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Full text of "The Medical and Surgical History of the War of the Rebellion. Part III, Volume II. (3rd Surgical volume)"

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riiE 



MEDICAL AND SURGICAL HISTORY 



OF THE 



WAR OF THE REBELLION. 



PART III. 



VOLUME II 



SURGICAL HISTORY. 



Prepared, under the direction of JOSEPH K. BARNES, Surgeon General United States Army. 

BY 

GEORGE A. OTIS, Surgeon United States Army, 

AND 

D. L. HUNTINGTON, Surgeon United States Army. 



FIRST ISSUE 



Washington; 

GOVERNMENT PRINTING OFFICE. 
1883. 



WAR DEPARTMENT, 

Surgeon General's Office, 

Washington, D. O, January 2, 1883. 
Brigadier General Charles H. Crane, 

Surgeon General, U. S. Army. 
Sir: 

With the present volume, which I have the honor to submit to you, the surgical series 
of the Medical and Surgical History of the War of the Rebellion is complete. 

The treatment of regional injuries of gunshot, origin is continued, and those of the 
Lower Extremities are taken up and thoroughly discussed in Chapter X. Miscellaneous 
Injuries not strictly gunshot in character, but incident to the military status, form the sub- 
ject of Chapter XL Chapter XII, on Wounds and Complications, includes facts of general 
interest and of statistical value relative to wounds; to the nature, peculiarities, and effects 
of missiles and projectiles; to conditions affecting the course and results of wounds, with 
especial reference to the graver complications of secondary haemorrhage, erysipelas, pyasmia, 
gangrene, and tetanus; and, finally, a condensed summary of operations and treatment. 
Anaesthetics, with reference to their use in the Army, are treated of in Chapter XIII. A 
brief historical sketch of the Medical Staff, and a description of the Materia Chirurgica 
will be found in Chapter XIV. The methods of field, railway, and water transportation 
of the wounded are detailed in the concluding Chapter (XV). 

It was attempted, from the inception of the work, to give, in the beginning of each 
chapter, the number of cases to be treated therein. But, as the work progressed, new cases 
had to be added, duplicates had to be eliminated, or additional information changed the 
nature of a case, so as to transfer it to a group different from the one to which it had been 
originally assigned. Thus the total number of cases given in the beginning of a chapter 
was frequently found to be incorrect at its close, and as the preceding pages had been 
stereotyped, it was not practicable to make the necessary corrections. The percentages and 
general deductions, however, were not materially affected by these discrepancies, which 
have been corrected in the summary^ of cases given in Chapter XII, in this volume. 

In undertaking the completion of this work, interrupted by the untimely death of its 
distinguished author, it may be proper to say that no change in, or deviation from, the 



PREFATORY. 



original plan has been attempted; that, so far as known, his wishes and intentions with 
regard to the arrangement and development of the History have been scrupulously regarded. 
The work was entered upon, not without serious misgivings as to the wisdom of the 
choice of successor, and with a full appreciation of the delicate nature of the task and the 
difficulties involved in its satisfactory solution ; its prosecution has been a source of pleasure, 
while the labor has been materially lessened by the valuable assistance afforded by Mr. 
G. J. Myers, who has been associated with the work as colaborer since its inception, and 
to whose faithful and assiduous care the reliability and accuracy of the History is largely 
due. The completed volume now awaits your approval and the judgment of the profession. 
It is hoped that its short-comings may not seriously impair or detract from the beauty and 
harmony of the masterpiece, which must remain a living monument to the intelligent 
industry, perseverance, and professional learning of the late Surgeon George A. Otis. 

I am, sir, 

Very respectfully, 

Your obedient servant, 

D. L. HUNTINGTON, 

Surgeon, U. 8. Army. 



IV 



TABLE OF CONTENTS 

OF 

PART III OF VOLUME II 



OK TIIK 



MEDICAL AND SURGICAL HISTORY OF THE REBELLION, 



BEING THE 



THIRD SURGICAL VOLUME. 



CHAPTER X. WOUNDS AND INJURIES OF THE LOWER EXTREMITIES. 



INTRODUCTION 

TABLE I. Collated returns. Indicating the relative fre- 
quency of shot wounds of the lower extremity In 
aggregates of wounded men who Game under treatment 

TABLE IF. Partial numerical statement of shot wounds 
of the lower extremities in the field or primary hospitals 
in various campaigns during the last year of the war, 
1 804-'t;5 

SECTION I. Flesh Wounds of the Lower Extremities. .. 

Punctured and Incised wounds 

Bayonet wounds 

Abstracts of four cases 

Sabre wounds , 

Other Punctured and Incised wounds 

Ligations 

Abstracts of three cases 

Amputations 

Abstracts of four cases 

Shot Flesh'wounds 

Flesh wounds of the Lower Limbs with injury of the 

Nerves 

Abstracts of seven cases 

Flesh wounds of the Lower Limbs with injury of the 

Larger Blood-vessels 

Wounds of Blood-vessels treated without operation 

Abstracts of six cases 

Wounds of Blood-vessels treated by ligation 

Abstract of one case 

Wounds of Blood-vessels treated by amputation. .. . 

Abstracts of two eases 

Plats XXVUI. Gangrene following a shot lacera- 
tion of the Femoral Artery, facing 

Wounds of Blood-vessels treated by ligation and 

subsequent amputation 

Abstract of one case 

Flesh wounds of the Lower Limbs unattended by 
Primary injury of the Large Nerves and Blood- 
vessels 

Shot Lacerations. 

Abstracts of five cases 

Lodgement of Missiles 

Abstracts of six eases 

Peri-articular wounds. Hip, Knee, and Ankle 

Abstracts of twenty-nine cases 

PLATE LVT. Dry Traumatic Arthritis of the Right 
Hip, facing 



'age. 
1 



27 



Page. 
SECTION I. Shot Fucsll Wounds— [Continued. 

Complications of shot Flesh wounds of tin- 

Lower Extremities, 32 

Pyemia 32 

Abstnats of three cases 32 

Hospital Cnngrene 33 

Abstracts of three cases 33 

Tetanus 35 

Abstracts of three cases 36* 

Erysipelas 37 

Abstracts of two cases 37 

Hemorrhage 37 

Abstracts of tw T oc;ises 38 

Ligations of Blood-vessels of the Lower Limbs 

after Flesh wounds 38 

Ligations of the Common Iliac Artery 39 

Abstract of one case 39 

Ligations of the External (Mao Artery 39 

Abstracts of eleven cases 39 

Ligations of the Femoral Artery 43 

Abstracts of seven cases 43 

TA1H.E HI. Summary of one hundred and 
twenty -seven eases of ligations of the 

Femoral Artery 47 

Ligations of the Profunda Artery 49 

Abstracts of six eases 49 

Ligations of large branches of the Profunda 

Arlery 50 

Abstracts of three eases 50 

Ligations of the Popliteal Artery 50 

TABLE IV. Summary of seventeen eases of 

ligations of the Popliteal Artery. 50 

Abstract of one ease 51 

Ligations of the Posterior Tibial Artery 51 

TABUS X. Summary of seventeen cases of 

ligations of the Posterior Tibial Artery 51 

Ligations of the Anterior Tibial Artery 51 

Abstracts of ten eases 51 

Ligations of the Anterior and Posterior Tibial 

Arteries 52 

Abstracts of two eases 52 

Ligations of Veins 52 

Abstract of one case 52 

Amputations in the Lower limit- after Shot 

Flesh wounds 53 

Amputations in the Thigh 53 

Abstracts ot two cases 53 

v 



TABLE OF CONTENTS. 



CHAPTER X. WOUNDS AND INJURIES OF THE LOWER EXTREMITIES— Continue,.. 



I 'age. 



SECTION I.— FLESH WOUXDS, ETC.— [Continued. 

Plate XX VI I. Effects of Hospital Grangrene, 
t'neing; 

TABLE VI. Summary of one hundred and thirty - 

one amputations in the Thigh 

Amputations at the Knee 

TABLE VII. Summary of six cases of amputa- 
tions at the Knee 

Amputations in the Leg 

Abstracts of two eases 

TABLE VIII. Summary of sixty-three amputa- 
tions in the Leg 

Amputations of the Toes 

Abstract of one case 

Tenotomy 

Abstracts of three eases 

SECTION II. Wounds and Injuries of the Hip Joint 

Shot fractures at tlie Hip Joint 

TABLE IX. Tabular statement of Jhree hundred and 

eighty-six shot fractures of the Hip Joint 

Shot fractures at the Hip treated by conservation . .. 

Recoveries 

Abstracts of twenty-one cases 

1 j LaTE LVII. Gunshot fracture of the Right Ace- 
tabulum and the Head of the Femur, facing. . . 
Plate XXXIII. Consolidated gunshot fracture 

of the Femur, facing 

Fatal cases 

Abstracts of fifty-two eases 

Excision at the Hip Joint after shot injury 

TABLE X. Numerical statement ofsixty-six cases 
of excision at the Hip Joint for shot injury. . . . 

Primary excisions at the Hip Joint 

Abstracts of thirty-three cases 

Table XI. Summary of thirty- three cases. 

Intermediary excisions at the Hip Joint 

Abstracts of twenty-two cases 

Table XII. Summary of twenty-two cases. 

Secondary excisions at the Hip Joint 

Abstracts of eleven cases 

TABLE XIII. Summary of eieven cases . . . 
Excisions at the Hip Joint for shot injury in the 

United States service since the war 

Abstracts of six cases 

Amputations at tin: Hip Joint 

Table XIV. Numerical statement ofsixty-six 

cases of amputation at the Hip Joint . . 

Primary amputations at the Hip Joint 

Abstracts of twenty-five cases 

Table XV. Summary of twenty-five cases 

Intermediary amputations at the Hip Joint 

Abstracts of twenty-three eases 

Table XVI. Summary of twenty-three 

cases 

Secondary amputations at the Hip Joint 

Abstracts «>f nine cases 

Table XVII. Summary of nine cases 

lit- amputations at the Hip Joint 

.Abstracts of nine eases 

Table XVIII. Summary of nine ousts . . 

SECTION III. Injuries in the Shaft of the Femur 

Shot contusions of the Shaft of the Femur 
Table XIX. Numerical statement of one hundred 
and sixty-two cases of shot contusions of the Shaft 

of the Femur 

Abstracts of four cases 

Ligations after shut contusions of the Femur 

Abstracts of eight cases 

A mputatioiis consequent on Bbot contusionfl of the 

Femur 

Abstracts of nine cases 

Shot fractures of the Shaft of the Femur 

TABLE XX. Numerical statement of sixty-five hun- 
dred and seventy-six shot fractures of the Shaft of 
the Femur 

VI 



53 

54 
56 

5(i 
57 
57 

57 
5!) 
59 
5!) 
51) 
61 
61 

65 | 

rJ 

67 



74 
77 
77 

81) 

8!) 
92 

92 
!>'.) 
loi 

ID] 

111 
U3 
I l:l 
II!) 

120 
120 
127 

127 
131 
13! 

lis 

Kill 
139 

144 
115 
145 
151 
158 
1 5s! 
I.V.I 
Hi!) 

iii'.i 



171) 
171) 



173 

173 
174 



175 



176 



177 
178 



188 



190 
1!)1 



Page. 
.SECTION HX— INJURIES of I'emur— [Continued. 

Partial shot fractures of the Shaft of the Femur 175 

Abstracts of two cases 176 

Shot fractures of the Shaft of the Femur treated by 

conservation 

Shot fractures of the upper third of the Shaft of 

the Femur 

Recoveries (abstracts of thirteen eases) 
PLATE LIX. Consolidated gunshot fractures of the 

Femur, facing 178 

PLATE LVIII. Consolidated gunshot fractures of the 

Femur, facing 180 

Plate LV. Two views of a united shot fracture of the , 
Right Femur over eleven years after injury, facing 182 

Fatal cases (abstracts of seven cases) 184 

PLATE XXV. Secondary inflammation if the Knee 

Joint, facing 184 

Shot fractures of the middle third of the Femur 

treated by conservation 187 

Recoveries (abstracts of eleven cases) 187 

Plate LX. Consolidated gunshot fractures of 

the Femur, facing 

PLATE LXI. Consolidated gunshot fractures of 

the Femur, facing 

Fatal cases (abstracts of five cases) . . . 
PL-ATE LXII. Consolidated gunshot fractures of 

the Femur, facing 192 

PLATE XXIV. Osteomyelitis in a fractured Fe- 
mur, facing 104 

Shot fractures of the lower third of the Femur 

treated by conservation 1 04 

Recoveries (abstracts of eight eases) 104 

Plate LXIII. Consolidated gunshot fractures 

i if the Fein ur, facing 

Fatal (rases (abstracts of three eases) . .. 
Plate LXIV. Consolidated gunshot fractures 

of tlie Femur, facing 188 

Shot fractures of the Femur, without indication 
of the seat of injury, treated by conservation 
Fseudarthrosis after shot fractures of the IV 

in ii r 

Abstracts of two cases 

Kxcisions in the continuity of the Femur for 

shot injury 1»)>I 

Table XXI. Numerical statement of one hundred 
and seventy -five excisions in the Shaft of the Fe- 
mur for shot injury 2t:0 

Primary excisions in the Shaft of the Femur - - 2o0 

Recoveries (abstracts of four cases) 200 

TABLE XXII. Summary of twenty eases of re- 
covery C03 

Plate XXX. Obstructed femoral vein, facing.. 204 

Fatiil cases (abstracts of five cases) £04 

TABLE XXIII. Summary of sixty-live fatal pases 266 

Undetermined cases 207 

TABLE XXIV. Summary of six eases with un- 
known results 207 

Intermediary excisions in the Shaft of the Femur . 207 

Recoveries (abstracts of two cases) 207 

TABLE XXV. Summary of nine cases i.$ re- 
covery 208 

Fat.. I cases (abstracts of three cases) 209 

TABLE XXVI. Summary if thirty-nine fatal 

cases 210 

Secondary excisions in the Shaft of the Femur 210 

Recoveries (abstracts of two cases) 210 

Fatal eases (abstract of one ease) 211 

TABLE XXVII. Summary of nineteen cases . . 212 
Kxcisions in the Shaft of the Femur at an unknown 

period 212 

TABLE XXVIII. Summary of seventeen eases 212 

Amputations in the Shaft of the Femur 213 

TABLE XXIX. Numerical statement of sixty-two 
hundred and twenty-nine amputations of the Thigh 

for shot injury 213 



196 
1!.7 



1U8 



1118 
193 



TABLE OF CONTENTS. 



CHAPTER X. WOUNDS AND INJURIES OF THE LOWER EXTREMITIES— Continued. 



Page. 

SECTION MI. -IXJiraiEfi OF Femur— {Continued. 

Primary amputations in the Shaft of the Femur . 214 

Primary amputations in the upper third of the 

Femur 214 

Successful cases (abstracts of four cases) ... 215 

Fatal cases (abstracts of three cases) 216 

TABLE XXX. Summary of live hundred and 

thirty-three cases 21? 

Primary amputations in the middle third of the 

Femur 223 

Successful cases (abstracts of live cases) . . - . 223 
PLATE LXIX. Tubular sequestra, from am- 
putations of the Femur, facing 224 

Fatal cases (abstracts of five cases) - 225 

Plate XXXII. Diseased stump of Femur, 

facing 22b 

Table XXXI. Summary of eleven hun- 
dred and fifty-seven cases 227 

Plate XXXI. Gangrene of the Medulla . . 228 
Primary amputations in the lower third of the 

Femur ." 241 

Successful cases (abstracts of seven cases) . - 241 
Plate LXX. Involucra of the Femur, 

facing 242 

Fatal cases (abstracts of two cases) 244 

TABLE XXXII. Summary of nineteen hun- 
dred and fourteen cases 245 

Primary amputations in the Femur without in- 
dication of the seat of incision 2G8 

Table XXXIII. Summary of three hun- 
dred and forty-five cases 208 

Intermediary amputations in the Shaft of the Femur. 272 
Intermediary amputations in the upper third of 

the Femur 272 

Successful cases (abstracts of four cases) 272 

Fatal cases (abstract of one case) 274 

TABLE XXXIV. Summary of one hundred and 

forty-seven cases £75 

Intermediary amputations in the middle third of the 

Femur 277 

Successful cases (abstracts of four cases) 277 

PLATE XXVI. Osteomyelitis of Femur, facing. 278 

Fatal cases (abstracts of two cases) 279 

TABLE XXXV. Summary of four hundred and 

seventy-one cases 280 

Plate XLII. Itound musket ball in the medul- 
lary cavity of the Femur, facing 280 

Intermediary amputations in the lower third of the 

Femur 287 

Successful cases (abstracts of five cases) 287 

Fatal cases (abstracts of five cases) 280 

Plate XLIII. Results of Osteomyelitis, facing . 290 
Plate XXI. Gangrene of a Thigh Stump, 

facing 292 

TABLE XXXVI. Summary of six hundred and 

seventy-six cases 293 

Plate XX. Femoral artery and Femoral vein 

after amputation, facing 294 

Intermediary amputations in the Femur without in- 
dication of the seat of incision 303 

Table XXXVII. Summary oftwenty-six cases. 304 
Secondary amputations in the Shaft of the Femur.. . 304 
Secondary amputations in the upper third of the Fe- 
mur 304 

Successful cases (abstracts of four cases) 304 

Fatal cases (abstracts of three cases) 306 

Plate LXVI. Shot fracture of the middle third 

of the Femur, facing 306 

TABLE XXXVIII. Summary of fifty-five cases. 308 
Secondary amputations in the middle third of the Fe- 
mur 3C9 

Successful cases (abstracts of five cases) 309 

Fatal cases (abstracts of three cases) 311 

PLATE XXIII. Separation of Periosteum in Os- 
teomyelitis, facing 312 



Page. 

SECTION ill. — Injuries or Femur— [Continued, 

TABLE XXXIX. Summary of one hundred and 

sixty-eight cases 313 

Plate XL IX. Medullary abscesses of the Fe- 
mur, facing 314 

Secondary auiputationsin the lower third of the Femur 316 

Successful cases (abstracts of four cases) 316 

Plate LXX.II. Involucra of bones of the Leg, 

facing 317 

Fatal cases (abstracts of two cases) 318 

TABLE XL. Summary of two hundred and seven 

cases 320 

Secondary amputations of Thigh, point of ablation 

not specified 323 

Abstract of one fatal case 323 

Table XLI. Summary of twelve cases 323 

Amputations in the continuity of the Femur 

of uncertain date 324 

Amputations in the upper third of the Femur of 

uncertain date 324 

TABLE XXII. Summary of thirty-three cases. . 324 
Amputations in the middle third of the Femur of 

uncertain date 324 

Table XL III. Summary of seventy cases 325 

Amputations in the lower third of the Femur of un- 
certain date 326 

Table XLIV. Summary of one hundred and 

four cases 326 

Amputations in the Femur of uncertain date, and 

seat of operation 327 

Table XLV. Summary of three hundred and 

eleven cases 327 

Recapitulation 331 

TABLE XLVI. Tabular statement indicating the 
seats of injury In six thousand two hundred nnd 

t went3'-nine amputations in the Thigh 332 . 

TABLE XLVII. Results of amputations of the Thigh 
on the occasions named and from the authorities 

quoted 334 

Concluding observations on -.lint injuries of 

the Femur 335 

Table XLVIII. Results of shot fractures of the Fe- 
mur treated by conservation on the occasions named 

and from the authorities quoted 336 

Table XLIX. Summary of twenty-one ligations of 
the Femoral artery in cases of shot fractures of the 

Femur treated by conservation 353 

Table I,. Numerical statement of Union and 
Confederate soldiers treated by conservation 

after shot fracture of the Femur 355 

Excisions in tho Shaft of the Femur 355 

Amputations in the Thigh 355 

Plate LXX III. Thigh stumps, facing 356 

Table LI. Statement of the ages of six thousand 
two hundred and nine patients who submitted to 
amputation of the Thigh for shot injury 358 

SECTION IV. Wounds and Injuries of the Knee Joint. . . 359 

Punctured and incised wounds 359 

Punctured wounds (abstracts of ten cases) 360 

Incised wounds 361 

Incised wounds treated without operative inter- 
ference 361 

Abstracts of ten cases 361 

Amputations in the Thigh after incised wounds. . 362 

Abstracts of six cases 362 

Shot injuries of the Knee Joint 363 

Shot contusions of the Knee Joint 363 

Treated by conservation 364 

Recoveries (abstracts of ten cases) 364 

Fatal eases (abstracts of six cases) 365 

Treated by amputation 367 

Shot fractures of the Knee Joint 367 

TABLE LTI. Numerical statement of thirty-three 
hundred and fifty-five cases of shot fractures 

of thoboneB of the Knee Joint 367 

VII 



TABLK OF CONTENTS. 



CHAPTER X. WOUNDS AND INJURIES OF 

Page. II 



>,1 by 



SECTION IV.— INJURIES OF Knee JOIST— [Contiuued. 
Shot fractures "f the Knee Joint treat 

servation 

Recoveries (abstracts of twenty-three cases) . 
PLATE LXVIII. Kesults of shot injuries of 

the Knee Joint, facing 

PLATE LXVII. I'.all lodged in outer con- 
dyle of Left Femur over 15 years, facing- .. 

Fatal cases abstracts of fifteen eases) 

Excisions at the Knee Joint for shot injury - - 
Table LIU. Classified statement of fifty- 
seven cases of excisions at the Knee Joint 

lor shot fracture 

Primary excisions at the Knee Joint 

Abstracts of thirty-two cases 

Plate l.XV*. Successful excisions of the 

Knee Joint after shot injury, facing 

Intermediary excisions tit the Knee Joint 

Abstracts of thirteen cases 

Secondary excisions tit the Knee Joint 

Abstracts of seven cases 

Excisions tit the Knee Joint of uncertain date 

Abstracts of five cases 

at the Knee Joint 

Table LIV. Summary of one hundred and 
eighty-nine amputations at the Knee Joint 

for shot fracture 

Primary amputations tit the Knee Joint ... 

Abstracts of five eases 

Table LV. Summary of one hundred 

and eight cases 

Intermediary amputations at the Knee Joint 

Abstracts of five eases 

TABLE LVL Summary of fitly -one 



31 .8 

sea 

370 

372 

3811 
384 



Ampiituti 



380 

386 
391 
391 
394 
394 
397 
397 
397 



398 
398 
399 

401 

404 
401 



Secondary amputations at the Knee Joint- . . 407 

Abstracts of four cases 407 

TABLE LVII. Summary of twenty-six 

cases 4U!) 

Amputations at the Knee Joint of uncertain 

date 4lu 

Table LVIIL Summary of four cases 410 
Concluding observations on shot injuries 

of the Knee Joint 411 

Table 1.1X. Shot wounds of tlie Knee Joint 
treated by conservation on the occasions named 

and from the authorities quoted 417 

Excisions at the Knee Joint 419 

TABLE I.X. Excisions at the Knee Joint for 
shot injury on the occasions named and 

from the authorities quoted 

Amputations at the Knee Joint 

SECTION V. Wounds and Operations in the Leg 

Shot contusions of the bones of the Leg. 

Treated by conservation 

Recoveries (abstracts of six cases) 427 

PLATE l.X X r. Tubular sequestra and pieces of 

necrosed bone from tibia, facing '■ 

Deaths (abstracts of three eases) 

Followed by amputation 

Abstracts of eight cases 

Shot fractures of the Bones of the Leg 

TABLE I.XI. Descriptive numerical statement of 
the nature and treatment of eight thousand nine 
hundred and eighty-eight shot fractures of the 

bones of the Leg 432 

Shot fractures of the bones of the Leg treated by con- 

43° 
servation ■ 

Shot fractures of the Tibia treated by conservation 433 

Recoveries (abstracts of nine cases) 433 

Plate LXXIV. Upper portion of right 

Tibia sawn longitudinally, facing 434 

Deaths (abstracts of three eases) 436 

Shot fractures of the Fibula treated by con 

servation 



Jo-J 

423 



427 
427 



430 

430 

■i:tl 
433 



437 



THE LOWER EXTREMITIES— CONTINUED. 

Page. 

SECTION V.— WOUKDS oe LEG— [Continued. 

Recoveries (abstracts of two eases) 437 

Deaths (abstract of one case) 4:!7 

Shot fractures of both bones treated by con- 
servation ''p 8 

Recoveries (abstracts of eight cases) - - 438 

Deaths (abstracts of three cases) 441 

Excisions In the continuity of the hones of the 

Leg for shot injury 444 

Table LXII. Numerical statement of three 
hundred and eighty-seven excisions in the 

bones of the Leg for shot fracture 445 

Primary excisions in the bones of the Log 440 

Abstracts of nine eases 445 

TABLE LX1II. Summary of two hundred 

and fifteen cases 449 

Intermediary excisions in the bones of the Leg.. 453 

Abstracts of six cases 453 

TABLE I.X IV. Summary of eighty-seven 

oages 455 

Secondary excisions in the bones of the Leg 456 

Abstracts of four cases 456 

Table LXV. Summary of fifty cases 458 

Excisions in the bones of the Leg of uncertain 

, . 459 

dato 

TABLE LXVI. Summary of thirty-five oases 460 
Amputations in the continuity of the Leg for 

shot fracture 4, '° 

Table LXV1I. Numerical statement of fifty- 
four hundred and fifty-two amputations of the 

Leg for shot injury 4<u 

primary amputations in the continuity of the Leg 

for shot injury - 4m 

Primary amputations in the upper third of 

tbeLeg 461 

Abstracts of ten cases 461 

Table LXVIII. Summary of one thou- 
sand and twenty-nine cases 466 

Primary amputations In the middle tiiird of 

theLeg ™ 

Abstracts of eight eases 478 

Plate LXXVI. Laceration of right 

Leg by solid shot, facing 478 

TABLE LXIX. Summary of eight hun- 
dred and ninety-two cases 480 

Primary amputations in the lower third of 

theLeg "91 

Abstracts of eight cases 491 

Table LXX. Summary of nine hun- 
dred cases 4 J4 

Primary amputations in the Leg— seat of 

operation not indicated 5° 5 

Successful cases (abstracts of ta cases) 505 

Fatal cases (abstracts of two eases) 506 

Table LXX1. Summary of five hun- 
dred and seventy-one cases - ■ • 506 

Intermediary amputations in the continuity of the 

Leg for shot injury 513 

Intermediary amputations in the upper third 

of the Leg 513 

Successful eases (abstracts of six cases) 513 
Fatal cases (abstracts of three cases) . - 514 
TABLE LXX1I. Summary of two hun- 
dred and ninety -six cases 515 

Intermediary amputations in the middle third 

of the Leg 519 

Successful cases (abstracts of five cases) 520 
Fatal eases (abstracts of three cases) ... 521 
Table LXXIII. Summary of three 

hundred and sixty -eight cases 522 

Intermediary amputations in the lower third 

of the Leg 528 

Successful cases (abstracts of six cases) 528 

Fatal cases (abstracts of four eases) 529 

Table LXXIV. Summary of three 
hundred and thirty-five cases 531 



VIII 



TABLE OF GOFTEUTS. 



CHAPTER X. WOUNDS AND INJURIES OF THE LOWER EXTBEMITfES-CosnxUED. 



i 
SECTION V.— Wounds OF Lbo— tOoMluaed. 

Intermediary amputations iu the Leg— point of 

operat ion not spedlled 

Abstracts of two tsmmpltm 

Table L.XXV, Summary of forty-seven 

cases .. ..-.--,.......,.. 

Secondary amputations in the coatioutty of she Leg 

for shot injury 

Secondary' amputations in the upper third of (he 

Leg ■ • 

Examples of recovery {abstracts of five cases) 

Fatal eases {abstracts of four cases! 

Table LXXVI. Summary of one hundred 

and thirty -three eases 

Secondary amputations in the middle third of 

the Leg 

Recoveries (abstracts of five cases) 

Fatal oases (abstracts of three cases) 

TABUS IiX X VII. Summary of oae hundred 

and seventy-four oases 

Secondary amputations iu the lower third of the 

I-eg - • 

Recoveries (abstracts of three cases) 

Fatal cases (abstracts of three eases) 

Table JjXXVIH. Summary of one hun- 
dred and twenty-one cases 

Secondary amputations in the Leg— third not 

indicated 

Beeoveries (abstract of one ease) - - - 

Fatal cases (abstract of one ease! 

Table LXXIX. Summary of sixteen eases 
Amputations in the continuity of the Leg of uncer- 
tain date 

Amputations in the upper third of the Leg- of 

uncertain date 

TABUS LXXX. Summary of fifty-oca eases 
Annotations in the middle third of the Leg of 

uncertain date 

TABLE LXXXI. Summary of forty-seven 



Amputations in the lower third of the Leg of 

uncertain date 

TATMJ5 LXXXIX Summary of Sfty-one 



Amputations in the Leg of uncertain date and 

seat of operation 

Table LXXXIII. Summary of four hun- 
dred and twenty-one eases 

Recapitulation - 

Concluding; observations on shot fractures 

of the Bones of the teg 

TABLE LXXXXY. Results of shot fractures of the 

tones of the Leg treated by conservation on the 

occasions named and from the authorities quoted. - 

Excisions in the continuity of the bones of the Leg. . 

Table T.XXXV. Results of shot fractures of 

the bones of the Leg- treated by excision on the 

occasions earned and from theauttsoritiesquoied 

Amputations in the Leg 

Table LXXXVI. Summary of seven thousand 
six hundred and f hirty-seven atnputatioas in the 
Leg for shot injuries on the occasions named and 
from the authorities quoted 

SECTION VI, Wounds and operations at tne Ankle Joint 
Shot contusions of the Ankle Joint — 

Shot contusions of the bones of the Ankle Joint 

treated by conservation 

Abstracts of seven coses 

Shot fractures of the Bones of the Ankle 

Joint .... 

Table LXXXVII. Summary of one thousand seven 
hundred and eleven shot fractures of the Tibio- 

tarmi Articulation 

Shot fractures of the bones of the Ankle Joint treated 

by conservation 

Abstracts of twenty cases 

2* 



age, 

536 
53fi 

530 

53? 

537 
537 
£39 

541 

344 
.-.It 
546 

547 

550 

550 
551 

554 
554 
554 

S55 

555 

555 

555 

556 

556 

557 

557 

558 

558 
5(53 

,563 



564 

569 



57c I 

572 



5T3 
577 

577 

577 
577 



57* 



579 
579 



SECTION VI.— Wounds Of ASKUt Joist— [Continued. 

Excisions at I lie Ankle Joint for shot injury. , 
TaoLK LXXXVKI. Numerical statement of 
thirty-three excisions at the Ankle Joint for 

shot injiirv 

Primary excisions at the Ankle Joint 

Abstracts of eleven cases 

Intermediary excisions at the Ankle Joint 

Abstracts of eight eases 

Secondary excisions at the Ankle Joint 

Abstracts of nine eases 

Excisions at the Ankle Joint — time between the 

injury and operation unknown 

Abstracts of five eases 

Amputation* at the Ankle Joint. 

Table LXXX1X, Naroerieai table of one hun- 
dred and sixty-one amputations at the Ankle 

Joint for shot injury ............ 

Primary amputations at the Ankle Joint.. ...... 

FLATK LXXV. Amputations at the Ankle Joint, 

facing 

Successful cases (abstracts of eight cases) . . 

Fatal ciLses (abstracts of four ernes) 

TaULB XC. Summary of one hundred and 

three cases • 

Intermediary amputations at the Ankle Joint 

Successful eases (abstracts <>f five cases) . 

Fatal eases (abstracts of two eases) 

TaIH.E XCI. Summary of thirty-nine cases 

Secondary amputations at the Aukk' Joint 

Abstracts of two eases 

Table XCII. Summary of thirteen cases 
Amputations at the Ankle Joint of uncertain date 
TABLR XCIII. Summary of six cases ..... 
Concluding observations on shot injuries of 

the Ankle Joint — ..„..,... ., 

Excisions at the Ankle Joint for shot injury 

Table XC1V. Results «f excisions at the 
Ankle Joint on the occasions named and 

from the authorities quoted 

Amputations at the Ankle Joint 

Table XC1V, Results of amputations at 
tan Ankle Joint on the occasions named 
and from the authorities quoted 

SECTION VII, Wounds and Operations in the Foot 

Bayonet wound* of the Bones of the Foot... 
Shot wounds of the Bones of the Foot. 

Shot contusions of the bones of the Foot 

Abstracts of two eases 

Shot fractures of the bones of the Foot 

TAULB XCV. Summary of five thousand eight 
hundred and thirty-two shot fractures of the 

bones of the Foot 

Shot fractures of the bones of the Foot treated 

by conservation.., ......... 

Abstracts of sixteen cases 

Excisions in the Bone a of l he Foot 

Table XCVi. Numerical statement of 
ninety-seven cases of eaccisbns iu the bones 

of the Foot 

Primary excisions hi the bones of the Foot. . 

Abstracts of seven eases. 

Intermediary excisions in the bones of Ilia 

Foot , 

Abstracts of four cases 

Secondary excisions in the bones of the Foot 

Abstracts of two cases , 

TABLE XCVII. Summary of ninety-seven 
eases of excisions iu (lie bones of the Foot 

A imputations in t he Foot 

Table XCVUI. Numerical statement of 
one thousand five hundred and eighteen 

cases of amputations in (he Foot 

Primary ampuiations in the Foot ........... 

Abstracts of ten cases 

IX 



585 



585 
566 
586 

588 
568 
591 
591 

594 
594 
595 



595 
595 

596 
596 
598 

599 

603 ' 

003 

0)4 

605 

606 

006 

607 

60S 

008 

608 
610 



610 
612 



614 

617 
6)7 

617 
617 
017 

6)8 



618 

618 

619 



ess 

B53 

023 

024 
CK4 

025 
025 

620 

027 



028 
CM 



TABLE OF CONTENTS. 



CHAPTER X. WOUNDS AND INJURIES OF THE LOWER EXTREMITIES— Continued. 



SECTION VII.— Wounds of Foot— [Continued. 

Table XCIX. Summary of one hundred 

and sixty-one cases 030 

Intermediary amputations in the Foot 033 

Abstracts of three cases - &•?■> 

Table C. Summary of fifty-two cases . 633 

Secondary amputations in the Foot 6&J 

Abstracts of two cases (334 



Page. 
SECTION' VII.~Wou.ndc> of FOOT— [Continued. 

Table CI. Summary of eighteen cases 635 

Amputations in the Foot of uncertain date. . 635 

Abstract of one case 636 

Table CII. Summary of sixty eases. 636 

Concluding observations 637 

Excisions in the bones of the Foot 637 

Amputations in the Foot 639 



CHAPTER XL MISCELLANEOUS INJURIES. 



SECTION I. Table CHI. Summary of one hundred and seventy- 
one thousand five hundred and sixty-five miscel- 
laneous injuries 

Table CIV. Summary of one thousand three hun- 
dred and thirty-six deaths from various causes 

Burns aud scalds 

Abstracts of four cases 

Contusions and sprains 

Abstracts of six eases 

Concussion and compression of the Brain 

Dislocations 

Abstracts of fourteen cases 

Simple and compound fractures 

Abstracts of fifteen cases 

Punctured, incised, and lacerated wounds 

Abstracts of nine cases 

Other accidents and injuries 

Abstracts of six cases 

SECTION II. Operations for Miscellaneous Injuries 

Excisions 

TABLE CV. Numerical statement of forty-five cases 
of excisions following miscellaneous injuries or 

diseases 

Abstracts of two cases 

Table CVI. Summary of twenty cases 

Amputations 

Amputations in the Upper Extremities 

Table CVII. Numerical statement of one hun- 
dred and ninety -five cases of amputations in 
the Upper Extremities for disease or for Injury 
not inflieted by weapons of war 



641 
641 
641 
642 
642 
644 
644 
644 
649 
649 
652 
65S 
G54 
654 
657 
657 



657 
657 

658 
659 
659 



Page. 

SECTION H. — Operations fob Mjscel. Ikjueibs — | Continued. 

Abstracts of three cases - 660 

Table CVIII. Summary of one hundred and 

i wo cases 661 

Amputations in the Lower Extremities 664 

Table CIX. Table of five hundred and eighty- 
three cases of amputations in the Lower Ex- 
tremities for disease or for injury not inflicted 

by weapons of war 664 

Abstracts of four cases 66."J 

TABLE CX. Summary of one hundred and forty- 
nine amputations in the Thigh for miscel- 
laneous injuries or diseases 666 

Exarticulations at the Knee Joint 670 

Abstracts of four eases 670 

Amputations in the Leg 670 

Abstract of one case 671 

Table CXI. Summary of two hundred and 

fifty-nine cases 671 

Amputations iu the Foot 677 

TABLE CXIL Summary of fifty-one cases. 677 

Amputations of the Toes 678 

Abstract of one case . 678 

ligations 679 

Abstracts of ten cases 680 

Operations on the Eyo or its appendages 681 

TABLE CXIII. Summary of seventy-six cases 681 

Operations on the Mouth and its appendages 684 

Operations on the Air Passages 684 

Operations on the Chest aud Abdomen 684 

Operations on the Genito-l'rinary organs 684 



CHAPTER XII. WOUNDS AND COMPLICATIONS. 



Page. 



Table CXIV. Frequency of sabre and bayonet and shot 
wounds on occasions named and from authorities quoted. 

Sabre and Bayonet Wounds 

TABLE CXV. Summary of nine hundred and twenty- 
two sabre and bayonet wounds recorded during the 

American civil war, 1861-65 

Shot Wounds 

Table CXVI. Tabular statement of the shot wounds 
of the Head, Face, and Neck recorded during the 

American civil war 

Table CXVIL Tabular statement of the shot wounds 
of the Spine, Chest, Abdomen, Pelvis, aud Back re- 
corded during the American civil war 

TABLE CXVIII. Tabular statement of the shot 
wounds of tho Upper and Lower Extremities 

recorded during the American civil war 

Table CXIX. Table indicating percentage of fa- 
tality and relative frequency of shot wounds re- 
corded during the War of the Itebellion 

TABLE CXX. Tabular statement of the relative fre- 
quency of shot wounds of the different regions of 

the body 

Definition of shot injuries 

Fire-arms and their projectiles 

Table CXXI. Table indicating the seat of the 
injury and nature of the projectile in the cases 

of shot wounds reported during the war 

Explosive balls 



685 
686 



686 
687 



688 



689 



600 



68] 



693 
694 
695 



096 
701 



Page. 

Abstracts of sixteen cases 702 

Effects of large projectiles 704 

Abstracts of five cases 704 

Effects of missiles and projectiles from small arms. . 708 

Abstracts of two cases 709 

PLATE LXXVIII. Distorted bullets, facing 710 

Entrance and exit wounds 71 1 

PLATE XXXIX. Early appearance of entrance and exit 

wounds, facing 712 

Effects of projectiles on muscular tissue and tendons. 719 

Effects of missiles and projectiles on bony structure. 713 

Abstracts of eleven cases 714 

Plate XL. Early appearances of entrance and exit 

wounds, facing 714 

Table CXXIL Numerical statement of shot contu- 
sions of the bones of the Head, Trunk, and Ex- 
tremities 716 

Simple fractures (abstract of one case) 718 

Partial fractures (abstract of one case) 719 

Penetrations of bone (abstract of one case) 719 

Perforations of bone (abstracts of three cases) 721 

Complete fractures (abstracts of two cases) 722 

Effects of missiles and projectiles on nerves 725 

A bstracts of t hirty cases 726 

PLATE XXXVIII. Facial Paralysis consequent on shot 

injury, facing 741 

Effects of missiles and projectiles on Blood-vessels . . . 750 

Abstracts of eleven cases. 750 



TABLE OV CONTENTS. 



CHAPTER XII. WOUNDS AND COMPLICATIONS— CONTINUED. 



Table CXXIIJ. Summitry of one hundred and 
eighteen cases of complete division of the larger 
Blood-vessels, indicating the number of eases in 

which primary bleeding occurred 

Lodgement of missiles and projectiles 

Primary symptoms common to gunshot wounds. ... 

Shock (one case) 

Pain (abstract of one case) 

Primary haemorrhage 

Haemorrhages and Ligations 

Arteries 

TABLE CXXIV. Summary uf two thousand two hun- 
dred and thirty-live cases of arterial haemorrhages 
of the Head, Nock, Chest, Trunk, and Upper and 
Lower Extremities En which the bleeding vessels 

were indicated by name 

TABLE CXXV. Tabular statement of one thousand 
one hundred and fifty-live ligations for shot injuries 

Ligations of the Common Carotid artery 

Abstracts of two cases 

TABLE CXXVI. Condensed summary of 
eighty-two cases of ligations of the Com- 
mon Carotid for shot injuries 

Ligations of the Internal Carotid artery 

Ligations of the External Carotid artery 

Table CXXV1T. Condensed summary of 
seven cases of ligations of the External 

Carotid artery for shot injuries 

Ligations of minor branches of the External Ca- 
rotid artery (abstracts of eight cases) 

Ligations of the Temporal artery 

Table C XXV HI. Condensed summary of 
eighteen cases of ligations of the Temporal 

artery for shot injuries 

Ligations of the Facial artery (one example) 

Table CXXIX. Condensed summary of 
eight ligations of the Facial artery for shot 

injuries 

Ligations of the Subclavian artery (one abstract) 

Table CXXX. Condensed summary of fift y- 

one cases of ligations of the Subclavian 

artery for shot injuries 

Ligations of branches of the Subclavian artery. . 

Abstracts of twelve cases 

Ligations of the Axillary artery 

Table CXXXL Condensed summary of 
forty-nine cases of ligations of the Axillary 

artery for Shot injuries 

Ligations of branches of the Axillary artery. . . . 

Abstracts of four cases 

Ligations of the Circumflex artery 

TABLE CXXXIL Condensed summary of 
eighteen ligations of the Circumflex artery 

for shot injury 

Ligations of the Brachial artery 

Table CXXX III. Summary of one hun- 
dred and seventy eases of ligations of the 

Brachial artery 

Ligations of branches of the Brachial artery. . . . 

Abstracts of eleven cases 

Ligations of the Radial artery 

Table CXXXIV. Condensed summary of 
fifty-nine ligations of the Radial arter}- for 

shot in j ury 

Ligations of the Ulnar artery 

Table CXXXV. Condensed summary of 
twenty-two ligations of the Ulnar artery 

for shot, injuries 

Ligations of the Interosseous artery of forearm. 

Abstracts of nine eases 

Ligations of arteries of the Hand 

Table CXXXVI. Condensed summary of 
twelve cases of ligations of arteries of the 

Hand 

Ligations of the Common Iliac artery 



757 
759 
759 
760 
761 
762 
763 



763 



770 



772 



Page. 
Table CXXX VII. Summary of five unsuc- 
cessful cases of ligations of the Common 

Iliac artery 786 

Ligations of the Internal Iliac artery 786 

Table CXXXVIIL Condensed summary 

of three ligations of the Internal Iliac artery 787 

Ligations of the Gluteal artery 787 

Table CXXXIX. Summary of six ligations 

Of the Gluteal artery 787 

Ligations of the Sciatic artery 787 

Abstracts of two cases 787 

Ligations of the External Iliac artery 787 

Table CXL. Summary of twenty-six liga- 
tions of the External Iliac artery 788 

Ligations of the Spermatic artery (one abstract) 788 

Ligat ions of the Femoral artery 788 

Table CXLI. Summary of three hundred 
and seventy-four ligations of the Femoral 

artery 789 

Ligation of the External Pudic artery 798 

Ligation of the Profunda Femoris 798 

Abstract of one case 798 

TABLE CXLLL Summary of twenty-two 

cases of ligations of the Profunda Femoris. 798 

Ligations of the Perforating arteries 799 

Abstracts of six instances 71>9 

TABLE CXLIII. Summary of twenty- 
four ligations of muscular and other small 

branches of the Femoral artery 799 

Ligations of the Popliteal artery 800 

Table CXLIV. Summary of thirty-six li- 
gations of the Popliteal artery 800 

Ligations of the Articular branches of the 

Popliteal artery 801 

Abstracts of three cases 801 

Ligations of the Anterior Tibial artery 801 

TABLE CXLV. Summary of forty -seven li- 
gations of the Anterior Tibial artery 802 

Ligations of branches of the Anterior Tibial ar- 
tery 803 

Abstracts of three cases 803 

Ligations of the Posterior Tibial artery 803 

Table CXLVI. Summary of forty-eight li- 
gations of the Posterior Tibial artery 803 

Ligations of Plantar arteries 805 

Abstracts of three cases 805 

Ligations of the Peroneal artery 805 

Abstracts of four cases 805 

Remarks on haemorrhages and ligations 805 

Abstracts of five cases 806 

TABLE CXLVIL Table indicating the days on 

which the first lueinorrhage occurred 805 

Traumatic aneurism (abstract of one case) 808 

Table CXLVIIL Summary of seventy-four 

cases ot Traumatic aneurism 808 

Plate LXXVIL Traumatic aneurism 808 

Causes of haemorrhage (abstracts of three cases) 809 

Treatment (abstract of four cases) 810 

TABLE CXLIX. Summary of two thousandtwo 
hundred and thirty-five cases of haemorrhage, 

indicating mode of treatment 810 

Ligations (abstracts of three cases) 813 

Table CL. Table indicating the various 

Modes of Ligations and their fatality 814 

Veins (abstracts of three cases) 816* 

Table CLI. Summary of one hundred and six 

cases of haemorrhage from veins 816 

PLATE LXXIX. Fig. 1. The left Femoral vein after 
death from pyaemia. Fig. 2. Gangrene of Foot after 

shot wound of Leg. upper third, facing 818 

Tetanus (abstracts of ten cases) 818 

TABLE CLII. Summary of five hundred and five 

cases of tetanus, indicating seat of injury and result. 819 
Table CLI1I. Statement indicating the day after 

injury or amputation on which tetanus appeared. . . 819 

XI 



TABLE OF CONTENTS. 



CHAPTER XII. WOUNDS AND COMPLICATIONS— Continukd. 






Page. 

TABLE CLIV. Numerical statement of results of 
three hundred and fifty-eight cases of tetanus in 
which the duration of the disease was reported - - . S'M 
Gangrene (abstracts of nine cases) 8:23 

TABLE CLV. Summary of two thousand six hun- 
dred and forty-two cases of gangrene, indicating 
the result and frequency 621 

TABLE OLYJ. Indicating- the years in which the 
gangrene occurred 825 j 

TABLE CLVII. Summary of cases of hospital gan- 
grene, giving treatment and results 83ti* 

TABLE CLYVIII. Summary of nine cases of hospital 
gangrene, showing date and grade of disease 842 

Plate XXIX. Dry gangrene of the Feet, facing . . 850 

Dry gangrene (abstracts of seven cases) 850 

Traumatic Erysipelas (abstracts of eight cases) 851 

TABLE CLIX. Numerical statement of one thousand 
and ninety -seven cases of traumatic erysipelas 852 

TABLE CLYX. Numerical statement of one thousand 
and ninety-seven cases of traumatic erysipelas, in- 
dicating causes of death 854 

Pyaemia (abstracts of seven cases) 857 

TABLE CLYXI. Summary of cases of pyaemia, indi- 
cating location of injury and result 859 

Table CLXII. Indicating day of appearance of 
pyaemia after injury and after operation 860 

Condensed summary of forty-eight post-mortem ex- 
aminations in cases of pyaemia 862 

Concluding observations on Shot wounds ... 866 

Climatic, hygienic, aud moral influences 867 

Multiple wounds (abstracts of two cases) 868 

Conservation* Excision, Amputation 869 

Table CLXIII. Tabular statement of eighty-seven 
thousand seven hundred and ninety-three cases of 
shot injuries of the Upper Extremities, indicating 
seat of injury, mode of treatment, and final results. 870 



B70 



3 



Page 
TABLE CLX1V. Tabular statement of eighty-six 
thousand four hundred and thirteen oases of shot 
injuries of the Lower Extremities, indicating seat 
of injury, mode of treatment, and final results . . 

Table OLXV. Summary of sixty thousand twohui 
died and sixty-six shot fractures of the Extremities 

showing treatment and results 

Excisions J-74 

TABLE CLXVI. Numerical statement of four thou- 
sand six hundred and fifty-six excisions in the Ex- 
tremities 875 

TABLE CLXV1I. Tabular statement of excis- 
ions, indicating the months in which the opera- 
tions were performed _ _ 876 

Amputations 877 

TABLE CLXVIII. Tabular statement of twenty- 
nine thousand nine hundred and eighty amputa- 
tions, indicating seat of operation and results. . 877 

Table CLXIX. Table indicating the rate of 
mortality after amputations and excisions in the 
Extremities 878 

Table CLXX. Summary of twenty-three thou- 
sand seven hundred and sixty-two amputations, 
indicating the period of the operation. 879 

TABLE CLXXI. Summary of eighteen thousand 
seven hundred and eighteen cases of amputa- 
tions in the Extremities, indicating the side 
upon which the operation was performed 880 

Table CLXXII. Nnmerical statement of one 
hundred and seventy-two cases of double am- 
putations for shot injuries. 881 

Table CLXXIII. Condensed summary of one 
hundred aud seventy-two double amputations 
after shot injury 881 



CHAPTER XIII. AN/ESTHETICS. 



Prolegomena 887 

Deaths from chloroform " 890 

Abstracts of thirty-seven cases 890 

Deaths from chloroform and ether 894 

Abstracts of two cases 894 

Deaths from ether 894 

Abstracts of four cases 894 



Page. 

Table CEXXIV. Statement of five hundred and ninety- 
seven cases of the employment of anaesthetics, showing 
quantities used, time to induce anaesthesia, and period 
during which it was maintained 896 

TABLE CLXXV. Statement showing the frequency of 
vomiting, excitement, and prostration in five hundred 
and ninetv-seven cases of anaesthesia 897 



CHAPTER XIV. THE MEDICAL STAFF AND MATERIA CHIRURGICA. 



Page. 

Prolegomena 899 

An Act to Reorganize and Increase the Efficiency of the 

Medical Department of the Army - 900 

Duties of the Medical Director of a Corps 903 

Duties of the Medical Inspector of a Corps 906 

Duties of the Surgeou-in-Chief of a Division 906 

Duties of a Surgeon-in-Chief of a Brigade 907 

D.uties of the Surgeon in Charge of a Division Hospital . . . 908 

Duties of the Medical Recorder of a Division Hospital 909 

Duties of the Attending Surgeon of a Division Hospital .... 909 



Page. 

Duties of the Operating Surgeon 909 

Duties of the Regimental Surgeon 910 

Duties of the Assistant Regimental Surgeon 912 

Duties of the Commissary of Subsistence of a Division 

Hospital 912 

Duties of the Chief Ambulance Officer of a Corps 913 

Duties of the Chief Ambulance Officer of a Division 913 

Duties of the Chief Ambulance Officer of a Brigade 914 

Materia Chirurgica 914 



CHAPTER XV. TRANSPORTATION OF THE WOUNDED. 



Page. 

Hand Litters 923 

Wheel Litters 926 

Mule Litters 926 

Cacolets 927 

Ambulance Corps 931 

Ambulance Wagons 944 

Railway Transportation 957 

Water Transportation 971 

Steamer City of Memphis 974 

TAliLE. Tabular statement of trips of Steamer City of 

Memphis 975 

XII 



Pago. 

Steamer Louisiana and K. C. Wood 975 

Table. Tabular statement of trips of Steamer Louisiana 976 

Table. Statement of trips of Steamer R. C. Wood 976 

Steamer D. A. January 977 

Table. Statement of trips of Steamer D. A. January 979 

Steamer Empress 981 

Steamer J. K. Barnes 982 

INDICES. 

List of Plates I 

List of Operators and Reporters Ill 

Subject-Matter Index XVII 



THK 



MEDICAL AND SURGICAL HISTORY 



OF THE 



WAR OF THE REBELLION (1861-651 



PART III, VOLUME II. 

BEING THE THIRD SURGICAL VOLUME. 



ON SPECIAL WOUNDS AND INJURIES— CONTINUED. 



CHAPTER X. 



WOUNDS AND INJUEIES OF THE LOWER EXTREMITIES. 



In attempting to furnish a description, as adequate as practicable, of the various 
classes of injuries inflicted by war-weapons that were reported during the late war in 
this country, I have reviewed and analyzed at great length, in two preceding volumes, 
histories of cases of wounds of the head, neck, trunk, and upper extremities. It remains, 
to complete this branch of the subject, to discuss, in like manner, Wounds of the Lower 
Extremities, a very important group, comprising not only a larger number of those cases 
that come under the treatment of the military surgeon than any other group, but a greater 
proportion of cases demanding operative interference than is observed in other regions, 
and presenting to the field surgeon, especially in connection with lesions of the hip and 
thigh, some of the most difficult practical problems he has to encounter. 

Gf the 253,142 cases of wounds returned during the War that have been examined 
and classified and entered on the permanent registers of the Surgeon-General's Office, 
89,528 are cases of Wounds of the Lower Extremities. Of these, 59,376 are entered as 
Flesh Wounds, of which 674 were punctured or incised wounds, and the rest shot wounds. 
The remaining 30,152 cases were all returned as shot fractures, and were distributed as 

IS LUG. Ill— 1 



2 



INJURIES OF THE LOWER EXTREMITIES. 



[Chap. x. 



follows: Shot Fractures of the Femur, including fractures penetrating the hip joint, 7,776; 
Fractures involving the Knee Joint, 3,557; Fractures of the Shafts of the Tibia or Fibula, 
or of both, 10,026; Fractures implicating the Tarsus, Metatarsus, and Phalanges, 8,793. 
It must be borne in mind that this total of 89,528 cases of wounds of the lower extrem- 
ities represents only those cases that have been accurately determined and entered on the 
registers, and by no means all the cases belonging to this group that were reported during 
the War, and hence as the work progresses the figures will need to be modified. Besides 
the 253,142 registered cases, quite a number, reported with insufficient details for class- 
ification, have been noted for investigation; and, by searching the Pension Records, and 
through Union and Confederate reports which continue to be sent in, even at this late date, 
and by special reports from surgeons who kept note-books, and who, since the publication 
of the First Surgical Volume, have been led to transmit particulars of their cases, it will 
be possible, as each successive subject is taken up for analysis, to sensibly augment the 
aggregates of each group. This was observed in the discussion of the Wounds of the 
Upper Extremities. In Table XII, on page 454 of the Second Surgical Volume, but 
84,718 cases of such wounds are recorded as registered, but in examining Chapter IX it 
will be found, as mentioned in the Memorandum at page III of that Volume, that 88,741 
eases are actually specified, the particulars of 4,023 additional cases having been obtained 
through information derived from various sources. Such additions may be expected in 
this Volume also; but they will not invalidate the approximate correctness of the figures 
above given, so far as relates to the relative frequency of wounds of the lower extremities. 
For such a purpose, the numbers 89,528 : 253,142 are ample, and the ratio is perhaps 
quite as reliable as it could be made by larger aggregates. 

The relative frequency of wounds of the lower extremities received in battle, com- 
pared with the total number that came under treatment, appears from the above returns 
to be represented by a ratio of 35.3 per cent., or a little over one-third. There is good 
reason to believe that this is a very near approximation to the precise facts. Note, for 
example, its correspondence with returns from other campaigns: 



Table I. 

Collated Returns, indicating the lielative Frequency of Shot Wounds of the Lower 
Extremity in Aggregates of Wounded Men who came under Treatment. 



Wars, Campaigns, and Other Occasions. 



July, 1830, days in Paris and Lyons (Serriek's table 1 ). 

Crimean War (Matthew's return') 

Crimean War (Ciienu'b return 3 ) 

Italian War of 1859 (Chexu's return 4 ) 

Italian War of 1859 (Demme's estimates 5 ) 

Danish War of 1864 (HEINE ) 

Franco-German War (Consolidated returns 7 ) 



Totals 106, 212 



Aggregate 
Wounded. 



Wounds of 
Lower Ex- 
tremity. 



784 


185 


23.5 


7,660 


2, 396 


31.2 


34,306 


11,873 


34.6 


19, 672 


7,704 


39.1 


17, 095 


5, 248 


30.6 


1, 907 


553 


28.9 


24, 788 


7,560 


30.5 



35, 519 



Ratio. 



33.4 



1 Serrier (L.), Traite ties plaies d'armes a feu, Paris, 1844, p. 30. The insurgents fighting behind barricades, the proportion of injuries of tho 
lower extremities is less than usual. * MATTHEW (T. P.), Med. and Surg. Hist, of the Brit. Army in the years 1854-55-56, London, 1858, Vol. II, p. 355. 
3 CHENU (J. C), Rapport, etc., de Campagne d' Orient en 1854-55-56, Paris, 1865, p. 627. 4 CHKNL" (J. C), Statistique Med. Chir. de la Campagne 
d'ltalieen 1859 el I860, Vol. II, p. 850. »DEMME (H.), Studien, Wurzburg, 1861, B.I, p. 20. e Helve (C), Die Schussverletzungen der Unteren Extrem- 
itdten, Berlin, 1866. I much regret that, in regard to the statistics of the Danish War of 1864, I cannot refer to the conclusions of the lamented Gen- 
emlarzt V, LCSFFLEii, from whose excellent General- Bcrinht ubr.r den Cesundheitsdienst im Feldzugc gegcn Ddnemark 1864, Berlin, 1867, the statistics 



INTRODUCTION. 



WOUNDS OF THE LOWER EXTREMITIES. 



It will be observed, by comparing the tubular statement on page 434 of the /Surgical 
Volume of Part II, that the relative frequency of shot wounds of the lower extremities 
does not exceed that of wounds of the upper limbs to the extent that might be anticipated 
from the greater size of the lower limbs. This is doubtless due to the fact that, in all 
fighting in entrenched positions, the lower part of the person is partially screened from 
injury. In the last year of the War, the field casualties of the Union armies were reported 
with much completeness and accuracy, as has been already noticed (supra, Part I, Vol. II, 
p. 600, Part II, Vol. II, pp. 6, 917), and over a hundred thousand cases of wounds were 
recorded with careful discrimination of their nature and position. In the engagements 
during this period, the combatants had learned to cover their positions with hastily 
improvised earthworks; and this may partly account for the smaller ratio of wounds in the 
lower limbs presented in these returns. Notice, for example, in the following tabular 
statement, the very small proportion of wounds of the lower limbs in the siege operations 
before Mobile. Another probable cause why the proportion of wounds of limbs was 
smaller in the field than in the general hospital returns, is that a large number of rapidly 
mortal wounds of the head and trunk appear on the held casualty lists, representing 
patients who never reached the base hospitals. 



Table II. 

Partial Numerical Statement of Shot Wounds of the Lower Extremities in the Field or 
Primary Hospitals in various Campaigns during the last year of the War, 1864-65. 



CAMPAIGNS. 


FLESH WOUNDS. 


FRACTURES. 


FOOT. 


MISSILE. 


ci 
M 

g 

b 
o 

'f- 

o 
H 


o 

Pal CO 

a a 

is 

M 


Navies and Dates. 


THIGH. 


Leg. 


Thigh. 


LEG. 


£ 

a 
O 

2, 269 

1,044 

93 

62 

33 

48 

718 

16 

403 

555 


a 
B 

a 
i 

i 


Large projec- 
tiles, eaniioD 
shot, sbcll, 
.it. J bomb Irag- 
ment.. grape, 
and canister. 


Small projec- 
tile*, in ii , k .- 1 . 
carbine, i ifle, 

pistol ball*, 
and .sin..!] mis. 

silo from 
sIu.im.'-I and 

10, 828 

5,720 

1,025 

498 

178 

137 

3, 899 

554 

2,540 

2, 581 


CO 

& a 
a 1 » 

o { a 


M 

a 
O 


CO 

33 

Q 
6 
6 

1 


i 

3 
Q 


ts 

a 
o< 
ft 


CO 

E 

3 
o 


W 
« 

B 

O 


Army of Potomac, from May 4 to August 31, 1864 . . 
Campaign to Atlanta, from May 4 to Sept. 8, 1864 . . 
Gen.G- II. Thomas's Army, from Oct. 25 to Dec.Ul,'G4. 
Gen."\V. T. Sherman's Army through Carulinas in '65. 

From Fort Fisher to Goldsborough, N. C-, 1805 

Siege of Mobile, from March 26 to April 19, 1865 . . . 
Army of James, from May 4, 1864, to April 9, 1865. 
Shenandoah Valley, from May 4 to August 20. 1861. 
Shenandoah Valley, from Aug. 21 to Dec. 30, 1864. . 
Army of Potomac, from Sept. 1, 1864, to Ap'l i), 1865. 


4,037 

3,312 
370 
225 
11C 
100 

1,091 
253 
829 

1,017 


10 
1C 

6 

jjj 

1 
1 


3,843 

2,058 

450 

148 

124 

84 

1,856 
265 
949 

1,126 


812 

573 

81 

46 

32 

40 

390 

29 

273 

269 


104 
73 

3 

8 

4 

18 
32 


938 

581 

106 

47 

32 

33 

436 

23 

3-!0 

272 


21 
31 

1 

1 

n ; 
i 

5 
10 


978 

543 

74 

16 
43 
57 
504 
32 
226 
176 


38,944 

23,308 
3,610 
1,533 
1,075 
2,111 

16,120 
2, 196 
7,542 

10, 407 


30.5 
32.4 
30.6 
34.4 
31.5 
14.4 
27.8 
26. 7 
26.6 
31.1 

30.7 




11,336 39 


10,903 


11 


2,545 


271 


2,787 


81 


5,243 


n 


2,649 


27, 960 


106,846 








1 





of wounds of the upper extremity in this campaig-n were cited in the Second Surgical Volume (Chap. IX, p. 434). This eminent surgeon died in 1874; 
and I have been unable to procure the second volume of his most painstaking and accurate treatise; or to learn that it has been published. Fortunately, 
Dr. Heine's statistics cover the ground, if not as thoroughly, at least with commendable precision. 7 These 24,788 cases are collected from the following 
authors; McCORMAC (W.) {Notts and Recollections of an Ambulance- Surgeon, London, 1871, p. 129; total number of cases, 610, lower extremities, 257); 
Billroth and Czer.vy (Chirurgische Briefe, Berlin, 1872, p. 180 ;— 277— 135); RuPPKECHT (Mililararztliche Erfahrungen, 1871, 8. 10;— 361— 128); 
MOllLUAUElt (Erfahrungen aus dem Feldzuge, etc., in Bayerisclies drtzliches Intelligcnzblatt, 1871, S. 374;— 1899— 849); Steinberg (Die Kriegslaz- 
arethe und Baracken von Berlin, Berlin, 1871, S. 146; — 8531 — 974); Goltdammeb (Beriehi uber die Thiitigkeit des ReservcLazarethes des Berliner 
Hiilfsvereins, iu Berliner Klin. Wochenschr., 1871; — 639 — 67); Hkyfeldkk (O.) (Bericht iiber meine Wirksamkeit am Rhein, in Petersburg Med. 
Zeitschrift, 1871 ; — 226 — 81); SOCIN (A.) (Kriegschirurgische Erfahrungen, Leipzig. 1872, p. 8; — 643 — 328); MUXDY and MOSKTIG (Service Med. chir. 
del ambulance du Corps ligislatif in Gaz. des Hip., 1871, No. 149;— 136 — 58); BECK (B.) (Chir.der Schussv.,1812, S. 160; — 4344—1787); Fischek (II.) 
(Kriegschir. Erfahrungen, Erlangen, 1872, S. 28; — 875 — 356): KlBCHNER (C.) (jErtzlicher Bericht u. s. w. (m Palast zu Versailles, Erlangen, 1872 ; — 
2099 — 751); Graf (E.) (Die Konigl. Reservelazarethe zu Dusscldnrf, 1872:— 298— 101); SchCli.er (Kriegs. chir. Skizzen, Hannover, 1871 ; — 491—166); 
GltOS (F.) (Notice sur Vhopital civil, etc., de Strasbourg, iu Gaz. Med. de Strasbourg, 1872, No. 17;— 140 — 53); BEUTHOLD ( Deutsche Md.-ij.rzt Zeitschrift, 
1872, B. I, S. 429,-1804—723); and MossAKOWgK,Y (P.) (Deutsche Zeitschrift fur Chir.. |g72, B. I. S. 323;— 1415— 744), 



4 INJURIES OF THE LOWER EXTREMITIES. [CHAP. x. 

Examining carefully several series of a thousand each of the 89,528 registered cases 
of wounds of the lower extremities, 1 including only those in which the seat of injury was 
noted with precision, a predominance of wounds of the left lower extremity is found in the 
following proportion: Both limbs, 3.4 per cent.; left limb, 53.1; right limb, 43. 5. 2 

A word may be added regarding the recorded instances of evulsion of one or other 
of the lower limbs by solid shot, fragments of shell, torpedoes, or other large projectiles. 
Of 164 such instances 93 recovered, 62 or 40 per cent, were fatal, while in 9 instances 
the results were not ascertained. In 129 of the 164 cases it is noticed that ablations, 
many of them doubtless resembling merely the paring and regularization of the soft tissues 
with removal of splinters or sharp projections of bone, rather than legitimate amputations, 
were performed. Two of these, however, were successful formal disarticulations at the 
ankle joint, 2 successful amputations at the knee joint, 1 a fatal exarticulation at the hip. 
Seventy-six, with 56 recoveries, 14 deaths, and 6 unknown terminations, were opera- 
tions in the continuity of the leg; forty cases, 26 successful, 13 fatal, 1 doubtful, were 
amputations in the thigh. In 4 cases, both legs were removed in the continuity with 2 
recoveries, 1 fatal and 1 unknown result. In 1 fatal case the left thigh and right leg were 
simultaneously removed; in 1 case of recovery amputation was performed in the right 
thigh and through the left knee joint; in 1 fatal case simultaneous amputation of both 
thighs in the continuity was practised; and in one instance disarticulation of the left hip 
and ablation of the right leg was performed, the case terminating fatally. In 35 of the 
aggregate of 164 cases there is no record of operative interference. Of these, 1 was a 
fatal instance of evulsion of both limbs in the continuity of the thigh; in 6 fatal cases 
both limbs were torn off in the leg; in 4 fatal cases the right or left limb was torn off in 
the thigh, and in 24 the mutilation took place in the continuity of the leg with 4 recoveries, 
19 deaths, and 1 with unknown result. 

An additional proof that of the shot wounds received in action those inflicted upon 
the lower extremities ordinarily constitute about one-third of the aggregate, is found in 
the carefully prepared statistical researches of Councillor G\ Fischer. 3 

1 The lamented LtEFFLEU, one of the soundest of modern Prussian military surgeons, sets forth (Gcneral-Bcricht iiber den Gcsundheitsdienst im 
Feldzuge gtgen Danemark, 1804, Berlin, 1867, p. 48) that of 2,388 Prussians killed and wounded iu the Danish War of 1804, about 31 per cent, were 
struck in the lower extremities, and remarks (S. 49): " The comparatively small proportion of wounds of the lower extremities may appear strange. 
One is accustomed to regard the preponderance of such injuries as considerable. The protections above referred to (trenches, and, in Schleswig, brush- 
hedges f Knicks]) would undoubtedly partially protect the lower limbs. But statistics that omit the killed are defective ; they give to the shot wounds 
of The extremities an undue preponderance, because their immediate fatality is much more limited than is observed in wounds of the head and trunk." 
Professor H. Fischer (Lehrbuch der Allgemeinen Kriegschir., Erlangon, 18G8, S. 25) observes : " In later wars, in which the fighting was mainly in tho 
open field, the remarkable fact has almost uniformly appeared, that among shot injuries those of the lower extremities far exceed those of the upper limbs. 
Dr. MACLEOD'S statistics refer 68 per cent, of wounds in action to wounds of the lower extremities. [This is an oversight. Dr. MACLEOD (Notes on the 
Surgery of the War in the Crimea, 1858, p. 414) gives the proportion of wounds of the lower extremities among the men as 31.7; among officers 35.2. 
Professor Fischeu seems to have added these ratios together.] DJOERUF reports the proportion of wounds of the lower limbs in the Danish army, in the 
war of 1848-50, as 40.5 per cent. In Paris in 1848, and in Italy in 1859, the wounds of the lower extremities constituted a third, and those of the upper 
limbs nearly another third. When it is considered that the remaining third was made up of cases of injuries of the head, chest, abdomen, and pelvis, it is 
apparent how enormously large is the number in modern wars that have to be transported with the utmost care and skill. Hence, perhaps, the most 
difficult problem for the modern military surgeon is the management of the ambulance trains. Losffler, it is true, has said that the preponderance of 
wounds of the lower limbs in modern wars is seeming rather than real, and is conditioned on the less proportion of immediate fatality in wounds of the 
limbs. This assumption, though assuredly founded on facts, might explain the conspicuous fact that the shot injuries of the limbs predominate greatly 
over those of the head and trunk ; but does not explain the extraordinary disproportion between the shot injuries of the upper and lower limbs." I may 
remark that the statistics I have examined do not show any greater disparity in the frequency of wounds in the upper and lower limbs than is warranted 
by the relative size and position of the extremities. 

* HEINE (C.) {Die Schussverletzungcn der unteren Extremitaten, Berlin, 18G6, p. 30) remarks that in the Schleswig-Holstein War, 1800,27 of tho 
502 cases of injuries of the lower extremities both limbs were injured, or a percentage of 4.8, and FISCHER (G.) (Statistik der in dem Kriege 1870-'71, rfc, 
vorgekommenen Verwundungen und Tddtungcn, Berlin, 1876) tabulates 780 cases of injuries of both limbs in a total of 20,100 cases of injuries of the lower 
extremities, or 3.8 per cent. 

3 The Statistik der in dem Kriegc 1870-1871 im Preussischen Beerc, vorgekommenen Verwundungen und Tddtungcn von G. FISCHER comes to 
hand as these pages are going to press. Tabelle C (loc. cit., p. 59) contains a recapitulation of the seat of injury in 04,897 cases (7,735 killed and 57,162 
wounded). In 18,905 instances, or 29. 14 per cent., the upper extremity was injured, and in 20,100, or 31. 00 per cent., the lower extremity was involved, 
The latter percentage varies but little from that given on page 2 (ante 30. 5), which was consolidated from a number of publications by various authors 
that have appeared since the late Franco-Prussian War. 



SKCT. i.) FLESH WOUNDS. 



Section I. 



FLESH WOUNDS OF THE LOWER EXTREMITIES. 



The reader is respectfully referred to the introductory observations to the first section 
of the Ninth Chapter, in Part II, Volume II, page 435, for many remarks on the Flesh 
Wounds of the Upper Extremities, which are equally applicable to the cases of the cate- 
gory now to be considered. The gravity of flesh wounds in the lower extremities greatly 
exceeds, however, that of analogous injuries in the upper limbs. The dangers arising from 
lesions of the great blood-vessels and nerves of the lower extremities, from peri-articular 
wounds, and especially from deep seton wounds and lacerations of the massive muscles 
of the thigh, are great. Many perforations of the thigh that are lightly regarded at the 
outset, present ultimately formidable complications. Dr. H. Fischer remarked, 1 in the late 
Franco-German War, that "many a wounded man sent to the rear with the diagnosis 
'slight shot wound of the thigh,' succumbed to burrowing of pus, detected too late and 
treated with too little vigor. We had five such cases, and succeeded in all in controlling 
this terrible complication by early and deep incisions, absolute rest, and disinfecting band- 
ages. When the first stage is neglected, the surgeon loses the mastery, pyaemia delighting 
to develop in deep phlegmonous cavities." 

It was impossible, with the clerical force available, to make more than a superficial 
examination of the individual cases of the immense series of nearly sixty-thousand flesh 
wounds of the lower extremities. 2 All that has been attempted has been to sift out dupli- 
cated cases and those that ultimately proved to be complicated by contusion of bone or by 
fracture, and to scrutinize the series sufficiently to select instances illustrating the different 
varieties of injuries of this group, to determine the average distribution of the wounds in 
the several regions of the limb, and to ascertain approximative^ the mortality. 

Of the series of flesh wounds of the lower extremities, six hundred and seventy-four 
were punctured or incised, and fifty-eight thousand seven hundred and two were shot 
wounds. 

PUNCTURED AND INCISED WOUNDS.-There were reported six hundred and 
seventy-four cases of punctured or incised wounds of the lower extremities, including a 
hundred and seventy-six bayonet wounds, twenty-two sabre wounds, and four hundred and 
seventy-six wounds from daggers, knives, axes, or other pointed or cutting weapons. 

Bayonet Wounds. — The series of bayonet wounds included sixty-two stabs in the 
thigh, with two deaths; seventy-seven penetrations of the leg, with two deaths; and thirty - 

1 FiscnER (H), Kriegscltirurg. Erfahrungm, Yor Mttz, Erlangen, 1872, S. 1R4. Dr. Fischer, professor of surgery at Breslau, was a volunteer 
surgeon in the Prussian army during the campaign from Saarbriicken to Metz, August 10 to October 27, 1670. 

2 Of the 89,528 registered cases of wounds of the lower extremities, 30,153, or 33.() percent., were returned as fractures, so that, as in the uppor 
limbs, the wounds of the soft parts alone constitute very nearly two-thirds of the aggregate — 59,376 in 89,528 cases. 



b INJURIES OF THE LOWER. EXTREMITIES. [CHAP. X. 

seven wounds of the soft parts of the foot, with one death, — the series of a hundred and 
seventy-six cases thus presenting a mortality of 2.8 per cent. Several of the cases present 
particulars of interest: 

Case 1. — Private P. Dietrich, Co. E, 151st New York, aged 34 years, was wounded at Spottsylvania, May 12, 1364, 
and admitted to the field hospital of the 3d division, Sixth Corps. Surgeon E. Barr, G7th Pennsylvania, recorded : "A bayonet 
thrust through the right leg.'' The patient was transferred to Douglas Hospital, Washington, subsequently to Summit House, 
and lastly to the Satterlee Hospital, Philadelphia, whence he was discharged April 27. 1805, because of "lameness of the right 
leg, caused by chronic eczema," following a bayonet injury. Examiner H. X. Loomis, of Buffalo, New York, May 8, 1805, 
certified : "A bayonet was thrust through the right leg between the tibia and fibula, about six inches below the knee. The 
wound healed; but is followed by chronic eczema, extending from the knee to the ankle, much inflamed, with some ulceration, 
and producing so much lameness as to unfit him for any kind of labor." In August, 1808, the pension examiner states that the 
eczematous eruption occupies about half the space between the knee and the ankle, and that the limb is still inflamed, ulcerated, 
and swollen. This pensioner was paid to March 4, 1870, since when he has not been heard from. 

In two cases the femoral artery was reported severed by a bayonet. One of these is 
related by Surgeon J. A. Lidell, 1 U. S. V.: A soldier of the 106th Pennsylvania received 
a thrust in the upper inner part of the thigh from a sabre-bayonet, in a picket skirmish 
near Fair Oaks, in June, 1862, and perished from haemorrhage before assistance could 
reach him. The result of the second case suggests the probability that a minor branch, 
rather than the main femoral trunk, was injured by the weapon: 

Case 2. — Corporal E. Hacket, Co. A, 1st Pennsylvania Chasseurs, was accidentally wounded near Camp Whipple, 
Philadelphia, in August, 1803. Acting Assistant Surgeon L. D. Eadzinsky reported : "While at bayonet exercise he received 
a punctured wound of the right femoral artery, below Poupart's ligament. The wound was received a short distance from the 
camp. When brought to the hospital tent the man was considerably exhausted from loss of blood. Judging from the clots 
found in his clothes he must have lost at least twelve ounces. The haemorrhage was immediately controlled by manual pressure 
upon the external iliac artery, a compress and spica bandage applied, and pressure continued with a tourniquet for three days, 
at which time the tourniquet was removed, a new dressing applied, and pressure continued with the spica bandage. He was 
returned to duty five days afterwards, and lias not had any untoward symptoms since." Hacket is not a pensioner. 

Surgeon T. H. Squire, 89th New York, reports a case in which the synovial cavity of 
the knee was penetrated by a bayonet without bad results, remarking that Dr. James 
Allen, of Marathon, New York, examined the recent wound and concurred in the diagnosis: 

Case 3. — "Private C. A. Ball, Co. K, 89th New York, aged 10 years, in the spring of 1802, at Roanoke Island, while 
jumping for exercise, accidentally sprang against the point of a bayonet. At a moment when the joint was partially flexed, 
the point of the bayonet penetrated the cavily of the knee joint, the wound being immediately above the centre of the patella. 
The patient was immediately received into the regimental hospital, and Assistant Surgeon W. A. Smith, 89th New York, 
enjoined perfect rest in bed and low diet, with cold applications to the joint. The wound was from the first regarded as a 
dangerous one. Some days after the accident occurred, Dr. Squire saw the case with Dr. Smith. There was then synovial 
swelling of the joint, and other conclusive evidences that the joint had been penetrated. The boy was kept in hospital till the 
recovery was complete, when he again entered the ranks for duty. The recovery was complete, and no bad effects followed. 
The wound was not very extensive. The point of the bayonet may have gone through the synovial membrane half an inch or 
so, and in such a glancing direction as not to injure the cartilage or bone. Dr. Squire did not know exactly how long the boy 
was kept in hospital, but thought about four weeks." The field registers show that this Private Ball received a gunshot wound 
of the right side of the thorax at the battle of Chapin's Farm, September 29, 1804, which fact is corroborated by the examining 
surgeons. For this injury he is a pensioner, but the Pension Records make no mention of a bayonet injury of the knee. 

Of the five fatal cases in this subdivision of bayonet wounds in the lower limbs, three 
succumbed from gangrene, one from pyaemia., and one from primary haemorrhage. The 
following is one of the cases complicated by gangrene : 

Case 4. — Private S. Dick, Co. E, 79th Indiana, was wounded at Chickamauga, September 19, 1863, and sent to hospital 
No. 13, Nashville, October 1st. Assistant Surgeon J. K. Bauduy, U. S. V., reported: "He was admitted with a flesh wound of 
the calf of the left leg, caused by a bayonet. The wound was superficial and slight, and did well for several days ; treated 
with cold-water dressings. On October 20th, hospital gangrene manifested itself; the disease was then prevailing endemically 
in the hospital. This patient was immediately transferred to the gangrene ward, and applications of pure bromine were made. 
Tincture of iron and fluid extract of cinchona were freely administered. Milk-punch and beef-tea were also given at stated 
intervals. His bowels, which were inclined to be costive, were kept open with enemeta of salt, molasses, and tepid water. 
The disease steadily progressed, and large sinuses formed in all directions in the intermuscular spaces. One immense sinus ran 

■LIDKLL (J. A.), Bayonet Wounds, with castt, In Am. Med. Times, 1866, Vol. VII, p. 153. 



SECT. 1.1 PUNCTURED AND INCISED WOUNDS. / 

along the course of tlie tendo-achilles. The sinuses were freely opened and injected with chlorinated soda solution, and bromine 
was thoroughly applied, taking great care to get it well into the intermuscular spaces. Disinfecting poultices were used in the 
removal of the sloughs. November 4th, the gangrene at this date was entirely arrested, but symptoms of pyemia arose. The 
pulse became frequent and weak, ranging between 140 to 150. Rigors; skin cold and clammy; breathing oppressed and 
labored. Patient complained of pain in chest. The conjunctiva assumed an icteroid hue, and the whole surface of the body 
became tinged with a pale yellow appearance. The knee and ankle joints commenced to swell and cause great pain. The 
following treatment was then resorted to: Carbonate of ammonia in large and frequent doses; stimulants every half hour; 
iron and cinchona continued; tincture of iodine and blisters to swollen joints; surface of body washed with whiskey and 
water. Patient continued to sink, and died on the afternoon of November 7, 18(33. Post-mortem : Lungs healthy ; no metas- 
tatic foci could be found in either of them or in the liver; but microscopical examination of the latter revealed a fatty infiltra- 
tion. The liver was also greatly hypertrophicd. The heart, spleen, pancreas, bowels, and kidneys were all healthy. There 
was an accumulation of pus in the left knee joint. - ' 

Sabre Wounds. — None of the twenty-two reported sabre-cuts of the lower limbs 1 were 
of a sufficiently grave character to prove fatal. Seventeen of the patients returned to 
duty, and five were discharged for slight disabilities. Six cases were flesh wounds of the 
thigh, ten of the leg, and six of the foot. One of the patients, Corporal Rice, 1st Vermont 
Cavalry, whose case is recorded on page 22 of the Mrst /Surgical Volume, suffered also 
from a sword-cut of the frontal; but he, with the rest, recovered without serious trouble. 

Other Punctured and Incised Wounds — Besides wounds caused by legitimate 
weapons of war, a considerable number were reported as inflicted by daggers, dirks, or 
bowie-knives, arrows, picks, and other pointed implements, and by knives, scythe-blades, ■ 
hatchets, axes, and other cutting instruments. There were seventy-two of these serious 
punctured wounds of the lower limbs, and four hundred and four cases of severe incised 
wounds. There were eight deaths in this series of four hundred and seventy-six cases, a 
mortality-rate of 1.6 per cent., and disability leading to discharge from service resulted in 
a hundred and two of the cases. Twenty-eight cases were wounds of the thigh, a hundred 
and seventeen wounds of the leg, three hundred and thirty-one wounds of the foot. 

Ligations. — In four instances, at least, of this series, ligations of arteries were practised 
on account of haemorrhage or aneurism. One of these, an instance of aneurismal varix 
from puncture of the femoral artery and vein, by a pocket-knife, has been narrated, with a 
figure of the specimen, at page 336 of the Surgical Volume of Part II. 2 The three other 
cases were ligations of the tibial arteries: 

Cases 5, 6, 7. — Assistant Surgeon J. C. G. Happersett, U. 8. A., reports that Private T. J. Moore, Co. B, 82d Ohio, 
aged 29 years, received, July 14, 1805, a punctured wound near the right ankle. The haemorrhage was so uncontrollable that, 
on July 23d, Assistant Surgeon II. M. Lilly, U. S. V., ligated the posterior tibial artery, placing a single proximal ligature. 
July 24th, unhealthy gangrene attacked parts, and bromine dressings were applied. The patient recovered, and was transferred 
to Jeffersonville October 19th, and to Post Hospital, Louisville, December 16, 1863. — (5. Surgeon C. A. Cowgill reports that 
Lieutenant T. Linder, Co. E, 158th New York, aged 30 yean, received, May 11, 1804, a punctured wound by a sharp knife on 
the inner side of the right leg at the juncture of the lower and middle thirds, dividing the posterior tibial artery through one 
half its diameter and causing a diffused traumatic aneurism. He was admitted into the Foster Hospital, New Berne, May 20th; 
the cellular tissue and intermuscular spaces were filled with coagula, which had temporarily arrested haemorrhage. There 
was great tension and considerable sloughing of the soft parts. May 22d, Surgeon C. A. Cowgill, U. S. V., made an incision 
five inches long over the wound, through the integuments down to the posterior tibial artery, and, ligating it above and below 
the wound, the coagula were removed and the wound closed by adhesive straps. A good recovery ensued, and the officer 

returned to duty June 29, 1864. — 7. Surgeon G. A. Otis, 27th Massachusetts, reports that Private C. D , Co. B, 27th 

Massachusetts, in December, 1863, at Newport News, Virginia, received a severe wound in the left leg from an axe, about three 
inches above the annular ligament. The tendons of the tibialis anticus, the common and proper extensors, and the anterior 



'In old times, aud in the combats of the trained European Cavalry, Babrc cuts of the lower limbs were not uncommon. Ravaton (Chirurfjie 
d'armee, 17G8, Chap. IX, p. 518) gives many examples, in which not only the soft parts but the bones were hacked by sword-cuts. M LEdOUEST also 
(Vhirurgie d'armee, 2eme ML, 1S7J, p. 461) details several such examples, and refers to illustrations in the Museum of Hutin at the Hotel den Invalides- 
Abstracts of interesting incised wounds of the lower limbs may be found also in T.E Dkax (Observat. dt Chir., 1731, T. II, p. 33J) and in La Motte 
( Traiti compute de Chirurgie, 1771,'T. Ill, p. 143 et seq.). 

2 First the femoral, then the external iliac, and finally and fatally the common iliac were ligated by Dr. J. B. Cutteie. The operator has published 
abstracts of these ligations in the Am. Jour. Med. Sci., 1864, Vol. XI.VIII, p. 36, Ibid., 1863, Vol. L, p. 391. The pathological specimen, showing tbo 
communication between the artery and vein and the huge sacculation of the latter, is numbered 3597 in Sect. I of the Army Medical Museum. 



8 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

tibial artery veins and nerve were divided, and the periosteum. The wound gaped widely, and the artery gave freely per saltum. 
The vessel was completely severed. Ligatures were at once placed by Dr. Otis about the upper and lower orifices of the artery, 
and the wound was united by sutures. Recovery was rapid and uncomplicated, and the soldier returned to duty. 

Amputations. — In four instances, after deep incised wounds by axes, complications 
arose, and recourse was had to amputation. Two were thigh amputations: 

CASES 8, 9.— Private Christian Webber, 8th Co., New York Independent Volunteers, received, September 24, 1863, a 
severe wound from an axe, severing the quadriceps of the left thigh two inches above the patella. He was sent to Fairfax 
Seminary Hospital, September 26th, and deep-seated suppuration having appeared, burrowed, and finally penetrated the knee 
joint, Surgeon D. P. Smith thereupon decided to amputate the limb. The operation was practised, October 4th, at the junction of 
'-.lie lower and middle thirds of the femur. The patient was transferred, convalescent, to York, Pennsylvania, October 30th, and 
subsequently discharged. The portion of the femur amputated has been catalogued in the Army Medical Museum, 1 but exhibits 
nothing abnormal— 9. Private T. H. Breckridge, Co. C, Cth New York Artillery, received a wound by an axe in March, 1864, 
and was sent to Armory Square Hospital. Surgeon D. W. Bliss, U. S. V., reported that the wound involved the right tarsus 
and metatarsus, and presently became erysipelatous, and that gangrene then supervened. On this account, on May 27th, Dr. 
Bliss amputated the limb, at the junction of the middle and lower thirds of the femur, by antero-posterior flaps formed by 
transfixion. Recovery was satisfactory. On December 28, 1864, he was supplied with an artificial limb at Ladies' Home, New 
York, by Dr. E. D. Hudson, at Government expense. The stump was then soundly healed, and "creditable" in shape. This 
soldier was discharged July 12, 1865, and pensioned. His pension was paid March 4, 1876. 

In two instances the leg was amputated for incised wounds of the ankle or foot: 

CASES 10, 11.— Private M. Dunham, Co. D, Engineer Battalion, aged 23 years, received a severe incised wound of the 
left ankle January 24, 1804. He was sent to hospital at Alexandria. Surgeon E. Bentley, U. S. V., reports that long-con- 
tinued suppuration had ended in necrosis of the tibia-tarsal articulation, the patient being of a strumous habit. Dr. Bentley 
practised a circular amputation in the lower third of the leg May 5, 1804. Pysemia supervened, and death ensued June 18, 
1804.— 11. Private A. Stacy, Co. H, 12th Kansas, received a severe wound of the left leg by an axe on March 17, 1864. He 
was sent to hospital at Fort Leavenworth. In September, 1864, the limb was amputated by short anterior and long posterior 
flaps by Dr. Clark. The patient recovered with a good stump, and was fitted with an artificial limb by B. Frank Palmer, at 
New York, June 23, 1866. He is a pensioner, and was paid March 4, 1876. 

The foregoing instances comprise nearly all the seriously complicated cases reported 
of punctured and incised wounds of the lower extremities. There was a case (Private 
Wherry, 115th New York) where half the small blade of a pocket-knife broke off against 
the femur after perforating the quadriceps two inches above the knee joint; attempts at 
extraction of the foreign body failed; the patient recovered with partial false anchylosis 
at the knee. Except those noted, the examples of sloughing or consecutive bleeding were 
trivial, and no case of tetanus was observed. 

SHOT FLESH WOUNDS.— In the vast series of fifty-eight thousand seven hundred 
and two cases of shot wounds of the soft parts of the lower limbs placed on the registers, 
it is difficult in many cases to determine, from the hasty field notes or brief hospital entries, 
the exact positions and extent of the wounds. As nearly as can be approximated, how- 
ever, it would appear that about twenty-six thousand of these wounds were in the thigh, 
about twenty-one thousand in the leg, and about ten thousand in the foot, a certain number 
of reports presenting no indication of the precise seat of injury. 

These wounds were of eveiy grade of severity, from trivial skin-scratches to huge 
lacerations by large projectiles; long furroughed wounds with tortuous tracks, deep seton 
perforations, superficial or deep penetrations with lodgement of the missile, filling up the 
gamut. In reviewing the great series, two small groups especially claim attention — the 
wounds attended by lesion of the principal nerves, and those with injury of the mam 
blood-vessels. We shall consider these first, and then typical examples of shot injuries 
of the soft parts, selecting for illustration those cases remarkable for extent of lacerations, 
those in which foreign bodies were lodged in the limb, those ultimately complicated by 
extension of inflammation to the joints, or by disease of the arteries, or by gangrene, 
tetanus, and other complications. ^_ 

1 See No. 2004, Section I, p. 3(14, of Catalogue of the Surgical Section of the Army Medical Museum, Washington, 1866. 



SECT. 11 SttOT FLESH WOUNbS. 9 

Flesh Wounds of the Lower Limbs ; with Injury of the larger Nerves.— Instances 
in which wounds of the larger nerves were sufficiently distinct and uncomplicated to be 
returned under this head were comparatively few; they were less frequent, indeed, than in 
the upper limbs. 1 The relations of the large nerve trunks of the lower extremities to the 
blood-vessels, bones, and joints are such that they are more liable to share in the injuries 
of these parts than in wounds mainly involving the muscular tissues. Moreover, it is 
probable that in many flesh wounds, nervous branches of magnitude were implicated with- 
out manifestation of any very serious results, and that such cases were not returned as 
injuries of nerves. 2 Presenting less urgency in relation to immediate treatment than lesions 
of the arteries and bones, these accidents nevertheless were frequently very grave, entail- 
ing a vast amount of protracted misery, and sometimes fatal consequences. Of fifty-nine 
cases referred to this category, thirty-one were reported as wounds of the sciatic, two of 
the crural, five of the long saphenous, one of the middle cutaneous, nine of the popliteal, 
five of the anterior tibial, three of the posterior tibial, and three of unspecified large nerve 
trunks. Eleven cases proved fatal, of which six succumbed from tetanus. Amputation 
was resorted to in four cases, briefly noted in succeeding tables. Two amputations in the 
thigh were successful; one through the knee joint, and one in the leg proved fatal. 

Of thirty-one cases of wounds of the sciatic nerve, twenty-five recovered, including 
one in which amputation in the thigh was practised, and six were fatal. Four died of 
tetanus. 3 One succumbed, long after the injury, from secondary traumatic coxitis. 4 
Eiysipelatous inflammation with sloughing, extending to the hip joint, and resulting in 
ulceration of the cartilages and caries of the head of the femur and acetabulum. The 
fourth fatal case 5 was an example of exhaustion from protracted suffering. Of the 

1 As indicated in Part II, Vol, II, p. 461, there were 9G cases distinguished as nerve lesions of the upper extremities, contrasted with 59 instances in 
the lower extremities. Professor A. SOCIN {Kriegschir. Erf., Leipzig 1 , 1872, p. G4) remarks a similar disproportion in the Franeo^German War. Relating 
16 cases of shot injuries of the nerves, he observes that: " more than five-eighths of these concerned t lie upper extremities." 

