AND DISLOCATION OF THE HEAD OF THE BONE; EXCISION OF THE JOINT; GOOD RECOVERY. (Under the care of Mr. URE.) WILLIAM S-, aged eight years, was admitted Jan. Isi He is a very sickly child, and the subject of disease of the hi for three years, the greater part of which time he has been i hospital. There have been abscesses and sinuses constantl forming in connexion with the disease of the hip-joint. On hi first admission, he had an abscess of the right bursa over th tuberosity of the ischium, which was found to be rough an exposed. Subsequently to this, fresh abscesses formed on th anterior and upper part of the thigh, communicating wit] various sinuses leading to the head of the femur, which wa dislocated on to the dorsum of the ilium. Other sinuses wer situated further backwards and outwards over the trochanters also leading to the carious femur. The patient’s general health was first improved by good die and regimen, with cod-liver oil and tonics, and when a change for the better had ensued, Mr. Ure excised the head of th, femur, on the llth of February. An incision four inches lon! was made, curving backwards, directly over the dislocate( head of the bone, which was easily removed by cutting througl the neck with a pair of large forceps. The acetabulum wa: slightly softened by the contact with the surrounding diseasec parts, but was otherwise healthy. It was, however, scraped. and as much of the neck of the femur as was found diseasec was gouged away. The head of the bone was almost entirely denuded of cartilage, and was somewhat eroded, with loss of thE greater part of its articular lamellæ; its tissue generally seemed to be much softened and unusually vascular. His progress was most favourable; the openings on the anterior and posterior aspect of the thigh gradually contracted and healed; his general health further improved, he increased in weight, and looked contented and happy. His diet was carefully attended to at the same time. For a fortnight after the operation, Mr. Ure directed the thigh to be kept slightly bent and abducted, in order to maintain the remaining portion of the neck of the femur in relation with the cotyloid cavity. This was done because in extension of the thigh there is always a tendency in the bone to be carried backwards. At the end of six weeks after the operation, during which he never complained of pain, he was able to sit up for some time, to walk about the ward with the help of crutches, and to move his thigh gently away from the hip, both in flexion and abduction. As his case progressed, the shortening of the limb was not perceptibly greater than before the operation, and allowed the foot to be planted on to the ground. This could be done even with some weight upon it. He was seen within the last few days, (not in hospital,) and found in tolerable health. He walks pretty well, but with the heel raised from the ground. A little discharge oozes from one or two of the old fistulous openings below the level of the seat of operation. The termination to this case was most gratifying, and the boy, we have no doubt, will have a very useful limb in the course of time. This case also completes our present series of excision of the hip-joint ; and, on glancing over them, we have reason to be satisfied with their results. Thus there are ten cases in which the operation was performed, and amongst them there are three deaths. Of these three cases, as we have already pointed out in our last number, two had the operation per- formed merely as a palliative measure-namely, Mr. Hancock’s and Mr. Simon’s cases. The third, by Mr. Stanley, was really in no better condition than the others, for rapidly advancing chest disease soon cut the poor boy off. The recoveries in all the others are really gratifying, with but one single exception, Mr. Bowman’s little girl, who is suffering from severe disease of the heart. In her case the ope- ration itself has completely succeeded, with the drawback mentioned, which is a circumstance entirely unforseen. We may, therefore, say of the seven cases, there have been seven successful operations. Now, in conclusion, if these are con- trasted with seven amputations, we fear the comparison will be vastly against the latter in the ratio of success. The result of these seven cases, together with that in others which have preceded them in former " Mirrors," very clearly and satis- factorily demonstrate, and most convincingly prove, that actual disease of the acetabulum is not an objection to the operation; and we are permitted to go even a little further, and can state, that in commencing tubercular deposition—that is, where the first stage of phthisis only is present, and the softening of tubercle has not already occurred, the surgeon will do good by removing a terrible source of irritation and exhaustion; and if attention is carefully paid to the general health by administering cod-liver oil and tonics, the phthisical affection may yield, as in Mr. Erichsen’s really very Valuably illustrative case. GREAT NORTHERN HOSPITAL. CASE OF NECROSIS OF THE RADIUS IN A BOY, AGED NINE YEARS; EXCISION OF THE ENTIRE SHAFT. (Under the care of Mr. SAVORY.) 