I performed the first operation of excision of the hip undertaken in the East on the 6th July, 1855, on a rifleman, whose case is subjoined: Couch, a soldier of the rifle brigade, was struck, on the 18th of June, by a ball, close below the elbow-joint of his left arm. The ulna was fractured by the bullet, which then struck the femur on the great trochanter of the same side. The trochanter and neck of the bone was split, and otherwise severely injured. The patient did not come under my care till the 5th of July, when I found a large ragged wound over the injured trochanter, from which a very profuse discharge of pus flowed. At the bottom of this wound the bone was seen to be hollowed out into a large cavity, and to be split in all lark and dead.
The limb was not shortened or distorted. The wound on his arm him much van. v. and tin- pain from the hip was so -Teat, that he urgently r some operation to be performed, which miirht relieve him. He was brought under the influence of chloroform, in order that the injury miirht Inmore compl.; nined than could otherwise be accomplished the patient's irritable condition, and tl.le me to -et the limb put into a proper apparatus. ( >n enhiru-in-the external wound, so as to make it dependent, and to allow the necessary steps to be taken for the removal of the dead portions of bone, a large fragment of the external part of the femur, which comprised what remained of the great trochanter. found detached, and a lissure runnim: upwards, apparently into the capsule.
It was found impossible to remove the dead bone without opening the joint; and, as but a very thin shell of the shaft was sound, a consultation led on the propriety of excising the head of the bone, and removing with it what osseous substamv was was done without difficulty, the original wound beinir increased a little upwards. Hardly a drop of blood was lost. Tin- wound was lightly dressed, and 1 on an inclined plane, BO arranged that the large dep retained, could be at without havi the patient. The relief from pain and irritation whieh w.is experieneed almost immediately. was very marked and ' day the patient's markedly Letter, and he declared!
Bate. The limb, in a few days, was shortened about two inches. Suppuration became establishrd; his strength improved; hectic disappeared; he slept well; and his appetite, which, before the operation, was nearly gone, was now restored, and he was totally free from pain or uneasiness. His pulse, on an average, continued about 85 beats in the minute, and was of good character. He continued to progress most favourably for about a week. Part of the wound closed, and the rest of it was clean and healthy. At the end of that period he was suddenly seized with violent diarrhoea, accompanied by vomiting and severe cramps, and followed by suppression of urine, which continued for 18 hours previous to death.
His stools soon assumed the characteristic appearance of cholera evacuations, his strength sunk, he became rapidly collapsed, cold, and blue, and died during the night. Cholera was prevalent in the camp at the time. After death, some crude tubercles were found in both lungs. There was no symptom of purulent absorption anywhere. The vessels in the neighbourhood of the wound were healthy. There were old ulcerations in the intestine, and recent enlargement of the solitary glands. The left ulna was fractured obliquely up towards the elbow joint. The wound over the hip was sloughy, an action it rapidly took on shortly previous to death, and the cut end of the bone was smooth and unchanged. If I had seen this patient earlier, when the nature of the injury could have been more exactly determined, I would have contented myself with merely gouging out the destroyed portion of bone, trusting to the remaining scale to throw out callus, fixing the limb carefully, giving free exit to the suppuration, and strenuously supporting the patient's strength.
The state of the lungs and intestine, as revealed on post-mortem examination, made this.>4 patient, at best, hut an unpromising subject for operation: but it' tinfut:il diseas- which terminated his existence, supervene 1. I would have liccn sanguine of the ii In- came under my care, 1 feel sure he was in such a condition, that it' no operation had been undertaken to relieve him from the mass of dead bone which his system was futilely trying to get rid of, and which was setting up further disease all around it, he would, in a very few days, have died, exhausted by. These are, however, points more easily sett Id si paper than at the bedside. Mr.