2 Iu their treatise on Gunshot Wounds and other Injuries of Nerves. By 8. WWB MITCHELL, M. D. t GEORGE B. MOREHOUSE, M. D., and 
"William W. Keen, M. D., Philadelphia, 1864, the authors detail (pp. 02, OH) two cases of shut injury of the sciatic nerve: Private K. flrim, Co. B t 
121st Pennsylvania, who received at Fredericksburg, December 13, 1862, a shot perforation of the left thigh, the ball entering externally four inches 
above the upper border of the patella, and emerging on the insideof the thigh, two inches lower down, slightly injuring the sciatic nerve. He had, July, 
1803, severe burning on the dorsum of the left foot, and eczema, with ulceration about the nails, complete paralysis of the flexors of the foot and partial 
paralysis of the flexor communis and calf muscles. The other patient entered the hospital about the same time, a ball wound passing close to the sciatic. 
He had complete loss of power in the flexors of the foot, defective sensation on the; outside of the leg and foot, and eczema with burning pain. Both 
patients were treated with electricity, with gradual gain of motion and relief of pain, and were regarded as fair types of partial wound or commotion of 
a nerve. At page 128, of the same work, the case of Private J. S. h. Scott, Co. V, 121st New York, aged 31 years, is related: He had a shot wound of 
the calf of the right leg. at Chancellorsville, May 3, 1863, The ball passed between the fibula and tibia about mid-leg. Total loss of motion below 
knee, slightly tactile insensibility, foot extended and powerless. September, 1863, rapid improvement followed alternated cold and hot douches, with 
faradization, and a splint to correct the malposition of the foot. Discharged, improved, February 12, 1864. The reports of Pension Examiners Maun and 
Lanning, of Manchester. Ohio, where this pensioner now resides, recapitulate the foregoing facts, nnd describe the paralysis as in all probability perma- 
nent. The latest report by Dr. Lanning, February 4, 1874, states that "paralysis of the foot and toes is nearly complete," and recommends that the 
pensioner be excused from further biennial examinations, as his disability is considered irremediable. This recommendation was opposed, and the pen- 
sioner's condition was unchanged when he was last paid, March 4, 1876. Iu Circular 6, S. G- O., 1864: On lZ*Jtex Paralysis resulting from shot wounds, 
the same authors narrate two examples of reflex paralysis of the upper extremity induced by shot flesh wounds implicating the nerves of the lower 
limbs : Private W. W. Armlin, Co. D, 134th New York, aged 23 years, was shot at Gettj'sburg, July 1, 1863, the ball entering anteriorly about midway 
on the inner part of the right thigh and emerging outside and below the tuberosity of the ischium, just above the fold of the uates. The sciatic nerve 
was probably injured. There was partial paralysis of the right leg, and reflex paralysis of the right arm. The latter speedily recovered. — Private I>. 
Kent, Co. B, 145th Pennsylvania, aged 24 years, was struck, at Gettysburg, July 2, 1863, over the upper third of the right rectus femoris, by a musket 
ball, which passed through the thigh, emerging at the inner side a little below the fold of the nates. There was loss of motion and sensation in the 
thigh and leg, and reflex motor paralysis in the right arm. The patient was discharged January 20, 1864, for tuberculosis. The paralysis had amended 
under the use of hot and cold douches, active motor, and faradization. In his work, entitled Gunshot Wounds of the Nerves and their Consequences^ 
Philadelphia, 1872, Dr. S. Weir Mitchell cites the case of Sergeant C. Beatty, 26th Pennsylvania, shot through the calf, at Chancellorsville, May 
3, 1863, who suffered intensely from causalgia. The foot, a few days after injury, was prickling and burning intensely. After a fortnight the prickling 
ceased; but the burning persisted. He recovered in about five months, without treatment. In this valuable work, abounding in illustrations of the 
effects of shot lesions of the nerves of the trunk and upper limbs, I find no other example of shot wound of the nerves of the lower extremities. 

3 Privates Albro, 27th Michigan ; Fry, 3d New Jersey ; Riley, 10th New York ; and Smith, 46th New York. 

4 Case of Private T. J. Dame, Co. E, 18th Mississippi, wounded at Antietam, September 17, 1862. Died June 1\), 1863. See Spec. 3849, A. M. M. f 
Cat. Surg. Sect., 1866, p. 243. 

•Case of Private E. M. McGregor, Co. C, 76*li New York, shot through the left sciatic nerve September 6, 1862. The missile lodged and could 
not be detected during life. He had motor paralysis of the leg muscles, and intense pain in the upper part of the track of the perineal and anterior tibia, 
and used hypodermic injections of morphia. He died February 1, 1863. 

SUBG. ni— 2 



10 INJURIES OK THE LOWER EXTREMITIES. [CHAP. X. 

twenty-five survivors, one fully recovered and returned to duty, three entered the Veteran 
Reserve Corps, and twenty-one were discharged. With few exceptions, they suffered from 
neuralgia or from partial motor paralysis. One (Private Armlin, 134th New York) had 
reflex paralysis of the arm on the side corresponding with the injury to the sciatic nerve. 
Notes of two of the cases of persistent neuralgia are appended: 

Case 12. — Private W. T. Burk, Co. F, 151st New York, aged 24 years, was wounded at Monocacy, July 9, 1864, and 
admitted to hospital at Frederick the following day. Acting Assistant Surgeon E. R. Ould reported: "Gunshot flesh wound 
of both thighs, perforating upper third and injuring the sciatic nerve of the right thigh. The patient is of a nervous and 
irritable temperament. Simple dressings were applied, and opiates given at night; wound healing. July 20th, great pain 
complained of in the course of the sciatic nerve and increasing in the region of the foot and ankle ; pulse accelerated, 100 per 
minute; pain increasing; general appearance moderately good; appetite poor. Applied pounded ice to foot and gave two 
drachms of solution of morphia four times a day. August 1st, the ice moderated the amount of pain; treatment continued. 
Patient slept half the night. August 12th, patient much improved; ice discontinued; prescribed morphia, iron, and quinine 
four times a day. September 1st, pain more severe; the wounds have entirely healed ; treatment continued. September 20th, 
walking about with crutches, but very lame; stimulating and anodyne liniment used night and morning. September 25th, 
patient finds great relief by keeping his hands wet with water; bowels regular; pulse natural. October 1st, but slight 
improvement; continued the quinine and iron mixture, also one drachm of fluid extract of cimicifuga. October 30th, still 
walks lame, the leg being very painful on motion. October 31st, furloughed this day; patient has but little prospect of a speedy 
recovery." He subsequently returned to the hospital, and was mustered out of service May 31, 18G5, and pensioned. Examiner 
J. II. Helmer, of Lockport, New York, February 9, 1868, certified: "Ball entered right thigh, upper third, passed through in 
front of the bone, and through the left thigh back of the bone, destroying the femoral nerve. Left leg two inches smaller than 
the right; muscles flabby; no voluntary motion of the left foot. He can walk, but walks like a paralytic." At a subsequent 
examination it was additionally reported that "the temperature of the left leg and foot is reduced," etc. The pensioner was 
paid June 4, 1876. 

Case 13. — Private C. J. Keegan, Co H, 80th New York, aged 40 years, was wounded at Gettysburg, July 1, 1863, and 
entered the York Hospital on July 19th. Acting Assistant Surgeon G. Byers reported: "Gunshot flesh wound of right thigh; 
ball entered the middle third below the edge of the sartorius muscle, passing upward and outward, made its exit two inches 
below and behind the trochanter, injuring the great sciatic nerve in its course. The wound closed kindly; the leg and foot, 
however, continued oedetnatous, and the man has suffered very greatly with pains of a darting character. Ho has at no time 
been able to use the limb since the receipt of the injury. Liniment of aconite was applied to the leg, and opiates were given 
internally. May 23, 186J, the pain has much diminished in intensity within the last two months." The patient was discharged 
from service June 28, 1864, and pensioned. Examiner H. B. Day, of Utica, New York, certified, February 16, 1865: * * 
" The great ischiatic nerve must have been injured, as he has constant pain, numbness, and partial paralysis of the parts supplied 
by this nerve and its branches, rendering him unable to stand for any length of time," etc. Examiner I. Spencer, of De Ruyter, 
certified, October 19, 1865: "Permanent lameness of the thigh. The foot is also deformed by an unnatural action of the muscles 
contracting the toes obliquely, and there is an unnatural fixedness of the arch of the foot," etc. Subsequent examiners reported 
substantially the same, and all concur in their belief as to the nerve injury. This pensioner was paid June 4, 1876. 

The two patients wounded in the anterior crural nerve, were discharged without 
relief of the persistent pain that followed their injuries. Surgeon I. I. Hayes, U. S. V., 
has furnished a detailed report of one of the cases : 

Case 14. — Private W. H. Cookson, Co. E, 42d New York, aged 23 years, was wounded at Antietam, September 17, 
1862, and entered the Satterlee Hospital, Philadelphia, nine days afterwards. Four months after his admission Surgeon I. I. 
Hayes, U. S. V., reported: "He was wounded by a mini*) ball entering on the outer side of the right thigh, about midway 
between the anterior superior spinous process of the ilium and the trochanter major, and, passing obliquely upward, made its 
exit near the middle of Poupart's ligament, wounding, I infer, the anterior crural nerve, from the intense pain he has suffered 
in the course of that nerve. The wound has long since healed. The suffering experienced over the front and side of the thigh, 
parts supplied by the anterior crural nerve, is instructive as showing the effect of an injury in the course of a nerve manifesting 
itself in the extremities of that nerve. The pain has not abated by the use of the most powerful anodynes, and sleep is only 
procured through the influence of sulphate of morphia. A question, which is still 'subjudice,' arises: Shall we excise that 
portion of the nerve which is wounded, hoping thereby to relieve his almost intolerable suffering ¥' The patient was discharged 
from service February 28, 1863, and pensioned. Drs. T. S. Johnston and R. H. Hope, of Rock Hill, S. C, in certifying to the 
results of the wound, May 9, 1874, stated that "from this cause he is now suffering with neuralgia and partial paralysis of the 
extensor muscles of the thigh." The pensioner was paid June 4, 187C. 

Of the five cases of wounds of the long saphenous, one resulted in complete recovery, 

1 J. Masox Wahben, in an interesting article on Neuralgic Affections following Injuries of Nerves, in Am. Jour. Med. Set., N. S., 1864, Vol. 
XLVII, p. 316 (which is reproduced in his excellent Surgical Observations, Boston, 1867, p. 46o). details the case of a soldier with wound of the sciatio 
nerve, who was probably Private D. Callahan, Co. E, 111th Massachusetts, aged 'J, 1 years, whose history on the registers of this Office closely corresponds 
to the graphi-' description given by Dr. Warren, to which the reader is referred. His Tension Report for 1876 ma}' be added : Thero was atrophy of the 
injured thigh and leg, with diminished temperature and grea'ly diminished motor power iu the muscles of the leg and frwt. 



SECT. I.] SHOT FLESH WOUNDS IMPLICATING NERVES. 11 

four in more or less paralysis and atrophy. 1 The case of wound of the middle cutaneous 
nerve was attended with severe neuralgia, which yielded to blistering and other remedies, 
and the patient returned to duty. 

The series of nine cases of wounds of the popliteal nerve comprises a fatal case of 
tetanus. 2 The other patients recovered, and three entered the Veteran Reserves, while 
five were discharged, one after recovery from amputation in the thigh, and one with 
excruciating neuralgia. 

The category of five cases of wounds of the anterior tibial included one death from 
tetanus. 3 The four survivors had partial paralysis of the extensor muscles. An instance 
is detailed : 

Case 15. — Private D. S. Pierce, Co. P>, 1st Michigan, aged 22 years, was wounded at Bull Run, August 150, 1862, and 
admitted to Eyland Chapel Hospital, Washington, three days afterwards. Surgeon J. A. Lidell, U. S. V., reported: "The 
patient was admitted to Stanton Hospital from Ryland Chapel, December 5th, with wound in the right leg. The bullet entered 
the outer part of the front of the middle third of said leg, about midway between the tibia and fibula. The bullet did not go 
through the limb. It, however, went in so deep that it could not be reached by exploration. The wound has been healed since 
the middle of October. The missile has gravitated through between the tibia and fibula, and can now be i'elt deeply seated in 
the muscles of the calf. It gives him no trouble. The anterior tibial nerve was divided by the bullet, in consequence of which 
the muscles of the front of the leg are paralyzed. The end of the foot points downward from activity of those on the back of 
the leg, and the case resembles talipes equinus. The patient walks haltingly, but without a cane, by the aid of a high-heeled 
shoe. He has suffered but little pain since the wound healed, and considers himself to be slowly improving. lie was discharged 
December 16, 1862." Examiner D. Hudson, of Lansing, Michigan, reported, May 8, 186;}: "Ball passed through both peroneal 
muscles, dividing the tibial nerve * * and lodging deep in the soleus muscle. Ankle joint became stiff at an obtuse angle, 
requiring a heel more than an inch higher on the right shoe than on the left one. Neuralgic pain in foot and ankle daily and 
hourly." Drs. J. B. Hull and I. H. Bartholomew, of the Lansing Examining Board, certified, December 7, 1870: "The ball 
passed down, and now lies under the skin above the inner malleolus. He cannot stand on his leg but a short time, and is getting 
worse," etc. They also stated that they excised the ball, and reported, September, 1872: "The nerve is diseased, and he suffers 
great pain through the whole leg; is emaciated and feeble, and growing worse." This pensioner died of "consumption," 
November 22, 1872, superinduced, in the opinion of the attending physicians, by "the continually depressing effects of the pain 
and tenderness of his limb." 

The three cases of wounds of the posterior tibial nerve were fatal. Two involved 
unsuccessful amputations, one at the knee joint and one in the leg, and the third was fatal 
from gangrene. 4 The two amputations were practised after tetanus had supervened: 5 

Case 16. — Corporal B. Prather, Co. D, 103d Ohio, aged 18 years, was wounded at the battle of Nashville, December 
15, 1864, and was admitted to the Cumberland Hospital on the following day. Surgeon B. Clark, U. S. V., reported: "Gun- 
shot wound of right foot, ball entering immediately under the metatarsal bone of the great toe and burying itself in the plantar 
fascia. The soft parts were remarkably sensitive in the vicinity of the wound, showing a great degree of muscular and nervous 
irritability. The foot was not swollen, the bones were not fractured, nor the tissues severely lacerated. December 26th, the 
ball was removed by Acting Assistant Surgeon S. G. Ayres ; second operation, exsection of a half inch of the posterior tibial 
nerve, behind the inner malleolus, by Assistant Surgeon W. B. Trull, U. S. V.; third operation, amputation of the toe, with 
removal of the first metatarsal bone, by Acting Assistant Surgeon L. E. Tracy. The patient complained, on December 26th, 
saying that a feeling of stiffness had been coming on for three days, especially in the shoulders, neck, and jaws. The latter 
gradually closed until it was impossible to introduce food into his mouth. There was a tetanic spasm of the muscles of deglutition, 
so that the patient was dying from inability to swallow. Chloroform alone seemed to afford temporary relief from his intense 
sufferings. Relaxation of the jaws was effected by division of the nerve, but the spasms of the muscles immediately returned. 
At midnight of the 27th, amputation at the lower third of the leg was performed by Acting Assistant Surgeon S. G. Ayres, but 
without effect. Large opiate injections were afterward given, and the patient obtained sleep. A copious warm perspiration 
breaking out upon the face and the improved pulse were considered favorable symptoms. Died December 28, 1864." 

The three cases of shot wounds of unspecified nerves were probably examples of 

1 Cases of Lieutenant A. Rodman, 2d Wisconsin, wounded in 1862, and who recovered. Also of Private W. Lette. Co. F, 29th New York, wounded 
at Bull Run, August 09, 18G2; Corporal A. McNeal, Co. A, 121st New York, wounded October 19, 1862; Sergeant C J!. Clark, Co. H. 32d Virginia, 
wounded at Spottsylvania, May 12, 1864 ; and Private P. J. Vitnont, Co. C, 7th Kentucky Cavalry, who were discharged for disability. 

'Case of Private J. G. Grissetta, Co. D, 2d Alabama; wounded at Fort Blakely, April 9, 1864; died April 21st. It is stated that the popliteal 
nerve was "dark and disorganized." 

3 Private James Rollins, Co. H, 28th North Carolina, aged :!0 years ; wounded at Gettysburg, July 3, 1863 ; tetanus July 20th ; death, July 22, 1863. 

4 Case of Private G. Richmoud, Co. D, 111th New York, wounded at Bristow Station, October 14, 1863, in the upper third of the left calf by a 
carbine ball. He was setit to the Third Division Hospital at Alexandria. The wound was dilated by an incision. Gangrene appeared and spread very 
rapidly, and death took place October 23, 1863. 

5 CaSR 16, and the case of Private J. Leonard, Co. G, 5th Ohio, aged 22 years, wounded at Gettysburg, July 3, 1863 ; tetanic symptoms July 14th. 
■imputation at knee joint July 16th, and death three hours after. 



12 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

injuries of the sciatic in one instance, of the anterior and posterior tibials in the others. 
Abstracts of two of the cases are subjoined; the third case has been published, and has 
been noticed in the foot-note on page 9 (case of Private J. S. L. Scott, 121st New York). 

Case 17. — Sergeant J. W. Crane, Co. A, 79th New York, aged 27 years, was wounded at Bull Run, August 30, 1862, 
and admitted to Judiciary Square Hospital, Washington, one week afterward. On May 9, 1863, he was transferred to DeCamp 
Hospital, David's Island, whence Acting Assistant Surgeon J. W. Dickie reported: "A ball passed through right thigh at about 
the junction of the upper and middle thirds. The wound closed about the first of March, and a small abscess formed, about 
that time, a little below the wound. When the abscess healed a pain commenced in the left hip joint, extending to the foot. This 
pain was constant. No pain was felt in the right leg except when pressure was made on the wound. The pain was most severe 
in the hip and calf of the leg. It would at times ascend and affect the respiratory muscles, causing great distress and difficulty 
in breathing. Appetite poor when admitted, yet the patient is quite fleshy. Had taken considerable quantity of morphia, so 
much as to be free from pain. May 13th, had recurrence of pain and dyspnoea, and spasm of upper extremities. Gave chloro- 
form, twenty drops, and repeated the dose in fifteen minutes. May 17th. had another spasm; same treatment. Has slighter 
attacks more frequently, which are relieved by exposure to cold. May 19th, had another spasm ; two grains of sulphate of 
morphia given ; pain checked. May 24th, another spasm ; gave chloroform one drachm, and sulphate of morphia one grain ; pain 
relieved. On the next day cauterization was performed along the course of the great ischiatic and peroneal nerves. May 28th, 
gave nine grains of sulphate of quinine and a half grain of sulphate of morphia, and repeated every evening. May 29th, 
had a recurrence, but not much spasm. June 12th, the cauterized surface is healed; patient improving and has but little pain. 
June 22d, walked out, supporting himself by means of canes." The patient was subsequently transferred to McDougall 
Hospital, where he was recorded as having been "returned to duty December 28, 1803." The records, however, do not show 
that he resumed active duty in the field. He was mustered out October 0, 1804, and pensioned. The Hartford Examining 
Board certified, May 3, 1871: * * "The muscles and skin are bound down to the bone and are much impaired in action. 
Partial paralysis of both limbs, owing to the injury to the nerves." The same Board reported, September 15, 1873, that "owing 
to the injury to some nerve he suffers excruciating pain on slight exercise or change of temperature," and, at a subsequent 
examination, they stated that "pain extends to the spine and down the other leg, and the limb at such times is drawn up 
spasmodically ;" also that " he is confined to bed from one to three months every year," etc. The pensioner was paid June 4, 1876. 

Case 18. — Private J. W. Young, Co. E, 137th New York, aged 27 years, was wounded at Gettysburg, July 2, 1863, 
and admitted to Harewood Hospital, Washington, three weeks afterward. Acting Assistant Surgeon T. II. Elliott reported: 
"Gunshot wound of right leg. Ball entered through upper portion of gastrocnemius muscle and emerged near the head of the 
fibula. The foot, immediately after the injury, dropped to full extension; all of the muscles of the leg paralyzed from division 
of nerves; flexors of thigh contracted, causing the heel to be raised from the floor three inches in the erect posture. Patient is 
unable to bear any weight on the limb. August 6th, wound unhealed; paralysis of extensor muscles complete. Patient 
discharged from service August 10, 1863." Examiner J. G. Orton, of Binghamton, New York, September 15, 1866, certified: 
"The power of flexion of the foot upon the leg is impossible in consequence of injury to flexor muscles; walking is performed 
with much difficulty and not without assistance." On February 29, 1876, he reported : * * "The power of flexion of the 
foot is entirely gone. It is at present almost worthless, the foot being swollen, and drags when he walks; he cannot walk 
without assistance." The pensioner was paid March 4, 1876. 

In addition to the cases of reflex paralysis cited from Dr. Keen in foot-note 2 on 
page 9, a report of an instance of this rare affection is given below. 1 Special reports of 
operations on tins subject are infrequent. 2 

1 Private C. Sullivan, Co. K, G9th New York, aged 3(i, was wounded at Spottsylvania, May 10, 18(14. From a field hospital of the Second Corps 
he passed to Douglas Hospital at Washington, and thence to South Street at Philadelphia, from all of which places "a shell wound of the left leg" was 
reported. Assistant Surgeon S. A. STORROW, U. S. A., in charge of the Filbert Street Hospital, described the injury as ''a shot wound of the gastro- 
cnemius muscle, involving the posterior tibial nerve." Acting Assistant Surgeon L. Tosier reported the patient's admission tothe Ladies' Home Hospital, 
New York City, November 7th, and the following history: "A shell wound of the posterior portion of the leg, severing the lower portion of the gastro- 
cnemius muscle. The wound has healed with considerable contraction of the parts, flexing the foot strongly and leaving the ankle joint exceedingly 
tender and painful — almost immovable. On the morning of July 11th the patient awoko with almost complete paralj'sis of each forearm and band, in 
which condition they yet remain." The patient was discharged December 9, 1864, and pensioned. Examiner E. Bradley, of New York, on February 10, 
1806, certified to atrophy of the wounded limb and an open ulcer occupying the lower nnd posterior surface: also to partial paralysis of the right hand. 
The New York Examining Board reported, September 11, 1872: "A shell wound, etc., leaving a tender cicatrix which is constantly breaking open. 
Locomotion is interfered with. The limb is very tender, and it is painful for him to walk. He cannot move his right hand on account of total paralysis 
of it. nor close the fingers. He states that both hands became paralyzed after he was wounded, and that he recovered the use of the left hand, but the 
other hand remained useless. We cannot discover any connection between the wound of the leg and the paralysis of the hand." Dr. A. B. MOTT, of 
New York City, who was surgeon in charge of Ladies' Home Hospital at the time of the pensioner's discharge from service, certified, February 22, 
1873: 'At the time of his admission to the hospital the patient had lost the use of both arms, but he recovered the use of the left arm. As far as my 
memory serves me, it was my opinion at that time that the paralysis was due to shock at the time of receiving the wound." The pensioner was paid 
June 4, 1877. 

2 On wounds of the nerves of the lower extremities the reader can consult, in addition to the works already cited, and the researches of CuuiK- 
SHANK, FONTANA, J. F. MECKEL, ItETZIUS, TIEDEMANN, and other experimenters in surgical physiology on the results of division of the nerves, the 
following authors: DESCOT, Diss, sur les affections locales des nerfs, Paris, 1823, No. 233 ; Swan (J.), A Treatise on Diseases and Injuries of the Nerves, 
2d ed., London, 1834 ; HAMILTON (J.), On some effects resulting from Wounds of Nerves, in Dublin Jour, of Med. Sci., 1834, Vol. Xin, p. 38 ; WALLER, 
Nouv. meth. anat. pour Vinvestigation du systeme nerveux, Bonn, 1852; PHILLIPEAUX and VULPIAN, Recherches sur la regeneration des nerfs, in Mem. 
de la Sort He de Biologic. 1859; DuCHEXNE, De electrisation localisie, etc., 2d ed., 18G0; LoNUE, Recherches sur les n&vralgics, consicutives aux lesions des 
nerfs, Paris. 1860, No. 199 ; TILLAUX (P.), Des Affections Chirurgicales des Nerfs, Paris, 1866 ; PAULET, Les Suites immediates et eloignees des lesions 
traumatiques des nerfs, in Gaz. LTebdom. de Paris, 1868, T. V, p. 283 ; FOLLK (E.), Traitl Hem. de path, ext., Paris, 1807, T. II. p. 233. 



sect. I.] shot FLESH WOUNDS IMPLICATING BLOOD-VESSELS. 13 

Flesh Wounds of the Lower Limbs with Injury of the larger Blood-vessels. — As 

indicated in my preliminary surgical report in Circular 6, S. G. 0., 1865, p. 38, shot 
wounds of the larger arteries of the lower extremity, the femoral, profunda, peroneal, and 
tibials, uncomplicated by fracture of the adjacent bones, or by extended disorganization or 
complete removal of the limb by the impact of large projectiles, that come under the treat- 
ment of the military surgeon, are comparatively infrequent. It is difficult to convince 
surgeons who have had little field practice of the rarity of this form of accident. 1 It is 
strikingly illustrated by the fact that, in the series of fifty-eight thousand seven hundred 
and two cases of shot flesh wounds of the lower extremities we are now discussing, only a 
hundred and fifty-six instances of this particular lesion, or 2.6 per thousand, were reported. 
Of one hundred and fifty-six cases, thirty-three were treated without operative inter- 
ference, eighty-seven by ligation, twenty-three by amputation, and eight by ligation 
followed by amputation. These four groups will be separately considered. 

Wounds of Blood-vessels treated without Operation- — This group comprises eighteen 
cases of wounds of the femoral artery, in two of which the femoral vein was likewise 
implicated. Of these fifteen terminated fatally. There were three fatal cases in which 
ihe femoral vein alone was involved. There were four cases of wounds of the popliteal, 
with two recoveries. Of two cases of wounds of the posterior tibial, one complicated by 
wound of the peroneal was fatal. Of two cases of wounds of the peroneal one was fatal, 
and the result in the other case cannot be ascertained. Two cases of wounds of the 
mternal saphenous vein resulted favorably, as did a case of wound of the dorsalis pollicis. 
A case of wound of an unspecified artery of the lower extremity had a fatal result. 
Twenty-three of the thirty-three cases terminated fatally, a mortality of 71.8 per cent. A 
few examples of these injuries will be detailed, commencing with a case of occlusion of the 
femoral artery from contusion, and two instances of direct lesion of that vessel: 2 

Case 19. — Private S. T. Newell, Co. B, 1st U. S. Artillery, aged 21 years, was wounded at Gettysburg, July 2, 1803, 
and entered the Satterlee Hospital, Philadelphia, July 11th. Acting Assistant Surgeon W. C. Dixon reported: "The missile, 
<i piece of shell, struck the inner side of the left thigh, middle third, producing a severe flesh wound. Simple dressings were 
applied. On the 19th the wound assumed a gangrenous appearance; a mixture of equal parts of creasote, alcohol, and water 
was applied. Under that treatment it remained about the same until July 28th, when the sloughing commenced to spread 
rfipidly and nitric acid was applied. On the 29th the femoral artery was exposed at the upper and lower edges of the wound, 
with a large amount of sloughing tissue occupying the intermediate space. Two days later the slough was removed from 
around the artery, which was found to have been converted into a fibrous cord bearing no resemblance to an artery. It was 
watched closely to guard against haemorrhage. At 2 o'clock P. M. on August 1st the artery separated, and the proximate and 
distal extremities of the vessel were found to be perfectly occluded. The wound healed rapidly, and in September the patient 
was transferred to Fort Hamilton." He was discharged, at Fort Independence, December 7, 1863, and pensioned. Examiner J. 
H. Crombie, of Derry, N. H., certified, May 6, 1874: * * "Was struck by a piece of shell, * * making a wound six 
inches in length and three in width, penetrating nearly to the bone. The limb is weakened very much. The muscular power 
is considerably limited. He is unable to walk or labor on the limb for any length of time by reason of weakness." The 
pensioner was paid June 4, 1876. 

1 Heine (C.) (Die Schussverletzvngen der unteren Extremitaten, Berlin, 1866, p. 127) remarks that : " The rarity with which shot injuries compli- 
cated by serious arterial haemorrhages present themselves to surgeons at the stations for first dressings (erste Vrrbandplatz) is an experience that repeats 
itself in every campaign. Hence operative interference on account of wounded blood-vessels is seldom necessary at this stage. From the last war [the 
Danish war of 1864J I cannot recall a single case in which ligation or amputation was performed fur primary bleeding at the field ambulance stations." 
Tho first chapter of GUTHRIE'S Commentaries on the Surgery of the Peninsular War, that excellent vade-mecum of the military surgeon, and the chap- 
ter on gunshot wounds of the extremities by MATTHEW, the historian of the surgery of the British army in the Crimea, have already established the 
doctrine above enunciated. The misconceptions which such an authority as Valentine Mott adopted in his paper On Hxmorrfiage from Wounds, — 
n paper contributed to the publications of the SAN1TABY Commission, — can only be explained by his comparatively slight acquaintance with the effects 
of shot injuries. 

2 Of the remaining fifteen cases of shot wounds of the femoral artery treated on the expectant plan, one resulted successfully — case of Wammack, 
5th North Carolina — and fourteen fatally, viz: Dinguid, Griffin's Battery; Ledbetter, 9th Alabama; Sylvester, 9th New Hampshire; Riming. 8lst Penn- 
sylvania; Corris, 17th Illinois; Collins, Ordnance Corps; Blaisdell, 17th Massachusetts; Lawrence, 9th New York Cavalry; Masser, 14 Jd Pennsyl- 
vania; Craft, 144th New York; Stephen, 147th New York ; Geary, 4th Georgia; Bailey, 8th Illinois Cavalry, and Clarendon, 26th Massachusetts. In 
the last two cases the femoral vein was also implicated. It is impracticable to give the details of these cases, but the names are mentioned in order that 
students of this special subject may be enabled to refer to them in the M.S. records of the Surgeon General's Office. 



14 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

Of the cases of wounds of the femoral artery treated without operation, a case of 
recovery and a fatal case will be detailed: 

Case 20. — Lieutenant L. Hallman, Co. D, 51st Pennsylvania, aged 24 years, was wounded at South Mills, April 19, 
1862, and admitted to Hygeia Hospital, Fort Monroe, five days afterwards. Surgeon K. B. Bonteeou, U. S. V., reported: 
"Gunshot wound of femoral artery, a bullet traversing the middle of the left thigh, entering anteriorly, and escaping on the 
posterior aspect just opposite. Pulsation could indistinctly be felt in the pedal and posterior tibial arteries. About one week 
after admission a smart arterial haemorrhage came from the anterior wound. Compression by a bandage and cold wet applica- 
tions were made, and the haemorrhage was controlled, but returned the next day. We proceeded to his room to tie the femoral ; 
on consultation, however, it was decided to wait, and, if it should bleed again, to operate. He continued doing well. Treat- 
ment : Absolute rest and cold wet applications, ice in small portions being allowed to melt on the bandage which surrounded the 
thigh. May 20th, abscess of the skin appeared, and discoloration of the great toe, which eventually sloughed to the first pha- 
lanx; temperature of the foot all the while good. He was sent to Philadelphia, in June, quite well." Lieutenant Hallman 
was transferred to the Veteran Reserve Corps on March 14, 1864, and ultimately mustered out of service June 30, 1866, and 
pensioned. Examiner W. Carson, of Norristown, Pennsylvania, March 3, 1867, certified : " Ball passed through left thigh, * 
* wounding the sciatic nerve; has lost first joint of great toe, with immobility of all the toes. Atrophy of limb equal to one 
inch in circumference; foot cold." Examiner H. E. Goodman, of Philadelphia, certified, September 18, 1869: * * "Limb 
much weakened and painful all the time." The pensioner died, of consumption, November 24, 1871. 

Case 21. — Sergeant II. Booth, Co. E, 7th Indiana Cavalry, aged 24 years, was admitted to the Gayoso Hospital, 
Memphis, April 18, 18G4, having been wounded on the previous day by the accidental discharge of a revolver held in the hands 
of one of his comrades. Surgeon F. N. Burke, U. S. V., made the following report : "The ball entered the left thigh directly 
over the course of the femoral vessels, two inches below Poupart's ligament, and escaped at the crease of the nate and median 
line of the left thigh. There was copious haemorrhage at the time the wound was received, but it was arrested by application 
of the tourniquet. As a precautionary measure it was left on at the time of admission, but not tightened. The wound became 
unhealthy and had a gangrenous smell on the fourth day. Charcoal cataplasms were then applied, and Labarraque's solution 
used to the wound. On the sixth day haemorrhage again occurred, amounting to about six ounces, but pressure again arrested 
it. For the twenty-four hours preceding this the whole limb had become swollen and cedematous, especially the upper portion 
of the thigh. The patient had become very much prostrated and his pulse quite weak. He was naturally of a weak constitu- 
tion. It was thought that to tie the artery there would result in gangrane of the limb, as its vitality was evidently quite low, 
and, the wound being unhealthy, secondary haemorrhage from the sloughing of the vessel would be imminent. Amputation 
was then thought of, but it was obvious that the patient was too much prostrated to hope for a successful result. Oozing of 
blood occurred a couple of times during the ensuing few days, but the formation of a small clot was sufficient to arrest it. He 
died on April 28, 1864. The post-mortem examination discovered the femoral artery to have been perforated so as to admit the 
passage of a duckshot through the wound about half an inch below the origin of the profunda. The femoral vein was found 
to have sloughed for a distance of about one and a half inches, gangrene having extended along the fascia and cellular planes 
from one to one and a half inches at different parts along the course of the wound. The ball had passed between the femoral 
vessels and the femur." 

Of the four casss of injury of the popliteal artery, a fatal instance and one that 
eventually resulted in fatal aneurism arc selected for illustration - 1 

Case 22. — Private J. C. Mapes, Co. K, 103d Pennsylvania, aged 22 years, was wounded in the left leg at Kinston, 
December 14, 1862, and entered the Stanley Hospital, New Berne, six days afterwards. Acting Assistant Surgeon J. B. Upham 
reported : "A minie ball entered three inches above the knee joint, on the inside, over the track of the femoral artery, and 
passing downward and backward emerged in the popliteal space near the insertion of the biceps, lacerating, in its course, the 
popliteal artery. His condition at the time of his admission was one of great mental and bodily depression. He was treated 
by stimulants, warm applications, and generous diet. Three days afterwards, secondary haemorrhage coming on, attempt was 
made to ligate the femoral artery by dilating the wound, which failed. Amputation was not resorted to on account of the con- 
dition of the patient. Gangrene below the point of the injury came on rapidly, and the patient died December 29, 1862, fifteen 
days after the reception of the wound. The post-mortem examination revealed the injury of the artery already alluded to, 
which extended for a considerable distance, the track of the ball being almost in a direct line with the course of the vessel itself." 

The other case referred to is a remarkable example of aneurism developed after 
fourteen years, as the remote result probably of a shot contusion of the popliteal artery: 

Case 23. — Private W. Young, Co. K, 4th New York, aged 19 years, was wounded at Fredericksburg, December 13, 
1862, and admitted to Campbell Hospital, Washington, four days afterwards. Surgeon J. H. Baxter, U. S. V., recorded: 
"Gunshot wound of leg; patient transferred to Baltimore January 8, 1863 " Surgeon L. Quick, U. S. V., reported that the 
patient was discharged from McKim's Mansion Hospital, March 18, 1863, for "gunshot wound of left leg, ball entering near 
the head of the tibia and emerging through the internal belly of the gastrocnemius muscle, producing lameness." The Boston 
Examining Board certified, October 27, 1865: "Has had wound of leg below knee, * * ball emerging one inch below and 
behind the internal condyle of the femur, evidently passing across the internal saphenous vein. Cicatrices not adherent, but 
there is some loss of substance of muscle, and the veins of the leg are varicose, probably in consequence of the wound. Mo- 
tions of joint good. He says he has pain in leg on walking or standing, and much pain in popliteal space while sitting." On 
August 25, 17i\">, thi,s pensioner came under the care of Dr. J. Collins Warren, at the Massachusetts General Hospital, who 

1 The other two cases of shot wounds of the popliteal artery are those of Pogue, 110th Ohio, who recovered and was discharged, and of Thompson, 
120th New York, who died sixteen days after the reception of the injury. 



SECT - '-J SHOT FLESH WOUNDS IMPLICATING BLOOD-VESSELS. 15 

reported tin- further progress of the case to the Boston Society for Medical Improvement, in the Boston Medical and Surgical 
Journal, Vol. XCV, No. 18, as follows : "Was wounded fourteen years ago, at the battle of Fredericksburg, by a musket ball, 
which entered the calf of the left leg a little to the inside, and came out opposite the inner aspect of the knee joint. There 
was no unusual amount of haemorrhage at the time, and the wound healed well, but on recovery a small bunch remained in 
the popliteal space, growing larger at times, and again almost wholly disappearing. One year ago it grew larger than before 
and began to pulsate. It soon filled the hollow of the knee, and during the last two months has spread rapidly on the inside 
of the thigh. The skin over the popliteal space is made tense by an ill-defined pulsating mass, which spreads along the course 
of the femoral artery to within eleven inches of the anterior superior spinous process of the ilium. The left knee is nineteen 
inches in circumference, while the right knee measures but thirteen and one-fourth inches. The patient suffers severely from 
pain in the calf and foot, which is relieved only by frequent subcutaneous injections of morphine. A pound cannon-ball applied 
to the femoral diminishes but does not arrest pulsation in the vessel. Heavy pressure with the hand arrests pulsation entirely. 
August 30th: The patient was etherized and pulsation in the femoral was arrested by two hospital tourniquets applied, near 
the apex of Scarpa's triangle, alternately every fifteen minutes for twelve hours. During this period the patient was kept 
profoundly etherized, about a pound and a half of ether having been consumed for that purpose, with the exception of a few 
minutes during the afternoon, when some beef-tea and brandy were administered. The pulse during this time gradually rose 
from the normal rate to about 120, but subsided somewhat after nourishment, had been taken. On removing the tourniquets 
pulsation had ceased, although on auscultation a slight murmur was heard beneath the tumor. At midnight there was no 
return of the pulsation, but the next morning a slight pulsation was observed, which gradually increased to its previous force. 
September 10th: Pressure was applied as before by tourniquet without other, the patient preferring to bear the pain, and was 
continued for twenty hours, but had no effect upon the pulsations, which reappeared after it was removed. September l'Jth : 
The patient was etherized, the sac laid open, the clots, which were numerous, everted, and the artery tied at each end. Il was 
found that the sac extended to the point of bifurcation of the popliteal artery. Two ligatures were therefore necessary at this 
point. The patient rallied well from the operation, and for the first week the wound healed rapidly. An attack of erysipelas 
arrested the healing process and reduced the patient greatly. On October 3d, haemorrhage occurred from the upper end of the 
wound during the afternoon, and although digital pressure was immediately resorted to by an attendant, and in a few minutes 
the tourniquet was applied, the patient sank, and died the same evening. Dr. Eitz showed the specimen, which consisted of the 
aorta from its origin, the left femoral, and a portion of the aneurism in continuity. The fatal haemorrhage had resulted from 
the sloughing of the walls of the artery at the upper end of the aneurismal sac, where the ligature had been applied. There 
was no alteration of the inner surface of the femoral artery, but the fibrous tissue was indurated around it, corresponding with 
the region where compression had been applied. The entire inner coat of the thoracic aorta was thickened, wrinkled, elevated 
in patches of an opaque grayish-white color, and the canal was dilated, especially that of the arch. Just above the coeliac axis 
these alterations ceased abruptly, the interior of the abdominal aorta being smooth and yellow, its walls evidently in a normal 
condition. The specimen was particularly interesting from the absence of changes at the point of compression and the presence 
of chronic inflammatory conditions of the thoracic aorta, such as are associated with the formation of aneurisms in a young 
man in whom a popliteal anuerism had arisen directly or indirectly from a traumatic cause." 

Of five cases in which large veins were wounded, three in which the femoral vein 
was separately injured proved fatal, and two, in which the internal or long saphenous was 
believed to be lacerated, recovered. One of these is detailed: 1 

Case 24. — Lieutenant L. D. Martin, Co. A, 29th Illinois, aged 32 years, was wounded through the left thigh at the 
siege of Fort Donelson, February 15, 1862. Dr. Madden, of Nashville, noted the following history of the case, which was 
forwarded by Surgeon E. Swift, U. S. A., Medical Director: "A rifle ball entered the limb at a point directly over the 
saphenous opening and glanced around upon the fascia lata to the outer aspect of the thigh, where it emerged one inch below 
the trochanter major. There was a copious flow of blood from the wounded veins at the time of the injury, but this was readily 
checked with lint. The patient was conveyed to the Academy Hospital at Nashville. On the eighth day there was a recur- 
rence of venous haemorrhage from the inguinal wound. This was again arrested by pressure, and the patient continued to 
improve till the evening of the 5th of March, when the bleeding was suddenly renewed to such a degree that the coats of the 
femoral artery were supposed to have yielded. Surgeon E. Swift, Medical Director in this city, having been consulted, he 
directed that the artery should not be ligated but judiciously compressed, and it was decided to postpone till the next morning 
any attempt to place a ligature upon the vessel. Pressure with the fingers upon the artery at the point of its emergence from 
beneath Poupart's ligament was maintained during the whole night by relays of assistants. Next morning, on intermission of the 
pressure, there was no haemorrhage, nor was there any pulsation distinguished below the wound. A compress was placed over 
the artery, and a bandage applied from the toes to the groin. This was removed at the expiration of twelve hours, and the 
limb was wrapped in flannels. Pulsation below the groin was not perceptible for several days. The limb, however, retained 
its temperature and its vitality, and the circulation gradually became re-established. There was no recurrence of haemorrhage. 
The patient recovered his strength rapidly, and returned to his home April 5, 1862, at which time he was able to walk with the 
assistance of a cane." Lieutenant Martin resigned the service September 17, 1862, and was pensioned. Examiner J. W. 
Redden, of Shawneetown, Illinois, March 1, 1864, certified: ''The ball entered the front of the left thigh near the femoral 
artery, which seems to have been wounded; there is general derangement of the nerves affecting the joints, and muscular 
activity and strength of the limb." Examiner H. W. McCoy, of Golconda, Illinois, September 16, 1873, reported the pensioner 
as having received a "flesh wound of the left shoulder" in addition to the above injury, but no mention is made of this in any 
previous reports. The pensioner was paid June 4, 1876. 

1 Tbe three cases of injur)- of the femoral vein are : Scullen, 25th Ohio, who died of pyaemia on the lGth day ; Bninbrulge, o'4th New York, fatal on 
the 23d day (fur autopsy see Lincoln Hospital Case Book No. 17); and Schumaker, 2d New York Cavalry, who died on the eighth day after the reception 
of the injury. The ether case tA injury of the internal saphenous vein is that of Johnson, 7th Connecticut, who recovered and was discharged. 



16 INJURIES OF THE LOWER EXTREMITIES. TCHAP. x. 

The result of this series of thirty-three shot wounds of the larger arteries and veins 
of the lower limb sufficiently prove that compression, styptics, or a let-alone practice 
cannot be safely adopted in such grave accidents. The histories of three fatal cases of 
wound of the femoral vein corroborates the argument of Surgeon S. W. Gross, U. 8. V., 
in favor of the ligation of wounded venous trunks. 1 Surgeon J. A. Lidell, U. S. V., in 
his excellent memoir on traumatic haemorrhage, 2 has cited two or three other instances of 
shot lesions of the great vessels of the thigh, reported by Surgeon W. Clendenin, U. S. V., 
of which I am unable to find any mention in the official returns. The comparative rarity 
of profuse primary bleeding from shot wounds of the large blood-vessels of the extremities 
can hardly be seriously contested. 3 

Wounds of Blood-vessels treated by Ligation. — Eighty-seven cases were reported of 
shot flesh wounds of the lower extremities with lesions of the larger blood-vessels, treated 
by primary or intermediary ligation of arteries. Only twenty-six of these resulted 
favorably, leaving the formidable mortality-rate of 70.1 per cent. Six cases in which 
the external iliac artery was tied for wound of the femoral or profunda, or of these vessels 
and their accompanying veins, were fatal. Of sixty-two ligations of the femoral but 
seventeen, or 27.4 per cent., were successful. One of two ligations of the profunda was 
successful. In seven ligations of the popliteal, two patients survived. There were two 
ligations of the anterior tibial with one recovery, — live of the posterior tibial with four 
recoveries, — two of both tibials with one recovery, — and one fatal case of ligation of the 
peroneal artery. All of these cases will be hereafter enumerated in brief abstracts or in 
tabular form; but, as there are many other cases of deligation of the same vessels in shot 
flesh wounds without primary arterial lesion, it will be most convenient to classify the 
analogous cases further on, and there will be presented here only a single abstract of a 
remarkable recovery after, ligation of the femoral artery for shot injury: 3 

Case 25. — Assistant Surgeon R. S. Vickery, 2d Michigan, aged 33 years, was wounded at Petersburg, July 30, 1864, 
and admitted to the field hospital of the 3d division, Ninth Corps. Surgeon P. A. O'Connell, U. S. V., reported : "Gunshot 
wound of upper third of left thigh by minie' hall; ligation of femoral artery performed by Surgeon W. B. Fox, 8th Michigan." 
From the field hospital the patient was moved to City Point, and subsequently to New York. Assistant Surgeon J. E. Semple, 
U. S. V.. reported his admission to the Officers' Hospital, Bedloe's Island, August 25th, with "flesh wound involving direct 
injury to the large artery of the thigh." In January following, the invalid was transferred to Armory Square Hospital, Wash- 
ington, where he was discharged from service March 11, 1805. Examiner J. Nichols, of Washington, certified, March 24, 
1865 : " Gunshot wound of left thigh, inner aspect, upper third, ball severing femoral artery. Limb much atrophied and shrunk 
away almost to the bone; leg partially flexed upon the thigh; inability to extend it. Great danger of secondary hemorrhage 
from the artery, which requires a long time for restoration. Limb perfectly useless; prognosis doubtful — may yet have to be 
amputated." Dr. Vickery was a pensioner until May 14, 1867, when he was appointed Assistant Surgeon in the regular army. 



1 GROoS (S. W.), Iiemarks upon the General Applicability of Ligation as a Venous Hemostatic Agent, in Am. Jour. Med. Sci., 1867, Vol. LIU, 
pp. 17, 305. 

* In his paper on the Wounds of Blood-vessels, Traumatic Hemorrhage, Traumatic Aneurism, and Traumatic Gangrene, in the Surgical Memoirs 
of the Sanitary Commission, 1870, Vol. I, p. 51, eto., Dr. JOHN A. LIDELL published several abstracts, contributed by Surgeon W. CLENDENIN, U. S.V., 
purporting to bo descriptions of examples of "complete division of arteries by gunshot projectiles. 1 ' Although these abstracts aptly illustrate the subject 
in hand, it lias been found impracticable to verify the cases on the regimental and hospital returns ; but in tho confusion of the battle-field it is probable 
that not c ow important surgical accidents failed to get recorded In the case of James Brown, 3d Tennessee Mounted Infantry (loc. cit., p. 51), it 
api ars i ...t this regiment was never in action, and the patient's name is not on the hospital registers, nor does it appear on the death records. In 
the case of James O'Neal {loc. cit., p. 55), it is left to conjecture whether tho man belonged to the 10th Tennessee Mounted Infantry or to Wheeler's 
Cavalry. No reference to such a case is found on the files of the "War Department. In the case of Sergeant French, 4th II. S. Cavalry (loc. cit., p. 56), 
neither the date of the injury nor the engagement in which it was received are given, and on inquiry of the Adjutant General it has been ascertained 
that "there is no record of the enlistment of any soldier by the name of French in tho 4th U. S. Cavalry, from 185G to 1865, inclusive." 

3 BILLROTH (Til.) (Chirurgische Brief e, etc., Berlin. 1872, p. 113) remarks: "Of the immediate results of injuries of the larger blood-vessels, of 
profuse haemorrhages on the field of battle, 1 have as little to relate as other surgeons that have served in the field. None of tho colleagues with whom 
I conversed had observed such bleedings. Nowhere did I find a case of primary ligation of a large blood-vessel. It has been asserted that injuries of 
this kind prove fatal so rapidly on the battle-field that any assistance comes too late. There is no valid proof of this assertion. * * Observations are 
accumulating that arteries, even of the size of the aorta, when perforated by some modern shot projectiles, do not invariably bleed. In Carlsruhe, I have 
learned of a case a priori incredible, but attended by a careful autopsy, in which a shot through the aorta caused no bleeding until several days after the 
injury; the patient was therefore transported from Worth to Carlsruhe with a hole in his aorta without any bleeding. I have, myself, seen three cases 
of shot wounds of the external iliac and fomiral artery in which no bleeding occurred." Froiessor BILLROTH then details the cases. 



SECT. I ] 



SHOT FLESH WOUNDS IMPLICATING BLOOD-VESSELS. 



17 



Dr. F. H. Hamilton states (Appendix to Treatise on Military Surgery and Hygiene, 1865, p. C40) that in this case "the 
bleeding was arrested temporarily by a tourniquet, and three hours afterwards Surgeon Fox, of the 8th Michigan, enlarged the 
wound and tied the femoral loth above and below the scat of injury." 

No military surgeon now disputes the propriety of tying both ends of a bleeding 
artery at the wounded point, 1 and it is probable that if the judicious practice of Surgeon 
Fox had been more generally followed, and the precepts of Guthrie better appreciated, the 
deplorable fatality of this series of cases might have been largely averted. 

Wounds of Blood-vessels treated by Amputation. — There were twenty-eight cases in 
which amputation was practised on account of uncontrollable bleeding from shot wounds 
of the larger blood-vessels of the lower extremity, and eight cases mentioned in the next 
subsection, in which recourse was had to amputation after proximal ligation of main 
arterial trunks had proved ineffectual. The series of twenty-eight cases includes twenty- 
six thigh amputations with only seven recoveries, a fatal amputation at the knee, and a 
fatal amputation in the leg. In this series the femoral artery was wounded in eleven 
instances, the profunda in one, the popliteal in nine, one of the tibials in six, and the long 
saphenous vein in one. All of these cases are tabulated further on. Details of two are 
inserted here : 

CASE 26. — Corporal H. Scbatt, Co. H, 64th New York, aged 30 years, was wounded at Hatcher's Run, March 25, 
1865, and was admitted to the field hospital of the 1st division, Second Corps, where Surgeon F. M. Hammond, 120th New 
York, noted "a shot wound of the leg." On the following day the man was sent to City Point and thence to Washington. 
Assistant Surgeon II. Allen, U. S. A., reported his admission to Mount Pleasant Hospital April 2d, and contributed the follow- 
ing history: "Gunshot wound of left lower extremity, ball passing through popliteal space from without inward, injuring the 
popliteal artery. When admitted the patient's pulse was small, sharp, and fast; face 
pale and tongue coated. His toes were of a bluish tint, and the foot was covered with 
bluish and yellowish purple spots. The entire leg was greatly swollen and the super- 
ficial veins enlarged; the small veins of the lower third of the thigh, on the external 
surface, were somewhat discolored, and the integument was assuming a yellowish color. 
The limb was amputated at the lower third of the thigh, on the day of admission, by 
Acting Assistant Surgeon H. Craft. The operation was peiformed by the circular 
method, very little blood being lost. Two double ligatures were applied to the femoral 
and four to the branches. The anaesthetic consisted of equal parts of Bother and chloro- 
form. After the oper- 
ation, cold-waterdress- 
ings were applied, and 





a stimulating course 



Fig. i!. 



.. — Stump after intermediary amputa- 
adopted. Ihehgatures tion of thigh. Sptc. 2283. 
FIG. 1. — Cylindrical sequestrum from stump of left femur. Spec. 171. J. ,v • ,i 

» ~-» * j 3 came away on the sixth 

and seventh days. On May 10th, there were symptoms of the femur exfoliating. The 6tump was nearly healed, when a 

collection of pus formed around the bone, and to give exit to it an incision was made just above the end of the stump. This 

was kept open by a tent and the stump (jncouraged to heal. Simple dressings were continued, and the tonic and stimulating 

course was persevered in. The exfoliating process steadily progressed up to June 19th, when a sequestrum was removed 

which proved to be nine inches long and was nearly a perfect shaft, extending nearly or quite to the trochanter major. It 

had only been partially destroyed on its under surface, and a new shaft of bone had formed around it. The stimulants and 

tonics were now increased, with nourishing diet, and by Juno 30th the patient was progressing favorably." The sequestrum 

was forwarded to the Army Medical Museum by Dr. Allen, and is represented in the annexed cut (FlG. 1). The patient was 

subsequently transferred to Rochester, and ultimately discharged from Ira Harris Hospital, Albany, September 25, 1865. 

Assistant Surgeon J. II. Armsby, U. S. V., contributed a cast of the stump (Cat. Surg. Sect., 1866, p. 554), which shows the 

inferior portion to be baggy, and a deep and poorly healed cicatrix at that point, caused by loss of substance over; he b$ne 

(Fig. 2). Examiner G. W. Cook, of Syracuse, N. Y., July 9, 1873, certified: "Tenderness of stump and slight covering over 

end of bone. He does not, nor can lie, wear an artificial limb." The pensioner was paid June 4, 1876. 

Another case of this category is selected for illustration because it affords quite a 
typical example of what is likely to occur after a shot wound of the popliteal artery 

— ■ ♦ - ■ - 

1 Heine <C.) (Die Schussverktzungen tier untercn Extremitdttn, Berlin, 1866, p. l&J), speaking of shot flesh wounds with injury of the arteries, 
remarks : " The ligation of the femoral artery was practised eight times [in the Danish War of 1864] and the external iliac was tied twice. In one of 
the latter cases, the femoral artery had been previously ligated; but as bleeding recurred, the external iliac was tied. This is the only case of the ten 
ligations that proved successful. * * The bleeding was primary in two cases only. * * In two other oases, no bleeding at all occurred, although tho 
artery was completely severed in the wound ; in the rest cf the cases the bleeding was secondary, — from the seventh to the seventeenth day after the 
injury. 

Surg. Ill— 3 




18 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

unless the proximal and distal ends of the vessel are promptly secured by ligature, and 
the formation of traumatic aneurism in the ham and consequent gangrene of the leg 
prevented. Moreover, in this instance, the patient having been brought to Washington, a 
very conscientious artist was able to depict the appearance of the gangrenous limb, in a 
water-color drawing, which is reproduced with tolerable accuracy in the chromolithograph 
opposite : 

Case 27. — Sergeant G. W. Gardner, Co. A. 12th Illinois Cavalry, aged 29 years, was wounded at Mitchell's Ford, 
on the Rappahannock, October 11, 1863. Surgeon S. B. Wylie Mitchell, 8th Pennsylvania Cavalry, reported that he was 
struck by a conoidal carbine ball, which entered four inches above the right knee, passed through the inner hamstring muscles 
and the adductor maguus, outward and downward, and lodged under the integument on the outer side of the thigh. Upon 
extracting the ball through an incision there was a profuse haemorrhage, which ceased spontaneously. The patient was sent 
by railway tj Washington, and entered Emory Hospital on October 13th. Acting Assistant Surgeon J. Walsh reported that 

"he was feeble/and pallid; no pulsation could be detected in the tibial arteries of the injured limb. 
There was loss of sensibility and slight discoloration of the skin of the right foot. The leg was 
packed in raw cotton, and the temperature was kept up by bottles of hot water. Frictions with a 
Stimulating liniment were occasionally employed. After October 18th, the leg was daily immersed 
in a bath of oxygen gas. On October 25th, two bits of blue cloth and a small piece of white cotton 
cloth were extracted from the wound. The foot was decidedly gangrenous, and gangrene began 
to advance rapidly up the leg." At this time a sketch of the appearances of the limb was made, 
under Surgeon J. H. Brinton's direction, by Hospital Steward B. Stauch. This drawing was 
elaborated, after the lamented death of Mr. Stauch, by Hospital Steward Schultze, and has been 
reproduced by chromolithography in the plate opposite (PLATE I, 28). On October 29th, Acting 
Assistant Surgeon W. H. Ensign amputated the limb at the lower third of the thigh. On exam- 
ination of the amputated member it was found that the artery had been completely divided by the 
ball near the point at which it passes through the opening in the great adductor. The divided 
extremities of the artery were occluded by dark grumous clots. After the operation the patient 
was attacked by diarrhoea, and, on December 5, 1863, the case terminated fatally. A wet prepa- 

^ „ _ .... ration of the lower half of the right femur, with a portion of the soft tissues, including the popliteal 

Fir.. 3. — Preparation of lower . . D ' F . . „ 

half of the right thigh, showing artery and vein, was contributed to the Army Medical Museum by Acting Assistant Surgeon J. 

arfe'ry.'^c!"™.' 118 popliteal Walsh (Cat. Surg. Sect, 1866, p. 521), and is represented in the adjacent wood-cut (Fig. 3). 

Wounds of Blood-vessels treated by Ligation and subsequent Amputation. — Of the 
eight instances in which consecutive amputation was had recourse to after the failure of 
proximal ligation of large arteries for primary bleeding, six succeeded ligation of the 
femoral, one ligation of the popliteal, and one ligation of the posterior tibial. Five were 
amputations in the thigh, and three of the leg. Only one of the eight patients recovered, 
a case of wound of the popliteal artery treated by tying the femoral and subsequently 
amputating at middle thigh. One of the fatal cases is detailed: 

Case 28. — Corporal J. M. Harris, Co. E, 14th Iowa, aged 20 years, was wounded in the right thigh at the battle of 
Tupelo, July 15, 1864, and entered the Adams Hospital, Memphis, five days afterwards. Assistant Surgeon J. M. Study, U. S.V., 
made the following report: "A minie' ball entered the lower portion of the middle <rf the thigh and passed beneath the bone 
without fracturing it. Aneurism of the femoral artery resulted. On July 27th, Surgeon J. G. Keenon, U. S. V., probed the sac 
with the finger, when excessive haemorrhage ensued, and, after great difficulty in finding the ends of the artery, the vessel was 
ligated above and below the sac. Acting Assistant Surgeon S. S. Jessup assisted at the operation. Sphacelus of the foot and 
leg afterward necessitated amputation, which was performed, just below the knee joint, by Acting Assistant Surgeon R. W. 
Coale. The patient died of pyaemia August 3, 1864." 

Recurrent haemorrhage from the lower end of the wounded vessel was what com- 
monly necessitated amputation in these cases. 

Flesh Wounds of the Lower Limbs unattended by Primary Injury of the Large 
Nerves or Blood-vessels. — While in the two hundred and fifteen cases discussed in the 
two foregoing subsections, direct shot injury of the larger blood-vessels or nerves was 
regarded as the paramount lesion distinctively characterizing them, there were many other 
instances in the immense category of recorded shot flesh wounds of the lower extremities 
where the nerves and vessels shared in the laceration of the muscular and other soft parts 
by large projectiles, or were indirectly involved in the morbid processes following penetra- 



M-.l andSurg.HisI of the War of the Rebellion hirt II Vol II 



Plate XXVIII 




Srlniltzi- jniix 



.1 Hu-ii I'hromoliUi 



CANCRENE FOLLOWING A SHOT LACERATION OF THE FEMORAL ARTERY 



SECT. I.J SHOT LACERATIONS OF THE SOFT PARTS. 19 

ting or perforating wounds by small missiles. These are included in this third subsection 
of shot flesh wounds of the lower extremities, a group of fifty-eight thousand four hundred 
and eighty-seven reported cases, which (as stated on page 8) it is difficult to classify. 
Some instances remarkable for the extent of laceration of the soft parts will be cited, some 
of lodgement of foreign bodies, and some distinguished by the complications of pyaemia, 
tetanus, gangrene, erysipelas, haemorrhage, secondary involvement of joints, etc., will be 
adverted to. In a hundred cases, ligation of the larger arterial trunks was resorted to, and 
in a hundred and sixty-one recourse was had to amputation. It will be recollected that in 
the two preceding subsections ninety-five examples of ligations and forty of amputations 
have been alluded to, as connected with primary injury of the nerves or vessels. All of 
these cases of ligations and amputations will be cited in consolidated tabulations at the 
close of this section. Some cases of shot wounds of the lower limbs, in which no operative 
interference was undertaken, will now be detailed. 

Shot Lacerations. — After extensive destruction of the fleshy parts of the thigh and 
leg, reparation was usually slow and imperfect, sometimes as much so as in the remarkable 
case of laceration of the buttocks, narrated at page 430 of the Second Surgical Volume. 
Practitioners accustomed to regard mere flesh wounds as of little moment were not always 
happy in their prognoses of shot injuries of the soft parts in the lower limbs. 1 

Case 29. — Sergeant J. W. White, Co. F, 14th New Jersey, aged 24 years, was wounded at Monoeacy, July 9, 1864, 
and admitted to hospital at Frederick on the following day. Acting Assistant Surgeon J. H. Baftholf reported : " The patient 
was wounded by a cannon ball, or, as he says, by an unexploded shell, which tore through the back of his left thigh and killed 
a man close by him. It produced a very extensive lacerated wound, extending on the back of his thigh from near his knee to 
the fold of his buttock — a huge flap hanging downward and a shorter one attached at the upper end of the wound. He was 
admitted here the next day, without then suffering from any shock. Free suppuration followed, but not any sloughing, and 
simple measures only were required, viz: poultices, dilute solution of permanganate of potash, balsam of peru, water dress- 
ings, oakum, simple cerate. It granulated, contracted, and healed till, on November 25th, the raw surface was only four inches 
square. No loss of motion at the knee joint, strange to say, resulted from this extensive involvement of the muscles. Decem- 
ber 22d, he is transferred to hospital at Beverly this day. The wound is very nearly healed, and the patient in good health." 
Subsequently the man was transferred to the Whitehall Hospital, whence he was discharged June 17, 1865, and pensioned. 
The Trenton Examining Board certified, September 4, 1873: "The muscles of the posterior portion of the left thigh were very 
badly lacerated by a fragment of a shell ; all the flexor muscles were torn through and a most persistent and gangrenous sore 
followed the wound, and the cicatrix is very large and tender, the leg weakened, so that he cannot walk far or stand long on 
it." The pensioner was paid June 4, 1876. 

Even in young and healthy subjects the progress of repair was slow after large 
solutions of continuity: 

Case 30. — Corporal A. W. McCausland, Co. B, 16th Maine, aged 18 years, was wounded at Gettysburg, July 2, 1863, 
and admitted to the field hospital of the First Corps. On August 24th he was transferred to Camp Letterman, where he came 
under the care of Assistant Surgeon W. F. Richardson, C. S. A., who recorded: "A Bhell struck the outer side of the left 
thigh, inflicting a terrible flesh wound eight inches long by four in width, with ragged edges. When admitted the patient was 
in good health, the wound looking well and filling up with healthy granulations. Up to date the treatment has been cold- 
water dressings. Stimulants are given and simple cerate dressings now used. The patient improved rapidly, and the wound 
closed." In October the man was transferred to Satterlee Hospital, Philadelphia, and on January 10, 1864, he was discharged 
from service by reason of "lameness of left leg resulting from the wound." Examiner T. Hildreth certified, September 4, 1873 : 
" Was wounded by a shell in the posterior part of the thigh, carrying away a very large part of the muscles and integument, 
resulting in a tender cicatrix. He now sutlers from numbness of the limb." The pensioner was paid June 4, 1876. 

Sometimes small projectiles produced extended lacerations by driving into the soft 
parts coins, 2 knives, or other hard objects carried in the pockets of the soldiers: 

Case 31. — Private J. C. Haggerty, Co. I, 124th New York, aged 21 years, was wounded at Chancellorsville, May 3, 
1863. Surgeon J. S. Jamison, 86th New York, noted a "shot wound of the right thigh." The patient passed from a Third 

1 Dr. 0. IIEIXE {Die Schussverletzungen der unteren Extremitaten, Berlin, 1866, p. 65) thinks that large 6hot lacerations of the fleshy parts of the 
lower extremities are peculiarly liable to be followed by tetanus ; but I find in the records under discussion little to corroborate this view. 1 will revert 
to the subject in treating of Tetanus. 

2 SociN (A.) (Kriegschir. Erf., Leipzig, 1872, p. l(i) gives a drawing of a flattened Langblei (the missile of the needle-gun), together with three bent 
French copper sous pieces and two vest buttons, all of which wei j extracted from the thigh of a French soldier at the Swiss ambulance at Lure. The 
ball and the large copper coins were detected and removed soon after the reception of the injury, but the buttons were not extracted until three months 
afterwards. 



20 



INJURIES OF THE LOWER EXTREMITIES. (CHAP. x. 



Corps hospital to Fairfax Seminary, and thence to Satterlee Hospital, when Acting Assistant Surgeon I. Roberts reported the 
case as interesting, inasmuch as the ball struck a silver coin in the right pocket of the man's trousers and was thus detlected 
from the track of the femoral vessels; but passed through the soft parts, driving fragments of the pocket-book into the tissues, 
and escaping at the gluteal fold. The wound progressed favorably for a time, but, about July 20th, deep abscesses formed, and 
there was some sloughing at the aperture of entrance and exit. The abscesses were incised, and several fragments of the 
pocket-book came away with the pus. There was so much constitutional irritation that quiuia and stimulants were freely 
exhibited. The wound healed about the middle of December, and the man was transferred to the Veteran Reserves. He was 
quite lame, and the right foot was much everted. He was discharged October 7, 1834, and pensioned. Examiner J. Nichols, of 
Washington, certified : "Ball entered anterior aspect of upper third of right thigh, passing directly through, and indicting a 
frightful flesh-wound. Rone uninjured; cicatrix very deep and adherent to all the soft parts below, nearly to the bone, render- 
ing free motion of the limb impossible, and, if much used, very painful." Examiner J. Gordon, of Newburgh, New York, 
reported, February 28, 187G: * * '"There remains a large ambilicated cavity, with adhesions of skin, fascia, and muscles. 
He suffers more particularly from distress in the leg, extending in part to the foot, accompanied, before atmospheric changes, 
with shooting, darting pains, * * so severe at times as to unfit him for manual labor." This pensioner was paid June 4, 1876. 

Extensive lacerations of the calf were very slow in healing, and usually resulted in 
adherent cicatrices with atrophy of the remaining muscular tissues, greatly disabling the 
functions of the leg and foot: 

Case 32. — Sergeant F. A. Ingerson, Co. K, 27th Massachusetts, was wounded at New Berne, March 14, 1862. 
Surgeon G. A. Otis, 27th Massachusetts, reported that "a large fragment of shell striking the calf of the left leg carried 
away the greater portion of the bellies of the gastrocnemius and soleus muscles. There was inconsiderable bleeding. The 
laceration was so very extensive that it was difficult to coaptate or adjust the wound, and much of it had to be dressed open." 
The patient was sent to Academy Green Hospital. After the separation of sloughs, there remained a huge granulating sur- 
face. On April 19th, the patient was sent to a northern hospital, and discharged December 19, 18G2. Examiner A. Lambert, 
of Springfield, reported, March 11, 1863, the wound " unhealed and discharging constantly." The Boston Examining Board 
stated, March 23, 1870: "A fragment of shell engaged the left calf. During the suppurating process that ensued a considerable 
portion of the belly of the calfrvas lost. The wound has not entirely closed, and the injured leg is notably larger than the other." 
In October, 1875, Examiner A. W. Nelson, of New London, reported: "There is a large cicatrix of left calf, with loss of most 
of the substance of the gastrocnemius ; * * patient unable to walk a long distance." 

In a similar case, amputation was contemplated; but the patient ultimately made a 
satisfactory recovery without operative interference: 

Case 33. — Private P. C. WTiidden, Co. B, 13th Massachusetts, aged 22 years, was wounded at Antietam, September 17, 
1862, and entered the Mason Hospital, Boston, January 22, 1863. Acting Assistant Surgeon W. E. Townsend noted : " Shot 
wound of left leg. Patient returned to duty November 1, 1863." The following detailed account of his injury and its result 
was forwarded by the man in July, 1866, through Dr. II. I. Bowditch, of Boston : "Was struck by a piece of shell on the 
posterior aspect of the left leg, causing extensive laceration and loss of the soft tissues, without injury to the bone. The wound 
extended from just above the ankle joint about eight inches up the hack of the leg, from which, within these bounds, the soft parts, 
integuments, tendons, muscles, both arteries, and the posterior tibial nerve were entirely carried away, exposing the bones 
through nearly the whole length of the wound. On the front of the leg, corresponding to the middle of the wound, but about 
an inch of sound skin was left. A rounded flap, about an inch and a half long, containing the lower portion of the tendo- 
achilles, was torn up and laid back over the heel. The upper part of the wound was ragged and contused, and the middle 
portion cleanly cut away. There was but little haemorrhage. He walked with great difficulty to the rear, and was then carried 
to a house a short distance from the field, where a consultation as to the propriety of amputation was held, six surgeons being 
present. Four decided that amputation was necessary to preserve life; one assented to this under existing circumstances, but 
thought that under more favorable conditions there was a possibility of recovery without the operation; the other that amputa- 
tion was uncalled for. The patient decided to retain the limb. The wound was dressed with lint and was not disturbed for five 
days. On the fifth day, he was carried in an ambulance a distance of twelve miles to the hospital in Ilagerstown. Upon 
examination the wound was suppurating profusely and full of maggots, and it was dressed with yeast poultice and powdered 
charcoal. It was then determined to amputate, but the operation was postponed for three days, and nourishing diet and stim- 
ulants were ordered. On the fourth day an examination preliminary to the operation was made, when healthy granulations 
appeared along the edges of the bones, and the operation was abandoned. The patient was then carried to a private house, 
where he received proper nourishment and good nursing, and at the end of a month, no bleeding having at any time occurred, 
went to his home in Boston Granulations had been going on rapidly; the wound had been filling up without a sign of inflam- 
mation, and a pellicle was spreading out from the sound skin all around the borders of the wound. After the journey the parts 
became irritated and inflamed, and the process of cicatrization went on much more slowly. By the first of March following 
the parts were perfectly healed, and the patient walked about with the aid of a cane. But the pellicle covering the surface being 
excessively thin was easily abraded, and the newly formed tissues possessing but little vitality, it healed slowly, new portions 
being rubbed off before the old were renewed, so that at no time since the wound was first closed has it been entirely free from 
slight superficial ulceration. At the present time the gap is partially filled up with cicatricial tissue, which has undergone con- 
traction, making the wound appear much smaller than it originally was. It is covered with a thin layer of epithelium which 
constantly desquamates. The flap torn up and laid over the heel, as referred to above, instead of presenting the narrow outline 
of the tendo-achilles, has, in healing, become a thick flabby mass beneath the cicatrix, and after long walking becomes oedema- 
tous. The length of the cicatrix from top to bottom, on each side of the flap, is seven inches in the median line; from the top 



SECT. I.] 



LODGEMENT OF MISSILES IN SOFT PARTS. 



21 



of the cicatrix to the edge of the flap five inches; across the widest part at top and hottom, three and a half incites; in the 
middle, the narrowest part, three inches. Four inches and a half above the malleoli the leg measures in circumference six and 
a half inches; the sound leg at the corresponding part, nine inches. The integument on the front of the leg, at its narrowest 
part, is three and a half inches in breadth. The muscles of the calf contract but exert no influence over the foot, the tendons 
being absent, and extension cannot be performed, but the foot drops with its own weight. Owing to contraction of the cicatrix 
the foot can be flexed to but little less than a right angle with the leg. Sensation, which was lost in the external border of the 
foot and heel, has gradually returned. There is slight obstruction to the circulation from the slow return of venous blood. The 
patient walks with ease, unaided by a cane, and without the slightest perceptible limp." The report of the Adjutant General 
of Massachusetts shows that Private Whidden was discharged from service, by order of the War Department, December 11, 
1863. He is not a pensioner. 

In extensive lacerations of the soft tissues of the thigh and leg by shell fragments, or 
other large projectiles, it was often difficult to make out the exact extent of the injuries 
inflicted, and the field returns of the surgeons who examined the primary wounds, and the 
later reports of the hospital surgeons and pension examiners were often, of necessity, 
wanting in precision regarding such lesions. 1 



Lodgement of Missiles.— A few cases o 
driven by them into the soft parts of the lower limbs will be cited 



lodgement of projectiles or of foreign bodies 



Case 34.— Private W. H. King, Co. E, 17th Maine, aged 24 years, was wounded at Bartlett's Mill, November 27, 18G3, 
and admitted to Prince Street Hospital, Alexandria, one week afterwards. Acting Assistant Surgeon J. Cass contributed the 
specimen (Fig. 4), with the following history: "He was wounded by a musket ball which struck two pocket knives, breaking 
them and driving the fragments with the ball into the anterior side of the middle third of the left thigh. A hundred fragments 
of the knives and four of the ball wore removed on the Held. Lime-water dressings applied to the wound, and fifteen drops 
of tincture of iron given before meals. On December 13th, he suffered considerable pain in the wound, and on the following 
day an incision was made two and a half inches from the wound, and a jagged piece of ball an inch long and three-fourths of 
an inch wide was extracted. ICth, complained of strangury and some pain in the. limb. A teaspoonful of spirits of nitre 
given three times a day. 17th, was restless during the night; sweats profusely, and had a chill this morning. Gave morphia 
and whiskey, also half an ounce of castor-oil. Has had no stool for forty-eight hours; pulse 115 
and feeble; tongue coated ; vary thirsty; some soreness in inguinal glands. Prescribed extract of 
ginger and turpentine ten drops each, to be repeated in six hours if it does not operate, and gave 
tonics and stimulants. 18th, pulse 100, tongue moist and coated. Sweats all the time, and vomited 
in the night. Bowels moved freely and urinates more freely; appetite better. There is a 
greater discharge of pus from the wound. 19th, pulse 115 and feeble; vomited considerable during 
the day. Ordered two quinine pills to be taken before meals, and an anodyne injection at bedtime. 
50th, about the same; had a chill yesterday; granulations are pale and flabby. 21st, pulse 140 and 
very feeble; great prostration ; had a chill this morning and is delirious. Takes stimulants every 
hour. 22d, rested well, but is more prostrated and shows tendency to coma. Died at 4.30 r. M. 
Autopsy eighteen hours after death: On cutting through the muscles of the thigh, an inch and a 
half from the surface and an inch from the main channel of the wound, a sliver of horn from a knife- 
handle was found, half an inch long and one-sixteenth of an inch wide; also a brass rivet one-sixteenth 
of an inch in diameter and one-fourth of an inch long. In another place two pieces of horn from the 
other knife-handle, one three-eighths of an inch long and one-fourth wide, and the other one-eighth 
each way, were found; also a piece of a blade one-fourth of an inch long and one-eighth wide; and 
two pieces of brass, one being three-eighths of an inch long and one-sixteenth wide at one end and 
tapering to a sharp point at the other, and the other piece measuring one-eighth of an inch each way. Opposite the external 
wound the periosteum was found in places thickened, inflamed, jagged, discolored, slightly ossified, and separated from the 
bone for the space of two and a quarter inches longitudinally, and one inch transversely, with some pus beneath it." Dr. Cass 




Fig. 4 — Fragments of ball 
and pocket knife extracted 
from thigh. Spec, 3230. 



1 ClIEXU (J. C.) (Apcrcu hist. stat. et din., etc., pendant la guerre de 1870-71, T. I, p. 283) observes: " U&clat de bombe ou dobus cause le plus 
souvent de targes plaies avec pert?, de substance. Nous connaissons quatre faits dans lesquels la partie antero-interne des t6guments de la cuisse fut 
enlev6e d'un seul coup sans lesion do Torture femorale ; on voyait les battements du vaisseau au fond de la plaio." The same surgical annalist cites a 
case, in which disarticulation at the hip joint was performed in extremis by M. MAURICE Raynaud on a soldier of the National Guard, aged 19, with 
a terrible flesh wound of the thigh. 

2 Among interesting published cases of lodgement of shot projectiles in the thigh is that of Major It. H. Stephenson, 24th Massachusetts, described 
by the late J. Mason Wauukn (Surgical Observations, with Cases and Operations, 1807, p. 540): A musket ball, entering the front of the left thigh, 
about two inches below Poopart's ligament, was concealed somewhere beneath the rectus, and eluded the researches of a number of experienced surgeons. 
"Waiuiex, after ineffectually searching for the ball a month after the injury, advised that the patient should use (he limb with a view that'muscular action 
would bring the ball from its hiding place. This prevision was justified, and a fortnight afterwards the position of the ball was recognized, and WauUEX 
cut down and extracted it, and the officer speedily rejoined his regiment. The same writer has related (Boston Med. and Surg. Jour., 1802, Vol. L-XVI, 

p. 473) the case of Lieutenant C , 2d Massachusetts, wounded in the retreat from Winchester, a musket ball makingalong track in the gastrocnemius, 

and carrying before it, like a glove-finger, a patch of trousers and flannel underclothing, making a huge plug, which could only be removed the following 
day by free incisions. I)r. M. GOLDSMITH, of Rutland, Vermont, formerly Surgeon U. S. V., has described ( The Search for Balls in old Gunshot Wounds, 
in Nevf York Med. Jour., 1868, Vol. VI, p. 420) the case of a color-bearer of a Vermont regiment, in which a ball deeply buried in the thigh was reached 
by dilating the sinus leading to it by sponge-tents. 



22 INJURIES OF THE LOWER EXTREMITIES. fenAp. x. 

also contributed five inches of the shaft of the femur of the injured thigh, which constitutes specimen 1985 of the Surgical 
Section of the Army Medical Museum. It is sawn longitudinally, and shows the shaft to he denser than usual and apparently 
somewhat hypertrophied. (See Cat. Bury. Sect., I860, pp. 258, 617.) 

There were several eases in which large missiles buried in the fleshy parts escaped 
recognition; but none have been observed in which such concealed foreign bodies equalled 
in magnitude the projectiles that have been cited in some works on military surgery as 
embedded in the great muscles of the lower limb: 1 

Case 35. — Lieutenant L. Soistman, Co. II, 98th Pennsylvania, aged 23 years, was wounded at Salem Heights, May 3, 
1883. Three days afterwards he entered the Campbell Hospital, Washington, where he obtained a leave of absence on May 19th. 
On July 8th, he was admitted to the Officers' Hospital, Philadelphia, where Acting Assistant Surgeon W. Cammac recorded 
the following history: "A piece of shell entered the right thigh at the most depending inner part of the middle of the upper 
third, went under the deep fascia, and upward under the femoral artery anil buried itself. The missile appears not to have been 
noticed at first, as the wound was sewed up. After going to his home in Philadelphia he was attended by a private physician, 
but the missile remained still undiscovered. On July 8th, Acting Assistant Surgeon W. Hunt was called in, who was struck 
by the peculiar feel, and on introducing a probe immediately found the foreign body, and ordered the patient to the hospital to 
have it removed. On July 9th, Dr. Hunt enlarged the wound, and, after considerable trouble from the proximity of the large 
vessels, removed, with the assistance of the forceps, a piece of shell weighing nine ounces, which had lodged in the thigh sixty- 
six days. Its presence had given rise to no great disorganization, but he complained, he says, of a weight in the part during 
the whole time. After recovery from the effects of the ether, a half grain of sulphate of morphia was given. Cerate dressings 
and light pressure were applied, and the wound drawn together with adhesive straps. The patient's general health was 
excellent. He did remarkably well and felt greatly relieved by the operation. On July 13th, cataplasms were ordered, the 
wound looking well and suppurating moderately, and the patient having better appetite than any time since wounded. On 
September 5th he was attacked with intermittent fever, which was checked after several days by quinine. By October 1st the 
wound had nearly healed, but the leg was still weak from extensive disorganization of the great muscles of the thigh. On 
November 9, 1833, he was returned to duty. This officer was again wounded, at the battle of the Wilderness, May 5, 1804, in 
the right side, for which injury he was treated in hospitals at Philadelphia and Annapolis. On August 2, 1804, he was again 
returned to duty, and on October 13, 1884, he was mustered out of service. The Philadelphia Examining Board certified, 
October 19, 1870 : * * "A deep flesh wound, which, in healing, caused a cicatrix about five inches long and four inches wide, 
with loss of portion of muscular tissue, causing partial loss of power in the limb upon making much exertion," etc. The pen- 
sioner was paid March 4, 1876. 

Sometimes musket balls buried themselves in the muscular parts of the lower limbs 
aftep ricochetting from stony or metallic surfaces : 

Case 36. — Private A. Wegner, Co. A, 16th Michigan, aged 25 years, was wounded at Gaines's Mill, June 27, 1862. 

Surgeon P. B. Goddard, U. S. V., contributed the specimen (FlG. 5), and reported: "He was wounded in the right hip by 

a shell and ball, taken prisoner June 30th, and carried to Richmond ; paroled July 25th, and arrived at Sixth 

and Master Streets Hospital, Philadelphia, July 30th. This ball ricochetted from a stone or some hard 

substance, entered the front of the thigh near the femoral artery, and was cut out at the gluteus maxim us 

muscle four inches higher up than the orifice of entrance. It did not touch the bone, but carried in with it a 

long strip of trousers." The patient was discharged January 26, 1863, and pensioned. In the certificate of 

disability Surgeon Goddard stated that "the ball wounded the sciatic nerve." Examiner R. G. Jennings, of 

Little Rock, certified, Septembers, 1873: * * "One ball entered the right hip near the joint, glanced, 

ami was cut out from the gluteal muscles. The wound occasionally discharges pus. Suffers from frequent 

pain in the joint. The leg remains weak and of comparatively little service to him, as he is unable to walk 

Fio.o. Distorted or s (and long upon it." In January, 1876, the same examiner reported : "Has periodical discharges of pus 

moved from tlio and spiculao of bone. The sensation of the right leg is much impaired and the motion impeded by partial 

ig . .per.. /„. paralysis," etc. The pensioner was paid June 4, 1876. 

1 Henxex (Principles of Mil. Surgery, 3d ed., 1829, p. 79) has recorded several examples of the lodgement of large projectiles in the thigh. He 
remarks that : " Masses of very extraordinary and almost incredible sizes are found. . . I have frequently seen them," he says, " of one and sometimes 

two pounds weight." He then cites the case of Lieutenant F , 12th Regiment, wounded at Seringapatam. A cannon shot rolled over the banquet 

behind which this officer was lying down, and buried itself in the muscles of the hip. The bearers who conveyed him on a dooley to the tent of the 
chief medical officer, Dr. Ai.r.XAXDEa AxoEUsox, complained of the difficulty of carrying him from the trenches, owing to the litter "having been 
unusually heavy on one side.' 1 The officer was moribund on his arrival ; but, after his death, Dr. AxoEtisON cut out what he told Dr. IIEXXEX was 
"unequivocally a thirty-two pound shot." GUTIIUIE (Treatise on Gunshot Wounds, 1871, p. 72) relates the ease of a soldier at Dadajos, with a large 
piece of shell 1 idged in the thigh and buttock. llF.NXEN says (loc. cit., p. 79) that the projectile weighed eight pounds. It was removed, and the man 
recovered. LARRBt {Mem. tie Chir. Mil., 1812, T. Ill, p. 582) describes a case in which he removed a ball weighing five pounds from the thigh of a 
soldier. It had caused him little inconvenience, except a feeling of weight in the limb. Paillako {Relation chir. du siege d'anvers) mentions that 
Begix told him of a case in which a nine-pound shot was embedded in the muscles of the thigh. Dr. O. M. IS. MACLEOD (Notes on the Surgery of the 
War in the Crimea, 5th ed.. p. 108) states that he "saw a case at Scutari, in which a piece of shell weighing nearly three pounds was extracted from 
the hip of a man wounded at the Alma, which had been overlooked for two months, and to which but a small opening led." He further relates that 
Baudf.ns describes the case of a French soldier in the Crimea, in which a shell fragment weighing 2 kilog. 150 grammes, or about five and three-quarters 
pounds avoirdupois, buried itself in the thigh so as to be invisible. I have not found this case in the Guerre de Crimee of Bauoens, or in his letters of 
that date to the Gazette Medicate. A surgeon of a Maine regiment told me of a twelve-pound solid shot, that he had extracted from the muscles of the 
thigh of a volunteer soldier at Portland, which he should send to the Museum ; but the missile never arrived, nor could the injury referred to be identified 
on the surgical records. 





SECT. I.] LODGEMENT OF MISSILES IN SOFT PARTS. 23 

The small iron balls from spherical case-shot, having only a slight velocity at a little 
distance from the point of explosion, often lodged: 

Case :S7. — Private E. E. Middleton, Co. C, 12th Now Jersey, aged 24 years, was wounded at Gettysburg, July 3, 1863, 

and admitted to Newton University Hospital, Baltimore, several days afterwards. Surgeon C. W. Jones. U. S. V.,' reported : 

" The patient was in good condition when admitted. A ball entered near the posterior border of the tibialis anticus, a little 

above the middle third of the left leg, and, passing downward and backward, was removed July 13th, from the posterior 

portion of the leg by a counter-opening about four inches below the point of entrance. The missile on being removed proved 

to be a round ball from a spherical ease shot. The wound has healed well and rapidly, but the contraction of 

the muscles makes the man look as if he had talipes equinus. However, the contraction is growing less by 

passive motion, and there is reason to hope that he will soon have perfect use of the limb. Simple dressings 

were used all the time." The missile was contributed to the Museum by Surgeon Jones, and is represented 

in the cut (FlO. (i). On February 2, 1834, the patient was transferred to Patterson Park Hospital, and one 

week afterwards he was returned to his command for duty. On June 4, 1865, he was mustered out of service. 

In his application for pension lie alleged that "the wound healed, but broke out afresh in the sprinff of 18(35. Flr '- ''• — Iron 

case-shot extract- 
and discharged pieces of bone." Examiner B. II. Stratton. of Masonville, N. J.. September 4. 1873, reported ed from the thigh. 

the leg as being in an ulcerated condition from necrosis of bone. Examiner F. Ashurst, of Mount Holly, ^ prc ' 3199 " 

certified, September 18, 1875: * * "The cicatrices are healed, and the pensioner enjoys very good health." This pensioner 

was paid June 4, 1876. 

Ill the next case, a musket ball had remained, innocuously, for more than two years, 
encysted near the outer hamstring tendons, and was not removed until the patient under- 
went amputation in the thigh on account of a complicated fracture of the leg. The cyst 
is of dense connective tissue. 1 

Case 38. — Sergeant H. M. Lambert, Co. D, 12th Illinois Cavalry, aged 29 years, sustained a contusion of the right leg 
by the falling of his horse during a charge on the enemy near Germanna Ford, October 10, 1803. Three days after the accident 
he was admitted to Emory Hospital, Washington, whence Surgeon N. K. Moseley, U. S. V., contributed the specimen (FlG. 
7), with the following report: "Slightly comminuted fracture of both bones of right leg at middle third, followed by copious 
discharge of sanious pus. The patient having become weak and debilitated, tonics and stimulants were resorted to with the 
desired effect. On October 25th, double-flap amputation at the upper third of the leg was performed by 
Acting Assistant Surgeon W. H. Ensign. Simple dressings and adhesive straps were used. The patient did 
well, and the stump had almost entirely healed, when, on November 8th, haemorrhage supervened. Graduated 
compresses were resorted to without avail, and on November 10th the limb was reamputated at the lower third 
of the thigh by the double-flap method. The stump was again well-nigh healed, when, on November 2(ith, 
haemorrhage again set in, and Dr. Mott's tourniquet was applied with perfect success. On December 10th 
the tourniquet was removed, and no return of the haemorrhage followed. By January 18, 18C4, the patient 
was up and about the ward, and doing well. The specimen, a conical ball enclosed in a sac, was removed 
from the amputated leg at the second operation. The patient had received this ball in a skirmish with the crated in connect- 
enemy in Kentucky, in October, 1861, and the missile had remained in the popliteal space beneath the outer ivetissue.Sp.lSTfl. 
hamstring tendons, without inconvenience, for two years and one month." The amputated tibia and fibula, showing no attempt 
at union, were contributed by the operator (See Cat. Surg. Sect., 1866, p. 511), and constitute specimen 1744 of the Surgical 
Section of the Army Medical Museum. The patient was subsequently transferred to Judiciary Square Hospital, and discharged 
from service July 30, 1864. He is a pensioner, and was paid June 4, 1876. 

There were cases in which missiles gravitated for considerable distances from the 
point at which they at first lodged: 

Case 39. — Pri vate A. J. Dougherty, Co. 1, 13th Indiana, aged 19 years, was wounded in the thighs at Turkey Bone Bridge, 
November 2, 1861. After being treated for a time at the regimental hospital he was returned to his company for duty, and 
subsequently he received a furlough to visit his home in Philadelphia. Acting Assistant Surgeon H. M. Bellows reported the 
following history : "He was admitted to Broad and Cherry Streets Hospital, April 13, 1863, at which time a foreign body was 
discovered beneath the skin on the front of the right thigh, five inches above the patella, which gave rise to considerable pain 
whenever the patient walked. On the next day it was removed by Surgeon J. Neill, U. S. V., and proved to be the half of a 
round leaden ball. He stated that the missile entered the left thigh just below and in front of the trochanter, where the only 
visible scar was found. After the injury he had some pain and tenderness on pressure over the lower part of the abdomen, with 
difficult micturition for a few days. On examination the presumption was that the fragment must have crossed from left to 
right, either in front or just above the pubes, and thence gradually downward into the thigh. The wound healed by granula- 
tions and by the 5th of May had completely cicatrized." The missile was contributed to the Museum by the operator, and 
constitutes specimen 1776 of the Surgical Section. The patient was subsequently transferred to Indiana, and mustered out at 
the expiration of his term of service, June 19, 1864. He afterward again enlisted, and was finally discharged June 21, 1865, 

1 At the points a a the ball is uncovered by the cyst ; but the cellular envelope was probably nicked by the scalpel in cutting out the ball. This 
is one of the few good examples the Museum possesses of the " Kyste definiUf" surrounding balls as defined by Baudens {La Guerre de Crimec, Seme 
6d., 1858, p. 119). This " Kyste primitif" which he claimed to havo "peremptorily demonstrated" to always invest balls embedded in the muscular 
tissues, even when extracted immediately after the infliction of injury, has not been observed by others (See MACLEOD, Notes, etc., op. cit., p. 109), and 
doubtless means nothing more than that missiles sometimes get uu investment from the intramuscular areolar tissue. 




24 INJURIES OF THE LOWER EXTREMITIES. [chap, x. 

and pensioned. Examiner E. A. Smith, of Philadelphia, August 28, 18C5, certified: * * "Pain in right testicle, and left 
leg feela perfectly dead at times; walks with difficulty." The Philadelphia Examining Board reported, February, 18, 1874: 
* * "Complains of pain in both limbs. Alleges that he has difficulty in passing water at times from irritable condition oi 
bladder, and pain in the whole course of the ball. Cicatrices are without adhesions to the bone, and there is no atrophy of the 
limb. Slight stiffness about the left hip joint." This pensioner was paid June 4, 1876. 

As in Chapter XI the peculiarities of shot wounds in general will be discussed, it 
would be superfluous here to dwell longer on the particular instances of missiles lodged in 
the fleshy parts of the lower limbs. 1 While not wishing to be rudely incredulous in regard 
to the almost marvellous accounts that some authors have given of large projectiles 
embedded in the soft parts of the thigh and leg, I may say that analogous authenticated 
examples are not to be found in the experience of the American War, and that in most of 
the remarkable heretofore recorded cases there is reason to believe that they were probably 
associated with fractures. 

Peri-articular Wounds. — After the shot wounds of the soft parts of the lower 
extremity implicating the larger vessels and nerves, or producing great lacerations, or 
complicated by the lodgement of foreign bodies, cases are to be considered in which mis- 
siles, without immediately injuring the osseous articular surfaces, so injure the surrounding 
ligaments and other soft parts, in some instances even the synovial membrane, as to light 
up immediate or consecutive inflammation in the capsular cavity, or to induce, through 
the formation of cicatricial bridles or bv other deformities, a diminution or even abolition 
of the movements of the joint. These injuries have been discriminated by M. Legouest 
under the title of Peri-articular Wounds? He apparently includes in this group only 
cases in which the capsular cavity is not primarily opened; but I prefer to adhere to the 
definition proposed in my monograph on Excision of the Head of the Femur? and have not 
felt at liberty to exclude from this category the rare instances in which evidence indicates 
the probability of a primary lesion of the synovial membrane without direct implication 
of the bones of the articulation, and I observe that Drs. Beck and Fischer adopt a similar 
view- 4 After a careful analysis of the reports of cases liable to belong to this group, four 
hundred and thirty-seven have been classified as instances of peri-articular shot wounds of 

1 The Army Medical Museum is rich in specimens of projectiles extracted from the soft parts of the lower limbs. Besides those described in the 
text, there are twenty examples of small missiles extracted from the soft parts of the thigh. These specimens are numbered 176, 
1095, 1308, 2559, 2654, 2971. 4460, 4476, 4480, 4501, 4502, 4507, 4520, 4521, 4552, 4553, 4561, 4574, 4624, 4693. Brief notes of the 
particulars regarding those cases may be found in the Catalogue of the Surgical Section, of 1866, from pages 593 to 597. Two of 
the most remarkable are illustrated in the annexed wocd-euts. That represented in FlGUEE 8 was extracted by Assistant 
Surgeon J. T. CAU10UN', U. S. A., from the thigh of a private of the 12Cth New York, at the battle of the Wilderness, May 7, 
1864, and was regarded as an explosive ball. Specimen 4553 (FlO. 9) was remarkable for having entered 
the left thigh below and in front of the great trochanter, and having passed subcutaneous!}' around the 
pubic region and lodged in the right' high five inches above the patella. The ease is that of Private A. 

G. D , 13th Indiana, wounded at Gauley River, November 2, 1862 ; the ball was extracted by Surgeon 

JOHN' NRIU,, U. S. V., April 14, 1863. There are seven specimens of missiles extracted from the fleshy 
parts of the leg in the Museum, viz: Numbers 1586. 2326. 3199, 4482, 45C0, 4514, 4695, and two specimens 
extracted from the soft parts of the foot, viz: 1580 and 4523. All of these specimens are described, with 
notes of the cases to which they belong, in the 27th Chapter of the Surgical Catalogue already referred 
to. These specimens arc neatly mounted on brass rods. Dr. A. ScniNZlXGEK (Das Reservdazareth 
Schwetzingen im Kriege 1870-71, Freiburg, i. B., 1873, p. 37) relates that he has a small collection of 
Fro. 8. Distorted extracted bullets remarkable for their deformation, and that those extracted from German soldiers have r „ nn fl ball extracted 

thhrb. Spec 4561 been mounted in silver, and on the setting the name of the wounded man and the date of the battle from thigh. Spec. 4553. 

engraved, at the thoughtful suggestion of the princess of that province. 
2 Legouest (L.) (Traite de Chirurgie d'Armee, 2e > me 6d., Paris, 1872, p. 442). Some citations from his remarks on this subject may be found in 

the Surgical Volume of Part II of this work, footnote 1, p. 503. His further observation on this point is worthy of consideration, that "when shot wounds 

and notably even slight contused wounds are situated on the side of extension of joints, where they are exposed to continual attritions and tractions, they 

readily inflame and sometimes give rise to circumscribed abscesses or diffused phlegmous of more or less gravity.'' 