1 THE entire ulna has been removed several times with success, Mr. Fergusson, Mr. Jones, of Jersey, Mr. Erichsen, and others, having performed the operation. The radius, again, has had ! the greater part of its shaft, with one end, excised, but seldom both of its extremities; to-day we have an opportunity of reo , cording a case in which the entire shaft, with both ends, were successfully removed, and this has been in consequence of sepa. ; ration of the epiphyses, which has thus permitted of complete isolation. The notes of the case have been taken by Mr. Paul , Belcher, house-surgeon to the hospital. : Thos. K-, a boy, aged nine years, admitted on the 29th of September with necrosis of the right radius, which can be distinctly felt bare. The highest aperture is near the upper extremity of the bone, and the two lower (one of which is in front) are near the wrist. No loose fragments of bone can be detected. The elbow and wrist joints move freely. The boy states that nine months ago he first perceived pain of a slightly intermitting character, but always aggravated at night, over the styloid process of the radius. Shortly afterwards, abscesses formed on the wrist and on the front of the forearm, just below the bend of the elbow. He was under treatment in the country, but the arm grew worse. At the beginning of August last, he became a patient at the Royal General Dispensary, Bartho- lomew-close, under Mr. Savory, who watched the case, and finally admitted him here for operation. Considering the present condition of the limb, the history and duration of the disease, there can be little doubt that a considerable portion of the radius is necrosed; and as the state of the boy’s health appears to demand some interference, it is proposed to remove the dead bone. Oct. 2nd.—Chloroform having been given, Mr. Savory made an incision along the back of the forearm, over the middle two- thirds of the radius and through the sinuses; the bone was at once exposed, and the whole shaft was found to be free from periostium, and dead; it was divided in the centre, and each half drawn out with the greatest facility. The articular ex. tremities remained untouched, and the wrist and elbow joints therefore uninjured, and their movements unimpaired. The shaft had in all probability separated at the epiphyses, from the extremity of each of which new bone had been thrown out, so as to encase the ends of the necrosed shaft for an inch or more. There was scarcely any haemorrhage, and the wound was closed by sutures and strapping. The forearm, supported by a bandage, was placed in a prone position on a straight splint. 3rd.-Had a good night; the arm comfortable. To have ordinary diet, and a bark and acid mixture three times a day. 4th.-Slept very well. The wound dressed. The greater part has healed very perfectly by adhesion, and the remainder is granulating. 9th -The wrist evincing a tendency to twist outwards, this was counteracted by placing a small splint on the radial side of the forearm, resting at each extremity respectively on the outer condyle of the humerus and the styloid process of the radius, and therefore having an axis as nearly as possible identical with that of the removed shaft. The wound is nearly all closed, and the boy in a much better state of health than on admission. Left the hospital. The great object of future treatment of course will be to maintain the limb in a proper position until a new shaft is pro’ vided, for that this will occur there can be little doubt. The case will be carefully watched, and at a future time a further report may appear. CLINICAL RECORDS. EXCISION OF TWO CANCEROUS BREASTS. I WE had the opportunity of seeing operations performed upon three breasts at Guy’s Hospital on the 6th of October, two of which were affected with cancer, and the third with cystic

