It was a secondary operation. The b.ine, " to two inches below the small tmchanter," was removed. He died of pycemia on the seventh day after operation. s to another case, operated on by Dr. Ross, and related in the 41st number of the r nmrhua COXae, gives a stiinin.-ny,!' tiotu of thi sort performed uj nrc<l li.inilv ail<l. ili.it many the very great difference, however, that exists between the operation as performed for disease and for accident, prevents any comparison being made between their results.
Much might have been done, if we had had another campaign, to determine the exact value of excision, as applied to gun-shot wounds of the hip-joint. If the r were selected with care, and the operation early performed, before the vital powers began to flag, and if the after treatment were carefully conducted, much might be expected from this operation in military practice. It is often very difficult to tell how far the destruction of the bone extends, either upwards or downwards; but if the case should turn out to be too complicated for excision, then performed. Stromeyer has shown that, although the splitting of the bone barely extends into the capsule as it did in my case yet excision should be at once performed, as suppuration is sure to be set up in the articulation, and death by exhaustion follow.
The same surgeon has also shown how it happens that, although the neck of the bone be fractured by a ball, yet the usual signs of such an injury the shortening and rotation of the foot may be absent, from " the fragments hanging together better on account of the partial preservation of their fibrous covering," and, in one case which he examined, a considerable power of flexion and extension remained, although the neck of the bone was fractured; while, in another case, " the fragments fitted so well together that the patient did not experience have been performed since Dr. Sayre wrote. He classifies 30 cases, of v hom 20 recovered and 10 died, only 4, however, within a week of the operation. fOT WOUNDS OF JOINTS. the least pain, and the leg could be moved without itation." Tin- existence of the fractur.
in this case by the presence of a profuse -lent himself may even be able to move his foot, and so mask tindiagnosis. Esmarch -welling occurring rapidly, and the pain on ni'tion, r as the only signs which arc nearly always pivsent. 1 hardly lie added, that if, in fracturing the neck of the bone, the ball or any of the osseous fragments injure the great blood-vessels, the case is not one for excision. The kn- e was only once excised, so far as I know, during tl. The operation was performed in the general hospital by Mr. Lakin, whose notes of the case been kindly furnished to me. " Henry Gribben, aged 19, a private in the 77th n mcnt, was admitted into the general hospital on September 8th,
While retreat ing from the Redan on that day, '. ed a musket ball in his left popliteal s; causing him much difficulty ill walking; nevcrth the advanced tivnchrs, distant about 100 yards. He was a man of average muscular developin of habitually good health. On admission, a circular wound, with vs, was found popliteal i at the and middle thirds of that I off diainrt.-r just sulliciriit to admit the I finger, which could be passed to its full length in a di, -rward, and sli;:htly upward, between the i unihtr jury uld furt i. of the ball be ascertained by means of a probe or elastic catheter. It -was not considered prudent to use mueli force with these instruments, in consequence of the close proximity to the joint, and of the absence of any satisfactory evidence that its cavity was already opened.
There was no aperture of exit, the limb was not altered in shape; flexion and extension, especially the former, were limited, and any attempt to move the limb beyond these limits was attended with much pain, which was otherwise slight. Simply bearing the weight of the body only caused some uneasiness, and there was no tenderness on pressure from without. There was no appearance of synovia about the wound, nor was there any bleeding. Under these circumstances it was considered that any operative measures for the purpose of removing the ball were not justifiable." The limb was placed upon its outer side, with the knee semiflexed, that being found the most agreeable posture, and cold dressing was applied. The patient remained almost free from pain, except when the limb was moved, and in good health, until September 20th, twelve days after the injury, when the joint became somewhat inflamed, as indicated by increased pain and heat, slight tenderness to pressure, and moderate swelling.