3 Otis (G. A.), A Report on Excisions of the Head of the Femur for Gunshot Injury. Circular No. 2, War Department, Surgeon General's Office, 

Washington, D. C, 1869, pp. 63, 90, 92. 

4 BECK (B.) (ClUrurgie der Schussverletzuvgen, 1872, p. 609) details 25 cases, in which the soft parts of the knee joint were either primarily or 

secondarily involved. Four, or 16.0 per cent., terminated fatally. He also gives 7 cases of flesh wounds of the ankle joint; no deaths. FISCHER (H.) 

(Kriegschir. Erfahr., lster Theil, Yor Metz, Erlangen, 1872, p. 102) gives an account of 7 cases in which the knee joint was injured without lesion of the 

bony structure. Two, or 28.5 per cent., had a fatal termination. 





SECT. I.] PERI-ARTICULAR WOUNDS. 25 

the lower limb, of which forty-nine are referred to the hip joint, three hundred and fifty- 
one to the knee joint, and thirty-seven to the ankle joint. Each of these subdivisions will 
be concisely discussed. 

In peri-articular shot wounds of the Hip Joint, the difficulties of diagnosis are almost 
insurmountable in the present state of our knowledge. In the cases of recovery, the exact 
extent of the lesions can only be surmised, and in the fatal cases necroscopic examination 
will scarcely determine with absolute precision whether the articular capsule was primarily 
or secondarily opened. Memoranda of forty-nine cases of shot wounds, which the reporters 
believed to have led to the opening of the coxo-femoral articulation without direct injury 
of the bones, are found on the registers. Thirty-five instances are adduced in which it 
was supposed that there was primary lesion of the joint capsule; twenty-one of them are 
reported as recoveries. Abstracts of seven of these have been already published. 1 Of the 
remaining fourteen recoveries, such scanty information as can be found in the reports is 
condensed in the appended abstracts: 

Cases 40-48. — Lieutenant D. H. Miller, Co. II, 75th Ohio, aged 28 years, was wounded and captured at Gettysburg, 
July 1, 18G3. After remaining a prisoner for a few days, he was admitted to the Eleventh Corps Hospital. Several weeks later 
he proceeded to his home in Logan, Ohio, where he was attended by Drs. G. W. Pullen and J. Sharp, who reported his case 
as follows: "The ball entered the posterier and inferior part of the glutei muscles of the left hip, passed over the neck of the 
femur, and came out on the inner side of the trochanter major. February 15, 1864, the wound has closed, but the motions of 
the hip joint are diminished to a great extent, and the leg is so weakened that he is unable to walk without the use of crutches." 
The patient was discharged from service January 22, 1864, Surgeon A. M. Speer, U. S. V., certifying to "shot wound of hip 
joint without fracture." Examiner T. O. Edwards, of Lancaster, Ohio, in February, 1871, stated that "the wound had opened 
and discharged a portion of his blouse," etc. Examiner W. C. Hyde certified, September 10, 1873: "There is flattening of 
muscles of the hip, the cavity of the joint injured by the missile, and the joint partially ancbylosed." The pensioner was paid 
March 4, 1877. — Corporal L. Bertram, Co. A, 6th Louisiana, entered a Confederate hospital at Richmond with "shot wound of 
right hip, involving the joint," received May 4, 1863, and was furloughed April 15, 1864.— T. J. Brandon, a member of Co. F, 
14th Alabama, was treated in the Confederate hospital at Farmville for "shot wound in the buttock with injury to hip joint," 
and was furloughed October 22, 1862.— Private If. Eimb'erlin, Co. G, 48th Virginia, received a gunshot injury of the right hip 
joint, producing lameness, and was furloughed from the Confederate hospital at Farmville. — Private C. C. McMurray, Co. H, 
15th North Carolina, was admitted to hospital No. 24, Richmond, with "shot wound of hip joint," and was discharged Septem- 
ber 13, 1862. — Private G. TV. Williams, Co. F. 3d North Carolina, appears on a Confederate hospital case-book as having 
received a "shot wound of the hip joint, May 3, 1833, the ball being extracted near the knee." Furloughed.— Private J. Hilk, 
Co. B, 112th Pennsylvania, was wounded in June, 1862. Surgeon E. Griswold, of the regiment, reported, "an injury to hip 
joint by a pistol ball." The man was discharged from service October 16, 1832. He is not a pensioner.— Private I. J. Brown, 
Co. A," 18th Infantry, was wounded at Stone River, December 31, 1862. He was treated at various hospitals, and lastly at 
Camp Thomas, Ohio. Acting Assistant Surgeon C. R. Reed reported that he was discharged March 17, 1864, by reason of 
"shot wound of left hip joint." He is not a pensioner.— Private M. Ahern, Co. E, 183d Pennsylvania, aged 24 years, was 
wounded at Spottsylvania, May 14, 1864. Surgeon L. A. Edwards, U. S. A., reported his admission to Lovell Hospital with 
"shot wound of right hip joint." The man was mustered out July 13, 1835, and is not a pensioner. 

Spontaneous luxation after traumatic coxitis from shot injury of the hip joint with- 
out fracture, was reported in three instances: 

Cases 49-51. Serjeant I. Murdick, Co. I, 134th Pennsylvania, aged 23 years, wounded at Fredericksburg, December 

13 1862. He was admitted to Stone Hospital, Washington, December 20th, with "gunshot wound of left thigh." Assistant 
Surgeon C. A. McCall, U. S. A., reported that the man was discharged from Mount Pleasant Hospital, April 16, 1863, because of 
"gunshot wound over left trochanter, passing in the direction of the hip joint ; ball undiscovered and interfering with the free use 
of the joint." Examiner G. McCook, of Pittsburg, June 22, 1834, certified : * * "Inflammation and suppuration have ensued 
and have progressed until the round and capsular ligaments of the left hip joint have been destroyed and the femur drawn at 
least two inches above the acetabulum. The left leg is thrown across the right at least two inches or more above the right knee, 
resemblin" the position of a dislocated femur. The heel is elevated, and it is with extreme difficulty that he can walk with the 
aid of crutches. The toes of the left foot rest on the dorsum of the right." On November 22, 1837, the pensioner was furnished 



1 OTIS (GEOUGE A.) (A Report on Excisions of the Head of the Femur for Gunshot Injury. Circular So. 2, War Department, S. G. O., Washington, 
1869 pp. 90-92): CASE 166, Corporal H. C. Boyd, 39th 111.; Case 169, Lieut. C. Duncan, 18th Ind.; Case 176, Pt. G. W. Micnick, 7th Md.; Cask 177, 
Pt W M. Moore 3d Ohio; Case 178, Pt. W. N. Morgan, 9th Peun'a Reserves ; Case US, Pt. Jacob Widmann, 97th Xew York; Case 186, Pt. Henry 
Witzleben 28th Ohio. Id all seven cases the evidence of direct lesion of the articulation was inconclusive, and the opinions of the several surgical 
attendants were conflicting in each instance. Two cases (Witzleben, Morgan) terminated in false anchylosis. In the latter the adhesions were forcibly 
and successfully broken up by Professor S. D. GROSS. In one case (Widmann), after suppuration of the joint, the head of the femur was apparently 
luxated. Professor B. von LAKGEXBECK holds (Ueber die SchussverUtzungen da Iliiftgelenks, in Archiv fur Klin. Chir., B. XVI, p. 286) that, "the 
most usual result (constanteste Ausgang) of healing shot injuries of the hip joint is in anchylosis." 
SURG. Ill— 4 



26 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

with an apparatus for dislocated hip joint, by Dr. E. D. Hudson, of New York City. Examiner J. K. Reinholdt, February 7, 
1871, certified : ''The downward momentum caused the hall to imbed itself securely in the hip joint. * * Parts swollen and 
tender; wound discharging; more or less injury to great sciatic nerve; limb deficient in temperature; more or less constant 
pain; confined to bed months at a time," etc. This pensioner died May 7, 1874, of convulsions superinduced by the results of 
his wound, his attending physician and others stating that the serious attacks of inflammation, resulting in the formation of 
abscesses, proved a severe tax upon his vitality and prepared the way for his sudden demise. — Private R. Emerick, Co. D, 82d 
Pennsylvania, aged 28 years, was wounded at Cold Harbor, June 1, 1864, and admitted to hospital at Alexandria, and subse- 
quently to Pittsburg. Surgeon J. Bryan, U. S. V., reported that he was transferred to the Veteran Reserve Corps, October 8, 
1864, by reason of "a grapeshot wound, dislocating the right femur." Not a pensioner. — Lieutenant F. Heck, Co. I, 74th Penn- 
sylvania, aged 37 years, was wounded in the right thigh at Kappahannock Ford, August 22, 1862, and was discharged from 
service October 9, 1863. In 1874, the Examining Surgeons report : "Firm anchylosis, with head of femur thrown out of socket; 
knee and ankle joints entirely stiff; foot in an extended position, and limb shortened two inches." 

Two cases are reported as injuries of the hip joint by large projectiles: 

Cases 52-53. — Private J. Teeters, Co. A, 84th Pennsylvania, aged 34 years, was wounded at Bull Run, August 30, 1862, 
and discharged from service March 29, 1863. Assistant Surgeon J. D. McClure, of the regiment, certifying to ''an injury in 
the right hip joint by a piece of shell, producing paralysis of the whole leg." This man was a pensioner, but has not been heard 
from since September 4, 1864. — Private TV. S. Gardiner, Co. A, 14th South Carolina; injury to hip joint from bomb; furloughed. 

The entire subject of traumatic lesions of the hip joint is of such importance that it 
is deemed proper to adduce or to refer to the previous publication of all the information 
that can be found on the registers, with the warning that, in many instances, the facts are 
derived from reports suggestive of superficial examination, and sometimes of diagnoses 
that must be regarded as little more than conjectures. 1 

Of the fourteen Fatal Cases in the series of thirty-five shot injuries believed to have 
been attended with primary lesion of the hip joint without, fracture, the details of all are 
published in Circular 2, S. G. 0., 1869, already cited. 2 In the reports of many of these 
cases it is stated that the character of the lesions was verified by necroscopic examination, 
and in others it may be inferred that autopsies were made, so that the series is, as a whole, 
more reliable than the preceding. 3 

Of the series of forty-nine cases of reported peri-articular shot wounds of the hip 
joint, fourteen may be classified as examples of secondary traumatic coxitis. 4 Seven were 

1 VOX LANGENBECK (B.) (tjber die Shussverletzungcn dcs Huftgelenks, in Archivfiir Klinische Chxrurgie, Berlin, 1874, B. XVI, p. 280) remarks: 
"It may be taken for granted that a gunshot injury of the hip joint may heal under favorable circumstances without traumatic coxitis beginning. Coxitis 
may certainly be avoided in simple capsule wounds, which are kept perfectly quiet from the commencement, as well as in gunshot injury of the knee 
joint, as I have seen the recovery of several cases without any inflammation arising. As, however, in most cases (Pott's) side splint was recommended 
by the surgeon or adopted by the patient, and as during the last war not a few of the men were subjected to distant transport, and, injury of the hip joint 
not having been discovered, were allowed to go about, it was difficult in such cases to avoid inflammation. It appears to me that we must admit that in 
all those cases in which coxitis suddenly appears a considerable time after the injury, recovery is certain under favorable external circumstances without 
any further trouble occurring." [The translation is the version of James F. West, F. It. C. S.j 

2 Circular No. 2, S. G. O., 18G9, op. cit., pp. 90, 91, 92. The names of the patients, the duration of life after injury, and the names of the reporters 
are noted: Case 105, W. Blair, survived injury 23 days; extent of injury demonstrated by autopsy; McKEE, reporter. — Case 167, A. D. Bradshaw, 
survived 19 days; verified by autopsy; Burne, reporter. — CASE 168, P. Cornell, survived 3 days; WOLFE, reporter. — Case 170, J. W. Falconer, 
survived 13 days; autopsy; MORONG, reporter. — Case 171, S. Finnegan, survived 1 day; Cole, reporter. — Case 172, G. Green, survived 14 days; 
Graham, reporter. — Cask 173, F. M. Hate, survived 102 days; Hatchitt, reporter. — Case 174, J. E. Leedy, survived 7 days ; LEAVITT, reporter. — 
Case 175, J. McMahon, survived 19 days; Bliss, reporter.— Case 179, B. F. Pittman, survived 73 days; JANES, reporter.— Case 180, W. E. Reeves, 
survived 16 days; autopsy; Harrington, reporter. — Case 181, T. Smith, survived 28 days; autopsy; Vanderkieft, reporter. — Case 182, R. Taylor, 
survived 4 days ; autopsy ; Seabrook, reporter. — Case 183, B. K. Wagoner, survived 265 days ; Hatchitt, reporter. — Case 184, of J. Wells, was also 
reported in Circular 2 as belonging to this group ; but the carbine ball inflicting the injury, much deformed, with large bone fragments embedded in it 
(Specimen 2994, Cat. Surg. Sect., 1866, p. 603), has since been discovered, and the case has been transferred to the category of shot fractures of the neck 
of the femur. In three cases, in which the patients died within a few days after the infliction of the injury, it is probable that there were grave concom- 
itant lesions. In those in which they survived two months, three months, and eight months, respectively, there were no autopsies held, and the lesions 
were not accurately determined. In the eight remaining cases, the patients lived from one to four weeks ; the mean was 16 days. 

'Billroth (Th.) (Chir. Briefe, u. 8. w., Berlin, 1872, p. 238) observes: "I am of opinion, that neither the direct injury of the joint capsule and 
bone, nor the secondary necrosis, can always be early diagnosticated. In cases resulting favorably, the diagnosis can generally only be made ex post, 
from the total anchylosis of the hip joint, and in many cases only after the discharging of some necrosed bone. . . Nevertheless I had not imagined 
the diagnosis to be so difficult ; I had thought that there must be, under all circumstances, symptoms of acute coxitis ; but I was mistaken therein. . . 
But gradually we arrive at a correct diagnosis in the majority of these cases from the slow progress after the injury, the copious suppuration, rapid 
debilitation, and speedy decubitus." 

4 Circular No. 2, S. G. O., 1869, op. cit., pp. 93, 94. The cases of five of the seven patients who partially recovered have been enumerated in the 
Circular above cited : Case 190, of Capt. H. C. Mason, 20th Massachusetts, is more extensively reported by J. MASON Warren in his excellent Surgical 
Observations with Cases and Operations, BostoD, 1867, p. 565. A fortnight after the accident, acute inflammation of the hip joint came on, and WARREN 
out down and removed the ball from directly over the capsule of the joint. He ultimately recovered with stiff joint. The next case, No. 191, A. McGce, 
will be noticed on the next page. In Case 193, Private S. Schafer, 81st Ohio, was struck in the left hip at Resaca, May 14, 1864, and recovered with a 
•tiff joint, according to Surgeon W. THRELKELD, U. S. V., and others. Case 196, Private W. A. Shingledecker, 101st Pennsylvania, Gettysburg, July 




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SECT. 1.1 



PERT-ARTICULAR WOUNDS. 



27 




fatal, and seven resulted in recovery. Abstracts of five of the latter have been published 
in Circular 2, and two others are here noted: 

Cases 54-55. — Sergeant J. A. Heady, Co. B, 15th Kentucky, aged 22 years, was wounded at Chickamauga, September 
20, 1863, and was discharged from Camp Chase July 18, 18C4. Surgeon J. T. Carpenter, U. S. V., certified to "shot wound 
of left hip, the ball entering three inches above and posterior to the trochanter major and remaining; function of hip joint inter- 
fered with, and marching impossible." This man is an applicant for pension. The Louisville Examining Board reported, in 
1875, that the missile was still unextracted. — Private E. D. Bates, Co. B, 24th New York Cavalry, aged 21 years, was wounded 
in the left hip at Petersburg, June 17, 1864, and was treated at various hospitals. Surgeon R. B. Bontecou, U. S. V., reported 
his discharge from Harewood Hospital, Washington, May 5, 1885, by reason of "shot wound resulting in necrosis of head of left 
femur." The various Examining Surgeons certify to more or less injury of the bone, also that the missile remains in the limb. 

Of the seven examples of secondary coxitis from shot wounds which recovered, the 
most interesting is the one numbered 191 of Circular 2, in which the nature of the 
injuries was observed more than seven years after reparation had taken place. 

Case 56. — Albert McGee, a negro refugee, aged about 30 years, is reported to have been struck at the first battle of Bull 
Run, July 21, 1861, by a musket ball, which probably entered the right hip at the level of the trochanter major, and, passing 
downward and forward, made its exit from the inner surface of the thigh just below the perineum. He made a complete 
recovery with the right lower limb shortened two 
and a half inches. About seven years subsequently 
McGee entered the Howard Grove Hospital, at Rich- 
mond. Assistant Surgeon J. H. Janeway, U. S. A., 
then stationed at Richmond, learned from Dr. D. R. 
Brower that the man came to Howard Grove Hos- 
pital in the latter part of October from the settlement 
of refugees at Hampton, Virginia, aud was then 
suffering with Bright's disease. Professor Hunter 
McGuire, of Richmond, and Dr. J. N. Upshur, at the 
time resident physician at the Howard Grove Hos- 
pital, have kindly contributed their recollection of 
the case. 1 An autopsy was made by Dr. J. N. 
Upshur, and the surgeons who examined the injury 
of the hip were of the opinion that the head of the 
femur had been grooved by the ball at its lower part. 
The pathological specimen 3 was sent to the Army Medical Museum, and there a vertical section of the epiphyses and upper 
portion of the femur was made, and it clearly appeared that there had never been a fracture of the head, and that the groove, 
supposed to have been made by the ball, was a depression resulting from a former abscess. The appearances closely resembled 
those sometimes observed in cases of chronic rheumatic arthritis. They are represented in the wood-cut above (FlG. 10), and 
yet more satisfactorily in the heliotype opposite (Plate LVI). 

2, 1863, after a gunshot wound disordering the functions of the right hip joint, recovered with a stiff joint, according to the testimony of Examiner of 
Pensioners G. MCCOOK. — Case 1D7, Private T. Swartwood, 25th Ohio, was wounded May 8, 1862, by a musket ball which injured the right hip joint. 
Pension Examiner C. HUPP testified that the limb was shortened two inches and all movements of the articulation caused severe pain. 

1 Dr. HUNTER McGuiRE writes, Richmond, Va., October 17, 1877 : " I have received your letter of the 12th inst., and am sorry to be able to give 
you so little information about the case you speak of (Case 101 of your report on excisions at the hip joint). I think I gave you at different times two 
specimens of shot wounds of the head of the femur. One uf these cases you saw in the College Hospital here, before I operated. [Heference is made to 
Specimen No. 6*217, Surg. Sect., A. M. M., an excised head and upper extremity of the right femur with osteomyelitis.] The other is the specimen Dr. 
Upshur speaks of, the one you here refer to. My recollection of this case is not very distinct, but I am quite certain that I looked upon it at the time 
as a case of peri-articular gunshot wound of the hip, and that the changes about the head and neck of the femur were due to the resulting coxitis. . . 
Dr. D. It. Brower was in charge of the Howard Grove Hospital when this specimen was obtained. He was, afterwards, superintendent of the Insane 
Asylum at Williamsburg, Virginia, and I think is now in Chicago and holds some office there under the government. lie may be able to give you 
further information about the case, but I do not think it probable that he will remember anything about it." Dr. J. N. UPSUUK iu a letter to Dr. HUXTKlt 
McGuire, dated Richmond, October 16. 1877, remarks : "In compliance with your request, I would state in regard to the history of the negro man eon- 
cerning whom you have received a letter from the surgeon in charge of the Medical Museum at Washington. He came to Howard Grove Hospital, 
then a hospital for freedmen— suffering with Bright's disease of the kidneys. Having noticed considerable shortening of the right leg, with inversion 
of the foot, I enquired if he had had fracture of the thigh ; he replied that he had been in the army, and was shot by a Confederate sharpshooter 
stationed in an apple tree, the ball passing just below and through the hip joint. The wound had healed perfectly, and he possessed some motion in the 
joint. There was no reason for surgical interference at that time. After his death, which occurred a few weeks subsequently, I made a post-mortem exam- 
ination, removing the head of the femur, which I found had been fractured within the capsule, and recovered with perfect bony union. As well as I 
remember, the bone bore plainly on its surface the track of the ball. The specimen was removed and given to you, and sent by you to the Medical 
Museum. I could not obtain from the man, who was an ignorant negro, a clinical history of the case." 

2 This specimen closely resembles one figured by M. LBI3EUT ( Traiti d' Anatomic, pathologique gin. tt spec., Folio, 1861, T. II, p. 603, et Atlas, T. 
II, PI. CLXXXI (Figs. 1-3), in his magnificent iconographic work. This is a specimen presented by M. VEttXEUIi. as "a beautiful typical specimen of 
dry arthritis (arthrite sgche) of the upper part of the femur. The upper ledge of the head of the bone is crushed down in the shape of a mushroom. At 
the anterior part of the neck a considerable projection is seen, a true exostosis of irregular surface, perfectly isolated by a line of demarcation from the 
rest of the bone. This tissue was at that point very red and vascular. On the surface of the head of the femur is found a multitude of rounded cartil- 
aginous vegetations, some of which, narrow at their base, might have ultimately detached themselves and fallen as foreign bodies into the articular 
cavity. In spots the diarthrodial cartilage is ossified abnormally. On the specimen a condensation or kind of concentric hypertrophy of the head of the 
femur is observed in the section, while the lower part of the head of the bone presents, on the contrary, an atrophic rarefaction of its tissue. There is, 
therefore, an unequally distributed process of osteocartilaginous new formation, of atrophio absorption, and of ossification of the normal cartilage." Loc, 



Fig. 10. — Chronic traumatic arthritis of the right hip joint following a shot injury, 
with secondary suppurative transformations which ultimately eventuated in recovery. 
Spec. 5518. 



28 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

Abstracts of six of the seven fatal cases of secondary arthritis from peri-articular shot 
wounds of the hip are published 1 in the oft-cited Circular 2. The following is the seventh: 

Case 57. — Private C. M. Blackweldcr, Co. A, 52d North Carolina, was wounded at Gettysburg, July 2, 1863, and 
admitted to hospital at Chester about three weeks afterwards. Surgeon E. Swift, U. S. A., reported : " Gunshot wound, followed 
by a dissecting abscess involving the head of the femur and its ligaments. The patient died of pyaemia, September 21, 1863. 
The post-mortem showed inflammation of the arachnoid membrane with serous effusion, also effusion of serum in the other serous 
membranes, and twelve ounces of pus in the left pleura." 

Of peri-articular shot wounds of the Knee Joint, three hundred and fifty-one cases 
were reported. It would appear that of two hundred and fifty-five of these cases, accord- 
ing to the evidence available, the articular capsule of the knee joint was directly involved 
without fracture, and that in ninety-six cases the projectiles did not injure the joint, which 
was opened by secondary traumatic arthritis. 2 Of the aggregate of the three hundred and 
fifty-one cases, ninety-eight or 27.9 per cent, had a fatal termination. Three hundred and 
thirteen cases were treated without operative interference and thirty-eight were followed 
by amputation. The latter will be enumerated in the tabular statements of amputations 
following shot flesh wounds of the lower extremities. Of the three hundred and thirteen 
cases treated without operative interference, two hundred and forty-four recovered and 
sixty-nine or 22 per cent, proved fatal. 

In the following two cases of recovery the joint appeared to be directly injured. The 
patients recovered with considerable use of the limbs: 

Case 58. — Private A. Parker, Co. K, 5th Maine, aged 18 years, was reported by Surgeon C. S. Tripler, U. S. A., as 
having received a "bullet wound of the left knee" at the battle of West Point, May 7, 1862. Surgeon A. B. Mott, U. S. V., in 
charge of the Ladies' Home Hospital, New York City, recorded the following description and result of the injury: "A musket 
ball entered the left knee joint at the junction of the tibia and fibula, passed through the joint, and emerged at the inner edge of 
the internal hamstring. Bleeding occurred freely for about forty-five minutes and then ceased spontaneously. The pain after 
the wound was very Bevere. On the day following a consultation of surgeons was held, when it was thought amputation would 
be necessary; but tlie operation was postponed. Two days after he went to Fort Monroe, where he remained until May 25th, 
when he came to this hospital. While at Fort Monroe he suffered considerable pain for six days after the receipt of the injury, 
and cold-water dressings constituted the entire treatment, with perfect quiet of the limb. When admitted here the leg and foot 
were badly swollen; discharge slight and watery; orifice of exit closed. The external wound was attacked with gangrene, and 
a deep slough came away. Charcoal poultices were used, and creasote, and the wound stuffed with pulverized cinchona. After 
the slough came away there was some synovitis, and tincture of iodine was applied for several weeks. The general treatment 
was tonic and sustaining ; porter and ale were taken occasionally but not regularly. September 5th, wound has healed with a 
good cicatrix. There is stiffness in the knee which is gradually improving. Treatment : cold douche, passive motion and 
careful use of the limb. Patient has used crutches and afterwards a cane, but now uses neither. December 30th, the knee can 
be flexed to but little more than a right angle and is very straight. Patient walks without a limp, and there is very little weak- 
ness in the limb. He has been on guard duty for more than two months." This man was assigned to the Veteran Reserve 
Corps November 27, 1863. ne is not a pensioner. 

tit., p. 603. In many respects this specimen closely resembles that of McGee, which is represented in FlGUIIE 10, and in the heliotype print, Plate 
LVI, Med. and Surg. Hist, of the War of the Rebellion. Part III, Vol. II, op. page 27. In the specimen in the Army .Medical Museum there is more 
extensive ossification of the cartilage at the rim of the acetabulum, and the neighboring osseous surfaces are more densely studded with osteophytes. 
The atrophic rarefaction and absorption are more pronounced at the inferior portion of the head, giving rise to the appearance which was mistaken for a 
groove made by a ball. On such lesions consult further CARL ROKITAXSKY, Lehrbuch der Pathologischen Anatomic, Dritte Umgearbeitete Auflage, 
Wicn, 1856, B. II, S. 205. 

1 Circular No. 2, S.G. O., 1869, op.cit., pp. 93. 94. The six published cases are: Case 187. Pt. J. Delaney, 51st New York, wounded at Antietam, 
Sept. 17, 1863; matter burrowed about the left hip joint, and the thin part of the acetabulum was perforated. Dr. WILLIAM M. NOTSON" reported his 
case and death, Dec. 24, 18J2. — Case 198. Pt. O. J. Dunn, 18th Mississippi, was struck at Antietam, Sept. 17, 1862. Secondary involvement of the head 
of the left femur, from which he died June 19, 1863. A wood-cut of the specimen is reproduced in the Circular. — CASE 189. Pt. A. Hall, 1st Cavalry, 
was wounded in Louisiana, Sept. 27, 1865, the ball penetrating ultimately into the hip joint of the left side. Death, January 12, 1866, Asst. Surgeon A. 
Hartsuff, U. S. A., having reported the case. — Case 194. Serg't C. M. Scovil, 14th Connecticut, wounded May 12, 1864, received a musket contusion 
of the left hip joint. He died July 14, 1864, as reported by Surgeon T. R. SPEXCER, U. S. V. — Case 195. Lieut. J. G. Seldon, 2d Cavalry, received 
July 3, 1863, at Gettysburg, a wound of the left thigh in the vicinity of the hip. The hip joint became involved secondarily. He died Sept. 17, 1863. 
Asst. Surgeon R. F. WEIR reported the case. — Case 198. Serg't C B. Wheeler, 81st Indiana, received a shot wound of the left hip joint, near Atlanta, 
August 8, 1861. The injury soon affected the articulation, and Surgeon M. S. Siiehman, 9th Indiana, reports that ho had profuse suppuration, and died 
October 7, 1864. 

2 Hkin'K (C) (Die Schussverletzungen der unteren Extremitdten^crYin, 1866, p. 58) observes: "Shot wounds of the soft parts, in which, secondarily, 
suppuration of the joint resulted from the breaking down of the tissues surrounding the shot channel, especially at the knee joint, were not very rare, 
while at the hip joint we only observed a solitary but very remarkable case of this kind." KIRCHXKR (C) (Aerztlicher Bericht iiber das Koniglich 
Prevtische Feld-Lazareth im Palast zu Versailles, Erlangen, 1872, p. 86) tabulates 27 injuries of the soft parts of the knee joint ; but does not give the 
results. Arnold (J.) (Anatomischc Beitrage zu der Lehre von den Schusswunden, Heidelberg, 1873, pp. 123, 124) gives details of 2 cases of shot 
wounds of the knee joint, in which, at the autopsies, the bones of the joint were found uniDJured. 



SECT. I.] PERI-ARTICULAR WOUNDS. 29 

Case 59. — Private G. Deacon, Co. G, 14th Virginia Cavalry, aged 25 years, was wounded at Boonesboro', July 8, 1863, 
and admitted to the Cavalry Corps Hospital. Surgeon S. B. W. Mitchell, 8th Pennsylvania Cavalry, noted a "flesh wound at 
the knee joint." One week after the reception of the injury the wounded man was transferred to hospital at Frederick, whence 
Acting Assistant Surgeon W. S. Adams reported the following history: "He was wounded by a spent ball, which entered on 
the outer lateral surface of tlie right knee, passing inward and forward, striking the patella and lodging. The patient worked 
the ball out witli his finger on the field. By examination I find no evidence of the ball having entered the cavity; the joint can 
be moved without pain, and there is no evidence of effusion. Simple dressings were ordered to the wound. On July 25th the 
external opening had closed and an abscess was forming at the point of lodgement of the ball. Enlarged the external opening 
so as to communicate with the abscess, when about a half ounce of pus escaped, but no synovial fluid, although there was 
evidence of the joint being involved, but perhaps not communicating with the opening. On the following day the swelling of 
the joint was more extensive and fluctuation well marked. Tincture of iodine was then ordered to be applied to the joint twice 
a day, and the limb was placed in Smith's anterior splint. On August 10th the wound had nearly healed, effusion within the 
joint had almost entirely subsided, and the patient was comfortable. By August 20th the wound was entirely healed ; appearance 
of joint natural. Considerable anchylosis existed, partly owing perhaps to deposit and partly to long continuance in one 
position. About a week later the splint was removed, and afterwards passive motion was resorted to without producing much 
pain or tenderness. On September 5th the patient was transferred to Baltimore, having considerable and daily increasing 
motion of the knee." He was paroled from West's Buildings Hospital on September 25, 1303. 

Then follow three fatal cases of direct shot injury involving the cavity of the knee 
without lesion of the osseous surfaces: 

CASE 60. — Private J. Wagoner, Co. F, 116th Pennsylvania, aged 23 yeans, was wounded at Petersburg, June 22, 1864, 
and admitted to the field hospital of the 1st division, Second Corps, where Surgeon D. II. Houston, 2d Delaware, recorded: 
"Flesh wound of left thigh by a niinie' ball." Surgeon G. L. Pancoast, U. S. V., contributed the pathological specimen (Cat. 
Surg. Sect., 1866, p. 333, Spec. 3260) with the following notes of the case: "The patient entered Finley Hospital, Washington, 
July 1st, with shot wound through left knee joint. The bone was not injured. He died July 17, 1864. Two days before death 
signs of pneumonia presented themselves. An autopsy was made by Acting Assistant Surgeon G. II. ilopkins, who found 
extensive inflammation extending all around the joint and its neighboring parts. The femur and tibia were denuded of cartilage 
around the edges. In the cavity of the thorax there was considerable pleuritic adhesion, with effusion of thick pus, the lungs 
themselves being very much congested and hepatized — in fact, the lungs were diseased throughout their entire extent. There 
was also effusion both in the pleura and pericardium." The specimen consists of the bones of the injured knee joint. 

Case 61. — Private E. Dolan, Co. D, 5th U. S. Cavalry, aged 21 years, was wounded at Gaines's Hill, ^"\ 

June 27, 1862. Acting Assistant Surgeon R P. Thomas contributed the pathological specimen (Cat. Surg. M t j!J 

Sect., 1836, p. 333, Spec. 227), with the following description : " The patient was wounded by a bullet, which M r f 

entered on the outside of the left knee joint opposite its lower portion, and made its exit at the inside of the jfTL <■ 
popliteal region, nearly on a horizontal line with the wound of entrance. He was admitted to the Episcopal ■. ,li^V<i >j3t 
1 [ospital, Philadelphia, July 30th, and died on September 30, l^ii'i. During this period he was in a very low VC '■".Vj&jtt 
condition, the wounds and abscesses in the neighborhood of the joint discharging profusely the greater part of '>33fiH* v 
the time; lie also suffered from diarrhoea. An autopsy, performed a few hours after death by Acting Assistant ^ItSst 
Surgeon 11. I'. Thomas, showed "loss of cartilage, and ulceration of the heads of the femur, tibia, and fibula, I jffrS 
with extension of the disease on the posterior aspect of the femur and between the heads of the tibia and \ 'jffcVv 
fibula. There was also ulceration of the posterior face of the patella and abscesses in the soft parts." The ■ 

specimen (FlQ. 11) consists of the bones of the knee. The age of the patient is perhaps overstated. The (jjj 
epiphyses, both in the tibia and fibula, were not united, and the real age was, probably, under 20; possibly did no. 11. Boimof 
not exceed 19 years of age. left knee. &.9S7. 

CASE 62. — Private U. Conn, Co. M, 12th Pennsylvania Cavalry, aged 28 years, was wounded during a cavalry skirmish 
at Frederick, July 10, 1364, and was admitted to hospital the same day. Acting Assistant Surgeon J. II. Bartholf reported: 
"He was wounded in the right knee joint by a pistol ball. The missile entered at the lower inner edge of the patella, and I 
removed it from the joint, having put in my finger between the femur and tibia after enlarging the wound to feel the ball. There 
was no fracture of any bone. On consultation, it was determined to try to save the i mb. The joint was freely opened and local 
antiphlogistic treatment was employed. Great pain and swelling, for a few days only, ensued, with but slight irritative fever at 
any time, and the pulse for weeks ranged from 85 to 95. Sometimes for a fortnight at a time he had a really good appetite ; this 
notwithstanding that extra capsular abscesses appeared early and continued throughout to discharge much; at other times he 
was in a precarious condition. He was placed on a water-bed, being thin in flesh on admission and soon troubled with bed-sores. 
About a month before his death there was some cough. He sank very gently, and died October 14, 1864. The post-mortem 
examination revealed the recovery from the joint wound by obliteration of its cavity and bony anchylosis, which was not so firm, 
however, but that accidental violence partly broke it. The crucial ligaments were still uudestroyed. There was one vast abscess 
from the knee to the groin encircling the femur, and another four inches long from the kuee downward — neither of them com- 
municating with the joint. He had gray hepatization (pneumonic) of two thirds of the middle lobe of the right lung, all the 
rest of the lungs being healthy. The heart was very small and its weight six ounces. All the other organs were healthy." 

In the three following cases the projectile did not open or enter the knee joint, and 
the involvement of the articulation was secondary in its nature: 

Case 63. — Private E. Williams, Co. E, 5th Michigan Cavalry, aged 26 years, was wounded during the engagement 
at Shepherdstown, August 26, 1864. Acting Staff Surgeon N. F. Graham reported his admission on the day of the injury to 



30 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

the field hospital at Sandy Hook with "shot wound of right thigh," and his transfer to Frederick two days afterwards. 
Acting Assistant Surgeon J. C. Shinier, from the latter hospital, made the following report of the case: " He was wounded 
by a fragment of a shell, which lodged in the external muscles of the lower third of the thigh in close proximity to the bone. 
It was extracted on the field through the opening. Upon admission the patient's general condition was good. He experienced 
no pain whatever from the injury. Suppuration was going on finely and everything indicated a speedy recovery. The wound 
was thoroughly examined with the finger and a sinus found leading in the- direction of the knee, but not into the joint. Sep- 
tember loth, patient complains of slight pain and tenderness in knee. The discharge has nearly subsided and the wound is 
healing. I enlarged the opening so as to allow free vent for the pus. Tincture of iodine is directed to be applied every other day. 
September 25th, for the last few days there has been some general derangement of the whole system ; appetite somewhat impaired ; 
pulse excited; bowels irregular. The knee is still painful, especially upon pressure, and the discharge is the same in quantity. 
Ordered fifteen drops of tincture of iron three times a day, with a half pint of milk-punch, a poultice of flaxseed meal to be 
applied around the joint, and the limb to be kept at rest. September 30th, no change in the general condition. The discharge 
of pus has ceased, but a thin oily looking material, resembling synovia, constantly exudes from the small opening that remains 
at the entrance of the wound. October 10th, patient has been doing well until to-day; is very restless; pulse accelerated to 
128; appetite very moderate; complains of excruciating pain in the knee. The wound has healed externally. Tonics, stimu- 
lants, and generous diet are continued; one pill of opium is given four times a day, and blisters are applied over the joint. 
October 20th, patient has received considerable relief from the blisters. The blistered surface having healed on October 
25th, I directed them to be reapplied and the surface to be kept excoriated by an ointment of Goulard's cerate and powdered 
cantharides. The other treatment was continued. 28th, pulse 113; suffers but little pain in knee, and feels quite encouraged. 
An opium pill is given at bedtime. 30th, pulse 110; appetite improving; bowels regular; tongue clean; knee of its original 
size and no pain on pressure. November 10th, general health rapidly improving; the ointment is discontinued. November 
18th, walks about the ward with a splint adjusted to favor the knee and keep it at rest; general health excellent. On Decem- 
ber 1st the tonics and stimulants were discontinued and the splint removed from the limb ; the knee is anchylosed, and no 
passive motion is made for fear of exciting inflammation. On December 21st the patient received a fall, the entire weight of 
the body resting for the time on the injured limb. He was directed to be confined to bed, the limb to be kept at rest, and 
iodine to be applied over the knee; parts painful. December 24th, doing well; no constitutional disturbance. December 29th, 
pain and swelling subsided; patient on crutches again. January 10, 1865, patient transferred to Michigan." Assistant 
Surgeon D. O. Farrand, U. S. A., reported that the man was discharged from Harper Hospital, Detroit, May 20, 1865, by 
reason of "anchylosis of the knee joint, produced by the wound." Williams is a pensioner, and has been reported by various 
examiners as suffering from "complete anchylosis of the right knee joint." He was paid June 4, 1876. 

Case 64. — Private T. G. Scott, Co. B, 54th North Carolina, aged 45 years, was wounded at Harper's Farm, April 6, 1865, 
and admitted to the field hospital of the 3d division, Second Corps. Surgeon O. Everts, 20th Indiana, noted, 
"shot flesh wound of left knee." From the field hospital the wounded man was transferred to City Point, 
and thence, on April 22d, to the West's Buildings Hospital, Baltimore. Acting Assistant Surgeon A. Kess- 
ler contributed the specimen, represented in the annexed wood-cut (FlG. 12), with the following descrip- 
tion : "A mini6 ball passed through the left leg just below the knee joint, implicating the joint but not laying 
it open. The leg became much swollen and discolored, and from the openings flowed a quantity of what 
appeared to be arterial blood. Soon after the patient's admission there appeared severe constitutional 
symptoms : rigors followed by high and continued fever, delirium, extreme nervousness, much prostration, 
constant vomiting, and sleeplessness. Amputation, which, at an earlier period, might have saved his life, 
was then pronounced impracticable, and the patient died with symptoms of pyaemia, May 4, 1865. A 
post-mortem examination of the limb revealed the fact that the tissues above and below the joint, the 
muscles, fascia, etc., were a gangrenous mass, and that the greater portion of the joint itself was divested 

Fig. 12.— Caries of left °f ' ts periosteum and rapidly assuming the character of caries. Otherwise the joint was found to be intact, 

knee joint. Spec. 4205. exhibiting no fracture." 

Case 65. — Private W. P. Werden, Co. K, 34th Massachusetts, aged 20 years, was wounded at New Market, May 
15, 1864. Surgeon J. V. Z. Blaney, U. S. V., reported his injury as "a shot wound of the knee." Acting Assistant 
Surgeon J. II. Bartholf contributed the following history from the General Hospital at Frederick : " The patient was ad- 
mitted here May 25th, from the post hospital at Martinsburg, with a flesh wound of the left leg near the knee, caused by a mini6 
ball. The missile entered a half inch below the patella, between it and the tuberosity of the tibia, directly over the 
quadriceps extensor tendon, and lodged superficially just under the skin, whence it was extracted the same day. He was 
removed in an ambulance sixty miles to Martinsburg. The joint soon became inflamed and swollen, and remained so until his 
admission here. Water dressings had been applied. I found the joint inflamed and very much distended, probably with 
synovia or a collection of pus, over the tendon of the quadriceps. A counter-opening was made at the lowest part of this, and 
evaporating lotions applied, on the 29th of May. On the 1st of June the patient was somewhat better. June 4th, ice applied 
to the knee. June 11th, patient has made very rapid and great improvement, so that the synovitis is nearly gone and the 
abscess is almost healed ; but there is communication with the knee joint from the abscess, a minute orifice having been made 
by ulceration apparently, through which healthy-looking synovia has been flowing in small quantities for a couple of days. 
There is no constitutional trouble. June 12th, no more synovia comes out. June 17th, patient is permitted to get out of bed 
and walk a little. July 4th, has gone on very favorably to this time, walking with a cane. Is now transferred to Baltimore." 
After this date the patient was treated in hospital at Annapolis until September 13, 1864, when he was returned to duty. The 
Adjutant General of Massachusetts reports that the man was mustered out June 30, 1865. He is not a pensioner. 

Of thirty-eight recorded instances of lesions of the knee joint without injury to the 




SECT. l.j PERI-ARTICULAK WOUNDS. 31 

articular surfaces, followed by amputation, twenty-nine or 76.3 per cent, were fatal. Two 
of the cases will be detailed, and all will be enumerated in the tables of amputation at 
the end of this section: 

Case 66. — Lieutenant J. A. Boies, Co. H, 13th Infantry, aged 22 years, was wounded in the assault on Vicksburg, 
May 22, 18G3. He was admitted on a hospital transport and conveyed to Memphis, whence he was admitted to the Marine 
Hospital at Chicago on June 8th. Acting Assistant Surgeon R. N. Isham reported : "He was struck upon the outer side 
of the left knee by a cannon shot from a distance of about two miles. The ball probably only glanced over the surface, for 
there was the merest trifling appearance of a redness, but no wound or bruise upon the surface. Amputation at the upper third 
of the thigh was performed on June 18th, and death resulted June 28, 1803, from pyaemia. A frequent pulse, brown tongue, 
anxious expression of the face, and diarrhoea indicated the existence of the poison on admission. The strongest symptom, that 
of profuse discharges from the bowels, almost involuntary, and of a color, smell, and consistency of the discharge from the 
stump, together with the sickening sweetish odor of the perspiration and chills, indicated the invasion of the disease in a marked 
manner on the night of the 18th. The treatment was by iron, quinine, and stimulants. Scrupulous attention was given to the 
stump, removing all soiled dressings three times a day and injecting the wound with a solution of bromine and occasionally 
with tincture of myrrh and balsam pern. This partially succeeded in correcting its unhealthy appearance and producing the 
secretion, for a short time, of good-looking pus. There never was any attempt at healing in the wound, the edges of which 
looked like 'cut edges of pork.' The discharge from the wound was of a dark-colored thin offensive character. There was no 
sloughing or gangrene. The system seemed to make great efforts to eliminate the poison, as evidenced by the profuse per- 
spiration and diarrhoea. The blood seemed to part with its serum easily. No clot was formed in the stump, and late in the 
progress of the disease the discharge consisted of altered blood. The pulse during the case was from 130 to ICO. No post- 
mortem was allowed by his friends, but the sudden invasion of pain in the joints, a swelling of the knee and fluctuation, 
satisfied me that pus had formed in the synovial cavity." 

Case 67. — Sergeant G. A. Dyer, Co. G, 6th Maine, aged 21 yeo*" , was wounded at Rappahannock Station, November 
7, 1863, and was admitted to Armory Square Hospital, Washington, two days afterwards. Surgeon D. W. Bliss, U. S. V.,. 
reported: "A niinid ball entered four inches below and in line with the trochanter major of the right thigh, took a down- 
ward and inward course, and could not be found on admission to the hospital. On November 29th, 
the missile was extracted from the popliteal space; suppuration continued free and of good char- 
acter. Two weeks subsequent to the extraction of the ball a bit of woolen cloth came from the 
lower wound. December 10th, patient was allowed to get up and move about, using crutches. 
December 25th, knee joint became painful and continued to swell from this date. Under iodine the 
swelling subsided to a considerable extent, but the pain continued; suppuration still free and at 
times thin and poor in character. On February 1, 1864, synovial fluid was observed from the upper 
point in the discharge; pain in knee joint still considerable at night, and leg enlarged. On February 
19th. the thigh was amputated above the condyles by flap operation; four arteries tied; loss of blood 
small ; patient in fair condition constitutionally. On opening the knee joint after the operation, 
erosion of the cartilages was discovered, and an abscess below the knee joint communicating with it. 
February 22d, patient doing well." The specimen represented in the adjacent cut (Fig. 13) was 
contributed by Surgeon Bliss, and consists of the bones of the knee of the amputated limb, showing 
a slight deposit of callus on the posterior aspect of the shaft, apparently due to the irritation set up 
by contact with the ball in position. The patient was discharged from service April IS, 1864, and 
pensioned, and subsequently furnished with an artificial limb. In his application for commutation, 
dated 1870, he described the stump as being in a sound condition. The pensioner was paid June 4, 
1876. In the cut only a portion of the specimen, which consists of the four bones entering into the f em ,',' r studded with oateo- 

articulation, is represented. The amputation was done at the middle of the femur, and not through P h J' te J "? er shot c " n,uslon - 

. , , Spec. 2047. 

the lower third as represented in the cut. 

Of peri-articular shot wounds of the Ankle Joint, thirty-seven cases are indicated on 
the records; 1 but the evidence in regard to the precise nature of the injury may be termed 
unsatisfactory. In fifteen cases, of which one proved fatal, no operative interference was 
deemed necessary. In the remaining twenty-two cases the limb was amputated at the 
leg, with fatal results in twelve instances. One case may here be detailed; all the cases 
of amputations of leg for peri-articular shot wounds of the ankle joint will be enumerated 
in the tables of amputations following shot flesh wounds of the lower extremities: 

Case 68. — Corporal E. D. Goodell, Co. D, 25th Massachusetts, aged 21 years, was wounded at Cold Harbor, June 3, 
1864. Surgeon S. A. Richardson, 13th New Hampshire, recorded his admission to the Eighteenth Corps field hospital with 
"shot wound of right ankle." Surgeon R. B. Bontecou, U. S. V., reported the result of the injury a» follows: "The patient 
entered the Harewood Hospital, Washington, June 10th, with shot wound of right foot near os calcis, the ball severing the 

1 The records of shot flesh wounds of the ankle joint without injury to the bones are very meagre. KluciiSEIl (C.) (Aerztlicher BericM iiber das 
Koniglich Preussische Feld-Lazareth im Palast zu Versailles. Erlangen, 1872. S. 86) tabulates 8 eases of flesh wounds of the tibio-tarsal articulation but 
gives no results. HEISE (C.) (Die SchussverUtzwngen der unUren Extremitdten, Berlin, 186f>, S. 5) thinks it very remarkable that not a single case of 
secondary arthritis following "shot wound of the ankle joint without lesion to the bone " was observed. 




32 



INJURIES OF THE LOWER EXTREMITIES. [CllAr. X. 



tendo-achilles. On admission, lie was very weak. The parts were swollen and suppurating freely, and became subsequently 
gangrenous, the tarsal and metatarsal bones denuded. An operation was deemed necessary, and performed on July 22d by 
Acting Assistant Surgeon 13. E. Butcher, who amputated the leg at the lower third by the circular method. Sulphuric ether 
was used. The patient improved after the operation, and was furloughed August 17th, the stump looking well." The bones 
of the amputated ankle were contributed to the Museum by the operator, and constitute specimen 3332 of the Surgical Section. 
In December following the man was admitted to Dale Hospital, Worcester, whence Surgeon C. II. Chamberlain, U. S. V., 
reported that the stump assumed a large suppurating surface with several sinuses leading to diseased bone, and that on February 
20, 1835, he removed a sequestrum eight inches in length by a longitudinal incision. After this the patient, was reported as 
having made excellent progress, and the stump as being nearly healed on March 31st. He was ultimately discharged from the 
Soldiers' Rest, at Boston, October 31, lSGo, and pensioned. The pensioner was paid March 4, 1877. 

Peri-articular shot wounds of the joints should be treated at the outset by complete 
immobilization of the articulation, by wire-cloth splints, or plaster bandages, the wound 
being covered with simple dressings of thick compresses saturated with cold lotions. The 
complications are to be combatted.as they arise. 

Complications of Shot Flesh Wounds of the Lower Extremities. — In the great series 
of 58,702 shot flesh wounds of the lower limbs, besides the groups characterized by lesions 
to the principal blood-vessels and nerves, by extensive lacerations, by lodgement of foreign 
bodies or extension of inflammation to the joints, there were many examples of compli- 
cations of Pyaemia, Gangrene, Tetanus, Erysipelas, and Haemorrhage. A certain number 
of cases haVe been classified in each of these categories. The reader, however, must guard 
'against the belief that this class of cases is complete, for, as explained heretofore, there 
was neither time nor clerical assistance for an exhaustive search. The cases, however, 
have been impartially selected, and the results probably present a fair average. 

Pyaemia. — Three hundred and twenty-eight cases, of which three hundred and twenty, 
or 97.5 percent., resulted fatally, were found recorded. One of the eight cases of recovery 
will be detailed: 

Case 69. — Private S. S. Chase, Co. L, 1st Maine Cavalry, aged 43 years, was wounded at Stony Creek, October 27, 
1864, and admitted to the field hospital of the 2d division, Cavalry Corps, where Surgeon F. LeMoyne, 16th Pennsylvania 
Cavalry, noted: " Shot flesh wound of both legs." The patient was moved to City Point on the following day, and on November 
14th ho was transferred to Washington. Surgeon D. W. Bliss, U. S. V., made the following report: "He was admitted to 
Armory Square Hospital with wounds of the right thigh and left leg. The first ball entered the thigh posteriorly, about the 
junction of the middle and upper thirds, passing inward and a little downward, and emerging on the inner side of the thigh; 
the second ball entered the left leg on the posterior aspect, about the middle, and passed directly forward, emerging on the inner 
side, one and a half or two inches from point of entrance. The patient had an unhealthy appearance and was considerably 
emaciated when admitted, the wounds discharging a very thin and offensive matter, not very profusely. On November 26th, 
pytemia became developed ; patient had several violent chills, which were repeated on the following days, when his wounds 
became dark colored and dry and ceased to discharge, and he grew delirious. From this period quinine, iron, and chlorate of 
potassa were prescribed, with stimulants and the most nourishing diet, together with applications of creasote, tannin, and solu- 
tion of chlorate of patassa to the wounds, under which treatment he gradually improved. At present (December 31st) his 
wounds are about healed and he is able to leave his bed, being greatly improved in every respect, and convalescent." The man 
was discharged from service March 24, 1865, because of "permanent contraction of the gastrocnemius muscle of the left leg, 
resulting from the wound." Examiner J. O. Perry, of Portland, Maine, certified, April 30, 1868, that "both wounds are very 
tender;" and that "the wound in the leg so far involved the nerves that the leg below it and the foot are quite numb." The 
Portland Examining Board reported, in 1S73 and 1875, that they find deep, and, on the left leg, adherent scars, with considerable 
loss of tissues in both wounds. The pensioner was paidjune 4, 1876. 

In the greater proportion of the fatal cases, although the ratio of mortality was so 
large, necroscopic appearances were not recorded: 

CASE 70. — Sergeant M. Armstrong, Co. M, 6th Cavalry, was wounded at Williamsburg, May 4, 1862, and admitted to 
the Hygeia Hospital, Fort Monroe, five days afterwards, when Surgeon R. B. Bontecou, U. S. V., noted a "shot wound of 
left thigh." Acting Assistant Surgeon S. J. Radcliffe contributed the following history, from Hospital No. 1, Annapolis : "The 
ball entered the external aspect and posterior of the upper third of the thigh, passing inward and downward, and emerged 
about the centre of the middle third. The patient was in hospital at Fort Monroe about ten weeks, when he rejoined his 
regiment. He went through most of the great battles and skirmishes until Gettysburg, in July, 1863, when he was taken 
prisoner at Fairfield, Peun., and went to Richmond via Staunton, arriving there on July 20th. He was paroled and left 
the enemy's lines on the 23d, arrived at Annapolis on the 24th and at Camp Parole on August 2d, and entered this hospital 
September 20th. He states that the leg has not been painful except in cloudy weather, and has not swelled, and that his health 



SECT- !•] COMPLICATED SHOT FLESH WOUNDS. 33 

has been good. Prescribed pills consisting of quinine one and a half grains, and blue mass and capsicum one half grain each, 
to be given every four hours. September 25th: Had a chill yesterday ; tongue coated; skin dry; pidse quick; conjunctiva 
yellow; countenance dejected and of painful expression; great lancinating pain in leg; nervousness; bowels irregular. 
Stopped the pills and gave quinine in solution, five grains every six hours. September 27th : Has lost flesh during last week. 
Has had continued fever, and the leg has been swelling for two or three days and is very painful, the least motion being painful; 
abscess forming between the former orifices of the •wound on the posterior aspect; general condition unfavorable. A large 
flaxseed poultice was applied to envelope the whole thigh, and the quinine was continued. Patient objects to U.king stimulants, 
and takes but little. October 1st, A. M.: The thigh, from the groin to the knee, has continued to enlarge to this date, with 
sharp throbbing pain, sleeplessness, depressed nervous condition, deafness, fever of a low type, diarrhoea and loss of appetite; 
patient quite hectic, pulse quick, and cheeks flushed; abscess pointing at the eschar or orifice of wound of exit. Made an in- 
cision from one to five inches long, and a full stream of dark, thin, offensive matter followed, amounting to nearly two pints; 
bathed with warm water and vinegar, and continued the stimulants, beef-tea and quinine, with an occasional dose of compound 
mixture of catechu. 5 P. M.: Patient feels better; pulse quick and feeble; skin in good condition; tongue cleaner; bowels 
better. Ordered spirits of mindereri, one half ounce, to be given alternately with the other medicine. October 3d: Abscess 
still discharging very dark, thin, and fetid matter; patient very prostrate; emaciation very rapid and distinct. Gave stimu- 
lants freely and often. October 3, A. M.: Patient very feeble, pale and thirsty; pulse quick and sharp; bowels worse ; delirium 
most of the night, and nausea; abscess still discharging; leg very much swollen and highly sensitive; sloughing about the 
wound. Applied charcoal and yeast poultices, and gave tincture of chloride of iron, twenty-five drops, with quinine every four 
hours. 3 r. M.: Pupils contracted; stupor; pulse 120, feeble, sharp, and quick; very sensitive to touch; bowels more invol- 
untary; leg largely infiltrated, red and swollen, and pits at the knee; very little discharge of bloody serum; patient sinking. 
Died at 5.30 a. M. on October 4, 18G3." 

An example of the series of fatal cases in which autopsies were made is subjoined. 
This series constitutes seventy-three of the three hundred and twenty cases. 

Cask 71. — Sergeant D. A. Lent, Co. A, Cth New York Heavy Artillery, aged 24 years, was wounded at Cedar Creek, 
October 19, 1864. Surgeon W. A. Barry, 03th Pennsylvania, noted his admission to the Sheridan Field Hospital with "shot 
flesh wound of right leg." Several days after being wounded the man was transferred to the Camden Street Hospital, Baltimore, 
and subsequently to ltulison, Annapolis Junction, whence Acting Assistant Surgeon A. Marion reported the following history : 
"The patient was admitted to this hospital January 4, 1865, with a wound of the right leg, middle third, a miui6 ball entering 
on the anterior aspect one inch outside of the tibia, lodging between the tibialis amicus, tibialis posticus, and the anterior tibial 
artery. When admitted the wound was completely healed up, but the leg was much swollen and no ball could be detected. 
During the first week after his admission the patient had his leg rolled up with a bandage, and the swelling completely disap- 
peared. He became able to walk about until January 18th, when he again complained, and on examination I found the leg 
again much swollen, with a dark spot located where the wound first healed up. After this flaxseed poultices were constantly 
applied until February 2d, when, on opening the wound, the ball was carefully removed from its place of lodgement. On the 
two days following the operation the patient had a severe fever and chills, with extreme pain and great depression. I ordered 
eight grains of calomel with ten grains of rhubarb to be taken at once, followed by a saline aperient. On the morning after the 
4th, I ordered strong beef-tea, with brandy, to be taken freely. This treatment was continued until February 7th, with some 
saline draughts, according to the condition of the bowels. On the morning of the 8th, I found the patient greatly depressed and 
complaining of extreme pain in the joints, and on examining the wrists and the left shoulder joint I discovered them to be very 
much swollen, with a peculiar boggy feel to the touch. All these symptoms were attended with rigors, drowsiness, yellowness 
of the skin, and offensive perspiration, sometimes accompanied with delirium. Poultices were applied over the joints, with 
warm fomentations, and opium was given to relieve the pains every night. The treatment was continued, but no amelioration 
whatever of the symptoms took place, the patient gradually sinking until the morning of February 15, 1865, when he died. 
At the post-mortem, an abscess was found in the upper lobe of the right lung, about two and a half inches long and two inches in 
width and depth, filled with thick pus. Both lungs were much congested. The right ventricle of the heart was filled with a 
semi-organized clot. Kidneys about six inches long and four inches wide; small abscesses were found in the cortical portion of 
each one. Pus was also found in the urethra. Liver, spleen, pancreas, stomach, and intestines normal. About one teaspoonful 
of thick fetid pus was found in the right knee joint, and about half as much in the right wrist joint. There was no pus in the 
ankle joints." 

It is to be regretted that autopsies were not more generally practised in cases of this 
group, and that in the exceptional cases the necroscopical records were so imperfect. 

Hospital Gangrene. — The shot flesh wounds of the lower, extremity that were 
distinguished by the supervention of hospital gangrene 1 numbered two hundred and 
eighty-three, with one hundred and fifty-eight deaths, or 55.8 per cent. Details of three 
cases of recovery are appended: 

Case 72. — Private W. J. Briggs, Co. A, 102d Pennsylvania, aged 27 years, was wounded at Chancellorsville, May 
3, 1863. Assistant Surgeon J. C. McKee, U. S. A., in charge of the General Hospital at Pittsburgh, reported the following 

! In Investigations upon the Nature, Causes, and Treatment of Hospital Gangrene as it prevailed in the Confederate Armies. 1861-1865, by Joseph 
JONES, M. D., published in tho Surgical Memoirs of the War of the Rebellion collected and publisJud by the U. S. Sanitary Commission, the author details 
many illustrations of gangrenous wounds resulting from shot wounds of the lower extremities. Instances may be found in the San. Comm. Memoir, 
Surg. Vol. 11, pp. 234, 250, 310, 311, 315, 318, 329, 331, 334, 337, 347, 375, 3S0, 388, 394, 399, 406, 411, 437. 
SURG. Ill— 5 



34 INJURIES OF THE LOWER EXTREMITIES. [CHAi>. x. 

history : " The ball passed between the tibia and fibula, about the middle of the leg, escaping through the calf opposite the point 
of entrance. The patient was four days at Falmouth Hospital, seven days at Douglas, Washington, and was then removed 
to Satterlee, Philadelphia. Seventeen days after his admission to the latter he was furloughed and came to Pittsburgh. 
The wound had healed at its entrance and was still discharging at its exit, but was considered fit to travel with. lie had 
several slight chills before leaving Philadelphia, and one of a more severe character after his arrival home, followed by haemor- 
rhage from the posterior wound, which was arrested. The next day he came to the hospital. The wound presented the 
unmistakable evidence of gangrene. He was isolated, and nitric acid was freely applied to all parts. The disease was found 
very extensive, involving the greater part of the calf of the leg. Poultices of charcoal and pyroligueous acid, etc., were applied. 
The constitutional remedies were quinia, muriated tincture of iron, stimulants, beef-tea, etc. The disease was checked, and 
the patient is (July 31st) recovering rapidly. The interest in this case is the distance the man carried the contagion, the 
great rapidity and destructiveness of its attack, apparently uninfluenced by the comforts of a good home and the best of food 
and nursing.'' The patient remained in the hospital until September 3, 1864, when he was mustered out, his term of service 
having expired. The Pittsburgh Examining Board certified, in 1873 and 1875, that there was wasting of the gastrocnemius 
muscle from gangrene, and that the resulting adhesions have impaired the action of that muscle and cause pain in the ankle. 
The pensioner was paid June 4, 1870. 

Case 73. — Private A. W. Bretz, Co. D, 49th Ohio, aged 23 years, was wounded in the right thigh, at Murfreesboro*, 
December 31, 1862. Surgeon J. R. McClurg, U. S. V., in charge of the General Hospital at Cleveland, contributed the follow- 
ing history: ''The ball entered upon the outer and posterior aspect of the limb, passed through the biceps, semi-meinbra- 
nosus and semi-tendinosus muscles, and out upon the inner side of the thigh. The patient was in Hospital No. 21, Nashville, 
about ten days, after which he was sent to the West-End Hospital, Cincinnati, where he remained over three months. Ho 
says his limb was at one time almost healed, but it soon manifested symptoms for the worse, and afterward discharged consid- 
erably for several days. He was forwarded to and arrived at this hospital upon the evening of the 29th of April, and on the 
30th his wound was examined and dressed. At this time we found a ragged, foul ulcer upon the back part of the limb, where 
the ball entered, about one and a half inches in diameter, surrounded by an erysipelatous — or a halo of dusky red — inflamma- 
tion, hard and painful to the touch. The patient was feverish, restless, unable to sleep; had poor appetite, and appeared much 
prostrated. He complained of severe shooting pain in the limb and of the disagreeable odor of the wound. We dressed the 
wound with the creasote ointment and prescribed a tonic treatment. Some three days afterwards the whole integument and 
cellular tissue, previously inflamed and diseased, became one putrid mass and dropped out, leaving a large cavity, large enough 
to admit the whole hand. The hemorrhage at this time was considerable, and was arrested at the time by applying the pure 
creasote to the whole bleeding cavity, together with compresses, adhesive strips, and a roller from the foot to the groin. The 
haemorrhage was by this process arrested, and for two or three days afterwards my assistant surgeons reported the case favor- 
ably. But I was again called upon to visit the patient, who was reported to be sinking very fast, and that the wound was 
bleeding very much. I found to my surprise the whole bandage and bed saturated with blood, and the patient truly in a 
dangerous condition. Upon removing the bandages and compresses a large mass of coagulated blood and dead tissue dropped 
out, having the most intolerable stench imaginable. The haemorrhage was still very great, and I was almost at a loss to know 
how to stop it. The whole back part of the thigh appeared to be one bleeding cavity. I introduced my hand into the wound 
and found I could pass my fingers almost up to the tuber ischii. At the bottom of the cavity, entirely exposed to view, were 
the belly of the biceps, the semi-membranosus and semi-tendinosus muscles. We used cold water, which succeeded in a measure 
to stop the hemorrhage temporarily. Immediately afterward, or as soon as the patient had recovered from the shock produced 
by the loss of blood, I put him under the influence of equal parts of sulphuric ether and chloroform; then commencing imme- 
diately below the tuber ischii and cutting through the parts down to the muscles, I brought the knife down and out at the upper 
part of the cavity, turning the flaps outward and exposing the whole cavity; with a pledget of lint tied to a probang I cauterized 
every part of this cavity — the flaps and even the muscles — with pure nitric acid until they became perfectly charred and nil 
hemorrhage entirely ceased. The flaps were now brought together and fixed with wide adhesive strips around the thigh. A 
compress saturated with a lotion of nitric acid was applied, and over this a roller from foot to groin. The patient was ordered 
sulphate of quinine one grain, and tincture of chloride of iron fifteen drops, every two hours; also, eggnog, brandy-punch, 
and essence of beef. From this moment he began to improve rapidly and complained of no more severe stinging pain in the 
limb. Not the least haemorrhage ensued afterward, and that most offensive fetid discharge subsided at once. We dressed the 
sore twice per day afterward, still using a weak lotion of nitric acid. It has progressed and is still (June 1st) progressing 
most favorably." The patient was assigned to the Veteran Reserve Corps December 11, 1863. There is no record of his ever 
having applied for pension. 

In addition to the history of the case, Surgeon McClurg submits the following remarks in relation to the treatment 
of gangrene: "There is not a doubt in my mind but that the nitric acid is one of the most, if not the most, eificient remedy 
in use for sloughing phagedena and hospital gangrene. I am aware that of late bromine 1 and its compounds are exciting 
considerable interest in the medical profession as curative agents in hospital gangrene, but I must acknowledge that my expe- 
rience with these agents will not allow me to call them specific, and I certainly regard them as secondary remedies to nitric 
acid. The acid is an old and common remedy, and I believe the reason it has not oftener proved its superiority over all other 
remedies in hospital gangrene has been on account of the cautious manner in which it has been used. This is a serious disease, 
and the remedy should be freely applied. In the above case, I placed one ounce of acid in a tumbler, dipped my pledget of 
lint in again and again until the whole diseased part was effectually cauterized. All danger was at once over, and the disease 
that moment arrested." 

1 Among published papers on the local application of bromine in hospital gangrene may be mentioned Bromine, in Hospital Gangrene, by K. L. 
Stanford, M. D., Surgeon U. S. V., in Am. Med. Times, 18G3, Vol. VII, p. 24, and Remarks on Hospital Gangrene, by Surgeon G. R. Weeks, U. S. V .. 
in Am. Med. Times, 1863, Vol. VII, p. 46. GOLDSMITH (M ), A Report on Hospital Gangrene, etc., Louisville, 1863. THOMSON (WM.), Report of Cases 
of Hospital Gangrene treated in Douglas Hospital, Washington, D. C., in Am. Jour. Med. Sci.. 186*4, Vol. XLVII, p. 378. 



SECT. I.) COMPLICATED SHOT FLESH WOUNDS. 35 

Case 74. — Private' H. Barr, Co. I, 21st Iowa, aged 4i! years, was wounded at the Black River Bridge, May 17, 1863, 
and was transferred from a field hospital to Memphis, two weeks after the injury. Acting Assistant Surgeon W. M. Dorran 
contributed the following history: "He received a flesh wound of the right leg, the hall entering about two inches below the 
head of the fibula, external aspect, passing inward and downward behind the bones of the leg. and escaping three inches below 
the head of the tibia, internal aspect. On June 4th, he was admitted into the Jackson Hospital, in this city. The wounds 
were then small, the external one nearly healed; both wounds were suppurating, and the pus was 'darkish,' the patient stated. 
Either pus burrowed or a diffuse abscess formed six inches below the internal wound on the calf of the leg, pointed and broke 
there, discharging a considerable quantity of pus. The tissues all around this new sore began to slough, and a destructive 
process extended down to within two inches of the ankle, up to the internal wound, forward to the spine of the tibia, and 
backward to the median line of the muscles of the calf. A consultation was held over the case, and it was decided to ampu- 
tate, the patient states; but the superintendent of the hospitals happened to be present and overruled the decision, and had the 
patient transferred to the gangrene section of this, the Union Hospital, on June 30th. On admission, a large portion of black 
dead tissue surrounded the breach of the surface, which, when cut away by the scissors, made the ulcer to be about eight inches 
long and four inches in width at the middle of the leg. The tibia was denuded of periosteum to the extent of four inches in 
its middle third. The internal saphenous vein was a black cord for about six inches. The gastrocnemius and soleus muscles 
had sloughed to the median line, and the fascia between these two muscles, and also under the soleus, had sloughed away 
much farther in extent than the muscles. After it was cleaned as well as possible by cutting and washing, fuming nitric acid 
was applied, or almost poured on the dead and dying tissues still remaining, and with a piece of wood it was worked into their 
structure, and the semifluid slush or mud was cleaned away, as it formed, by the application of the acid. Then the whole leg 
was enveloped with a poultice of charcoal and linseed-meal, covered by an oilcloth, and bandaged from the toes to the knee. 
After the cauterization, when the patient was under the influence of some stimulants and morphia given to him during the 
operation, lie expressed himself as feeling better than he had for two weeks past, and the leg easier. July 1st, Sloughing by 
acid not ready to be removed yet ; acid again applied where gangrenous ulceration still proceeded, also the poultice and tight 
bandage. July 4th, The patient rests well at night, and his appetite is rather improved. He is cheerful and hopeful, and of 
the opinion now that there is a chance of his leg being saved, whereas before he had made up his mind that it was to be lost. 
The slough by the acid was removed to-day, and the sore is fresher in appearance anteriorly, but posteriorly the fascia is still 
sloughing. The strong acid was again applied in this region, causing the formation of a mass to be cleaned away to the 
amount of two or three ounces. Lint saturated with a solution of bromine and bromide of potassium is now introduced into 
every crevice and sinus and over every sloughing part, and over this a poultice and bandage. Stimulants are given four times 
a day, also tonics of quinine and tincture of chloride of iron. July 8th, By assiduous attention to treatment, after the manner 
already described, the sore has been brought to present a fresh and rather healthy base, and some granulations are springing up 
on the anterior part. Nitric acid has still to be applied under the muscles of the calf, and at the lowest margin of the ulcer 
some dead tissue remains. July 12th, The ulcer is quite clean and has quite a healthy appearance; granulations are springing 
up very beautifully, except at the lower margin. The patient's general condition has improved. Resin cerate is used to dress 
the parts where granulations are springing up, but solution of bromine or Labarraque's solution where any unhealthy appear- 
ance presents itself. July lGtli, The sore appears quite healthy and granulating all over. The muscles that were separated 
from each other by destruction of tissue between them are beginning to grow together. The tibia, which was bare for some 
distance, is again being covered by granulations. The edges of the ulcer are becoming depressed and rather inverted instead 
of being indurated and everted. The internal saphena vein has been destroyed for eight inches of its length and cut away. 
There was no haemorrhage at any time. September 1st, Ulcer very much reduced in size. Nitrate of silver is used at times 
to depress exuberant granulations. October 1st, Wound almost completely healed, and patient able to walk about." He was 
discharged April 6, 1864, and pensioned. Examiner R. S. Lewis, of Dubuque, Iowa, certified, June 16, 1864: "The right leg 
has been pierced by a hall about three inches below the knee, * * * followed by gangrene ; is still discharging, leaving 
the limb useless." This pensioner was last paid September 4, 18C8, since when he has not been heard from. 

The pathology and treatment of gangrene of the lower extremities will be considered 
in the chapter on the general subject. In the lower limbs traumatic gangrene is usually 
of the humid variety and commonly progresses with great rapidity. 

Tetanus. — Among cases of shot wounds of the lower extremities not attended by 
lesions of the bones, joints, great vessels or nerves, 1 there were one hundred and seventeen 

1 Surgeon J. JULIAN ClIISOLM, C. S. A., in his Manual of Military Surgery for tlie use of Surgeons in the Confederate States Army (Columbia, 
S. C, 3d ed., 18G4, p. 257), observes that the results described by Laruey in his campaigns in Egypt and Germany (Memoires de Chir. Mil. et Cam. 
pagnes, PariB, 1812. T. lit, p. €66), in the frequent appearance of tetanus in wounded soldiers upon exposure on battle-fields to cold and damp night air, 
never followed the leaving of wounded soldiers upon the battle-fields of the Confederacy. Dr. Edwaku Warrex, Surgeon General of the -State of North 
Carolina, declares (An Epitome of Practical Surgery for Field and Hospital, Richmond, 1863, p. 132) that "the experience of all surgeons establishes the 
fact that changes of temperature are prolific sources of this disease;" and Professor Samuel D. Gross {A System of Surgery, etc., 5th cd., 1872, Vol. I, 
Chap. X, p. 238) remarks that gunshot wounds are peculiarly liable to be followed by tetanus only when the sutTerers are neglected, or permitted to lie 
upon damp, cold ground, or in currents of cold air, after an engagement. Dr. ClIISOLM says (I. c, p. 258) that "a trifling puncture or scratch is. at times, 
sufficient to cause an attack ; and it has been noticed by military surgeons that the scraping of the skin by a ball, with bruising of the nerves, is more 
liablo to this complication than the more severe wounds." " Wounds in certain situations," Dr. CH1S01.M adds, "are thought to favor its appearance, viz : 
injury to the hands, feel, joints, etc." . . "Its common period for appearing is between the fifth and fifteenth days.*' Professor Jos. JONES, Surgeon 
P. A. C. S., in an article on Traumatic Tetanus, in Confed. States Med. and Surg. Jour., 1864. p. 1, dwells upon the good effects of chloroform mixture, 
administered by the stomach, in shot flesh wounds. The compilers of A Manual of Military Surgery prepared for the use of the Confederate States Army, 
Richmond, 1863 [Surgeons A. Tallev, VV. P. Campbell, St. Georok Peachey, A. E. Peticolis, and J. Duxx are reported to have constituted the 
commission that prepared this workj. in the chupter on Tetanus, on page 9, refer to the effect of draughts of cold air in determining violent exacerbations 
of muscular rigidity. 



36 INJURIES OF THE LOWER EXTREMITIES. t CHAP. x 

cases of tetanus noticed, with one hundred and six deaths, or 90.5 per cent. An example 
of one of the eleven instances of recovery is appended: 

Case 75. — Private G. C. Nichol, Co. C, 22d Iowa, aged 20 years, was wounded at Vicksburg, Way 22. 1863. Surgeon 
T. F. Azpell, U. S. V.,- noted his admission to the Steamer R. C. Wood, from a field hospital, June 4th, with ''shot wound of 
right thigh." Assistant Surgeon J. M. Study, U. S. V., reported the following history from Union Hospital, Memphis, where 
the patient was admitted June 8th: "The injury for which this man was admitted was an ordinary flesh wound, the ball 
passing transversely from without inward, through the posterior aspect of the right thigh. At the time of his admission the 
wound showed no indication of having made any progress toward reparation, but presented an extremely irritable margin. 
Warm-water dressing was applied, and on the following day there were marked symptoms of tetanus, chietly confined to the 
jaws, which, however, soon became more general, and in addition to the trismus there was that frightful condition of the body 
intermediate between opisthotonos and pleurothotonos. Sufficient quantity of chloroform was administered by inhalation, to 
produce complete anaesthesia, twice regularly in twenty-four hours. Sulphate of morphia, in half-grain doses, was given each 
evening at bed-time, and brandy ad libitum. June 11th, no notable change in the case ; patient is stupid, and there is an absence 
of muscular rigidity as long as the combined effects of the chloroform and morphia continue. June 14th, patient much in the 
same condition as wdien last noted, excepting an extensive tumefaction of the left limb, which tumefaction, so far as the most 
careful scrutiny would show, is entirely idiopathic in its nature. A roller was applied to this limb from the toes to the groin; 
otherwise the treatment of the case is the same. June 18th, tetanic symptoms subsiding somewhat; the wound has changed in 
appearance but little since first noted; tumefaction in left leg still present. Chloroform is given less freely than before; morphia 
continued the same, also the brandy. June 21st, patient is now able to separate the jaws to the width of half an inch; his 
general condition is improving rapidly; appetite is ravenous; the bowels are regular; swelling in left leg disappeared; wound 
beginning to suppurate. Morphia, in one-third doses, is given at bed-time; brandy, one ounce every two hours. June 28th, 
the wound has been suppurating freely, a large amount of the adjacent tissues having sloughed away. The warm-water dress- 
ing, which has been continued until now, is stopped, and scraped lint moistened with glycerine is applied. Patient takes one 
pint of ale daily. July loth, the wound is quite healed, and the patient walks with the aid of a cane. On August 19th, he was 
furloughed." The registers of the Union Hospital show that this man returned from furlough, and was sent to his regiment for 
duty September 30, 1863. 

Two examples of fatal cases are subjoined. It has been impracticable to discover 
any details of autopsies throwing any light on the subject. 1 Apparently there were no 
instances recorded in this group in which microscopical examinations of sections of the 
spinal cord were undertaken : 

Case 76. — Private P. Brown, Co. A, 169th New York, aged 36 years, was wounded at Cold Harbor, June 3, 1834, and 
admitted to Harewood Hospital, Washington, five days afterwards. Surgeon R. B. Bontecou, U. S. V., reported : "Shot flesh 
wound of left leg. Patient furloughed July 29th." Assistant Surgeon M. F. Coggswell, U. S. V., in charge of the Albany 
Hospital, reported the following result of the case: "The patient was admitted August 1st. having a large ulcer, measuring six 
by five and a half inches, on the calf of the leg, the result of a gunshot wound. His general health was very poor, and he was 
anasmic and debilitated. Gangrene had appeared previous to his admission to this hospital, and the ulcer was indolent, foul, 
and unhealthy. Nitrate of silver was applied and solution of chlorinate of soda, also poultices of flaxseed-meal mingled with 
pulverized charcoal. This treatment was followed in twenty-four hours by a healthy discharge of pus and a general improve- 
ment of the ulcer. Beef-tea, milk-punch, and extra diet were ordered. On the 2d of August his tongue was red and dry, his 
appetite failed, and he manifested great uneasiness and appeared to labor under an impression of impending evil. That night 
(August 2d) the weather, which had been very hot and dry for several days, suddenly became damp and chilly, and on the 
morning of August 3d, at 4 o'clock, symptoms of trismus appeared, and were followed in two hours by a general spasm of all 
the voluntary muscles. The risus sardonicus was marked, and the patient was in great distress; deglutition was impossible. 
Beef-essence and milk-punch were administered by enemata, and half a grain of sulphate of morphia was injected hypodermic- 
ally over the epigastrium. The latter acted so speedily and powerfully that in two hours all the muscles were relaxed. The 
patient's strength, however, was completely exhausted, and at 8 o'clock p. M. he expired, there being no recurrence of the 
tetanic symptoms. No general post-mortem was made; a local examination did not reveal anything. The trunk of the posterior 
tibial nerve was intact, but its muscular and cutaneous branches were involved." 

Case 77. — Sergeant W. "Walters, Co. B, 87th Pennsylvania, aged 29 years, was wounded at the Wilderness, May 8, 
18G4. Surgeon N. R. Moseley, U. S. V., reported his admission to Emory Hospital, Washington, May 16th, with "shot 
wound of foot." Surgeon J. II. Taylor, U. S. V., reported the following result of the injury: "The patient was admitted to 
Summit House Hospital, Philadelphia, May 20th, having been wounded by a ball striking the plantar surface of the left foot 
at the first interosseous space, one and a half inches from the metatarso-phalangeal joints, going directly through on the dorsum 
and producing a flesh wound. Cold-water dressings were applied. The patient is of strumous diathesis, having scars on the 
side of his neck, the remains of scrofulous abscesses. May 30th, at 8 a. M, lie was in excellent health; at 12 M. he com- 
plained of stiffness and pains in the jaws and neck; great pain, referred to articulation of left inferior maxilla with temporal 
bone, together with constant fixed pains at the epigastrium, shooting around to the spine; jaws seemingly tied, as the patient 
expressed; mouth gradually closing; twitching of facial muscles; some difficulty of respiration, but none of deglutition. 

1 ClIISOLM (J. Jui.iax), 51. D., (in his Manual of Military Surgery, 3d cd., Columbia, 1864, p. 259) states: "That fruitful source of information, 
pathology, gives us no instruction in this disease. An autopsy reveals to the eye nothing commensurate with the intensity of the symptoms. A slight 
congestion of the spinal cord and medulla oblongata is all that can be discerned. '' 



«ect. i.j COMPLICATED SHOT FLESH WOUNDS. 37 

Treatment: Bowels unloaded by injections; brandy and quinine given in large quantities, milk-punch and beef-tea by mouth 
and rectum. Liquor of morphia, one half ounce, was given every two hours for eight or ten hours, but with no effect. Injected 
one grain of sulphate of morphia, dissolved in one drachm of water, hypodermically just over the temporal region; but even 
this failed to produce any narcotic effect. Counter-irritation was used at the spine with chloroform and covered with oiled silk, 
but so severe was the burning pain : hat it soon had to be discontinued. On May 31st, the patient was attacked with severe 
cramps in the abdomen, the muscles here becoming hard and tense, the muscles of the back rigid and prominent; great pain, 
referred to chest in inspiration ; pupils contracted. There was profuse perspiration over the entire body from the commence- 
ment of the disease; pulse natural. A solution of sulphate of atropia, one grain to an ounce of water, was now injected, in 
quantities of one drachm, a little to the left of the median line of the neck at first, and subsequently on each side of the spine, 
below the scapula, at intervals of one half, one, and two hours, in all seven or eight times. The pupils were now dilated, but 
• there was not tiie slightest relaxation of muscular spasm ; perspiration still profuse. An effort to rouse him from this state with 
cold douche had but little effect. The spasms continued to increase in frequency and violence until 3 A. M. on June 1, 18C4, 
when he died." 

Extraction of foreign bodies, removal of all causes of irritation to the wound, avoid- 
ing cold and currents of air, were the prophylactic measures advised. Anaesthetics and 
narcotics were generally employed, but in grave and confirmed cases the therapeutical 
results were most discouraging. 

Erysipelas. — In forty-five cases, of which thirty-four proved fatal, extended erysipe- 
latous inflammation was the most characteristic feature. An example of recovery from 
this complication is detailed: 

Case 78. — Private W. Howling, Co. B, 1st Maryland Cavalry, aged 22 years, was wounded at Gettysburg, July 4, 1803, 
and entered the Frederick Hospital two days afterwards. Acting Assistant Surgeon W. S. Adams reported: "The patient was 
wounded by a minie ball winch entered two inches above the right patella, passing downward, striking that bone and glancing, 
and came out at its lower border, without causing fracture or involving the joint. The patient's general health was good. Cold- 
water dressings were ordered, and rest. July 20th, evidence of erysipelas appeared this morning; bowels constipated; pulse 
quick. Ordered lead and ojnitm wash to the knee joint, and gave three compound rhubarb pills. 21st, bowels open freely; 
pulse less frequent ; tongue furred, with red edges and tip; skin dry; loss of appetite; erysipelas extending above and below 
the wound. Applied tincture of iodine around the limb beyond the disease. 23d, erysipelas extending rapidly; considerable 
gastric irritation ; pulse quick but feeble. Ordered one pint of milk-punch a day, and three grains of quinine three times a day. 
24th, erysipelas still extending and now occupying the entire right leg and thigh, and the pelvic region down the left thigh as 
far as the knee; right limb very oedematous and assuming a decided phlegmonous character. Evaporating lotions of ether were 
ordered to the worst points, and the other treatment continued. 30th, erysipelas still extending up the body and now occupies 
the entire left limb. It has subsided in its original seat, and desquamation has taken place. Numerous longitudinal incisions, 
extending from the instep to the toes of the left foot, were made to relieve the tension. Stimulants were increased to one pint of 
whiskey per day, and beef-tea and generous diet pushed as far as possible. August 2d, general condition much better, but 
erysipelas still continues on the feet and ankles, and there is some sloughing of the integuments over the metatarsus of the left 
foot owing to the incisions not having been made in due time. August 6th, condition still improving; erysipelas has nearly 
disappeared. 9th, decidedly convalescent; ulcer of left foot granulating finely; appetite good. 30th, ulcer entirely healed; 
wound ^>f knee nearly so. October 13th, wounds entirely healed, and patient this day transferred to Baltimore." Surgeon T. 
II. Bache, U. S. V., reported that the patient was paroled from West's Buildings Hospital November 12, 1803. 

The graver cases of erysipelas complicating flesh wounds were pernicious and contagious : 

Case 711. — Private L. Brittin, Co. M, 1st Pennsylvania Cavalry, aged 35 years, was wounded at Hanoverton, May 28, 
1864, and admitted to the field hospital of the 3d division, Fifth Corps, where Surgeon L. W. Read, U. S. V., noted "a shot 
wound of leg." From the field hospital the patient passed to Washington and thence to Philadelphia, entering the Summit 
House June 28th, and subsequently the Satterlee Hospital. Surgeon I. I. Hayes, U. S. V., recorded the following history : " The 
injury was caused by a mini6 ball passing transversely and producing a slight flesh wound of the upper third of the right leg. 
The wound healed, when it was attacked by gangrene, and after again becoming healthy the whole limb was seized with erysip- 
elas. On March 24, 1865, the whole external lateral surface of the knee presented two sloughing wounds, one on a line with 
the head of the tibia, the other just above the tendon of the muscle. The whole limb was swollen, red, and painful. General 
condition poor, with headache, fever, dry tongue, and dry hot skin. On March 26th, a large collection of pus, amounting to 
about six ounces, was evacuated immediately below the patella. The patient's bed was moved, the old splint removed and a 
Smith's anterior applied. On rinsing the limb a sloughing wound involving nearly the whole popliteal space was found. On 
the following day the patient was slightly more comfortable, but there was not much change in his general condition. On March 
31st, there was no change in the appearance of the wound, but the patient's strength was evidently becoming exhausted. There 
were symptoms of pyaemia, and he was delirious during the afternoon, but better toward evening. His pulse was 120 and very 
small ; countenance sunken, with hectic spots on the cheeks. He complained of no pain, but was evidently partially unconscious. 
He died April 6, 1865." 

Haemorrhage. — In addition to the group of cases of shot flesh wounds of the lower 
limbs with primary lesion of the large blood-vessels, as discussed on pp. 13,' 18, ante, one 



38 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

hundred and fifty cases have been noted- — and this is probably an imperfect summary — 
of consecutive bleeding from the large vessels, among which were sixty-four examples of 
recovery, eighty deaths, and six cases with unknown results, a mortality rate of 55.5. 
Consecutive bleeding was from vessels varying in magnitude. 1 Tabulations have been 
made showing the time from the reception of the injury to the onset of the bleeding, the 
amount of blood lost, and the treatment, but there is not space to reproduce this analysis. 
Two illustrative cases are appended: 

Case 80. — Private J. C. Corliss, Co. G, 17th Illinois, aged "21 years, was wounded before Vieksburg, May 19, 18C3, and 
entered the Jackson Hospital at Memphis eight days afterwards. Acting Assistant Surgeon II. D. Garrison recorded the follow- 
ing description of the injury and its result: "A conical ball entered the left thigh anteriorly, about five inches below Poupart's 
ligament, passing upward and slightly inward in its course. The wound was examined at the time by a surgeon, who was 
unable to extract the ball. When admitted to this hospital the man was in good health, and his wound gave him but very little 
pain. Water dressings were applied and all went well until about noon on the 28th, when, from some slight motion, copious 
(Hemorrhage commenced suddenly. The femoral artery was almost instantly compressed over the pubic arch, but not until much 
blood was lost. A consultation being called, it was believed that the profunda femoris was probably severed, and that a tourni- 
quet with a small roller for a pad placed over the track of the ball would probably be sufficient, to prevent the recurrence of 
haemorrhage until nature had time to permanently close the vessel. This plan was accordingly adopted and proved successful 
for twenty-four hours, when — while Surgeon E. M. Powers, 7th Missouri, in charge of the hospital, was looking at the appliance 
and congratulating the patient on his safety — the haemorrhage again set in with all its former force. On consultation it was 
then agreed to inject the wound with solution of persulphate of iron, which was accordingly done, and the tourniquet was 
re-applied. No further haemorrhage occurred afterwards, but in spite of stimulants freely administered the patient expired 
fourteen hours after the last attack. The post-mortem examination revealed the fact that the femoral artery was opened about 
an inch below the origin of the profunda. The opening was about the size of a small pea and seemed to have been caused by 
the sloughing of the coats. In this case the pulsation of the tibial and popliteal arteries demonstrated that the flow of blood 
through the femoral was uninterrupted and led to the adoption of an erroneous diagnosis." Surgeon Powers in his report 
stated that the loss of blood in this case amounted to four and a half pints, also that the bullet was extracted from its place of 
lodgement after the patient's admission to Jackson Hospital. 

Cask 81. — Private A. Kunkle, Co. B, C'2d Pennsylvania, aged 18 years, was wounded at Gettysburg, July 2, 1863, 
and remained at a field hospital for two weeks, when he was transferred to Baltimore. Acting Assistant Surgeon J. Dickson 
made the following report from Jarvis Hospital: "He was wounded through the right thigh, the missile entering near the 
tuberosity of the ischium, and, passing about fourteen inches through the deep muscles, emerged outside of the femur four inches 
from the knee. He stated that he bled very freely on the field, and after being taken to a neighboring house there was a recur- 
rence, lasting all night. No further haemorrhage occurred until the patient was brought to this hospital. At. that time he was 
very anaemic and feeble. Generous diet and iron were ordered. On July 17th, an alarming haemorrhage occurred from both 
wounds, which was arrested by compression and the local application of persulphate of iron. Two days afterwards there was 
another haemorrhage as profuse as before, and the same treatment was resorted to with the same result. On July 28th, there 
was a recurrence nearly as profuse as the last. Amputation and ligation of the femoral artery was thought of; but it was 
concluded he would die after either, and compression upon the femoral and along the course of the wound was resorted to. On 
July 30th, the patient was rallying. On August 6th, another slight haemorrhage came on, followed by a discharge of sanious 
pus, the contents of an aneurismal sac. By August 29th the wounds had almost healed and the patient quite built up and walking 
on crutches, his leg being considerably contracted but straightening gradually." In October following the patient was trans- 
ferred to the Satterlee Hospital, Philadelphia, and subsequently to Pittsburg, whence he was returned to his regiment for duty 
February 12, 1864. The Adjutant General of Pennsylvania reports that the man was mustered out with his command July 13, 
1864. He is not a pensioner. 

Ligations of Blood-vessels of the Lower Limbs after Flesh Wounds. — At page 16 it 
will be recollected that attention was called to a considerable number of cases of direct 
injury of blood-vessels treated by primary or consecutive ligation, and that it was promised 
that further on such examples would be enumerated, together with cases of deligation of 
the same vessels for flesh wounds without primary arterial lesion. The series which will 
be here presented numbers one hundred and ninety-five instances, — one hundred and 
ninety-four ligations of arteries and one of the saphenous vein. It will be noticed, how- 
ever, that among the hundred and ninety-four cases of arterial ligations there were six 
instances in which the femoral vein was simultaneously tied with the artery it accompanied. 

1 An analysis of the series shows 1 fatal ease of bleeding from the external iliac ; there were 23 eases of haemorrhage from the femoral, with 18 fatal 
results, 3 recoveries, and 2 unknown. The haemorrhages from the profunda, circumflex, and other branches were 19 with 5 deaths. There were 13 cases 
of secondary bleeding from the popliteal with 8 deaths; 6, of bleeding from the anterior tibial with 1 death, and 15 of the posterior tibial with 9 deaths. 
It is hardly necessary to follow out the statistics of the smaller vessels. There were 13 cases of profuse venous haemorrhage of which 10 were fatal. 
This includes 4 cases of bleeding from the femoral veins, all of which were fatal. 



SECT. I.] LIGATIONS AFTER SHOT FLESH WOUNDS. 39 

A fatal instance of deligation of the common iliac artery is first detailed, constituting 
one of the six instances in which this operation was practised during the American civil 
war. This operation now (1877) foots up sixty-one cases with forty-eight deaths: 

Case 82. — Private J. Boner, Co. I, 48th Pennsylvania, aged 19 years, was wounded at Tolopotomy Creek, May 31, 1804, 
and admitted to the field hospital of the 2d division, Ninth Corps. Surgeon J. Harris, 7th Rhode Island, noted, "shot flesh 
wound of both thighs hy a minie ball." Four days after being wounded the man entered Judiciary - Square Hospital. 
Washington. Assistant Surgeon A. Ingram, U. S. A., corroborated the above description of the injury, and reported the result 
as follows: "Disorganization of tissue from a deep flesh wound; hemorrhage took place on June 10th, from the small vessels, 
and was controlled by pressure, but recurred on June loth, when the femoral artery was taken up at Scarpa's triangle. This 
vessel was again ligated, on June 18th, at Poupart's ligament ; hemorrhage again occurred on the morning of June 22d, when 
the common iliac was ligated. The patient died during the day.'' The report does not show which of the two limbs was 
operated on, and diligent search has revealed no additional record of the particulars of the case. 

The reader may compare, on page 333 et seq. of Volume II of Part II, the details and 
comments on four other examples of ligation of the common iliac artery practised during 
the War, two for shot wounds of the pelvis and two on account of aneurisms arising from 
punctured wounds. Yet another instance of unsuccessful ligation of the common iliac 
artery for consecutive haemorrhage after a shot wound of the pelvis has been recorded by 
Medical Inspector F. H. Hamilton, U. S. A. The particulars, so far as they can be 
ascertained, are stated in the foot-note. 1 

Ligations of the External Iliac Artery. — In four of these examples ligatures were 
placed at first on this trunk, but in the seven remaining cases after the femoral had been tied. 