ST. MARY'S HOSPITAL. DISEASE OF THE HIP-JOINT IN A BOY AGED EIGHT YEARS, WITH ABSCESSES, SINUSES, CARIES, AND DISLOCATION OF THE HEAD OF THE BONE; EXCISION OF THE JOINT; GOOD RECOVERY

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418

ST. MARY’S HOSPITAL.

DISEASE OF THE HIP-JOINT IN A BOY AGED EIGHT YEARS, WITHABSCESSES, SINUSES, CARIES, AND DISLOCATION OF THE HEADOF THE BONE; EXCISION OF THE JOINT; GOOD RECOVERY.

(Under the care of Mr. URE.)

WILLIAM S-, aged eight years, was admitted Jan. IsiHe is a very sickly child, and the subject of disease of the hifor three years, the greater part of which time he has been ihospital. There have been abscesses and sinuses constantlforming in connexion with the disease of the hip-joint. On hifirst admission, he had an abscess of the right bursa over thtuberosity of the ischium, which was found to be rough anexposed. Subsequently to this, fresh abscesses formed on thanterior and upper part of the thigh, communicating wit]various sinuses leading to the head of the femur, which wadislocated on to the dorsum of the ilium. Other sinuses wersituated further backwards and outwards over the trochantersalso leading to the carious femur.The patient’s general health was first improved by good die

and regimen, with cod-liver oil and tonics, and when a changefor the better had ensued, Mr. Ure excised the head of th,femur, on the llth of February. An incision four inches lon!was made, curving backwards, directly over the dislocate(head of the bone, which was easily removed by cutting througlthe neck with a pair of large forceps. The acetabulum wa:

slightly softened by the contact with the surrounding diseasecparts, but was otherwise healthy. It was, however, scraped.and as much of the neck of the femur as was found diseasecwas gouged away. The head of the bone was almost entirelydenuded of cartilage, and was somewhat eroded, with loss of thEgreater part of its articular lamellæ; its tissue generally seemedto be much softened and unusually vascular.

His progress was most favourable; the openings on theanterior and posterior aspect of the thigh gradually contractedand healed; his general health further improved, he increasedin weight, and looked contented and happy. His diet was

carefully attended to at the same time. For a fortnight afterthe operation, Mr. Ure directed the thigh to be kept slightlybent and abducted, in order to maintain the remaining portionof the neck of the femur in relation with the cotyloid cavity.This was done because in extension of the thigh there is alwaysa tendency in the bone to be carried backwards.At the end of six weeks after the operation, during which

he never complained of pain, he was able to sit up for sometime, to walk about the ward with the help of crutches, and tomove his thigh gently away from the hip, both in flexion andabduction. As his case progressed, the shortening of the limbwas not perceptibly greater than before the operation, andallowed the foot to be planted on to the ground. This couldbe done even with some weight upon it.He was seen within the last few days, (not in hospital,) and

found in tolerable health. He walks pretty well, but with theheel raised from the ground. A little discharge oozes from oneor two of the old fistulous openings below the level of the seatof operation.The termination to this case was most gratifying, and the

boy, we have no doubt, will have a very useful limb in thecourse of time. This case also completes our present series ofexcision of the hip-joint ; and, on glancing over them, we havereason to be satisfied with their results. Thus there are tencases in which the operation was performed, and amongst themthere are three deaths. Of these three cases, as we have alreadypointed out in our last number, two had the operation per-formed merely as a palliative measure-namely, Mr. Hancock’sand Mr. Simon’s cases. The third, by Mr. Stanley, was reallyin no better condition than the others, for rapidly advancingchest disease soon cut the poor boy off.The recoveries in all the others are really gratifying, with

but one single exception, Mr. Bowman’s little girl, who issuffering from severe disease of the heart. In her case the ope-ration itself has completely succeeded, with the drawbackmentioned, which is a circumstance entirely unforseen. We

may, therefore, say of the seven cases, there have been sevensuccessful operations. Now, in conclusion, if these are con-trasted with seven amputations, we fear the comparison willbe vastly against the latter in the ratio of success. The resultof these seven cases, together with that in others which havepreceded them in former " Mirrors," very clearly and satis-factorily demonstrate, and most convincingly prove, that actualdisease of the acetabulum is not an objection to the operation;and we are permitted to go even a little further, and canstate, that in commencing tubercular deposition—that is, where

the first stage of phthisis only is present, and the softening oftubercle has not already occurred, the surgeon will do good byremoving a terrible source of irritation and exhaustion; and ifattention is carefully paid to the general health by administeringcod-liver oil and tonics, the phthisical affection may yield, asin Mr. Erichsen’s really very Valuably illustrative case.