CASE 83. — Private G. W. Husk, Co. F, 1st Maryland Cavalry, aged 47 years, was wounded at Deep Bottom, August 
l(i, 1804. Assistant Surgeon C. Wagner, U. S. A., reported, 2 from the hospital at Beverly, New Jersey: "Admitted from City 
Point with a gunshot flesh wound of the upper third of the right thigh. Bleeding occurred from the femoral artery on Novem- 
ber 10th, fifteen ounces of blood being lost. The patient was feverish, pulse 130, appetite wanting. Acting Assistant Surgeon 
.1. C. Morton administered chloroform and ligated the external iliac artery. The patient died November 17, 18C4, from recurrent 
haemorrhage." 

Case 84. — Private J. H. Gatewood, Co. F, 21st Georgia, aged 32 years, wounded at Manassas, August 28, 1862, Surgeon 
J. Chambliss, P. A. C. S., reported : 3 " Small ball entered just behind the left trochanter, passed out below the perineum, entered 
the right thigh opposite, and emerged at the external aspect at middle of upper third of the thigh.; bleeding was profuse for 
several minutes. Aneurism of the femoral artery; digital compression repeatedly used without avail. January 31, 1864, liga- 
tion of the external iliac artery, pretty much after Cooper's method, by Surgeon Jackson Chambliss, P. A. C. S. February 3d, 
erysipelatous inflammation subsided. February 15th, the wound presented a healthy granulated appearance and discharged 
healthy pus. Pie continued to improve until February 17, 1804, when violent arterial haemorrhage occurred, from which he 
died in a few minutes." 

1 Professor Frank Hastings Hamilton*, A. M., M. D., LL. P., in The Principles and rraclice of Surgery, Xew York, 1873, in treating of liga 
tions of the common iliac, states, at page 232, that: "On the 15th of May, 1804, after the battle of the Wilderness. 1 tied the same vessel in the presence 
of Dr. WALSEK and my student Mr. IlOYN. The patient, John E. Preston, of the tilth Pennsylvania Vols., had been wounded by a rifle-ball which had 
traversed the pelvis, and the operation was made to arrest a haemorrhage which had already nearly proved fatal, lie died on the following day. but 
without a recurrence of the bleeding. 1 ' In editing the surgical report iu Circular No. 0, S. G. O., 1805, p. 78, 1 cited from the records but three cases of 
ligation of the common iliac practised during the American civil war, — the operation ou the left common trunk by Surgeon J. Cooper MclvEE, U. S. A., 
for haemorrhage after shot wound of the pelvis (which afforded the specimen 3464, Sect. I, A. M. M.), and the operations by Acting Assistant Surgeon It. 
N. lsi'AM of Chicago, and J. B. Cutter of Newark, for aneurisms consequent on stabs. In the seventh chapter of Volume II, of Part II, of the Medical 
and Surgical History of the War, pp. 233-0, these three cases of ligation of the common iliac artery were detailed, and a fourth operation of ligation of 
this trunk for hemorrhage following shot injury, in the case of Colonel J. 11. Scott, 19th Illinois, was quoted from the report of the operator, Professor 1>. 
Brainaieu, in the Chicago Medical Journal, 1804, Vol. XXI, p. 97, and reprinted in the Am. Jour. Med. Sci., 1864, Vol. XLVH, p. 565. Tho operation 
of ligation of the common iliac for haemorrhage after shot flesh wound of the lower extremity reported above (Case 82) by Assistant Surgeon A. INGHAM, 
U. 8. A., is the fifth, and the case adduced by Professor F. 11. HAMILTON is the sixth, example of the war-series of this important procedure. From 
Professor Hamilton's printed report of tho case of Preston I was unable to trace the injury upon tho records, as there is no mention made of it either in 
the 19th or 1 19th Pennsylvania Volunteers; but after repeated diligent search the original manuscript entry of the case was found on the field register of 
the 3d division of the Sixth Army Corps hospital, at tho Baptist Church, Fredericksburg, Virginia. It is there stated that Corporal John E. Preston, of 
Co. G, 1 19th Pennsylvania, was wounded at the battle of the Wilderness, receiving a " gunshot injury of the anterior superior spinous process of the left 
ilium." The precise date and extent of the injury is not noticed, nor the disposition made of the patient ; but, in a list of deaths in the 3d division 
hospital. Sixth Corps, at the Baptist Church, Fredericksburg, the death of Corporal John E. Preston, on May 14, 18G4, is recorded. In another part of 
the register, signed by Dr. J. W. Walser, is a list of operations performed at Baptist Church Hospital after the battle of the Wilderness, by Drs. Ham- 
ilton and BUCK, which comprises: " One ligation of the common iliac, — death in twenty-four hours." The data are very imperfect, but the probabilities 
are. from the documentary evidence accessible, that Corporal Preston, 119th Pennsylvania, was struck, on May 7th, at the Wilderness, by a musket ball 
which fractured the anterior superior spinous process of the left ilium, and that he was sent to Fredericksburg by the hospital trains that reached that 
town on May 11th. Further, that uncontrollable haemorrhage arose, and that Medical Inspector F. II. Hamilton, U. S. A., ligated the left common iliac 
artery on May 13th, and that the filial termination of the case took placo twenty-four hours afterwards, May 14, 1804. 

2 See Report on Interesting Surgical Operations performed at Vie Hospital at Beverly, N. J., by Assistant Surgeon C. Wagner, U. S. A., 1804, p. 13. 

3 Chambliss (J.), Case of Traumatic Femoral Aneurism — Treated by Digital Compression — Ligation afterwards of the External Iliac Artery, in 
Confed. States Med. and Surg. Jour., 1804, Vol. I, p. 97. 



40 



INJURIES OF THE LOWER EXTREMITIES. 



[CHAP. X. 



Cask 85. — Private J. R. Spaulding, 1 Co. F, 112th New York, aged 23 years, was wounded at Fort Fisher, January 15, 
18G5. Assistant Surgeon S. H. Orton, U. S. A., reported, from McDougall Hospital, New York Harbor: "A minie ball entered 
the upper and inner aspect of the left thigh, and, passing a little downward and outward, emerged near the knee, apparently 
avoiding the hone and all important vessels. Simple dressings were applied for about three weeks, when the wound began to 
look unhealthy and had a tendency to slough. Solution of the permanganate of potash was freely used and tonics given. On 
March 23d, haemorrhage occurred from the posterior wound and was arrested by sulphate of iron and pressure. On March 31st, 
bleeding commenced from the anterior wound. Dr. Orton applied a ligature to the external iliac artery. On April 21st, the 
haemorrhage recurred from the anterior wound, probably through the collateral circulation, which in the meantime had become 
established. The bleeding was successfully restrained by the application of the horse-shoe tourniquet, which was kept con- 
stantly retained for the space of two weeks, -when it was omitted without any subsequent recurrence of the haemorrhage. At 
this time the patient was greatly afflicted with bed-sores, which were a source of great annoyance and sufficient to exhaust his 
strength. The wounds, however, were healing kindly. On May 31st, the. patient was attacked with dysentery, which, in his 
enfeebled condition, resisted all efforts at once. The patient continued to sink under this complication, and died June 15, 18G5, 
five months after the receipt of the original injury and about two and a half months after the operation of ligating the artery. 
At the time of his death the wounds were nearly healed." 

The fourth case of this group is that of Private J. Langford, printed in full in the 
American Medical Times, 1863, Volume VI, page 256. A somewhat extended abstract 
of this interesting case is here appended: 

Case 86. — Private J. H. Langford, Co. F, 10th Georgia, was wounded at Antietam, September 17, 18C2. Assistant 
Surgeon R. F. Weir, U. S. A., reported from the hospital No. 1, Frederick, that the patient entered that hospital October 27th. 
He had been struck by a musket ball which entered half an inch below Poupart's ligament, below the right groin, just, over the 
vessels, and made its exit on a line with the right tuber ischii, about two inches and a half behind it. Profuse immediate 
haemorrhage of arterial color produced syncope, and there was recurrent bleeding when the fainting was over. The patient 
was confined to his bed only about a week, and, by September 27th, both orifices had cicatrized. When he left his bed the thigh 

was Hexed on the pelvis, extension causing pain. On October 27th, an examination revealed an 
aneurismal pyriform tumor in the right groin, its apex directed toward the scrotum and the 
greatest transverse diameter corresponding with Poupart's ligament. At the base its diameter 
extended to the vessels about four and a half inches; at the apex, internal to the vessels, and 
about three inches external to the vessels. Starting from Poupart's ligament, the tumor extended 
in its outer portion three fingers' breadth toward the anterior superior spin?, and in the iliac fascia 
it extended a similar distance. Near the cicatrix of the wound of entrance the aneurismal thrill 
was very distinct. The patient said he perceived this thrill since he had been able to go about. 
The prominence of the tumor was moderate. The limb was flexed on the pelvis at an angle of 
about 45°. Neuralgic pains affected the anterior surface of the thigh and bitterly increased in its 
intensity. Pressure on the aorta or external iliac completely arrested pulsation. The pulsation 
of the posterior tibeal at the ankle was feeble. The patient was of fine physique, and reported 
himself as in excellent health prior to injury. By November 5th the tumor had rapidly aug- 
mented in bulk, and, after consultation, it was determined to operate by Syme's method on the 
following day. The measures proposed contemplated compression on the right common iliac, an 
incision through the cicatrix oftthe wound of entrance sufficient to introduce the left index, and 
feel and plug the original opening into the artery, then to freely lay open the sac and ligate the 
vessel above' and below the point of injury. November 6th, at noon, patient was placed under 
ether. A straight incision two inches long, starting from just within the middle of Poupart's 
ligament and running obliquely downward along the thigh, was made. The upper end of this 
opening was prolonged by a curved incision one and a half inches long, running upward and 
outward as far as the ligature of the external iliac artery. This incision was deepened through 
the superficial fascia, and the knife being then laid aside, the dissection was carried on by means 
of the handle of the scalpel and the finger nails. The lymphatic of the saphenous opening was 
thus brought into view, immensely enlarged, congested, and pushed upward. The aneurismal tumor was found to have 
partially forced its way through this opening, overlapping its upper edge like a femoral hernia. Commencing at the inner 
margin of this opening the dissection was carried on without much difficulty to Poupart's ligament, which was found very tense, 
and the artery could be felt beating just beyond. The upper end of the incision was then prolonged one inch toward the umbil- 
icus, and after dividing the tendons of the external oblique on a director, the ligament was divided directly over the artery by 
blunt-pointed scissors. The sheath of the artery was soon brought plainly into view and its covering pushed up to one-half 
inch beyond the epigastric and circumflex arteries, at which point a ligature was placed around from within outward by means 
of a Mott's aneurismal needle. The effect of ligation was to arrest pulsation in the tumor. The curved wound was closed by 
means of silver interrupted sutures. One small artery, the superficial epigastric, required ligation. Not more than one ounce 
of blood was lost during the operation. The limb was enveloped in cotton batting. An anodyne was given after recovery from 
the anaesthetic, and repeated at midnight. At 4 o'clock P. M. the patient was quiet; pulse 120, temperature of sound limb 93, 
of limb operated upon 95 in popliteal space. November 7th. patient passed a quiet night, though sleeping but little, and states 
that the neuralgic pains have ceased. In a paper on Hospital Gangrene, by Acting Assistant Surgeon A. North, printed in the 




Flu. 14. — Ligation of rijrlit ex- 
ternal iliac forshot injury. Sp. '.Y.)86. 



1 The case is briefly noted by Surgeon J. A. LlDELL, U. S. V 
coll. and pub. by the U. S. San. Comm., 1870. Surgical Vol. I. p. 231. 



Gunshot Wound of Thigh, etc., in Surgical Memoirs of the War of the Rebellion. 



SECT. 1. 1 LIGATIONS AFTER SHOT FLESH WOUNDS. 41 

American Medical Times, 1833, Volume VI, p. 257, the sequel of the history is given: "The operation was successful, and in 
two weeks the wound was nearly healed, when it took on an unhealthy action, and patient then complained of a burning pain 
in it. Anticipating what was coming, he was immediately moved to a stone building where there had previously been no gan- 
grene; and here. November 21st, he came under my care. He remained here for four days before the disease became sufficiently 
developed to justify his removal to the gangrene tent. November 25th, patient is very desponding, and is growing weaker day 
by day; has considerable headache ; pulse 120 and almost imperceptible; tongue furred, brown, tip and edges red and dry. 
The ulcer, which is three inches in width, extends from the pubes up nearly to the anterior spine of the ilium; has an unhealthy 
and sloughy appearance. Patient complains of a slight burning pain in wound, the edges of which are everted, jagged, and 
undermined for about two inches; the integument is indurated and tumefied, and extremely sensitive to the touch or the least 
movement of the limb; characteristic odor not well marked. The sinuses extending under the integument were freely laid open 
and the surface of the ulcer scraped with a spatula, to which the acid was first applied with a mop, and then worked in with a 
stick so as to get it down to the comparatively healthy tissue, and was also applied in a similar manner to the tissue surround- 
ing the ulcer, to destroy, in this way, both the cuticle and cutis vera and thus to limit the extension of the disease. Superficially 
antiseptic poultices were applied, and opiates given to relieve pain ; takes half an ounce of brandy and beef-tea every half hour. 
November 20th, although the pain following the application of the acid was so severe as to cause slight convulsions for a time, 
patient is feeling better to-day; pulse 108 and gaining in strength. Fearing that the progress of the disease lias not been 
entirely arrested, the acid was again thoroughly applied. Takes stimulants and tonics, with fifteen grains of tartrate of iron 
and potass three times a day. November 28th, the black, charred slough has separated, revealing a healthy, granulating 
surface beneath. The extreme sensitiveness to the touch, together with the induration and swelling of the surrounding parts, 
has almost entirely disappeared; applied oakum saturated with acid wash to the ulcer. December 5th, patient represents 
himself as feeling much better; mind hopeful and cheerful ; appetite good; ulcer is cicatrizing rapidly ; continue stimulants and 
tonics. December 15th, all unfavorable symptoms have disappeared and patient is regarded as convalescent. For two months 
after this date patient was up and about the ward, when secondary haemorrhage, following sloughing of the sac, supervened, 
and in four days resulted fatally," March 15, 1801?. Assistant Surgeon R. F. Weir's notes state that a sudden change occurred 
on February 25th, when, in the evening, the patient had high fever; pulse 140 and almost imperceptible. On February 
27th, considerable pain over the right tuber ischii and knee joint. A consultation failed to discover the cause of this change 
for the worse. On March 2d, an opening formed at the upper portion of the cicatrix and discharged twelve ounces of ill- 
conditioned pus. The opening was enlarged and examined digitally and with a probe; the cavity was syringed out. March 
9th, the patient's condition had improved since the opening of the sac. March 13th, about the same, discharge increasing in 
quantity. It was decided to make a counter opening at the lower extremity of the sac, on the inside of the thigh, and seven 
ounces of fetid pus escaped, which was soon succeeded by a jet of arterial blood. The sac was laid freely open, and a compress 
of sheet-lead was held over the sac by an assistant provided with relays of assistants. About seven ounces of blood was lost 
during the operation. On March 14th, at 9 o'clock A. M., pressure was removed and bleeding occurred, five ounces being lost. 
Pressure was again applied. On March 15th, the patient was much brighter, and it was decided to keep up pressure until 
bleeding recurred, and then to enlarge the lower opening, search for the bleeding point, and, if it could not be found, to freely 
lay open the sac. At 7 o'clock P. M., seven ounces of blood were lost. Chloroform was given and the opening enlarged; clota 
were turned out, the entire cavity was exposed, and nothing more than a general oozing could be found. The cavity was 
thoroughly cleansed, and the slight oozing of blood was stopped by cold water. The patient sank soon afterwards, from the 
antecedent haemorrhages and the shock of operation. An autopsy was made four hours after death: "Body much emaciated; 
rigor mortis well marked: right thigh flexed on pelvis and everted. The incision, made for the purpose of opening the suppu- 
rating cavity to arrest the hasmorrhage which occasioned death, was seven inches long, commencing about one and a half inches 
to the inner side and on a level with the anterior superior spinous process, and terminating on the inner side of the thigh. The 
thickness of the tissue divided, part of which was cicatricial, was about three and a quarter inches, in which ran the femoral 
vessels. These were found to have been divided by this incision but did not otherwise directly communicate with the aneur- 
ismal cavity. This cavity occupied the iliac fossa of the right side and was situated between the fibres of the iliac muscles, and 
had crowded the caput coli toward the median line. It extended from a level with the fourth lumbar vertebra to four and a 
half inches below Poupart's ligament. The sac or abscess in the thigh was about four inches in diameter and of a size nearly to 
contain a foetal head. It had dissected up the tissues with the exception of the tendons, psoas, and iliacus from lesser trochanter, 
and anterior and inner surfaces of the femur. Below this point, at the bottom of the cavity, a track extended to the inside 
of the lesser trochanter and approached to within an inch of the surface of the tuberosity of the ischium. Another track 
extended in front of the pubes toward the root of the pubis. This extensive cavity contained about four ounces of coagulum 
mixed with blood, which gave to the smooth wall a sloughy appearance. At the inferior, beneath the femoral artery, a small 
quantity of fresh coagulum was found in the cellular tissue, suggesting the idea that the hemorrhage had proceeded from this 
point, but the vessels causing it could not be found. An attempt had been made to inject the artery, but had failed for the want 
of proper instruments. On dissection of the abdominal walls the peritoneal cavity and its contents were found in a healthy 
condition. The external iliac artery of the right side, from its origin to the point of ligation, had diminished to a small cord 
about one-eighth of an inch in diameter, firm to the touch, and of a dark color from its containing clot. The principal branch 
of the external iliac, the epigastric, and circumflex were found larger than the corresponding arteries of the left side. The 
sacral artery was also enlarged. The chain of lymphatic ganglia along the inside of the iliac artery was much enlarged and 
indurated, and the tissue in the region of Poupart's ligament had been much altered and firmly matted together by inflamma- 
tory action. The femoral artery, as it passed under the ligament, was nearly three-fourths of an inch nearer the pubis than 
usual. The femoral vein was in a normal condition. The artery below the point of ligature to the point of division, in the 
operation immediately preceding death, was about three and one-fourth inches in length. This portion was laid open, together 
with the upper portion of the femoral artery, in order to ascertain, if possible, the locality of the original injury. About one 
and a half inches below the origin of the epigastric and its inner margin there was a faint permanent discoloration, which also 
Surg. Ill— 6 



42 INJUEIES OF THE LOWEE EXTREMITIES. [chap. x. 

presented a slight linear appearance; elsewhere the artery presented no peculiar appearance." The specimen is represented in 
the wood-cut (Fig. 14), drawn from the preparation 3986, Section I, A. M. M., and presented by Dr. Weir to the Museum. 

In the other seven cases of ligation of the external iliac the femoral artery had 
previously been ligated. Successful results were finally attained in two instances: 

Cases 87-93. — Private J. S. Degolia, Co. A, 7Gth Pennsylvania, aged 32 years, wounded at Drury's Bluff, May 1(5, 
1864. Surgeon A. Heger, U. S. A., described the injury and its result as follows : " The patient was admitted to the Point 
Lookout Hospital May 19th, having been wounded by a musket ball entering the right hip at the external and posterior aspect, 
passing across, over the pubes, to the left thigh, and downward toward the knee, wounding the great vessels of the left side, 
and making its exit one inch above the knee, on the external surface. On May 24th, the femoral artery was ligated above the 
wound two inches below Poupart's ligament. The patient was much prostrated from the severity of the wound and loss of 
blood. Stimulants were used, and warm applications to the limb. Eepeated haemorrhage required the ligation of the external 
iliac on May 29th. The patient died, of gangrene, June 1, 1864. The first operation was performed by Surgeon A. Heger, 
U. S. A., and the second by Surgeon J. IT. Thompson, U. S. V." — Private W. S. Marshall, Co. E, 11th Pennsylvania Reserves, 
aged 26, wounded at Gaines' Hill, June 27, 1862. Assistant Surgeon C. Wagner, U. S. A., reported that the patient was admitted 
into Hammond Hospital with a "gunshot wound of the right thigh and false aneurism of the femoral artery. The aneurism 
measured six and a quarter inches in its longest diameter. Dr. Wagner ligated the femoral near Poupart's ligament. On 
September 6th, haemorrhage to the extent of forty ounces occurred from the femoral artery. Dr. Wagner then tied the external 
iliac. The bleeding did not recur. The patient died September 16, 18C2, from exhaustion." — Private II. Locke, Co. II, 6th 
Vermont, aged 23 years, wounded at the Wilderness, May 5, 1864. Surgeon Henry Janes, U. S. V., reported, from Sloan 
Hospital, Montpelier: "Gunshot wound, right thigh; ligation of femoral and iliac arteries for secondary haemorrhage. Trans- 
ferred to Veteran Keserve Corps December 5, 1864." — Sergeant-Major L. C. Sears, Oth New Hampshire, aged 22 years, 
wounded at Fredericksburg, December 13, 1862. Surgeon T. Antisell, U. S. V., reported from Harewood Hospital, Wash- 
ington : "A conical ball entered the right thigh two inches below Poupart's ligament. On the morning of December 19th there 
was a slight haemorrhage from the wound. Search was made for the ball without result. A counter opening was made and a 
seton inserted. He remained very comfortable until the 22d instant, when a severe haemorrhage occurred, which necessitated 
the tying of the femoral in the ward, by Dr. Antisell. On Sunday, January 4, 1863, there occurred a haemorrhage which was 
arrested by means of styptics and compression. Another haemorrhage followed on the evening of January 7th, which could 
not be controlled by styptics. Search was made for the bleeding vessel without result. The patient lost much blood. On the 
following morning, January 8th, the patient was again brought into the operating room and the wound was carefully explored, 
hut the bleeding vessel was not found. The operation of tying the external iliac artery was then performed by Dr. Antisell, in 
the hope of arresting the haemorrhage permanently. The operation was no sooner completed than there was a welling up of 
blood from the point from which the previous haemorrhage had proceeded. Styptics and compression were applied, and the patient 
was returned to the barrack. Stimulants and beef-tea were freely given, and warmth was applied to the extremities to restore 
reaction. He revived toward evening, and remained sensible and quite comfortable until the evening of the 10th instant. He 
died January 11, 1863, from exhaustion." — Lieutenant J. A. McQuillan, Co. I, 38th Ohio, aged 25 years, wounded near Atlanta, 
July 29, 1864. Surgeon J. H. Phillips, U. S. V., reported, from Hospital No. 1, Chattanooga: "Gunshot wound of right 
thigh. Haemorrhage occurred on September 20th, thirty ounces of blood being lost. The femoral artery was ligated Sep- 
tember 20th, in the wound, which was gangrenous. On the 26th, the haemorrhage again returned, and it being found 
impossible to ligate it again in the wound, the external iliac was ligated just above Poupart's ligament, after which the 
haemorrhage did not recur, but the gangrene continued, and the patient sank, and died October 2, 1864." — Private E. B. Corn- 
well, Co. A, 93d Ohio, aged 23 years, wounded at South Mountain, September 14, 1862. Assistant Surgeon W. E. Waters, 
U. S. A., reported from Caspari Hospital that the patient died November 3, 1862, of peritonitis. Acting Assistant Surgeon L. 
Heard reported: 1 "The shot had entered some four inches below Poupart's ligament, over the track of the femoral artery. An 
examination gave evidence that the femoral artery had been wounded and that a traumatic aneurism was forming. Water 
dressing was applied till the 29th, when compression by means of a horse-shoe tourniquet was made, and continued until Octo- 
ber 4th. On October 10th, Drs. J. F. May and Shippen, assisted by Drs. Hall and Seeley, ligated the femoral artery. Ligatures 
were placed on the cardiac and distal sides, and the vessel was divided between the two ligatures. On the sixth or seventh 
day bleeding occurred, which was soon arrested and a tourniquent placed upon the limb. In about a fortnight after the oper- 
ation the proximal ligature came away of itself, with knot and loop at the end. On October 30th, profuse secondary haemor- 
rhage took place, which greatly reduced the strength of the patient. Dr. May ligated the external iliac artery. The patient 
gradually sank, and died November 3, 1862.'' — Sergeant J. K. Zeiders; Co. I, 53d Pennsylvania, aged 19 years, wounded near 
Gettysburg, July 3, 1863. Acting Assistant Surgeon W. V. Keating reported, from Broad Street Hospital, Philadelphia: 
"Gunshot flesh wound of the right thigh by a conical ball. The wound sloughed, and secondary haemorrhage occurred from the 
femoral artery on July 28th. The haemorrhage recurring on August 4th, Acting Assistant Surgeon A. Hewson ligated the 
femoral artery just above Scarpa"s triangle, and on August 11th again ligated the vessel higher up. The thigh became some- 
what oedematous; by October 28th the wounds of the previous ligations had nearly healed externally. A sinus extended into 
the tissues below, which were found to he in a softened broken-down condition ; ligature separated. On October 8th, Dr. 
Hewson administered ether and ligated the external iliac artery through a curved incision about three inches long; about six 
ounces of blood lost. October 25th, slight haemorrhage from point of ligature, and another in the afternoon, amounting in all to 
about six ounces; controlled by styptics to wound and oil of turpentine and veratrum viride internally. Pulse 130 and weak." 
The patient was discharged from service May 14, 1864. 

1 Heard (L.), Wound of the Femoral Artery — Ligation of both Cardiac and Distal Sidesof Severed Vessel — Secondary Hiemorrhage — Ligature 
qf External Iliac— Peritonitis— Death ,■ in Am. Med. Times, 1862, Vol. V, p. 337; and Boston Med. and Surg. Jour., 1862, Vol. LXVTI, p. 369. 



SECT. I. 



LIGATIONS AFTKR SHOT WOUNDS. 



43 



Professor John Ashhurst, jr., has lately remarked 1 that a study of the statistics of 
the operations of tying some of the larger 'arteries impresses the fact that "as cases have 
accumulated, the percentage of mortality has greatly increased." 2 This comment, however, 
is less applicable to the series of ligations of the external iliac artery. 3 In studying the 
statistics the operations for disease and for traumatic cause must be discriminated. The 
war cases have a fatality more than twice as great as those in civil practice. 4 

Ligation of the Femoral Artery. — In a previous portion of this section, commencing 
at page 16, reference is made to sixty-two ligations of the femoral artery for direct shot 
injury of the vessel, with the large mortality of 72.6 per cent. An interesting example 
of a well-managed successful case is adduced, and the great importance of ligating the 
distal as well as proximal extremities of the vessel is urgently enjoined. In addition to 
these sixty-two cases there were sixty-five instances in which the femoral artery was tied 
for consecutive bleeding unattended by primary injury to the vessel. The hundred and 
twenty-seven examples are enumerated in the summary entitled Table III. This series 
presents the same grave mortality as when the cases of direct lesion of the vessels were 
separately considered. References to publications of detailed cases arc given; a few 
abstracts will be presented of cases which furnished pathological material for the Museum : 

Case 94. — Private B. Ayres, Co. A, 5th Iowa, aged 40 years, was wounded at Vicksburg, May 19, 18015, transferred by 
hospital steamer to Memphis, and admitted into Gayoso Hospital on the 'J7th. On the Medical Descriptive List appear the 
following notes by Acting Assistant Surgeon A. W. Nelson: "A minie ball entered the left thigh through the centre of Scarpa's 
triangle, passing to the inside of the vein and out at the lower part of the left nates. At the time . 

of admission the wound was in a very dirty and sloughing condition and the skin had a dark tinge. 
There was considerable diarrhoea, with free perspiration; he was dozing a good deal of the time 
without any opiate; pulse 100. Water dressings were applied, and he was ordered to lie on the 
abdomen occasionally to allow the discharge to escape. Ale was given daily. He had a severe 
rigor on the evening of the 30th, and on the 31st, at 7 o'clock P. M., had hemorrhage from the 
anterior wound, which was checked by a compress. Fifteen grains of quinine were divided into 
four powders, one powder to be given every four hours. At 2 o'clock P. M. on June 1st the wound 
was opened to the sheath of the femoral vessels and a darning needle removed from the sheath; 
there was no hemorrhage, and all compression was removed. The wound was thoroughly cleansed, 
and the patient removed to bed. About 8 o'elcjpk r. m. blood, in large quantities, burst forth in a 
jet, apparently from below ; it was quite dark, but the exact shade was not observed. The femoral 
artery was immediately ligated, but with difficulty owing to the thickened and diseased condition of 
the parts. There was no hemorrhage after ligation, but patient did not rally under the use of 
stimulants, and he died at 11 o'clock P. M. Chloric ether was used during the operation. The 
autopsy disclosed great sloughing in the course of the wound. There was a slough of the femoral fig. 15.— Femoral artery and 
vein of the size of a three-cent piece. The vein was pierced by the large needle alluded to above, JJSs' I^K atlon of nrler >'- Specs. 
two small holes existing opposite each other; the artery was healthy. It was observed that well 

marked symptoms of pyemia existed several days before his death; however, the autopsy was not carried far enough to verify 
this diagnosis." The specimens (Fig. 15) consist of wet preparations of the left femoral artery ligated below 7 the origin of the 
profunda, and of the femoral vein, showing the point of perforation by the needle, which were contributed by Dr. Nelson. 

1 Transactions of the International Medical Congress of Philadelphia, 1877, p. 572. 

"Thus Professor AsniumsT observes that when Dr. G. W. NORMS published his classical paper in 1847 (Am. Jour. Me.d. Set., Vol. XIII, p. 24), 
he had collected sixteen eases of ligation of the common iliac artery with eight recoveries and eight deaths, a mortality of fifty per cent., while there 
are now recorded sixty-one cases with only thirteen recoveries and forty-eight deaths, a mortality of seventy-nine per cent. 

3 Thus Honcsox (Treatise on Diseases of Arteries, etc., 1815, p. 416) enumerated rweaty-one instances of ligations of the external iliac following 
the first operation by AiiERNETIIY. in 1796, and fifteen of the twenty-two patients completely recovered, or G8.2 per cent. In 1875, Dr. 1: at.k collected 
(Deutsche Zeitschrift fur Chir.. Leipzig, 1875, 15. V, p. 213) two hundred and seven cases of ligations of the external iliac, of which one hundred and 
thirty-five recovered, or 63.9 per cent., advancing the dcatli rate but 3 per cent., though the number of cases is decupled. 

4 Among American Surgeons two principal methods of ligating the external iliac artery are taught and practised. ARERXETHY, who first ligated 
this vessel on the living subject in 179(1 ( Tlie Medical avd ]Viysical Journal, London, 1802, Vol. VII, p. 97, and The Surgical and Physiological works 
of Joux Abernetiiy, London, 1830, Vol. I, p. 292), made a perpendicular incision "about three inches in length, through the integuments of the 
abdomen in the direction of ttie artery, and thus laid bare the aponeurosis of the external oblique muscle, which was next divided from Poupart'e liga- 
ment, in the direction of the external wound, for the extent of nearly two inches. The margins of the internal oblique and transversalis being thus 
exposed, the finger was introduced beneath them for the protection of the peritonaeum, and they were divided. Next, the peritonaeum and its contents 
were pushed upward and inward, and the external iliac artery taken hold of with the finger and thumb. It now only remained to pass a ligature round 
ttie artery and tie it ; but this required caution on account of the contiguity of the vein." In his second case. ABKRXETIIY made his incision in a line a 
little external to the artery to avoid the epigastric. Both of these operations failed, but Abernethy"s third and fourth attempts were completely suc- 
cessful. Sir Astley COOPER'S operation is generally preferred as endangering the peritoneum less, and less weakening the abdominal parietes so as to 
pive a tendency to hernia. Sir A. Cooper saved four of his six patients. His method of operating is described in HODGSON (op. tit., p. 42), by HARRISON 




44 



INJURIES OF THE LOWER EXTREMITIES. 



[CHAP. X. 




Fig. 16.— 
Ligation 
of femoral. 
Spec. 1024. 



Cask 95. — Private S. Brown, Co. G, R!4tli New York, aged 1C years, was accidentally wounded on August 30, 1862, 
and entered the Mansion House Hospital, Alexandria, six days afterwards. Assistant Surgeon W. A. Conover, U. S. V., 
contributed the following report of the injury : "The ball entered the left leg at the posterior middle third, penetrated the tibialis 
posticus muscle, and was extracted at the same opening. At first there was free discharge of laudable pus, but 
suppuration increased rapidly, and by September 26th infiltration of the tissues had nearly reached the popliteal 
space. Under a supporting treatment the patient seemed to gain rapidly until November 14th, when, 
during his sleep, a profuse haemorrhage occurred from the sloughing of the posterior tibial artery and 
a great quantity of blood was lost before it was discovered. His condition not admitting an operation, 
the wound was plugged with styptics and a bandage was applied from the toes to the hip. This treat- 
ment controlled the haemorrhage for eight days, stimulants being given freely in the mean time in order 
to prepare the system for an operation, if necessary. On November 28th another attack of bleeding 
was promptly controlled by the attendant, and, upon consultation, ligation of the femoral artery at the 
lower third was agreed upon as giving the patient a chance for his life. The operation was performed 
with some difficulty, owing to the abnormal structure of a branch artery which had to be carefully 
avoided. The patient bore the operation very well considering his condition, and, on the following day, 
his extremities were perfectly warm and remained so, showing that circulation had been re-established. 
The discharge, however, continued excessive, and although stimulants and tonics were used very freely, 
the patient sank steadily, and died of pyaemia on December 7, 1862. The autopsy confirmed the 
extensive disorganization from infiltration of pus, the artery being in an unhealthy condition up to 
within an inch of the ligature. The tying of the artery was a success, the clot having been perfectly 
formed and the circulation re-established by the profunda, which was sufficiently enlarged for the 
purpose.'' The ligated artery was contributed by Dr. Conover, a wet preparation of which is shown 
in the cut (Fig. 16). 
Cask 96. — Private W. Colgan, Co. C, 2d Massachusetts Cavalry, aged 21 years, was wounded at Berry- 
ville, September 1-1, 1804. On the following day he was admitted to hospital at Sandy Hook, and three days 
afterwards he was transferred to Frederick. Assistant Surgeon R. F. Weir, U. S. A., reported: The wound was — JQ ]7_ Left 
caused bya conoidal ball, which entered on the outer border of the popliteal space of the left limb, took a diagonal femoral artery 
course up behind the femur, and emerged on the inner aspect at the lower portion of the upper third. The half inches be- 

patient was-verv anaemic when admitted, and stated that he lost a considerable amount of blood on the field. lowthcpmfun- 

da Spec 3972 
Stimulants and generous diet were ordered. On September 24th there was an attack of haemorrhage to the 

amount of twelve ounces, which was checked by compression. On the following day another haemorrhage occurred, when the 
femoral artery was ligated four and a half inches below the profunda by Acting Assistant Surgeon J. C. Shimer. On the morn- 
ing of September 28th there was slight oozing of arterial blood, when the openings were enlarged and the source of bleeding 
searched for ineffectually. Recourse was had to digital compression. Death ensued at 10 o'clock, September 28, 1864. At the 
post-mortem (see the adjoining wood-cut, Fig. 17) the femoral and profunda arteries were found to be intact. (See the Catalogue 
of the Surgical Section of the Army Medical Museum, 1866, p. 463.) 

Case 07. — Private I. Curler, Co. G, 5th Michigan, was wounded at Fair Oaks, May 31, 1862, and admitted to Hygeia 
Hospital, Fort Monroe, four days afterwards. Surgeon, R. B. Bontecou, U. S. V., reported: "Gunshot wound of femoral 
artery, the ball entering the anterior and middle portion of the right thigh amkjiassing out opposite posteriorly, going close to 
the inside of the femur. The temparature of the limb was good, although the artery at the ankle beat feebly. 
Haemorrhage from both wounds occurred on June 10th, and returned in a few hours. An unsuccessful attempt 
to find the artery below the wound was made, and I tied the femoral, as I supposed, above the profunda; but 
pulsation being so strong in the artery exposed below the ligature, further search was made and the profunda 
was found unusually high up. This was also tied, and no haemorrhage returned. The foot, before the operation 
warm, now became cold; but by the aid of external heat its temperature returned on the following day. The 
patient was a fine healthy looking young fellow. He was transferred to New York by steamer on June 12th." 
Surgeon S. W T . Gross, U. S. V., contributed the specimen shown in the annexed cut (Fig. 18) and reported the 
result of the case as follows : "The patient was admitted to DeCamp Hospital, David's Island, New York, June 
15th, and was placed under the charge of Acting Assistant Surgeon W. K. Cleveland. At the time of his admis- 
sion the ligature had come away but the wound had not united. On June 17th, profuse haemorrhage occurred 
from the profunda femoris, around which a ligature was cast. The patient, however, had lost so much blood 

The specimen (FlG. 18) consists of a small section of the 




Via. 18.— Sec- 
tion of right fem- 
oral and profun- 
da. Ligatureon 

the former has that he succumbed two hours alter the operation, 
out its way out 
Spec. 1004. 



femoral and profunda arteries, and shows the femoral blocked up with a clot at the seat of the ligature, also the 

ligature around the profunda, where another clot was formed. 

Case 98. — Private D. Rapp, Co. K, 7th Indiana, aged 20 years, was wounded at Robinson's Creek, November 30, 1863. 

He was admitted to the field hospital of the 1st division, First Corps, where Surgeon G. W. Metcalf, 76th New York, noted: 

"Gunshot wound of left thigh." On December 6th, the wounded man was transferred to Douglas Hospital, Washington. 

Three days afterwards he was operated on by Assistant Surgeon W. Thomson, U. S. A., who furnished the following detailed 

{Surg. Anat. of the. Arteries, 4th ed., 183!>. p. 351), and most of the text-books. Dr. STEPHEN Smith has published a good aecount of thirty-two deliga- 
tions of the primitive iliac artery (Am. Jour Med. ScL, 1860. Vol. XL, p. 17). I have mentioned many of the more recent cases in a foot-note to Part II, 
Vol. II, p. 333, of the Med. and Surg. Hist, of the War. But h}* far the most comprehensive analytical summary furnished is given by Dr. L. RACK [Zur 
irnterbindung der grassen Grfassstamme in der Continuitdt by Erkran-Kungen and Verletzungen der vnteren Extrcmitaten, in Deutsche Zeitschrift fur 
Chir.. Leipzig. 1875. It. V, p. 213), who tabulates 207 cases of ligations of the external iliac, of which 72, or 34.7 percent., proved fatal. Of these 207 case* 
the author distinguishes 34 with 22 deaths (u'4.7 %) as war cases, and 173 with 50 deaths (28.0) as cases from civil practice. In four of the cases from 
civil life the common iliac was afterwards ligated (twice successfully), and in one of the cases from war practice the same vessel was tied with temporary 
success. This was Dr. BitADIAUD's case, published in the Chicago Med. Jour.. 18C4. Vol. XXI, p. 97, which Dr. Raise quotes from Professor GURLT'8 
Jahresberirtd for 1864. 



SECT. l.J LIGATIONS AFTER SHOT FLESH WOUNDS. 45 

report of the case: He was a well developed and very muscular man and bad been apparently in good health. At the moment 
of injury be was retreating, and was struck by a bullet on the posterior aspect of the left thigh a short distance below the 
gluteal fold, which passed through the limb to the inside of the bone, divided both femoral artery and vein, and made its exit 
three anil a half inches below Poupart's ligament, at the point of election in ligating the femoral in Scarpa's space. There was 
profuse haemorrhage at the time of injury, and an immediate want of sensibility in the leg and foot. When examined on t lie 
7th of December, the whole limb was found warm and the collateral circulation had been established ; lint there was uo pulsa- 
tion in either of the tibial arteries. At the superior margin of the wound of exit there was a small tense swelling, which 
pulsated synchronously with the systole of the heart. An aneurismal thrill, resembling the loud purring of a cat, was distinctly 
felt, extending along the course of the vessels into the pelvis, but not communicating laterally. The little linger was intro- 
duced into the wound at the time of the operation, and the pulsation and thrill were found to be closely localized and confined 
to the divided ends of the femoral vessels. There was no extensive effusion of blood into the tissues of the thigh, and hence 
this was not in the strict surgical sense of the word a traumatic aneurism. It was concluded that the sac was composed only 
of the sheath, which had been united by inflammation after the division and retraction of its vessels, and had then been some- 
what distended after the heart had regained its force. It was also suggested by Surgeon Lidell, who kindly saw the case with 
me, that there was a free communication between the divided artery and vein in this sac which permitted the arterial blood to 
return freely by the vein, as evinced by the pulsation communicating with such force backward toward the heart in the line of 
the vessels. It was unmistakable that there existed a wound of the femoral artery sufficient to cause its obliteration, that an 
aneurism was being developed at the divided proximal extremity, and that the proper surgical procedure would be to secure 
the ends of the vessel at the point of the injury. It was determined to emulate the example of Mr. Syme, to lay open boldly 
the sac by a free incision and search for and secure the bleeding orifices. It was hoped that the profunda had escaped injury, 
and every precaution was to bo used to secure the femoral below its origin. A small haemorrhage on December 9th rendered 
immediate interference necessary, and the following operation was then done with the assistance of Surgeon 
Lidell and the medical officers of the hospital. After the patient had been fully etherized and the femoral artery 
thoroughly compressed on the pubes by the thumb of a reliable assistant, as evinced by the loss of pulsation in 
the tumor, an incision four inches in length was made through the skin and fascia;, immediately over the tumor 
and including the gunshot wound, in a line parallel witli the sartorius. A second incision was now made into 
the tumor, which was dilated instantly by the finger to the size of the first. Distal haemorrhage was anticipated, 
and it caused but little surprise when a most profuse dark colored torrent poured out from the incision. The 
lower angle of the incision was rapidly searched in vain for the source of the haemorrhage, and it was feared 
that it might come from the dark softened depth of the track of the ball. No pressure on the artery hod the 
least controlling effect upon it. The removal of the sponge was followed instantly by a boiling dark torrent of 
venous blood, which so quickly filled the cavity as to prevent any examination. So profuse and uncontrollable 
was the flow that visions of ligating the external iliac were vividly presented to the mind. When the flow 
was found to arise from the superior angle of the incision numerous and ineffectual efforts were made to secure 
the vessel, but the parts were so hardened by local inflammation that the forceps glided over them as it would 
over a cartilaginous surface. This point, from whence the dark blood seemed to flow, was finally compressed 
by the point of the left index finger, and by means of the nail of the small finger of the right hand a vessel was 
isolated, a ligature passed around it with an aneurism needle, and this haemorrhage, most embarrassing because 
uncontrolled by pressure, was finally suppressed. The first ligature was applied at the superior angle of the J™*" f^'Teiniirai 
incision to the proximal extremity of the divided femoral vein, from which this unexpected and most annoying artery and vein, 
haemorrhage escaped by regurgitation from the saphena. The blood found its way into the limb by means of ' pec ' 
arteries arising from the iliac above the point compressed, was finding its way back by the saphena, enlarged to compensate for 
the occlusion of the femoral, was poured into the femoral a short distance above its divided proximal extremity, and then regur- 
gitated through the stump of the femoral into the superior angle of the incision. The proximal end of the femoral artery, from 
which a crimson tide escaped on relieving the pressure slightly, was now easily found, and this was ligated. The wound was 
now thoroughly cleansed of all clots of blood. The femoral artery and vein, denuded of their sheath for a distance of two inches, 
were clearly seen at the bottom of the wound, their divided extremities having become adherent to the neighboring tissues during 
the inflammatory action of the previous ten days. As a precautionary measure a ligature was cast around the femoral artery at 
the lower angle of the wound, and some little difficulty was experienced in discriminating between the artery and vein, owing 
to the fact that from ten days' disuse the vein in becoming an impervious cord had become similar in size, color, and consistency 
to the artery. A small orifice was observed in the vein near its distal extremity, and from this occurred a free black flow on 
moving the limb. This was also included in a ligature. The wound was now closed by one or two sutures and the patient 
placed in his bed. A brief recapitulation may give clearness to the above account. The first vessel tied was, therefore, the 
proximal extremity of the femoral vein near the entrance of the saphena; the second, the femoral artery a short distance below 
the origin of the profunda, both at the superior angle of the incision; the third, the femoral artery at the lower angle of the 
incision and two inches from its distal extremity; the fourth, the femoral vein near its distal extremity at the centre of the 
incision, and to control a How from an incision through its coats, which may have been made accidentally. The profunda had 
not been seen, and it was hoped that it would suffice to keep up the circulation. No important arterial channels had been 
interfered with by the operation, and a successful issue might be expected. The man was stimulated, took morphia, and his 
leg was covered closely in bed with blankets to preserve the animal warmth. This man had lost blood freely at the time of the 
injury; he had been subjected to a very long and fatiguing transport in ambulances and cars before reaching the hospital, and 
for seven days his food had not been as good or sufficient as might have been desired for one about to undergo such an operation. 
He was pallid and haggard looking, and iron, nutrients, and stimulants were freely ordered. There was great pain and restless- 
ness during the ensuing night, and large quantities of morphia were required to procure sleep. December 10th, no interference 
with the circulation; leg and foot both warm. The whole limb is swollen, and bloody serum escapes freely at the point of 




46 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

the injury. December 1 — 1 1 ■ . the restlessness has been the most marked symptom, caused seemingly by constant and severe 1 in 
indescribable pain in the limb. The pulse is 120. the countenance pale and haggard, the tongue dry and coated, and the 
general symptoms indicate great nervous prostration. Large quantities of morphia have been found requisite. The whole 
limb and foot are much swollen and cedematous. On the evening unmistakable signs of sphacelus appeared, the foot became 
cold, and a hue of purple discoloration was observed as high up as the ankle. The neuralgic pain and restlessness still con- 
tinued. On December 13th, all the symptoms were worse. The discoloration, the dark purple hue of gangrene, extended 
rapidly upward, particularly on the inside of the limb. The whole thigh became crepitant, the pulse more rapid and feeble. 
He became more and more depressed, and finally died at 12 o'clock at night. These final scenes all surgeons can imagine. The 
post-mortem revealed nothing interesting in the great cavities. The whole thigh and leg were found gangrenous as far as the 
point of the injury. The vessels were dissected, spread upon a board, and a most faithful picture was made of them by the 
artist under Dr. Brinton's direction. Only the proximal extremities of the vessels were found in the softened gangrenous 
mass; but they threw light upon the history of the case. The artery was divided below the origin of the profunda, which was 
uninjured, but not enlarged, as one would expect if the whole force of the circulation had been directed toward it by the oblit- 
eration of the main artery. In ten days the profunda should here have been as large as the femoral, if'all the blood brought 
to the divided femoral had been seeking a passage through its calibre. Its undilated condition gives color to the idea that most 
of the blood brought to the divided femoral extremity found its way quickly back by the divided femoral vein ; that the pressure 
was thus relieved, and that the profunda received only its usual supply of blood. That the limb was nourished by a collateral 
circulation, arising above the brim of the pelvis, is clear from the fact that no pressure on the external iliac would restrain the 
How of blood from the saphena through the femoral vein. The saphena vein is normal, and its relation with the femoral 
indicates how easily the regurgitating haemorrhage was caused, as no valves are there to prevent it. For several days — from 
the 9th to the 12th — there were no signs of an interference with the circulation, but at that time gangrene appeared and spread 
with great rapidity. This may have been due to the recent phlebitis of the profunda vein, which is now filled with a pink 
firm coagulum. The irritation caused by the operation, or due to the passage of the ball, may have induced the 
inflammation of this vein, now so vital to the support of the circulation. This seems to have been a wound 
of an artery, resulting in an aneurism the sac of which was composed of the re-united sheaths and enlarged 
probably by some dissection upward, in which a free passage of blood took place from the artery to the vein. No 
question as to the propriety of the operation now exists in my mind, since, as the sequel shows, no digital com- 
pression over the femoral would have sufficed to prevent or control a secondary haemorrhage." The two speci- 
mens were contributed by the operator, Dr. William Thomson (see FlG. 19). The case is cited by Dr. Lidell. 1 
Case 99. — Lieutenant R. W. Smith, Co. I, 5th Pennsylvania Reserve Corps, was wounded at the battle 
of Bull Run, Virginia, August 30, 1862, in the right thigh. He was conveyed to Alexandria in a rough wagon, 
and thence brought to Washington, and admitted to Douglas Hospital, September 5, 1862, with a circumscribed 
false aneurism of the femoral artery. The vessel was ligated in the continuity on September 7th. Secondary 
haemorrhage followed, and the patient died September 8, 1862. At the autopsy it was ascertained that the 
haemorrhage had been temporarily restrained by the direction of the wound and coagula in the large aneurismal 
sac. Recurrent haemorrhage had led to the fatal result. The preparation is well represented in the accompanying 
wood-cut (Fig. 20) reduced to one-half. 

Cask 100.— Private J. Hubner, Co. K, 5th Michigan, aged 29 years, was wounded at Fair Oaks, May 

successful prox- 31, 1862, and conveyed to New York City one week afterwards. Dr. F. T. Foster, of the New York (Civil) 

rmal ligation of H gpjtal reported the following history: "He was admitted on June 8th, having been wounded by a musket 

the right femo- " ' * ° J ' D J 

ral artery for ball, which entered the posterior fleshy part of the right thigh and had not been removed. The case presented 

rism™''.^" silt" uofbing peculiar, and under simple treatment progressed well until June 27th, when there occurred from the 

wound a copious arterial haemorrhage, controlled with difficulty by the application of lint and pressure. On 

the same day he was etherized and the wound opened; but the source of the haemorrhage was not discovered. The wound 

was again stuffed with lint and the limb bandaged, after which Dr. T. M. Markoe tied the femoral artery a short distance 

below the origin of the profunda. The ligature came away on the 8th of July, and the incision and the original wound soon 

began to close by granulation. On the 29th the ball could be felt encysted beneath the integument on the anterior aspect of the 

thigh, but he declined to have it removed. On September 3d he was discharged from the hospital with the wound entirely 

healed and the limb in good condition." The man was discharged from service, at Fort Hamilton, New York Harbor, October 1, 

1862, and pensioned. Examiner H. F. Montgomery, of Rochester, New York, certified, February 2, 1863: "A ball entered the 

right thigh in middle third, over the femoral artery, and was not abstracted. There is a long cicatrix in this region, and 

another behind, on the inside of the bone. His foot is benumbed, and, on exercise, swells and is painful. He is apparently in 

good health. He has a buckshot in the right leg below the knee." Examiner J. J. Lutze, of East Saginaw, Michigan, reported, 

March 4, 1874: * * "Large tender cicatrices on outer and inner posterior thigh, points of entrance and incision. Adductor 

brevis and longus muscles impaired and injured." This pensioner's rate of compensation was reduced from five-eighths to 

one-fourth on March 4, 1873, since which date he has not drawn any pension. 

Besides the cases of ligation of the femoral artery above detailed, numerous other 
cases have been narrated at length in journals or elsewhere, to which references are given 
further on. In Table III, the entire series of thirty-six r«»covcries and ninety-one fatal 
cases are noted alphabetically, and the principal facts regarding them are soncisely recorded. 

1 Lidell (J. A.). On the Wounds of Blood- Vessels, Traumatic Hemorrhage, Traumatic Aneurism, and Traumatic Gangrene, in Surgical 
Memoirs of the War of the Rebellion, collected and published by the United States Sanitary Commission, 1870, Vol. I (Surgical), p. 143. 




SECT. I.) 



LIGATIONS AFTER SHOT FLESH WOUNDS. 



47 



Table III. 
Summary of One hundred and Twenty-seven Cases of TAgaiion of the Femoral Artery for Haemorrhage 

from Shot Injuries unattended by FraxsLurcs. 



Name. Military 
Description, and Age 



Ambrose, T. L.. Chap- 
lain, 12th New Hamp- 
shire, nge 35. 

Archibald, T., Ft, O, 

24th Mass., age 18. 

Atwood, L. IX. Pt.. II, 
32d Mass.. age 31. 

'Ayres. I!., Pt., A, 5th 
Iowa. age 40. 



Bailey, J., Pt., I. 55tli 

Perm., age 20. 
nautili, T., Scrg't. C, 

19th Indiana, age 20. 

Barkeloo. J., Pt.. M, 2d 
Ohio Cav., age 28. 

Bcdinofirld, J. 7'., Capt., 
G,60thGoorgia,ngo25. 

Bell, J. C, Pt., E. 34 th 
Iowa, age 23. 



Hills. C, Pt., K, 17th 
New York, ago 20. 

Blake, G„ Pt., I, 3d 
West Virginia. 



Brown, S.. Pt., 6, 1:14th 
New York, age lti. 



Brown. IF., Serg't, 1st 
Maryland Artillery. 

''Check, .11., Pt., I, 01st 
North Carolina. 

Clark, W. L., Pt.. II, 
25th North Carolina, 
age 20. 

Claypole, 8., Pt., D,62d 

Penn.. age 27. 



Clelland, W., Pt., A, 8th 
New York Heavy Art., 
ago 18. 

Clover. B., Civilian, age 
16. 

Clymer, .1., Pt., B, 104th 
Pennsylvania. 

3 Coble. J. .1., Pt., F,45tli 

North Carolina, age 20. 



Colgan, W., Pt., C, 2d 
Mass. Cavalry, age 21. 



Council. M., Pt., K, 2d 
NewY'ork Heavy Art., 
age 34. 

Coultes, W. H., Lieut, 
C, 61st New York. 

Coy, J. H., Scrg't, K, 
0th Maine, age 28. 



Dates. 



J ul v 25, 

Aug. 15, 

ltU4. 

April 2, 

12, '05. 

Sept. 30 

Oct. 31, 

1804. 

May 22, 

June 1, 

1863. 



June 18, 
Ttll.9,'64 
May 12, 
Juno 12, 

1864. 
Julv 19, 

1863. 

Mar. 25. 
April 15, 

1865. 
April 0, 
17, '65. 



Aug. 30, 
.Sept. 20, 

1802. 
Aug. 26, 
Sept. 0, 

1863. 

Aug. 30. 

Nov. 28, 

1862. 

Dec. 10, 
— , '63. 
July 30, 
Aug. 3, 

1804. 
April 1, 
10, '65. 



May 30. 

Juno 8. 

1804. 

Juno 1, 
Julv 24, 

1803. 
Aug. 23, 
Sept. 1, 

1804. 
May 31, 
June 10, 

1862. 
Nov. 27, 
'63, Jan. 
23, '64. 

Sept. 14, 
25, '64. 



April 7, 
Juno 15, 

1865. 
June 1, 
18, '62. 

\ov. 7, 
24, '63. 



Injury, Operator, axl> 
Result. 



Right thigh; lucm.: femoral lig.; 
hsBm. from branch of profunda — 
large branch tied. Died Aug. 
20, 1864. 

Rightfemoral artery wounded and 
ligatcd: one end tied. Died 
April 26, 1805. pyaemia. 

Loft thigh, middle third ; ligation 
of femoral, both ends tied. Died 
November 0, 1864. 

Left thigh; ha?m.; woundopencd 
and a darning needle removed 
from sheath of vein; artery lig- 
atcd. Died June 1, '03. pyemia. 
Specs. 2020, 2085. A. M.*.M. 

Left thigh; ligation of femoral. 
Died July 10, 1804. 

Left thigh; femoral ligated, by 
Surg. '1'. R. Crosby, U. S. V. 
Died June 12, 1864, pyaemia. 

Right popliteal artery severed; 
primary lig. of femoral artery; 
amp. thigh. Disch'd Mar. 17. '65. 

Both thighs; left femoral ligatcd, 
by A. A. Surg. N. A. Robbing. 
Died April 25, 1805, exhaustion. 

Left leg, cutting post. tib. artery; 
fem. lig., by Surg. A. Mc.Yluhon. 
U. S.V.; amp. thigh forreourrent 
litem. Died A p. 23, '65, exhaus'n. 

Wound of thigh, involv. profunda 
artery : both ends femoral tied; 
sloughing. Died Oct. 4, 1862. 

Shot wound of left femoral artery; 
vessel tied, by Surgeon W. D. 
Stewart, U. S. V. Purloughed 
Nov. 12, 1863. Wounds healed. 

Left leg; fem. lig. in lower third, 
by Asst. Surg. W. A. Connor, 
U. S. V. Died Dec. 7, 1862, 
pyaemia. Spec. 1024, A. M. M. 

Left thigh ; femoral ligatcd. Ke- 
covcred. 

Femoral artery severed; femoral 
artery ligated, by Surg. D. F. 
Wright, P. A. C. S. Recovered. 

Shot wound lower third right fem- 
oral artery; arterytied, by A. A. 
Surg. J. Morris. Died April 19, 
1805, gangrene. 

Right leg ; femoral lig.. by Asst. 
Surg.W.F. Norris, U.S.A. Died 
Aug. 4. '64, astheniaand pleuro- 
pneumonia. 

Left thigh : one end of femoral 
tied. Died July 24, '64, typhoid 
fever. 

Left fem. artery injured; aneur- 
ism; femoral tied. Recovered. 

Left popliteal space ; femoral lig., 
bv A. A. Surg. M. K. Cleveland. 
Died June 16. 1862. 

Left thigh; diffused trail, fem'l 
aneurism; fem. lig. above and 
below ; femoral vein also tied. 
Recovered. 

Left thigh ; fem. lig. in continuity, 
by A. A. Surg. J. C. Shrime'r. 
Died Sept. 28. '64, loss of blood 
andexhaust. Spec. 3972. A.M. M. 

Right thigh ; one end of fem. tied, 
by A. Surg. O. P. Sweet, U.S.V. 
Died June 16, 1865, exhaustion. 

Middle of thigh; both ends femoral 
tied, bv A. A. Surg. W. Hunt. 
Died June 23, 1862. shock. 

Left thigh; femoral lig., by A. A. 
Surg. J.C.W. Kcnnon ; ha?m. re- 
curred; rcligated, byA.A.Surg. 
T. O. Bannister. Dec. 1 ; again 
on Dec. 23, bv Surg. D.W. Bliss. 
U. S. V. Died Deo. 23, 1863. 



NO. 



Name. MILITARY 
Description, and age 



Cromlrr. />. ./.. l't.. 

Stamford's Bat rv, age 

23. 
Cummings, J. M.. l't., 

D, 49th Indiana. 
Cummins. II.. l't.. A. 7th 

West Virginia, age 21. 
Curler, L, P., G, 6ih 

Michigan. 



Darling. S. (!.. Pt., D. 
32d Maine, age 19. 



Delamater. M., Corp'J. 
O, 7th Michigan Cav- 
alry, ago 20. 

Dicr,W.,Corp'l.A, 129th 
Pennsylvania, age 23. 

Doyle, L., Pt.. K. 8th 
Maine, age 34. 



Dunn, (!. 11.. Serg't, I".. 

25th S. Carolina. ag<-\'n. 

Edwards, J. W.. l't.. B, 

28th Illinois, ago I*. 

Edwards, 1!., Pt., G, 
981 h Illinois. 

Eiiioit. K., pt.. ii. neth 

Pennsylvania, age 21. 

Freeman. C. A., Serg't, 
li, 37th Muss., ngu 22. 

Gardner, R. 71, Ft , A, 

1st MU. Battal'n.age 19. 
Billey, M.. Pt., 1. 9th 

N. York State Militia. 

age 37. 
Goodwin, A., Pt., B, 2d 

New Hampshire. 
Graham, J. A., Serg't, 

H, 116th Penn., age 21. 

Gray, J.. Pt.,D, 2d Penn- 
sylvania Heavy Art'y, 
ago 17. 

■•Gross. C. Pt., K, fith 
Pennsylvania Cavalry, 
age 26'. 

'Hagan. J., P., C, 70th 
Pcnnsvlvania. 



Hamilton, F... Cnpt., G. 
15th New Jersey, age 
19. 

Harbatigh, II. . Serg't. K. 
7th Wisconsin, age 22. 

Harrington. W. J.. Pt., 
C, 16th Wisconsin. 

Harris, J. M.. Corp], C : 
14th Iowa, age 20. 



Harrison, L\. Serg't. P., 
inth New York. 

Hickcy, T.. Pt., G. 73d 
Pennsylvania, age 53. 

Horn. S.. Pt.. H. 53d 
North Carolina, age 21. 



Dates. 



I lee. 10. 

01, Jan, 

9, '65, 

Doe. ■.'.-'. 

1802. 

May 8. 

25, ''0-1. 
.May 31, 
June 10, 

17, '62. 

May 12, 

1864, 
On field. 

May 28. 

Julv 10, 

180-1. 

Dec. 13, 

62. Feb. 
22, '03. 
May 20, 
June 1, 
1804. 



May IC, 

29,' '04. 

.Mar. 20. 

April 20, 

1865. 

June 25. 

Jul. 6. '03. 

June 3, 

13. '04. 

April 6. 
15, 'Cj. 

Julv 2. 
23. '03. 
Mav 5, 
— , ''64. 

Julv 2, 

20, '03. 
June 1. 
10, '64. 

June 18, 

30, 'fi4. 

May 30, 

31, '01. 

July 17, 
23.' '64. 



Mav 6, 
15, '64. 



July 2, 
Sept. 13, 

1803. 
Julv 5, 
16, '64. 

July 15, 
27, '114. 



Mav — , 
1864. 

Aug. 30, 

Re. 27. '62. 

Mar. 25, 

Julv 9, 

1865. 



Injury, operator, axi> 

Result. 



Right thigh: ligation of femoral. 

by A. A. Surg. D. D. Talbot. 

Died Feb. 3. 1865, gangrene. 
Shot wound right femoral artery: 

vessel ligated. Died Jan. 2!'. '03. 
Right thigh: femoral tied above 

profunda. Died May 23, 1804. 
Right thigh; fem. and profunda 

lig.; ha'iu. recurred; profunda 

relig. Died Juno 17, 1802. Sjkc. 

1004, A. M.M 
Fem. artery severed: vessel lig.; 

May 20th, thigh amp., by Surg. 

R. 11. Bontecou, U. s. V. Died 

May 26, 1804, haemorrhage. 
Right thigh: lig. of femoral, by 

A. Surg. H. M. Sprague, 11. S. A. 

July 12th. thigh amputated. 

Died Aug. 7. 1864, pya'mia. 
Left popliteal space; femoral lig. 

Died Mar. 4, 1803, pya-mia. 

Right thigh: femoral and several 
branches ligated above ami be- 
low wound, by Surg. A. lleger. 
IT. S. A. Juno Olh. thigh amp. 
Died .lone 0, 1861, exhaustion. 

Right thigh; femoral ligated. 
Recovery. 

Right leg- femoral ligated, by A. 
A. Sorg. II. B.Colo. Recovery. 

Both thighs; femoral ligated. 

Died July 11. 1863. 
Right thigh; femoral ligated, by 

Asst. Sing. II. Allen. U*. S. A. 

Died June 21. 1804. gangrene. 
Left thigh : femoral art'y ligated, 

by Surg, B. A.. Ynndoi kieft, 11. 

8.V. Died April 18, '05, ananiia. 
Both thighs: left femoral ligated. 

Doing well November 30. 1803. 
Right thigh, involving femoral 

artery; femoral ligated. Died 

May 27, 1804, of pyaemia. 
Left thigh ; femoral ligated above 

and below. Died Aug. 8. 1803. 
Right thigh : Iwrin.: profunda lig.; 

bsem. recurred: fem. lig. Died 

June 13. 1804. 
Left thigh: femoral lied in con- 
tinuity, by Surg. N. R. Mosely. 

II. S.'V. * Died July 12. 1864! 
Left femoral artery divided ; liga- 
tures placed above and below. 

Died Juno 8, 1864, exhaustion. 
Right thigh ; fem. tied at proximal 

extrem. and accompanying vein 

at prox. and distal ends; gnn:^. 

Died July 27. 1864. 
Right femoral vein and branch of 

profunda divided : femoral tied. 

bv Surg.Il. W.Ducuohot.U.S.V. 

Died May 16, 1864 ; exhaustion. 
Left thigh: femoral ligated. Dis 

charged July 21, 1864, atrophy 

of thigh and leg. 
Left thigh : both ends of femoral 

tied, by Surg. G. F. French, II. 

S. V. 'Died July 20. 1864. 
Right fem. art. injured ; aneurism ; 

art. ligated above and lielow sac. 

by Surg. J. O. Keenon, U. S.V.; 

amp. leg, by A. A. Surg. R.W. 

Coale. Died Aug. 3. '04. pyaemia. 
Right thigh: ligation of femoral. 

bv Surg. M. Rizer, 72d Penn. 

Died May 22, 1864. 
Right thigh : common femoral tied 

in continuity. 1 lied Sept. 27, '62. 
Left thigh; femoral ligatcd. by 

A. A. Surg. J. Morris. Died 

July 14, 18li5. haemorrhage. 



1 Lidell (J. A.), On Wounds of Veins, in Surg. Mem. of the War of the Rebellion, coll. and pub. by U. S. San. Comm.. 1 870. Vol. I, p. 141. 
''Dudley (J. G), Case of Diffused Traumatic Aneurism, in Confederate States Medical and Surgical Journal, 1865. Vol. I, p. 35. 
3 Wright (D. F.), The Effects of the LTuntenan Method of Ligation, in Confed. States Med. and Surg. Jour.. 1864, Vol. I. p. 177. and Richmond 
Med. Jour., 1866, Vol. I, p. 309. 4 Lidell (J. A.), op. cit.. p. 53. 

•MUNN (C. E.), Post-mortem Examinations of Cases, etc., in Boston Med. and Surg. Jour., 1864, Vol. LXXI, p. 113. 



48 



fNJURIES OF TIIK l.offKl: EXTREMITIES. 



[CHAP. X. 



No. 



75 



NAME, MlI.ITAIIY 

Description, and At 



ll.uiscr. P., Serg't, ](, 
76th Pennsylvania, ago 
S!6. 

Hiibner, J., l't.. K, 5th 
Michigan, ago 29. 

Hoggins. W., Serg't. G, 
50th Illinois, ago 33. 



Hunt, J. L., Pt.. G. 57th 
New York, age 41. 

Hurlbut, G. Q., Pt.. G, 
109th N. York, age 37. 



Jones, W. II., Pt., C, 

14th New Y'ork Heavy 
Artillery. 

Jones, IF. IF"., Ensign, 
Thomas's Legion, age 

Judd, I. E., Lieut., K, 
49th Mass., age 25. 



Karlmyer, P., Pt., K, 
48th New York, ago 37. 

Kimher, \V., Pt., D, 36th 

Illinois, age 33. 

London. L., Lieut., II, 

tith Colored Troops, 

age 20. 
Lang, W. JL. Pt., C, 

40th New York, age 34. 
Lapp, C, l't., 1. 22d 

Wisconsin, ago 21. 

Layne. J. B., Pt., 13, 

i'.ith Virginia, age 18. 



Lee. J. A.. Pt., I. 17t!t 

Mississippi, age 25. 

Lelino.O, Serg't, C, 8th 
Michigan, age 27. 



'Lenneghan. P.. Serg't, 
B, 88th New York, age 
30. 

Lesler, .1., Pt„ K, 148th 
New Y'ork, ago 28. 

Lund, E. T., Pt., 0, 4th 
New Hampshire, age 
20. 

MeNally,J..Pt., G. G9th 
New York, ago 24. 

McRevnolds, J., Corp'l, 
COth'OhioS. S., ago 20. 



Mason. J. W., EH., 1, 12th 
New York, age 21. 

Miller, O. II.. Pt., F, 3d 
Iowa, age 23. 

Mills, .L. Pt.. n, 4th 
Missouri Cavalry. 

Moore. IF., Pt.. G. 5th 
North Carolina, age 27. 



Aug. Ill, 

Sept. 10, 

18(14. 

May 31, 
Juno 27, 

1862. 
Mar. Ill, 
April 3, 
5, '05. 



May 5, 
Julv '■>, 

i8f;4. 

May 17, 

June 8, 

1864. 

June 9, 

Julv 5, 

1864. 

Sept. 19, 
Oct. 2, 

1864. 
May 25, 
June 12, 

1863. 

Juno 1, 
9, '0'4. 

Nov. 29, 
'114, Jan. 

20, '(;.-». 

Sept. 29, 

Oct. 9, 

18(14. 

April 2, 
13, '65. 

July 28, 

Auk-. 11, 
1864. 

April (i, 
25, '65. 



Julv 2, 
21, '63. 

Nov. 28, 
Dec. 5, 

1864. 

April 6, 
20, '65. 



June (i. 
Julv 28, 

1864. 
June 30. 
Aug. 12, 

1864. 



June 16, 
July 4, 

1864. 

Aug. 19, 

Sept. 5, 

1864. 



Aug. 30, 
— , '62. 
May 18, 
June 3, 
1863. 

Jan. lfi, 
Eeb. 7, 
1864. 
Oct. 19, 
20, 'G4. 



IXJUKY, OPERATOR, AN1> 
RESULT. 



Left thigh: femoral ligated in 

continuity, by A. A. Surg. J. II. 

Packard." Disch'd May 20, 1865, 

and pensioned. Lameness. 
Right thigh; femoral ligated. by 

Dr. T. M. Markoc. 1 tiseharged 

Oct. 1, 1862; pensioned. 
Right thigh : ha'm.; profunda lig., 

by A. A. Surgeon H. Sanders; 

loom, recur.; fern. tied, by A. A. 

Surg. E. DeVVitt. Died April 

8, 1865. 
Left thigh ; femoral ligated ; dry 

gangrene of toes; Sept. 5th. amp. 

toes. Disch'd Juno 6, 1865. 
Both thighs; haem.: tern. lig. in 

continuity; haem.; profunda lig.; 

ha?m.: vessel religatod. Died 

Juno 8. 1864. 
Right thigh ; fern, tied in wound, 

by Surg. II. Palmer, U. S. V. 

Died Sept. 25, 1864, chronic 

diarrhoea. 
thigh, involving fern, artery; 

ligation of femoral artery. Died 

Oct. 5, 1864, haemorrhage. 
Right thigh ; fern. art. tied at both 

ends, by Med. Insp. P. Pineo, 

V. S. A.; fern, vein included in 

a ligature. Died June 13, 1863. 
Right thigh; femoral ligated. by 

Surgeon E. llentlev, U. S. V. 

Discharged May 20,' 1865. 
Left thigh ; botli ends of femoral 

tied. Died January 26, 1865. 

Left thigh ; alsofraet. left radius ; 

both ends of fern, tied in wound. 

Died Oct. 28, '04, pyaemia. 
Right leg; femoral ligated. Died 

April 16, 1865, mortification. 
Left fern, art'y wounded j vessel 

lig.. by A.A.Surg. J. M. Brown. 

Died Aug. 11, '64, haemorrhage. 

Right thigh : fcm. veiu rupt.; fcin. 
lig. at middlo portion, and vein 
above and below rupt., by A. A. 
Surg. J. Morris; haem. recurred 
Mav 6, fem. relig. abo. profunda. 
Died May 7, 1865. 

Left leg; femoral artery ligated. 
Transferred to prison at Fort 
McIIenry, Md., March 2. 1864. 

Right fem. art'y injured; ligature 
applied, by A. A. Surg. S. T. 
Williams. Died Dec. 5, 1864, 
shock and haemorrhage. 

Right thigh; femoral ligated in 
continuity, by Surg. J. Aiken, 
71st Penn. Disch'd July 26, '65; 
pensioned. Died Nov. — ,1875. 

Left leg; both ends femoral tied, 
by A. A. Surg. W. P. Moore. 
Disch'd January 11, 1865. 

Left thigh, and tract, right knee 
joint; left fem. tied above and 
below, by Asst. Surg. W. Thorn- 
son, U. "S. A. Died Aug. 23, 
'64, pyaemia. Spec. 3592. A.M.M. 

Right thigh; femoral tied in con- 
tinuity, by A. A. Surg. O. P. 
Sweet. Furloug'd Nov. 1, '64. 

Both thighs; femoral tied, by A. 
A. Surg. H. B. Maben; litem, 
recur. Sept. 11th j artery relig., 
by A. A. Surg. E. De Witt. 
Died Sept. 17, '64, haemorrhage. 

Right femoral artery; ligature 
applied. Died Sept. 28, 1862. 

Both thighs, dividing right pro- 
funda artery: right fcm. ligated. 
Died Juno 10, '63, haemorrhage. 
Spec. 2086, A. M. M. 

Left fem. nrtery wounded: liga- 
ture applied. Died February 
17. 1861. 

Right fem. artery wounded ; lig. 
npplied. by Surg. J. F. Pearson. 
5th N. C. Exch'd Feb. 16, '65. 



N vmf.. Military 
Description, axu Age 



95 Row 



96 

97 
98 

99 

loo 
101 

102 

103 

104 

105 
106 



Moserip, \V. S.. Serg't, 

K, 19th Wis., ago :;:;. 
"O'Keefe, J., Major, 2d 

New York Cavalry. 

age 24. 
I', id:. ./. R.. Pt., D,39th 

North Carolina, age 17. 

Paden, W., Corp'l, G, 
10th Pennsylvania Re- 
serves, age 22. 



Palmer, .1. C., Pt., G, 
10th Conn., age 18. 

ZJ'aschal. J., l't., I, 2d 
N. Carolina Cavalry. 

Pennsyl, E., T>t., II, P3d 

Pennsvlvania. 
Perry. T ., Serg't.D, 16th 

Michigan, age 30. 

Peters, W. C, Tt., C, 

68th Penn., age 19. 
Pickett, J., Pt., F, 8th 

Illinois Cavalry. age2l. 
Pope, P. P.. Pt., M, 67th 

Ohio, age 22. 
Pope. W., Pt., I, 2d N. 

York Artillery, age 19. 
4 I!app, D., Pt., K, 7th 

Indiana, age 20. 



Reed, J. P., Pt., 19th 
Alabama, age 20. 

Ringer, O., Pt., C, 60th 
Ohio, age 21. 

Roberts, A. P., Pt.. I, 

127th Illinois, ago 20. 

Rodgers, S. J., Pt., A, 

2d Michigan, age 21. 



Ross, A. O., Corp'l, I, 
13th Mississippi, age 21. 



towe. J. B., Pt., G, 12tn 
N. Hampshire, age 22 



Kb, 



« S W 

New Y'ork. 



, 1, 17th 



Sager, W., Serg't. E, 
188th N. Y'ork, age 19. 

Sassaman, L. II., Pt.. E, 
12th Penn. Reserves, 
age 24. 

S-lf. J., Pt., H, 11th 

Alabama. 
Sharpe, A„ Pt., D, 11th 

Pennsylvania. 

Sheaffer, C, Pt., D, 1st 
New Y'ork Cavalry. 

Sheffer, G. W., Pt., C, 
5th U. S. Art., age 22. 

Simmons, T.,Pt., F. 97th 
New York, age 26. 

Smith, II, Pt., F, 21st 
Virginia, age 41. 



Smith, J., Pt., D, 97th 
Pennsylvania, age 22. 

Smith, R. W.. Lieut., 
G, 5th Penn. Reserves, 
age 24. 



Dates. 



Aug. 22. 

27, VI. 
Mar. 31, 

— , '65. 

April 8, 
27, 'Go. 

May 23, 
June 1, 

1864. 



April 2, 
10, '65. 
Aug. 16, 
27, '64. 

Mav 31, 
J'o 16.62. 
Sept. 30, 
Nov. 19, 

1864. 
Julv 2, 
15, "'63. 
Juno 20, 

20, '63. 
Mav 9, 

21. '64. 
June 3, 
20, '64. 

Nov. 30, 
1 863. 



April 6, 
May 29, 

1862. 
July 6, 
Aug. 22, 

1864. 
May 1!'. 
J'o 5, '63, 
Juno 17, 
July 26, 

1864. 

Oct. 19, 
— , '64. 

May 14, 

June 12, 

1864. 



Sept. 1, 
12, '64. 



April 1, 
22, '65. 

May 8, 

Juno 4, 

1864. 

— , July 
11, '62. 

Juno 21, 
21, '64. 
June 5, 
July 8, 
1864. 

May 24, 
24, '64. 

June 18, 
July 27, 

1864. 
Oct. 19, 
Nov. 10, 

1864. 

May 18, 
Juno 2, 

1864. 
Aug. 30, 
Sept. 7, 

1862. 



INJURY, OI'KRATOIt, 

Result. 



Left fcm. artery injured; femoral 
ligated. Died Sept. 14. '64. ha'm. 
Rigltt fcm. art'y injured: femoral 
tied, and, haem. recurring, vessel 
rcligated. Died May 31, 1865. 
Right fcm. artery wounded ; lig- 
ated, by A. A. Surg. H. B. Cole. 
Died April 27, 1865, Cong, chill. 
Great laceration right thigh; fem. 
tied in continuity, by Surg. G. 
L. Pancoast, U.S.V.: leg gang.; 
amp. leg by same operator. Died 
June Sol 1864, gangrene. 
Right thigh; femoral tied at both 
ends. Disch'd July 5,'65; pen'd. 
Right thigh; femoral ligated, by 
Surg. D. F. Wright, P. A. C. S. 
Retired February 22, 1865. 

fem. artery wounded: vessel 

tied. Died July 5, '62, pyaemia. 

Right thigh ; femoral tied at both 
ends, by A. A. Surg.G.B.R. Rob- 
inson, Died Nov. 21, '64, exh'n. 

Left thigh ; artery secured. Died 

July 15, 1863, haemorrhage. 
Right fem. artery severed ; artery 
secured. Disch'd June 9; '64. 

Right thigh ; fem. tied in continu- 
ity. Died May 22, '64, exh'n. 

Lei't thigh; one end of artery tied. 
Died June 24, '64, haemorrhage. 

Left thigh ; fem. art. and vein di- 
vided; double lig. placed upon 
fem. art. and vein. Died Dec. 13, 
1863. Specs. 2249, 2250, A. M. M. 

Bight thigh ; fem. artery ligated, 
bv Surg. J. T. Hodgen, U. S. V. 
Died Juno 30, 1862. 

Right thigh; femoral ligated, bv 
A. A. Surg. J. F. Holt. Died 
Aug. 25. 1864, haemorrhage. 

Left popliteal space ; fem. artery 
tied. Died Juno 7, 1863. 

Right thigh. July 22d, aneurism ; 
fem. tied, two ligatures, bv A. A. 
Surg. O. W. Peck. Died July 
30, 1864, haemorrhage. 

R't and left thighs ; fem. wounded 
and lig.; Nov. 8, amp. right leg 
ahoveank. Retired Mar. 14, '65. 

Right thigh; gang.: fem. artery 
lig. in wound, both ends tied, by 
Surg. A. Heger, U, S. A., and 
A.A.Surg. T. Liebold. Disch'd 
June 5, 1865 ; pensioned. 

Right thigh; proximal endof fem. 
artery tied, by Surg. E. Batwell, 
14th "Michigan. Sent to rear ten 
weeks after injury. 

Right thigh ; both ends of femoral 
tied, by Asst. Surg. W. F.Norris, 
U.S.A. Died ApT29, '65, pyaem. 

Right leg. wounding ant. tibial 
artery; femoral tied, by A. A. 
Surg. J. S. Cohen. Disch'd July 
21, 1865 ; pensioned. 

thigh; femoral ligated. Died 

July ll, 1862. 

Both thighs ; both ends of 

femoral tied. Died June 26, '64. 

Right fem. artery injured; vessel 
secured, by Surg. R.F. Baldwin, 
P.A.C.S. DiedJ'y21,'64,gang. 

Left fem. artery severed ; ligated, 
by Surg. N. Hayward, 20th 
Mass. Disch'd Jan. 30, 1865. 

Left thigh; femoral ligated in 
continuity and wound. Died 
August 3, 1864, gangrene. 

Both thighs, scrotum, right fem. 
artery severed : vessel tied, by 
Surg. W.W.Wilkerson, C.S.A. 
Retired from service Mar. 14, '65. 

Both thighs ; haem. from circum- 
flex ; right femoral tied. Died 
June 5, 1864, haemorrhage. 

Right thigh : fem. art'y wounded ; 
lig. in contin'y. Died Sept. 7, '62, 
loss of blood. Spec. 509, A.M.M. 



1 Udell (J. A.), op. cit.. p. 262. * Ibid., p. 233. 

3 Blackman (G. C), On the Treatment of Inflammation of the Limbs by the Compression, or Ligature, of their Main Arterial Trunk, in 
Cincinnati Lancet and Observer, 1868. Vol. XI, p. 77, and Richmond Med. Jour., 1866, Vol. I, p. 307. 

4 Lidell (J. A .), On the Wounds of Blood-vessels, etc., in Surgical Memoirs of the War of the Rebellion, collected and published by the U. S. San- 
itary Commission, 1870, Vol. I, p. 143. 5 Batwf.ll (E.), Surgeon, Nth Michigan, in Med. and Surg. Reporter, 1865, Vol. XIII, p. 50. Probably 
the case of M. Shaw, Pt., I, 17th New York, ago 19. Died Nov. 16, 1864. 



SECT. II 



LIGATIONS AFTER SHOT FLKSll WOUiNDS 



49 



N(i 


Name, Mn.trun 

DESI IIU'TKIN', AMi Ann. 


Dates. 


INJURY, OPERATOR, AND 
RESULT. 


NO. 


Name, mimtakv 

DKSCIllraOK, AM' Ai;i:. 


Dates. 


Ixjury, Operator, ami 
Result. 


III? 


Smith, W. I'., Major, 1st 


Oot. 27, 


Right thigh; fern. lig. above and 


118 


Wilder. H.. Corp'l, A. 


Aug. 10, 


Lett leg: ha?m. from post, tibial 




lii.laware. 


27, '04. 


below, vcinnlsotiod; amp. (high. 
Surg. A. N". Dougherty. O.S.V. 
Died Nov.fi, 1804. 




100th N. York, age 19. 


Sept. 21, 
1804. 


artery ; feui. lied in continuity, 
by A". A. Surg. J. C. Morton. 
Deserted March 20, 1805. 


108 


Sockwell. r. 1,.. Pt., K, 


Mav S, 


Right thigh; femoral secured. 


11!) 


Williams. C., Pt., 1''. 5th 


Sept. 20. 


Laceration left thigh: both ends 




12th X. Jersey, ago 32. 


6, '64. 


Disch'd June30, '05; pensioned. 




Colored Troops, age 23. 


Oct. 15. 


nf fem. lied in wound, by A. A. 


10!) 


'Spiraj, D., Pt., (j, 5th 


, July 


Left thigh, also right leg; ancnr- 






1804. 


Surg. 0. Warner: haemorrhage 




N. Carolina, age to. 


8, 'S3.' 


ismal tumor of left fern, art.; fern. 
tied, by Surg. E. 1!. Haywood, 








recurred. Died 1 October SI, 1801. 
phlebitis. 








01. S. A. Recovered Jan. 10, '04. 


120 


Williams, G., Pt., K.Oth 


July 9. 


Left thigh : art'y tied below origin 


110 


Stury, !•'., Pt., K, 38th 


July 23, 


Right thigh ; gangrene ; both ends 




X. York, Heavy Art., 


Aug. :i. 


of profunda, liy A. A. Surg. .I.e. 




Ohio, age 2-. 


Sep. 9, 04. 


of fern. tied. Died Sept. 10, '04. 




age 31. 


1804. 


shinier. Died August 4. I80I, 


111 


Sweeney, J. L., Serg't, 


Mav 15, 


Right fern, artery injured and lig. 








exhaustion. 




1>. 1 *Jt'h Mass., ago 25. 


30, '64. 


Disch'd from hospital Oct. 15, 


121 


Willis, jr.. A., Pt., I, 7th 


Dec, 13, 


Right femoral artery injured and 








1804 ; pensioned. 




Rhode Island, age 25. 


25, '02. 


ligated. Died Dee. '28, 1802, 


112 


Thorn, II. C Pt., I, 14th 


July 20, 


Right thigh; fern, ligated; hfem. 








from previous bleeding. 




West Virginia, age 1!). 


Aug. 7. 


recurred from profunda; thigh 


122 


3 Wilson. J.. Pt., 27th X. 


Mav 20, 


Left thigh; ball passed close to 






180-1. 


amp., by Surg. J. It. Lewis. 1 r . 
S. V. Died Aug. 12, 1804. 




York llattery, age 20. 


July 10, 
1803. 


femoral vessels: large aneurism 
of fem. artery: fein. tied above 


113 


Tompkins, — , substitute, 


July 28, 


Right leg and left arm ; femoral 








and below, by A. A. Surg. G. D. 




age 21. 


29,'63. 


ligated: gang. Aug. 3d, trismus. 








Hammond. Duty July 31. 1803. 








Died Aug. 4, 1803, tetanus. 


12!1 


Winchell, C. I)., Pt.,K. 


April 2. 


Left thigh : fem. lie;, in continuity. 


114 


Unknown 


Sept. 17, 

OO '(J.l 


Wound of fern, art.; proximal end 
tied in wound. I lied Sept. 22. '02. 


1 


38th Wisconsin, age 1 9. 


12, '05. 


by Surg. J. ('. McKee. I'. S.A. 
iiisch'd July 3, 1805: pensioned. 


115 


Vearing, W.. Pt., G, 


Mav 22, 


Rigid thigh; small aneurism of 


1 24 


Winchester, D. W.. Pt.. 


May 10, 


Left thigh: sloughing: femoral 




12th Missouri, age 30. 


June 22, 


femoral artery ; femoral tied. 




I. 1st Mass. H'vyAr'v. 


28,' '04. 


tied in continuity, bv Surg. T.it. 






1803. 


Returned to duty Dec. 10, 1803. 




age 21. 




Crosby, U. S. V. Duty t'obru 


110 


2 Vickery, R. S., Asst. 


July 30, 


Left thigh ; femoral tied, by Surg. 








ary ill 1805. 




Surgeon, 2d Michigan. 


30, '04. 


W. B. Fox, 8th Mich. Disch'd 


125 


Witham. A.. Pt.. A, 1st 


Mav 11', 


Left thigh : fem. ligated. by A. A. 








Mar. 14, '05; pens'd. Appointed 




Maine Heavy Art'y, 


June 29, 


Surg. J. Newcombe. Died July 








Asst. Surg. U.S.A.. May 14, 67. 




age 20. 


1804. 


2. 1804. loss of blood. 


in 


irnA-c7(dm., ./. £'., Corp'l, 


Mar. 31, 


Left fern, artery involved ; lig. of 


120 


Wood, W. R., Pi., 11, 


Dee. 31. 


Right thigh : femoral tied. Duty 




E, 18th Virginia, ngc 


April 10, 


artery above profunda, by A. A. 




81st Indiana. 


'02, Jan. 


June 22, 1803; pensioned. 




27 


1805. 


Surg. J. Morris. Il;em. recur' ci ; 






17, '00. 










relig. just below l'oupart's lig. 


127 


Worley, S., Pt., A, 13!lth 


Mav 5, 


Right thigh : fern. ligated. Died 








Died April 28, '05, exhaustion. 




Pennsylvania, age 20. 


20, "'04. 


June 2, 1804. 



Of this series of one hundred and twenty-seven cases with ninety-one deaths, the 
mortality rate of 71.7 per cent, of the aggregate scarcely varies from that of the smaller 
series of ligations for direct shot injury of the femoral adverted to on page 16. 

Ligations of the Profunda Artery. — Six instances were reported of ligation of the 
profunda in addition to the cases in which that vessel was tied in connection with ligations 
of the femoral. Brief abstracts of the two successful and four fatal cases are subjoined: 

Cases 101-106. — Sergeant 11. W. Bcdingficld, Co. G, COth Georgia, age 18 years, wounded at Monocacy, July 9, 1864; 
admitted into hospital at Frederick ; conoidal ball passed through upper third of left thigh and lodged near the inner side of 
right femur, wounding the right profunda artery; traumatic aneurism, sac five inches in length, containing at least a pint of 
clotted blood. August 15th, Acting Assistant Surgeon J. II. Bartholf laid open the aneurismal sac. Bleeding came from the 
profunda artery; a ligature was applied above and below the wound of the artery by an incision four inches along the sartorius 
muscle; the patient was in good condition though irritable and depressed; brandy was given every hour during the day after 
the operation; haemorrhage did not recur. August 25th, ligature came away; the wound healed, and the patient was trans- 
ferred to Point Lookout, October 25th, for exchange. — Private J. II. Bean, Co. E, 45th Pennsylvania, aged 18 years, wounded 
at the Wilderness, May 6, 1864. Admitted into Campbell Hospital, Washington; shot wound of thigh. May 28th, bleeding to 
amount of forty-eight ounces from profunda artery; profunda ligated at one end in wound; haemorrhage recurred June 14th, 
and death on the same day. — Lieutenant J. T. Lowe, Co. D, 12th New Jersey, wounded at IJristoe Station, October 14, 1863; 
admitted into Third Division Hospital, Alexandria; gunshot wound of left thigh by conoidal ball ; haemorrhage to extent of 
twenty-four ounces from profunda artery; both ends of profunda femoris tied in the wound. Patient died October 30, 1863. — 
Corporal T. Machelent, Co. B, 140th New York, aged 27 years, wounded at the Wilderness, May 8, 1864 ; admitted into Mower 
Hospital, Philadelphia; missile entered middle of posterior surface of upper third of right thigh, passed in a direct line and 
emerged from inner surface; slight wound. July 4th, haemorrhage to the extent of thirty ounces from the profunda artery; 
the proximal end of the artery was ligated in the wound. Patient was discharged May 31, 1865. — Private M. Murphy, Co. G, 
5th Kentucky ; wounded at Mission Ridge, November 25, 18C3; admitted into hospital No. 4, Chattanooga; contused shell 
wound of left thigh. On January 1, 1864, gangrene appeared, which was checked, but reappeared on the 17th and 20th, and 
spread. On January 26th, the profunda gave way and was ligated by Surgeon A. H. Stephens, 6th Ohio. The patient died 
January 27, 1864. — Corporal T. Patterson, Co. D, 5th Michigan, aged 32 years, wounded at the Wilderness, May 5, 1864 ; 
admitted into the hospital at Chester, Pennsylvania; shot flesh wound of upper third of both thighs. On July 13th, bleeding 
occurred from a branch of the left profunda; one end of the artery was tied in the wound; haemorrhage recurred on July 16th, . 
and death ensued July 20, 1864, from pyaemia. 

' HAYWOOD (E. B.), Anturism of Femoral Artery cured by Ligature, in Confederate States Med. and Surg. Jour.. 1804. Vol. I. p. 30. 
* HAMILTON' (F. II.), A Treatise on Military Surgery and Hygiene. 1805, p. 639. 

•LIDELL (J. A.), On Gunshot Wounds of Arteries. Traumatic Iltemorrhagc and Traumatic Aneurism, in Am. Jour. Med. Sci.. 1804, Vol. XLVII, 
p. 110. and San. Comm. Mem.. Vol. I, p. 119. 

Surg. Ill— 7 



50 



INJURIES OF THH LOWER EXTREM1XIKS. 



[CHAP. X. 



There were also a few examples of ligations of large branches of the profunda involv- 
ing very difficult and troublesome dissections; instances in which the external circumflex, 
posterior perforating, and anastomotica arteries were tied are here briefly noted. In 
several cases it was impracticable to determine what particular branch was severed: 

Cask 107. — Private S. Michaels, Co. E, 9th Maine, aged 35 years, wounded at Petersburg, June 28, 1864. Surgeon J. 
J. Craven, U. S. V., reported Ids admission into the 2d division hospital of the Tenth Corps with a "gunshot wound of both 
thighs." Assistant Surgeon E. MeClellan, U. S. A., reported from Hampton Hospital, Fort Monroe: "On July 30th, bleeding 
occurred from the descending branch of the external circumflex artery: six ounces of blood were lost. Assistant Surgeon E. 
Curtis, U. S. A., applied ligatures at both ends of the bleeding vessel in the wound — the injury was about the middle of the 
thigh. On August 4th, a haemorrhage occurred from the femoral artery of the left thigh of about one pint; it was arrested by 
pressure, but the patient died from exhaustion a short time after.*' 

Cask 108. — Private Theodore B. Benedict, Co. D, 7th Connecticut, age 32 years, wounded at Drury's Bluff, May 10, 
1804. Assistant Surgeon E. MeClellan reported from Hampton Hospital, Fort Monroe: "Gunshot wound of right thigh, flesh. 
On June 9th, haemorrhage to the extent of eight ounces occurred from one of the posterior perforating arteries. The bleeding 
vessel was ligated in the wound at one end. The haemorrhage did not recur." On July 25th, the patient was sent north. He 
was Subsequently treated in McDougall Hospital, New York, and Knight Hospital, New Haven. Surgeon P. A. Jewitt, II. S.V., 
reported from the latter hospital that the patient died May 3, 1865, of pneumonia. 

Case 109. — Corporal Thomas Haglemeyer, Co. D, 41st Ohio, aged 49 years, was wounded at Nashville, December 1(1, 
1804. Surgeon C. N. Hoagland, 71st Ohio, reported from the 3d division, Fourth Corps: "Gunshot wound of hip ; simple 
dressings." Surgeon J. E. Herbst, U. S. V., reported that the patient was admitted into hospital No. 2, Nashville, December 
22, 1804, with a "gunshot wound of the upper third of the right thigh. Wound gangrenous from Scarpa's triangle to the 
popliteal space. December 29th, separation of the slough caused haemorrhage from the superior perforating and anastomotica 
arteries — oozing surface. The patient was much exhausted from repeated haemorrhage — blood detibrinated. Acting Assistant 
Surgeon S. Blackwood applied proximal ligatures to the bleeding arteries in the wound and lint to the oozing surface. Simple 
dressings were applied, and iron and ale ordered. The patient died January 15, 1804." 

Ligations of the Popliteal Artery. — Of seventeen cases of. ligation of the popliteal 
for shot flesh wounds of the leg, thirteen were fatal, or 76.5 per cent. Five patients 
succumbed after amputation of the thigh following ligation of the popliteal. The series 
is enumerated in Table IV, and a case is detailed: 

Table IV. 
Summary of Seventeen Cases of Ligation of the Popliteal Artery for Haemorrhage from Shot Injuries 

unattended by Fractures. 



No 



Name, Military 

DESCltU'TIOX, AND AGE. 



Dittus. W., I't., H, 42d 

Illinois, age 27. 



Elliot, J. K., Corpl. E, 

2d Pennsylvania Cav- 
ulry. age 24. 

Fletcher, .1. M.. Corpl, 

V, 3:)th Massachusetts, 
age 28. 

Gray, W\, Pt., E, 18th 

Infantry, ago 20. 

Kmisohe, G.,Pt.. D. 20th 
New York, age 35. 

Kraher. J. P.. Pt., D. 
u'th New York Heavy 
Artillery, age 35. 

Leonard.'. 1.. Pt., L, 7th 
New York Heavy Ar- 
tillery, age 21. 

Lynch, J., Corp'!, K, 
14.ith N. York, age :I4. 

Srl'l'n. B., Pt., II, 0th 
Virginia Cav., ago 23. 



May 14. 

June G, 

18(14. 



April 1, 
29, 'G3. 



June 18, 

Aug. 14, 

18ii4. 



Dec. 31, 
'62, Jan. 

12, "S3. 
Sept. 17, 

17, '62. 

June 1, 
July 24, 

1864. 
.May 30, 
July 3. 

18.14. 
May III. 
17, •(14. 

July 8. 
t/l, 'G3. 



Injury, Operator, and 
Result. 



Right popliteal region; sloughing; 

both ends of popliteal art'ry tied 

in wound, by Ass't .Surg. B. E. 

Fryer, IT. S. A. Disch'd Aug. 

lb', 18G5; pensioned, 
ln'rside left leg: poplit'l art. iig., 

lower portion; hami. recurred; 

thigh amp. May 5th. Died from 

shock two hours after operation. 
Flesh wound up. third right leg; 

sloughing : both ends artery tied 

in wound, by A. A. Surg. J. M. 

MoOrath. Died Aug. 24, 18U4, 

typhoid fever. 
N'ear popliteal region ; both ends 

artery tied in wound. Died Jan. 

2-', 1863. gangrene. 
Laceration of right poplit'l space; 

up. end art. tied in wound ; luem. 

recurred. Disch'd Aug. 13, '03. 
Left thigh near knee ; gang.; one 

end of artery tied in wound. 

Disch'd Mar. 15. 'Go: pensioned. 
Left leg; art. tied boh. knee; baam. 

recur d: thigh amp. just abuve 

knee July 8. Died ,Iuly23,'G4. 
Left popliteal region : lig. poplit'l, 

by Ass't Surg. C. A. MoCnll, U. 

S. A. Died May 23, '64. pyemia. 
Left post. tib. art. wounded ; pop- 
liteal tied, by A. A. Surg. VV.S. 

Adams. Died Aug. 2, '63, pysetn. 



NO 



1G 



Name, Military 
Description-, anl> Age. 



Smith, A. M., Serg't, F, 

20th Maine. 
Smith. F., Pt.. Ii, 1st 

Mass. Heavy Artillery. 



Smith, P. D., PL, C, 8th 
Iowa Cavalry, age 20. 



Dates. 



May 15, 

15, 'G4. 

May 23. 

June 20, 

1864. 

Mar. HI, 
-May 6, 

18G4. 



Taber, J. A., Serg t. E, Mar 31 

5th Michigan, age 23. April IS 

1865. 

Vnnn, D., Pt., B. 8th June 3, 
New York Artillery, 16, 'G4. 
ago 18. 



Walker, M.. col'd serv- 
ant, K, 58th Penn., age 
13. 



June 3. 
2G, 'G4. 



'Wick. J.CPt., C, 155th Mar. 25, 
Pennsylvania, ago 22. May 23, 
i 1HG5. 

Wild, C. B.. Corp'l, E, ' Sept. 10, 
114th New York. I Oct. 1, 

18G4. 



Injury, Operator, and 
Result. 



Wound of popliteal artery; art'y 
tied. Died May 22, 18G4. 

Rt. and 1'ft thighs; luem. from post, 
tib.: rt. post. tib. lig. in continu- 
ity: luem. recurred: poplit'l lig. 
Died Juno 20, 18G4. 

Rigid ankle; gang.: hsem. from 
post. tib. art'y; poplit'l arty lig. 
in continuity, by A. A. Surg. D. 
McLean. Disch'd Mar. 21, 1865. 

Right leg ; poplit'l art'y lig. in 
contin'ty, bvSurg. J. C. McKee, 
U.S.A. Died April, 18, '65, luem. 

Left poplit'l art y injured; art'y 
lig., by Surg. R. B. Bontecuu, 
U. S. V.: h£em. recurred; new 
lig. applied June 20; same day 
amp. thigh. Died June 22, 18G4, 
gangrene. 

Right poplit'l art'y injured: vessel 
tied above bleeding point, by 
Surg. R. B. Bonteeou. I'. S. Y. 
Died July 3,'G4, diarrhoea. [See 
Case 107.] 

Both thighs; left poplit'l art'y tied 
above and below, by Ass't Surg. 
A. Delany, IT. S. V.; June 14, 
amp. thigh. Died June 20, '65. 

Right thigh thro' poplit'l space; 
lig. of poplit'l: luem. recurred; 
Oct. 12. amp. thigh. Died Oct. 
13, 18G4, of exhaustion. 



1 This is probably the case referred to by Prof. A. C. POST, in the Addendum to Section I of the Surg. Mem. of the IVar of the Rebellion, pub. by 
the V. S. San. Comm., 1870, Vol. I, p. 262. 



SECT. I.] 



LIGATIONS AFTER SHOT FLESH WOUNDS. 



51 



Case 110. — M. Walker, a colored servant of the 58th Pennsylvania Volunteers, aged 13 years, was wounded at Cold 
Harbor, .June .'J. 1804, by a ininie ball, which entered on the inner side of the lower third of the right thigh, passed through the 
popliteal space, injuring the popliteal artery, and making its exit latterly. Twelve days after the reception of the injury lie 
was admitted to llarewood Hospital, Washington. Hemorrhage to the amount of from three to five ounces took place on 
June 25th, and was controlled by pressure. On the following day haemorrhage recurred, and the popliteal artery was ligated by 
Surgeon II. li. Bontecou, U. S. V., by enlarging the wound of entrance, the patient being under the influence of sulphuric 
ether. The leg was placed in Smith's anterior splint with a fenestra opposite the wound to facilitate dressing, and a supporting 
treatment was ordered. The patient exhibited typhoid symptoms with very profuse diarrhoea until death, which occurred July 
3, 1834. An autopsy showed that the coats of the artery had been injured by the ball, causing sloughing and the subsequent 
haemorrhage. The history was reported by the operator. 

Ligations of the Posterior Tibial Artery separately. — In a series of seventeen liga- 
tions of the posterior tibial artery for shot wounds of the soft parts of the leg and foot, 
thirteen recovered, or 76.5 per cent. Three patients submitted to consecutive amputation, 
of whom one died. The cases are enumerated in Table V: 

Table V. 
Summary of Seventeen Cases of Ligation of the Posterior Tibial Artery for Haemorrhage from Shot 

Injuries unattended by Fractures. 



No, 



Name, military 
Description, and Age. 



Ball, J. D.. Corp'I, A, 
125th New York, age 



Brown, W. II., Bugler, 
5th New Jersey Batte- 
ry, ago 25. 

Backer, J. F.. PL. B, 1st 
Confederate, age 21. 

Dow. . I. A.. Pt.,E, 136th 
New York, age 20. 



Emery. R.. PL, D, 5th 

Vermont, age 33. 



Elannugan, H. A., Ser- 
geant, H, IGth Penn. 
Caw, age 25. 

Gilmore. M., Pt., B, 9(')th 
Illinois, age 22. 



Hagey, J. D., PL, I, 
138th Pennsylvania, 
age 24. 



Dates. 



May 13, 
28, 'G4. 



May 24, 

June 10, 

1864. 

April 6, 
16, '62. 
June 20, 
20, '64. 



May 5, 

Aug. 4, 

1864. 

April 7, 
May 14, 

1865. 
Aug. 3, 

3, '64. 



April 2, 

May 8, 

1865. 



Injury, Operator, and 

Result. 



Right post. tin. artery wounded ; 
artery tied in wound, by Ass't 
Surg. A. Ingram, U. S. A. Dis- 
charged Dee. 20, '64 ; pens'd. 

Left leg ; posterior tibial art. tied. 
Died July 7, 1064, pyamiia. 

Right leg ; posterior tibial artery- 
tied. Recovered. 

Right posterior tibial art, severed; 
vessel tied, by Surgeon I. N. 
Dimes, 73d Ohio, Disch'd June 
13, 1865; pensioned. 

Left leg ; gang.: ends of art'y tied 
in wound, bv A. A. Surg. J. B. 
Crandall. Disch'd Dec. 16, '64 ; 
pens'd ; Aug. 28. '65. amp. leg. 

Left posterior tib. art'y wounded; 
vessel tied at its middle third. 
Died June 15, 1865, erysipelas. 

Left leg, involving posterior tib. 
artery ; vessel tied, by Surgeon 
S. H. Kersey, 36th Indiana. 
Disch'd Jan. 10, 1865; pens'd. 

Left posterior tibial art. opened; 
one end of arterv tied in wound, 
by A. A. Surg. II. M. Bellows; 
sloughing; May 10, amp. leg, by 
A. A. Surg. II. A. Drane. Dis- 
charged July 26, 1865; pens'd. 



NO. 


10 

11 

12 
13 



name, Military 

Description, anu Ace. 



Ingalls, II. 1!., PL, L. 
1st Maino Cavalry, age 

25. 
Maran, M., PL. A, 2d 
New Jersey Cavalry, 
age 20. 

Oaklcv. C. N.. PL, A. 

85th New York, age 31. 
Righcy, T., PL, C, 9th 

N. Hampshire, age 23. 
1 Hitter, D. T„ Corp'I, F, 

208th Pennsylvania, 

age 10. 

Sherdan, J., Pt., D, 68th 
Pennsylvania, age 31. 

Thompson. S., PL, E, 
4 th N. Jersey, ago 23. 



Trowbridge. D. A., Cor- 
poral. L, 5th Illinois 
Cavalry. 

Wright, E., PL, F, 119th 
Pennsylvania, age 18. 



Dates. 



Mar. 31, 

April 0, 

1865. 

Feb. 11, 
27, '64. 



March 8. 
8, 1865. 
June 20, 
J'y3, 64. 
Mar. 25, 
April 7, 
1865. 

July 3, 
25, '63. 

Sept. 22, 

Oct. 10, 

1864. 

July 8. 

Sept. 23, 

1863. 

May 5, 

23, "'64. 



Injury, Operator, and 

lfr.su lt. 



Right leg; post. tib. arterv lig.. 
by Surg. E. Griswold, U. S. V. 
Disch'd Aug. 12, 1865; pens'd. 

Right leg; gang.; posterior tibial 
art. ligated on ulcerated surface, 
by A. A. Surgeon S. S. Jcssop. 
Disch'd Oct. 21, 1865 ; pens',';. 

Left leg; lig. post. tib. and pero- 
neal arteries. Died Mar. 23. '65. 

Left leg ; post. tib. artery tied at 
wound. Furl'd Aug. 11, 1864. 

Left post, tib, art. wounded ; both 
ends of vessel ligated, by Surg. 
G. L. Pancoast. It. S. V. Dis- 
charged June 37, 1865; pens'd. 

Right leg; posterior tibial artery 
tied at both ends. Discharged 
Feb. 6. 1865: pensioned. 

Right leg; both ends of posterior 
tibial arterv ligated in wound, 
bv A. A. 'Surg. J. \Y. Kerr. 
Duty March 30. 1865. 

Right leg: artery ligated in 
wound. Disch'd Nov. 17, 1863. 

Ball cutting right post, tibial art.; 
gang.: art. tied in wound, bv 
Surg. E. Bentley. U. S. V.; May 
25, hasm. recur'd ; leg amp. Died 
May 28, '64, asthenia ami pyaun. 



Ligations of the Anterior Tibial Artery. — Of ten cases of ligation in which the 
anterior tibial was separately tied, seven were successful, one after consecutive amputation. 
The cases are here briefly noted: 

Cases 111-120. — Captain C. C. Brewster, Co. D, 10th Connecticut, aged 45 years ; wounded at Bermuda Hundred, May 
16, 1864; shot flesh wound of left leg. Admitted into Chesapeake Hospital, Fort Monroe, May 21st. Bleeding from the anterior 
tibial artery to the amount of eight ounces occurred. The vessel was ligated in the wound at the cardial end. Haemorrhage 
did not recur. Discharged September 19, 1864, and pensioned. Examiner G. C. Jarvis, of Hartford, reported, August. 24, 
1869: "The wound is now an open, deep ulcer; occasionally pieces of bone come out from some part of the sore.'' Pensioner 
died June 17, 1873, of phthisis pulmonalis. — Private \V. Brommel, Co. E, 15th New York Artillery, aged 30 years; wounded at 
Boydton Plank Road, March 31, 1865; shot wound of left leg, lower third. Admitted into Columbian Hospital, Washington. 
Haemorrhage from anterior tibial artery ; vessel ligated by Acting Assistant Surgeon P. W. Briggs. Pied May 2, 1865. from 
exhaustion from loss of blood. — Corporal T. Condon, Co. ('. 2d New York Artillery, aged 21 years; wounded at Deep Bottom, 
August 16, 1864; shot flesh wound of the middle third of the right leg; the ball entered the posterior portion of the leg and made 
its exit at a corresponding point anteriorly. Admitted into Satterlee Hospital, Philadelphia. Haemorrhage. August 26th, Ligation 
of anterior tibial artery above and below bleeding orifice by Acting Assistant Surgeon W. F. Atlee. Collateral circulation 
re-established in twenty-four hours. Discharged July 26, 1865, and pensioned. The New York Examining Board reported, 
March 4, 1876 : "There is a cicatrix three and a half inches in length on anterior surface of right leg ; the ball emerged through 



1 The case numbered 13 in Table V is detailed by Professor A. C. POST in the Surg. Memoirs of the U. S. San. Comm., Surgical Vol. I, p. 262. 



52 INJURIES OK THE LOWER EXTREMITIES. 



|rn.\r 



the calf. Bdili cicatrices arc adherent and interfere witii locomotion and tlic strength of llic limb." — Sergeant M. C. Glass, Co. 
P, KitJi Michigan, aged 24 years; wounded at Hatcher's Run, February 7, 18(*>. r >: shot wound of right anterior tibial artery. 
Admitted into Jarvis Hospital, Baltimore. Ulceration and haemorrhage; six ounces of blood lost. Ligation of anterior tibial artery 
in continuity, February 20, 1865. Hied February 28, 1805, of hemorrhage. — Private J. L. Renshaw, Co. H. 191st Pennsyl- 
vania, aged 28; wounded at Petersburg, Juno 24, 18C4 ; shot flesh wound of left leg by a conoidal ball; sloughing and 
haemorrhage from anterior tibial artery to extent of eight ounces. Ligation of artery above and below wound. The patient 
recovered, and was discharged May 18, 1865. — Private S. Riley, Co. H, 92d New- York, aged 21 ; wounded at Cold Harbor, .1 me 
1, 1804 ; conoidal ball passed through the integument of tho left leg one inch below the knee. June 25th, sloughing and erys'p- 
elas. July 8th, recurrent haemorrhage to the extent of six ounces from the anterior tibial artery. The artery was tied in I he 
wound. The patient was discharged February 9, 1865, and pensioned. Examiner II. O. Hitchcock, of Kalamazoo, report! d, 
June 8, 1867: "Ball passed below the patella and under the ligament. The wound was followed by gangrene and large 
sloughing, and now there is an extensive cicatrix, causing lameness and great weakness of the knee.'' Examiner J. A. Brow •, 
of Detroit, reported, September 28, 1869 : "Gunshot wound of left knee, the ball striking the inner condyle of the tibia and 
the patella, causing weakness and impaired motion of the knee, mostly from contraction of the cicatrix." Examiner D. F. 
Wooley, of Big Rapids, reported, April 1, 1875: "Ball entered at upper and inner third of the tibia, passing directly in front 
and under the patella and out, severing the attachment of the lower end of the patella and fracturing the upper end of the 
tibia; resulting in loss of part of upper portion of the tibia and weakening of knee joint to a serious extent, with slight 
adhesions of the muscles; on the whole seriously impeding locomotion and requiring care to maintain a standing position upon 
it." The pensioner was paid March 4. 1876. — Corporal I. Sampson, Co. F, 1st Massachusetts Cavalry, aged :>5. was wounded 
during Sheridan's raid, May 11, 1864; shot wound of right leg, middle third, outside. Admitted into Hammond Hospital, 
Point Lookout. Gangrenous sloughing set in, destroying the coats of the anterior tibial artery. June 28th, haemorrhage to the 
extent of four ounces from the anterior tibial artery. Both ends of artery tied in the wound by Acting Assistant Surgeon T. 
Liebold. The bleeding did not recur. The patient recovered, and was mustered out October 16, 1864. Examiner W. H. Page, of 
Boston, reported. April 11, 1865 : " Ball struck about the middle of the left leg, fracturing and splintering the tibia, a large part of 
which, at seat of injury, has been removed, and there is a deep cicatrix throe inches by one and a half The whole leg is much 
swollen and ccdematous, and there is probably more dead bone to be removed." The Boston Examining Board reported, Decem- 
ber 2, 1874: "Ball entered middle third of leg anteriorly and passed directly through. The tibia was shattered, and necrosis 
has resulted therefrom. The leg is weak and the wound is still open, an ulcer at the time of examination existing the size of 
a five-cent piece, surrounded by an areola four inches in diameter and somewhat eczematous. His leg is painful and weak 
upon long standing, and this interferes with the performance of manual labor." In September, 1875, tho Board reported: 
"Large adherent cicatrix, inflamed and very tender; anchylosis of ankle." Pensioner paid June 4, 1876. — Private W. Sauls- 
bury, Co. K, 39th U. S. C. T., aged 36; wounded at Petersburg, July 30, 1864; flesh wound of lower third of right leg. He 
was admitted into Summit House Hospital, Philadelphia. Secondary haemorrhage ; ligation of anterior tibial artery January 
19, 1865. Amputation of right leg at lower third by double-flap method. Transferred to hospital at Beverly, and discharged 
May 26, 1865. He died July 16, 1871.— Private J. Skiffington, Co. I, 2d New York Heavy Artillery, aged 28; wounded at 
Petersburg, June 16, 1864; flesh wound of lower third, right leg. Admitted into Satterlee Hospital, Philadelphia; wound 
sloughing. Acting Assistant Surgeon W. F. Atlee ligated both ends of the anterior tibial artery in the wound, on account of 
haemorrhage, July 28, 1864. The patient died August 29, 1864, of pyaemia. — Private L. Weaver, Co. G, 4th Virginia, aged 23 ; 
wounded at Gettysburg, July 3, 1863. Admitted into Twelfth Corps Hospital. Shot flesh wound of both legs and face. July 
13th, bleeding of eight ounces from the anterior tibial artery, which recurred on the 14th, sixteen ounces of blood being lost. 
The anterior tibial artery was tied above and below the point of division. The patient was paroled November 12, 1863. 

Ligations of the Anterior and Posterior Tibial Arteries. — There were two instances 
in which the posterior and anterior tibial arteries were conjointly tied for shot flesh wounds: 

Cases 121-122.— Private J. Hoar, Co. G, 144th New York, aged 22 years, wounded at White Plains, July 24, 1863. 
Shot wound of right foot; admitted into Douglas Hospital, Washington; haemorrhage to the extent of six ounces occurred 
from the metatarsal artery on August 1st. Assistant Surgeon W. Thomson, U. S. A., ligated the anterior tibial artery in the 
continuity at the instep and the posterior tibial behind the malleolus. The wounds healed well, and the patient was returned to 
duty from Central Park Hospital, New York, April 11, 18C4. He is not a pensioner. — Private J. Kercher, Co. D, 7th Michigan 
Cavalry, wounded at Gettysburg, July 2, 1863. Shot wound of right leg and of anterior and posterior tibial arteries; admitted 
into McDougall Hospital, New York Harbor. July 29th, ligation of anterior and posterior tibial arteries. August 10th, 
haemorrhage, amounting to thirty-two ounces of blood. Died August 10, 1863. 

Zdgation of Veins. — Six cases in which the femoral vein was tied simultaneously with 
the artery are noted on page 38. Specimens from two of the cases are shown in Figures 
15 and 19. A case of ligation of the saphenous vein is detailed: 

Cask 123. — Private A. Kendig, Co. B, 97th Pennsylvania, aged 31 years, wounded at Bermuda Hundred, May 18, 1864. 
Assistant Surgeon E. McClellan, U. S. A., reported from Hampton Hospital, Fort Monroe: "Gunshot wound of left thigh, 
inner surface, upper third ; the ball entered near the apex of Scarpa's space, passed through the adductor longus muscle, and 
made its exit over the upper third. Gracilis muscle wounded; phagedaena. On May 24th, haemorrhage to the extent of six 
ounces occurred from the saphenous vein. Both extremities of the vein were ligated in the wound. The haemorrhage did not 
recur, but the patient sank and died of exhaustion June 4, 1864." 

Amputations following shot flesh wounds will next be considered. 




u 

Z 
u 

DC 
O 
2 
< 



Q- 

co 
O 

x 



I- 
o 
bj 

L. 
L_ 
U 



SECT. 1. 1 



AMPUTATIONS AFTER SHOT FLESH WOUNDS. 



53 



Amputations in the Lower Limbs after /Shot Flesh Wounds. — Two hundred and one 
cases were reported of amputations in the lower extremity for shot wounds involving only 
the soft parts, comprising one hundred and thirty-one amputations in the thigh, six 
disarticulations at the knee, sixty-three amputations at the leg, and one of the toes. 

Amputations in the Thigh. — In the hundred and thirty-one cases of this series, ninety- 
four or 71.7 per cent, were fatal. The cases are enumerated in Table VI. Ten of the 
operations were primary, with only two recoveries. Fifty-seven intermediary operations, 
with forty-eight deaths, gave a mortality rate of 84.2 per cent.; sixty-four secondary 
operations, with thirty-eight deaths, had a death-rate of 59.4 per cent. The amputations 
were necessitated for the most part by complications of consecutive haemorrhage, gangrene, 
or secondary disease of the bone or joints, and in some instances were resorted to after 
ligations, removals of sequestra, or other interference had been unavailingly employed : 

Case 124. — Private H. Boot, Co. 15, 104th New York, aged 2G years, was wounded at Petersburg, June 22, 1804, 
and admitted to the field hospital of the 3d division, Fifth Corps. Surgeon L. W. Read, U. S. V., noted, "buckshot flesh 
wound of right leg, slight." On June 30th, the patient entered the Harewood Hospital, Washington, whence Surgeon R. B. 
Bontecou, U. S. V., contributed the specimen (Fig. 21), with the following brief history: "Gunshot wound of 
right leg, middle third, injuring soft parts. On admission the constitutional state of the patient was very poor; 
condition of injured parts tolerably good, but wound very painful. The parts subsequently became gangrenous, 
with rapid sloughing of soft parts; about one half of the lower third, and three-fourths of the upper third, and 
all of the middle third of the tibia exposed and denuded of periosteum. The tibia became necrosed throughout 
its whole extent, and at this time the patient became jaundiced. On October 29th, about ten inches of necrosed 
bone was extracted by Acting Assistant Surgeon D. I. Evans. The general condition of the patient improved 
soon afterwards, under a supporting treatment throughout, and was doing tolerably well, parts improving, 
when transferred to hospital at Elmira, January 4, 1865." Two weeks after his transfer the patient obtained a 
furlough and proceeded to his home in Tioga County, New York, where his limb was subsequently amputated 
at the middle third of the thigh. Dr. S. Knapp, his attending physician, certified that "he found him suffering 
from a badly cared for and neglected wound," etc., and that "on February 28, 1865, it, became necessary to ampu- 
tate the leg," which operation he performed, being assisted by Dr. E. Daniels. About two months afterwards 
the patient returned to the hospital, and on Jury 21, 1865, he was discharged from service and pensioned. • He 
died July 25, 1870, of consumption, resulting from the wound and its effects, more than five years after the ampu- 
tation. The parts removed by the amputation at mid-thigh by Dr. Knapp were not transmitted to the Museum; 
but the large sequestrum comprising the greater part of the diaphysis of the tibia is represented in the wood-cut 
(FlG. 21), and, as mounted, is nine inches in length (see Catalogue of the Surgical Section of the Army Medical 
Muesum, Washington, 1866, p. 405). 

In a grave case of hospital gangrene following a shot wound at the ankle, the lamented 
artist, Hospital Steward E. Stauch, made a colored drawing of the appearances after the 
sloughing surfaces had cleaned off under the applications of fermented cataplasms. The 
drawing is copied in the chromolithograph opposite, Plate XXVII. 

Case 125. — Corporal C. H. Dudley, 11th Indiana Battery, received at Chicamauga, September 20, 1863, a wound of the 
right foot, a conoidal ball entering the under portion just below ankle joint. He was taken prisoner, conveyed to Richmond, 
and on October 29, 1803, was admitted to Division No. 1 hospital, Annapolis, from the steamer New York. The wound had 
sloughed extensively. On October 30th and 31st there was hemorrhages from the dorsalis pedal artery, which was promptly 
arrested by the use of styptics. Soon after admission a phagedenic ulcer made its appearance on the posterior face of the right 
leg, immediately below knee joint, and an examination, made November 19, 1863, revealed a deeply excavated sloughing 
wound. Yeast poultices were applied to the sloughing tissues, and when the gangrenous masses had cleaned off a colored 
drawing was made of the parts by Hospital Steward E. Stauch. November 23d, haemorrhage amounting to eight ounces 
occurred from this wound, and was restrained by finger compression on the femoral artery; tourniquet was loosely applied on 
limb, and stimulating draughts given. On November 24th, Assistant Surgeon W. S. Ely, U. S. V., who had charge of the case, 
reports that the "wound from which the haemorrhage proceeded was thoroughly examined and the diseased tissues found 
more extensive than had been supposed ; the finger could be passed beneath superficial border of ulcer to a considerable extent, 
and the popliteal artery was found to be divided by the extent of the ulcerative process, and the ligamentous structures of the 
knee joint were found extensively destroyed. Amputation was determined on as the only rational treatment. It was imme- 
diately performed, after the circular method, directly above the knee joint, by Surgeon T. A. McParlin, U. S. A., assisted by 
Surgeon B. A. Vanderkieft, U. S. V. Patient bore the operation well, and the tissues at seat of amputation appeared healthy. 
No sutures were used to approximate the flaps, wet straps being the only retentive treatment employed." The case progressed 
favorably until December 2d. Acting Assistant Surgeon C. Hayes kept the further record of the case. On December 8, 1863, 
haemorrhage, amounting to eight ounces, occurred from the stump. He failed rapidly after this, and died December 11, 1863. 
Surgical Series of Drawings, Nos. 59, 60, S. G. 0., Plate XXVII. 



FlO. 21.— Se- 
questrum of 
right tibia. 
Spec. 3T>01. 



54 



INJURIES OF THE LOWER EXTREMITIES. 



[CHAP. X. 



Table VI. 

Numerical Statement of One Hundred and Thirty-one Amputations in the Thigh for Shot Injury 

unattended by Fracture. 



K0. 



Name, militaki 
Description, and Ac.b. 



Atwood. II., l't.,K, Mth 
New Hampshire. 



Raker, J., Pt., A. lltli 
Connecticut, ago 32. 



Barkeloo, J., rt.. M. 2d 
Ohio Cavalry, age 28. 

Iiaruum, C. I".. Pt., IS, 
187th Penn., ape 30. 



Barry. 1'... Pt., A, 82(1 
Penn.. uge 24. 



6 | maker. J. I'.,Pt.,E, 15th 
Infantry, ape Id. 



Bras1ed,A.A., Scrg't.H, 
96tb New York, age 2-2. 



Bell. .1. C. Pt.. E, 34th 
Iowa, ago 23. 



9 Belt. W. II. II.. Pt., A. 
lllth Ohio Cavalry, ag< 

21. 



Bishop. .1.. Pt., M, 22(1 
New York Cavalry, 
age 20. 



Black. J. M., Corp'I, D, 
35th Ohio, ago 21. 

Blaisdell. II.. Pt.. II. 
58th Pennsylvania. 



Boies, .1. A.. Lieut.. II, 
13th Infantry, age 22. 

Brockman. II.. Pt.. I. 
6th Kentucky. 

<HurJ:e. IT., Pt., B, 24th 

Alabama. 
Burroughs, II. C, C, 

7th C. S. Cavalry. 

Butler. II.. Pt.. II. 1st 
New York Artillery, 
aire 2!. 

Cameron. ,1., Serg't, K, 
31st Maine, age 27. 

Carroll, R. A.. Pt.. F, 
3d Alabama, ago 19. 



Case. E. I'., Pt.. G, 13th 
Michigan. 



Chapman. C. II.. Scrg't. 
E. 13th New Hamp- 
shire, age 26, 

Chapman. J. S.. Pt.. F.. 
4th Maine, ago 33. 

Chan-go. M. W.. Pt., H, 

401h New York, ago 21. 



Dates. 



Sept. l!i 
2:i, '(14. 



June 15 
26. 'HI. 



Julv Id. 
20. 'o3. 

Juno IS'. 

Sept. 7, 

1804. 

June 3. 
Aug. 11. 

1804. 
Aug. 7. 
.Sept. Hi. 
, 1804. 

I .rune 1, 
Nov. 7. 
1 8114. 

April (1. 
18, '65. 



Feb. in, 

April 21 

1863. 

Aug. 2.7. 

Sept. (!, 

1864. 



July 2(1. 
Aug. 1.7, 

1804. 
April 21). 
June 28, 

1803. 

Slav 22, 
June 18. 

1803. 
April II, 
June 2d, 

1802. 
Sept. 19, 
2:t. '03. 
April 1. 
Mnv 1.7, 

18(1.7. 
June I . 
Aug. 5, 

1864. 
Juno 2". 
'64, July 
5. 'Co." 
July 3, 
Nov. 29, 
1SC3. 

Sept. 19, 
26, '(13. 



Sept. 30, 
(14. Apr. 
7, '65. 

June 18, 

Julv 5, 

18(i4. 

May 13, 
17,' '64. 



IXJLUY, OPEKATOB, 
RESULT. 



NO. 



Bight fem, art. injured : circulat'n 
destroyed; gang.: circ. amp. at 
low. third thigh, bv A. Surg.W. 
Fritz, 12th Mo. Died Sept. 30, 1,1. 
Sheath (fright fern. art. wounded : 
loom, from branch of profunda : 
flap amp. thigh, bv A. A. Surg. 
J. S. Hill. Died June 29, 18n4. 
Bight popliteal artery severed; 
lorn. art. ligated : Hapnmp. thigh 
at up. third. Disch'd Mar. 17,'05. 
Left log: amp.bel. tubere. of tibia ; 
htsm.; amp. thigh, circ lo. third, 
bv A. A.. Surg. J. Morris. Died 
(let. 13, CI. AJ)«c.3132.A. M. M. 
Left leg: flap amp. at mid. third, 
bv Dr. J. shields. Discharged 
Sept. 2. 1863. 
Left leg; gang.: ant. post., lower 
third thigh, bv A. A. Surg. K. 
\V. Forrest. Died Sept. 18, 1864, 
exhaustion. 
Bight knee joint ; gang.; joint 
opened; circ, low. third thigh, 
bv A. A. Surg. A. .1. Smith. 
Died Nov. 30, 1864, exhaustion. 
Left posterior tibial artery cut by 
ball: gang.; h:v:n.; lig. of fem. 
artery: amp. at low. third thigh, 
by A. A. Surg. L. M. Cowan. 
Died April 23. 'Ii,7. exhaustion. 
Shot perforation left thigh ; ery- 
sipelas: flap amp. at mid. third, 
bv Surg. J. I!. MeClurg. F.S.Y. 
Disch'd ,s,.pt. 2, 1863. 
Bight leg. destroying post, tibial 
artery, vein, and nerve; b:em.: 
thigh amp. at low. third, by A. 
A. Surg. \V. J. Mellcnoh. Died 
Sept. 1.7, 1804. py;emia. 
Bight leg: gang.: llapamp. thigh. 
low. third, by A. A.Surg. .1. E. 
Crowe. Died'Aug. 18,'(il.e.\h'n. 
Bight leg near knee: no fracture; 
thigh amp. at middle third, by 
Siirg. J.F. (lallo-pe. 17th Mass. 
Died July Mi. 18o3. 
Left knee. by spent shot ; pyaemia : 
amp. of thigh at upper third. 
Died June 28, 1863. 
Bight femoral artery cut : double 
flap amp. thigh. Disch'd Aug. 
9. 1803. 

thigh : gangrene ; thigh amp. 

Died Sept 23. 1803. 
Poplit'l space, rt leg ; gang.: circ. 
amp. thigh, bv Surg. YV. Hayes. 
F.S.Y. Died'May 17. '65, gang. 
Left leg just below poplit'l space : 
gang : amp. thigh, bv A. A Surg. 
\V. C. Way. Died'Aug. (>. '04. 
Bightthigh ; ch. arthritis: double 
flap, thigh, by Ass't Surg. II. E. 
Brown, ( r . S. A. Recovery. 
Bight leg: daub, dap amp. thigh, 
by A. A. Surg. J. E. Steele; 
haemorrhage: fem. nrt'ry ligated. 
Died Feb. 17, 1864, pyaemia. 
Left fem. artery severed; gang.; 
Sept. 24. amp. leg four inches 
below knee ; 20th. thigh amp. at 
upper third. Died Sept. 27. '03. 
Bight thigh : gang., destroying 
profunda art v; litem.; circ. amp. 
up. third, by Surg. It. LP. Good- 
win. Died live hours after ope'n. 
Left knee ; amp. post. flap, thigh, 
by Surg. E. Bcutley, U. S. V. 
Died July 0, 18(!4, exhaustion. 
Bight leg: gang.: ha?m.: amp. at 
low. third, by Asst. Surg. C. A. 
MoCall, IT. S. A. Died May 19. 
1864, pyaemia. 



Name, Military 
Description, and Age 



Cheseltine, YV. ('.. Pt., 
C, 1st Maryland Cav- 
alry, age 22. 

Christ, J., Corp'I. M.. 
198th Penn., ago 27. 

Cook, L., Scrg't, C,2Gth 
Ohio, ago 25. 



Cooper, T., Pt., C, 4th 
Penn. Reserves, age 18. 



Curtis, J. A., Pt., D, 

101st Ohio, ago 25. 

Curtis, G„ Pt., A, 1st 
Colored Troops, age 23. 



Daniclson. II. A.. Pt., 
G, 7th Minnesota, age 
23. 

Darling. S. G., Pt., D, 
32d Maine, age 19. 



Decker, E., Pt., II, 81st 
Ohio. 

Dcinlein, D., Pt., C. 5th 
Ohio, ago 43. 



Delaniater, M., Corp'I, 
G, 7th Mich. Cavalry, 
ago 20. 

Deniker, D. H., Pt., E, 

2d Maryland, age 20. 

Dodge, YV. M., Serg't, 
F, 137th New York, 
ago 4.7. 

Doyle, L., Pt., K, 8th 
Maine, age 34. 



Drilling, II., Pt.,C, 124th 
New York, age 30. 



Dudley, C. II., Corp'I, 
1 1th Indiana Battery. 



2 Dutcher, .1. IL, Pt., M, 
2d New York Heavy 
Artillery. 

Dyer, G. A., Serg't, G, 
6th Maine, ago 21. 

Edwards, C. S., rt., G, 
57th Indiana. 

Elliot, J.. Corp'I, E, 2d 

Pennsylvania Cavalry, 
age 24: 

Fardcr, J., Pt., 1st N. 

Carolina Cavalry, age 
25. 
Fcarv. G. M., Pt., B, 
108th Now York. 



Dates. 



May 27, 

June 4, 

1804. 

Mar. 2.7. 
April 7, 

180:7. 
June 18, 
Aug. 10, 

1864. 

June 22. 

'04, Mav 

3, '70.' 



June 27, 

Aug. 7, 

1804. 

Oct 27, 

Nov. 19, 

1804. 

Dec. 16, 

01. Fob 
11, '65. 
May 12, 
26,' 'C4. 



Julv 22, 
1864. 

Mav 2,7. 

Julv 10, 

18G4. 

May 28. 

Julv 12. 

1864. 

Sept. 26, 
28, '04. 

Julv 2, 
10, ''63. 

May 20, 

June 0, 

1864. 



Oct. 26, 

Nov. 1, 

1864. 

Sept. 20. 

Nov. 24, 

1803. 

May 31, 

June 5, 

1864. 

Nov. 7, 
•63. Feb. 

19, 'C4. 
Dec. 31, 
'62, Mav 

26, '63.' 
April 0, 

Mav 5, 
1863. 

Juno 20, 
Sept. 1, 
1864. 
Julv 2, 
14, '63. 



injubt, opebatob, and 

Result. 



Bight thigh, severing fem. vein; 

gang.; circ. amp. thigh, by Asst. 

Surg. YV. F. Norris. I'.* S. A. 

Died June 9, 1804, exhaustion. 
Bightthigh ; circ. amp. thigh, by 

A. A. Surg. J. II. Gillman. Died 

April 2.7, 180.7. pyaemia. 
Bight thigh. Aug. 9, luoni.; amp. 

post, flap, mid. third, by A. A. 

Surg. E. H. Sands. Died Aug. 

11, 1804. 
Left thigh and leg ; contraction of 

muscles ; Dee. 31, hamstring ten- 
dons divided. Disch'd June 23, 

'65 ; leg deform 'd and paralyz'd ; 

amp. above knee, by Surg. O. 

Pemberton, F. R. C. S.. of Birm- 
ingham, England. 
Right thigh ; gang.: tlaps of skin. 

cir. of muscles, bv Surg. S. E. 

Fuller, U.S. V. Died Aug. 15, 

1864, pyaemia. 
Shell contusion of right thigh and 

leg ; gang.; amp. thigh, bv Asst. 

Surg. J. H. Fronts, II. S. A. 

Died Jan. 13. 1805. pyaemia. 
Left thigh ; gang.: am]». thigh, by 

A. A. Surg. S. YV. Thompson. 

Disch'd August 10, 1865. 
Bight fem. artery severed; artery 

tied on field: gang.: thigh amp. 

by Surg# R. B. Bontecou. F.S.Y. 

Died May 26, '64, haemorrhage. 
fem. art. wounded: primary 

amputation of thigh. Died Aug. 

3. 1864. 
Right popliteal space, producing 

aneurism : amp. thigh, bv A. A. 

Surg. O. D. Norton. Died Aug. 

I, 1864, in lowtyphoid condition. 
Right thigh ; gang.: haem.: July 

10, femoral ligated : amp, thigh, 
by Asst. Surg. II. M. Sprugue, 
U.S.A. Died Aug 7. '64, py'mia. 

Right leg ; thigh amp. at lower 
third, by A. A. Surgeon M. M. 
Townsend. Died Sept. 29. '04. 

Right leg: gang.: luem.: amp. 
thigh, by Surg. IL E. Goodman, 
28th Pe'nn. Died July 13, '63. 

Right thigh perforated: June 1, 
luem; fem. ligated: recurred; 
amp. thigh, by Asst. Sure. AY. 

II. Gardner, U.S. A. Died June 
6, 1864, exhaustion. 

Right fem. vein and art'ry wound- 
ed : hasm.: amp. thigh, bv Surg. 
D. YV. Bliss, U.S.Y. Died Nov. 
21, 1864, pyaemia. 

Bight foot ; gang., involving pop- 
liteal artery; baem.; amp. thigh, 
bv Surg. T. A. Mcl'arlin.U.S. A. 
Died Dec. 11, '63, hann., debility. 

Left popliteal artery divided near 
end ; gang.: thigh ump.,bv Surg. 
J. A. Lidell, U. S.V. Died June 
8, '64, exhaustion. 

Bight thigh ; amp. thigh, bv Surg. 
I). YV. Bliss, IT. S. V. Disch'd 
April 19, '64. Spec. 2047, A.M. M. 

Left leg; amp. thigh, by A. A. 
Surgeon J. B. Burns. Disch'd 
Aug. 23, 1863. 

Left leg ;ha?m.: April 29, popliteal 
artery ligated: hsem. recurred; 
amp. thigh. Died May 5, 1863, 
from shock, 2 hours after amp. 

Right thigh and left leg; amp. left 
thigh, bv Surg. II. L. YV. Bur- 
rift. IT. 8. V. Died Sept. 2, '64. 

Bight thigh, severing fem. artery; 
luem.: gangrene; amp. of thigh. 
Died Julv 24. 1863. 



1 FEItf'.v ((T.I, Report of Wounded treated in Field Hospital of landman's Division, etc.. in Confederate States Med. and Surg. Jour., 1864, Yol. 
2 L111ELL (J. A.), Wounds of the Arteries, in Surg. Mem. of the War of the Rebellion, by the C S- Sanitary Commission, 1870, Vol. I, p. 59. 



SECT. I.] 



AMPUTATIONS OF THE THIGH AFTER SHOT FLESH WOUNDS. 



55 



No, 



46 



49 



5] 



Name. MiLlTAlt? 
DESCRIPTION, and AGE. 



Dates. 



[•"enton, C, Serg't, E, 

]st Penn., ago 25. 



r..ss. A. J.. Pt., F, 13th 
N. Hampshire, age -1 . 

Foul, •/.. ft., — , North 
Carolina Artillery, age 
37. 



Gardner. G. W., Serg't, 
H, 12th Illinois Cav- 
alry, ago 29. 

Goldsborough, II. J., 
Pt., 13, 31st Illinois. 



Gooding, H. P., Pt., H, 
10th Michigan Cav'ry. 



Hasey.W. II. It., Serg't, 
E iiuth Maine, age 23. 

Haskell, A. M., Corp'l, 
K, ISth .Maine, ago 23. 



Ilaynes, A., Major, 29th 

Virginia. 
l Uemherf/, A. J., — , K, 

<lth Alabama. 

Hickey, J., Pt., C, 23d 
Massachusetts, age 1!). 



Hogstead, P., Corp'l, A, 
187th New York, age 
21. 

Hopper. B., Pt.. P, (i4th 
New York, age 28. 



Huhhaeh, H., Corp'l, P, 
68th New York, age 42. 



Hyatt, J. B., Pt., E, 7th 
Indiana Cavalry, age 
18. 

Jenkins, W. H., Pt„ C, 
39th Illinois. 



Johnson, P., Pt., E. 2d 
Penn., age 27. 

Johnson, W„ Pt.,G, 31st 

Alabama, age 22. 
Jones. J. T., I't„ II. 8th 

Wisconsin, age 21. 

Keep, M., Pt., E, 3Gth 
Massachusetts, age 23. 



66 Keller, B., Pt„ E, 1st 

Mich. Cavalry, age 3(1. 

67 Kenyon. B. G-, Corp'l, 

II, 11th New Hamp. 

68 Kintnor, S. L., Corp'l. 
A. 24th Iowa. 

2 Kogel. C, Pt., D, 15th 
Now York H'vy Art'y, 
age 39. 

Lane, D., Pt., K, 14th 
Ohio, age 34. 



69 



71 



Larkin, T., Pt., K, 4th 
Mass., age 18. 



I 



May 6, 

22, %i. 



April 27. 
U y8/63. 

Mar. 27, 
June 17, 

1800. 



Oct. 11. 
29, '03. 



June 26, 

Dec. 16, 

1863. 

Jan.' 3D, 

Feb. 27, 

1865. 

Julv 1. 

30, ''64. 

Oct. 19, 

Nov, 15. 
1864. 



May — , 
27. '64. 

Sept. 19, 

Oct. 1, 

1863. 

July 2, 

Aug. 5, 
1863. 



Feb. 7, 
26, '65. 

May 12. 

June 16. 

1864. 

Aug. 30, 

'62, Oct. 

6, '65. 



July 9, 
19, '64. 



Oct. 13, 

1864. 
Mav 5. 

1863. 



June 27. 
Oct. 19, 

1864. 
June 15. 
J'yl,'04. 
Dec. 16, 
'61, Pel). 
26, '65. 
May 19, 
June 4, 

1864. 

May 11. 

Julv 2, 

1864. 

Je.16/64. 

Jan.3,'67. 

Julv 12, 

—,''63. 

May 30, 

June 6, 

1864. 

June 14, 

Aug. 7, 

1864. 
June 23. 
63, June 

15, '64. 



Ixjukt, Operator, and 
Result. 



T.el't thigh, wound'g profunda art.; 
frequent lurins.; amp. thigh, by 
Surg. R. B. Bonteeoll. U. ,S. V. 
Died Mil}' 22, '64, exhaustion. 

Bight leg; gang.; amp. thigh. 
Died May 8, 1863. 

Left knee, not involv'g joint ; ex- 
tensive siippurat'n in vol v'g joint; 
am]), thigh, by A.A.Surg. J. Gil- 
man ; luem.; artery lig.; July 10, 
pya?mia. Died J 'y 25, 'ii~t, exh'n. 

Right fern, artery injured: gang.; 
amp. thigh, by A. A. Surg. Yv*. 
II. Ensign. Died Dec. 5, 1863, 
debility. Spec, 1760, A. M. M. 

Left knee; ulceration of articular 
surface of hone ; amp. thigh, bv 
A. A. Surg. .1. 1). Davis. Died 
April 15, 1864. 

Left knee; extensive siippurat'n. 
joint disorg'zed ; tlap. low. third, 
by A. A. Surg. 'P. \V. Branch. 
Died March 4. 1865 ; pyaemia. 

Right leg : gang, and hieui.: amp. 
thigh, by A. A. Surg. II. B. Ma- 
ben. Died Sept. 28, '64, exh'n. 

Right knee ; amp. post, flap, June, 
lower third, by A. A. Surg. YV. 
Kempster. Nov. 21, hffim.; lig. 
fern.; hsem. 27th and 30th. Died 
Dec. 1, 1864, exhaustion. 

Right fern. art. injured: single flap 
amp. of thigh. Died May 30, '64. 

Lower portion popliteal space; 
DSBm. from popiit'l art.: amp. just 
above knee. Died end third day. 

Right leg, follow 'd by trail, ancur. 
of ant. and post, tibial arteries; 
hsem.; gang.: amp. thigh, by 
Surg. C.W. Jones, U.S.V. Died 
Aug. 16/63. Spec. 1698, A. M. M. 

Left leg; amp. thigh, by A. A. 
Surgeon R. Wosteding. Died 
March 8, 1865. 

Left knee; destructive inflamma- 
tion in joint; amp. thigh, bv A. 
A. Surg. J. E. Dexter. Died 
June2f. 1864. pyamiia. 

Left thigh. Discii'd Nov. 20, '63. 
Contract'n of flex, of thigh, and 
atrophy; flap amp. thigh seven 
inches from body, by Dr. L. 
Bauer, of Brooklyn. Recovered. 

Left popliteal art. inj.; gang.; amp. 
thigh, by Surg. J. Or. Keenon. 
U.S. V.: gang, of stump and left 
lung. Die'd Aug. 1 1 .'64, pyaemia. 

Righ'tthigh. Disch'd. May 18/65, 
three large exostoses rein., bone 
scraped ; Oct. 24, rem. large se- 
questrum : May 5/68. thigh amp. 
at base of trochanter, bv Surg. 
C. M. Clark, late 39th ill. Re- 
covered, Oct. 2, 1869. 

Right knee; sloughing; amp. 
thigh, bv A. A. Surg. W. P. 
Moon. Died Oct. 21, 1864. 

Left gastrocnemius ; amp. thigh. 
Died July 12, 1864, pyaemia. 

Left leg ; gang.; amp. thigh. byA. 
A. Surg. C. P. Barnard. Trans- 
fer'd Sept. 20, '6T>, for musterout. 

Left popliteal space; knee joint 
ope'dby suppurat'ii; amp. thigh, 
by Surg. D. P. Smith, tl. S. V. 
Died Juno 9, 1864, pyaemia. 

Right thigh ; eire. amp. of thigh, 
by Surgeon A. Heger. IT. S. A. I 
Died July 3. 1864. exhaustion. | 

Left leg ; amp. thigh, by Prof. A. 
II. Crosby, Disch'd Sept. 27. '65. 

B't thigh : amp , Surg. J. L. Dick- 
ey. 47th Ind. Died July 16. '63. 

Right leg : gangrene: amp. thigh, 
by A. A. Surg. C. H. Osborne. 
Died June I6 t 1864, pyaemia. 

Leftknee: sloughing : amp. thigh. . 
by Asst. Surgeon B. E. Fryer. 
Died Aug. 16, 1864, pyaemia. 

Left thigh and wrist. Diso'd Aug. 
20, '63. A trophy and exe. pain ; 
nmp. at up. third thigh, by Dr. 
C. II. Stedman, Boston. Ree'd. 



NO. 



78 



Name, Militaky 
Description, and age. 



Dates. 



Lauch, II., Pt., Brax- 
ton's Artillery, ago 34. 



Lee, W. H., Corp'l, F, 
32d Colored Troops, 
age 26. 



Leonard, J., Pt„ L, 7th 
New York H'vy Art'y, 

Lloyd" R., Pt., B, 1st 
Kentucky. 

Lyon, II. J., Serg't, H, 
4Uth Illinois, age 24. 

McCarthy, D., Pt., C, 
2d Mass., age 22. 

McClure.R., Pt., L, 15th 
Kansas, age 18. 



McMahon, E., Lieut., D, 
80th New York, ago 21. 



Maher, L., Pt., C, 69th 
New York. 



Martin, J. H., Pt., E, 

100th Pennsylvania. 

Martin, M., Pt., II, 1st 
Artillery, age 24. 

3 McCroary, S.C., Pt.,F. 

lOllth Pennsylvania. 
Mather, II. G., Pt., H, 

90th Penn., age 20. 

Mathers, YV. D., Pt.. I, 

6th Vermont, age 28. 

Meyer, M., Pt., L, 15th 

New York Artillery, 
age 44. 
Miller, P., Pt., A, 64th 
Ohio, age 40. 

Moore, T., Pt., E, 51st 
Virginia, age 19. 

Moss, B. P., Corp'l, B, 
101st Illinois, age 43. 



Nichols, M. S., Pt., G, 
91st Ohio, age 23. 



Nobler, B., Pt., F, 85th 
Illinois, age 21. 



4 Nottingham, G. M., Pt., 
I, 56th Ohio. 



'Parte, A. C, Capt., D. 
21st Virginia. 



Percel. J.. Pt., — , 148th 
Pennsylvania. 

Pittce. R., Corp'l, F, 50th 
New York. 



Ports, I. A., Pt., D, 27th , Oct. 3, 
Ohio. ' 12, '62. 

Price, G., Pt., C, 2d July 2. 2. 
Delaware. 1863. 



Rayser.J.J., Pt.. B, 14th 
Penn. Cav., age 40. 



Injury, Operator, and 
Result. 



Sept. 19, Left thigh, severing fein. art. and 

28, '64. vein: luem : amp. thigh. by Surg. 

G. M. Burditt, P. A. (J. s" Died 

Sept. 28, shock opera and gang. 

Feb. 10. Right thigh: exten. suppii n. knee 

.Mar. 11, joint inv.; cire., lower third, bv 

1865. Surg. A. II. Thurston. I'. S. V. 

Died March 14, 1865, irritative 

fever, shock. 

May 30. Left leg: July 3. beam.; ligation 

July 8, of posterior tibial artery; amp. 

1864. thigh. Died July *3, 1864. 
Dec. 31, Left thigh: amp. thigh at lower 
•62, Ap'l third. Disch'd Aug. 26, 1863. 

4. '63. 
Julv 21, Left popliteal space: gang.: amp. 
28,"'64. of thigh, bv Surg. E. J. Buck. 
18th Wis. Disch'd April26. '65. 
Aug. 9, Right popliteal space: amp. right 
Sept. 15, thigh, by A. A. Surg. T. B. 
1862. Townsend. Disch'd June 17/64. 

Jan. 21, Right leg. severing ant. tibial art. 
24, '64. and nerve ; mortification j amp. 
thigh, by Surg. A. C. Van Dozen, 
U. S. V. Disch'd Nov. 14. 64. 
Aug. 30, Left knee; circ, lower third, by 
'62, Feb. Asst. Surg. E.J. Marsh, U.S.A. 
7/63. Jul. Re-amp., bv Prof. W. Parker. 
— , 1864. Recovery. 'Spec. 1054. 
Sept. 17, Right knee: amp. post flap. up. 
Nov. 24, third, by Surg. II. S. Ilewit, U. 
1862. S. \'.; necrosis. Disch'd April 
12,1864. Spec. 754. 
May 12, Left leg, injuring saphenous vein j 
12, '64. gangrene; amp. thigh at lower 
third. Died May 18. 'til. 

June 24, Left ki ; eire., mid. third, by 

Aug. 14, Surg. E. Bentlev, U. S. V. To 

1864. | duty I 9. 1864. 

Sept. J, Right loir. perioral 'g ant. lih.art'v; 

I 14. '62. amp. thigh. Disch'd Dec. 4. '62. 

June 17, Left leg; gang.; amp. thigh, bv 

July 20, A. A. Sure. (1. Badger. Died 

' 1864. July 20, 1864. 

Oct. 19, Left leg; gang, and liaun.: amp. 

Nov. 13, thigh, by A. A. Sitrg. F. F. Mur- 

1864. dock. Died Dec. Hi. 'til. pyaemia. 

Aug. 18, Left leg: gang.: amp. thigh, by 

Oct. 6. A. A. Surg. j. P. Arthur. Died 

1864. Oct. 7, '64. Spec. 3280, A.M. M. 
Dec. 16, Left leg: gang.: thigh amp., by 
Jan. 22, Surg. R. II. Gilbert, U. S. V. 

1865. Died Feb. 9. '65. pyaemia. 
Sept. 19, Right knee; abscess': circ, lower 
Nov. 14, ! third, bv Surg. B. M. Cromwell, 

1864. | C. S. A. Died Nov. 14, 1864. 
July 25. | Left leg: gang.: amp. leg, bv A. 
Nov. 11, Surg. W.lS.Trull. U.S.V. Nov.9, 
1864. diffused aneur. in popiit'l region; 
litems.: amp. thigh, by Dr. Trull; 
lueins. from and ligation of fern. 
artery. Disch'd June 25, '65. 
Sept. 19. Left leg: knee joint opened by 
Nov. 14, i ulceration: ami), thigh, by Asst. 
1864. I Surg. N. F. ( iraliam. U. S. \ r . 
I Died Dec. 7. '64. pyaemia. 
June 30. ! Right leg ; sloughing and hffinl.; 
Aug. 4, | amp. thigh at lower third, bv A. 
1864. ! A. Surg. S. c. Ayres. Died 
Aug. 14. '64. atnrmia. 
May 1, ! Left popliteal region secondarily 

20, '63. involv'g popliteal artery: lupin.; 

amp. thigh, bv A. A. Surg. L. 
Dyer. Died Slay 29, '63. 
Sept, 16, Post. tib. art. cut bv ball ; incip. 
16, '62. mort.: amp. thigh, by R. T.Cole- 
man, chief surg. Gen. Stonewall 
Jackson's Corps. Recovered. 
Slav 3, Thigh : aneurism : amp. up. third. 

21, '63. by Surg. C. S. Wood, With New- 

York. Died May 21, 1863. 
Dec. 11, Popliteal space, destroying popli- 
11, '62. teal vessels and nerves: hsem.; 
amp. thigh. Died Dec. 12, 62. 
Perfor. right popiit'l space: gang.; 
amp. thigh. Discii'd April 7, '63. 
Left foot and leg : gang.: primary 
amp. thigh, bv Sure- C.S.Wood, 
66th N. Y. Died July — , 'fi& 
Oct. 19, Right knee: joint opened by in- 
Nov. 8, ■ flam.: amp. post. flap. mid. third, 
1864. | bv A. A. Surg. A. W. Emory. 
Died Nov. 8, 1864. 



' Eve (P. P.), Cases of Secondary Hemorrhage, etc., in Surff. Mem. of the War of the Rebellion, XT. S. San. Comm., 1870, Vol. I (Surgical) p. 210. 
2 LTDELL (J. A.), op.cit., p. 61. ZIbid.. p. 57. 4 BRYAN (J). Amputation of Left Thigh, upper third, in Am. Med. Times, Vol. VII, p. 5. 

COLEMAN (R. T.), Items of Army Experience, in Virginia Clinical Record, 1872, Vol. II, p. 141. 



56 



INJURIES OK THE LOWER EXTREMITIES. 



[CHAP. X 



SO. 


NAME, MILITARY 


Dates. 


IXJUIIT, l tl'ERATOH, AM' 


No. 


Name. MILITARY 


Description, axd Aoe. 


RESULT. 


DESCRIPTION, AND Aid:. 


99 


Rennick, L., l't.. I. SCth 


Sept. 1!>, 


Right thigh : profuse suppiiratii ; 


110 


Spencer, C, Capt., I, 1st 




Missouri. 


Dee. 30, 

1862. 


amp. thigh. Died Dec. 31, '62. 
pyaemia. 




Michigan. 


100 


Rickard, ,T. 11.. I't.. D, 


Jan. 27, 


Right thigh : ulceration popliteal 


117 


Stark, (). II., Serg't, H, 




1st Alabama Cavalry. 


Feb. 28. 


art.: liiBm.: thigh amp., by Surg. 




13th New Hampshire, 






1804. 


J. U.Keenon, U.S.V. Died Feb. 
29, '04. exhaustion from luem. 




age oo. 


101 


Robericht, C I't.. li, 


July IP, 


Kxtt'tis. laee. right leg. Diseh'd 


118 


Sultz. S. A., l't., B, 1st 




48th New York, age 44. 


'03, Mar. 

15, '05. 


Aug. 2 J. '01 : flap amp. thigh, by 
Dr. L. Ratter, of lironklvn. Died 
Aug, 23. I, -71. 
I, oft log: necrosis; thigh at mid. 




.Missouri, age 25. 


102 


Rolf. L. F.. I't., M, 1st 


June 18. 


119 


Taylor, James, l't,, K, 




Maine Artillery. 


'04. June 


third, by Dr. J. C. Manson. 




7t'h New York Heavy 






30, '00. 


Recovery. 




Artillery, age 22. 


103 


Roork, E. P., Pt., F, 3d 


Nov. 27, 


Right popliteal nerve and artery 


120 


Thorn, II. C, Pt„ 1, 14th 




Pennsylvania Cavalry, 


Dec. C, 


severed; thigh amp., bv Surg. 




West Virginia, age 19. 




age 22. 


1803. 


E. Bentlev, V. S. V. Diseh'd 












June 18. 1804. 


121 


Townsend, E., Pt., F, 


104 


Root, II. V.. Pt„ B. 104th 


June 22. 


Right leg: gang.: necrosis j Oct. 




5th New Hampshire, 




New York, age 20. 


'til. Feb. 


29, remov. of 10 inches necrosed 




age 35. 






29, 05. 


tibia: thigh amp. Diseh'd July 












21, 05. Sptc. 3G01, A. M. M. 


122 


Trees. J., Corporal, D, 


105 


lioxce, G., Pt., B, Cist 


July 9, 


Right knee: gangrene, involving 




188th Peau., age 21. 




Georgia, age 32. 


Aug. 5, 


joint: tliirrh amp., bv A. A. Surg. 










1804. 


J. II. Coover. Died Aug. 7, '04. 
Spec. 3809, A. M. M. 


123 


Yann. D., Pt., B, 8th N. 
York Artillery, age 18. 


106 


Royaler, J. M., Pt., C, 


July I , 


Lett thigh: amp. thigh, by A. A. 








47tli North Carolina, 


20, '03. 


Surg. (1. M. l'aullin. Died July 








age 29. 




29, 1803. Sprc. 3901, A. M. M. 






107 


'Schatt, II., Corp'l, II. 


Mar. 25, 


I.eft thigh, dividing popliteal art.: 


124 


Waller, J. R., Corp'l, A, 




64th New York, ago HO. 


April 8, 
1805. 


nmp. thigh, by A. A. Surg. II. 
Craft. Diseh'd Sept. 20. 1865. 




lpth Infantry, age 17. 








Sperx. 171, 2283. A. M. M. 


125 


Watson, .7. II.. l't., B, 


108 


Shugert. J.I,., Corp'l. !!. 


April 1. 


Right knee: second, disease. joint ; 




loth N. Jersey, age 30. 




49i'h Penn., age 20. 


Mav 20, 
1 805. 


nmp. thigh at low. third, by A. 
A. Surg.W.B. Chambers: litem.; 












May 21, lig. femoral. Died May 


120 


Whit*, J. L., Guerilla, 








25, 05. oxh'n from hemorrhage. 




age 38. 


109 


Shape, J., I't., I), 4'.Uh 


Dec. 15. 


Lett leg, amp. thigh. Died Jan. 








Ohio. 


15, '04. 


1 . L8ii:>. gangrene. 


127 


Wick, J. C., Pt.,C, 155th 


110 


Simpson, P.. I't . I', 3Gth 


Sept. 20, 


Left Ihigh: amp. thigh. Died 




Perm., age 22. 




Colored Troops, age 21!. 


If 04. 


Oct. 22. '04. exhaustion. 






III 


Slanker, .1., Pt., C. 102,1 


Juno ll 1 . 


I.eft thigh, injuring poplit'Iart'y; 








Ohio N. (i. 


Julv2. 


gang.; amp. thigh. bv A.A.Surg. 


128 


Wild. C. B.. Corp'l. E. 






1804. 


W. 11. linny. Died July 2, '04, 
12 li.»t us after oper'n. from shock. 




114th New York. 


112 


Sloss, A., I't., A, 5th 


Dee. 10, 


Left knee; destrttc. ol tissue: amp. 








Penn., age 35. 


'04, June 


jnnot. low. thirds, by Asst. Surg. 










10, '05. 


J. 11. 1'rautz. Dis.' Nov. 22, '05. 


129 


Wing. J. W.,Pt.,H,27th 


113 


Smith, .1. A., Pt..C, 4th 


May 14, 


Right knee; seeond. invulv. joint ; 




Mass., age 45. 




Maryland, age 18. 


June 9, 


amp. of thigh, by A.Surg. A. In 










1864. 


gram.C.S.A. Disc'd Mar.23,'65. 


130 


Wolf, J., Corp'l, I), 4th 


!! 1 


Smith, W.P., Major, 1st 


Oct. 27, 


R'ht thigh; lig. feni. art. anil vein; 




New York Cavalry. 




Delaware. 


27, '04. 


iitnp.1h.,bv Surg. A. N.Dougher- 












ty. 1'. S.Y. Died Nov. 0. 1804. 


131 


Wright, D., l't., A. 57th 


113 


Spalding, J. K., Pt., C, 


Aug. 30, 


I.eft popliteal artery severed ; 




New York, age 23, 




35th New York, age 30. 


Sept. 12, 

1802. 


atnp'n thigh. Died same day, 
from haemorrhage. 







Injury, Operator., axd 
Result. 



Julv 2, 
Dec! 28,' 

1803. 

Sept. 29, 

'64. Jan. 

•■'., '05. 

Nov. 30, 
'04, Feb. 

7, '05. 

June 10. 

04. Jan. 

17, '65. 
July 20, 

Aug. 7, 
1804. 

June 2, 

21, '04. 



June 2, 
28, '04. 

June 3, 
20, '64. 



July 30, 
Oct. 25, 

1804. 
June 4, 
24, '04. 



Mav — , 
1803, 

Primary. 

Mar. 25, 

June 14, 
18C5. 

Sept. 19, 

Oct. 12, 

1804. 



Mar. 14. 
April 7, 

1802. 
Oct. 12, 
Nov. 20. 

1803. 
Sept. 17 
Dee. 2, 

1802. 



amp. thigh, by A. A. Surg.D.O. 

l-'arrand. Diseh'd May Hi. '04. 

Right leg; sloughing: Dec. 25, 

amp. leg; reamp. in thigh, by A. 

A. Surg. II. H.James; haun.; 
art'ylig. Diedjan.l3,'65,pysem. 

Right thigh ; gang.: popliteal art. 
sloughed ; amp. thigh, bv Surg. 

B. B. Breed, II. S. V. Died Feb. 
10, 1805, exhaustion. 

Left leg: thigh amp., by A. A. 

Surg. E. J. Farwell. Diseh'd 

July 0. 1805. 
Right thigh; Aug. 7, hem.; lig. 

fern.; amp. thigh, bv Surg. J. 11. 

Lewis, U S.V. Died Aug. 12,'64. 
Leltknee ; joint ope. by uleerat'n; 

amp. post. tlap. upper third, by 

Surg. E. Ilentlcy.U.S. V.; hsem.; 

lig'n. DiedJuly 1, '64, asthenia. 
Right knee. June 20, hasiu.; pop. 

liteal flaps, mid. third. Diseh'd 

Dec. 8, 1804. 
Left thigh, injuring popliteal art.; 

ha?in.: Juno 10, popliteal lig.; 

hsem. recurred : amp. thigh, by 

A. A. Surg. E. Vogel. Died 

June 22, '04, gangrene. 
Right knee: gang,: thigh amp., 

by A. A. Surgeon M. L. Herr. 

Died Nov. 5, '04, pyaemia. 
Left knee ; joint ope. by suppu'n ; 

muscular flaps, mid. third, by 

Surg. E. Bentley, U.S.V. Died 

June 28, 1804, exhaustion. 
Both legs perforated; left post. 

tibial art. and nerve completely 

sev'd; gang.: amj). thi Reeov'd. 
Both thighs; May 23, luem from 

left popliteal ; lig'n ; amp. thigh, 

by A. Surg. A. Delaney. U.S.V. 

Died June 20, '05. exhaustion. 
Right popliteal space: Oct. 1. 

litem, from popliteal arterj : lig.: 

amp. thigh, bv Asst. Surg. R.A. 

Fordyee. 160th N. York Died 

Oct. 13, 1804, exhaustion. 
Right leg; gangrene: amp. thigh. 

bv Surg. (1. A. Otis, 27th Mass. 

Died April 17, 1862, exhaustion. 
Left thigh : gang.: amp. thigh, by 

A. A. Surgeon J. F. Thompson. 

Diseh'd Oct. 11, 1804. 
Right thigh; gang.; amp. thigh. 

by A. A. Surg. A. V. Chorbou 

nier. Died Dee. 20. '02. gang. 

Spec. 888, A. M. M. 



Amputations at the Knee. — But one of the six disarticulations at the knee for com- 
plications involving shot flesh wounds of the leg had a favorahle result. Three of the 
operations were intermediary, three secondary: 

Table V.IT. 

Numerical Statement of Six Disarticulations at the Knee Joint for Complicated Shot Injuries unattended 

by Fracture. 



No. 


Name, military 


Dates. 


INJURY, Operator., and 


No. 


Name, Military 


Dates. 


Injury, Operator, and 


DEscitirnoN", axd Aoe. 


Resoi.t. 


Description, axd ace. 


Result. 


1 


Cole. D. D.. Corp']. A. 


April 7. 


Leftleg; gang.: amp at the knee 


4 


Huntington, I.. Pt., B, 


June 3. 


Leftleg; slough'g: reeur't luem.: 




2d New York Cavalry, 


Aug. I, 


joint, patella retained, by Ass't 




92d New York, age 29. 


Aug. 2. 


amp. at knee joint, by Surg. R. 




age 23. 


1865. 


Surg. G. M. MoGill, U. S. A. 

Diseh'd Nov. 22. 1865. 






1804. 


B. Bontecou, D. S. Y. Died 

Aug. 8. 1804, exhaustion. Card 


n 


Dempsev. M.I't., I. 17th 


Oct. 5, 


Left leg : obliteration of fern, art., 








Pluit, Vol. HI, p. 23. 




Vermont, age 18. 


Deo. 27. 


sloughing, and recurrent luem.: 


5 


Leonard, J.. Pt.. (I. 5th 


Julv 3. 


Right leg. injur 'g post, tih. nerve : 






1804. 


amp. at knee joint, by Ass't Sur- 
geon W. A. Harvey, U. S. V. 
Died March 26, 1805; 




Ohio, age 22. 


10, '03. 


tetanus; atnp. tit knee joint, bv 
Ass't Surg. 11. C. May, 145th N. 
Y. Died; July 16. '03. tetanus. 


3 


Crimes. F. A., Pt., C, 


April 16. 


Right leg, injuring popliteal art.: 





Taggart. S. D.. Serg't. 


Feb. 0, 


Left leg; gang.: recurrent lueni.; 




4th \ ermont, age 22. 


22, '62. 


litem.: atnp. at knee joint, by 
Surg. R. B. Bontecott. U. S. V.; 
gang. Died April 28, 1862. 




(1, loOth Pennsylvania, 
age 25. 


20, '05. 


amp. tit knee joint, byAss t Surg. 
J. Vansant. IF. S. A. Died Feb- 
ruary 20, 1865. 



1 LlDELt. (J. A.), op.cit., p. 47. 



SECT. 1. 1 



AMPUTATIONS IN TIIK LEG FOR SHOT FLESH WOUNDS. 



57 



Amputations in the Leg. — Of sixty-three operations in this category thirty-three 
proved fatal, or 52.8 per cent. Two primary cases were successful : ol twenty-four inter- 
mediary operations, seventeen, or 70.8 per cent., proved fatal; ol thirty- 
secondary amputations, sixteen, or 43.2 per cent., proved fatal. The Mi 

possesses pathological specimens from some of the cases. Two "I 
are detailed, and all are enumerated in Table VIII: 

Case 126.— The late Dr. Bodisco Williams, of Georgetown, D. C, who served in tin' Confederate Army, 

presented Acting Assistant Surgeon F. Schafhirt, of the Army Medical Museum, with the specimen figured below, 

with the accompanying history : " Rev. J. L , a young priest from New Orleans, acting voluntarily as field 

chaplain, tried to persuade a company of Irish railway laborers to take up arms to fight against the Yankees in 



-even 
useum 

cases 



Fig. 22.— si* 

Inches of shaft 
of the left tibia, 
carious and erw 
.led. Spec. 858. 



front of Fredericksburg, December VZ, 1802; but during his speech a large shell exploded close in front of the 
group and killed three and wounded eight, including the priest, who received a small skin wound over the 

inner surface of the left tibia, about five inches above the tarsal articulation. Rev. L did not take much 

notice of the wound until the leg was in full inflammation up to the knee. He had returned to Lynchburg, 
where he applied bread and milk poultices for several weeks, but afterwards he sent for a physician, who 
exerted all his knowledge to save the leg. Hut nothing would avail, anil caries of the bone having supervened, 
gangrene at last reminded the attendant of amputation, which was performed by Dr. Pearson, of \ irginia, who 
took the leg off one inch below the tuberosity of the tibia. August ~'.">. 1863. But even this remedy did not 
improve the physical health of the patient; and his soul left Lynchburg, September 2, 1863, for that great and 
blissful haven, it may be hoped, which he had promised to those Irishmen in front of Fredericksburg.' The 
specimen represented in the adjacent wood-cut (FlO. '2'2) presents great erosion, as though from caustic 
applications made to arrest the progress of gangrene, and there are neighboring evidences of extensive periosteal 
thickening with osseous exudations and deposits. See Cat Surg. Sect., Army Medical Museum, 1863, p. 394. 

Case 1'27. — Private G. Brown, Co. C, 97th Pennsylvania, aged 18 years, was wounded at Petersburg, dune 17. 1864, 
and was admitted to hospital at Fort Monroe two days afterwards. Assistant Surgeon F. McClellan, IT. S. A., reported: 
"Gunshot wound of right foot, flesh." From Fort Monroe the wounded man was transferred to Knight Hospital. New Haven, 
where amputation was performed but not recorded. Subsequently the patient was transferred to 
McDougall Hospital, and lastly, on .January I'd, 1865, to Central Park, New York City, whence 
Surgeon 1!. A. Clements, U. S. A., reported: "Gunshot wound of light foot; a uiinic hall passed 
through the metatarsus, entering on the dorsum of the fool. Mortification supervened and the 
condition of the injured parts became very bad; constitutional condition of patient feeble; loss of 
appetite; unable to sleep from pain in wound. On July 11th, amputation (apparently circular) of the 
leg just above the ankle joint was performed at the Knight Hospital, New Haven, by Acting Assistant 
Surgeon C. Lindsley. Two ligatures were applied, and ether was used as the anaesthetic. Healing 
progressed well for three weeks, when the stump sloughed, which was arrested in four or five days." 
The specimen represented in the annexed wood-cut (FlG. 23) was contributed by Acting Assistant 
Surgeon S. Teats, who performed re-amputation on April 16, 1S(>.">, on account of "a sloughing ulcer 
and a cold and blue condition of the stump." The stum]) healed at the end of five weeks after the 
last operation, and the patient was supplied with an artificial leg about two months afterwards. He 
was discharged from service August 17, 1865, and pensioned. In his application for commutation, 
dated 187"), the pensioner described the stump as being in good condition. He was paid bis pension June 4, 1876. 




Fig. 23.— Two and a half 
inches of stump of right leg. 
Spec. 4329. 



Table VIII. 

Summary of Sixty-three Qises of Amputations of tlie Leg for Complicated Shot Injuries unattended by 

Fracture. 



No. 


Name, Military 


Dates. 


INJURY, OPERATOR, AM) 


., | Name, Military 

■ Description, AXD Ace. 


Dates. 


Injury, Operator, ash 


DESCRIPTION, AX1) Aoe. 


Result. 


result. 


1 


Addington, .L.Serg't, A, 


June 20, 


Uight ankle: gangrene; amputa- 


Batherie, N. TV, Corp'l. 


June 6, 


Left leg; gang.: amp. leg, by A. 




84th Indiana, age 25. 


July 2D, 

1804. 


tion leg. by Surg 1!. M. s. .lark- 
son, V. 6.V. Died Sept. 2. 1864, 
pva?mia. 


A, 15th Mass., age 34. 

1 


24, '64. 


A. Surgeon M. F. Price : ha?m. 
Died June 30. '64. asthenia from 
wound, and diarrhcea. 


2 


Ainsworth.W.IL.Serg't. 


Hay <i. 


Iiight leg; amp. leg. by Surg. 


7 | Becker. 11., Pt., P, 50th 


May '.). 


Right leg; sloughing: amp. leg. 




K, 43d Now York, age 


June 2.1, 


W. D. Stewart. U. S.V. Diseh'd 




Penn., age 28. 


Aug. 10, 


by A. A. Surgeon <;. E. Galea. 




22. 


18(14. 


Nov. 3. 1865. 






1864. 


Disch 'd Slav 22. 1805. 


3 


Alexander. E. J., Corp 1, 


June 14. 


Right leg; amp. of leg. Died 


8 


Bell, J., Corp'l. O. 6Sth 


Dec. 13, 


Left leg ; sloughing ; h;pni.: amp. 




B. 1 10th New York. 


— , '(13. 


Julv 2, 1863. 




Penn., age 40. 


'02. Mar. 


leg, bv A. A. Surg. F. II. Oet- 


-1 


rsamum. 0. P., Pt., E, 


June 18, 


Left leg : amp. leg, hv A.A.Surg. 






Ill, '63. 


chell. Diseh'd Dec. 14, 1863. 




187th Penn., uge 30. 


Aug. 27, 


J. P. Arthur; htrm.: Sept. 7, 


9 


Bicklcv, 11.. Serg't. E, 


May 14, 


Left ; slough ; ami*, leg, by A. A. 






1864. 


amp. thigh. Died Oct. 13. 1861. 


luth New Jorscv, age 


Aug. 13. 


Surg. C W.^'ebb; ha'm. Died 








Spcc.ZMS, A. M. M. 




21. 


1864. 


Aug. 23, '64. Spec. 3005, A.M. M. 


5 


Barron, C, Pt., D, 14IU 


May 12, 


Left foot ; gang.: amp. leg. by A. 


10 


Bloomer, A. S., Pt.. O, 


May 15, 


Right foot ; gang.; amp. leg, bv 




Connecticut, age 45. 


Sept. 10, 


A. Surgeon S. Smith. Disch d 
June 18. 1865. 




55th Ohio, age 20. 


Julv 21. 


Ass t Surg. J. A. Freeman, V. 






1864. 






18G4. 


S. V. Diseh'd Feb. 10. 1865. 



Suito. Ill— * 



58 



INJURIES OF THE LOWER EXTREMITIES. 



[CHAP. X. 



Name, Military 
description', am) aoe. 



Drown, «>.. rt., C, 97th 
Penn.. ago 18. 



Bor&a, a., Serg't, C, 
155th N. York, age 51. 

Barley. 31. !">., I't . G, 

4.»ih Penn.. ago i?. 

Burns. T., Ft., n, 8th N. 

Vi r'.c II. Art'rv. age 34. 
Case. E P., I't".. O, nth 

Michigan. 



Cousins. J. A.. Corp'l, 
I. 1st Slaine If'vy Art., 
age i>4. 

Cross. G. P.. Pt.. F, 1st 
Mass. Heavy Artillery, 

age 10. 

Dixon, J. II, Pt.. K, 24th 
N. Carolina, ago 24. 

Downey, J., Pt., F. 29th 
Penn., age 30. 

Emery, R., Pt.. I). . r >tli 
Yermont, age 33. 

Gilbert. G. II.. Lieut.. II, 

122U New York. 



Goooh, A. B., Pt., P, 

12th Ohio, ago 21. 

Goodell. E D.. Corp'l, 
D, 25th .Massachusetts, 
age 21. 

Goodrich, .1.. Pt., (1. 
148th N. Yurk. age 40. 

Green, J. A.. Serg't. P.. 

2d Connecticut Art'ry, 

age 2j. 
Gutting. A.. Pt„ D, Uth 

Mich. Cavalry, age 96. 

Hagey, J. 1>., Pt., I. 

138th Peun., age 24. 



Harris. J. SI., Corp'l, C. 
14th Iowa, age 20. 



Hays, A.. Corp'l, P, 3d 
Delaware, age 20. 



James, A, Pt.. I, 2d Ten- 
nessee Cavalry, age 20. 

Kane, H„ Pt., A, 24th 
Iowa, ago 25. 

'Knoble, H.,Pt.,D,149th 

New York, age 27. 

Kuentzler, J., Pt., H, 
56th Penn.. age 24. 

Leasure, J.. Pt., F. 62d 
Penn., age 23. 

L J , Chaplain 

(field). 

McCurley, H., I't.. D, 
1st Maine, age 18. 



Maguire, E., Pt.. I. 8th 
Conn., age 26. 



Dates. 



Juno 17, 
Julv 11. 
04,'Ap'l 

16. '65. 
June 3, 
Aug. 26, 

1864. 
May (i. 
Sept. 13. 

1864. 
June 17, 

17. '64. 
Sept. 19. 
24, '63. 



May 19. 

June 16, 

18.14. 

June 16, 

Aug. 18. 

1864. 

Mar. 25. 
April 12, 

18&». 

May 15, 
Julv 13, 

1854. 
M'v5.'64. 
Aug. 28, 

13(i5. 

N'nv. 8, 

Dec. 7. 

1863. 

May 9. 

Nov. 19. 

1864. 

Juno 3. 

Julv 22. 

1864. 

May 9, 
Juno 5, 
1864. 
June 7. 
28. '64. 

Oct. 2, 
Nov. 9, 

1864. 
April 2, 
May 19, 

1865. 

July 15, 
27. ''64 



Juno 18, 

Aug. 10. 

18C4. 

Dec. 17, 

'64. Feb. 

4, '65. 

Sept. 19. 
Deo. 30, 

1864. 
Nov. 27, 
Dec. 14, 

1863. 

June 18, 
Julv 2.!. 

1864. 
May 12, 
June 2, 

1864. 
Dec. 11, 
'62. Aug. 
25, '63. 
June 21. 
July 23. 

1864. 

Sept. 29. 

1864. 
Mar. 22. 

1865. 



INJI'UV, OrEUATOR, AM) 

Result. 



Right foot: gang.: amp. just above 

ankle, by A. A Surg. Limlslcv; 

sloughing: reamp. leg. Disoh d 

Aug. >8,'U5. .V/w. 4329. A.M.. M. 
Right leg; sloughing; amp. leg, 

by A. A. Surgeon M. Lampeu. 

Died Aug. 27. 1864, pyaemia. 
Itiglit leg': amp, leg, by A. A. 

Surg. IV. Wilson, gang.; hann. 

Disch'tl Jan. 2.'. ISim. 
Right leg: amp. log. Discharged 

June 2U. 1865. 
Left thigh, sevo'gfem. art.: gang.: 

amp below knee; gang, extend- 
ing; Sept. 25. amp. at up. third 

thigh. Died Sept. '.7. 63. gang. 
Lett foot: slonghingnnd crysipe- 

Ions : flap amp. at up. third, by 

Dr. SleCunnor. Disch'd July 

10, 1865. 
Right leg : gang.: hsem.: amp. leg, 

by Surg. E. Bentlcy. V . S. V.: 

two ounces of blood injected into 

veins. Disch'd Juno 9, '65. 
Right leg: gang.: amp. leg. by 

A. A. Surg. J. P. Arthur. Died 

May 4. 1865. exhaustion. 
Left leg; caries; amp. leg. by 

Ass't Surg. II. '1. Legler.U.S.V. 

Disch'd Sept 1, 1864. 
Left leg; gang.; hiem.; Aug. 4, 

18.il. post, tibial lig'n. Disch'd 

Dec. 10. '64; log amp. 
Both feet contused by spent ball ; 

gang, left foot ; amp. left leg. by 

Surg. II. YV. Dueaehet. I*. S.Y. 

Disch'd May 23, 1804. 
Left ankle; caries inv.ank. joint: 

flap amp. mid. third, by Surg. 

N. (lay. (J. S. Y. Disch'd Feb. 

13. 1865. 
Itiglit foot: gangrene; amp. leg. 

by A. A. Surg. B. F. Butcher. 

Disch'd Oct. 31, '65. Spec . 3:33.!, 

A. M. M. 
lloth ankles: gang.; amp, right 

log. by Ass't Surg. 11. C. Roberts. 

U. S.Y. Died Juno 5, '64. oxh'n. 
Left foot : eirc. amp. up. third leg. 

by A. A. Surg. P. Wilson. Died 

July 7. 1864. pyaemia. 
Right leg: amp. leg. by Surg. J. 

I). Murphy. U. S. A.' Disch'd 

Sept. 14. 1865. 
Left log; artery opened: hsem. 

from post, tibial artery: art. tied; 

amp. leg. by A. A. Surg. II. A. 

Drane. Disch'd July 26. 'Ho. 
Right thigh: aneurism: sphacelus: 

ati'mal sac probed: execs, lue.m ; 

fern, tied: amp. leg. by A. A. 

Surg. R. W. Coale. Died Aug. 

3. 1864, pj-aemia. 
Right foot : slough'g uleer : amp. 

leg. by A. A. Surgeon W. W, 

Sharpie v. Disch'd May 18, '65. 

Spec. 3668, A. M. M. 
Left ankle: ball removed: gang.; 

circ. amp. lower third leg. by 

Ass't Surg. W. B. Trull, IJ. S.Y. 

Died May 16, 1865. 
Left leg; gangrene: amp. leg. by 

A. A. Surg. J. W. H. Baker. DiS 

charged May 29. 1865. 
Botti thighs, ball impinging on 

sheath ot'left fern, artery: gang.: 

amp. left thigh. Died' Jan. 14, 

'64, pyaemia. Spec. 2114, A.M.M. 
Itiglit leg : sloughing: amp. leg, 

by A. A. Surg. E. K. Tell. Died 

Aug. 6, 1864, pyaemia. 
Left leg: hfem. ; amp. leg. by A. 

A. Surg. John Priestley. Died 

June 15. '64, haein. and pyaemia. 
Left leg; gang.: amp. leg. by Dr. 

Pearson. Died Sept. 2, '1863. 

Spec. 858. A. M. M. 
Right ankle; gang.; circ. amp. 

mid. third, by A. A. Surg. (1. E. 

Brickctt. Died Aug. 28, 1864, 

pyaemia. 
Right leg: gang.; ulceration of 

ante, tibial art.: amp. leg, by A. 

A. Surg. W. B. Casey. Disch'd 

Nov. 28. 1865. 



49 



i 
56 



Name, Military 
Description, and Age 



60 



Siangan, J.. Pt., F. 82d 
Ohio, age '-8. 



Moudenhall, J., I't., B, 
97th Penn., age 30. 

Moser. ('.. I't., K, 5th 
Michigan, ago 4.1. 

.Moss, B. P., Corp'l, B, 

101 st Illinois, age 43. 



Mott, J., Pt.. E, 105th 
Illinois, age 37. 



Paden, W., Corp'l. G, 
10th Penn. Reserves, 
age 22. 

Pannenter, J. D., Pt., 
(1, 67th Penn., age 16. 

Prather. P... Corp'l, D, 
103d Ohio, ago 18. 



Reed. J., Corp'l. P, 101st 
New York. 



Iioss, A. G.. Corp'l, I, 
loth Mississippi, age21. 

Saulsbury, W., Pt., K, 
3.1th Colored Troops, 
ago 36. 

Smith, W., Pt.. D, 17th 

Infantry, ago 22. 



Stark, O. 11., Serg't. II, 
13th New Hampshire, 
age 36. 

Stebbins. E., Serg't, L, 
3d New York Cavalry, 
age 26. 

Stultz, G., Serg't, K, 
5th New Jersey, age 26. 

Sullivan, D., Pt., F, 1st 
Penn. Rifles, age 23. 

Tawncy, A.,Pt„ D, 74th 

Indiana, age 38. 

Tewksbury. D., Pt., F, 
73d Ohio; age 22. 

Thompson, J. A., Corp'l, 
K. 10th Indiana, age 

27. 

Thornton, R. SI., Serg't, 
K, 4th Rhode Island, 
age 26. 

Tillotson, C. A., Pt., E, 
39th Iowa, age 32. 



Tryan, N.. Pt., E. 4th 
Ohio, age 26. 

Wares, D., Corp'l, 22d 
Massachusetts, age 31. 



61 Williams, C... Pt., II, 

j 29th Colored Troops, 
I age 37. 

62 ] Wolf, C, Corp'l, D, 5th 
I Minnesota, age 31. 

63 , Wright, E.,Pt., F, 119th 
Penn., age 18. 



Dates. 



July 20, 
22," '64. 



May 20. 
July 22. 

1864. 
June 18, 
July 10, 

1864. 
July 25, 
Aug. 24, 

1864. 



June 26. 

July 26, 

1864. 

Slay 23, 

June — , 

1864. 

April 6, 
June 21. 

1865. 
Dec. 15, 
27, '64. 



lune, '62. 
Interme- 
diary. 

Oct. 19, 

Nov. 8, 

1864. 

Julv 30, 
1864. 

Jan. 19, 
1865. 

May 12, 

July 8, 

1864. 

Sept. 29, 

Dec. 25, 

1864. 

Sept. 6, 
Oct. 12, 

1862. 
June 16, 
'64, Jan. 
9, '65. 
Dec. 13, 
29, '62. 

Sept. 19, 

Nov. 29, 

1863. 

July 2. 

'63, Ap'l 

8, '04. 

Aug. 3, 

Sept. 3, 

1864. 

July 30, 
Sept. 28, 

1864. 
Oct. 5, 
Dec. 25, 

1864. 

May 5, 
Julv 3, 
1864. 
Slay 5, 
20, '64. 

Sept. 27, 
Oct. 22, 

1864. 

Dec. 16, 

'64, Jan. 

5, '65. 

Slav 5, 
25, ''64. 



Injury, operator, and 
Result. 



Left leg; amp. leg. by Surg. II. 
K. Spooncr, tilsf Ohio; hsem.; 
lig.of anteiiortibial artery Aug. 
15, '04. Disch'd May 23,' '65. 

Right leg; sloughing; amp. leg, 
by A. A. Surgeon A. 1). Hall. 
Died July 29, 1864, pyaemia. 

Left ankle and thigh : gang. : amp. 
log. bv A. A. Surg. F. D Weisse. 
Died July 26, 1864, pyaemia. 

Left leg; gang.; amp. leg. bv A. 
Surg. W. li.Trnll. U. S.V.; dif- 
fused aneurism ; litem.; Nov. 11. 
amp. thigh ; huem.: Dec. 15, lig. 
fcm. Disch'd June 25, 1865. 

Lel't leg: slough, ant. tibial; hsem.; 
amp. leg, by Ass't Surg. B. E. 
Fryer. U. S. A.; July 27, trans- 
fusion. Died Aug. 5, '64. haein. 

Right thigh; Slay 29, 31, hsem.; 
June 1. femoral tied; amp. leg. 
by Surg. G. L. l'nnooast, U.S V. 
Died June 20, 1864. gangrene. 

Left foot ; gangrene and necrosis ; 
amp. leg. bv Surg. R. B. Bontc- 
cou, TJ.S.V. Disch'd Nov. 23, '65. 

Right foot: exe'nhalf in. post. til), 
nerve ; Dec. 26, amp. groat toe ; 
amp. leg, by A. A. Surg. S. O. 
Ayres. Died Dee. 29, '64, tetanus. 

Shot flesh w'nd of ank. joint ; circ. 
amp. at jnnct. of low. third leg, 
by Ass't Surg. P. S. Connor, If. 
s'. A. Died July 29. 1862. 

Right fern. art. injured ; also w'd 
of left thigh ; gang.; lig. (if fern.; 
amp. right leg three ins. above 
ankle. Retired .March 14, 1865. 

Rigltt leg; sloughing: hsem. ant. 
tibial art.; art. lig. in w'nd ;hsem. 
recur'd; art. relig.: amp. leg. by 
A. A. Surg. o. Shiftier. Disch'd 
Slay 26, '65. Died July 10. 71. 

Right ankle joint; suppurative in- 
flam'n, caries; amp. leg, by A. 
Surg A. Ingram, V. S. A. Died 
July 20, '64. Spec. 2865, A. SI. SI. 

Right ; slough.; amp. leg. by A. A. 
Surg.ILII James; sloug'g; Jan. 
3, 1865, amp. thigh; hsem.; lig. 
Died Jan. 13, '65, pyamiia. 

Lel't leg: haem.: amp. leg. Dis- 
charged June 15, 1863. 

Left leg; gang, and necrosis: amp. 

leg. bv Surg. E. Bentley.U.S.V. 

Left hospital April 18. '1865. 
Left foot; extensive inflammat'n ; 

amp. leg, by A. A. Surg. C. H. 

Bowen. Discharged. 
Left leg: hsem.; amp. leg. by Surg. 

(4. Grant. IT. S. V.; gang. Died 

Dec. 6, 1863, gangrene. 
Left leg.; gang.; amp. leg. by 

Surg. A. 3L Speer, U.S.Y. Died 

Slay 8, 1864, pyaemia. 
Left leg; gang.; amp leg. by A. 

A. Surg. A. L. Rice; haem. from 

popliteal artery; artery tied. 

Died Oct. 4, 1864. 
Lett leg; lisein.; amp. leg. by A. 

Surgeoa S. A. Orton, U. S. A. 

Disch'd January 28, 1865. 
Right ankle ; slough'g and hsem.; 

ant. post flap amp. at mid. third. 

by Ass't Surg. B. E. Fryer, U. 

S. A. Died Jan. 6, '65, pyaemia. 
Left foot; gang.; amp. leg, by A. 

A. Surg. A. SIcLetehie. Died 

Aug. 10, 1864, asthenia. 
Righfrleg; amp. leg. by Surg. D. 

W. "Bliss, U. S. V. Discharged 

October 25, 1664. 
Left leg ; haem.: amp. leg. by A. 

A. Surgeon J. II. Buchanan. 

Died Oct. 25, '04, exhaustion. 
Left leg, also wound of right leg ; 

amp. left leg. bv A. A. Surg. L. 

E. Tracy. Died Jan. 19, 1865, 

gangrene. 
Right leg, cutting post, tibial art.; 

gang.: haem.; May 22. lig.: hsem. 

recur'd; amp. leg. bv Surg. E. 

Bentley, U. S. V. Died Mayi8, 

1864, asthenia and pyaemia. 



1 LIDELL (J. A.), Wounds of the. Arteries, in Surg. Mem. of the War of the Rebellion, coll. and pub. by the V. S. San. C'omm., 1870, Vol. I, pp. 27, 551. 