GREAT NORTHERN HOSPITAL.

CASE OF NECROSIS OF THE RADIUS IN A BOY, AGED NINE

YEARS; EXCISION OF THE ENTIRE SHAFT.

(Under the care of Mr. SAVORY.)1 THE entire ulna has been removed several times with success,

Mr. Fergusson, Mr. Jones, of Jersey, Mr. Erichsen, and others,having performed the operation. The radius, again, has had

! the greater part of its shaft, with one end, excised, but seldomboth of its extremities; to-day we have an opportunity of reo

, cording a case in which the entire shaft, with both ends, weresuccessfully removed, and this has been in consequence of sepa.

; ration of the epiphyses, which has thus permitted of completeisolation. The notes of the case have been taken by Mr. Paul

, Belcher, house-surgeon to the hospital.: Thos. K-, a boy, aged nine years, admitted on the 29th

of September with necrosis of the right radius, which can bedistinctly felt bare. The highest aperture is near the upperextremity of the bone, and the two lower (one of which is infront) are near the wrist. No loose fragments of bone can bedetected. The elbow and wrist joints move freely. The boystates that nine months ago he first perceived pain of a slightlyintermitting character, but always aggravated at night, overthe styloid process of the radius. Shortly afterwards, abscessesformed on the wrist and on the front of the forearm, just belowthe bend of the elbow. He was under treatment in the country,but the arm grew worse. At the beginning of August last, hebecame a patient at the Royal General Dispensary, Bartho-lomew-close, under Mr. Savory, who watched the case, andfinally admitted him here for operation. Considering thepresent condition of the limb, the history and duration of thedisease, there can be little doubt that a considerable portion ofthe radius is necrosed; and as the state of the boy’s healthappears to demand some interference, it is proposed to removethe dead bone.

Oct. 2nd.—Chloroform having been given, Mr. Savory madean incision along the back of the forearm, over the middle two-thirds of the radius and through the sinuses; the bone was atonce exposed, and the whole shaft was found to be free fromperiostium, and dead; it was divided in the centre, and eachhalf drawn out with the greatest facility. The articular ex.tremities remained untouched, and the wrist and elbow jointstherefore uninjured, and their movements unimpaired. Theshaft had in all probability separated at the epiphyses, fromthe extremity of each of which new bone had been thrown out,so as to encase the ends of the necrosed shaft for an inch ormore. There was scarcely any haemorrhage, and the woundwas closed by sutures and strapping. The forearm, supportedby a bandage, was placed in a prone position on a straightsplint.3rd.-Had a good night; the arm comfortable. To have

ordinary diet, and a bark and acid mixture three times a day.4th.-Slept very well. The wound dressed. The greater

part has healed very perfectly by adhesion, and the remainderis granulating.

9th -The wrist evincing a tendency to twist outwards, thiswas counteracted by placing a small splint on the radial side ofthe forearm, resting at each extremity respectively on theouter condyle of the humerus and the styloid process of theradius, and therefore having an axis as nearly as possible

identical with that of the removed shaft. The wound is nearlyall closed, and the boy in a much better state of health thanon admission. Left the hospital.The great object of future treatment of course will be to

maintain the limb in a proper position until a new shaft is pro’vided, for that this will occur there can be little doubt. Thecase will be carefully watched, and at a future time a furtherreport may appear.

___

CLINICAL RECORDS.

EXCISION OF TWO CANCEROUS BREASTS.

I WE had the opportunity of seeing operations performed uponthree breasts at Guy’s Hospital on the 6th of October, two ofwhich were affected with cancer, and the third with cystic