SECT. I.] DEFORMITIES AFTER SHOT FLESH WOUNDS. 59 

Amputations of the Toes. — There was a single example of amputation of the great 
and second toes for gangrene following ligation of the femoral artery for a shot wound of 
the thigh. (Case 55 of Table III, p. 48.) 

Case 128. — Private J. L. Hunt, Co. G, 57th New York, aged 42 years, was wounded at tlie Wilderness, May 5, 18C.4. 
Assistant Surgeon J. C. McKeo, U. S. A., reported his admission to Lincoln Hospital, Washington, May 26th, with ••gunshot 
wound of left thigh.'' Two weeks afterwards the patient was transferred to Camden Street Hospital, Baltimore, and on 
October 23d he entered Mower Hospital, Philadelphia, where Acting Assistant Surgeon F. W. Saunders recorded the 
following: "A minie ball entered the thigh at the inner side, upper third, and, passing backward and outward behind the 
femur, emerged just below the tuberosity of the ischium. Deficient circulation from ligature or otherwise of the great trunks 
occasioned mortification in the foot, rendering necessary the amputation, previous to admission, on September 5th, of the first 
and second toes at the second joints." The patient was subsequently transferred to McDougall Hospital, New York Harbor, 
whence he was discharged June 5, 1865, Assistant Surgeon S. il. Orton, U. S. A., certifying, " the wound has been gangrenous ; 
extensive cicatrix remaining, causing great contraction of muscles; little use of leg." On June 1. 18G(i, the pensioner was 
supplied with a supporting anil extensor apparatus by Dr. E. D. Hudson, of New York, who in his statement reports the 
ligation as having been performed on "July 9." The New York City Examining Board certified, December 8. 1875: "There 
is a cicatrix five inches by four on inner side of left thigh, middle third, which is adherent and radiated. The femoral 
artery has been cut and tied. There is great loss of muscular substance. The great and second toes have sloughed away ; 
foot poorly nourished. Has to wear an artificial appliance to enable him to walk. There is considerable atrophy of muscles 
of the limb. The disability is equal to the loss of the limb." The pensioner was paid March 4, 1876. 

Tenotomy. — There were five examples of tenotomy for the relief of deformities result- 
ing from shot wounds of the lower extremities. The case of Sergeant Louis Morel] (Case 
243, Med. and Surg. Hist, of the War, Part II, Vol. II, Chap. VI, p. 80, and Plate V, 
Pig. I) has been detailed. In the case of Private H. B. Franklin, Co. E, 52d Indiana, 
aged 21, Surgeon A. Hammer, U. S. V., divided the tendo Achillis at the Marine Hospital, 
St. Louis, November 5, 1864, and relieved talipes of several months' standing. He was 
returned to duty January 24, 1865. 

Case 129. — Private J. H. Armidon, Co. I, 49th New York, aged 19 years, was admitted to Satterlee Hospital. Phil- 
adelphia, June 21, 1863. Acting Assistant Surgeon M. J. Perry reported: "The patient was received from hospital at 
Washington, suffering from diarrhoea. He had previously received a gunshot wound of the leg at the battle of Antietam. Leg 
bent almost on to thigh. The hamstring tendons were cut by Acting Assistant Surgeon T. G. Morton, formerly in charge of 
the ward. October 30th, leg much straighter; is obliged to walk with crutches. November 20th, is able to walk about 
with a cane; leg still a little bent. December 13th, wound nearly healed; general health good. January 1, 18j4, patient 
returned to duty, cured." Several weeks afterwards the man entered Augur Hospital, whence he was discharged for disability, 
February 10, 1864, Surgeon S. B. Hunt, U. S. V., certifying to " Shell wound of popliteal space of right leg. received at 
Chancellorsville, May 3, 1863, causing permanent lameness; still discharging." The Washington hospital records show that 
Armidon was "admitted to Lincoln Hospital on February 27. 1833, with intermittent fever," and that he "deserted June 20, 
1863," but no note was made of the wound. He is not a pensioner. 

Case 130. — Private T. Caswell, Co. C, 6th New Hampshire, aged 30 years, was wounded in the right leg, "at Bull 
Run, August 29, 1862. He was admitted to the Georgetown College Hospital, subsequently transferred to Satterlee, Philadel- 
phia, and lastly to Lovell, Portsmouth Grove. Assistant Surgeon W. F. Cormick, U. S. A., in charge of the latter, reported: 
"Wound healed with severe contraction of the tendo-achilles, resulting from extensive and repeated sloughing. On October 
5, 1863, tenotomy was performed, by dividing the tendo-achilles, by Acting Assistant Surgeon J. W. dishing. The wound 
caused by the operation healed by November 25th, and the splints, etc., were removed, the foot and ankle resuming their former 
positions and functions. On December 15th the patient was able to walk without crutch or cane. He was discharged from 
service December 30, 1833." Examiner W. G. Perry, of Exeter, N. H., February 17, 1864, certified: "Ball entered the out- 
side about midway between the knee and ankle joints, passing directly across the leg. * * There is contraction of the tendo- 
achilles, which has been partially relieved by division, but he cannot bring his heel entirely down. Standing causes pain." In 
October, 1869, he reported that contraction in the use of the leg had produced irritation of the eschar, resulting in ulceration. 
Examiner E. B. Hammond stated, September 11, 1875: "The foot is reduced in size, the leg is weak, etc." The pensioner 
was paid June 4, 1876. 

The fifth case in which tenotomy was practised has been already noted as 27 of Table 
VI, on page 54, amputation being resorted to twelve years after the reception of the injury 
on account of the uselessness.of the limb. 

Case 131. — Private T. Cooper, Co. C, 4th Pennsylvania Reserves, aged 18 years, was wounded near White Sulphur 
Springs, June 22, 1864. He was admitted to the Post Hospital at Beverly, and, on August 8th, transferred to the Grafton 
Hospital. Surgeon S. N. Sherman reported : " Gunshot wound of left thigh; ball entered two inches above knee, on outer side, 
exit near tuberosity of the ischium; also flesh wound of middle of leg. December 31st, leg flexed at nearly right angle to the 
thigh, caused principally by contraction of the semimembranosus and semiteudiuosus ; motion of knee joint perfect; consid- 



60 INJURIES OF THE LOWER EXTREMITIES. [CHAP, x 

erable talipes varus, though without anchylosis. Subcutaneous division of the hamstring tendons performed by Surgeon S. N. 
Sherman, U. S. V.; chloroform used. Patient reacted promptly, being in good health, though of rather delicate constitution. 
After division of the tendons the leg was forcibly extended and secured to a straight splint, extending from nates to heel. 
Twenty-four hours after operation patient rested quite easy and entirely free from pain." The patient was furloughed on April 
11, 186,"), and admitted to the Emory Hospital, Washington, several weeks afterwards. On June 23, 1865, he was discharged 
by reason of "paralysis and deformity of the left leg caused by the wound," and pensioned. The man subsequently removed 
to Birmingham, England, where, in December, 1870, he was seen by Mr. J. B. Gould, the U. S. Consul, who described his 
condition as follows: "His left leg and foot are withered, the foot icy cold and curled up like a bird's claw, and the leg with- 
ered and dead to the hip joint," etc. About this time the pensioner was also examined by Surgeon Jos. Morris, M. K. C. S., 
who certified : "I find him suffering from the effects of a gunshot wound of the left thigh. The sciatic nerve has been injured, 
and the entire limb rendered permanently and entirely useless. He suffers great pain in the injured limb," etc. This certificate 
was corroborated by Surgeon Jordan, F. R. C. S., and Professor of Surgery at Queen's College, at a subsequent examination 
on March 4, 1871 . Surgeon Oliver Pemberton, F. R. C. S., in charge of the General Hospital at Birmingham, certified, on 
June C, 187C: "On the third day of May, 1876, I amputated the left leg of Thomas Cooper above the knee, the said limb 
having become useless on account of a gunshot wound," etc. The pensioner was paid June 4, 1876. 

A case of shot injury of the foot in a distinguished general officer may conclude the 
illustrations selected for this section: 

Case 132. — Major-General J. Hooker, U. S. V., was wounded at the battle of Antietam, September 17, 1862. The injury 
was reported by Assistant Surgeon B. Howard, U. S. A., as follows: " He was wounded in the right foot by a minie ball while 
leading his command, being on horseback at the time, and standing in the stirrups with his weight thrown on his right foot, 
which was turned outward. The ball struck the inner side of the foot inferiorly to the middle of the scaphoid bone, passing 
between the first and second layers of the plantar muscles, almost transversely across the plantar portion of the foot, and emerg- 
ing inferiorly to the anterior border of the cuboid bone. The bones of the foot were uninjured. On the morning of September 
18th, I was sent by the Medical Director of the Army of the Potomac to attend General Hooker, * * then lying in a farm- 
house near the battle-field. Warm-water dressings had been applied previous to my visit. There was no constitutional 
disturbance, but the foot was hot and inflamed. By means of a syringe I thoroughly washed out the wound with warm water, 
and finding it most agreeable to the patient, substituted cold- for warm-water dressings. The next day I found the patient very 
comfortable; the appearance of the foot had greatly improved and the inflammatory symptoms had disappeared. I then ordered 
a lotion of plumbi instead of cold-water dressings as being more likely to allay any irritation that might arise in the parts. 
Before the General left that evening, for Washington, I advised him to resume the use of tepid water as soon as all tendency to 
active inflammation should cease. On October 25th, I heard that tetanic symptoms had manifested themselves, but received a 
letter from the General a few days afterwards stating to the contrary. On November 25th the General, who had returned to 
duty in the field, requested me to look at his wound, which still troubled him somewhat. I found the newly formed cicatrices 
somewhat tumefied; they were painful on pressure, and the General was still unable to mount his horse unaided, though he 
persisted in being on active duty. On November 30th, I found there had been a steady improvement, and, although the step 
bad not its former elasticity, the wound had left no serious inconvenience behind." General Hooker remained in active service 
until the close of the war, and was ultimately retired October 15, 1868. 

Wounds of the soft parts of the lower extremities, though constituting the largest 
group of injuries received in action, have seldom been much commented on by authors. 1 

1 In addition to the bibliographical references cited in previous pages of this section the following may be consulted with interest : Pare (A.) 
((Eucres'compliles, ed. Malgaiqxe, Paris, 1840, T. II, Chap. XXXVII, p. 110) remarks: " Les plaies faites au dedans des Cuisses sont souvent cause de 
mort snbite, quand elles penetrent en la grosse veine Saphene, ou grosse artere, et aux nerfs qui les aceompagnent: ce que j'ay veil souvent advenir" 
. . and "Mais quand elles penetrent profondement, souvent advient grands accidens, cotntne inflammation, aposteme, et pourriture aux membranes qui 
couvrent les muscles, qui causentque l'ulcere jette une tres-grandequantitede matiere, defacrm quele malade meurt en atrophie, et tout desseiche." . . . 
RAVATON (Chir. d'armee, ou Traite des plaies d'armes a feu, Paris, 1708, p. 321 et seq.) dwells on the importance of flesh wounds of the lower extrem- 
ities, and cites many and exceedingly interesting examples of extensive lacerations, lodgement of missiles and other foreign substances. He details six 
cases of shot flesh wounds of the thigh (Obs. 81, 83, 84, 85, 8C, 87), an instance (Obs. 00) of shot wound of the knee, the missile opening the joint without 
lesion (sans toucher) of bone, and four cases of shot flesh wounds in the leg (Obs. 91. 93, 94, 95), one of which {Obs. 94) was followed by amputation of the 
leg. . . . LE Dran (II. !•'.) (Obs. de Cliir., Paris, 1731, T. I, p. 347) records a case of shot flesh wound of the thigh followed by repeated haemorrhages. 
, . . WILI.IAM80X (G.) (Military Surgery, London, 18G3, p. 133), in a subsection on Simple Flesh Contusions and Wounds of the Lower Extremities, records 
130 cases of this kind from the mutiny in India, 1857-58 ; 117 were slight. 13 severe. Of the 130 cases, 90 were returned to duty, 15 to modified duty, and 
25 were invalided. . . . TuOMrsox (JOUN) (Report of Obs., etc., after the Battle of Waterloo, Kdinburg, 181(1, p. 125) refers to several cases of extensive 
lacerations of the soft parts by large missiles. . . . NEALE (JOHN) ( Chirurgical Institute, London, 1805, p. 247 et seq.). . . . GORDON (C. A.) (Lessons on 
Hygiene and Surgery, London, 1873, pp. 152, 153) cites several examples of flesh wounds of the thigh, and on page 157 gives three cases of recovery after 
periarticular wounds of the knee joint. . . . Klebs (B.) (Beitr'dge zur Path. Anatfrmie der Schusswunden, Leipzig, 1872, pp. 42, 58) cites six obductions 
in cases of shot flesh wounds of the lower extremities — 3 of the thigh and 3 of the leg. . . . CHF.XU (J. C.) (Apercu hist. stat. et din. pendant la guerre 
de 1870-71, Paris. 1874, T. T, p. 278) very briefly adverts to two cases of flesh wounds of the thigh, one of the leg and a penetrating flesh wound of the 
knee joint, followed by traumatic arthritis. . . . FISCHER (II.) (Kriegschir. Erf., 1872, p. 164) says : " The wounds of the soft parts of the leg, as a rule, 
progressed very favorably. . . Much worse proved the wounds of the soft parts of the foot. Nearly always circumscribed or diffuse phlegmonous 
abscesses developed necessitating repeated incisions. . . . MacCormac (\V.) (Notes and Recollections of an Ambulance Surgeon, London, 1871. p. 129) 
tabulates 63 cases of wounds of the soft parts of the thigh without fracture, with 6 deaths, and 30 cases of wounds of the soft parts of the leg, with 1 death. 
. . . LfJCKE (ALBERT) (Kriegschir. Fragen und Jleme.rk., Bern, 1871, pp. 0-9) details sir cases of shot flesh wounds of the lower extremities compli- 
cated by secondary bleeding, among them three cases of ligation of the crural artery, and remarks: "In recent injuries we yet ligate now and then 
successfully the crural artery, but we will more and more come to the conclusion rather to tie the external iliac than the crural artery." . . . SciiDllek 
(M.) Kriegschir. Skizxen, Hannover, 1871, p. 18) tabulates 130 eases of shot flesh wounds of the lower extremities. All recovered. . . . Schixzinuer 
(A.) (Das Reserve- iMzaretk Schwetzingen, Freibnrg i. Rr., 1873, p. 68) notes the gravity of Boot wounds of the soft parts of the thigh after the battle of 
Weistenburg. 



SECT, n | WOUNDS AND INJUK1E8 OK THE 1111' JOINT. 61 



Section II. 



WOUNDS AND INJURIES OF THE HIP JOINT. 



In the important class of injuries of the joints, those of the hip joint are preeminently 
hazardous to life, obscure in diagnosis, and difficult in treatment. In the Surgical History 
of the War of the Rebellion, a comprehensive and systematic classification of this group 
of wounds and injuries should include the contusions and sprains and dislocations and 
simple fractures at the articulation, shot wounds involving the tendinous and ligamentous 
structures about the joint, or laying open the capsule, and shot fractures implicating the 
acetabulum or head, neck, and trochanters of the femur, examples of secondary coxitis 
from extension of inflammation, or septic infection from injuries of the upper part of the 
shaft, and lastly, cases in which operative interference at the hip is imperative from the 
extension of lesions of the upper part of the shaft to the articulation. Yet, in this Section, 
it is proposed to treat mainly of shot fractures involving the hip joint, 1 and of operations 
at the hip following shot injuries, except in a single instance. 2 There appear on the records 
notes of about thirty-five examples of luxations at the hip, fifteen simple fractures believed 
to implicate the hip joint, and forty-four cases returned as contusions or sprains at the 
hip; but these cases will be referred to in subsequent chapters of this volume, as more in 
accordance with the classification heretofore adopted. Examples of coxitis from periartic- 
ular wounds, in which the primary lesions were believed to be confined to the membranous 
or ligamentous or other adjacent soft tissues, were discussed in the last Section, and of 
instances of secondary coxitis from extension of lesions of the shaft we shall find many in 
the following Section on shot fractures of the shaft of the femur. 

In the preceding Section (pp. 26, 28) all pains has been taken to collect the obser- 
vations that were recorded of periarticular shot wounds at the hip, and details are referred 
to of all the facts that could be collected of forty-nine cases that were reported. Professor 
H. H. Smith 3 and other systematic authors believe that shot wounds of the hip joint, 
unattended by injury of the bone, are very rare; but there seems to be a growing convic- 
tion among military surgeons that, owing to the extreme difficulties of diagnosis, many 
such cases may escape observation, or be misinterpreted until late in their progress. The 
early recognition of the precise extent of wounds of the hip joint is of the utmost practical 

1 JOHN Hennen, in his classical treatise, remarks : " The injuries occasioned by balls lodging near or about the joint of the hip arc among the 
most serious of military surgery. The fever, the profuse discharges, the tedious exfoliations, all tend to sink the patient, and arc but too often fatal. In 
some of these cases the course of tho ball is so obscure, and its place of lodgement so uncertain, that it can only be detected after death. I have seen 
balls lodged in almost every part of the trochanters, neck, and head of the bone, and yet the most accurate examination during life did not lead to a 
discovery of their situation." — Principles of Military Surgery, 2d ed., Edinburgh, 1820, p. 155. 

2 Among the coxo-femoral disarticulations one examplo will be cited where the operation was a re-amputation following an amputation in the 
continuity of the thigh for a bayonet stab in the knee joint, the only case to be adverted to not connected with shot wounds. 

8 Professor H. H. Smith (Princ. and Pract. of Surgery, 1863, Vol. I, p. 52(i) remarks that "wounds of the hip joint, uncomplicated by injuries of 
the bone, arc seldom seen. The joint lies quite deep, and is protected by the shelving outward of the ilium and by the prominence of the great trochanter. 
An injury reaching it is almost necessarily associated with some fracture of the bones." 



62 



INJURIES OF THE LOWER EXTREMITIES. 



[CHAP. X. 



importance, and demands a careful and prompt examination to determine whether conserv- 
ative measures are admissible or if operative interference is advisable. Yet here the 
greatest obstacles present themselves. It must still be admitted, and cannot be too much 
impressed on the minds of surgeons, that far greater attention and care and trouble are 
requisite in these than in the injuries of other joints. Until comparatively recent years 
shot injuries of the hip were regarded as almost inevitably hopeless, and military surgeons 
enquired into them but little; 1 but now it is agreed that recoveries may be obtained in this 
group of cases, either under conservative measures or by operative interference, and the 

1 In the section on the surgical literature of shot wounds of the hip juint with which Professor B. von Langexijeck prefaces his essay Ucber die 
Schussverletzungen des Iliiftgelenks, read before the second session of the German Surgical Congress, April 19, 1573, and printed in the Arclriv, B. XVI, 
S. 264, the learned professor observes that in ancient military surgical literature we find wounds of this joint seldom mentioned. This is emphatically 
true. Not only in SCHEXCKlus;of Graeffenburg, who laboriously summarized the labors of his predecessors in chronicling rare cases, in PLATER, in 
FAliRICIls HILDANU6, in the monumental BONETUS, and in other collectors of curious pathological observations, one searches in vain for instances of 
wounds of the hip; but wc scan the writings of the early teachers who treated specially of shot injuries with as little success. MAGGIES, FERRIUS, 
Rota, and the excellent Botallus, VlGO, Felix Wl'Rtz, Hieronymus of Braunsweig, GERBDORF, and even the so-called father of modern army 
surgery, Amijroisk Pake, are silent on this subject. At last, toward the end of the seventeenth century, we find a detailed example of recovery from a 
shot wound of the hip. MATTHIAS GOTTFUIKI) PURMANX (Funfftzig Sonder- und Wunderbahre Schusswundai Curcn, Frankfurt, 1721, Obs. XLI11, p. 
324) relates the case of Pt. S. Kirsky, of the regiment Gbtz, wounded at the siege of Stettin, 1677, in the right hip by a falconet ball, injuring ilium and 
upper portion of femur. Recovery in twenty weeks, with complete anchylosis of hip. In the writings of English surgeons of the time, in GALE, WISE- 
MAX, Buowx, andRANBY; among the Germans who were then eminent for treating of shot wounds, HEIBTER, Thedex. and ScilMUCKER; and of French 
authors who refer particularly to shot wounds of the joints, like LeDuax, Garengeot, and Faudacq, wo look in 
vain for instances of shot injuries implicating the hip. MORASlt and Uavatox, it is true, in the middle of the eight- 
eenth century, advocated coxo-femoral amputation for shot fractures high up in the femur, but do not allude to any 
fractures at or above the trochanters. BlLGUEQ, who cites (Chirurgische Walirnehmungcn, Berlin, 1763, p. 3SJ8 et seq.) 
117 cases of shot injuries of the lower extremities during the years 1736-62, among them cases of wounds of knee and 
ankle joints, gives not a single instance of a shot injury of the hip joint. JEAN MEHEE (Traite des plaics d'armes 
cL feu, Paris, An. VIII — 1800), who systematically divides the wounds of the joints into three classes, those of tho 
lower joints (ankle and wrist), middle joints (knee and elbow), and upper joints (hip aud shoulder), and who cites 
numerous examples, only gives examples of wounds of the shoulder joint in the last-named class, and entirely omits 
wounds of the hip joint. The next definite instance of shot injury of the hip joint found in surgical annals is remark- 
able on several accounts. The case is recorded by Dr. JAMES JOHNSTONE, of 
Worcester, in the London Medical Journal, 1780, Vol. VIII, pp. 135-140. Dr. 
JOHXSTONE took pains to have prepared a drawing the size of nature, representing 
the exfoliated fragment of the head of tho femur, which is accurately copied in the 
annexed wood-cut, FIGURE 24. The case was attended by Sir. JOSEPH BRAN- 
DISH, a " deserving surgeon and apothecary, at Alcester,"and has been sometimes 
cited as an early example of excision at the hip for shot injury. Mr. Brandish 
treated a lad aged 12, who had accidentally shot himself December 23, 1783. The 
contents of the gun "passed into the upper part of the thigh, adjoining to the 
middle of the groin, and came out about the middle of the glutaeus maximus." 
Several successive abscesses were formed, and several exfoliations came away; 
one. in particular, which appeared to be a considerable portion of the head of the 
thigh bone with a shot sticking in it. Much as Baron LARREY has to say of oper- 
ations at the hip joint, he only once describes a case of shot fracture involving 
the hip. It appears in the Clinique Chirurgicale (1836, T. V, p. 242): A young 
officer of the Dth deini-brigade of Infantry of the army of Egypt, at the siege of 
Alexandria, was wounded at the outer and upper part of the left thigh, the ball 
embedding itself in the neck of the femur. The officer recovered with anchylosis 
of the hip. The presence of the missile was not recognized until after the death 
of the patient, at Bruxellcs, twenty years after the injury. The specimen was 
presented to Baron Larkey by Dr. Seltin, and ultimately was deposited in the 
Museum at Val-de-grace. Professor Leg OU EST had a drawing made of it, which is copied in the adjacent wood-cut (FIG. 25). Tho chief British 
surgical authorities in the great Napoleonic wars, Hexnex, GUTHRIE, and BALLIXGAIX, cite no cases of shot wounds of the hip. HEXNEX, in his 
classical Observations, dwells (3d ed., 1821), p. 158) on tho extreme difficulties of detecting the course of balls lodged in this region. "I have seen," he 
remarks, " balls lodged in almost every part of the trochanters, neck and head of the bone, and yet the most accurate examination during life did not 
lead to a discovery of their situation.'' Dr. JOHN" THOMSON' (in his Report of Observations made in the British Military Hospitals in Belgium after the 
Battle of Waterloo, 1816, p. 123) refers to a case of wound of the hip joint, in which the ball lodged ; paralysis was produced, and great swelling of the 
foot and leg supervened ; and to another case, in which the head and neck of the thigh bone together with the acetabulum were, at the autopsy, found in 
a diseased state ; und to one or two other cases which seem to have progressed favorably but were not followed up to the final issue ; and to other instances 
where the ball, without penetrating the capsule of the joint had injured the parts around it, induciug abscesses in the joint and ulceration of the articular 
cartilages, with softening and absorption of the head aud neck of the femur. Writers on'more recent wars have cited but few cases and very few of recovery. 
ME-XlEiiK (P.) (L' flotdDicu de Paris en Juillet ct Anut, 1830, Paris, 1830, p. Hi) gives the case of M. Firer, aged 23, shot fracture of head of femur. Death 
August 30, 183'J. Jobert (A. J.) (Plaits d'armes a feu, Paris, 1833, p. 247) cites two cases of recovery after 6hot wounds of the hip joint received in the 
Paris Revolution of 1830- Baudkns (M. L.) (Clinique des Plaies, etc., Paris, 183d, p. 445) relates a fatal case, in which the ball had perforated the head of 
the femur, in Algiers, November 15, 1835, and adds: '" Had I remained at the Algiers Hospital I should have practised disarticulation or resection. 1 ' 
Alcock (J.) (06s. on Injuries of the Joints, in Med.-Chir. Transact., 1840, Vol. XXIII, p. 261) tabulates four cases of shot wounds of the hip ; but in two 
only tho. joint was primarily involved ; both wcro fatal. MACLEOP (G. H. B.) (Notes on the Surgery of the War in the Crimea, London, 1858, p. 300) 
relates the case of A. McPhail, aged 33, wounded at Dubba, March 24, 1843, by a matchlock ball, which entered anteriorly above the great trochanter of 
the right limb. The wound in tho skin cicatrized; but tho patient died of tetanus, May 9, 1843. The ball was found embedded in the head of the 
femur, having fractured the brim of the acetabulum. The specimen is preserved in the Fort Pitt Museum, and numbered 2604. HYRTL (J.) (Handbvch 
*Ur topog. Anatomic, Wien, 1805, p. 534) relates the case of a member of the national guard, wounded in 1848; the neck of the femur was fractured; the 




Fig. 24. — Carious fragment of 
the head of the femur: 1. Outer 
surface of exfoliation ; 2, same 
bone, showing cancellous surface 
with (A) lead shot sticking in it. 
[After JOHNSTONE, op. cit.) 




Fig. 25. — Musket ball lodged in 
the neck of the left femur. [After 

LECOL'EST.] 



SECT, it.) WOUNDS AND INJURIES OF THE HIP JOINT. 63 

credit of surgery, and still more the interests of humanity, imperatively require that the 
most favorable periods and conditions of treatment should be diligently sought. Drs. H. 
H. Smith, 1 H. Fischer, 2 E. Klebs, 3 B. Langenbeck, and other modern writers on military 
surgery, have dwelt on the inaccessibility of the parts to exploration through the long 
narrow shot tracks produced by missiles of comparatively small calibre, on the frequent 
ahsence of shortening or displacement, or escape of synovia, or indeed with scarcely any 
serious disturbance of the functions of the joint, until the inflammatory and infiltration 

patient recovered. STROMEYER (L.) (Maximal, u. s. w., Hannover, ]855, p. 750) tabulates five cases of shot fractures of the neck of the femur 
from the Dauish War, 1848-1850; all were fatal. Two of these five cases are detailed by Dr. H. Schwaktz (Beitrdge zur Lehre von den Schuss. 
wunden, Schleswig, 1854, p. 14'3). J. J. COLE {Military Surgery, etc., London, 1852, p. 13G) cites a case of fracture of ihe neck of the femur during the 
war in India, 1848-40, but the result is not recorded. Bertiieuand (A.) {Campagnes de Kdbylie, Paris, 1802. p. 301) relates the case of Mohammed 
ben Aehmed, shot in the right hip joint at Icheriden, June £5, 1857; death, August 31st. MATTHEW (T. P.) (Med. and Surg. Hist, of Brit. Army, 
London, 1858, Vol. II, p. 351) refers to three cases of wounds of the hip joint in the Crimean War, which proved fatal in a few hours. CHENU 
(.1. C.) (Rapport au Conseit de Saute" des Armees de Campagne d'Oricnt, Paris. 1605, p. 372) tabulates 30 cases of shot wound of the hip joint, of 
which two recovered. The same author (in Rapport, etc., de Campagne d'Jtalie, Paris, 1800, T. II, p. 000) groups 26 cases of shot wounds of the coxo- 
femoral region, of which 10 recovered, but it is not even indicated whether the wounds were fractures or simple flesh wounds. Demmk (II.) (Mil. Chir. 
Studien, Wiirzburg, 1801, p. 252) details two cases of recovery after shot fractures of the bones of the hip joint. HEINE (C.) (Die Schussverktzungen 
der Unteren Extrcmitiiten , Berlin, 1P0G, p. 305) records four cases of shot wounds of the hip joint from the Schleswig-IIolstein War of 1804 ; all proved 
fatal. STROMEYER (L.) (Erfahruvgen ubcr Schusswunden im Jahrc 1800, Hannover, 1807, p. 8) tabulates four fatal shot fractures of the hip joint 
treated at Langensalza. Laxgenbeck (IS. v.) (Vber die Schussverletzungen der Huftgelcnhe, in Arch, filr Klin. Chir., 1874, B. XVI, p. 270) relates the- 
case of Major J. Preuss, wounded in the hip joint at Munchcngratz, June 28, 1800. The patient died September 13, 1807 ; and another fatal case of a 
soldier wounded in 1804. In the latter instance, the autopsy showed that the ball had entered the outer point of the left trochanter major and passed 
through the neck of the femur in its length into the acetabulum. BRUCE (A.) ( Observations in the Military Hospitals of Dresden, London, 1800, p. 24) 
describes the case of a Prussian wounded at Sadowa^ July 3, 1800, which terminated fatally. Biefel (It.) (Im Reserve- Lazareth, in Langenueck's 
Archiv, B. XI, p. 441-2) treated a case of .shot fracture of the hip joint at Landesbut, in 1800, which proved fatal on the 17lh day. In the Archiv fiir 
Klinische Chirurgie, Berlin, 1874, B. XVI, p. 300, B. v. Langexbeck tabulates 25 cases of recovery and 03 fatal cases after shot wounds of the hip 
joint, during the Franco-Prussian War, 1870, collected from various sources. Among the cases of recovery he cites the case of 11. Rousseau (Cahe 12, 
p. 313), observed by Dr. ScilINZINGElt, although the latter (Das Reserve! azareth Schwetzingen, Freiburg, i. Br. 1873, p. 50) distinctly states "hip joint 
intact 1 ' (Uuftgelenk ijdact); also the case of Scha?fer (CASE 10, p. 315), observed by SOCIN (Kricgschir. Erf., Leipzig, 1872, p. 135), who remarks 
that the patient died, on the 188th day, of exhaustion. Of the ten cases treated by himself, Professor LaN'GENBECK. had the satisfaction of recording eight 
recoveries. Stabsarzt DEIXIXUER, of the Railway Battalion (Beitrdge zur den Schussfracturen des Hiiftgelenks nnter besonderer Berucksichtiguvg der 
Erfahrungen aus dem Fcldzuge 1870-71. und Benutzung der Aden des Kihiiglichen Kriegsministeriums, in Deutsche Militairdrztliche Zeitsrhrift, 1874, 
B. Ill, p 314), in his statistics describes GO cases of shot wounds of the hip joint, of which 13 recovered. All but 15 of these cases are contained in von 
Laxgexbeck's enumeration. Of the 15 cases not contained therein (CASES 5, G. 7, 8, 31. 32, 33, 37 [Recovery], 38 [Recovery!, 49, 50, 51, 54 [Recovery J, 
50, 5S), 12 were fatal while only 3 recovered. Besides the cases collected by Professor von Langenbeck and Dr. Delnlnger I have found the following 
from the Franco-Prussian War of 1870-71, not contained in the tables of either. Assistant Surgeon Evkrs, Saxon train battalion No. 12 (Celenkwunden 
undihr Ausgang, in Deutsche mil-arztl. Zeitcshrift, 1874, B. Ill, p. 381), gives the case of Frode. wounded August 29, 1870; ball penetrated the right hip 
joint ; patient recovered but is totally disabled. LOSBEN (H.) (Kriegschir. Erf. etc., in Deutsche Zeitschrift fiir Chir., 1873, B. II, p. 04), case of Th. 
Margaillon, 22d French Infantry, shot wound of neck and trochanter of left femur, August 18, 1870; died September 4, 1870. Mayer (L.) (Kriegschir. 
Mitth., etc., in Deutsche Zeitschrift fur Chir., 1873, B. Ill, p. 47), case of Sommerfeld, 3d Prussian Jaegers, shot fracture of head and neck of femur ; 
fatal. The cases referred to in this note give a total of 173 cases with 38 recoveries, 134 deaths (a fatality of 77.9 per cent.), and one result unknown. 

1 Smith (II. H.) (The Principles and Practice of Surgery, 1803, Vol. I, p. 520) says: "The diagnosis is difficult, as the joint lies so very deep as 
to be almost beyond the reach of the finger. There may be neither shortening of the limb nor eversion. and at first the patient may be able to move the 
limb without very much pain." 

2 Professor H. Fischer, of Brcslau, in his Kriegschirurgische Erfahruvgen Vor Metz (Erlangen, 1872, p. 201), remarks cm the difficulties encoun- 
tered in diagnosticating wounds of the hip joint : " The deep position of the hip joint, strongly protected by thick layers of muscles ; the generally long 
wound-canal, the termination of which is so difficult to determine; the absence of all severe disturbance of the functions of the joint, and the very trivial 
subjective complaints of the patient, render it often impossible to determine precisely the lesion soon after the injury. All authorities, from LARREY and 
GUTHRIE to contemporary surgeons, agree in this. LEGOUEST relates (Chirurgie d'Arme'e, 2 e ed., 1672, p. 440) that a zouave, who, at the Alma, received 
a shot in the hip, traversing from the groin to the buttock, and completely fracturing the upper rim of the cotyloid cavity, yet still walked about for ton 
days, escaping all our explorations," and adds that this apparent innocuity or benignity led into error our young surgeons and the patients themselves; the 
former not daring to propose, and the latter utterly rejecting, the sole means of averting the almost inevitably fatal termination. "In the case of our 
palieut Emmerich, '' Dr. FISCHER continues, "the ball had lodged in the shattered head in the hip joint. He moved about for some time after the injury 
and even from one bed to another a short time before his death, from syncope. The wounded man, Ilenkel. also repurted that he had walked a consid- 
erable time on his injured limb. This remarkable insensibility in the hip joint immediately after shot injury, if one reflects on the ordinary painfulness 
at the head of the femur in coxitis, appears to be explained only by the supposition of a contusion-paralysis, » r direct severing of the sensory nerves of 
the hip joint. In the course of time a view of the injury generally becomes clearer and the diagnosis easier. In Henkel's case, the characteristic pains 
at the knee joint set in, and the local pains at the hip joint were also present ; but with other patients these highly important diagnostic symptoms 
remained entirely absent. In Henkel's case the head of the femur was intact and its sensibility therefore undisturbed. Profuse suppuration, early septic 
infection and prostration, and the necessity of making counter openings, always led us, unfortunately too late, to the diagnosis. But here the question 
may be asked of what use is an accurate diagnosis if no help can be rendered when attained. It is for this reason that I deplore the difficulty, nuy, 
impossibility, of the same so much, because I believe that primary excision at the hip would be the best metlfbd of treatment for shot fractures at the hip, 
no matter how difficult the operation might be. All later operative interference is frustrated by the exhaustion and septic infection of the patients, by 
extensive and profuse suppuration, and by phlegmonous and gangrenous processes in deep tissues about The pelvis." 

3 KLEBS (E.) (Beitrdge zur Pathologischen Anatomic der Schusswurtdfn. Leipzig, 1672, p. 20) observes : " The shot injuries of the hip joint that I 
Jiad occasion to observe had this in common, that they proved fatal at a comparatively early date, viz: at from thirteen to twenty-four days; and also 
.hat even in the more protracted cases no vestige of a healing process was apparent.'' And. on page 34, he adds: "As you may surely depend upon the 
fact, that in all cases where the ball does not perpendicularly strike the spongy substance of the neck considerable fracture, generally into the joint, 
exists, and that these fissures, even after four weeks, show no inclination towards reparation ; but that they offer the most favorable conditions for infec- 
tion, namely thrombus of the veins; a cure without operation, according to my judgment, is absolutely not to be expected, and the dictum of the American 
Circular No. 6, 1805, S. 01, in which, on account of the absolute incurability of these fractures ' when abandoned to the resources of nature,' the excision 
of the head of tho femur was reoommended, has again been sadly confirmed by the experience of this war." 



64 INJURIES OF THE LOWER KXTREM1TIES. |CHAp. x. 

period arrived. The dictum of Henncn, cited at the outset of this Section,' that the diffi- 
culties of early precise diagnosis in shot injuries of the hip joint are sometimes insuperable, 
is corroborated by Dr. F. H. Hamilton 2 in reviewing the surgical experiences of the 
American civil war, and by Drs. Billroth 3 and Deininger 4 in recording their personal observa- 
tions and the contemporaneous surgical literature of the Franco-German War of 1870-71. 

The evidence regarding shot injuries of the hip joint presented in the annals of the 
protracted American civil war is numerically very imposing; yet attempts to analyze it 
with a view to learn the principles that should govern the treatment of these grave injuries 
are beset with difficulties. The abstracts of the individual cases are for the most part 
wanting in precision, still the material must be classified and consolidated as systematically 
as practicable, and permitted by the character of the reports. 

In the preliminary surgical report made by me in 1865, in Circular 6, S. G. 0., 5 at 
page 31, ninety-seven cases of shot fractures involving the hip joint were tabulated, and 
some of the more remarkable cases were detailed and several were illustrated by drawings. 
In 1867, in a monograph on amputations at the hip joint, 6 fifty-three examples of that 
operation practised during the civil war in America were described, and seven cases were 
narrated that resulted favorably under conservative measures, although it was alleged, 
though not absolutely demonstrated, that the shot lesions described involved the articulation 
at the hip. In 1869, in a report of excisions of the head of the femur for shot injury, 7 I 
detailed sixty-three instance's of this operation performed during the American civil war, 
with minutes of a number of doubtful or not well authenticated cases, and narrated the 
facts collected respecting two hundred and seventy-four examples of shot wounds believed 
to implicate the hip joint and treated either by extracting fragments or by strictly 
expectant measures. In 1871, in a report on surgical cases treated in the army of the 
United States from 1865 to 1871, 8 the histories of four examples of shot fractures involv- 

1 Hexsen (John) {Principles of Military Surgery, 2d ed., 1820, p. 155, cited in foot-note 1, p. 61, ante,). He asserts emphatically: "In some of 
these cases the course of the ball is so obscure, and its place of lodgement so uncertain, that it can only be detected after death. I have seen balls lodged 
in almost even,- part of the trochanters, neck, and head of the bone, and yet the most accurate examination during life did not lead to a discovery of their 
situation. " 

■Professor Frank. H. Hamilton (Princ. and Pract. of Surgery, 1872, p. 407), while regarding the results of excisions at the hip as favorable in 
comparison with those obtained in amputations at the hip joint, and possibly when compared with the results of the expectant plan, concludes: ''I see, 
in the probable inaccuracy of diagnosis, in both classes of cases many sources of error. Indeed, in my opinion, the surgeon is still justifiable in exercis- 
ing a considerable amount of discretion as to the course to be pursued. Jf, for example, he has reasons to believe that the comminution is not extensive, 
and the patient is in a favorable condition as to health ; if he is neither very fat nor very muscular ; if the limb can be kept at rest and moderate extension 
continuously applied, I believe an attempt may be properly made to save the limb without excision." 

3 BILLROTH (Til.) ( Chintrgische Brief eaus den Kricgs Lazarethcn, u. s. w., Berlin, 1872, S. 238) . In the foot-note No. 3, on page 26, of the preceding 
Section, some of Professor IJn.LROTll's emphatic declarations on the occasional impossibility of diagnosticating direct shot injury of the capsule or bones 
of the hip joint have been cited. The length of the shot canals and the great variety of direction in shot perforations of the muscular masses about the 
coxo-femoral articulation, greatly modified by the changing postures of the soldier, are great obstacles to satisfactory explorations, and, owing to the 
form of the pelvic bones and ligaments, the course of the missile is very liable to bo deflected. The index finger is generally too short to reach the 
projectile or fracture, and a sound or catheter is but a poor substitute. Moreover, the surgeon is puzzled by the absence of symptoms he has been taught 
were pathognomonic. In none of the cases examined by Billroth and CZERNY was found the displacement and peculiarity of position usually ascribed 
to fractures implicating the hip ; and the characteristic intense pain in the hip and knee, aggravated on motion, was missing in many instances. Space 
forbids further citations, but the reader may profitably consult the comments of tho Viennese professor on this difficult subject. 

4 IUCininoer (licilrdge zit den Schnssfracturen des Huftgelenks, u. s. w., in Deutsche Mil.-arztl. Zeitschrift, 1874, Jahrg. Ill, p. 237): "The diffi- 
culty of dingnosing a hip joint fracture in its first stages is very great, and frequently it can only be ascertained in the subsequent course whether the joint 
is really injured, and, sometimes, the fracture is not ascertained until after death. For instance, in the preparation exhibited by TBBXDJELENBURQ in the 
Second Congress of the Deutsche Gescllschafl fur Chirurgie, the Langblei ball had comminuted the head and nock of the left femur and lodged among 
the fragments of the head of tho bone; a slight fissure existed in the acetabulum. The patient died in consequence of purulent infiltration; during life it 
was not possible to determine with certainty an injury of the joint. The fragments had been held together by the periosteum, and a dislocation was not 
Indicated. Even walking on the injured limb is no proof that the hip joint has not been fractured." I>r. Deininger (I. c, pp. 238 and 245) refers to 12 
cases in which the injured limbs could be used for some time after the injury, although the autopsy subsequently proved fracture of the joint. 

5 Surgical Report of " Report? on the Extent and Nature of the Materials available for the Preparation of a Medical and Surgical History of the 
Rebellion." Printed at Philadelphia, 1865. CIRCULAR No. 6, War Department, Surgeon General's Office, Washington, November 1, 1865, 4to, pp. 88. 

■ A Report on Amputations at the Bip Joint in Military Surgery. Circular No. 7, War Department, Surgeon General's Office, July 1, 1867, 
4to, pp. 88, PLATES 9. 

7 A Report on Excisions of the Bead of the Femur for Gunshot Injury. Circular No. 2, War Department, Surgeon General's Office, Wash- 
ington, January 2, 1869, 4to, pp. 142. 

*A Report of Surgical Cases treated in the Army of the United States from 1865 to 1871. CIRCULAR No. 3, War Department, Surgeon General's 
Office, Washington, August, 1871, 4to, pp. 296. 



SECT. II.] 



WOUNDS AND INJURIES OK THE HIT JOINT. 



65 



ing the hip joint were detailed, one resulting fatally under expectant measures, and three 
treated by formal excision, of which two recovered and one had a fatal result. 

Three hundred and eighty-six cases of shot fracture directly involving the articular 
surfaces at the hip are found recorded in the returns of the Union and Confederate armies. 
Though the reports are, in many instances, very imperfect, they permit an approximate 
analysis of the cases in Table IX following, according to the particular portion of the 
articulation injured, and also with reference to the treatment of the cases, either by rest 
and suitable position, with splints and extension and other expectant measures, or by 
freely incising the joint and removing, if necessary, fragments of bone, projectiles, or other 
foreign bodies, cases numbering three hundred and four, 1 and grouped as treated by 
conservation; and then follow two groups treated by formal operative interference, a series 
of fifty-five cases of excisions at the hip, and a series of twenty-seven cases of amputations 
at the hip. 

Table IX. 



Tabular Statement of Three Hundred and Eighty-six Shot Fractures of 


the Hip Joint. 




Parts Injured. 


CO 

3 
B 

-t 
O 


Treated by Conser- 
vation. 


Followed uy Excis- 
ion AT HBP JOINT. 


FOLLOWED 11 Y AMPU- 
TATION AT HIP .JOINT. 


Cases. 


Recov. 


Died. 


Cases. 


Uecov. 


Died. 


Cases 


Recov. 


Died. 




11 

35 

19 

3 

o 

4 

34 

23 

5 

9 

1 

108 

35 

37 

2 

11 
2 

5 

40 


11 
33 
14 

n 

i 

3 

34 
12 


1 
1 

11 
1 


10 
32 
11 
o 

1 

3 

23 

11 


o 
4 
1 
1 

1 

10 
o 
2 
1 
10 
10 
9 


1 
1 


2 

4 
1 

I 
1 

9 
2 
o 
1 

10 
9 
9 












1 




1 














1 
3 
1 




1 

3 
1 










6 




6 






96 
16 
27 
2 
8 
2 


26 
o 
o 

1 


70 
14 
25 

7 


o 
9 
1 


1? 


n 

8 
1 










1 




1 


2 


1? 


1 


Trochanter Major, involving 1 the Hip Joint 








5 
2 




5 
2 




37 


10 


27 


1 




1 






386 


304 


55 


249 


55 


o 


S3 


27 


2? 


25 





In discussing the two series of excisions and of amputations at the hip, eleven instances 
must be added to the first, and thirty-nine to the second, in which the operations were 
practised for shot fractures of the shaft of the femur that did not primarily implicate the 
hip, or for injuries of the knee joint, thus giving a total of four hundred and thirty-six 

1 In Circular No. 2, S. G. O., 1869, from pages 65 to 106, two hundred and seventy-four abstracts of shot wounds at the hip joint were recorded as 
treated on (ho expectant or conservative plan, with forty-nine recoveries. Of these, forty-seven, with fifteen recoveries, are omitted from Taiji.E IX. Of 
this category of forty -seven, 22, with 7 recoveries (Cases 165-186, inclusive, of Circular 2„pp. 90-92), and 12 cases, with 2 recoveries (Cases 187-198, 
inclusive, of Circular 2, pp. 92-94), are discarded, the former as uncomplicated by fracture, an- 1 the latter as examples of secondary traumatic arthritis. 
These thirty-four cases havo already been referred to in SECTION I, at page 26, ante, under t'..j head of Peri-articular Wounds. Twelve cases, with two 
recoveries (CASES 216-227, inclusive, of Circular 2, pp. 96-98), are postponed fur consideration in SECTION III, as instances of fractures of the trochan- 
teric region, in which the hip joint became secondarily involved. One case of recovery (Case 224, Circular 2, p. 100) has been transferred to n future 
chapter, later information having proved that the injury was not inflicted by shot. On the other hand there were added to the cases summed up in Circu- 
lar 2, 66 cases, with 18 recoveries, since discovered and not heretofore published; 4 cases, with 1 recovery, already published in the Second Surgical 
Volume {Cases 859, p. 295, 920, p. 317, 922, p. 318, and 935, rf. 324); 5 cases, with 1 recovery, referred to in Circular 2, but not included in the enumerated 
list (Cases of Swanson, Greenwood, p. 113, Scott, p. 114, and CASES of Drs. A VENT and BRCNS, p. 57); 1 case of recovery (Case of Sweeney, noted in 
Circular 7, S. Gr. O., 1867, p. 73); and 1 fatal case {Circular 2, p. 92, CASE 184), reported in Circular 2 as a case in which the hip joint was involved but 
uncomplicated by fracture. The specimen, since received (Specimen 2994, A. M. M.), conclusively proves the fracture. 

Slug. Ill— 9 



66 INJURTKS OK THU LOWKR EXTREMITIES. LGHAr. x. 



cases to be considered in the three following subsections. If the conclusions deductible 
from these numerous examples are in many respects unsatisfactory, it may be borne in 
mind that the surgical experiences of the Six Weeks' Prusso- Austrian War of 1866, of the 
Franco-German War of 1870—71. and of the Russo-Turkish War of 1876-77, have not 
so far proved more fruitful in results tending to solve the difficulties that beset the subject. 

SHOT FRACTURES AT THE HIP TREATED BY CONSERVATION.-Thrce 

hundred and four cases in which shot wounds at the hip were believed to have been 
attended with fracture of the articular surfaces were treated on the expectant plan, 1 or 
with such incisions and removals of fragments or foreign bodies as was consistent with a 
true conservative treatment. 

Five modern writers on military surgery, 2 the late Dr. H. Demme, of Berne, Professor 

1 Professor B. VON LAXGEXIIECK, in seeking for examples of recoveries after shot wounds of the hip joint (Ueber die Scltussverletzungen des Iluft- 
gelenks, in Archiv fur Klin. Chir., 1874, B. XVI, p. 263) finds none recorded prior to recent wars, ''apart from a case communicated by Henxen, in Ins 
classical work (Obser cat ions on Some Important Points of Military Surgery, Edinburgh, 1818, p. 172), and several cases mentioned "by THOMSON 
{Report of Observations made in the British Military Hospitals in Belgium, Edinburgh, 1816, p. 123) of hip joint wounds which seemed to have pro- 
gressed favorably, but were not followed up to the final issue ;" but it can hardly have escaped Professor LAXGENUECK's notice, in IlEXXEX's account of 
his Cask XXVII, of .Spontaneous Luxation of the Hip Joint, that HEXXEX say* : " Whether the luxation in this case was produced from a primary 
injury of the bone, or of the cartilages, anil sebaceous glands of the joints, or from a secondary scrofulous affection, it is impossible to say with certainty," 
and by no means cites this instance of the mounted officer, wounded July 22, 1812, as an instance of recovery from shot wounds of the hip joint. In a 
later portion of his work, Dr. John THOMSON' (Report of Observations * * after Waterloo, Edinburgh, 1816, p. 275} observes: "The proportion of 
cures which has been obtained from amputation at the hip joint is, I believe, much greater than of cures from gunshot fractures of the head or neck of the 
thigh bone. Indeed, of recoveries from these injuries I know of none which have been recorded. Those who, for a time, seem to do well, in the end sink 
under the hectic which supervenes. This has been the fate, I believe, of the two cases which I have mentioned in the account of injuries of the hip joint as 
having put on a favorable appearance." With such examples, the propriety of caution in admitting recoveries after shot wounds at the hip as incontestable 
is apparent. Dr. RICHARD M. HODGES (The Excision of Joints, Boston, 1861, p. 94) observed: " The extent of injury, and the condition of the parts after 
a gunshot wound of the hip joint, are as notoriously difficult to determine as the cases are certain to terminate fatally. Even when the upper part of the 
femur has been shot through, shortening, rotation outwards, and crepitus are not always present, and sometimes a very considerable power of flexion and 
extension remains." After citing GUTHRIE'S famous picture (Commentaries, etc., Gfh London ed., 18.35, p. 77) of "a man lying with a small hole either 
before or behind in the thigh, — with no bleeding, no pain, nothing but an inability to move the limb, to stand upon it, — and Hunk that lie must inevitably 
die in a few weeks, worn out by the continued pain and suffering attendant on the repeated formation of matter burrowing in every direction, unless his 
thigh be amputated at the hip joint, or he be relieved by the operation of excision, which, I insist upon it, ought first to be performed,'' Dr. HODGES 
declared that : *' By following an expectant course and trusting to the resources of nature, an almost invariable mortality t\ ill ensue. A case occurring 
at the battle of Solferino, diagnosticated as fracture of the neck of the femur, and another seen at Nantes, in 1830, by M. BoiNET, are the only recoveries 
I am aware of which have followed gunshot wounds of the hip joint." Dr. HODGES refers to the two exceptional recoveries after Solferino and Nantes 
in L' Union Me'dicate, 28 Juin, 1800. The discussion of the Sociitd de Chirurgie here given, from p. 605 of V Union Midicale, is, in that journal, errone- 
ously attributed to May 30, 1860. The discussion was on June 6, 1860, and is correctly reported in the Bulletin de la Societi de Chirurgie de Paris, 1861, 
2 me ser., T. I, p. 3:26. The Solferino case refers to a soldier, wounded June 24, 1859, and presented before the Sociiti de Chirurgie June 6, 1860, bj- M. 
TjEGOUEST. This soldier, after receiving shot wounds of the left shoulder and of the neck of the left femur, the latter ball entering anteriorly and passing 
out through the sciatic notch, entered the hospital at Cremona. Numerous and largo splinters were extracted. The neck of the femur perfectly consoli- 
dated, with three centimetres shortening. M. BOIXET mentioned "a man wounded at Nantes, in 1830, by a shot fracture of the neck of the femur with 
grave complications, now perfectly cured, and able to take long walks notwithstanding the anchylosis that had followed the accident." (See Circular 2, 
S. G. O., 1869. p. 65.) Professor Richard VOLKMAXX (Die Resectionen der Gelenke, in \\\s Sammlung Klinischer Vortrdge, Leipzig, 1873, No. 51, p. 301), 
speaking of the American statistics of excision and exarticulation at the hip for shot injury, declares that they "demonstrate that after both operations only 
exceptionally a patient survives; but that also, under a purely conservative treatment, the result is invariably none better, on the contrary, rather still 
somewhat worse. The wounded with shot fractures of the hipjoint about nearly all perish. This is also the experiences which we, who participated in the 
two last great wars, the Austro-Prussian and Franco-German, alas, could only confirm. I myself saw only fifteen instances of this injury. Three times 
I performed resection, twice after the battles of Beaumont and Sedan, once in Dijon. All three patients died ; two, as I believe, chiefly from the eon- 
sequences of a coexisting decubitus ; in a third an extensive comminution of the pelvis was found at the resection ; but the remaining, about twelve cases 
treated conservatively, also perished. Among them also one in which the head of the femur, separated by the ball and sp v d in two halves, was extracted 
by an incision opening the joiut. Only one patient I see still now and then, who, at Toul. received an undoubted intracapsular shot fracture of the neck 
of the femur, but which had not been diagnosticated, and who recovered, after exfoliation of several pieces of bone with relatively little shortening, and 
with anchylosis of the joint.'* LOHMEYEit (C. F.) (Die Schusswunden und ihre Behandlung, Gottiiigcu, 1859, S. 198) remarks: "An operation for the 
simplification of the wound, in cases where the acetabulum has been crushed, is naturally out of the question ; but, in cases of comminution of the head or 
neck of the femur with injury of the capsule, one is called upon to operate, as such injuries, without artificial help, uniformly prove fatal after the patients 
have undergone terrible suffering." LOffler, (F.) (Grundsdtze und Regeln fur die Behandlung der Schusswunden im Kricge, Berlin, 1859, Erste 
Abtheilung, p. 66), speaking of shot injuries of the hip joint, remarks : " The conservative treatment of this injury, according to the experience hitherto 
acquired, gives no prospoct of saving life. Even if pyaemia does not supervene, death ensues sooner or later from exhaustion following endless suppuration." 
With such testimony as the foregoing, together with that of Drs. II. FISCHER and E. Kl.EBS, in the foot-note to page 63, ante, we are indispused to ooneur 
in the declaration of Dr. SAMUEL W. GROSS (Military Surgery, in Am. Jour. Med. Sci., 1867, Vol. LIV, p. 447) that "those surgeons who pointedly 
condemn all efforts to save the limb after gunshot fracture of the surgical or anatomical neck of the thigh bone, exercise, in our judgment, but little 
discrimination, when they declare, as does the surgical historian of ihc late American War, that 'experience has demonstrated the uniform fatality of 
gunshot fractures of the head or nock of the femur when abandoned to the resources of nature,* '' and that "no statement can be farther from the truth. 1 ' 
The compiler of the surgical report in Circular So. 6, S. G. O., 1865, might have said "almost uniform fatality," but his statement, if lacking qualifica- 
tion, was assuredly not widely apart from the truth. 

2 DEMME (H.). Spec. Chir. der Schusswunden, WUrzburg, 1864. S. 348- PlROGOFF (N.), Grundzuge der Allg. Kricgschir., Leipzig, 1864, p. 814. 
GnOBS (S. W.)i Military Surgery, in Am. Jour. Med. Sci., 1867, Vol. LTV, p. 447. Spd.lmann, £tude Anal, et Crit. d'un Rapport sur la Resection de la 
Tete du Femur, Paris, 1870, Extrait du Rcc. de Mem. de Mid, de Chir. et de Pharm. Mil., 3""> s6r., T. XXVIII, 1870. p. 48. LAXGENBECK (B. vox), 
Ueber die Schussverletzungen des Uuftgelcnks, in his Archives fitr Klin. Chir., Berlin, 1874, B. XVI. p. 263, nnd translated as Surgical Obs. on Gun-shot 
Wounds of the Hip-Joint, by JAMES F. WE£T, F. R. C. S., in Birmingham Med. Review, Vol. V, 1876, pp. 29, 88, 167. 



SECT. II. 1 WOUNDS AND INJURIES OF THE ITIP JOINT. ()'/ 

N. Pirogoff, Dr. S. W. Gross, Dr. E. Spillmann, and Professor B. von Langenbeck, have 
taught latterly that the expectant plan of treatment of shot injuries of the hip joint is 
inadequately appreciated by surgeons, and have collected instances more or less apposite 
to prove that the commonly received opinion that such injuries are uniformly fatal when 
abandoned to the resources of nature is altogether fallacious. 1 

It cannot be legitimately contested that, in very rare instances, of shot wounds 
involving the hip joint, life may be preserved without operative interference. A remark- 
able case, that has seldom been cited, was reported by Surgeon J. B. Porter, of the recovery, 
under expectant treatment, of a soldier wounded at Vera Cruz, August 3, 1847, by a mus- 
ket ball that shattered the neck of the right femur. 2 The case observed by Brandish, in 
1783, where a lad of twelve survived the exfoliation of a large fragment of the head of 
the femur with a lead shot sticking in it, demonstrated that such injuries are not inevitably 
fatal. Though the instances of recovery under expectant measures from shot injuries at 
the hip quoted by Dr. S. W. Gross from D. J. Larrey and M. Legouest were cases of 
extracapsular fractures at the trochanters, yet the case of recovery given by Hyrtl, and 
that observed by M. Legouest in the French soldier at Solferino, and that recorded by M. 
Boinet, of the soldier wounded in 1830, at Nantes, were indisputably illustrations of the 
successful terminations of shot injuries at the hip treated on the expectant plan. Of the 
twenty-five examples tabulated by Professor Langenbeck of shot injuries of the hip joint 
recovering under conservative treatment in the Franco-German War of 1870-71, it is 
incontestable that at least twenty-one appear to be indubitable examples of recovery after 
intracapsular shot fractures of the hip, implicating either the neck or head of the femur 
or the acetabulum, while four of the series are open to objection. 3 In the large series of 
three hundred and four cases of shot injuries reported from the American civil war of 
1861-65, a number of recoveries under expectant treatment are alleged. 

Recoveries after /Shot Fractures at the Hip under Conservative Treatment. — Of fifty- 
five tabulated examples of recovery, one is referred to the series of eleven cases in which 
the osseous lesion was confined to the acetabulum: 

Case 133. — Private J. L. Harvey, Co. F, 12th South Carolina, appears on a Confederate certificate of disability as 
having been retired from service, February 18, 18C5, by reason of "gunshot wound of right hip, partially destroying the 
acetabulum and luxating the head of the femur; lameness consequent upon the luxation resulted." 

There is no evidence that the diagnosis proposed in this case by the Retiring Board 
had been entertained at the time the injury was received. 

' II. Demme's 2 cases of alleged recovery from shot fracture involving the hip joint are those of C. Borelli and Franz Veter, wounded at Magenta, 
June 4, 1859 (DEMME, Mil.-Chir. Studien, Wilrzburg, 1861, pp. 252, 253). N. PIROGOFF'S 20 cases " observed in full process of healing," but not identi- 
fied by names, dates, or ulterior histories, are alluded to in Pirogoff's Grundziige der Allgemeinen Kriegschirurgie, Leipzig, 1864, p. 814. Dr. S. W. 
Gross quotes the 22 cases of DEMME and Pirogoff, 1 case mentioned by the elder Larrey (Clin. Chir., 1836, T. V, p. 242. See Fig. 25 in foot-note 
to p. 62, ante), 1 case of Hyrtl, in 1848 (Handb. der topog. Anat., "Wien, 1865, p. 534), 3 cases witnessed by LEGOUEST and described by him as shot 
fractures of the trochanters (Bee. de Mem. de Mid., de Chir., et de Phar. Mil., 1855, 2™° ser.. T. XV, p. 240), 1 case (Vanderbeck) related by Professor F. 
H. Hamilton (Treat, on Mil. Surg., 1865, p. 397), 2 cases (Bugh and McCabe) reported by Dr. B. B. Miles, and 1 case that occurred to Brandish in 
1783 (see FIG. 24 and reference in foot-note to p. 62, ante), and claims that this resume of 31 cases conclusively shows that attempts to save limbs after 
shot fractures of the hip are far from hopeless. Professor E. Spillmann adds no facts, but urges that such positive testimony as adduced by Demme, 
Pirogoff, and H. Larrey (Bui. de I'Acad. de Med., T. XXVII, 1861, p. 138) in favor of conservation should not be lightly rejected. Professor B. VON 
Langenueck, finding in ancient and recent military surgical literature few examples of recovery, under conservative treatment, in shot fractures at the 
hip, presents tables of 25 cases of recovery after shot wounds at the hip joint in the Franco-derman War of 1870-71, and of 63 fatal cases under like 
treatment. 

2 PORTER (J. B.), Medical and Surgical Notes of Campaigns in the War with Mexico, in Am. Jour. Med. Sci., 1852, Vol. XXIII, p. 34. 

'Langenbeck (B. VON), Ueber die Schussverletzungen des Huflgelenks, in Archiv fur Klin. Chir., 1S74, B. XVI, pp. 309-316. In Dr. ScniNZIK- 
gea'8 case, No. 12 of the Table, of R. Rousseau, Dr. S. states positively in his report "Das Beserve-Lazareth Schwetzingen, Freiburg i. B, 1873, p. 56," 
"rechtes HUftgelenk intact." In Professor II. Fischer's case of Renz, numbered 18, the author in his work " Kriegschirurgische Erfahrungen, Tor 
Metz, Erlangen, 1872, p. 173, pronounces the injury extracapsular. In Professor SociN's case of Scbaeffer. numbered 19, the patient died of exhaustion on 
tho 188th day, as noted by Professor SOCIN in his Kriegschir. Erfahrungen, Leipzig, 1872, p. 135. The case ascribed to Dr. \V. MACCORMAC (Notts and 
Recollections, etc, London, 1871, p. 118) is invalid, amounting only to the numerical statement that of three patients with hip joint shot wounds at Sedan, 
two died. 



68 INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

Of the thirty-three shot injuries in Table IX involving the "acetabulum and head of 
femur" and treated without operative interference, one terminated in recovery. Accounts of 
this remarkable case have been heretofore published by Dr. J. F. Miner, and by the editor 
of this volume in the Surgical Series of Photographs of the Army Medical Museum, Vol. 
IV, No. 6, 1866, in Circular No. 7, S. G. 0., 1867, p. 74, and in Circular No. 2, S. G. 0., 
1869, p. 105. Additional information, gathered from the records of the Pension Office 
since the date of the latter publication, has been added to the history, and the appearance 
of the patient's limb four years after the date of the injury is represented in Plate LVII. 
This well known case has been very generally cited by writers on military surgery as an 
incontestable example of recovery without operative interference after shot fracture of the 
articular surfaces at the hip: 1 

Case 134. — Lieutenant Colonel James C. Strong, 38th New York, was wounded at the battle of Williamsburg, May 5, 
1862, by a conoidal musket ball, which entered the right thigh in front, a little below the groin, and made its exit through the 
buttock, over the lower right-hand border of the sacrum. Surgeon A. J. Berry, 38th New York, examined the wound, and found 
that the ball had deeply grooved the head of the femur and had fractured the upper rim of the acetabulum. A detached 
fragment of the rim nearly an inch and a half in length, a part of it covered with articular cartilage, together with portions of 
clothing, were extracted from the wound. On the 8th of May the patient was transferred, by a steamer frem Queen's Creek 
Landing, to the Hygeia Hospital at Fort Monroe. Here he remained until the 13th, when he undertook a painful journey of 
five days, on a litter, and reached his home in Buffalo. The injured limb was semiflexed and rotated inward, the head of the 
femur being dislocated upon the dorsum of the ilium. Any attempt to place the limb in position produced such acute suffering 
that the effort was abandoned. For ten weeks there was profuse suppuration, with burrowing of pus in the thigh and intense 
pain, with chills, profuse perspiration, and great prostration, after which a very gradual amendment took place. On December 
12, 1862, the patient was removed to Philadelphia, and entered the Officers' Hospital, at Camac's Woods, where he was able 
to bear treatment by Buck's method of extension by weights. Here a number of spicule of bone were extracted or was-hed 
from the wound. On January 6, 1863, the patient was discharged from hospital. On June 1st the wounds wei ? nearly closed, 
and he rejoined his regiment on crutches, and was mustered out with the regiment on June 22, 18C3. On September 29th he 
was appointed Colonel in the Veteran Reserve Corps. He was subsequently brevetted Brigadier General. In July, 1836, he 
visited the Army Medical Museum, when his photograph was taken. This is represented in the lithograph opposite, Pl.ATK 
LVII. General Strong was in good health. His limb was shortened nearly five inches, but by the flexibility acquired by the 
lumbar vertebrae, the inclination of the pelvis and extension of the toes, he was enabled to walk with surprising ease with or 
without a cane. The head of the femur was firmly anchylosed on the dorsum of the ilium. The cicatrices appeared sound. 
Early in 1869 General Strong was in Washington, at Willard's Hotel, and sprained his ankle in falling in a dark corridor. 
The compiler was summoned to see him, and found that he had but little trouble with his anchylosed hip joint, and that his 
general health was excellent seven years after the reception of so grave an injury. The various reports of the Pension Exam- 
iners reiterate substantially the same account of the injuries until the report of January, 1875, of the Buffalo Board. Drs. H. R. 
Hopkins and M. B. Folwell state that "the ball destroyed a large portion of acetabulum and allowed dislocation of head ol 
femur upon dorsum of ilium, where it now remains permanently and firmly fixed. Limb shortened about five inches. Thigh 
six inches smaller than fellow. The pensioner claims partial hemiplegia of right side during the past two years, which, in the 
lower extremity, has apparently been on the increase, but is rather to be ascribed to the progressive atrophy of the muscles of 
the limb. Since the attack of hemiplegia he has not been able to dress himself." On June 6, 1877, Examiuers H. R. Hopkins 
and M. B. Folwell add : " Ball entered four inches below the origin of the sartorius and came out at right margin of lower edge 
of sacrum ; there is loss of a portion of the acetabulum and dislocation of femur on dorsum of ilium, with shortening of five inches ■ 
the thigh is six inches smaller than its fellow; patient claims incomplete hemiplegia of right side, which is increasing in lower 
extremity ; is unable to dress without the aid of another person to put on his sock. He further states that upon receipt of a 

1 MINER (J. F.), Gunshot Wound, with removal'of rim of acetabulum and dislocation of femur, in Buffalo Med. and Surg. Jour., May, 1866, Vol. 
V, p. 380. Dr. MINEK, who attended Colonel Strong after his painful transit from "Williamsburg to Fort Monroe, and thence, starting May 13th, to New 
York by water, and thence by rail to Buffalo, a distance in the aggregate of 842 miles, first published an account of the case, remarking that " perhaps 
the whole surgical history of the rebellion will not furnish a parallel." The regimental surgeon, Dr. BERRY, died soon after the battle of Williamsburg, 
and the records of Hygeia Hospital and Camac's Woods afford only the scanty data recorded in the text. The photograph from which the lithograph 
was copied was taken at the Army Medical Museum in July, 1866, and numbered 156 of the Surgical Series of Photographs, Vol. IV, No. 6, and a 
history was compiled by Assistant Surgeon G. A- Otis, U. S. A., from the hospital records above noted and from General Strong's oral statement, and 
this was reproduced in Circular No. 7, S. G. O., 1867, p. 74, and in Circular No. 2, S. G. 0., 1869, p. 105, with notes of the subsequent progress of the case 
by the same editor. Professor E. Spillman, of the military medical school of Val-de-Grace, has translated the case in full in his important Etude analit- 
ique et critique sur la resection de la tete du femur, Paris, 1870, as an incontestable example of recovery from an intracapsular shot lesion obtained "not 
by expectation, but by conservative surgery, a most important distinction." The history of the case has been cited by a number of European writers, 
most of whom have quoted, not the reports of Drs. MINER or Otis, but a careless summary in the Jahresbericht, in which the report of tl.e case is 
ascribed to the late Dr. A. H. HOFF. At page 70 of Circular 7 is an extended citation from Dr. Hoff's views of the treatment of shot injuries at the 
hip, and the reviewer has inadvertently ascribed to Dr. HOFF not only the succeeding illustrative cases of recovery without operation after shot injuries 
at the hip joint, but also the entire compilation of Circular 7. Professor B. v. Langenbeck in his memorable discourse Ueber die SchussverUizungen 
des Hiiflgelenks, in three places (in Archiv fur Klin. Chir., B. XVI, S. 265 and 285) has been misled by this erroneous reference. Even his transiator, 
Dr. James F. "WEST, in his English version of Surgical Observations of Gunshot Wounds of the Eip Joint, in the Birmingham Medical Review, 1876, 
Vol. V, p. 31 and p. 89, and issued separately in pamphlet form, fails to correct this error, although he has acknowledged his indebtedness to the Surgeon 
General's Office for copies of the Circulars on the hip joint, and professes to append an abstract of Circular 7. 



JW.and Surg. Hist.ofthe War of the Rebellion, Partlfl . Vol .IK 'I,.,,, X 




Ward phot 



Bicn hill 



PLATE LVII. GUNSHOT FRACTURE OF THE R IGHT ACETABU LU M AND THE HEAD OF THE FEMUR, 



l-iisc of I olonol .laim-s I .Strong 
.'!,'> * Now York 



SECT. II. 1 SHOT FRACTURES AT THE HIP TREATED BY CONSERVATION. 69 

wrench or twist of foot, lie has sudden pain running up the limb and spine to the head, causing convulsive action, lasting from 
one to four hours, followed by confinement to the house for two or three days. These attacks occur only as the result of violence 
to the ankle or foot." The Examiners state that they are unable to conneot the disability claimed with the original injury, and 
are of the opinion that the present degree of his disability does not require the constant attendance of another person or entitle 
him to an increase. The pensioner's brother and wife certify that since he was wounded he has always required and does now 
(April 28, 1877) require the attendance upon him of another person, and that the attacks of nervous prostration, occurring at 
times as often as once a week, and sometimes taking on the character of a violent mania, are such as to make it unsafe for him 
to go about alone. The pensioner was paid to September 4, 1878, having survived his terrible injury over sixteen years. 

In eleven cases of recovery the reports state that the "head of the femur" was 
involved. The testimony in regard to the opening of the articulation in these cases is 
very inadequate ; one will serve as an example •} 

Case 135. — Private Jacob Wright, Co. E, 96th Pennsylvania, aged 17 years, was wounded at Spottsylvania, May 8, 1864, 
by a conoidal musket ball, which fractured the head of the right femur. He was captured and remained in the hands of the 
enemy until August 14th, when he was paroled and conveyed by steamer to Annapolis, Maryland, and admitted into hospital 
No. 1. The diagnosis here was wound of the left thigh. On September 21st he was transferred to Camp Parole, and thence, on 
February 17, 1865, to Eulison Hospital, at Annapolis Junction. A fracture of the head of the right femur was diagnosticate'!. 
On April 13th he was transferred to the Satterlee Hospital, at Philadelphia. A gunshot wound in the upper third of the left 
thigh was recorded. July 16th, he was sent to the McClellan Hospital. A gunshot fracture of the upper third of the left femur 
was reported. Necrosis of the femur existed. He was discharged from service on September 9, 1865. His disability was rated 
at one-third. The case is reported by Assistant Surgeon John Bell, U. S. A. Pension Examiner G. M. Masser, of Scranton, Pa., 
reported, November 1,1866: " Gunshot wound of left thigh; fracture of the os femoris near trochanter, with dislocation down- 
ward, causing a lengthening of the leg three inches more than the right leg; is very lame and wound still discharging. Is unable 
to perform manual labor." The Scranton Board reported, September 4, 1877 : "Ball entered left thigh through trochantermajor, 
passed through gluteal muscles and coccyx ; loss of a portion of trochanter, great loss of soft parts, and adhesion of muscles. The 
whole limb is covered with a network of large varicose veins. Disability equivalent to loss of limb." 

The following is a case in which the head and neck of the femur was reported to have 
been injured; it was successfully treated without operative interference; but the evidence 
is entirely insufficient to prove an intracapsular fracture: 

Case 136. — Sergeant James M. Adams, Co. D, 13th Georgia, aged 37 years, was struck, in the action at Monocacy, July 
9, 1864, by a round musket ball, which slightly injured the head and neck of the left femur. He was conveyed the following 
day to the General Hospital at Frederick City. A gunshot wound of the left thigh and hip, involving the joint, was diagnosti- 
cated. Simple dressings were applied, and tonics and stimulants were given. Extensive abscesses formed in the anterior and 
posterior parts of the thigh. On September 20th the patient was conveyed to West's Buildings Hospital in Baltimore, and was 
transferred thence, on October 27, 1864, to Point Lookout, Maryland, for exchange. Surgeon A. Chapel, U. S. V., reports the case. 

1 The remaining ten cases were: 1. Pt. J", Hughes, G, 1st Alabama Cavalry, HartsviUe, Tenn., April 11, 1863, shot fracture head of femur; recov- 
ered and applied in person to a Confederate relief association for a suitable apparatus. Mr. Hughes resided in Crawford County, Arkansas. The case is 
recorded in the register of a Confederate Relief Association (Circular No. 2, S. G. O., "Washington, 1869, p. 74). — 2. Pt. O. A. Crymes, B, 22d Virginia 
Battery, Chancellorsville, May 2, 1863 ; shell fracture right femur, involving head of bone ; Nov. 11th, shortening and partial anchylosis ; furloughed 
for sixty days (Ci'rc. 2, p. 98).— 3. Serg't F. M. Hunter, Co. E, 24th Tennessee, age 24, Eesaca, May 15, 1864 ; appeared January 27, 1865, before Con- 
federate examining board, who reported: " "Wound by musket ball entering the superior articulation of right thigh, causing partial paralysis ; disability 
permanent. Soldier is unable to serve the government in any capacity;" retired from service (Circ. 2, p. 99). — 4. Colonel L. S. Slaughter, 56th Virginia, 
June 27, 1862; gunshot wound of thigh witli a fracture of the femur, which was believed to involve the hip joint; he appeared before a medical examin- 
ing board, of which Surgeons Crenshaw, Read, and Peebles were members, and was retired from service on account of "gunshot wound upper third 
of thigh, fracturing head of bone; deformity, shortening, and permanent loss of usefulness of limb" (Circ. 2, p. 99). — 5. Pt. J. 5. Smith, II, 2d North 
Carolina, age 22, Chancellorsville, May 3, 1863. Confederate Surgeons W. A. HOLT and F. W. HENDERSON certified to shot wound of right hip joint, 
fracturing head of femur, resulting in necrosis of femur. A Confederate board of examiners certified that he was permanently disabled on accouut of two 
gunshot wounds : one a wound of the left wrist, resulting in anchylosis of the joint and partial loss of use of the hand ; the other wound through right hip, 
fracturing femur ; wound still open and discharging; locomotion difficult and painful; retired from service (Ci re. 2, p. 99). — 6. Pt. It. Finkle, H, 15th 
Illinois, age 31, Shiloh, April 6, 1862; discharged at Marine Hospital, Chicago, August 9, 1862, on certificate of disability, by Acting Assistant Surgeon 
R. N. I8IIAM, for "wound of right nates with injury of femur." Examiner W.W. BURNS certified, September 14, 1863: "Bullet entered hip on posterior 
side, passed obliquely through to the front, and fractured the head of the femur." — 7. Pt. J. Kivel, B, 12th Wisconsin, age 21, Atlanta, July 5, 1864. At 
hospital No. 2, Chattanooga, and at Cumberland Hospital, Nashville, the injury was reported as a "conoidal ball wound of the left hip;" at Jefferson- 
ville Hospital as a "shot fracture of the left ilium, anterior spinous process." He was discharged at Swift Hospital, Prairie-du-Chien, May 22, 1865, for 
"shot wound of left hip, fracturing head of femur." Examiner C. Cowles, of Baraboo, reported, September 29, 1867: "Ball entered left groin and 
passed obliquely backward and downward close to the head of the femur." — 8. Pt. W. Swank, C, 78th Ohio, age 26, Atlanta, July 22, 1864. Surgeon J. 
Benson, 14th Wisconsin, from the field hospital, reported: "Gunshot wound of pubes and 6crotum." Ass't Surgeon G. Saal, U. S. V., reported, from 
Seminary Hospital, Columbus : "Gunshot wound of left groin, ball lodging." He was discharged at Marine Hospital, Cincinnati, November 16, 1865, for 
" inguinal hernia of right side and partial anchylosis of left hip joint from gunshot wound, ball entering groin and lodging near bead of femur." Exam- 
iner T. A. Reamy certified that the ball entered from the right 6ide, midway of Poupart's ligament, passed into the left groin and lodged in the head of 
the femur, shattering it. The Columbus examining board certified that the ball impinged upon the horizontal ramus of the pubis, remained lodged for 
seven years, and was finally removed just below the tuberosity of the ischium. — 9. Pt. O. Wilson, C, 13th Iowa, age 24, Atlanta, July 21, 1864 ; a "shot 
wound of left thigh" was recorded at the field hospital. At the hospital at Keokuk, Surgeon 51. K. TAYLOR reported: " Penetrating wound of left hip, 
fracture of trochanter major; ball entered posteriorly to hip joint and lodged beneath the integuments of the left groin. Ball removed by an incision 
two inches long over the point of lodgement." Mustered out May 15, 1865. Examiner S. G. WHALEY, of Osceola, certified, in September, 1873 : " Shot 
wound of left hip by canister shot entering about 1$ inches behind trochanter major and passing to groin, same side, where it was taken out, in its passage 
destroying the head of the femur and part of the acetabulum." — 10. Pt. C. Wilson, A, 20th Georgia, Chickatnauga, September, 20, 1863; in an applica- 
tion for retirement from the Confederate army it is stated that he was furloughed from the Confederate hospital at Fort Valley, Georgia, March 29, 1865, 
for "gunshot wound of right hip, fracturing head of femur, resulting in anchylosis of the joint and deformity of the limb." 



70 



INJUEIES OF THE LOWER EXTREMITIES. [CHAP. x. 



Twenty-six recoveries after shot fractures of the "neck of the femur M were reported. 
Several of these patients have since died, and it is to be regretted that it was imprac- 
ticable to obtain records of the autopsies, if such were made. Twelve of the cases are here 
detailed. 1 

Case 137. — Captain William A. Bugh, Co. G, 5th Wisconsin, aged 35 years, was wounded at the engagement at Wil- 
liamsburg, Virginia, on May 5, 1862, and after lying a few hours on the field he was removed to a temporary hospital, and thence 
to a hospital transport in the York River and sent to Baltimore, where he was received at the Camden street U. S. A. General 

1 Brief accounts of the remaining fourteen cases are here adduced: 1. Pt. J. W. Galyean, E, 10th Indiana, age 28, Atlanta, August 6, 1864; severe 
injury near left hip by conoidal ball, thought, however, to have only involved the soft tissues ; treated in various hospitals, and discharged May 24, 1865- 
Examiner C. Hays, of Warsaw, Indiana, probably relying on the patient's statements, reported, in June, 1865, that '"the neck of the femur had been 
shattered by the missile ; that spiculae were found at dressing of the wound, and others for several months were eliminated in the discharges." None of 
the various surgeons who treated the Injury reported any elimination of bone fragments or other indication of partial or complete fracture (Circ. No. 2, 
S. G. O.). Galyean was drowned near Keokuk, June 5, 1871. — 2. Pt. J. Doody, C, 6th New Hampshire, aged 23 ; Bull Run, August 29, 1862 ; discharged 
from service at Mower Hospital, Philadelphia, March 16, 1863, for shot wound through hip, just below the joint, breaking the bone. Examiner W. S. 
Pekry, of Exeter, X. H., reported, August 13, 1863: " Bone fractured and not united; the leg is shortened; the fracture was so near the head of the 
bone that union could not be obtained;" in April, 1867, Dr. Perry reported: " The bone is thrown hack onto the dorsum of the ilium ; leg shortened two 
inches." Doody is reported to have died July 9, 1873 (Circ. No. 2, p. 95). — 3. Pt. W. V. Trail, C, 57th Virginia, aged 27; wounded at Gettysburg, July 
3, 1S63, was retired from service in February, 1864, on account of a " fracture of the left thigh bone near the socket," permanently disabling him. — 4. Pt. 
S. T. Hook, B, 79th Indiana; Stone River, December 31, 1862; conoidal ball, stated by Surgeon F. Seymour, U. S. V., to have perforated neck of right 
femur; case diagnosticated as a gunshot flesh wound of right thigh at Louisville and New Albany hospitals. Discharged May 7, 1863, and pensioned. 
The Indianapolis Examining Board reported, in October, 1873: " Ball entered two inches below Poupart's ligament, anterior aspect right thigh, passed 
posteriorly and outward, and made its exit on outer aspect of right nates, fracturing femur in upper third, leaving it shortened one and a half inches." — 
5. Pt. W. Miles, A, 60th Illinois, aged 18 ; Bentonville, March 19, 1865; conoidal ball struck righthip; stated to have involved neck of femur. Discharged 
June 26, 1865; pensioned. Examiner G. W. SCHUCHARD, of Jonesboro', reported, July 29, 1867: "Ball entered the right hip, striking the ilium at the 
posterior crest of the acetabulum, and has never been extracted." Examiner W. C. Lence reported, in September, 1875: "Ball entered hip about two 
inches below the posterior superior spine of ilium, passed inward, and remains lodged in external iliac fossa; there were no bones fractured." — 6. The 
details of the case of Pt. T. Winans, B, 28th Illinois, wounded at Shiloh, April 6, 1862, in which the neck of the left femur was said to have been frac- 
tured, will be found at page 283, Second Surgical Volume, Case 816. — 7. Pt. J. "W. Britton, C, 16th West Virginia, aged 23; Lynchburg, June 18, 1864. 
Surgeon B. A. VANDF.RKiEFr, U. S. V., noted a "shot fracture of the right thigh;" Surgeon S. N. SHERMAN, U. S. V., a "fracture of the neck of the right 
lemur." He was examined July 15, 1865, and discharged on account of "shot fracture of right femur, upper third." Examiner SI. D. BENEDICT, of 
Washington, reported, August 8, 1865: "Ball passed through upper portion of thigh, fracturing neck of femur." Examiner T. KENNEDY, of Grafton, 
reported, September 4, 1873: " Fracture three inches below hip joint; imperfect union; overlapping of upper portion of bone." — 8. Pt. A. G. Cotton, Co. 
H, 6th Indiana, aged 20 years, was wounded at Stone's River, December 31, 1862, and admitted to hospital No. 6, Nashville, January 5th. Surgeon C. 
SCHUSI.EU, 6th Indiana, recorded: "Gunshot wound of left hip, dangerous." One week afterwards the patient was transferred to hospital No. 7, at Louis- 
ville. Acting Assistant Surgeon W. W. GOLDSMITH reported that the man was discharged from service March 19, 1863, by reason of "gunshot wound 
of ischium, ball ranging forward and lodging under the sartorius muscle." Examiner J. G. HtNDUICKS, of Madison, Indiana, certified, January 14, 
1864 : " Ball entered the posterior part of the head of the left femur, passing forward and outward, dislocating the head of the femur, and lodging in the 
trochanter major, whence it was extracted on March 7, 1863. The limb is shortened some three and a half inches and partial anchylosis of the hip joint is 
produced." Examiner W. W. Potter, of Washington, D. C., reported, March 28, 1871 : "A ball entered centre of left gluteal region, passed forward, 
transfixing the hip, and made its exit on the anterior aspect of the thigh on a line drawn horizontally with the pubis. The neck of the femur was fract- 
ured. Union has taken place with two and a half inches shortening. The thigh measures three and a half inches less than its fellow, and in progressive 
locomotion the weight of the body falls on the ball of the foot." Examiner J. C. BURT, of Vernon, Indiana, reported, September 13, 1873: "A musket 
ball entered the left hip posteriorly, nearly over the great trochanter, and, passing obliquely inward and downward, caused an oblique fracture of the 
femur through the trochanters. There is overlapping and shortening of the femur about one inch. Owing to contraction of the hamstring muscles the leg 
is shortened three inches. Walks with a great halt, and motion of the leg is limited and difficult to perform." Substantially the same was reported in 
1875. The pensioner was paid March 4, 1876. — 9. Pt. F. Kimball. E, 1st Vermont Cavalry; aged 37 ; Stony Creek. June 27, 1864. He was discharged 
February 22, 1865, by reason of "two inches shortening of left lower extremity, occasioned by fracture of the femur at the surgical neck, etc." Exam- 
iner H. M. Chase, of Lawrence, believes that the ball fractured the femurat or near the neck. The pensioner was paid December 4, 1875. — 10. Pt. R. P. 
McCutchen, A, 42d Indiana, aged 23; Chickamauga, September 20, 1863. Assistant Surgeon R. Baktholow reported, from the field hospital at Chatta- 
nooga: "Gunshot fracture of left femur." The man was discharged for gunshot wound of left thigh, fracturing femurat neck. Examiner T. C. Van Nay, 
of Evansville, certified to a compound comminuted fracture of neck of femur. Pensioner paid December 4, 1875. — 11. Pt. W. B. Reynolds, H, 46th 
Alabama; Champion Hills, May 16, 1863. Surgeon H. Z. Gill reported: "Gunshot fracture of neck of left femur. Sixty days after the injury the limb 
was shortened three or four inches, very crooked, and, in my opinion, there was no prospect of a useful limb." — 12. Lieutenant C. P. Stoneroad, G, 51st 
Pennsylvania, aged 24 years, was wounded at the Weldon Railroad, August 19, 1864, by a conoidal ball. He was treated at the field hospital of the 3d 
division. Ninth Corps, and on August 25th was admitted into the Third Division Hospital, Alexandria. Surgeon E. BENTLEY, TJ. S. V., reported: "Ball 
entered the posterior and lateral aspect of the right thigh about one inch below the trochanter major, striking and slightly fracturing the femur. The 
wound was much swollen. Cold-water dressings were applied and an anaesthetic given, while dressing the wound, to alleviate the severe pain. Septem- 
ber 10th, the wound had almost entirely closed and the swelling had nearly gone; the paiu was still very great and prevented any attempt to move the 
hip joint. October 4th, the wound had closed entirely and he began to go about on crutches. November 3d, he left the hospital on a leave of absence; 
he had very little use of his leg; there was considerable shortening of the limb, the toe turning inward ; he could bear but little weight upon it, and was 
compelled to use crutches." On December 18, 1864, Stoneroad entered the Officers' Hospital, Annapolis. Surgeon B. A. Vanderkieft, U. S. V., reports: 
" Ball entered at the upper margin of the acetabulum, dislocated the hip joint, fractured the neck of the femur, and lodged beneath the floor of Scarpa's 
triangle." He was discharged December 30, 1864. Examiner E. GREEN, of Bellefonte, June 16, 1865, reports that he cannot decide " whether the mis- 
sile fractured the neck of the femur or caused partialdislocation ; * * * the foot turns out and the limb is shortened about an inch and a half. He 
only complains of pain on taking severe exercise and in wet weather." Examiner G. F. Harris reports, September 4, 1873: "Ball still lodged, dis- 
location of joint, shortening two and a quarter inches." Examiner T. R. Hayes, September 8, 1875, makes a similar report, and states that "he is quite 
lame." Disability total. Last paid June, 1877.— 13. Pt. D. Strickler, H, 25th Virginia, aged 19 ; Gettysburg, July 2, 1863. Surgeon H. Janes. U. S. V-, 
noted: "A mini6 ball entered the right thigh externally, fractured the neck of the femur, and lodged ; October 26th, bone has united." Surgeon A. 
Chapel, U. S. V. reported a "gunshot fracture of right femur," and Surgeon A. Heger, U. S. A., a "gunshot fracture of upper third of right femur." 
He was transferred for exchange April 27, 1864.— 14. Pt. J. Weber, I, 68th Pennsylvania, aged 23; Gettysburg, July 2, 1863. Surgeon S. W. GROSS 
reported a "gunshot fracture of neck of left femur," and Ass't Surgeon D. BACHE, U. S. A., a "gunshot wound of left gro!te and fracture of femur." He 
was discharged July 1, 1865. The Philadelphia Examining Board reported, in October, 1871: "Ball entered left groin near anterior superior spinous 
process of left ilium, passed through hip joint and out three inches behind left trochanter," and in November, 1873, that "the ball fractured the surgical 
neck of the femur." 



sect, ii] SHOT FRACTURES AT THE HIP TREATED BY CONSERVATION. 71 

Hospital on May 1", 1862. A conoidal musket ball bad entered the right groin, passed slightly downward, traversed the line 
of union between thigh and trunk, fractured the neck of the femur in its transit, and emerged posteriorly at the fold of the but- 
tock. On Hexing or rotating the thigh crepitus was plainly distinguished. His limb was suspended by Smith's anterior splint, 
and this treatment was continued for two months. The case progressed without a single untoward symptom, and in the middle 
of July, 1862, consolidation of the fracture was sufficiently firm to permit the patient's removal to the house of a friend. The 
limb was shortened one and a half inches. In October Captain Bugh was able to move about on crutches, and the wounds were 
entirely healed. About this time he took a journey to Washington, and was promoted to a lieutenant colonelcy in the 33d Wis- 
consin and placed on recruiting service. He served until April '25, 1863. His recovery was so rapid and uninterrupted that he 
reluctantly assented to the opinion of his surgeon, Dr. Edmund G. Waters, that he woitld be incapable of active duty in the 
field. A letter was received from Lieutenant Colonel Bugh, dated June 12, 1867, more than five years subsequent to his injury, 
in which he stated that he had partial anchylosis of the hip joint and was unable to perform any labor in a stooping posture. 
Otherwise his condition was satisfactory, though he was more readily fatigued and debilitated than before he was wounded. He 
suffered no inconvenience from the slight shortening of the femur. His death occurred eight years afterwards, on August 19, 
1875, of phthisis pulmonalis. Examining Surgeon N. M. Dodson, of Berlin, Wisconsin, informed this office on December 13, 
1878, that " no post-mortem was had in the case of Captain Bugh. The wound healed in 1866, and the limb remained sound 
afterwards. Bugh filled the position of postmaster, was much upon his feet, and residing for some years three-quarters of a mile 
from the post office, he walked to and fro three times a day with very little inconvenience, using only a cane. The joint was 
firmly anchylosed. He suffered from pain of a neuralgic character in the whole limb, and at night frequently with cramps in leg 
and foot." 

Case 138. — Private J. T. Elliott, Co. H, 22d Georgia, of Sorrell's Brigade, aged 24 years, received, at the engagement at 
Deep Bottom, Virginia, August 16, 1864, a gunshot fracture of the neck of the left femur. He was conveyed to Richmond and 
admitted to the Jackson Hospital. He recovered with three inches shortening of the limb, and being permanently disabled and 
totally disqualified for any military duty, he was retired from the Confederate States service on February 17, 1865. The case 
is reported by' Surgeons A. J. Semmes, Thomas F. Maury, and W. D. Hoyt, members of the medical examining board of the 
Jackson Confederate Hospital, at Richmond, Virginia, in February, 1865. 

Case 139. — Private Charles Miller, Co. A, 9th Illinois, aged 26 years, was wounded at the battle of Shiloh, Tennessee, 
April 6, 1862, apparently by a small rifle ball entering at a point midway between the left trochanter major and the tuberosity 
of the ischium and fracturing the neck of the left femur. He was conveyed to the general hospital at Savannah, and a month 
afterward was transferred by steamer to Quincy, Illinois, and admitted to hospital on May 7th. An unsuccessful search for the 
missile was made, and Buck's apparatus was applied. The bone united and the wound healed. He was discharged from service 
on October 14, 1862, having limited motion at the hip joint. The case is reported by Surgeon R. Niccolls, U. S. V. On April 
7, 1864, Dr. John C. Hupp, Pension Examining Surgeon at Wheeling, West Virginia, stated that the limb was shortened by 
about two inches, a partial luxation of the head of the femur upward apparently having been produced. Any movement of the 
thigh created severe pain. The cicatrices were firm and there were no fistulous orifices. In December, 1870, Examining Surgeon 
C. Griswold, of Fulton, Illinois, reported : " The ball entered posteriorly through the glutei muscles, and fracturing the femur near 
the socket, resulted in partially stiffened joints both at hip and knee of left leg. The hip joint will admit of only a little forward 
motion and rotation outward. The knee joint allows only partial flexion, and cannot be crossed over the right leg in a sitting 
posture. The leg is shortened about one-quarter of an inch. He cannot walk without limping." In August, 1873, Examiner P. 
J. Farnsworth, of Clinton, Iowa, stated : " The bullet remained in for four years, and was found under the superficial fascia: three 
inches below the wound. Motion of hip joint impaired. Contraction of abductor muscles, causing stiffening and retraction of 
knee joint. Constant neuralgic pain of thigh and leg, and considerable atrophy of muscles. Thigh two inches less in circum- 
ference than right at upper third. The original disability has increased." On May 1, 1878, the Davenport, Iowa, Examining 
Board reported : " There is shortening of the thigh to the extent of three-quarters of an inch, whence it is inferred that fracture 
of the upper portion of the acetabulum, or neck of femur, occurred; there is partial anchylosis of the knee joint. The patient 
walks with a cane with considerable impairment of motion." 

Case 140. — Private T. L. Lomax, Co. K, 30th Virginia, wounded at Antietam, September 17, 1862, and admitted to hospital 
No. 5, Frederick, on October 20th. Dr. A. V. Cherbonnier communicated, in June, 1869, that "it was supposed, when Lomax 
was admitted to hospital, he was merely suffering with a fracture of the thigh, high up, with no accurate knowledge of the 
extent. He was removed to a private residence, and after removal his limb was explored and a full knowledge and extent of 
the injury was ascertained. The injury was found to be serious, involving the upper portion, the trochanter, and, if I remember 
correctly, the neck. In the presence and with the assistance of Surgeon H. S. Hewit, U. S. V., and Assistant Surgeon J. H. 
Bill, U. S. A., I removed all the fragments of bone, and with the gouging forceps removed a considerable portion of dead and 
rough bone. The operation was repeated a couple of weeks after. The whole of the trochanter major was removed, going deep 
into the shaft, and leaving, if I remember correctly, but a shell of bone. When I left Frederick I had the satisfaction of seeing 
young Lomax on crutches. I cannot, with no notes, do justice to what I consider a most interesting ease," etc. Surgeon Hewit, 
in a note dated July 26, 1869, stated : "It was a case of comminution of the hip. Three secondary operations by gouging were 
performed by myself, in which nearly all the head, neck, and trochanteric portion of the femur were removed. He subsequently 
made a good recovery." Dr. G. Johnson, of Frederick, subsequently, on October 21, 1869, furnished the following details of 
the case: " Mr. Lomax was wounded in the left hip. The ball struck the femur, shattering it by his account, but producing no 
solution of the continuity. He remained in the temporary hospital near the battle-field for weeks, was then brought to Frederick, 
and on October 31st was transferred to a private residence and came under my charge. His strength at this time was gradually 
succumbing to profuse suppuration and pain, and although he rallied somewhat at first by the change of circumstances and 
improved hygiene, it soon became apparent that surgical interference was demanded to arrest the downward tendency. Until 
this time his only treatment had been the abstraction of detached pieces of bone, detergent washes to the wound, and anodynes 
and tonics. Carious bone in considerable extent being evident to the probe, it was determined to attempt its removal, and on 



72 INJURIES OF THE LOWER EXTREMITIES. [chap. x. 

November 15th Drs. Hewit and Charbonnier operated for that purpose, under chloroform. A large quantity of diseased bone 
was removed from the outer part of the upper third of the femur. There was but trifling hemorrhage, but much depression and 
irritability of stomach succeeded the operation, yielding, however, in a few days, to stimulants and effervescing draughts. For 
a fortnight the patient steadily improved under nourishing diet and tonics. He then again began to deteriorate under increasing 
suppuration, and on December 15th it was determined to again operate for the removal of diseased bone. This was accordingly 
done on that day by Dr. Hewit, the patient being under chloroform. The great trochanter and about two-thirds in circumference 
of the shaft of the femur were removed for several inches. The depression consequent was not so great as before, but on 
December 17th congestion of the right lung occurred, with expectoration of a quantity of typhoid pneumonic sputa. I painted 
the chest thoroughly with iodine tincture, and gave hydrochlorate of ammonia, with milk punch and animal soup. No consolidation 
of the lung occurred, and after a few days his chest gave no further trouble. I will not weary you with a detailed account of 
his symptoms and treatment during the four months ensuing. There was at no time any inflammation of the hip joint. Erysip- 
elas twice gave much trouble, as also the usual disposition in such cases to form purulent sinuses. On January 23, 18G3, I 
noted hard and excessive swelling of the limb, with grave constitutional disturbance attributed to lymphatic inflammation, and 
after this subsided much cedematous infiltration. Pieces of carious bone became from time to time detached, and were removed 
as soon as detected; the feeble circulation was supported by careful bandaging; the wound was kept thoroughly clean and his 
hygiene perfect. He took exercise in the open air in carriage and on crutches as soon as strength permitted, and in May was 
quite convalescent. June 8th, he left Frederick for exchange, still on crutches and wound discharging slightly, but looking 
healthy — almost robust. A year after, he wrote that he was perfectly well and walked comfortably with a cane. In mentally 
reviewing this case some points of interest occur to me: As to the cause of so extensive a caries — this was a true bone ulcer. 
The several operations did not consist of merely removing sequestra or detached portions of dead bone, but in paring and pinching 
off the diseased bone from that which was still sound. The ulceration was progressive. The second operation was more extensive 
than the first and at a month's interval. These facts are consistent with the theory (suggested, I think, by Dr. Hewit) that the 
caries depended upon osteitis, and this probably caused by the peculiar velocity with which the mini6 ball strikes. The amount 
of callus effused after the final operation was immense, fully equalling the new bone of a prolonged case of necrosis, and soon 
allaying the fear at first felt of fracture of the continuity of the bone through muscular action or otherwise. As regards the 
statistical value of the case it ended well ; but after an illness in which his life was in extreme jeopardy several times, and under 
circumstances rarely attainable in private practice, and I should think impossible in military life. The patient had full advantage 
of every circumstance that affection could prompt and pecuniary means procure. He was in the prime of life and entirely free 
from constitutional taint. He was free from depressing influences of every kind, while in his medical and surgical treatment I 
had the counsel and assistance of scientific and thoroughly experienced men. Among them, both he and I are under lasting 
obligations to Dr. Hewit, to whose operative skill, no less than to his humanity in permitting his removal from hospital, is due 
whatever credit may pertain to the issue of the case." The bone removed at the two operations referred to consists of a number 
of fragments, and was subsequently contributed to the Museum by Dr. Johnson, and constitutes Spec. 5C52 of the Surgical Section. 

Case 141. — Private M. M. Phillips, Co. F, 42d Mississippi, aged 23 years, was wounded at the battle of Gettysburg, 
Pennsylvania, July 3, 1863, by a musket ball, which entered the posterior and outer aspect of the left buttock, fractured the 
neck of the femur, and emerged in the left groin. He was captured and removed to the hospital for Confederates, and was 
treated by the expectant plan. On July 22d he was transferred by rail to the De Camp Hospital, in New York Harbor. The 
wounds of entrance and exit had healed. He was able to walk by the aid of a crutch or cane and suffered no pain. The limb 
was shortened one and three-quarter inches. By flexing and rotating the limb true osseous crepitus was obtained. There was 
no inversion or eversion. The patient, much against his will, was placed upon a fracture-bed, where extension was produced 
for six weeks by a twelve-pound weight acting over a pulley. He was then permitted to rise and directed to use passive motion 
and friction. On September 20, 1863, he was paroled, being able to walk without assistance of any kind. The limb was short- 
ened one and a quarter inches. The case is reported by Acting Assistant Surgeon George Edwards. 

Iii the next case, as in the case of Private Charles Miller (Case 139, page 71), partial 
anchylosis of the knee joint had supervened many years after the injury: 

Case 142. — Private James Vanderbeck, Co. F, 145th New York, aged 21 years, was wounded at the battle of Chancellors- 
ville, May 3, 1863, by a conoidal musket ball, which entered the left thigh above and behind the trochanter major, passed forward 
and inward, fractured the neck of the femur, and made its exit at the groin. He was made a prisoner and remained in the hands 
of the enemy eleven days. He was then exchanged and conveyed to the Twelfth Corps Hospital, at Aquia Creek. The injured 
limb was simply placed in a comfortable position without any attempt at extension. On June 14th the patient was removed on 
a hospital transport to Alexandria and placed in the First Division Hospital. He was in good condition. The suppuration was 
comparatively slight, and no bone splinters were found loose and none had come away. Three days subsequently he was trans- 
ferred to Philadelphia, and thence, on October 12th, to New York, where he was admitted to the Ladies' Home Hospital. The 
wounds were closed at this date. The patient was discharged from the hospital and from the service of the United States on 
November 19, 1863. On that date he walked with crutches. His limb was shortened two inches, with eversion. He was allowed 
a pension. On August 2, 1866, Dr. E. Bradley, Examining Surgeon of the Pension Bureau, reported that Vanderbeck's general 
health was good, but that there was much lameness. The fracture was firmly consolidated. Commissioner C. C. Cox reports 
that Vanderbeck received his pension at the agency in New York City on March 4, 1868, and that his disability was then rated 
by the examining surgeon as total. On September !), 1873, Examining Surgeon T. F. Smith, of New York City, states: "Ball 
entered left nates and emerged beneath left popliteal ligament, fracturing the femur; there is union with deformity and three inches 
shortening." On September 7, 1875, the New York Examining Board, Surgeons T. F. Smith, J. F. Ferguson, and M. K. Hogan, 
report "that the knee is anchylosed and the patient is obliged to wear a sole on his shoe three inches thick, and to walk with a 
cane ; the leg is useless for purposes of labor." 



SECT, II.] SHOT FRACTURES AT THE HIP TREATED BY CONSERVATION. 73 

Cask 143. — Private T. C. Garvin, Co. 11, 94th Now York, aged 43 years, was wounded at Hatcher's Run, February 7, 
1865, and admitted tu the field hospital of the 3d division, Fifth Corps. Surgeon D. 0. Chamberlain, 94th New York, noted: 
" Gunshot wound of genitals." Four days after the reception of the injury the man was admitted to the Newton University 
Hospital, Baltimore, whence Surgeon R. W. Pease, U. S. V., reported: " Gunshot wound of penis and right testicle, ball emerging 
from right gluteal region, fracturing the femur." In a ease book it is recorded that Buck's apparatus and counter-extension 
were used, also that there was free suppuration from the wound, and that evidence of union of the bone set in about March 10th. 
Assistant Surgeon D. C. Peters, U. S. A., reported that the patient was admitted to Jarvis Hospital May 23d, and described the 
injury as follows: " Gunshot wound of penis, right testicle, and fracture of femur involving the neck. Urine escapes through 
the lower opening of the penis. He had some union of limb, with about three inches shortening." The patient was discharged 
from service June 11, 1865, and pensioned. Examiner G. \V. Cook, of Syracuse, New York, certified, April 25, 18G6: " Bullet 
struck the glans penis, passing downward and backward through the urethra, producing hypospadia, through which the urine 
is voided, thence into the right testicle, which is destroyed, thence into the right thigh, fracturing the same." The pensioner died 
January 3, 1869. Dr. A. Welch, his attending physician, certified that "to the time of his death Garvin was laboring under 
severe pain and difficulty from a wound which he received in the hip of the right side, passing through the joint and through 
the testicle, destroying the hip joint, and producing shortening of the limb, and an open wound from which pus and portions of 
the joint, consisting of splinters of bone, were discharged to the time of his death." 

Case 144. — Corporal Daniel Bachler, Co. G, 82d Illinois, aged 23 years, was wounded in the battle of Chancellorsville, 
Virginia, May 2, 1863, by a round ball, which, entering just above the right trochanter major, fractured the neck of the femur, and 
emerged beneath Poupart's ligament about two inches from the symphysis pubis. He stated that he lay thirteen days on the 
plank road unattended. He was admitted May 15th to the field hospital of the 3d division, Eleventh Corps, and was transferred 
thence, by steamer, to Alexandria, and admitted May 25th into the First Division Hospital. The patient had been informed 
that the wound involved the soft parts only; cold-water dressings had been applied. The limb was shortened about three inches. 
A fracture through the neck was discovered. Partial union had taken place. There was little suppuration and the pus was 
healthy ; the parts were but little swollen. Smith's anterior splint was applied and moderate extension made by weight and pulley. 
He was furloughed on July 14th for sixty days, and went to Chicago, Illinois. On September 10th Bachler was received into the 
City General Hospital in Chicago. A gunshot wound of the right hip joint was recorded. He was transferred to the 2d bat- 
talion of the Veteran Reserve Corps on August 7, 1864. The case is reported by Surgeon Norman S. Barnes, U. S. V. The 
patient was discharged on July 15, 1865. The Chicago Examining Board, Drs. Win. C. Lyman, E. D. F. Roler, and F. A. 
Emmons, report on September 10, 1873 : " The pensioner was shot through the hip close to the joint; there was loss of some small 
pieces of bone, and half an inch shortening of the limb." On April 3, 1878, the Board state: "There is partial loss of flexion 
and of power of leg, with neuralgic pains; the neuralgia is increasing." 

Case 145. — Private James McCabe, Co. A, 12th Massachusetts, was wounded on September 17, 1862, at the battle of 
Autietam, by a musket ball, which entered just below the right groin and made its exit at the buttock, fracturing the neck of the 
femur in its passage. He was conveyed to hospital No. 5, at Frederick, Maryland, and was treated witli the limb in an extended 
position. On November 9th he was transferred to Frederick Hospital No. 1. In December a large metastatic abscess formed about 
the right shoulder, which was laid open by Assistant Surgeon R. F. Weir, U. S. A., a large quantity of pus escaping. After the 
healing of the abscess there was much weakness of the muscles of the acromial and humeral region, and the patient could not 
raise his hand above his chin. On June 16th he was sent in good condition to the Jarvis Hospital at Baltimore, and thence to 
Point Lookout Hospital, where he remained until July 25, 1864, when, the wound being healed, he was discharged. He was 
mustered out of service August 5, 1864. On June 10, 1867, he was examined at the office of Surgeon General Dale, of Massa- 
chusetts. The fracture was firmly consolidated. There was but a slight limp in walking. His general health was excellent. 
He received a pension and was employed in the Soldiers' Messenger Corps. He experienced no pain, except on change of 
weather or when his walk was extended beyond two miles. He considered his injury but a slight disability in his business, 
since he had free passes on all the lines of horse cars in Boston. 

Case 146. — Sergeant Edward G. Gilliam, Co. C, 11th Virginia, aged 24 years, was wounded in the engagement at Drury's 
Bluff, Virginia, May 16, 1864, by a rifle ball, which, entering the upper portion of the right thigh in front, fractured the neck of 
the femur, and lodged. He was conveyed the same day to Richmond and admitted into Chimborazo Hospital. There was ever- 
sion of the limb, but no shortening. On placing the finger upon the seat of fracture and rotating the thigh it was observed that 
the trochanter major moved with the shaft. There appeared to be but little comminution, and there was no escape of synovial 
fluid. The parts were but little tumefied. The limb was comfortably adjusted on pillows. The patient complained of severe 
pain in the thigh, especially along its inner aspect, and had frequent twitchings of the muscles. The pulse was 80, the tongue 
clean, the appetite poor. Half an ounce of whiskey was directed every fourth hour, and a nourishing diet, with one-third of a 
grain of morphine given at bedtime. During the latter part of May there was severe local pain, with rapid emaciation, and a 
bed-sore formed over the sacrum. On June 15th the limb was swung in a Smith's anterior splint. The patient's appetite soon 
began to improve, the pulse about 96. On June 27th he yet suffered severe pain in the hip and along the inner part of the 
thigh. On July 1st synovial fluid in large amount issued from the wound, after which the pain subsided. His appetite continued 
to improve, and he now slept well at night. One or two small spiculce of bone were eliminated in the discharges. On July 10th 
he was stronger and had no pain ; the bed-sore was healing; the discharge from the wound was small in quantity, and the oedema 
was disappearing. For several days, about July 20th, he suffered pain at the knee, and the splint was removed. On July 30th 
the bed-sore was healed and his health was greatly improved ; but any movement of the hip joint continued to create severe pain. 
By August 10th he had become stout and fleshy and could suffer the limb to be moved, and August 22d it could be moved freely 
without producing pain. At this date a small spicula of bone was removed. There was only a slight discharge from the wound. 
On September 5th he was able to raise the limb a short distance from the bed, and September 14th he sat up in a chair. There 
was limited motion of the hip joint. He was furloughed for sixty days on September 20, 1864. The case is reported by Surgeon 
E. M. Seabrook, C. S. A. 
Surg. Ill— 10 



74 INJURIES OF THE LOWER EXTREMITIES. [CHAi>. x. 

Case 147. — Surgeon B. W. Avent reports tliut an officer received a gunshot fracture of the neck of the femur ; two fingers 
at entrance and exit fully explored the wound; date of injury unknown. The wound was dilated at entrance and spieulte was 
removed with saw and forceps. He lingered for months, but finally recovered with a limb four inches short, hut able to walk 
with the assistance of a cane. 

Cask 148. — Private E. Yerger, Co. I, 11th Pennsylvania, aged 31 years, was wounded at Antietam, September 17, 1862, 
and entered the Broad and Cherry Streets Hospital, Philadelphia, on December 12th. Surgeon J. Neil], U. S. V., reported : 
"He was admitted to this hospital with an undetected fracture of the neck of the right femur. A minie ball entered on the front 
of the thigh on a vertical line with the anterior superior spinous process of the ilium and four inches below it, and, passing 
obliquely upward and backward, was cut out on a line with and about two inches below the posterior superior spinous process 
by the surgeon of the regiment on the field. At the time of his admission the wound had entirely healed, but the patient was 
unable to bear weight on the limb without pain. The tissues over and above the trochanter were flattened, and the fold in the 
buttock was absent. Eotation was imperfect, and when an attempt was made to bear weight on the limb distinct crepitus could 
be felt in the neck of the bone, and he complained of pain at that point. Measurement from the xiphoid cartilage revealed two 
and a half inches shortening of the injured side, and from the anterior superior spinous process of the ilium it was three-fourths 
of an inch. The fracture appeared to be impacted, and the whole of the right innominate bone was considerably elevated above 
its normal position. The posterior superior spinous process of that side was also more prominent than that on the other side, 
giving the idea that the sacro-iliac symphysis had been injured and in that way accounting for the marked amount of shortening 
by measurement from the xiphoid cartilage. He stated that when shot he fell, the right hip striking the ground, and any attempt 
to move the limb gave rise to severe pain in the hip joint ; also that the surgeon told him it was only a flesh wound and would 
soon be well. He remained in a field hospital for nine days, when he was removed to Chambersburg and treated for nine weeks, 
during which time he was allowed to get up to go to stool. The wound healed about two weeks before admission to this hospital. 
No fragments of bone were removed; crepitis is not so distinct, and his general condition is good. The amount of shortening 
from the anterior superior spinous process has increased from three-fourths to a full inch since admission." The patient was dis- 
charged from service April 27, 1863, and pensioned. Examiner J. J. McCormick, of Irwin Station, Pennsylvania, certified, 
Septembers, 1873: '"Ball entered right thigh in front of trochanter major and came out one inch from lower end of sacrum, 
fracturing the neck of the femur. The limb is two and one-half inches shorter than the other; strength so much impaired that he 
cannot walk without a cane. Muscles of limb are atrophied." In an examination for increase of pension, in April, 1880, 
Examiner McCormick reports: "There is great impairment of the strength and usefulness of the limb. The pensioner cannot 
work at all, nor can he set on a chair except a little on the left hip. The injury is nearly equivalent to the loss of Uio limb." 

In five instances of recovery after alleged shot fracture of the hip joint the "neck 
and trochanters" or "the neck and shaft" of the femur were reported to have been frac- 
tured. Three of the cases 1 are here given in detail : 

Case 149. — C. F. Beyland, Q. M. D., aged 26 years, was wounded December 8, 1861, by a conoidal musket ball, which 
fractured the great trochanter and neck of the right femur. Excision was proposed and refused. The fracture was treated by 
Hagedorn's apparatus. After protracted and profuse suppuration the patient recovered with a limb shortened two inches. In 
July, 1863, he had dispensed with crutches and walked quite well. Assistant Surgeon C. K. Winne, U. S. A., reported the case. 

Case 150. — Corporal Luke English, Co. E, 2d Wisconsin, aged 21 years, was wounded at the battle of Gettysburg, Penn- 
sylvania, July 1, 1863, by a conoidal musket ball, which entered at a point between the left trochanter major and the tuberosity of 
the ischium, emerging near the anus, penetrated the right thigh and fractured its trochanters, and lodged. He was admitted the 
next day into the Seminary Hospital at Gettysburg. Search for the missile was unsuccessful. Two fragments of bone were 
extracted. Cold-water dressings were applied. On July 17th he was transferred by railroad to York Hospital. Early in 
August the average discharge of pus was about four ounces. The wound of entrance had nearly closed. On November 4th he 
could walk a little, the wound, however, discharged considerably. He was discharged from the service of the United States on 
June 23, 1864. Surgeon Henry Palmer, U. S. V., reports the case. His attorney, John Hancock, of Oshkosh, Wisconsin, 
reports that English died in 1867. 

Case 151. — Private Philip Sweeney, Co. C, 3d New York, was wounded in the affair at Big Bethel, June 10, 1861, by a 
conoidal musket ball, which shattered the trochanters of the right femur. He was admitted to Hygeia Hospital, Fort Monroe, 
on June 13th, and was treated by Surgeon E. B. Bontecou, U. S. V., by moderate extension and dilatation of the wound by 
sponge tents in order to facilitate the extraction of primary sequestra, of which many were removed. Suppuration and exfolia- 
tion persisted until March, 1862. In April there were two severe attacks of erysipelas, involving the entire limb, which greatly 
reduced the patient, but he quickly rallied, and in May was able to run a race on crutches with his wounded companions. He 
was transferred to Albany in June, 1862; but his name does not appear upon the hospital reports until March, 1863, when he 
was admitted to the Ladies' Home, in New York City, where a number of necrosed fragments were removed. On May 25, 1863, 

'The remaining two cases were: 1. Serg't P. Casserleigh, A, 38th Illinois; Chickamauga, Sept. 19, 1863; conoidal ball entered behind the right 
great trochanter, passed inward and forward, fractured the apophysis, and, it was believed, injured the anterior crural nerve. It was considered possible, 
though not probable, that the joint was injured. He was discharged July 11, 1803. Examiner T. S. HENIXG, of Springfield, reported, in May, 1865, 
that a ball entered the right hip a little posterior to the great trochanter, passed into the hip and remained concealed in the tissues ; limb one and a half 
inches shortened ; motion and power of joint destroyed; and in November, 1866, that "the ball fractured the head and neck of the femur." The Springfield 
Examining Board reported, in August, 3874: "Thelimhisanchylosed in a semiflexed position and shortened four inches (Circ. 2, p. 94, Case 201). — 2. Pt. T. 
Purcell, F, 96th Pennsylvania, aged 22; Chancellorsville, May 3, 1863; a conoidal ball was stated to have produced a fracture of left femur in upper 
third, extending into hip joint. From a field hospital of the Sixth Corps he was transferred to Armory Square Hospital, Washington, and subsequently 
to Cuyler Hospital, Germantown, Pennsylvania. No mention was made at either of the latter hospitals of the involvement of the hip joint. At Mower 
Hospital, Philadelphia, the injury was noted as a "gunshot wound of upper third of left thigh with loss of four inches of bone." He was discharged 
July 8, 1865. Examiner J. T. Carpenter, of Pottsville, reported, in September, 1873 : " Entrance of wound about four inches below anterior superior 
•pinous process of ilium, upper third of femur shattered ; five inches shortening; no power; wasting of limb." (Circ. 2, p. 95, Case 211.) 




ii'ii nil: 



CONSOLIDATED GUNSHOT FRACTURE OF THE FEMUR. 



sect, hi SHOT FRACTURES AT THE HIP TREATED BY CONSERVATION. 75 

he was discharged, being able to walk without a crutch and the limb being but slightly shortened, lie soon afterwards engaged 
himself as a laborer at an iron foundry in Troy, New York, where lie has since worked without intermission. On July 20, 18GC> 
he was examined by Brevet-Colonel R. 13. Bontecou, who found him in perfect health, the injured limb a trifle shortened, and 
the knee rather stiff, owing to the destruction of connective tissue about the extensor muscles of the thigh during the suppura- 
tion following the erysipelatous attacks, and, doubtless, the formation of adhesions. The knee joint was in good condition and 
had sufficient motion to allow a firm, good gait. In a letter dated November 23, 1808, Dr. Bontecou states that Sweeney is at 
work at Troy in a spike factory, and was able to sit at and run a machine. His knee was stiff from agglutination of the sheath 
of the extensor muscles of the thigh, otherwise the limb was useful. The Albany Examining Board, Drs. W. Craig, K. B. Bon- 
tecou, and C. H. Porter, record, in September, 1873 : " Gunshot wound through the trochanters, fracturing the femur at the neck, 
leaving adhesions of all the muscles of the thigh from deep-seated sloughing, the result of erysipelas, making knee joint stiff in 
the extended posture." In September, 1875, Examining Surgeon R. B. Bontecou certified that "adhesions have rendered the 
knee immovable and the limb comparatively useless." 

The parts injured were not particularly specified in ten instances of recovery after 
alleged shot fracture of the hip joint. Two are here detailed, and eight are briefly recorded 
in the foot-note. 1 

Case 152. — "Private William C.Watson, Co. A, 4th Michigan, was struck in the left hip, at the battle of Malvern Hill, 
Virginia, July 1, 1862, by a conoidal musket ball. A fracture through the trochanteric region, with fissures probably extending 
to the joint, was reported. He was conveyed to Philadelphia and admitted into the Episcopal Hospital July 30th, transferred 
to Master Street Hospital on March 18th, and to South Street Hospital May 11th. The patient stated that for weeks his life 
was despaired of in consequence of the excessive suppuration which took place. Abscesses formed in the upper third of the 
thigh. Spicules of bone escaped at intervals for months from the wound and through the incisions made for the evacuation of 
the abscesses. On January \, 1864, suppuration had nearly ceased. The limb was shortened several inches and there was much 
deformity. On March 24th he was admitted into Christian Street Hospital, where he was discharged from service May 5, 1864. 
He received a pension in September, 1868, and his disability was rated as total and permanent." Surgeon Paul 13. Goddard, 
U. S. V., reports the case. 

Case 153. — Private Samuel Hensel, Co. H, 114th Pennsylvania, aged 31 years, was wounded at the battle of Chancellors- 
ville, Virginia, May 3, 1863, by a musket ball, which entered the central portion of the left buttock. The soldier was conveyed 
by steamer to Washington, where, on May 8th, he was received into Armory Square Hospital. The wound was probed daily in 
search of the missile, which, at the end of two weeks, presented itself at the point of entrance and was extracted by the patient. 
He states that it was a round ball, but was flattened on one side, and had, in this surface, a clean cut filled with osseous matter. 
The treatment consisted of rest, position, and the application of cold-water dressings. On June 16th the patient was transferred 
to McKim's Mansion Hospital, in Baltimore. About the middle of July the nurse, while dressing the wound, discovered in it a 
foreign substance, which, upon removal, proved to be a portion of the haversack. The patient was soon afterwards transferred 
to Mower Hospital, Philadelphia. Early in September a spicula of hone, nearly two inches in length by one in width in its 

1 Cases of: Corp'l J. J. Atkenson, B, 1st Tennessee; wounded .at Murfreesboro* ; be was examined at Lauderdale, Mississippi, by Surgeons J. T. 
Kennedy, D. W. Whimfek, andll. YANDELL, P. A. C. S., who certified that he was suffering from a shot wound of left hip, fracturing bone, and wound of left 
hand, loss of use of two fingers ; shortening and deformity of leg ; retired to Confederate Invalid Corps (Circ. 2, p. 98, Case 228). — 2. Sergeant Albert G. 
Beebe, A, 85th Illinois, received, in the engagement near Perryville, Kentucky, October 8, 1802, a gunshot wound of the right hip, which was believed to 
involve a fracture of the joint. He was conveyed to hospital No. 7, in Perryville. He was discharged from service on February 15, 18G3. His disability 
was rated as total. He is a pensioner. Examiner P. L. Diffexuecheu. of Havana, Illinois, reported, May 29, 1870 "■ " Wound of right leg ; ball entered 
on the anterior aspect about three and a half inches below the groin, passed posteriorly and wounded trochanter major, superior aspect. Exit just 
posterior to the thigh joint ; bones and muscles destroyed; also large cicatrix at point of ingress. Hip joint and leg affected by rheumatism aggra- 
vated by fatigue and exposure." The case is reported by Assistant Surgeon H. S. WOLFE, 81st Indiana. — 3. Pt. D. J. C. Campbell, E. 3d Virginia, 
aged 30 ; Payne's Farm, November 27, 1803; shot wound left hip, ball entering near the trochanter major and lodging in the bone in the vicinity of the 
hip joint; retired from service, unfitted for any duty (Circ. 2, p. 98, Case 229). — 4. Corp'l H. Koch, F, 7th Missouri, aged 20; Chickamauga, September 
20, 1803; conoidal ball splintered left femur above the shaft; discharged May 10, 18G4. The St. Louis Examining Board reported, June 3, 1874: "Ball 
struck left thigh near trochanter major, shattering the bone" (Circ. 2, p. 100, CASE 245). — 5. Pt. A. C. Woodall, G, 55th Pennsylvania, aged 17 ; Drury's 
Bluff, May 10, 1804; fracture left hip, involving the articulation; mustered out June 8, 1805, and pensioned (Circ. 2, p. 101, CASE 254).— 0. Corp'l T. Gal- 
lagher, F, 105th New York, aged 30; Port Hudson, May 27, 1863; canister ball entered two and a half inches below great trochanter, passed backward 
and upward, and lodged three inches from place of entrance ; projectile and several fragments of bone removed ; discharged December 19, 1803, and pen- 
sioned. The New York Examining Board reported in October, 1872: *' Ball struck outer aspect upper third left hip, fracturing or splintering the femur, 
and leaving two well-marked cicatrices; interferes with locomotion" (Circ. 2, p. 103, Case 261). — 7. Pt. R. F. Carter, B, 20th North Carolina, aged 21 
years, was wounded at Gettysburg. July 1, 1803. His injury is entered on the register of the Gettysburg field hospital as a "gunshot wound of thigh and 
hip, with compound comminuted fracture of hip joint." On September 4th the patient was admitted to Camp Letterman, where Surgeon H. JAKES, U. 
S. V., recorded: "A mini6 ball entered outer side of upper third of left thigh, lodging in the left groin and fracturing the femur in its course. When 
admitted the general health of the patient was good; leg a little swollen. On September 12th a small piece of bone was removed. October 10th, wound 
discharging freely, and fracture united with firm callus thrown out. November 8th, improving slowly. Patient can bear about one-tenth of the weight 
of his body on the limb. November 10th, transferred convalescent." Surgeon A. ClIAPEL, U. S. V., reported that the man was admitted to West's Build- 
ings Hospital, Baltimore, with "gunshot wound of left hip," and that he was paroled November 12, 1803. — 8. Pt. II. Murlatt, G, 12th Illinois Cavalry, 
aged 19 years, was wounded at Upperville, June 2L, 1803. He was admitted to a Cavalry field hospital, where Surgeon J. B. W. MITC1IEM,, 8th Penn- 
sylvania Cavalry, noted : " Wound of left thigh by a pistol ball." Surgeon J. A. LlDELL, U. S. V., recorded his admission to Stanton Hospital, Wash- 
ington, June 23d, with "wound of thigh," and his "return to duty on November 25, 1803." It is believed, however, that the man did not return to active 
field service, but was discharged from the hospital only to accompany his command when changing station from the Army of the Potomac to the Western 
armies. He was subsequently admitted to Camp Gamble, whence he was transferred to the Lawson Hospital, St. Louis, on February 15, 1804. Surgeon 
C. T. Alexander, U. S. A., reported: "Gunshot wound of left thigh two inches below Poupart's ligament; ball passing downward, inward, and 
lodging. Wound healed when admitted, General condition good; uses crutches. Patient discharged from service February 27, 1864." Examiner C. 
Hay, of Warsaw, Illinois, certified, December 20, 1865: "A pistol ball entered the anterior upper third of the thigh, ranging towards the hip joint. The 
joint was in all probability injured, as he has not been able to move the limb upward since the casualty. The ball was lodged in or near the hip joint, 
upon the thigh bone, and still rests there. The bones composing the hip joint ore now carious. The urinary organs are much deranged in their functions." 



76 INJURIES OF THE LOWER EXTREMITIES. [CHAP. x. 

central portion, was extracted from the wound. Flaxseed poultices were applied. Subsequently ten other pieces, varying in 
size from one-fourth to one inch in length, were eliminated. The wound soon closed and the patient was able to get about on 
crutches. On September 24th he was transferred to McClellan Hospital, Philadelphia, where, on May 13, 1864, he was dis- 
charged from service "because of a compound fracture of the left thigh, upper third, incapacitating him for duty." Pension 
Examining Surgeon H. L. Hodge, of Philadelphia, reported, May 26, 1864 : "On account of a gunshot fracture, probably of the 
OS innominatum (left), there is a luxation of the head of the femur, which destroys the usefulness of the whole limb." On 
November 1, 1866, an apparatus was fitted to the disabled limb by Gemrig, of Philadelphia. Examining Surgeon James Cum- 
miskey reported, April 6, 1867 : "Was wounded by a ball entering the left buttock and lodging for a time in the left groin, frac- 
turing the head of the femur badly, and resulting in shortening of the limb about three and a half inches and much wasting and 
feebleness of the limb. He is obliged to wear constantly an iron instrument to support the limb in walking. He suffers much 
pain at night." In a communication to this office dated Philadelphia, February 13, 1868, Mr. Hensel states that he is unable to 
walk without the use of the apparatus and a cane, but by the aid of these he can walk from a half to three-quarters of a mile, 
being obliged, however, to rest for two or three minutes once or twice by the way on account of pain and weakness in the limb. 
The Philadelphia Examining Board, Drs. H. E. Goodman, T. C. Rich, and James Collins, reported, September 4, 1875: "Has 
had a ball enter the left buttock, which was extracted from the wound of entrance. Has lost bone from head of femur, and the 
limb is nearly three and a half inches shortened. He has to wear a support with a high heel and sole shoe. Motion of hip joint 
limited to one-eighth degree. Spine curved from short limb." 

Details of twenty-one of the reported cases of recovery after alleged shot fractures of 
the hip joint have been cited in the preceding pages, and the remaining thirty-four cases 
have been briefly alluded to in the foot-notes. The hip joint was undoubtedly involved in 
three of the fifty-five cases, viz: Case 134, of Lieutenant Colonel H. C. Strong, 38th New 
York Volunteers; Case 140, of Private T. L. Lomax, 30th Virginia; and Case 143, of 
Private T. C. Garvin, 94th New York Volunteers. The latter died four years after the 
injury, but the opportunity was not improved of ascertaining unequivocally the precise 
nature of the injury to the articulation. Twelve cases 1 were probably examples of fractures 
of the trochanteric region or base of the neck of the femur, without the capsule. In 
thirteen cases the evidence is, to say the least, contradictory as to the seat of injury. 2 In 
five cases the evidence adduced is compatible with the supposition that the fractures were 
extracapsular. 3 In five other cases it is not proven that the articulation was directly 
injured. 4 The case of Private A. C. Woodall {Note 1, page 75) seems to have been a 
periarticular injury only. In the case of Private J. W. Galyean, 10th Indiana Volunteers 
{Note 1, page 70), the Pension Examining Surgeon, years after the injury, diagnosticated 
an injury to the joint. In the case of Private J. Hughes, 1st Alabama Cavalry, the evi- 
dence consists of an affidavit of an unknown surgeon before an "Association for the relief 
of maimed soldiers." In thirteen cases 5 the evidence is entirely insufficient to prove that 
the injuries were intracapsular shot fractures of the joint. In the case of Private W. 0. 
Watson (Case 152, page 75), 4th Michigan Volunteers, there remains room for argument, 
but the weight of evidence is adverse to the supposition that the hip was implicated. 

Of the fifty-five cases of alleged recoveries after shot fractures of the hip joint treated 
without operative interference, eighteen were Confederate and thirty-seven Union soldiers. 
In the cases of the Confederate soldiers no information subsequent to the close of the war 
could be obtained. Of the thirty-seven Union soldiers four had died previous to 1880, 
one had not been heard from since 1866, and thirty-two were pensioners. 

■Cases of: Pt. Philip Sweeney (Case 151, p. 74, ante); Pt. Charles Miller (Case 139, p. 71); Pt. M. M. Phillips (Case 141, p. 72); Pt. James 
Vanderbeck (CASE 142, p. 72); Pt. J. Doody (Note 1, p. 70); Corp'l D. Bachler (Case 144, p. 73); Serg't E. G. Gilliam (Case 146, p. 73); Pt. J. Wright 
(Case 135, p. 69); Corp. L. English (Case 150, p. 74); Serg't A. G. Beebe (Note 1, p. 75); Corp. T. Gallagher (Note 1, p. 75); Pt. S. Hensel (CASE 153, p. 75). 

'Cases of: Pt. J. Kivel, Pt. W. Swank, and Pt. O. Wilson (Note 1, p. 69); Pt. J. W. Britton, Pt. A. G. Cotton, Pt. P. Kimball, Pt. R. P. 
McCutchen, Lieut C. P. Stoneroad, Pt. D. Strickler, and Pt. J. Weber (Note 1, p. 70); Serg't P. Casserleigh and Pt. T. Purcell (Note 1, p. 74); and of 
Pt. H. Marlatt (Note 1, p. 75). 

3 Cases of: Capt. W. A. Bugh (Case 137, p. 70); Pt. J. T. Elliott (Case 138, p. 71); Surgeon B. W. A vent's case of an unknown officer (Case 147, 
p. 74); Pt. R. Yerger (Case 148, p. 74); and C. F. Beyland (Case 149, p. 74). 

4 Casesof: Pt. J.McCabe (CASE 145, p. 73); Pt. S. T. Hook, Pt. W. Miles, and Pt. T. Winans (Note 1, p. 70); and Corp'l H.Koch (Note 1, p. 75). 

•Cases of: Pt. J. L. Harvey (CASE 133, p. C7, ante); Pt. G. A. Crymes, Serg't F. M. Hunter, Colonel L. S. Slaughter, Pt. 7. 5. Smith, Pt. R 
Finkle, and Pt. C. Wilson (Note 1, p. 69); Serg't J. M. Adams (Case 136, p. 69); Pt. W. V. Trail and Pt. W. B. Reynolds (Note 1, p. 70); Corp'l J. J 
Atkmson, Pt. D. J. C. Campbell, and Pt. S. F. Carter (Note 1, p. 75). 



SECT. II.] 



WOUNDS AND INJURIES OF THE HIP JOINT. 



77 




FIG. 26.— Erosion i«f light 
OS innominatum and head- of 
femur after shot contusion. 
Spec. 758. 



Shot Fractures at the Hip Joint unsuccessfully treated by Conservation. — Two hun- 
dred and forty-nine fatal cases of shot fractures of the bones of the hip joint treated by- 
conservation were found on the various reports and hospital registers. In ten instances 
the acetabulum was recorded to have been fractured: 

Case 154. — Private G. W. Gentle, Co. E, 5th Ohio, was wounded at Antietara, September 17, 1862, and admitted to 
hospital No. 3, Frederick, October 1st. Assistant Surgeon J. H. Bill, U. S. A., reported: "The ball entered to the outside of 
the right pyramidalis muscle, passed outward and downward in front of the femur, and emerged at a spot in the integument 
corresponding to the insertion of the gluteus maximus. Nothing happened in this case, and no injury 
of a grave character was suspected. On the 23d of October, however, a haemorrhage from both 
wounds took place. It was dark in color and readily checked by a tampon. Accordingly no action 
was taken, and, on the 25th, it recurred. It was now found that the thigh and hip were much 
swollen, an abscess present, seated in the track of the wound, and haemorrhage evidently due to the 
ulceration of some vessel. In consultation with Surgeon H. S. Hewit, U. S. V., ligation of the 
external iliac was determined on. The man, however, refused the operation, and as the haemorrhage 
externally had ceased, it was considered proper to wait. On October 27th, the haemorrhage returned 
and the man wanted the artery tied. He was nearly moribund, and the case otherwise being unprom- 
ising still, the operation was undertaken by an incision parallel to but outside of the epigastric 
artery. The external iliac was found and tied without any difficulty. Previous to tying the ligature 
it was intended to lay open the abscess and search for the bleeding vessel, knowing that the circu- 
lation could be controlled. But at this stage of the operation the shock to the patient was so severe 
that it was necessary to finish all operative interference as soon as possible. The patient survived 
the operation only twenty-four hours. The autopsy showed the external iliac tied a quarter of an 
inch below the internal iliac, and the vein and peritoneum uninjured. A syringe was introduced into 
the femoral artery below the origin of the profunda and water thrown upward, but the bleeding 
vessel was not discovered, notwithstanding a careful dissection and prolonged search. The syringe 
was now introduced into the internal iliac and the water thrown downward, but with no better result. 
Failing thus to discover an ulcerated vessel on the cadaver, what likelihood would there have been of a successful search for 
the bleeding point on the living patient? The operation performed was unquestionably the proper one, as it checked the hemor- 
rhage, and was the only feasible method of doing this.'' The specimen represented in FlG. 26 was contributed by Assistant 
Surgeon J. II. Bill, and consists of "the right os innominatum and head of the femur. The joint was opened and the ischium 
at the lower border of the acetabulum contused by a musket ball which escaped through the glutaeus maximus. The articular 
surfaces are eroded, but the implication of the joint was not suspected during life." — {Cat. Surg. Sect., A. M. M., 1866, p. 235.) 

The remaining nine cases of fatal shot fracture of the acetabulum have been detailed; 
seven in Circular No. 2, 1 and two in the Second /Surgical Volume. 2 The ten patients 
belonging to this group survived the injury 10, 11, 28, 31, 31, 32, 
41, 46, 85, and 160 days respectively, and in two instances frag- 
ments of bone were removed. 3 Autopsies verifying the injury to 

the hip joint were made and recorded in nine 

of the ten cases, and in seven instances the 

specimens are preserved in the Army Medical 

Museum. Specimen 1285 (Fig. 27) is from the 

case of Private Joseph D , Co. E, 129th 

Pennsylvania, aged 20 (Circular No. 2, 

S. G. 0., 1869, p. 90, Case 161). A conoidal 

ball had chipped the upper edge of the coty- 

-p^ZI.-Boves of left hip joint bid Cavity, Causing Slight exfoliation. The Fig. 2& -Carious bones of left hip 
with conoidal ball. Spec. 1285. , -,,,,,. -, i ,11 J ° mt " ** 6M ' 

head of the lemur and the acetabulum were 
deprived of periosteum. The injury to the bone was very trivial. The patient survived 
the injury thirty-one days. Specimen 694 (Fig. 28) is from the case of Private C. H. 

1 Circular No. ;, p. 88 : CASE 150, Pt. Win. P. F , 121st New York, Spec. 3525, A. M. M. Case 160, p. 89, Pt. J. Brandon, 119th New York, 

Spec. 1843. Case 161, p. 90, Pt. J. Donegan, 129th Pennsylvania, Spec. 1285. CASE 162, p. 90, Pt. T. McGowan, 121st New York. (See Boston Med. 

and Surg. Jour. 1863, Vol. 68, p. 439.) Case 163, p. 90, Pt. C. H. Roberts, 1st New Jersey, Spec. 694. Case 164, p. 90, Pt. Wm. H W , G, 4th 

New York. Case 257, p. 102, Capt. S. J. Alexander, B, 9th New Hampshire. 

'ifed. and Surg. History of the War of the Rebellion, Part II, Vol. II, p. 317: Case 920, Pt. L. M. B , I, 1st Massachusetts, Spec. 116; CAB* 

922, p. 318, Serg't T. A , C, 119th New York, Spec 1183. 

•CASE of J. Brandon, F, 119th New York, Circular 2, p. 89, and Case of Capt. S. J. Alexander, B, 9th New Hampshire, Circular 2, p. 102. 





78 



INJURIES OF THE LOWER KXTREM1TIES. 



ICHAP. X. 



Roberts, Co. C, 1st New Jersey Volunteers, aged 19 (Circular No. 2, p. 90, Case 163). 
The point of impact of the missile appears to have been at the lowest margin of the 
acetabulum, where a square inch of the ischium is necrosed and nearly separated. 

The acetabulum and head of femur were recorded as having been fractured in thirty- 
two of the two hundred and forty-nine fatal cases of shot fractures of the hip joint. Autop- 
sies are recorded in twenty instances, and in thirteen cases the 
specimens are preserved in the Army Medical Museum. Specimen 

1908 (Fig. 29) is from the case of Private Joseph W , K, 6th 

Maryland, aged 45 (Circular 2, p. 89, Case 154). Death occurred 




in thirteen days. The lower 



margin 



of the acetabulum was 




Fig. 29. — Bones of right hip joint. Dall 
impacted in head of femur. Spec. 1508. 



FIG. 30. — Shattered 
head of the left femur. 
Spec. 1 248. 

and seven will 



chipped by the ball, which lodged in the summit of 
the head of the right femur, splitting it perpendic- 
ularly. Specimen 1248 (Fig. 30) is from the case 
of Corporal G. Greenwood, D, 13th Massachusetts 
(Circular 2, p. 113). The patient survived the 
injury thirteen days. The ball had shattered the 
head of the left femur and lodged in the pelvis. 

Twenty-five of the cases have been published in detail in Circular No. 2, 1 

here be recorded: 

Case 155. — Lieutenant C. P. Bailey, Co. D, 6th Vermont, aged 40 years, was wounded at Lee's Mills, April 16, 1862. 
Surgeon J. B. Brown, U. S. A., described the injury as a "wound of the groin." Surgeon R. B. Bontecou, U. S. V., reported : 
"He was admitted into the Hygeia Hospital, Fort Monroe, on April 22d, having been wounded by a round ball, which entered 
the left groin, passing between the femoral artery and anterior crural nerve, then entering the ramus of pubis and acetabulum, 
furrowing deeply the head of the femur, and passing through the acetabulum into the pelvis and resting by the left side of the 
rectum, about four inches above its termination. On admission, he was suffering much pain when the limb was moved. Wet 
applications and soothing treatment, with perfect rest, made him for some days comfortable. Fever of a low form occurred, 
and a yellow condition of the skin followed, with delirium, and death on May 1, 1862." 

Case 156. — Private H. U. Cady, Co. K, 207th Pennsylvania, was wounded at Peters- 
burg, April 2, 1865, by a conoidal ball. He was carried to the field hospital of the Ninth 
Corps, and remained there until April 5th, when he was taken on board the hospital steamer 
State of Maine. He died April 6th, during the trip to Alexandria, and was buried from 
the Third Division Hospital. Surgeon E. Bentley, U. S. V., who presented the injured 
upper extremity of the left femur, with portions of the ilium and ischium, to the Museum, 
furnishes the following description of the specimen, No. 3205, A. M. M., represented in the 
adjoining wood-cut (Fig. 31): "The bullet entered one inch above the symphisis and to 
the left of the median line, shattered the ramus of the pubes, left the obturator vessels 
untouched, passed through the acetabulum, grooving the head of the femur, and lodged 
in the loose tissue beyond. The ramus of the ischium appears to have been fractured by 
indirect violence. The bony fragments in the track of the ball are thoroughly necrosed." 
Case 157. — Private W. Hobbs, Co. C, 22d Indiana, was wounded at Mission Ridge, November 25, 1803, and entered the 
General Field Hospital at Chattanooga, December 4th. Acting Assistant Surgeon C. E. Ball reported: "He was wounded by 
a minie" ball in the right inguinal region just above Poupart's ligament, the missile passing downward, toward and into the 
thigh apparently. The patient has double pneumonia. The bullet was in the wound, and the surgeons could not find it. The 
wound granulated well. Patient was in a recumbent position from the first. December 30th, has pneumonic symptoms still; 
wound granulating finely. Gangrene appeared in the wound January 3d. Bromine was applied and scissors used, also stim- 
ulants on poultice. Most of the wound granulated healthily again, but in spite of stimulants and iron, carefully given, the 
patient died January 23, 1864." Acting Assistant Surgeon G. E. Stubbs contributed the specimen (Cat. Surg. Sect., 1866, 
p. 240, Spec. 2103), with the following account of the autopsy : "A sloughing wound, circular in form, and five and a half inches 

1 Circular No. 2, 1809: CASE 40, p. 70. Corp'l Wm. Francks, G, 24th Iowa (Boston Med. and Surg. Jour., 1865, Vol. 72, p. 29), Spec. 3793. Cask 
123, p. 85. Corp'l II. Achlcy, (i, 2d New York II. A. Case 125, p. 85, Pt. J. H. Brown, A, 19th Mass. CASE 126, p. 85, Pt. C. 11. Calhoun, H, 7th North 

Carolina. Case 127, p. 85, Pt. J. II. Carlon, D, 184th Pennsylvania. CASE 128, p. 85, Pt. G. II. C , F, 59th Mass., Spec. 3582. Case 131, p. 86, Pt. H. 

De Coux, Depeak's Confederate Battery. Case 133, p. 86, Pt. J. S. Fabus, 1, 169th New York. Case 134, p. 86, Pt. David F , G, 111th New York, Spec. 

1616. CASE 135, p. 86, Sergeant S. Garvor, K, 69th Indiana. Case 136, p. 86, Pt. F. Geyser, F, 1st Minnesota. Cask 138, p. 86, Serg't W. N. Hinds, D, 152d 

New York. Case 141, p. 87, Pt. W. D. Little, G, 100th Indiana. CASE 144, p. 87, Pt. Royal S. N , A, 26th Mass., Spec. 3726. Case 146, p. 88, Pt. C. 

Robinson, C, 2d District Columbia. CASE 147, p. 88. Pt. C. R , 49th New York, Spiec. 1247. CASE 148, p. 88, Pt. Z. S , K, 2d Ohio Cavalry, Spec. 3904. 

CASE 149, p. 88, Pt. H. II. Stnrdivant, A, 179th New York. CASE 152, p. 89, Corp'l J. P. White, II, 115th Illinois. Case 154, p. 89, Pt. Joseph W , K, 6th 

Maryland, Spec. 1908. Case 155, p. 89, Pt. J. Wiley, A, 155th New York. CASE 156, p. 89, Pt, J. B. Wilson, E, 20th Mass. Case 157, p. 89, Pt. h. Winalow, 
A, 67th Ohio. CASE 239, p. 100, Pt. D. A. Brewer, E, 37th Kentucky. Case 275a, p. 113, Corporal G. Greenwood, D, 13th Mass., Spec 1248. 




FIG. 31 .-Grooved head of left femur.with 
portion of ilium and ischium. Spec. 3205. 



sect, ii] WOUNDS AND INJURIES OF THE HIT JOINT. 79 

in diameter, occupies the light inguinal region. The hall entered two inches from the anterior superior spinous process of the 
ilium, descended behind the caecum, one and a half inches from the ramus of the pubis, passing through the bone and laying 
open the acetabulum, and fractured the tuberosity of the ischium, where it lodged. The head of the femur is denuded. The 
left lower extremity is much larger than the right and pits under the finger. The femoral glands are enlarged and prominent; 
the tissues about them infiltrated with serum. The right femoral vein is filled with a thrombus more or less attached to its wall, 
which may be detached without impairing the integrity of the lining of the vein. This thrombus consists in the main of greyish 
granular matter with portions of black coagulum, and extends to the junction of the iliac veins. A similar thrombus is found in 
the left iliac and femoral veins." 1 The specimen consists of the bones of the right hip joint. Much of the head of the femur is 
eroded, but a small circular portion of sound bone remains on the anterior aspect, surrounded by diseased tissue. 

Case 158. — Sergeant M. B. Pendley, Co. E, Cth North Carolina, aged 36 years, was wounded at Gettysburg, July 1, 
1863. He remained at a field hospital until August 7th, when he was admitted to Camp Letterman. Acting Assistant Surgeon 
D. R. Good reported: "Gunshot wound of right hip joint. A minie ball passed through his pocket book, and entered the right 
iliac region one and a half inches inside of the anterior superior spinous process of the ilium, passed directly in the region of 
the joint and remained. The patient's general health has been very good, though he has suffered constant and severe pain from 
the injury and cannot endure the least motion of the limb. There has been comparatively very little inflammation and swelling 
of the surrounding parts. Simple dressings were applied and generous diet given. August 15th, for some time the limb has 
been flexed and drawn over and in front of the other leg. Administered chloroform and straightened the limb, and applied 
splint to keep the leg at rest. 22d, patient is comfortable so long as his limb is not moved, and is doing well. The general 
treatment is continued. 27th, general health not so good; limb more swollen. Administered tonics and some stimulants. 
30th, has slight diarrhoea; opiates prescribed. September 4th, diarrhoea continues; ordered opiates and astringents. 10th, 
considerably better ; treatment continued, with tonics and stimulants. 12th, diarrhcea still troublesome at times; his strength 
failing considerably. 16th, greatly prostrated ; evidence of pyaemia. 17th, gangrene in the parts about the wound. Died 
September 17, 1863, at 10 o'clock P. M. Post-mortem : The ball had passed directly into the joint, 
slightly fracturing the head of the femur, and was buried in the acetabulum. The cavity was filled 
up with bone, and a large quantity of pus was found to have accumulated in and about the joint." 
The os innominatum and the upper portion of the femur were forwarded to the Museum by Acting 
Assistant Surgeon E. P. Townsend. The specimen shows a fracture extending through the acetabu- 
lum at the point of impact, which is necrosed, nearly the entire remainder of the articular surface 
being carious. A large portion of the head of the femur has been absorbed. Slight osseous deposits 
exist on the outer margin of the acetabulum. — (Cat. Surg. Sect. 1866, p. 242, Spec. 1942.) 

Case 159. — Corporal G-. TV. Stepps, Co. C. 20th North Carolina, aged 20 years, was wounded 

at Spottsylvania, May 12, 1864, and entered Lincoln Hospital, Washington, on May 22d. Assistant 

Surgeon J. C. McKee, U. S. A., reported: "Gunshot wound of right groin, a minie ball entering half 

an inch below and exterior to the middle of Poupart's ligament, fracturing the head of the femur 

and the acetabulum, and escaping at the middle of the right nates. Death occurred on June 10, 

1864." A portion of the os innominatum, represented in the wood-cut (FlG. 32), was contributed 

bv Acting Assistant Surgeon H. M. Dean.— (Cat. Surn. Sect., 1866, p. 236, Spec. 2488.) 

° 6 V »>>*>* ' FIO. 32.— Portion of right in- 

Case 160. — Private G. S. Turner, Co. I, 19th Maine, aged 18 years, was wounded at Gettys- nominatum, with fracture of 
burg, July 3, 1863. He remained at the field hospital of the 2d division, Second Corps, until July base of the acetabulum. Spec. 
14th, when he was transferred to the Jarvis Hospital at Baltimore. Assistant Surgeon D. C. Peters, 

II. S. A., reported: "Gunshot wound of left hip joint. The anterior wound was about the middle, and above Poupart's 
ligament; the posterior near the tuberosity of the ischium. Blood oozed almost continuously from the wound in front, and 
twice alarming haemorrhages occurred. He had a bad and colliquative diarrhcea, and was nearly pulseless when admitted. No 
reaction came on such as would warrant so formidable an operation as tying the common iliac. Constant pressure by com- 
presses was made. Death occurred on July 19, 1863. The post-mortem revealed an immense traumatic aneurism and abscess 
about the hip joint. The femoral artery was lacerated and a mass of decomposed tissue. The musket ball struck the acetabu- 
lum and the head of the femur, gouging them, and subsequent disorganization denuded them of periosteum. The structures 
around were in an advanced state of decomposition, and it is a wonder the patient lived so long as he did." 

Case 161. — Private JET. West, Co. A, 3d North Carolina, aged 20 years, was wounded at Antietam, September 17, 1862, 
and admitted to the hospital at Locust Springs, November 22d, where Surgeon T. H. Squire, 89th New York, recorded: "The 
patient came to this hospital from Sharpsburg. He was wounded by a musket ball, which entered the right gluteal region 
midway between the summit of the trochanter and the crest of the ilium and lodged in some unknown part of the body. There 
is a general fullness, and some hardness and redness in the groin and region of Poupart's ligament, and possibly the ball may 
be in that neighborhood. The patient's general health is tolerable." On January 19th he was transferred to the Smoketown 
Hospital, and, on May 11th, to hospital No. 1, at Frederick. Assistant Surgeon R. F. Weir, U. S. A., reported that he died, 
July 6, 1863, of "gunshot wound of hip, involving the joint." Acting Assistant Surgeon G. M. Paulin contributed the os 
innominatum and the head of the femur of this case to the Museum. The specimen shows that a round bullet entered obliquely 
from the right front, fractured the superior portion of the head of the femur, perforated the acetabulum, and lodged in the body 
of the ilium without derangement to its own form. One half of the head of the femur has been absorbed; the anterior superior 
third of the acetabulum is carious and partially detached; near the fundus of the acetabulum ulceration has perforated the bone, 
and the bullet communicates with the head of the femur by a carious channel. The missile is encircled with a wall of new 
bone thrown out from the irritation of its presence; there is also considerable deposit of callus on the ilio-pubic legion, which 
caused, during life, a prominence in the region of Poupart's ligament. The dorsum ilii and the posterior surface of the body of 
the ischium show evidence of periosteal inflammation.— (Cat. Surg. Sect., 1866, p. 242, Spec. 3865.) 

^IDELL (J. A.J, in Memoirs of V. S. Sanitary Commission, New York, 1870, Surgical Vol. I, p. 551, describes the thrombosis with pyaemia. 




80 



INJURIES OF THE LOWER EXTREMITIES. 



|(JIIAl\ X. 




FIG. 3:5.— Bones of the left hip 
joint. Head of femur shattered at 
junction with the neck. Spec. 2174. 



In twenty of the two hundred and forty-nine cases with fatal terminations after shot 
fractures of the hip joint, the acetabulum with the head and neck or trochanters and shaft 
were injured. Post-viortevi examinations are recorded in seventeen instances, and the 
Army Medical Museum possesses eight specimens belonging to cases of this group. Fifteen 
of the cases have been detailed in Circular No. 2; 1 five will here be given in full: 

Case 162. — Private R. Snyder, Co. K, 13th Illinois, was wounded at Ringgold, November 27, 1803, and admitted to the 
general field hospital at Chattanooga on the following day, where Surgeon J. Perkins, U. S. V., recorded: "Gunshot wound 
of left hip." Two weeks afterwards the patient was transferred to Nashville, where he was admitted to hospital No. 19. 

Surgeon W. Foye, U. S. V., described the case as follows : "Admitted December 15th, with 
gunshot fracture of left femur; the ball, which proved to be a large mini6, entered about one 
and a half inches to the left and below the anterior superior spinous process of the ilium and 
had not emerged. The wound was quite small, and discharging a small quantity of pus of a 
somewhat serous character; pulse weak, about 90, and feverish. Simple dressings, supporting 
diet, and tonics were ordered. The following day the discharge was of a fair character and the 
patient feeling better. As the ball had been searched for twice without success, it was deemed 
best not to disturb the parts unless rendered necessary. On December 18th the discharge was 
very profuse, amounting to nearly a quart of sanious and watery matter of very fetid odor. 
The wound was laid open and probed; the path of the ball was apparently along the inner 
side of the femur, yet that was not sufficiently large for so profuse a discharge ; but no other 
path or sac was found, though the neck of the femur was ascertained to be much comminuted. 
He seemed more feverish during the day, and had some dyspnoea and cough ; pulse 100. Treat- 
ment continued. On December 19th the patient was evidently failing; pulse 110, and weak; 
discharge more profuse and of the same character. On the 20th the symptoms were all aggra- 
vated. He died on December 21, 1863. The autopsy showed that the ball had entered at tho 
point above described and struck the neck of the femur, completely severing it and partially dividing the head, comminuting 
the lower part of the acetabulum and passing through the ilium, and lay about an inch within the cavity of the pelvis. It was 
surrounded by coagula, but had done no injury to the intestines. A smaller track was made along the inner side of the femur. 
No piece of ball was found in this path. Intestines normal ; liver and spleen considerably enlarged and friable. The right lobe 
of the lungs was inflamed but not hepatized. There were no abscesses in any of these organs. The heart and other organs 
were in good condition." The bones of the injured hip joint were contributed to the Museum by Surgeon Foye. (Cat. Surg. 
Sect., 1865, p. 242, Spec. 2174.) The specimen (Fig. 33) shows the borders of the bony wound to be necrosed. 

Case 163. — Private A. Kibble, Co. C, 81st New York, aged 26 years, was struck in the right hip by a cannon ball 
during the engagement near Petersburg, May 19, 1864. He was admitted to the General Hospital at Fort Monroe, where he 
died May 25, 1864. Assistant Surgeon E. McClellan, U. S. A., reported: "Both the os innominatum and the femur were frac- 
tured and much comminuted, all the bones entering into the formation of the joint being literally crushed by a solid shot." 

Case 164. — Private C. Cook, Co. F, 18th Illinois, aged 41 years, is reported by Surgeon J. Simons, U. S. A., as having 
died of "gunshot wound," at the General Hospital at Cairo, December 4, 1861. In a report of surgical cases transmitted in 
April, 1873, by Dr. J. H. Brinton, late Surgeon U. S. V., the injury is described as follows: "Cook was shot while drunk, by 
a guard, on December 1st, at 6 o'clock P. M., at a distance of thirty yards. The missile, a Maynard rifle ball, entered in left 
side on a line with the crest of the ilium, passed outward and downward, and emerged at the posterior part of the left buttock. 
I saw him shortly after the injury in a state of collapse from the shock, pulse 132, feeble and thready; skin cold, white and 
waxy; cold sweat on forehead; constant venous dribbling from both openings. December 2d, no discharge from his bowels 
since being shot ; passes his urine; is in a very prostrate condition; has reacted but very little. Stimulants have been freely 
given. A few spicula; were extracted from near the exit orifice. December 3d, patient failing fast; pulse feeble and not to be 
counted; urine scanty; pulse imperceptible; skiu hot and dry; urine voided involuntarily; bowels have not been moved. Died 
at 9 o'clock A. M., on December 4th. Post-mortem two hours after death : Tissues around wound of entrance dissected up all 
around for an inch. Ball had passed obliquely outward and downward, grazing the anterior lip of acetabulum, passing through 
head of femur, splintering it and the neck, and destroying the posterior lip of the acetabulum. The extravasation of blood had 
passed down from wound of entrance, along and superficial to tendon of external oblique muscle as far as the external ring, 
then up the inguinal canal through the internal ring, and was collected in a clot of three or four drachms around the internal 
ring. Both rings were enlarged; a hernia came down after injury, which was reduced; no wound of the peritoneum. The 
tissues were loosened around the wound of entrance in a circumference of one and a half inches." In addition to this case Dr. 
Brinton makes the following. remarks: "This loosening of tissues around the entrance wound of a conoidal ball I have since 
observed in hundreds of cases. It is undoubtedly peculiar. Usually the point of a finger passed through the wound can be 
hooked under the skin and swept around without encountering resistance sufficient to impede its motion. The earlier the wound 
is examined the more perfectly will this phenomenon be observed, as clots, etc., afterwards block up the disintegrated zone." 

■ Circular No. 2, I860: CASK 80, p. 77, Pt. Wm. O. M , C, 24th Iowa, Spec. 3792. Case 124, p. 85, Pt. P. Baker, I, 3d Vermont. CASE 129, p. 85, 

Pt D. Combe, K, 209th Penn. Case 130, p. 86, Pt. Ch. Cushion, 179th New York. CASE 132, p. 86, Pt. S. N. E , G, 40th Indiana, Spec. 3390. CASE 137, 

p. 86, Corp'l J. T. Glancy, F, 2d Rhode Island. Case 139, p. 86, Pt. D. U. Johnson, 1, 13th Alabama. CASE 140, p. 86, Pt. George L , D, 5th Louisiana, 

Spec. 3946. Case 142, p. 87, Pt. L. L. Lowe, E, 101st Ohio. Case 143, p. 87, Pt. Peter M , A, 28th Mass., Spec. 4227. Case 145, p. 87, Serg't Charles G. 

P , G, 13th Penn., Spec. 3632. Case 151, p. 88, Pt. G. F. Tilton, E, 1st Mass. Car. Case 153, p. 89, Serg't William Whitney, K, 147th New York. Case 

158, p. 89, Pt A. Wormack, G, 48th North Carolina. CASE 159, p. 89, Corp'l M. F. Yoder, G, 51st Ohio. 



SECT. II. 



WOU-NDS AND INJURIES OF THE HIT JOINT. 



81 



Cask 1C5. — Private IT. ('. L"siuur. Co. C, 3d Georgia, was wounded at Liberty Gap, June 25, 1863, and admitted to 
hospital at Murfreesboro' two days afterwards. Assistant Surgeon \V. r. MeCullogli, 78th Pennsylvania, recorded: "Gunshot 
wound of right thigh, ball entering trochanter and passing inward and backward. The missile was traced through the 
trochanter but could not be found." The treatment is noted as having consisted of water dressings, morphia, stimulants, and 
tonics, and, in the latter stage, astringents were given to control the diarrheca. On .Inly Sth, the wound was suppurating freely 
and the leg was bandaged. On August 1st. an incision was made and some spicuUc of bone removed, 
a discharge of pus to the amount of eight ounces taking place. On August 9th the patient was 
slowly sinking, and, on the lGth, he was failing rapidly. He died August 19, 18C15. An autvpsy 
was held eight hours after death, and is recorded lis follows: ''The ball entered the trochanter 
major, passing through it and entering the capsule of the joint, carrying away a portion of the 
head of the femur and ligament um teres, and posterior portion of acetabulum, and was found 
lodging in the lower attachment of the latissimus dorsi. A large abscess was found in the locality 
of the iliacus interims and psoas muscle, the cartilage and bone of the joint much absorbed, and 
the cancellated structure infiltrated with sanious pus." 

Case 106. — Private M. J. II. Perkins, Co. K, 6th Maine, aged 21 years, was wounded at 
Cbancellorsvillc, May 3, 18.S3. He was admitted to Judiciary Square Hospital, Washington, May 
7th, and transferred to MeDougall Hospital, Fort Schuyler, New York Harbor, one month after- 
wards. Assistant Surgeon E. Bartholow, U. S. A., contributed the specimen (Cat. Stay. Sect., 
1866, p. 233, Spec. 1650), represented in the adjacent wood-cut (Fig. 34), with the following descrip- 
tion: "A minid ball entered the left hip, striking the neck of the femur within the capsule, passing 
through the obturator foramen and between the rectum and urethra without injuring either, and 
escaped behind the ramus of the right ischium. Inflammation of the prostate gland, and priapism 
set in. The patient died June 13, 1863." The specimen consists of the bones of the hip joint, the 
articular surfaces being entirely eroded. 




joint. 



.31.— Bones of the left hip 
Spec. 1G59. 



fractures of the hip joint, 
In ten instances autopsies 



Of the two hundred and forty-nine fatal cases of shot 
twenty-three were limited to the head of the femur alone, 
were performed, and six specimens are preserved 
in the Army Medical Museum. Two are represented 
in the adjoining wood-cuts. Specimen 1968 (Fig. 35) 
was obtained from Corporal J. E. G , Co. I, 2d 

South Carolina, aged 22 years, 

wounded at Gettysburg, July 

2, 1863. The head of the 

femur was slightly fractured; 

the acetabulum became cari- 
ous, and the patient died from 

exhaustion on Oct. 12, 1863, 

one hundred and two days 

after the. injury (Circular 2, 

Fig. 35.— Bones of the right hip joint. ^ » * 

Head of femur nearly absorbed. Spec, page 71, CASE 42). OpeCWtien 

2198 (Fig. 36) shows the bone 
of the left hip joint. The head of the femur is carious and the articular surface has been 
roughened by ulceration. The history of the case from which the specimen was obtained 
is given in detail in Circular No. 2, page 82, Case 104. Besides the specimen cases here 
referred to, fifteen have been detailed in Circular No. 2. 2 The histories of the remaining 
six cases will here be recorded : 

Case 167. — Private I. Conduri, Co. D, 1st Michigan Cavalry, aged 22 years, was shot in the right thigh while on scout 
near Culpeper, April 24, 1804. He was admitted to the Third Division Hospital, Alexandria, whence Surgeon E. Bentley, 





Fig. 3C. — Bones of the left hip joint with carious head of 
femur. Spec. SI £18. 



1 MOSES (J.). Surgical Notes, etc, in Am. Jour. Med. Sci., 18C4, Vol. XLVII, p. 337. 

'Circular No.2,1869: Case 9, p. GG, Pt. C. Benjamin, 118th Pennsylvania. Case 14, p. G7, Pt. F. Bowman, F, 1st U. S. Sharpshooters. Case 25, 

p. 69, Pt. J. A. Deyo, B, 20th Indiana. Case 53, p. 73, Pt. J. Harrigan, K, 3Gth Mass. CASE :~, p. 73, Pt. Root. N. II , D, 1st New Jersey Cav., Spec. 

3G36. Case 70, p. 76, Pt. J. Lawler, B, 12th New York Cav. Case 74, p. 76, It Chas. II. M , G, ;!d Maryland, Spec. 3!'23. Case 85, p. 78, Pt. lohn M , 

1, 61st New York, Spec. 1G02. Case 101, p. 82, Pt. H. Sault, 1, 5th New York. Case 1(8, p. 83, Pt. J. Spangler, A, 38th Ohio. Case 111, p. 83, Sergeant H. 
Stulter, D, 53d Pennsylvania. CASE 113, p. 83, Pt. Peter L. Swank, I, 38th Ohio. CASE 115, p. 83, Serg't V. Tidball, H, 122d Ohio. CASE 246, p. 100, Pt. 
F. Krergar, B, 18th Georgia. Case 251, p. 101, Pt S. Sellers, I, lGSth Ohio. 

Surg. Ill— 11 




82 INJURIES OK THE LOWER EXTEEMITIES. [CHAP. X. 

U. S. V., reported: '"The treatment consisted of water dressings, tonics, stimulants, and extra diet. The patient died June 11, 
18G-1. The post-mortem showed that the ball entered the thigh at its middle third, on its anterior aspect, passed upward ami 
entirely through the articulation of the hip joint, and lodged in the body of the sacrum." 

Case 103. — Sergeant J/. 1). Ensor, Co. C, 20th North Carolina, aged 2(5 years, was wounded and captured at Winchester, 
September 19, 1864. On the following day he was admitted to the Prisoner's Hospital, where Assistant Surgeon II. B. Noble, 
2d Ohio Cavalry, recorded: "Gunshot compound comminuted fracture of upper third of right femur; Desault's lung splints 
applied and simple dressings." Surgeon A. Chapel, U. S. V., reported the man's admission to West's Buildings Hospital, 
Baltimore, January l'J, 1865, from Winchester, with ''gunshot wound, the ball entering near the trochanter of the ihigh bone, 
producing fracture." On May 9th the prisoner was transferred to Fort Mcllenry. Surgeon W. Hays, U. S. V.. in charge of 
the Post Hospital at the latter place, reported that the man "died from exhaustion, resulting from excessive suppuration caused 
by gunshot fracture of head of femur, June 3, 18C5." 

Cask 109. — Private A. Fann, Co. C, 18th Tennessee, was wounded at Stone's River, December 31, 1862, and admitted 
to hospital No. 4, Nashville, January 27th. Acting Assistant Surgeon F. L. Tower reported: "Gunshot fracture of head of left 
femur and wound of abdomen. Death on January 31, 1863." 

Case 170. — Private S. Irwin, Co. C, 10th Massachusetts, aged 25 years, was wounded at the Po River, May 12, 1864. 
Surgeon S. F. Chapin, 139th Pennsylvania, noted his admission to the field hospital of the 2d 
division, Sixth Corps, with "gunshot wound of left thigh." On May 24th the wounded man was 
admitted to Prince Street Hospital, Alexandria, whence Acting Assistant Surgeon J. Cass con- 
tributed the specimen (Cat. Surg. Sect., 1866, p. 234, Spec, 2374) and the following report: "The 
patient suffered considerable pain, had chills, was very uneasy and anxious, had no appetite, hic- 
cough, and great prostration, and died May 28, 1864. At the autopsy the left groin was found 
considerably discolored, and, on examination, "it was discovered that the wound commenced just 
below the middle of Poupart's ligament, extending downward and inward, and terminating at the 
ischium, which was fractured. The ball was found near that bone, between it and the head of the 
femur, which was also fractured. The ligaments of the hip joint, the soft parts in the groin, and 
the upper part of the thigh were gangrenous." The specimen (FlG. 37) consists of a portion of the 
am and "upper part of femur" ' L 'ft ischium and the upper extremity of the femur. There is a partial fracture of the head of the 
Spec. 2374. femur at its articular border and of the ischium by a battered round ball, which is attached. 

Case 171. — Lieutenant J. Snyder, Co. K, 83d Ohio, aged 33 years, was wounded at Fort Blakely, April 9, 1863, and 
admitted to the St. Louis Hospital, New Orleans, five days afterwards. Surgeon A. McMahon, U. S. V., reported: "Gunshot 
wound of right thigh and nates, fracturing the ischium and the femur at its neck. Death resulted from peritonitis following 
inflammation of the pelvic fascia." 

Case 172. — Private A. Underbill, Co. C, 10th New York, was wounded at the Wilderness, May 6, 1864, and admitted 
to the field hospital of the 2d division, Second Corps. Surgeon J. F. Dyer, 19th Massachusetts, reported: "Gunshot fracture 
of head of femur." The wounded man was conveyed to Fredericksburg, where he died May 15, 1864. 

In seventeen of the fatal cases after shot fracture of the hip joint treated by conserva- 
tion the head and neck, or head, neck, and trochanters of the femur were injured. Full 
details of fifteen of the cases, with illustrations of eight specimens, have been given in 
Circular 2. 1 Meager details of two cases will here be added : 

Case 173. — Private H. Peters, Co. D, 18th U. S. Infantry, was wounded at Chickamauga, September 19, 1863. He 
was admitted to hospital at Chattanooga ten days after the injury. Surgeon J. S. Woods, 99th Ohio, reported: "Fracture of 
head and neck of right femur. Patient in bad condition; several pieces of bone were removed." The man died October 11, 
1863. On the list of casualties at the battle of Chickamauga, furnished by Surgeon G. Perin, U. S. A., Medical Director of the 
Army of the Cumberland, the injury in this case is reported as a "wound of privates and right side." 

Case 174. — Private F. Benda, Co. F, 26th Wisconsin, aged 19 years, was wounded at Gettysburg, July 1, 1863, and 
admitted to the field hospital of the 2d division, Eleventh Corps, where Surgeon W. II. Thorn, U. S. V., recorded: "Gunshot 
wound of left hip; ball extracted." On August 6th the patient entered Camp Letterman Hospital, where Surgeon II. Janes, 
U. S. V., recorded: "The patient suffers from a compound comminuted fracture of femur. The ball entered from the outsido 
of the hip, crushing the bone from the trochanter major upward, then passing obliquely upward entered the pelvis near the 
sacrum. No history of this case could be procured previous to his admission to this hospital. August 12th, the patient suffers 
from diarrhoea and hectic fever and is sinking rapidly. He died from exhaustion, August 20, 1863. Treatment: Exhibition 
of tonics, stimulants, and anodynes." 

1 Circular 2, 1869: Case 6, p. 66, Pt. J. Barnes, B, 52d Indiana. Case 8, p. 56, Ft. Anthony B , C. 12th Illinois, Spec. 466. CASE 10, p. 66, 

t»t. Charles It. B , E, 16th Maine, Spec. 598. Case 17, p. 67, Pt. \V. C , 159th New York, Spec. 1291. CASE 21, p. 08, Pt. D. Curran, A, 5th 

Kentucky. Case 45, p. 72, Major John J. G , G. 47th Pennsylvania, Spec. 3789. CASE 52, p. 73, Corporal Benjamin II , C, 9th West Virginia, 

Spec. 42G7. CASE 76, p. 77, Corporal Donald McD , E, 12th New York Cav., Spec. 2170. Case 89, p. 79, Serg't S. W. N , E, 15th Now Jersey, 

Spec. 1253. CASE 91, p. 80, Captain Samuel Oakley, 77th New York. Case 102, p. 82, Pt. C. Saunders, O,0th Louisiana Cavalry. Case 106, p. 82, 

Pt. G. II. S , II, 2d North Carolina, Spec. 1967. Case 118, p. 84, Pt. It. A. Walker, E, 2d Now Hampshire. CASE 275, p. 1 13, Pt. A. Kwanson, II, 

3d Michigan. In the case reported by Dr. J. Dickson Buuxs (Ci'rc. 2, S. G. O., 1869, p. 57), a first attempt to remedy the injury by an operation was 
itispendcd, as the hemorrhage was very great. Some ten days or two weeks after, an excision of the head of the femur was attempted, as an examination 
had shown that the neck was extensively split. After the primary incisions had been made, and several fragments of the neck had been removed, the 
operation was discontinued, as it became apparent that death was inevitable. 



SECT. II.] 



WOUNDS AND INJURIES OF TITK HIP JOINT. 



83 





FIG. 3a— Shot fracture 
of neck oi" left femur. 
Spec. 3951. 



Fig. 39.— Shot fracture 
of neck of right femur. 
Spec. 1661. 



'Gun- 



Seventy instances are recorded, among the two hundred and forty-nine fatal cases of 
shot fractures of the hip joint treated by conservation, in which the neck of the femur was 
stated to have been fractured. Fifty-six of the cases have 
been recorded in Circular 2; 1 fourteen will be recorded 
here. Autopsies were made in twenty-one of the cases, 
and eleven specimens are preserved in the Army Medical 
Museum. A specimen belonging to this group, represented 
in the adjoining wood-cut (Fig. 38), was received without 
history. It consists of the upper fourth of the femur, with 
a fragment of a round ball embedded in the neck within the 
capsule. There is no evidence of chronic articular disease. 
The specimen is a fair illustration of injury to bone by 
round balls at low velocities. A similar specimen is rep- 
resented in Fig. 39, showing a round ball embedded in the neck of the femur near the 
trochanter major, fracturing the neck within the capsule. The history of this case has 
been detailed in Circular No. 2, p. 81, Case 98. 

Case 175. — Private J. Boca, Co. A, 1st Confederate States Cavalry, was wounded at Stone's River, December 31, 1862. 
He was admitted into No. 19 Hospital, Nashville, January 20, 1863. Surgeon J. Shrndy, 2d Past Tennessee, noted : 
shot compound fracture of the neck of the right femur." He died February 4, 1863. 

Case 170. — Private J. W. Connor, Co. D, 81st Pennsylvania, was wounded at Fredericks- 
burg, December 13, 1862. Surgeon J. E. McDonald, 79th New York, recorded his entrance into 
the field hospital of the 1st division, Ninth Corps, with "Gunshot wound of left thigh." Surgeon 
J. A. Lidell, U. S. V., contributed the specimen represented in the adjoining woodcut (Fie. 
40) (Cat. Sun/. Sect., 1866, p. 243, Spec. 622), and reported the following history: "Admitted 
to Stanton Hospital, Washington, December 2Gth, with gunshot fracture of left thigh in upper 
third; ball not extracted. The injured limb was a good deal swelled; pus (lowing from the 
wound. Exploration did not discover the ball; thigh found fractured high up; amount of 
displacement small. The case did pretty well till December 31st, when symptoms of pyaemia 
showed themselves. He grew rapidly worse, and died January 2, 1863. The necropsy showed 
inflammation of the femoral vein, pus in the femoral and iliac veins, a comminuted fracture in 
the neighborhood of the trochanters, and the ball firmly impacted in the ischium." The specimen 
consists of the bones of the hip joint with a portion of the ligaments, the head of the femur being 
dislocated. The track of the hall is necrosed, but a small quantity of callus has been thrown 
out on the anterior surface of the femur. 

Case 177. — Private A. E. Davis, Co. E, 1st Maine Cavalry, aged 22 years, was wounded during the Richmond raid, 
March 2, 1864, and admitted to the General Hospital at Port Monroe five days afterwards. Assistant Surgeon E. McClollan, 
U. S. A., reported : "Gunshot wound of right hip. The patient was admitted in good condition; wound healthy. Pyaemia 
was developed on March 12th, and death occurred within twenty-four hours. The autopsy discovered that the ball had pierced 
the neck of the femur. There were symptoms of inflammation of the femoral vein; six ounces of dark bloody fluid in left 

' Circular 2, S. G. O., 1809.- Case I, p. 65, Pt. A. Baker, 5th Maiue Battery. Case :!, p. G5, Pt. J. Balines, C, 20th Wisconsin. Case 4, p. 06, Pt. W. 

Bancho, H, 3d New Hampshire. Case 5, Corp'1 M. Harden, K, 10th Mass. Case 12, p. 67, Serg't G. Bond, A, 137th Illinois. Case 18, p. 08, Pt. P. C , 

Q, 24th Alabama (see also Ctmftd. Stales Med. Juur., Vol. I, p. 76). Case 19, p. 08, Pt. J. Connelly, C, 1st Louisiana (Colored) Cavalry. Case 23, p. G6, Pt. 
II. Dumback, 1, 17th Ohio. Case 26, p. 09, Pt. J. Dice, 43d Missouri. Case 27, p. 09, Pt. C. ( i. Dodson, C, 13th West Virginia, Case 29, p. 01), Pt. E. II. 
Dunklcbcrg, F, 11th Infantry. Case 30, p. 69, Pt. N. II. Eisenhower, F, 103d Ohio. Case 33, p. 70, Pt. D. Elmer, M, 14th New York II. A. Case 05, p. 70, 
Pt. A. B. Fields, B, Cth Maine, Spec. 2932. Case 36, p. 70, Pt. S. Fleig, E, 45th New York. Case 38, p. 70, Pt. J. Foreman, E, 5th Alabama. Case 41, p. 

71, Pt. S. F , E, 111th New York, Spec. 14G2. Case 44, p. 71, Pt. J. G , B, New Hampshire II. A., Spec. 3540. CASE 47, p. 72, Pt. B. F. Green, E, 

125th New York. Case 48, p. 72, Pt. T. Green, L, 12th Tennessee Cnv. Case 50, p. 72, Pt. D. Haley, B, 57th Mass. CASE 54, p. 73, Pt. L. P. Harvey, B, 
11th New Hampshire. Case 58, p. 74, Pt. IP". Huger, D, 7th Virginia. Case 62, p. 74, Pt. P. C. Johnson, II, 15th Ohio. CASE 65, p. 74, Pt. D. A. Kimble, 
G, 3d Minnesota. CASE 72, p. 70, Corp'l J. G. Mallory, C, 31st Indiana. CASE 75, p. 70, Pt. J. Matthews, A, 11th Louisiana (Colored). CASE 77, p. 77, E. 
McGee, Secret Service. Case 78, p. 77, Lieut. T. H. McKinley, B, 29th U. S. C. T. Case 81, p. 77, Pt. J. W. Moore, II, 0th Penn. Cov. CASE 82, p. 78, Pt. 

J. M , F, 03d Now York, Spec. 782. Case 83, p. 78, Pt. J. R Morrill, D, 184th Penn. Case 84, p. 78, Pt. P. SI , B, 1st Virginia, Spec 3a Case 86, 

p. 79, Pt. J. B. Mullen, G, 13th Indiana. CASE 95, p. 81, Pt. J. L. RiUy, I, 21st Mississippi. Case 98, p. 81, Pt. L. It , F, 48th New York, Spec. 1061. Case 

100, p. 81, Serg't F. Snllyards, A, 70th Ohio. Case 107, p. 82, Corp'l H. F. Smith. B, 1st Wisconsin. Cask 109, p. 83, Corp'l J. A. Staunton, II, 1st Florida. 

CASE 1 10, p. 83, Pt. J. Stewart, B, 20th Ohio. Case 112, p. 83, Pt. J. S , B, 43d Ohio, Spec. 405. Case 117, p. 84, Pt. J. Wagoner, F, 81st Illinois. Case 

119, p. 84, Pt. I. W. Winans, C, 3d Wisconsin. Case 120, p. 84, Corp'l G. W. Wright, Blount's Virginia Battery. CASE 121, p. 84, Pt. W. I'. Ycargin, E, 
22d Georgia. Case 212, p. 90, Pt. 8. Randall, G, 118th New York. Case 236, p. 99, Serg't S. K. Arrison, A, 118th Illinois. Case 240, p. 100, Pt. J. T. Cone, 
7th Virginia (see Am. Med. Times, 1804, Vol. VIII, p. 13). Case 241, p. 100, Pt. W. A. Dibble, C, 106th Penn. Case 249, Pt. B. Page, I, 51st North Carolina. 

Case 255, p. 103, Corp'l G. W. W , Virginia Battery. Case 259, p. 102, Pt. B. T. Elam, A, 11th Virginia, Spec. 9. Case 268, p. 104, Pt. E. Longyear, D, 

72d Penn. Case 209, p. 104, Pt. L. N. P. Rodeubough, D, 55th Illinois. CASE 271, p. 105, Pt. L. Schmidt, II, 8th Kansas. CASE 270, p. 114, Serg't E. Scott, 
A, 1st New Jersey Cavalry, Spec. 3520. 




Fig. 40.— Bones of the left hip 
joint with dislocation of head of 
femur. Spec. 622. 



84 INJURIES OF THE LOWER EXTREMITIES. [CHAF. X. 

thorax, with an oily fluid floating on it; two ounces of light colored bloody fluid in pericardium; an oily substance collected on 
the blood from all parts of the body. Liver engorged and soft. No formation of pus discovered.'' 

Case 178. — Private G. W. Fierstine, Co. K, 93d Pennsylvania, was wounded at Fair Oaks, June 1, 1862, and admitted 
to the Fifth and Buttonwood Streets Hospital, Philadelphia, six days afterwards. Acting Assistant Surgeon A. C. Bournonville 
reported: "Fracture of neck of femur, tuberosity of ischium shot off and pelvic bones shattered; no wound of bladder or 
rectum. Prognosis fatal. Patient was most comfortable by having the limb elevated and supported by pillows. He died June 
12, 1862." 

Case 179. — Private J. M. Hayse, Co. K, 14th Kansas Cavalry, was accidentally wounded May 19, 1864, and admitted 
to hospital at Fort Smith. Surgeon C. E. Swasey, IT. S. V., reported : "Gunshot wound of left thigh into abdomen, with 
fracture of neck of femur. Death resulted, from perforation of the bowels, on May 20, 1864." 

Case 180. — Private F. M. Hayes, Co. A, 211th Pennsylvania, aged 21 years, was wounded at Fort Steadman, March 
25, 1865. He was admitted to the field hospital of the 3d division, Ninth Corps, where Surgeon M. F. Bowes, 211th Pennsyl- 
vania, recorded: "Wound of right hip by conoidal ball." Two days afterwards the man was moved to the Depot Hospital at 
City Point, and ten days later he was conveyed on a hospital steamer to Alexandria, where he entered the Third Division 
Hospital. Surgeon E. Bentley, U. S. V., reported: "Gunshot fracture of right hip. Light cold-water dressings and a bandage 
were applied over the thigh to facilitate the discharge of pus from the wound. The limb was retained in position by means 
of an inclined plane, with slight extension and counter-extension. Alcoholic stimulants and nourishing diet were freely admin- 
istered. He died April 14, 1865. Autopsy thirteen hours after death : Tissues of thigh very much disorganized by the extent 
of suppuration, involving the entire limb. The femur was fractured at the neck. The ball had passed under the pubis and was 
found in the pelvis, -external to the peritoneum." 

Case 181. — Private C. Hambrecht, Co. E, 4th New Jersey, was wounded at South Mountain, September 14, 1862, and 
admitted to the field hospital at Burkettsville. Assistant Surgeon H. A. DuBois, U. S. A., reported: "Gunshot wound through 
os pubis and neck of femur. Secondary haemorrhage occurred on October 18th. A ligature was applied to the external iliac 
and the femoral arteries. But little blood was lost, the surgeon being in the ward at the time the haemorrhage commenced. 
The operation was difficult, it being necessary in order to stop the haemorrhage to compress the artery on each side and close to 
the wound, which was directly below Poupart's ligament. The patient rallied after the operation and was able to read a letter, 
but died six hours after." 

Case 182. — Private W. J. Little, Co. I, 57th Pennsylvania, aged 22 years, was wounded 
at the Wilderness, May 5, 1804, and admitted to the field hospital of the 3d division, Second 
Corps. Surgeon O. Lvarts, 20th Indiana, noted: "Gunshot wound of left hip." Surgeon 
D. W. Bliss, U. S. V., forwarded the specimen (Cat. Surg. Sect., 1866, p. 241, Spec. 2398) 
and reported: "The patient entered Armory Square Hospital, Washington, May 28th. He 
was wounded by a conoidal ball, which entered the right gluteal region on a line with the 
coccyx, two inches above the anus, passing under the fascia in a direct line and through the 
ramus of the ischium, comminuting the left femur at its neck, and making its exit over the 
great trochanter. Powerful stimulants were given but with no effect. The patient died from 
the effects of the injury, May 30, 1864." The specimen shown in the wood-cut (Fig. 41) 

P, 0- 4i Hones of left hip joint, consists of the bones of the left hip joint, and shows the head of the femur, with the exception 

Neck of femur shattered. Spec. 2338. f a slight fissure on its articular surface, to be uninjured. 

* Case 183. — Private J. McAlpine, Co. C, 7th Illinois, was wounded at Allatoona, October, 5, 1864. Surgeon J. K. 

Zearing, 57th Illinois, reported his admission to the field hospital of the 4th division, Fifteenth Corps, with "gunshot fracture 
of neck of femur," and his death on October 8, 1834. 

Case 184. — Musician F. McNeil, Co. B, 17th Illinois, was wounded at Shiloh, April 6, 1862, and admitted to hospital 
at Quincy twelve days afterwards. Surgeon R. Niccolls, U. S. V., reported : "Compound comminuted fracture of right femur 
at the neck and transverse fracture of left femur at the middle third. Dr. Buck's weight and pulley were employed. Death 
took place on April 27, 1862. At the post-mortem a minie ball, split longitudinally, was removed from the neck of the femur." 

Case 185. — Private U. T. Palmer, Co. I, 1st Maine, aged 33 years, was wounded at Cedar Creek, October 19, 1864, and 
admitted to the field hospital of the 2d division, Sixth Corps. Surgeon S. F. Chapin, 139th Pennsylvania, noted : "Gunshot 
fracture of left thigh." On October 27th the wounded man was admitted to Camden Street Hospital, Baltimore, whence 
Surgeon Z. E. Bliss, U. S. V., reported as follows: "Gunshot wound of left gluteal region, with fracture of neck of femur. 
Smith's anterior splints were applied, and quinine and carbonate of ammonia, etc., were resorted to, but unsuccessfully. The 
patient died of pyaemia, November 3, 1864. At the post-mortem pus was found in the synovial cavities near the hip joint." 

Case 186. — Sergeant W. Peabody, Co. C, 10th Vermont, aged 22 years, was wounded at Monocacy, July 9, 1864, and 
admitted to hospital at Frederick the following day. Assistant Surgeon R. P. Weir, U. S. A., reported: "Gunshot fracture 
of neck of left femur and flesh wound of thigh and scrotum. Ball removed July 11th. Tonics, opiates, and stimulants 
administered; Buck's extension apparatus applied. Death, from exhaustion, July 23, 1864." 

Case 187. — Private J. H. Smith, Co. H, 12th South Carolina, appears on a report from the Confederate Hospital at 
Charlottesville as having died June 1, 1864, of "gunshot wound of left thigh; missile found in neck of femur." 

Case 188. — Captain R. Ward, Co. B, 33d Alabama, was wounded at Perry ville, October 8, 1862. On a report of "Sick 
and Wounded Confederates left behind after the battle," signed by Surgeon C. Longenbecker, 13th Louisiana Regiment, C. S. A., 
his injury is described as a "gunshot fracture of left thigh through neck of femur into the joint and os ischii, ball in pelvis," 
and his death is stated to have occurred on October 27, 1862. 




SECT. II. J 



WOUNDS AN!) LNJUIUKS OF TIIK HIP JOINT. 



85 



several musket balls. 





PIG. 42.-Comminuted frac- 
ture <if upper third of left fe- 
mur, with fissure extending 
into the neck. Spec. 49:10. 



FIG. 43. — Upper portion of left femur, 
with fragments of bone removed nfter 
shot fracture of the neck. Specs. 3143 
and 67. 



Of the two hundred and forty niue fatal shot wounds of the hip joint treated by conser- 
vation fifty were instances of shot injuries of the neck and trochanters, or neck, trochanters 
and shaft of femur. Autopsies were performed in thirty-two instances, and twenty-five 
specimens are deposited in the Army Medical Museum. All of the cases have been 
reported in Circular No. 2, 1 and only a few of those in which interesting specimens are 
preserved will be here briefly noticed. 

Case 1S9 .— Private C. H. Elliott, Co. U, 61st Pennsylvania, was wounded at the battle of Pair Oaks, May 31, 1862, by 
One entered near the right acromion process and emerged at the insertion of the deltoid muscle; another 
at the gluteal fold; a third passed through the tipper part of the thigh ; a finger was also shot away. 
Ho was conveyed to Portsmouth, and on June 5th was admitted into the Balfour General Hospital. 
A fracture of the head of the humerus was recognized, and, on June 
14th, Assistant Surgeon Sheldon, U. S. A., excised the head and 
about three inches of the shaft (see Second Surgical Volume, p. 58G, 
Case 23). Abscesses formed in the left thigh. Pyremia super- 
vened, and the patient died on June 17, 1862. At the autopsy the 
upper third of the femur was found to be shattered. There was a 
collection of pus near the wound in the hip. Assistant Surgeon II. 
L. Sheldon, U. 8. A., reports the case. The specimen, 4930, repre- 
sented in Fig. 42, was contributed by Assistant Surgeon W. Thom- 
son, U. S. A.— (Circular No. 2, p. 09, Case 31.) 

Case 190.— Private Philo Wilbur, Co. I, 185th New York, aged 

19 years, was wounded in action at the Southside Railroad, Virginia, 

March 25, I8C5. A conoidal ball entered over the left trochanter 

major, produced a comminuted fracture of the process, and emerged 

at the lower and inner border of the left buttock. He was taken to 

City Point and Washington and admitted, on April 2d, into the 
Mount Pleasant Hospital. On April 7th there was febrile action and anorexia. On April 9th, Assistant Surgeon H. Allen, 
U. S. A., removed several detached fragments of bone. Irritative fever and anorexia continued. On April 14th he had a rigor; 
pyaemia appeared, with vomiting and diarrhoea. On April 18th secondary haemorrhage of from six to eight ounces occurred 
from branches of the external circumflex, and was arrested by compression of the femoral. He died April 20, 1865. The 
history, with the specimens 3143 and C7 (Fig. 43), were contributed by Assistant Surgeon II. Allen, U. S. A. — (Circular No. 2, 
p. 106, Case 274.) 

Case 191. — "Alfred G. E , Adjutant 134th Pennsylvania, aged 24 years, was wounded in the upper part of the left 

femur by a round ball, which partially fractured the trochanter major, at the battle of Fredericksburg, December 13, 1862. The 
wound received no attention for some days, and was then dressed with side splints firmly bound by a roller, a plug of lint being 
tightly inserted in the wound. On the 20th of December he was admitted to E Street Infirmary, Washington. He stated that 
for some days he had experienced occasional twitchings in the limb, and had taken large doses of opium. The wound was a 
little behind the trochanter major. Upon removing the plug of lint about half a pint of blood and pus was discharged. There 
was no crepitus upon rotation, nor shortening. Owing to his weakened condition, no extended search was made for the missile. 
Simple dressings were applied, and half grain doses of sulphate of morphia were given. For the two succeeding days he 
seemed to improve. The twitchings of the limb occurred every few minutes, with occasional intermissions of a few hours. On 
the 23d the spasms became more violent and frequent, and it was deemed advisable to extract the missile. He was etherized, 
and the wound was enlarged two inches downward and backward. A gum catheter was made to follow the course of the 
missile behind and beneath the neck of the femur to the body of the pubis, where the ball was found in the scrotum near the 
spermatic cord. A flattened round musket ball was extracted through an incision at the base of the scrotum. A portion of it had 

1 Circular No. 2, 1869 : CASE 15, p. 67, Pt. T. B , 14th North Carolina, Spec. 548. Case 20, p. 68, Pt. J. C , 1, 10th New Jersey, Spec. 3806. 

Cask 23, p. G8, Pt. J. C , C, 5th New York Cav., Spec. 3181). Case 24, p. 68, Pt. M. D , U, 14th New York II. A., Spec. 3261. Case 28, p. 69, Pt. A. 

D , 1!, 43d New York, Spec. 3797. Case 31, p. 69, Pt. C H. E , D, 61st Penn., Spec. 4930. Case 34, p. 70, Pt. J. F , H, 1st Mass. Cav., Spec. 2704. 

Case 46, p. 72, Pt. F. G , 1st Louisiana, Spec. 1300. Cask 49, p. 72, Pt. G. H , D, 20th Michigan, Spec. 2839. Case 51, p. 72, Serg't W. D. H , A, 

0th Iowa, Spec. 3488. Case 55, p. 73, Pt. W. Ilerold, B, 6th Alabama. CASE 56, p. 73, Musician J. B. H , A, 41st Ohio, ■Spec. 2178. CASE 61, p. 74, Pt. 

H. J , P, 14tb N. York, Spec. 2309. CASE 64, p. 74, Pt. M. K , D, 65th N. York, Spec. 3419. CASE 66, p. 74, Pt. A. J. K •, E, 8th Florida, Spec. 1932. 

Case 67, p. 75, Pt. L. P. L , K, 91st Penn., Spec. 1343. Case 08, p. 75, Pt. J. Laner, F, 39th N. Jersey. Case 69, p. 75, Capt J. M. L , I, 20th Indiana, 

Spec. 505. Case 71, p. 76, J. McCarthy, E, 76th New York. Case 73, p. 76, Capt. II. D. M , K, 79th Illinois, Spec. 1747 {Am. Jour. Med. Sci.. 1864, Vol. 

XI.VII, p. 337). Case 88, p. 79, Pt T. M , C, 14th Maine, Spec. 1728. Case 90, p. 79, Serg't W. Norton, I, 5th Wisconsin ( U. S. Sanitary Commission 

Memoirs, Vol. I, p. 526). CASE 92, p. 80, Pt. W. O , K, 2d U. S. Cav., Spec. 2528. Case 94, p. 80, Adj't A. O. R , 134th Penn., Spec. 545. Case 96, p. 

81, Pt. J. R , C, 69th New York, Spec. 86. Case 99, p. 81, Pt. T. R , K, 210th Penn., Spec. 4168. Case 103, p. 82, Capt. E. F. S , K, 1st New York 

Cav., Spec. 4213. Case 114, p. 83, Corp'l J. M. Thompson, B, 29th .Mass. Cask 122, p. 84, Serg't D. Y , H, 100th New York, Spec. 3931. Case 199, p. 94, 

Serg't J. B. Bridwell, B, 87th Illinois Mounted Infantry. Case 200, p. 91, Pt. W. Campbell, A, 23d Missouri. Case 203, p. 95, Serg't W. G. Davis, II, 19th 
Ohio. Case 205, p. 95, Pt. C. Falk, E, 20th New York. Case 206, p. 95, Pt. W. T. Fostner, F, 28th Virginia. Case 207, p. 95, Pt. H. B. Gardner, F, 38th 
Illinois. Case 208, Pt. M. Haehl, A, 32d Indiana. Case 209, p. 95, Capt. J. D. Irwin, C, 124th Ohio. Case 213, p. 96, Pt J. Scbeets, 1, 111th Ohio. Case 
214, p. 96, Pt. D. Schamill, II, 50th Penn. Case 215, p. 90, Corp'l G. Williams, D, 11th Missouri. Case 242, p. 100, Corp'l M. J. Fitzharris, E, 42d N. York. 
Case 258, Pt. F. Beck, F, 115th Penn. Case 263, p. 103, Pt. T. Hay ward, F, 5th Penn., Spec. 592. Case 205, p. 104, Corp'l W. Hermka, D, 1st Maryland 
Cav. Case 206, p. 104, Pt. J. Leehart, C, 10th Mississippi. Cask 270, p. 104, Capt. II. A. Sand, 103d New York. Case 273, p. 105, J. T. Tindcll, K, 18th 
Mississippi Cav. (Confed. States Med. and Surg. Jour., January, 1865). Case 274, p. 106, Pt. P. Wilbur, I, 185th New York, Spec. 3143. Second Surgical 
Volume : Case 859, p. 295, Serg't W. Spend lovfl, E, 1st New York Cav., and Case 935, p. 324, Serg't C. Moulton, D, 2d Maryland. 



86 



INJURIES OF THE LOWER EXTREMITIES. 



[CHAP. X. 




FIG. 44. — Fracture 
of trochanter and neck 
of the left femur by a 
round musket ball. A 
fragment of lead is im- 
pacted in the neck. 
Spec. 545. 




Fig. 45. — Fissure of 
rig-lit femur, caused by 
a conuidal ball lodging 
in the neck. Spec. Z931, 



been chipped ofF. The patient rested well that night, but on the following day the spasms were increased in intensity, commencing 
in the injured limb and extending over the body. < Mollis saturated with chloroform and olive oil were applied to (lie limb, and an 
antispasmodic and anodyne mixture was prescribed. He rested quietly until the following morning, when clonic spasms returned 
and persistently increased. The patient's countenance became pinched, wan, and haggard, and expressive of fright. There 
was no pain nor trismus, and he partook freely of nouislnnent. At times there was complete opisthotonos. On December 25th 
he took four dozen pills of assaftetida of four grains each, and one half ounce of fluid extract of Cannabis Indies in divided 
doses, without any benefit. Sulphate of morphia in doses of one grain was then prescribed, to be administered every two 
hours, and a poultice of powdered opium and cinchona applied to the wound, but, as before, without apparent benefit. The 
mind, up to this time, continued clear and undisturbed, his pulse moderately full and strong, ranging at about 100. ITo now 
became drowsy, and at times lay in a semi-comatose condition. His pulse ran up to 150. Respiration was free, but at times 
hurried, from 525 to 28 per minute. The skin became bathed in sweat, which exhaled a peculiar pungent odor. The bowels 
were regular; the urine was scantily secreted and high colored, though voided without difficulty. The 
discharge from the wound was thin, bloody, and offensive. On December 27th opisthotonos recurred, 
and was temporarily relieved by the application of chloroform to the entire extent of 
the spine. Subsequently, violent epileptiform convulsions set in, and death resulted 
from exhaustion, on December 28, 1862." The pathological specimen is figured in 
the wood-cut (Fig. 44). and shows a fracture of the great trochanter of the left femur 
and a piece of a leaden ball embedded in the neck. The specimen and history were con- 
tributed by Surgeon C. L. Allen, II. S. V.— {Circular 2, S. G. O., 1869, p.80, Case 94.) 

Case 192. — "Sergeant David Y- , Co. II, 106th New York, aged 29 years, was 

wounded at the battle of Monocacy Junction, July 9, 1864, by a conoidal musket ball, 
which entered two inches posterior to and one inch above the right trochanter major, 
passed forward and inward, and lodged in the neck of the femur at its middle portion. 
He was admitted to General Hospital at Frederick, Maryland, on the same day, and 
the wound did well until the 12th of July, when it assumed tin unhealthy appearance. 
A careful examination was made with the finger and by the probe, and the integu- 
ments and fascia were divided, giving free exit to sanious and fetid pus. Large quan- 
tities of stimulants and beef tea were given. On July 19th symptoms of pyaemia made 
their appearance, such as rigors followed by profuse perspiration and acceleration of the pulse and respiration, dryness of the 
tongue, and anorexia. Another examination of the wound was made, and the ball was found embedded in the femur, but, owing 
to the patient's condition, its removal was deemed inadvisable. On July 20th another rigor occurred, and gradual aggravation 
of all the symptoms followed. He died at 3 o'clock P. M., July 22, 1864." The pathological specimen and history (Fig. 45) 
were contributed to the Army Medical Museum by Assistant Surgeon R. F. Weir, II. S. A. — (Circular 2, p. 84, Case 122.) 

Case 193. — "Captain James M. L , Co. I, 20th Indiana, was twice wounded in an engagement in front of Richmond, 

on June 27, 1862. The first wound was through the lumbar muscles, and, while lying on the field, he was again struck by a 
conoidal musket ball, which entered on the outer side of the left thigh a little below the great trochanter, 
and, passing upward and inward, lodged. He was conveyed to Washington, and on June 29th was 
admitted to the Columbia College Hospital. A finger could be readily passed into the perforation of 
the femur, but the ball could not be reached. There was no shortening or eversion of the limb, interfering 
with the motion of the joint. Three formal attempts to ascertain the position of the ball and accomplish 
its removal were unsuccessfully made. The patient died from exhaustion, August 19, 1862." The speci- 
men is represented in the adjoining wood-cut (Fig. 46). It shows the upper portion of the left femur 
perforated between the trochanters on the posterior surface. The track of the ball is carious. The 
great trochanter has been split off, but is reunited by callus. The space between the trochanters is 
bridged over by a displaced fragment of bone, attached in its new position by slight osseous deposits. 
The missile was found resting against the capsular ligament. Assistant Surgeon W. M. Notson, U. S. A., 
who attended and reported the case, is confident that the ball was external to the joint; but as the 
grooving of the neck extends upward nearly to the articular surface of the femur, it is hardly possible 
that the joint escaped. — (Circular 2, p. 75, Case 69.) 

In twenty-seven of the two hundred and forty-nine shot fractures of the hip joint with 
fatal terminations the parts of the joint involved were not indicated. The details in the 
cases are very meagre, and no autopsies were made. Fifteen have been recorded in Circular 
No. 2 ; x such information as was obtainable of the remaining twelve will here be given : 

Case 194. — Private J. Cilley, Co. E, 19th Maine, aged 22 years, was wounded at Petersburg, June 22, 18C4, by a conoidal 
ball. He was taken to the field hospital of the 2d division, Second Corps, where Surgeon J. F. Dyer, 19th Massachusetts, 
noted : "Shot fracture of the left hip joint." On July 1, 1864, he was admitted into the Carver Hospital, Washington, and he 
died August 30, 1864. Surgeon O. A. Judson, U. S. V., reports cause of death : "Exhaustion following shot fracture left ilium." 




FIG. 46. — -Perforation 
of the neck of left femur 
by aconoidal musket ball. 
Spec. 565. 



' Circular 2, 1863 : Case 2, p. 65, Corp'l J. A. Baker, C, 4!)th New York. Case 7, p. 66, Pt. C. S. Bates, G, 27th Michigan. Case 13, p. 67, Corp'l W. 
Bowen, K, 56th Penn. Case 37, p. 70, Pt. J. Forbes, C, 31st Mass. Case 39, p. 70, Pt S. Fowler, 4th Michigan Battery. Case GO, p. 74, Pt. W. Jackson, B, 
106th New York. Case 63, p. 74, Pt. II. Jones, 1, 151st Penn. Case 87, p. 7SI, Lieut. M. Mullen, G, 69th Penn. Cask 97, p. 81, Corp'l J. Robinson, 1, 3d 
Maryland Cavalry. Case 105, p. 82, Capt. R. Shaw, K, 56th Penn. Case 184, p. 92, Pt. J. Wells, C, 1st Mass. II. A. Case 202, p. 95, Pt. J. E. Clark, E, 23d 
Pennsylvania. Case 210, p. 95, Pt A. Latten, Morgan's Command (see Confed. Slates Med. and Surg. Journal, 1865, p. 9). CASE 250, p. 101, Pt. E. Powell, 
A, 3d U. S. C. T. Case 252, p. 101, Pt. J. Shafer, A, 7th Maryland, 



SECT. II.] 



WOUNDS AND INJURIES OK THE JUT' JOINT. 87 



Cask 195. — Private J. Fanvll. Co. 13, Wtli IT. S Infantry, aged 35 years, was wounded at Spottsylvania, May 12, 1804, 
and admitted to the field hospital of the 2d division, Fifth Corps. Surgeon W. R. DeWitt, jr., recorded: ''Gunshot wound of 
left thigh; severe." On May 18th the wounded man was received into Douglas Hospital, Washington, Assistant Surgeon W. 
Thomson, U. S. A., reported : ''Gunshot wound of left hip; fracture of pelvis and femur. Haemorrhage to the amount of two 
ounces occurred from a museular branch on May 28th, and ceased spontaneously. The patient died of asthenia May 28, 18C4. 

Cask 19ii. — Colonel C. Knoderer, 107th Pennsylvania, was wounded at Suffolk, January 30, 18G3. Surgeon D. M. 
Marshall, of the regiment, reported: "Wound of left hip produced by a piece of shell, completely shattering the hip joint and 
causing immediate prostration. Stimulants were given internally, and cold applications, combined with styptics, were used. 
Death occurred on February 15, 1803." 

Cash 197. — Corporal E. W. Mulford, Co , E, 74th Illinois, was wounded at Chattanooga, November 25, 1803, by a 
conoidal ball, which fractured the right hip. He died December 10, 1803, in the 2d division, Fourth Corps, field hospital. 
Surgeon F. W. Lyth, 30th Illinois, records the case. 

Cask 193. — Private M. Murphy, Co. D, 8th New York Heavy Artillery, was wounded at Cold Harbor, June 3, 1864, 
by a conoidal ball. He was taken to the field hospital of the 2d division, Second Corps, where Surgeon J. F. Dyer, 19th 
Massachusetts, records : "Shot fracture of the right hip joint and wound of both shoulders." He died June 6, 1864. The cause 
of death is given on the burial records as "shot wound of bowels." 

Cask 199. — Private A. Olds, Co. F, 8th New York Heavy Artillery, was wounded at Cold Harbor, June 3, 1864, and 
admitted to the field hospital of the 2d division. Second Corps. Surgeon J. F. Dyer, 19th Massachusetts, reported : "Gunshot 
fracture of left hip joint. Died June 5, 1864." 

Cash 200. — Private C. Tease, Co. C, 4th Michigan, was wounded in the left hip at Gettysburg, July 2, 1863. He was 
treated at a Kifth Corps field hospital until July 24th, when he was admitted to Camp Letterman. Surgeon H. Janes, U. S. V., 
reported that the man "died August 7, 1863, of gunshot fracture of left hip joint." 

Case 201. — Private H. Stratton, Co. U, 99th Pennsylvania, was wounded at Gettysburg, July 2, 1863, by a conoidal 
ball. He was taken to the field hospital of the 1st division, Third Corps, where Surgeon G. W.Lyman noted: "Gunshot 
compound comminuted fracture of the right thigh implicating the hip joint." He died July 4, 1863. 

('ask 202. — Private J. J. Stumple, Co. A, 7th West Virginia, was wounded at Cold Harbor, June 3, 1864, by a conoidal 
ball. He was taken to the field hospital of the 2d division. Second Corps, where Surgeon J. F. Dyer, 19th Massachusetts, 
noted: "Shot fracture of the right hip." He was admitted into the Second Division Hospital, Alexandria, June 7th, where 
Surgeon T. R. Spencer,' IT. S. V., records "shot wound, right thigh." He died June 25, 1864. 

Cask 203. — Private T. O. Tucker, Co. D, 01st Pennsylvania, aged 39 years, was wounded at Spottsylvania, May 15, 
1804, by a shell. He was taken to the field hospital of the 2d division, Sixth Corps, where Surgeon S. J. Allen, 4th Vermont, 
noted: "Wound of the right groin." On May 26, 1864, he was admitted into the Second Division Hospital at Alexandria. He 
died the following day. Surgeon T. R. Spencer, U. S. V., reported the cause of death "shot wound of the right hip joint." 

Case 204. — Private J. Volkommer, Co. C, 46th New York, aged 19 years, was wounded at Petersburg, July 30, 1864, 
and admitted to the field hospital of the 3d division, Ninth Corps. Surgeon P. A. O'Connell, U. S. V., reported: "Gunshot 
wound of left hip; ball entered one and a half inches from the trochanter major, wounding the capsular joint." Three days 
after the reception of the injury the wounded man was transferred to the Depot Hospital at City Point, whence he was sent to 
De Camp Hospital, David's Island, New York Harbor, August 7th. Assistant Surgeon W. Webster, U. S. A., in charge of the 
latter, reported that the patient died November 19, 1864, of "gunshot wound of left hip, with fracture of femur." 

Case 205. — Private S. Waisner, Co. E, 28th North Carolina, was wounded and captured at Gettysburg, July 3, 1863, 
and entered Camp Letterman on July 23d. Surgeon H. Janes, U. S. V., reported : "Gunshot fracture of right hip joint. 
Death on August 18, 1863." 

Of the series of two hundred and forty-nine cases of shot fractures of the hip joint 
unsuccessfully treated by conservation, fifty-two have been detailed in the preceding pages 
and one hundred and ninety-seven cases have been briefly noted, the details of the cases 
having been cited in Circular No. 2. 

In one hundred and eighty-four cases the injuries were caused by small, and in fifteen 
cases by large projectiles, while in fifty instances the nature of the missile was not indi- 
cated. Fragments of bone were removed in twenty-one of the two hundred and forty- 
nine fatal cases of shot fracture of the hip joint treated by conservation. Pya?mia was 
indicated in thirty-eight instances, gangrene in thirteen, tetanus in one case, erysipelas in 
one case, peritonitis in five cases, and secondary haemorrhage in fourteen cases. In one 
instance (Case of John McCarthy, Co. E, 76th New York, Circular No. 2, p. 76, Case 71, 
and foot-note 1, p. 85) the femoral artery was tied, and in two instances (Cases of: Cor- 
poral J. P. Smith, Co. B, 1st Wisconsin, Circular No. 2, p. 82, and 107, of Private C. 
Hambrecht, Co. E, 4th New Jersey, Case 181, p. 84, ante) the external iliac artery was 



88 SHOT INJURIES OK THE LOWER EXTREMITIES. ICHAP. X. 

ligated. In four instances the missile penetrated the abdomen; in nine cases the pelvic 
cavity was pierced, hut apparently without injury to the viscera. In fifteen cases a shot 
fracture of either the ilium, ischium, or os pubis was reported; in two instances the blad- 
der was involved, 1 and in twenty-two easc^ the injury to the hip joint was complicated by 
various other injuries of less gravity. Eleven patients died on the day of the reception 
of the injury; fifty-three survived the injury from one to ten days; scventv, from eleven 
to twenty days; thirty-two, from twenty-one to thirty days; twenty-one, from thirty-one 
to forty-days; the remaining sixty-two patients lived from forty-one to two hundred and 
sixty-three days, and one patient lingered for nearly two years and a half. 2 In eighty- 
three instances it was reported that the missile had lodged, in nineteen of which it was 
stated to have been extracted. 

In seventy-eight of the two hundred and forty-nine fatal cases of shot fracture of the 
hip joint treated by conservation, the specimens indicating the bony lesion at the hip are 
preserved in the Army Medical Museum. Illustrations of forty of these seventy-eight 
specimens were given in Circular No. 2, pp. 66-114, and twenty-one have been repre- 
sented by wood-cuts in the preceding pages. 

In tabular statement IX, on page 65, ante, the total number of alleged shot fractures 
at the hip joint treated by the conservative expectant mode was given as three hundred 
and four, of which fifty-five were reported to have recovered; but, from an analysis of the 
cases, it becomes clearly evident that it would be impossible to arrive at just conclusions 
regarding the mortality of injuries of this nature from the total number of cases tabulated. 
It has already been stated on pp. 76, 77, ante, that in fourteen of the fifty-five eases of 
recovery after alleged shot fractures at the hip joint the evidence is contradictory, or 
adverse to the supposition that the hip was implicated; that in nineteen instances the 
evidence is vague and insufficient, and that in two cases the testimony consists solely of the 
statements of examining surgeons based upon examinations made long after the injury had 
healed. Deducting these thirty-five cases, there remain two hundred and sixty-nine cases 
with twenty recoveries, giving a mortality of 92.5 per cent. But it was further stated on 
.pages 76 and 77, ante, that in twelve instances the evidence is compatible with the sup- 
position that the fractures were probably in the trochanteric region, and that in five 
instances the fractures were extracapsular. Eliminating these seventeen cases, there 
remain only two hundred and fifty-two cases with three recoveries, or a mortality rate of 
98.8 per cent. Of the three patients that recovered after undoubted intracapsular shot 
fracture of the hip joint, one, Private T. C. Garvin, Co. H, 94th New York (Case 143, 
ante), died nearly four years after the reception of the injury, from which pus and portions 
of the joint, consisting of splinters of bone, were discharged to the time of his death. In 
the case of T. L. Lomax (Case 140, ante), in which it remains a disputed point whether it 
should be regarded as an example of treatment by excision or by conservation, it was 
impracticable to ascertain whether the patient is still living. The third patient, Colonel 
J. C. Strong (Case 134, ante), was in tolerably good health in December, 1878. 

From the evidence recorded on the registers of this Office in the alleged examples of 
recovery after shot fractures of the hip joint treated by temporization, I must continue to 
share the unfavorable impression of the results in this class of injuries of Guthrie, and 

•The details of these cases have been published with Injuries of the Parts Contained in the Pelvis, Section II, Chapter VII, Second Surgical Volume, 

viz: Sergeant T. A , Co. C, 119th New York, Case 922, p. 318; see also Note 2, p. 77, ante; and Sergeant W. Spendlove, Co. E, 1st New York 

Cavalry, Case 859, p. 295, and Note 1, p. 85, ante. 

'Case of Private Louis Schmidt, 8th Kansas, wounded at Chickamauga, Sept. 19, 18li3, died Jan. 3, I860. Circular No. J, 18(59, Case 271, p. 105. 



sr.CT. ii. 



EXCISION AT THE HIP FOR SHOT INJURY. 



89 



many of the older as well as more modern writers on military surgery, and can only 
reiterate the conclusion I hat .1 have already expressed in Circular No. 6, at page 61, and 
in Circular No. 2, at page 117, that shot injuries of the hip joint, when abandoned to the 
resources of nature, prove almost uniformly fatal. 1 

With regard to the twenty-five cases of recovery after shot injuries of the hip joint 
under conservative treatment in the Franco-German War, 1870-71, tabulated by Professor 
vim Langenbeck, and alluded to on page 67, ante, it may be hoped, in the interest oi sur- 
gical science, that the future histories of these patients will be noted, and that when death 
ensues it may be found practicable to have the extent of the injury to the hip joint pre- 
cisely ascertained by post-mortem examination. The difficulties of such a task are apparent 
and have hitherto proved insurmountable. In five of the fifty-five cases of recovery after 
alleged shot fracture at the hip joint cited from the American civil war, the patients have 
since died; but so far the opportunity to verify the diagnosis by an autopsy has not been 
improved. 

EXCISION AT THE HIP AFTER SHOT INJURY.— A large addition to our 
statistical information on this subject was afforded by the experience of the American civil 
war as indicated by the accompanying tabular statement: 

Table X. 

Numerical Statement of Sixty-six Cases of Excision at the Hip Joint for Shot Injury. 



Operations. 


Cases. 


I'l'.U Cknt. 

OF 
MuiiTAi.nv. 


Recovery. 


Fatal. 


Total. 




l 
a 

3 


32 

20 

8 


33 
22 
11 


!I0. 
72.7 










c 


60 


66 


SO. D 



''Twelve cases of excision of the head of the femur for gunshot injury arc all that 
are recorded in print, prior to 1861," is correctly asserted at page 17 of the report from 
this Office 2 published in 1869; but it is now known 3 that in the Italian Campaign of 1859 
Dr. J. Meuddrfer excised at the hip for shot injury four times, at least, which gives a total 

1 In note 1, of page G2, ante, it was attempted to give, in chronological order, the earliest references to cases of shot wounds of the hi]) in military 
surgical literature, and the first case adverted to was that of Private S. Kirsky, in 1077, related by PuiiMANX (M. G-.) (Funfftzig Sonder-und Wander- 
bahre Schus.swunden Curcn, Frankfurt, 1721, Obs. XLI1I, p. 324). After page fi~ had gone to press, the following case, cited by Dr. JOSEPH SCHMIDT 
(Speculum C'lnrurgicum oder Spiegel der Artzney, Augspurg, 1656, p. 144.), which antedates the ease of PtiKMAXX by 33 years, came to the editor's 
notice : ''In the month of *May, lo"34, while the here-stationed Swedish regiment was being mustered in the eastle-yard, a sergeant, whose quarters were 
with -Mr. Peter Rchlinger, was accidentally shot through the hip. lie was conveyed in a trough to his quarters. 1 was called upon to see the ease, but 
found that there was great difficulty in the way of bandaging and that the thigh was greatly swollen, the wound of entrance being as large as a hen-egg. 
On probing the wound I readilj' discovered the bare bone, with every indication that the shaft must have been split. Great haemorrhage had also taken 
place ; his system was in a bad condition, unfavorable for a cure. The symptoms hourly grew more aggravated and became so severe as to terminate his 
life on the sixth da}*. After his death, I endeavored to obtain the consent of the officers to let him be opened, which was readily granted. When I did 
open hiin I discovered that the upper part of the femur, the head which enters the hip bone, was comminuted, as if it had been done with a hammer upon 
an anvil. There was also a long fissure in the shaft running down towards the knee ; the great trunk of the artery was torn, and the condition of the soft 
parts, inwardly near the bone, was so offensive that I can hardly describe it. It was no wonder tliat he lost his life from so severe an injury. Should lie 
have recovered he would have done so with a bad walk." An instance from the Turco-Kussian War of 1877, is related by KADE (E.) {Das tctnporare 
Kriegslazareth der Anstalten der Kaiserin Maria im Klostcr Mariahimmelfahrt by Sistowa, in St. Petersburger Mcdicinische Wochenschrift, 1877, No. 
4o, p. 383); A. soldier, on August 31, 1877, received a shot wound of the right ooxo-femoral joint without separation of continuity of bone. The ball 
lodged with its point in the neck of the femur. On September 12th, the wound was enlarged and the missile extracted. The patient died September 
17th, of septicaemia following suppuration of the joint. 

2 Otis (G. A.), A Report on Excisions of the Head of the Femur for Gunshot Injuries. Circular No. 2, War Department, Surgeon General's 
Office, January G, 1869, 4to, pp. 141. 

3 LONGMORE (T.), Gunshot Wounds, in T. HOLMES'S System of Surgery, 2d ed., London. 1870, Vol. II, p. 230. 

Surg. Ill— 12 



90 INJURIES OK T1TK LOWER EXTREMITIES. [CHAP. X. 

of sixteen examples of this operation in military surgery prior to our war. Of these, 
a primary excision by Mr. T. C. O'Leary, in the Crimea, in 1855, was successful. The 
patient died ten years afterwards of phthisis. A secondary excision, by Dr. Neudorfer, in 
1859, was followed by amputation at the hip, which the patient happily survived. In the 
foot-note 1 instances of excision at the hip for shot injury are enumerated, in addition to 
those practised in the United States service. 

At the date of the publication of Circular No. 2, S. G. 0., January, 1869, the records 
of this Office contained sixty-three, as was then believed, authenticated cases of excision 
of the head, or of the head and neck, or head and neck and portion of the shaft of the 

*1. OPPENHEIM (F. W.) (Die Extirpation des Schenkelkopfes aits der Gelenkhuhle, in Zeitschrift fur die gesammte. Afedicin, ll;mihurg, 1836, 
B. I, S. 137); a Russian chasseur wounded May 5, 18:29, at the battle of Eski-Arna-Utlar ; fracture of neck of left femur and rim of acetabulum. 
Primary excision May 5, 1829 ; death from plague May 23, 182!\ — 2. SElTlX (Resection de la partie supericitre du femur, in Bulletin General de Ther- 
apeutique, Paris, 1833, T. IV, p. 371); Private Lisieux, 25th Infantry; fracture of neck, trochanters, and upper fourth of right femur. Primary excision 
Decembers, 1832; death on the fourth day, from gangrene. — 3. C. TIZXTOU (KARL TEXTOR, Der Zweite Fall von Ausstigung des Schenkelkopfes mit 
volkommeneni Erfolg, Wtfrzburg, 1858, S. 15, No. 12); Kaspar Artes, aged 44 ; caries of head of right femur consequent upon gunshot fracture. .Secondary 
operation on November 8, 1847; death on November IS, 1847. — 4. Dr. H. SCHWARTZ (Bcilrdge zur Lehrc von den Schusswunden, Schleswig, 1854, 

p. 142); O , Danish soldier; shot fracture of trochanters of left femur. Intermediary excision May 13, 1849; death. May 20. 1849.— 5. Dr. G. ROSS 

( Deutsche Klinik, 1S50, B. II, p. 451); Karl Engelking, aged 23, received, at Frederieiu, May 8, 1848, a shot fracture of the left trochanter. Secondary 
excision, June 10, 1850; death, June 13, 1850. — 0. Professor BAUM (LOHMEYER, Vie Schusswunden, 1859, p. 1ST); a subaltern officer; shot comminu- 
tion of neck of femur. Primary excision in 1854 ; death in twenty-two hours. — 7. G. K. BLEXKIxs (G. IT. It. MACLEOD, JS'otes on the Surgery, etc., 
London, 1858. p. 311, and G. J. GUTHRIE, Commentaries, Loudon, 1855, p. 021); Private C. Monstcrey, 3d Batt. Grenadier Guards ; shell fracture of neck 
and trochanters of right femur. Primary excision in June, 1855; death in five weeks. — 8. G. II. B. MACLEOD (Notes on the Surgery of the War in the, 
Crimea, 1858, p. 338); Private Couch, of the Rifle Brigade; fracture of the neck of left femur, June 18, 1855. Intermediary excision .Inly 5 ; death firm 
cholera July 10, 1855. — 9. Surgeon J. C RE EAR (G. J. GUTHRIE, Comment 'a tic*, 6tli ed., London, 1855, p. (522); Private W. Smith, 1st Royals; grenade 
fracture of trochanter and neck of left femur. Primary excision August 6, 1855; died August 21, 1P55. — 10. T. C. O'Leauy (T. P. Matthew, Medical 
and Surgical History, etc., during the War against Russia, 1854-'55-'56, London, 1858, Vol. II, p. 378); Bpivate T. McKevena, 08th Regiment; shell 
fracture of trochanter and neck of left femur. Primary excision August 20, 1855; recovery.— 11. Dr. Gkorge HTDE (MATTHEW, t. &, Vol. II, p. 378); 
Corporal B. Shcehan, 41st Regiment ; grapeshot comminution of trochanter and neck of femur. Primary excision September 8, 1855; death September 
14, 1855. — 12. Dr. COOMHE (MACLEOD, loc. cit., p. 344); British artillery soldier; shot fracture of neck of femur. Intermediary excision in 1855 ; death in 
a fortnight. — 13-19. J. NeuhjRFEU (Das Endresultat der Gelenkrescctionen, in Wiener Med. Presse, 1871, B. XIT, p. 407) remarks : "I have performed 
the hip joint reseotiou for shot wounds seven times ; six died from the eighth to the eleventh day, and the seventh I exarticulated at the hip after a fen- 
days on account of purulent infiltration of the excised joint. The patient recovered after the exarticulation, and lives here in Vienna." J. Schranz. 7th 
Jmger Bat., wounded at Palestra, May 30, 1859. Excision at left hip joint November 27th. Purulent infiltration followed, and, on December J, 1859, 
amputation at the hip joint was performed by Professor NeuporfeR. The patient recovered, and lived in Vienna in 1808. During the Schleswig- 
Holstein War, 18*34, Dr. NKDDObfEB twice excised the hip joint, on Austrian soldiers, for shot fracture of the upper extremity of the femur. Inter- 
mediary operations. Both cases proved fatal (C. Heine, Vie Schussverletzungen, etc., 1866", p. 369). Of the remaining four operations by NEUUORFKK 
I have been unable to find any details. — 20. A successful secondary excision of the hip joint for shot wound received in the Austro-Prnssian War, 1866, 
was performed by Dr. Wagxer in Kontgsberg. NEUPORFER (Handbuch der Kriegschir., Leipzig, 1872, Zweite Halfte, Ahth. 2, p. 1458) states that 
he saw the patient in November, 1866, at Gdrlitz, when his recovery was yet doubtful, but that in 1872 the patient was living at Graz, entirely recovered. 
He could walk without a cane, and could ascend and descend stairs. — 21-23. B. von Laxgkxheck (fiber die Schussfracturen der Gele?ike. 18fP. p. 16); 
Kueharsky, aged IP, fracture uf left trochanter, March 22, 1863. Secondary excision July, 1863; death in fourteen daj-s. Austrian soldier, wounded 
July 3, 1866; shot fracture of the neck of the right fernur. Intermediary resection August 5, 1866: death August 12, 1866. Emil Bauer, ICth Saxon 
Infantry, wounded June 29, 1866; shot fracture of the neck of right femur. Secondary excision August 20th; death in September, 1866. — 24. Dr. 
Scmonborn (B. v. Laxgkniseck, loc. cit., p. 16); Maxim Glutschak, aged 24; wounded July 3, 1866, fracture of head of the right femur. Secondary 

resection August 22, 1866 ; recovery. — 25. B. BECK (Kriegschir. Erf., 1867, p. 351); A. F. S , "Wiirtemberg drummer, wounded July 24, I860; shot 

fracture of neck of femur and trochanter major. Intermediary resection August 5th ; died August 7, 1860. — 26. L. Stromeyek (Erfahntngen fiber 
Schusswitnden, 1867, S. 52); a debilitated subject; intracapsular shot fracture of the neck of the femur. Intermediary resection in 1866; death in two 
days. — Stabsarzt Dr. DEIXIXGER, of the Railway Battalion (Beitrdge zu den Schussfracturen des Hiiftgelenks writer besonderer Beriicksichtigung der 
Erfahrungen aus dem Feldzuge 1870-71, und Benutzung der Acten des Koniglichen Kriegsministeriums, in Deutsche Mil.-arztl. Zeitschrift, 1874, 
Jabrgang III, pp. 237-335), gives a tabular statement of forty-five cases of resection of the head of the femur for shot injury, from the Franco-Prussian 
War, 1870-71. The eases are: 1 primary case fatal, 26 intermediary cases (all fatal), and 17 secondary {with 5 recoveries and 12 deaths), and 1 ease 
in which the time of operation was not recorded. Brief details are given : 27. A. Stephan, 3d Pioneer Bat.; shot fracture of neck and trochanter 
major of left femur, September 20, 1870: excision same day, by Dr. B. BECK; died September 29, 1870. — 28. Piurko, 22d Infantry; shot fracture of 
trochanter and neck of right femur, September 23, 1870; excision October 25. 1870, by SZMUI.A ; recovered, with useless limb. — 29. A soldier wounded 
at Orleans; comminution of head of femur; intermediary excision, by Dr. METZLER ; died 4 days after operation. — 30. J. B. MUller, 85th French 
lane ; shot fracture of head of right femur and rim of acetabulum at Beaune la Rolande, November 28, 1870 ; excision, by Dr. RUITET,, December 
2d; died December 7, 1870.— 31. Corporal Heinartz, 75th Prussian, wonnded at Orleans, December 9, 1870 ; ball fractured acetabulum and opened joint; 
excision, December 14th, by Dr. LaxgexrecK; died of septicaemia, December 20, 1870. — 32. A. Eichner, 2d Prussian Lancers; shot fracture of head 
of right femur, Orleans, December 4, 1870; excision, by Dr. LAXGEXBECK, December 12th ; died December 18, 1870. — 33. J. Sehone, wounded at. VYeissen- 
berg. August 4, 1870, splintering trochanter and head of femur; excision, by Dr. C/ERNY, August 13th; died August 16, 1870. — 34. M. Echtetbruch, 
Corporal, 78th Infantry ; shot fracture of left femur below the greater trochanter, August 16, 1870 ; excision, by Dr. MulleR, August 26th ; died Sept. 7, 
1870.— 35. J. Pakowsky, 14th Inf., wounded Decembers, 1870, in left hip joint; excision, December 14th, by Dr. NEWHAUS; died December 20, 1870. — 
35, J. Unterberg. Oldenberg Infantry No. 91 ; shot fracture of left trochanter, August 16, 1870; excision, August 27th, by Dr. A. Ewalp; died Sept. 9, 
1870. — 37. J. Wiedener, 52d Infantry, shot wound in right hip joint, August 16, 1870; excision, by Dr. Trendelenberg, August 28th; died September 
2, 1870.— 38. F. Kopzinsky, 5th Artillery, shot fracture of left hip joint, Sept. 19, 1870; excision, October 2d, by Dr. Wegner ; died October 28, 1870.— 

39. J. Busse, 24th Infantry, shot fracture of the left femur, August 16, 1870; excision of hip joint, August 29th, by Dr. MARCUSE; died Sept. 7. 1870.— 

40. F. Patzwald, 9th Infantry, shot wound of left hip joint, December 2, 1870; excision, by Dr. BRA8CH, December 16th ; died December 21, 1870. — 41. 
V. Vaillant, 42d French Line, shot fracture head of left femur, September 30, 1870 ; excision, October 14tb, by Dr. Grandies ; died October 17, 1870. — 
42. A. Dettki, 4lst Infantry, shot comminution of neck of left femur, August 31, 1870 ; excision, by Dr. SACHS, Sept. 15th ; died October 11, 1870.— 43. P. 
Congacz, French Guards No. 3, shot fracture of head of left femur, August 18, 1870; excised, by Dr. LAXGEXBECK, September 1st ; died Sept. 2, 1870. — 
44. C- C. Petit, French Infantry No. 67, comminution of left hip joint, August 16, 1870; excision, by Dr. LAXGEXRECK, September 1st; died September 



SECT. II.] EXCISION AT THK HIP FOB SHOT INJURY. 



91 



femur, for shot injury. It lias since been ascertained that in one of these cases the head 
of the femur was not removed; 1 but records of four additional cases 2 have since been 
obtained and added to the list of this operation, making a total of sixty-six cases of 
excision at the hip joint done for shot injuries received during the American civil war. 
As indicated in Table IX, at page 65, ante, fifty-five of these operations were performed 
for shot injuries of the hip joint, while in eleven instances the excision was practised for 
fracture of the shaft of the femur that did not primarily implicate the hip. 

4, 1870. — 45. C. Paoot, 50th French Infantry, shot fracture of neck of right femur, Weissenburg, August 4, 1870; excision, by Dr. Billroth, Aug. 20th; 
died August 20, 1870.— 46. W. Liesegang, 24th Infantry, shot fracture of neck of left femur, Vionville, August 1G, 3870; excision, September Cd, by Dr. 
GAEHDE; died September 3, 1870. — 47. E. W. Hoffman, of the Prussian Guards, shot fracture of hip joint, St. Privat, August 18, 1870; excision, by Dr. 
LiJCKE, September 5th; died September 13, 1870.— 48. A. Weraert, Corporal, 10th Dragoons, wounded in trochanter major, August 14, 1870; excision, 
by Dr. FISCHER, September 1st; died September 13, 1870. — 49. 15. Payant, 32d French Infantry, shot fracture of upper third of right femur, August 10, 
1870: excision, September 4th, by Dr. NEUHAUS; died Septembers. 1870. — 50. A. Fiasecki, .5th Infantry, comminution of neck of left femur, September 
9, 1870; excision, by Dr. WAGXER, September 29th ; died October 11, 1S70. — 51. P. Perrot, 13th French Infantry, comminution of right femur into joint, 
Gravelotte, August 8, 1870; excision, by Dr. BUSCH, September 12th; died September 23, 1870. — 52. J. Fitzer, 83d Infantry, comminution of trochanter 
major and neck of left femur, Worth, August C, 1870; excision, by Dr. PagexsI'ECHER, September 1st; died September 10, 1870. — 53. Sergeant-major 

B , 3d French Infantry, shot fracture of trochanter and neck of right femur, Worth, August 6, 1870; excision, by Dr. BECK, at the end of August ; 

died in the latter part of September.— 54. C. Schmock, of the Guard Sharpshooters, shot wound in left hip joint, St. Privat, August 18, 1670; excised, by 

Dr. BKSSBKRO, September 14th ; died September 19, 1870.— 55. P , 61st Infantry, comminution of neck of left femur, January 21, 1871 ; excision, by 

Dr. VOLKMANX, February 20th; died February 22, 1871. — 5G. J. Blanchct, French Garde Mobilier, shot fracture of head of left femur, November 28. 1870; 
excision, by Dr. Heixemaxn, December 29th ; died January 12, 1871. — 57. K. Paschke, 58th Infantry, comminution of neck and trochanter of right 
femur, October 2, 1870; excision, by Dr. BORETIUS, November Gtli ; died November 16, 1870.— 58. A. Schoblock, 7th WUrtemberg Infantry, shot frac- 
ture of femur high up, Chainpign}*, December 2, 1870; excision, by Dr. HUETER, January (5, 1871 ; died January 13, 1871. — 59. Bnrtseh. 2d Guards, shot 
fracture below trochanter, with Assuring of neck of left femur, August 4. 1870; excision, September 13th, by Dr. ScHILLHACH ; died in a few hours. — 
GO. D. Blennemann, 7th Infantry, shot wound <>f hip joint, Gravelotte, August 18, 1870 ; excision, about six weeks later, by Dr. WlKDBCHEIDT; recovery, 
witli good use of limb and one and a half inch shortening.— fil. F. Geier, 9th Infantry, shot through left hip joint, Worth, August 6, 1870; excision, by 
Dr. BILLROTH, September 28th ; died October 27, 1870. — 6*2. Svhnal, 10th French Infantry, shot wound in right hip, August 10, 1870; excision, by Dr. 
JOSETHSON*, October 24th ; death October 25, 1870. — 03. F. John, 8th Infantry, shot wound of right hip, fracture of acetabulum, Saarbrlicker., August 

6, 1870 ; excision, by Dr. Hut'EDEX, November 4, 1870; recovery, with moderately free use of limb and one inch shortening. — 01. B , 2d Zouaves, shot 

fracture of upper third of femur, Worth, August 0, 1870 ; excision six months after injury, by Dr. WELKKK ; recovery. — 05. French soldier, shot fracture 
of hip joint September 30, 1870; secondary excision ; recovery, with comparatively good use of limb.— 00. J. Pieper, 21st Infantry, shot wound of left hip; 
secondary excision of head of femur, February 19, 1871, by Dr. JacohY; died Feb. 23, 1871. — 07. G. Rossmanieck, 4th Infantry, shot in left hip in August, 

1870; secondary excision of hip joint; died Sept. 7, 1870. — 08. P , 17th Infantry, shot wound of right hip joint; secondary excision of joint; died. — 09. 

Unknown soldier; secondary excision, by Dr. Rattlkhner; fatal.— 70. Unknown soldier; shot fracture of neck of femur j secondary excision, three months 
after Injury, by Dr. HErrXEE ; death in two weeks. — 71. Unknown soldier, shot fracture of neck and trochanter ; resection three and a half months after 
injury; died a week afterwards. In a tabular statement of cases of resection of the hip joint performed during the same period, and collected by Professor 
B. v. LAXGEXRECK (Vber die Schussvcrletzuvgen des Hiiftgelenks, in Archiv filr Klinische Chirurgie, Berlin, 1874, B. XVI, p. 263), I find 7 eases 
(2 intermediary fatal cases, CASES Nos. 2, 5, pp. 329, 330,) — 1 secondary fatal (CASE No. 14, p. 334) — and 4 fatal cases, period of operation not stated 
(CASES 12. 20, 21, and 27, pp. 333, 335, 336), not contained in Dr. DEIXINGER's tables. They are: 72. Lieut. Roma, 9th French Infantry, shot frac- 
turo of left hip joint, August 18, 1870; excision, by Dr. LAXGEXUECK, August 31st; died September 4, 1870. — 73. Petit, C7th French Infantry, shot 
fracture of right hip joint, Mare la Tour, August 10, 1870; excision, August 30th, by Dr. LaxgexbecK; died December 10, 1870. — 74. Unknown soldier, 
shot fracture of hip joint; excision, by Dr. BILLROTH; died 24 hours after operation. — 75. Unknown soldier, shot fracture of pelvis: secondary involve- 
ment of hip joint ; secondary excision of head and neck, by Dr. KCstek ; death eight days after the operation. — 70, 77. Unknown soldiers ; excisions, by 
Dr. VOLKMANX; fatal.— 78. Unknown soldier; excision of head of femur, by Dr. GUAF; fatal. — 79. Another intermediary case of excision of head of femur 
for shot injury during the late Franco-Prussian War, 1870-71, not reported by either Dr. Deixixger or Professor B. v. LAXGEXRECK, is reported by Dr. 
GEORGE FISCHER (Dorf Fining und Schloss Versailles, in Deutsche Zeitschrift filr Chirurgie, Leipzig. 1872, B. I. S. 227); unknown, fracture of head 
of left femur. September 30, 1870; wound of exit and entrance on a level with the trochanter major. October 20th, resection; October 28th. death from 
pyaemia. An operation ascribed to Dr. LUTTER, in Lancet, 1870, Vol. II, p. 452, is identical with the case described by Dr. H. FISCHER {Kricgschir. 
Erf. vor Metz, Urlangcn, 1872, p. 200), and included in cases collected by Drs. DEIXLXGEIt and v. LaXi;exheck. (No. 48, ante). — 80-97. ClIEXU (J. C.) 
{Aperqu hist, stat. et clin., etc., pendant la guerre de 1870-71, Paris, 1874, T. I, p. 493) tabulates eighteen cases of excisions of the hip joint for shot frac- 
tures, in the Franco- Prussian War, 1870-71, with three recoveries. The same author (loc. cit., T. II, pp. 1-150) records, by name, tho cases of recovery 
after amputations, disarticulations, and excisions ; but, after a careful search, I have been able to find onl}' one of the (3) successful cases of excisions at 
the hip joint among them. The case is detailed on p. 8^: " Lande (P. P.), born June G, 1849, at Valogncs (Maneho), 109th line. Fracture of head of 
femur for shot wound. Resection of head of femur.'*- The case is duplicated and again appears, on p.8G, as Laude, giving same details in every respect. 
I find no record of the two other cases. There is nothing to indicate whether the cases are primary, intermediary, or secondary operations. The eases 
reported by Dr. Duuheil (Gaz. mid. de Paris, 1871, T. XVI, p. 314) and Dr. ARXAUD (GrellOIh, Hist. mid. de blocus de Metz, 1872, pp. 351-353) are 
undoubtedly includedin CHEXU'S (loc. cit., p. 493) statistics. — 98. RORERTSOX (J. B.) (Resection at the Hip joint — Removal of the Had with Four Inches 
of the Femur — Tetanus — Cure by Physosiigma, in Pacific Med. and Surg. Jour., 1878, Vol. XX, p. 500), excised, on April P, 1870, the head and four 
inches of the shaft of the femur in the case of George Miller, aged 45, who had suffered for over a year from a sinus, evidently resulting from a rifle shot 
received two years previously. The wound healed by first intention. Tetanus, which supervened about three weeks after Ihe operation, was successfully 
treated with physostigma. In February, 1873, Miller was '"well and able to ride on horseback and herd cattle in the mountains." — 99. Dr. RUDDUCK 
(MAUXOUUI, Rapport sur It mouvement de I'ambulance No. 5 du Croissant Rouge a Orchanie, du 17 Octobre au 8 Novemhrc 1877, m Le Pmgris Medical t 
1878, No. 1, p. 0) excised, on October 21, 1876, the head of the left femur in tho case of Mehemet-Osman, for shot wound received in the Turco-Russian 
War; secondary operation ; pneumonia; death. Summing up the cases of resection of the hip joint referred to in this note we have a total of 99 cases 
with 80 deaths, a fatality of 86.8 per cent. Of these 99 cases 8 were primary operations with 7 deaths (87.5 per cent.); 37 were intermediary, all fatal ; 
27 were secondary with 18 deaths (GG.G per cent.); nnd in 27 instances with 24 deaths the time of operation was not specified. 

1 The case of Lieutennnt Dwight Beebe, 3d New York, cited in Circular 2, at page 32. Information received since the publication of the case 
proves it to be an example of removal of three and a half inches of the upper portion of the femur just without the capsule. The case will be detailed 
with excisions in the continuity of the femur in the third section of this chapter. 

2 Cases of: 1. Private,/. W. Epton, Co. I, 5th South Carolina, referred to in Circular 2. at p. 120, but not included in the tabular statements on 
pp. 59 and 137; 2. Private C. Raines, Co. E, 25th North Cnrolina; 3. Private G. W. Tilliston, 1st Ohio Light Artillery; and 4. Private T. W. Pease, 
Co. H, 19th Indiana. 



92 • INJURIES OF THE LOWER EXTREMITIES. [chap. x. 

Primary Excisions. — Ot thirty-three well authenticated primary excisions at the hip 
practised during the War, twenty were performed upon Union and thirteen upon Confed- 
erate soldiers. The only successful result was in the ease of Private Camion, a young 
soldier of a Georgia regiment, on whom Dr. J. J. Dement, of Huntsvillc, Alabama, 
operated. The particulars of the case were communicated by Dr. Claude H. Mastin, of 
Mobile, formerly Inspector of Hospitals in the Confederate service, and by Dr. J. B. 
Duggan, of Toombsborough: 

Case 20G. — Private Cannon, Co. A, 49th Georgia, aged 24 years, was wounded at the battle of tlie Wilderness, May 5, 
18G4, by a conoidal musket ball, which struck an inch below the left trochanter major, extensively comminuting the femur and 
lodging in the adductor muscles. The Confederate line being forced back, the wounded man lay on the ground all night until 
the early morning, when the Confederates recovered their wounded. In Cannon's case, the consultation at the field infirmary by 
Surgeons J. J. Dement, Holt, J. J. Wynne, and P. P. Henderson, it was determined to enlarge the wound and remove the 
detached fragments of bone. Accordingly, the patient having been chloroformed, Surgeon Dement made an incision two inches 
upward from the entrance wound, and extending from the wound downward four inches. On ascertaining the condition of the 
parts, it was decided to exarticulate the head of the femur. This was readily accomplished, and then the neck and upper extremity 
of the shaft were removed. The fragments of the upper extremity of the femur, when put together, measured four and a half 
inches. The haemorrhage during the operation was trivial. All the medical gentlemen present remarked upon the slight degree 
of shock induced by the operation. The limb and body were confined by roller bandage to a straight splint extending from the 
axilla to the foot, A full dose of sulphate of morphia was then administered. In a few hours the patient was placed in an 
ambulance wagon and conveyed to Orange Court House, twenty-five miles distant, and thence by rail to Staunton, about 
seventy miles farther, where the after treatment was conducted at the general hospital. Little can be learned of the after treat- 
ment, save that the patient was supplied with rich diet, a liberal allowance of wine, and that no untoward complication occurred 
except the formation of abscesses attendant on an exfoliation of a ring of bone from the upper end of the shaft. When this was 
eliminated, the wound rapidly healed. At the end of nine months the cicatrix was firm. The limb was shortened three inches, 
and was useless for purposes of locomotion. The patient was in fine health, and moved about on crutches. He went to his 
home, in Toombsborough, Georgia, in February, 1835, and earned a livelihood by his trade of shoemaking. He enjoyed good 
health until November 12, 18G5, when lie had an attack of diphtheria which terminated fatally on November 23, 1865. 

The thirty-two unsuccessful primary excisions at the hip may be arranged in three 
categories. The first comprises thirteen instances where the circumstances were favorable, 
the patients of mature and robust organization, the lesions of bone limited to the upper 
extremity of the femur, the important vessels and nerves intact; the injuries to the soft 
parts were not excessive; there were no complications of wounds in other regions, and the 
patients were not subjected to hazardous removals; yet all thirteen succumbed within two 
or three days, or in one case as late as the fourth day, from the conjoined shock of the 
injury and the operation. 

Case 207. — Captain Frederick M. Barber, Co. H, Kith Connecticut, aged 32 years, was wounded at Antietam, Septem- 
ber 17, 18G2, by a musket ball, which entered behind the right trochanter major and shattered the trochanters and neck of 
femur. He was conveyed to the field hospital of the 3d division of the Ninth Corps. His general health was good, and there 
was but little shock. There was no swelling of the soft parts; the fracture was accessible to exploration, and appeared limited 
to the epiphysis. The case was one in which excision seemed peculiarly applicable, and, after a consultation of several surgeons 
of the division, that operation was decided upon. On the morning of September 18th, the patient being anaesthetised by chlo- 
roform, Surgeon Melancthou Storrs, 8th Connecticut, made a straight incision four inches long, passing through the wound of 
entrance. The comminuted fragments of the neck and trochanter were extracted, the round ligament divided, the head of the 
femur removed, and the fractured upper extremity of the shaft was sawn off by the chain saw. The edges of the wound were 
then approximated by adhesive straps, and simple dressings were applied. Little blood was lost, and the patient rallied 
promptly from the operation, and appeared quite comfortable during the day. Surgical fever soon set in, however; the patient 
sank rapidly under the constitutional irritation, and died on September 20, 18G2. 

Case 208. — Sergeant Edwin T. Brown, Co. C, 21st Massachusetts, aged about 30 years, was wounded in front of Peters- 
burg, on July 23, 1864, by a ragged fragment of a mortar bomb, which struck the left thigh over the trochanter major and 
comminuted the upper extremity of the femur. The wounded man was immediately conveyed to the hospital of the 1st division 
of the Ninth Corps. Surgeon Whitman V. White, 57th Massachusetts, and Surgeon James Oliver, 21st Massachusetts, saw 
the patient a short time after his admission to the hospital. He was a strong, healthy man, five feet ten inches in height, 
weighing about one hundred and sixty pounds, with a constitution of iron, and was in perfect health when injured. The soft 
parts about the seat of injury were lacerated and torn, and the upper extremity of the femur, to an extent of five inches, was 
crushed to fragments. No important arteries or nerves were wounded. Excision of the fractured bone was decided upon. On 
the afternoon of the day on which the injury was received chloroform was administered, and Dr. White made a longitudinal 
incision and removed the shattered fragments. The ligamentum teres was divided and the head of the bone turned out. The 
broken extremity of the shaft of the femur was evened off with a chain saw. The patient reacted promptly from the shock of 




SECT. II.) EXCISION AT THE Ilir AFTER SHOT INJURY. 93 

tlie operation. The limb was placed in proper position, and stimulants were freely used. Dr. Oliver states that lie saw the 
man several times on the following duy, who was in excellent spirits, and talked and laughed, and did not complain of any 
pain. On the 20th his appetite failed and he began to sink. He died July 27, 18G4. 

CASE 20!). — Private Charles Beard, 12th Mississippi, was wounded and made a prisoner in the engagement on the 
Weldon Railroad, August 23, 1804. With nearly two hundred other Wounded Confederates he was received at the field 
hospital of the 1st division of the Fifth Corps at Reams's Station, where it was found that a conoidal musket ball had 
entered the front of the right thigh a little to the outside of the course of the great vessels, and had comminuted the neck of the 
femur and fractured the head, and lodged in the acetabulum, of which the lower portion of the rim was broken off. A few 
hours after the reception of the wound the patient was placed under the influence of chloroform, and, 
after a thorough examination, it was deemed expedient to excise the upper extremity of the femur. 
The operation was performed by Surgeon A. A. White, 8th Maryland. An incision, commencing a little 
below the anterior superior spine of the ilium, was carried downwards below and behind the prominence 
of the trochanter major. From the lower extremity of the first, another incision, Dr. McGill states, was 
carried backwards. The muscular attachments were then dissected aside, and the chain saw was passed 
around the bone, which was divided just above the lesser trochanter. The head of the femur was then 
readily exarticulated, and the ball and splintered fragments were removed. The wound was then approx- 
imated by sutures and adhesive strips, and the limb was suspended by Smith's anterior splint. The »f head of right femur. 

fsfiPC 1410 

patient reacted favorably; but very soon after the operation there was a marked rigor, and on the follow- 

ing day there was extreme irritability of stomach and retention of urine. The case terminated fatally on August 25, 1804, two 
clays after the reception of the injury. At the autopsy, it was found that the fracture of the acetabulum did not communicate 
with the interior of the pelvis; but the articular surface was intensely injected; its cavity was filled with offensive sanious pus. 
The sawn extremity of the femur was black. One report states that the patient's appearance was of one who had undergone 
great privations and was not in a favorable condition to undergo any severe operation. The excised portions of bone, repre- 
sented in the accompanying wood-cut (Fig. 47), were sent to the Army Medical Museum without a memorandum; but were 
ultimately identified, and numbered 1410 in the Surgical Section. 

Case 210. — Private Bartholomew Dempsey, Battery I, 4th Artillery, was wounded February 25, 1804, at Buzzard's 
Roost, Georgia, by a piece of shell, which passed through the upper portion of the right thigh, crushing the trochanter and neck 
of the femur, and producing fissures which extended to the head of the bone. The wounded man was taken to a private house 
in the neighborhood, at a place called "Big Spring," or in another report "Burke's Spring." a place ten miles northwest of 
Dalton, where, shortly after the reception of the injury, it was decided, on the recommendation of Surgeon S. G. Menzies, 1st 
Kentucky, that excision should be performed. Chloroform having been administered. Surgeon Nathan W. Abbott, 86th Illinois, 
made an incision five inches in length, commencing two inches above the trochanter major. After dissecting aside the muscular 
attachments and removing many fragments of the neck and trochanteric portions of the femur, the shaft of the bone was 
smoothly divided by the chain saw at a point an inch or a little more below the lesser trochanter. Then, with a straight 
bistoury, the capsular and round ligaments were divided, and the fractured head of the femur was exarticulated. The wound 
was then approximated by sutures and adhesive strips. The patient rallied satisfactorily from the shock of tin? injury and 
operation, and his condition was encouraging on the following morning, when the Union forces retired, sending all the wounded 
who could be moved to the hospitals at Chattanooga. Private Dempsey alone was left at Big Spring. On the evening of 
February 26th Surgeon Menzies sent Assistant Surgeon P. F. Ravenot, 7f th Illinois, with a cavalry escort from General Cruft's 
camp, to Big Spring, a distance of five miles, to learn of Private Dempsey's condition, and, if possible, to bring him off. The 
escort was dispersed and Dr. Ravenot was captured. The fate of Dempsey could not be definitely ascertained. He is dropped 
from the rolls of his company as "missing in action at Buzzard Roost Gap." Dr. Abbott afterwards heard, indirectly, that 
Dempsey survived the operation four or five weeks; but was not satisfied that this information was reliable. That the case bad 
a fatal termination there can be no doubt. The excised portions of bone were preserved by Dr. Barnes, of Centralia, Illinois, 
who was present at the operation. A statement has been received from Brevet-Major E. B. Atwood, 10th Infantry, that he had 
learned from parties who attended Private Dempsey after he was wounded that he died on February 28, 1864, at the house of a 
Mr. Rogers, ten miles northwest of Dalton, Georgia. 

Case 211. — Private T. J. Hohson, Co. H, 32d Tennessee, aged 23 years, was wounded at Kenesaw Mountain, June '-4, 
1804, by a conoidal musket hall, which struck the femur and comminuted the neck and trochanters. The fracture extended 
within the capsular ligament. The shock was very great. The patient was seen by Surgeon J. F. Grant, P. A. C. S., who 
found that amputation was not practicable except at the hip joint, and deemed it expedient to undertake the operation of excision, 
as giving, in his judgment, the best chance for recovery. The army was then retreating, and if the patient was removed to the 
rear it was doubtful if surgical relief could be had. Accordingly, about twelve hours after the reception of the injury, the patient 
being placed under the influence of chloroform, Dr. Grant proceeded to operate, by making a linear incision ten inches long on 
the outside of the thigh over the trochanters. The articulation was exposed, the capsular ligament divided, and the head of 
the bone enucleated. The shattered fragments were then removed, and the shaft of the femur was divided by a straight saw 
just below the trochanter. The loss of blood was slight. Immediately after the completion of the opeiation the patient was 
placed upon a box-car and transported forty miles over a very rough road to the rear. Reaction was never complete, though 
the patient lingered three days, and died on June 27, 1864. 

Case 212. — Lieutenant John A. McGuire, Co. I, 148th Pennsylvania, was wounded on May 12, 1804, at ?pottsylvania, 
by a musket ball, which smashed the trochanters and neck of the right femur. He was carried to the hospital of the 3d division 
of the Ninth Corps, where, after an exploration of the wound under chloroform and a consultation of the senior surgeons of the 
division, it was determined to excise the injured bone. The head, neck, and trochanters were accordingly removed through a 
longitudinal incision by Surgeon George W. Snow, 35th Massachusetts. The patient died on May 15, 1864. 



94 INJURIES OK THE LOWER EXTKKMITIE5 



tCHAP. X. 



Case 213. — Private O'Rourkc, 18th Mississippi, aged 24 years, healthy and of fine constitution, was wounded at the 
Wilderness, May 6, 1864, by a musket ball, which entered the right thigh a little behind the trochanter, shattered the neck of 
the femur, and lodged. There was little injury to the soft parts, and the important vessels and nerves were unharmed, lie 
was taken to a field hospital, and his injury was examined under chloroform, by Surgeon J. T. Gilmore, Chief Surgeon, 1st 
division, Longstreet's Corps. The limb was everted and shortened, the fracture appeared to be confined to the epiphysis, and 
there was no bleeding. Believing that removal of the injured bone offered the best chance of preserving life, Surgeon Gilmore 
proceeded to excise the head and neck of the femur. A curvilinear incision four or five inches long, with its convexity back- 
ward, was carried downward from a point a little above and behind the trochanter, and was made to pass through the entrance 
wound. The muscles inserted in the trochanter were then divided, the head was readily disarticulated, and the femur was then 
smoothly divided through the trochanters by a chain saw. The operation was accomplished with the loss of but little blood. 
Yet the patient did not react, but gradually sank, and died May 9, 1804. 

Case 214. — Private Thomas G. Pease, Co. B, 117th New York, was wounded October 28, 18G4, near Fair Oaks Station. 
The trochanters and neck of the right femur were shattered by a musket ball, which lodged against the head in the cotyloid 
cavity. The soft parts were not injured badly, and it was determined by surgeons on duty at the field hospital of the Tenth 
Corps that excision of the upper extremity of the femur was expedient. The operation was performed, a few hours after the 
reception of the injury, by Surgeon N. Y. Leet, 70th Pennsylvania. The patient died on October 29, 1864. 

Case 215. — Sergeant James M. Tolman, Co. H, 18th Wisconsin, aged 30 years, was wounded May 14, 1863, near Jack- 
son, Mississippi, by a conoidal musket ball, which comminuted the head and neck of the left femur, lodging, and producing 
fissures which extended about two inches below the lesser trochanter. The important nerves and vessels of the region and the 
walls of the pelvis had escaped injury. The patient was a somewhat, cachectic subject, debilitated by malarial disorders. It was 
deemed that the gravity of the injuries of the upper extremity of the femur rendered operative interference imperative. About 
twenty-four hours after the reception of the injury, the patient was placed under the influence of chloroform, and Surgeon Henry 
S. Hewit, U. S. V., exarticulated the head of the femur. The incision commenced a little above and anterior to the trochanter 
major and extended downward in a curved direction with the convexity backward, and passed through the wound of entrance. 
The splintered fragments of the head and neck and the ball were removed, and then the fissured upper extremity of the shaft 
was sawn two and a half inches below the lesser trochanter. The operation was well borne, and the patient was removed the 
same day to a hospital in the city of Jackson, where he was supplied with every comfort and provided with the most careful 
attendance. He did apparently well until the third day, when lie began to sink, the wound from this time forward exhaling a 
faint cadaveric odor. He died four days after the operation, May 19, 1863. 

Case 210. — An unknown private soldier of the Fifth Corps, Army of the Potomac, was wounded in the engagement at 
Laurel Hill, near Spottsylvania Court House, on May 10, 1804, by a musket ball, which fractured the trochanteric portion of 
the left femur. He was conveyed to the field hospital of the Fifth Corps, at Cassin's, on the Block House road. He was placed 
under the influence of chloroform, and the head, neck, and trochanters of the left femur were excised. Assistant Surgeon J. S. 
Billings, U. S. A., saw him on the following morning, when he appeared to be in a comfortable condition. Dr. Billings recollects 
that he was a young and healthy looking man. The attendants mentioned the character of the operation and the name of the 
operator, but Dr. Billings cannot recall these particulars. On revisiting the hospital three days subsequently, Dr. Billings 
learned that the patient had died on that morning, May 13, 1864. 

Case 217. — An unknown soldier of the Eighteenth Corps was wounded, in the assault on the enemy's intrenched lines 
at Cold Harbor, June 3, 1864, by a fragment of shell, which completely comminuted the trochanter and neck of the right femur. 
Shortly after the reception of the injury he was conveyed to the field hospital of the Eighteenth Corps, and immediately anaes- 
thetized and examined. Excision of the head, neck, and trochanters of the right femur was then practised. Assistant Surgeon 
Billings, U. S. A., saw the patient soon after the operation, and observed that he had rallied encouragingly, and was in a com- 
paratively comfortable condition. On June 7th the wounded of the Eighteenth Corps were placed in wagons and sent to the 
rear. Dr. Billings visited the hospital with a view of preventing the removal of this patient, but was informed by the director 
of transportation that the man had died the previous night, June 6, 1804. 

Case 218. — A Confederate private soldier was wounded at the battle of Fredericksburg, December 13, 1862, by a frag- 
ment of shell, which struck the trochanter of the right femur and fractured it and the neck of the bone, and lacerated the soft 
parts, but without injuring any of the important vessels or nerves. He was conveyed to a field infirmary, where, a few hours 
after the reception of the wound, he was placed under the influence of chloroform, and Surgeon Hunter McGuire, Medical 
Director of Jackson's Corps, having ascertained the extent of the injury, decided that although the lesions of the soft parts 
rendered the case an unpromising one, yet excision was the only resource that offered any hope, and proceeded to excise the 
head, neck, and trochanters, dividing the shaft just below the trochanter minor with a chain saw. The wound was left open; 
the limb placed in a comfortable position by means of pillows, without splints, and the patient was treated at the temporary 
hospital at which the operation was performed. Notwithstanding the most careful attention to the after-treatment, he succumbed 
two or three days after the operation. 

Case 219. — A Confederate soldier of Kershaw's South Carolina Brigade was wounded at the battle of Chancellorsville, 
May 3, 1863, by a musket ball which shattered the neck of the femur. It having been decided, after an examination of the 
wound under chloroform, that the case was a favorable one for the operation of excision, the important nerves and vessels being 
intact, and the injury limited mainly to the neck of the bone, the operation was performed by Surgeon James, 16th South 
Carolina, on the day after the reception of the wound. The patient died May 6, t863. 

In a second category are placed nine cases of primary excision at the hip which 
resemble each other in that in each the operations were fairly indicated and offered favor- 



SECT. II.] EXOlSiuM AT THE HIP AFTER SHOT INJURY. 05 

able prospects of success. The patients, for the most part, were robust soldiers, and the 
lesions were limited to shot fracture of the upper extremity of the femur. All made a 
struggle for existence, several lived three or four weeks and one for sixty days, and the 
fatal results were due, in several instances, to the imperative military exigencies that 
necessitated the removal and inopportune and disastrous transportation of the patients. 

Case 220. — Private Robert Cole, Co. B, 29th Connecticut (colored troops), was wounded near Fair Oaks, October 27, 
1864, by a musket ball, 'which shattered the upper extremity of the right femur without injury to any important vessels or 
nerves. He was conveyed to the hospital of the Tenth Corps, where the wound was explored, and it was decided to excise the 
head, neck, and trochanters of the femur. The operation was performed by Surgeon C. M. Clark, 39th Illinois, a few hours 
after the reception of the injury, by a longitudinal incision over the trochanter major, and division of the superior portion of the 
shaft by a chain saw. Dressings to secure the immobility of the limb were applied, and the patient was removed to the base 
hospital of the Army of the James, at Point of Rocks, where he was received on October 28th, and died on October 29, 1804. 
Case 221. — Private John Coon, Co. C, GOth Indiana, aged 20 years, a robust man, was wounded at Arkansas Post, Jan- 
uary 11, 1883, by a conoidal musket ball, which entered the right buttock and passed forward and outward, striking the femur 
on the inter-trochanteric line and comminuting the neck and upper part of the shaft of the bone. A few hours after the recep- 
tion of the injury the patient was conveyed to a hospital steamer, and a consultation was held, at which it was determined to 
excise the injured portions of bone. The loss of blood which had taken place and the patient's exposure to inclement weather 
were regarded as very unfavorable circumstances, but it was considered that on the whole an excision was the best thing to be 
done. An ounce of brandy and other restoratives were administered, and half an hour subsequently the wounded man was 
placed under the influence of chloroform, and Surgeon Milton T. Carey, 48th Ohio, made a semi-circular incision, beginning two 
inches above the prominence of the great trochanter downward in the direction of the shaft of the femur. The muscular 
attachments were then divided, and the capsular ligament freely incised. Some difficulty was then experienced in dividing the 
ligamentum teres; but this was finally accomplished, and the head of the femur removed. The extent of splintering having 
been determined, the shaft was sawn below the trochanter minor by means of a chain saw. The edges of the wound were then 
brought together, and a retentive apparatus was applied. After the operation the patient seemed much prostrated, but he 
rallied after a few hours, and was conveyed on the hospital transport D. A. January to Memphis, Tennessee, and placed in the 
military general hospital at that place, where he died ten days subsequently, January 21, 186:!. 

Case 222. —Private J. W. Epton, Co. I, 5th South Carolina, was wounded at Deep Bottom, August 16, 1864, and was 
conveyed to the third division of the Jackson Hospital at Richmond. Surgeon J. G. Cabell, in charge, entered on the hospital 
register, page 214: "A mini<5 hall penetrated the right hip joint, on account of which a primary resection of the head and neck 
of the femur was practised. The patient sank, and died September 2, 1864." 

Case 223. — Private Timothy Greely, Co. C, 74th New York, aged 20 years, was wounded October 5, 1861, by a round 
musket ball, which entered near the fold of the left natis, struck the left femur at the digital fossa, splintered the neck into the 
articulation, and made its exit outside the vessels anteriorly. He was conveyed to the E street Infirmary, Washington, on the 
same day. A stream of blood and another of clear and pellucid synovia issued from the wound of exit. There was but little 
constitutional irritation, the pulse was but slightly depressed, and the patient congratulated himself on having escaped with 
what he regarded as a slight injury. On the morning of October 6th Assistant Surgeon John W. S. Gouley, U. S. A., assisted 
by Surgeon C. H. Laub, U. S. A., Assistant Surgeon C. B. White, U. S. A., Surgeon T. Sim, and Assistant Surgeon H. E. 
Brown, proceeded to operate. Insensibility having been induced by chloroform, Dr. Gouley made an incision seven inches long, 
commencing above and behind the trochanter major and continued downward in the axis of the limb. The neck of the bone 
was found to be badly shattered, but the fracture did not extend to the shaft. A section through the great trochanter and base 
of the neck was made with the chain saw. The head of the bone was then disarticulated and removed, and the fragments of 
the neck were extracted. There was very little loss of blood. The wound having been approximated and dressed simply, the 
patient was put to bed, and the limb was kept in position by pads and cushions. Surgical fever set in soon after the operation; 
pyeemia was developed, and the patient gradually sank, and died on October 12, 1861. His friends would not permit an 
autopsy. The pathological specimen and Dr. Gouley's notes of the case were destroyed in the conflagration which shortly 
afterwards consumed the Infirmary. 

Case 224. — Sergeant Samuel Grimshaw, Co. H, 6th New York Cavalry, aged 31 years, was wounded at Cedar Creek, 
October 19, 1864, by a fragment of shell, which, after lacerating the scrotum, entered at the upper inner part of the left thigh 
near the femoral artery, making a wound one and a half inches in length, and passing upward and backward, shattered the 
head and neck of the femur and produced fissures extending four and a half inches in the shaft, and lodged in the acetabulum. 
The shock to the nervous system was great. The patient was desponding, and he complained of severe pain. He was con- 
veyed to a field hospital, and two hours after the reception of the injury he was placed under chloroform, and Surgeon A. P. 
Clark, 6th New York Cavalry, made a straight incision seven inches in length over the trochanter major, and excised the head 
and four and a half inches of the shaft of the femur. The wound was then dressed, and the limb was supported by pasteboard 
splints. On the following day no bad symptoms were observed. Beef essence and stimulants were freely given, and afterwards 
sulphate of morphia was administered. He was removed to the Sheridan Field Hospital at Winchester on October 20th, and 
there died on November 5, 1864. 

Case 225. — Private B. C. Johnston, Co. B, 56th North Carolina, Ransom's Brigade, was wounded on the night of the 
17th of June, 1864, in front of Petersburg, by a conoidal ball probably, in the right thigh. The ball entered on the inner aspect 
of the limb and passed obliquely upward and outward, producing a comminuted fracture of the neck of the femur and driving 
the fragments of bone into the surrounding tissues. The shaft of the bone was not shattered, and, as the man was very much 



96 injuries of Tin-: lower extremities, [chap.x. 

worn and exhausted, as most of the Confederate troops were at that time, it was considered advisable to perform resection of 
the head and neck of the femur, as offering a better chance of recovery than amputation. ' The operation was performed on 
June 18th, twelve hours after the reception of the wound, and tin' bono was sawn through the trochanters. He bore the opera- 
tion well, and, although weak, was hopeful. Ho was sent to the Fair Grounds Hospital, from which he was removed in a few 
days, placed in a tent, and attended by Surgeon Ladd, 56th North Carolina, and Dr. ('. J. O'Hagan. He survived the operation 
two months, and succumbed at last to suppuration, caused by the want of proper food and stimulants, and the general prevalence 
of pyemic infection, which at that period intervened in neatly all the surgical cases in the neighborhood of that hospital. To 
this account Dr. J. D. Jackson adds : " I recollect very distinctly of being present at the operation of Dr. Ladd, being then of 
the same division with him, hut not of the same brigade. It was on the 18th or 19th of June, 1804, that it was done, the place 
being an unfinished brick church in the centre of Petersburg, which we were then occupying as an hospital. There were also 
present some four or five other surgeons, among whom I recollect Surgeon C. J. O'Hagan, Dr. Wilson, of Virginia, then the 
senior Surgeon of Ransom's Brigade, Dr. Luckie, of the same brigade, and, if I mistake not, Dr. R. L. Brodie, then Medical 
Director of General Beauregard's army, was among the number. The man operated upon was of Dr. Ladd's own regiment; 
his age, and any other personal peculiarities, I have forgotten, though I think he was young and comparatively robust. The 
wound had apparently been done by a musket ball, and the range of the wound was, I think, from the inner and upper aspect 
of the thigh, and nearly transversely through, ranging slightly upward, the aperture of exit being over the trochanter major. 
If I recollect aright, the trochanter was torn oiFand most of the neck of the femur shattered to fragments, the shaft of the femur 
being entirely separated from the head. Chloroform was given, and Dr. Ladd operated by making a slightly curvilinear incision 
over the acetabulum and trochanter— the aperature of the wound being in its line — cut down upon the head of the femur, exartic- 
ulated and removed it, and cut off a sharp fragment of the remaining end of the femur. The difficulty of performing the opera- 
tion seemed to be small. The haemorrhage was trifling. I do not recollect that I saw the patient again, he being sent oft' to the 
General Hospital at what was then known as the "Fair Grounds Hospital," situated in the suburbs of Petersburg. But I 
further remember distinctly of hearing Dr. Ladd, Dr. O'Hagan, and probably others of Ransom's Brigade speaking of his 
death, which was on the sixtieth day after the operation, and which all agreed at the time in ascribing to want of good food in 
proper quantity. Owing to the scarcity of our supplies, and the immense number of wounded men then crowding the city in 
consequence of the battles fought in front of Petersburg on the 17th, 18th, and 19th of June, food really proper for wounded men 
was not obtained, and anything like delicacies were out of the question." 

Case 22C— Private Edward A. McDonald, Co. F, 149th Pennsylvania, aged 31 years, a robust, athletic man, was 
wounded on August 20, 1804, on the Weldon Railroad. A conoidal musket ball entered the upper anterior part of the right 
thigh and lodged in the head of the femur, after splintering its neck. He was carried to the hospital of the 1st division of the 
Fifth Corps, and placed under the influence of chloroform a few hours after the reception of the injury, and Surgeon F. C. 
Reamer, 143d Pennsylvania, assisted by Surgeon Thomas, 119th Pennsylvania, and others, proceeded with the operation. A 
V-shaped incision, arranged to traverse the entrance wound, exposed the muscular attachments of the neck and trochanter. 
These being divided, with the capsular and round ligaments, the head of the femur was exarticulated. Fragments of the neck 
were extracted, and then the femur was sawn through the trochanteric ridge by the chain saw. The wound was then partly 
closed by sutures and adhesive plasters, a pledget of lint being inserted at the lower end, and the limb was bandaged and 
suspended by a Smith's anterior splint. Little loss of blood had been incurred, and the patient reacted and his condition 
appeared hopeful. Two days afterwards it was deemed necessary to remove the severely wounded from the advanced position 
of the Fifth Corps, and McDonald was sent in an ambulance wagon several miles, over a rough road, to the railroad to the 
hospital at City Point. There he remained three days, and was placed on a hospital transport and sent to Philadelphia, entering 
Broad and Cherry Streets Hospital August '27th. The injured limb was extended by means of a weight and pulley, concentrated 
nourishment and stimulants were administered, with quinia and opium. August 31st, symptoms of pyaemia were noted and the 
complication made rapid progress. Death took place September 4, 1804. At the autopsy large metastatic foci were observed 
in both lungs. 

CASE 227.— Private Charles Morrison, Co. C, 185th New York, was wounded on the Quaker Road, south of Petersburg, 
on March 29, 1865. A conoidal musket ball struck the outside of the left thigh, fractured the trochanter, and separated the 
neck from the shaft. In less than two hours after the reception of the injury he was placed on the operating table at the field 
hospital of the 1st division of the Fifth Corps, and Lis wound was examined while he was under the influence of chloroform. 
He was a robust man, in the best health. In the judgment of the operating staff, the case was a very favorable one for the 
operatiou«f excisiou. Surgeon William Fuller, 1st Michigan, was requested to perform the operation, and proceeded with it 
without delay. He entered his knife an inch above the great trochanter and made an incision three and a half inches in length, 
divided the muscular attachments, and readily exarticulated the head of the femur. A fissure was found to extend downwards 
half an inch below the trochanter minor. The shaft was divided by a chain saw at this point. The ball could not be found, 
but, from the direction of its track, it was the opinion of the operator and his colleagues that it had entered the pelvis through 
the obturator foramen. There was scarcely any hemorrhage during the operation, no artery requiring ligation or torsion. A 
tent was introduced into the wound, which was then approximated by two sutures and covered by a compress dipped in cold 
water. A full dose of morphia was then administered, and the patient was made as comfortable as possible in a bed in a hospital 
tent. In the middle of the night Surgeon Fuller returned to the hospital to visit his patient, but found that he had been removed 
to City Point, in compliance with orders from a superior authority. Dr. Fuller was subsequently informed by Surgeon Joseph 
Thomas, 118th Pennsylvania, that the man died on the way to the base hospital, about twelve hours after the operation. There 
was some haemorrhage a few hours after the operation, but it was not considerable. The report of the patient's death was 
premature. The records of the City Point Hospital show that he was received there, and survived until April 26, 1865. 

CASE 228.— A Confederate private soldier of Ewell's Corps was wounded at the battle of the Wilderness, May 5, 1804, 
by a conoidal musket ball, which broke the neck of the left femur into several fragments and lodged in the bone at the junction 



SECT. II.J EXCISION AT TI1K HIP AFTER SHOT INJURY. 97 

of the head and neck. A few hours after receiving his wound he was placed under the influence of chloroform at n Geld hospital, 
and was examined hy Surgeon Hunter McGuire, the Medical Director of the Corps, who decided that the ease was well adapted 
for the operation of excision of the head of the femur, and proceeded to remove, through a longitudinal incision, the head and 
shattered fragments of the neck, and to smooth oft' with a saw the jagged upper extremity of the shaft. The operation was 
accomplished with hut trilling haemorrhage. It is Dr. McGuire's impression, hut, owing to the loss of his notes he cannot state 
positively, that in the subsequent rapid movements of the army it was necessary to send the patient to the rear, and besides the 
disadvantages of removal, he failed to receive such nourishment and careful treatment as his case demanded, lie died of 
pyaemia, May 22, 1804. As in the majority of the primary field excisions the shattered epiphysis removed was not preserved. 

Ten fatal cases of primary excision al the hip are placed in a third category. These 
ten might almost be set aside in estimating the value of the operation, inasmuch as the 
interference would hardly have been undertaken, had the extent of the lesion been fully 
ascertained. Four of the cases were complicated by penetration of the pelvic cavity, 
inducing hopeless peritonitis; four were prostrated from excessive loss of blood; in two 
instances extensive longitudinal splintering of the shaft of the femur forbade the anticipa- 
tion of a favorable result. 

Case 229. — Private J. T. Goodc, Co. K, 6th Virginia, aged 21 years, was wounded before Petersburg, July 31. 1864, by 
a conoidal musket ball, which fractured the upper extremity of the left femur. A few hours after the reception of the injury 
he was anaesthetized by a mixture of chloroform and ether, and the wound being explored excision was decided upon. Surgeon 
G. S. West, C. S. A., proceeded to perform the operation, assisted by Dr. W. L. Baylor and others. Upon making a linear 
incision in the axis of the limb and exposing the fracture, it was found that it extended longitudinally much lower on the shaft 
than was anticipated. Dr. Baylor reports that one of the surgeons present thinks that fully one-third of the femur was excised. 
The patient never fairly rallied from the shock of the operation, but he lingered until August 2, 1804, when he died. Dr. Baylor 
adds that the circumstances were very unfavorable, the patient being fully nourished and nosocomial gangrene at the time 
pervading the surgical wards. 

Case 230. — Private John McCullo ,h, aged 35 years, a recruit at the depot for volunteers at Camp Dennison, Ohio, was 
wounded on August 30, 1801, hy the accidental discharge of a musket. The ball, taking effect at the distance of a few yards 
only, severely shattered the upper part of tl»« femur and lacerated the soft parts extensively. The patient was conveyed to St. 
John's Hospital, in Cincinnati, and on arriving was greatly depressed hy loss of blood. Professor George C. Blackmail deter- 
mined that removal of the shattered bone oftrrcd the best resource for the preservation of life, and, the patient having been 
rendered insensible by chloroform, excision of the head, neck, and trochanters was practised without delay, through a vertical 
incision on the exterior of the thigh. The patient died August 30, 1801, four hours after the completion of 
the operation. This was the first excision at the hip for shot injury in this country. 

Case 231. — Private G. W. Mayo, Co. B, 25th Battalion Virginia Reserves, was wounded at the affair 

between Yellow Tavern and the outer defences of Richmond, Virginia, May 12, 1804, by a conoidal musket 

ball, at short range, which entered the right buttock and passed forward and outward through the thigh, 

striking the femur between the trochanters, and producing very extensive splintering of the neck and shaft. 

He was admitted to the Receiving and Wayside Hospital, at Richmond, early the next day, and his wound 

being examined under chloroform, Surgeon Charles Bell Gibson, C S. A., determined to proceed at once with 

the operation of excision of the head and upper extremity of the femur. The injured bone being exposed by 

a long straight incision, the muscular and ligamentous attachments were divided, and the head of the femur 

was disarticulated. Numerous detached fragments were then removed, and the shaft of the femur was sawn 

at a point five or six inches below the trochanter minor. The operation was rapidly accomplished, but the 

shock, added to the depression already existing from the injury, was such that the patient did not react. He Kio.48.-Shotcom- 

died at 9 o"clock a. m. on May 15, 1804, about forty-five hours after the operation. The pathological speci- "nd'tachan'tore'of 

men was preserved, and has lately been contributed to the Army Medical Museum by Dr. W. P. Richardson, left femur. Spec. 

. 5498 

It is represented in the annexed wood-cut (Fig. 48). 

Case 232. — At the assault on Knoxville, Tennessee, on November 10, 1863, a soldier of a Michigan cavalry regiment 
was wounded and made a prisoner. He was a man about eighteen years of age, five feet eight inches in height, with light hair 
and blue eyes, and was in robust health when he received the injury. A minie ball entering about the centre of the nates, 
passed forward, shattering the head and upper part of the neck of the femur, but did not injure the acetabulum. No haemor- 
rhage of importance followed the wound. It was considered that the case demanded excision of tho head of the femur, and the 
operation was performed on the day of the reception of the injury by Surgeon J. S. D. Cullen, P. A. C. S. "The operator 
made his incision posteriorly, directly through the thickest part of the gluteal muscles, on a line parallel with the os femoris, 
instead of laterally. In making his incision, which, at the least calculation, was ten inches in length, he cut the gluteal artery 
near its point of exit from the pelvis." The artery was ligated finally, though not until there had been much loss of blood. 
The head and neck of the femur were then excised. " When the siege was abandoned," another report states, " General Long- 
street retired to Russellville, and this patient was left behind. I am positive that he could not have recovered, for the suppura- 
tion that followed the operation was immense, and he was suffering from hectic fever when I last saw him, some six days after 
the operation." There can be but little doubt that the patient referred to in this account was Private Isaac Melcar, Co. A, 8th 
Michigan Cavalry, aged 18 years, who was found abandoned on the retirement of the Confederate army from Knoxville, and 

SUKG. Ill— 13 





98 INJURIES OF THE LOWER EXTREMITIES. [char ic 

was taken to hospital No. 3, in that city, and entered as a case of "gunshot fracture of left hip." No other Michigan cavalry 
soldier is reported at the period referred to with this or any similar wound. This man died on Decemher 2, 1863. The register 
of the Knoxville Hospital gives no particulars of the case. 

Case 233. — Private ./. ./. Phillips, Co. G, Cist Virginia, was wounded on the second day of the 
battle of thi! Wilderness, May 0. 1864, hy a conoidal musket ball, which entered at the posterior upper 
portion of the left thigh, fractured the femur, and lodged. He was immediately conveyed to Richmond 
liy rail, and was admitted to the Receiving and Wayside Hospital on May 7th. The wound was at once 
thoroughly explored under chloroform, and excision of the shattered bone was decided on. Surgeon 
Charles Bell Gibson, C. S. A., performed the operation. A long vertical incision over the trochanter major 
exposed the injured bone. It was found that the ball had produced extensive longitudinal splintering 
and had itself split, a small fragment lodging in the medullary canal, while a larger portion had buried 
itself in the gluteal muscles about two inches from the point of impact upon the bone. The muscles 
inserted into the trochanter having been divided, the head of the femur was exarticulated, and the upper 
extremity of the shaft was smoothed off with a saw. The operation was accomplished without much 
haamorrhage, and the patient rallied promptly from the shock. He had an anodyne, and passed a good 
night, and, on the following day, May 8th, he appeared to be doing well. On the 9th, however, there 
was much constitutional irritation, and on the morning of the 10th it was apparent that the man was sink- 
Fiu. 49.— Fissuring of ing. He died at 4 o'clock A. M., May 11, 18C4. The pathological preparation was contributed by Dr. 
r , ieMVmiir Pn 5;)«°549!) Richardson to the Army Medical Museum, and is a fine illustration of the characteristic longitudinal 
Assuring produced in the femur by conoidal balls. It is represented in the adjoining wood-cut (Fig. 49). 

In a letter dated Chicago, September 18, 1869, Dr. C. M. Clark, late Surgeon 89th 
Illinois Volunteers, reports the following case of excision at the hip : 

Cash 234. — " Private C. Euincs, Co. E, 2oth North Carolina, was wounded June 2, 18C4, by a conoidal ball, which 
entered the right thigh at the upper and outer third, near the great trochanter, passing obliquely downward and inward, and 
making its exit near the junction of the middle with the upper third of the femur. This man was not seen until eight hours 
after the wound was received, being among the last to be brought from the field. When he reached the operating table he was 
"almost exsanguinated and pulseless, having lost a large amount of blood. After free administration of milk punch and beef tea, 
with comfortable rest for two hours' time, ho was placed on the operating table at 7 o'clock P. M., and the following operation 
performed : Chloroform was given (which added greatly to the stimulation of the system — pulse 80 and full), and a longitudinal 
incision made from the great trochanter down to the extent of six inches. The femur was found to bo extensively comminuted, 
and some sixteen fragments were removed, leaving the periosteum behind. There was diffused ccchymosis with clots through- 
out the extent of the fracture. The lower fragment was turned out and smoothly sawn off, and then attention paid to the upper 
portion, which was found comminuted within the capsule to such a degree as warranted the removal of the head of the bone, 
which was done by extending the incision upward one inch, opening the capsular ligament, turning head of bone out and 
dividing the ligamentum teres. The parts were then thoroughly cleansed and brought together with eight interrupted sutures. 
Applied strip of lint to the wound, wet with solution of tannic acid and collodion, then bandaged with spica turns about hip and 
splint, etc. He rallied well from the operation and passed a comfortable night at the hospital. In the morning he was taken, 
per hospital transport, to the Chesapeake Hospital, and I have no knowledge of the case since that time, but presume the records 
of that hospital will furnish the result. The bone removed below the trochanter major measured three and a half inches." This 
case has been identified as that of " C. C. Kaines, a rebel prisoner," aged 23 years, who was reported hy Assistant Surgeon E. 
McClellan, U. S. A., as having been admitted to hospital at Fort Monroe, June 4, 1864, with "shell wound of right side and 
abdomen," and as having died the same day of "exhaustion." 

Case 235. — Captain Thomas R. Robeson, 2d Massachusetts, aged 24 years, an athletic man, was wounded July 3, 1863, 
at Gettysburg, his regiment having become warmly engaged under a musketry fire at short range. A rifled musket ball struck 
him over the right trochanter major, shattering the neck and head of the femur, and, as was subsequently ascertained, fractured 
the pelvis and penetrated its cavity. He was carried a short distance to the rear, where the stretcher-bearers became exhausted 
and laid him down. Sergeant Francis O'Doherty, of his regiment, coming shortly afterwards wounded to the rear, impressed 
some stragglers and had the wounded man conveyed to a field station of medical officers of the Twelfth Corps. In the after- 
noon he was brought into the Twelfth C'orpsjiospital, and was examined by Surgeon John McNulty, U. S. V. The sufferings 
of the patient were intense, and he urgently demanded some operative interference for his relief. Although the prospect was 
very discouraging, it was decided to comply with his request. An exploration of the wound indicated that there was some 
injury of the pelvic wall. The patient was placed under the influence of chloroform very soon after his admission to the hospital, 
and a few hours subsequent to the reception of the injury Dr. McNulty made an incision over the trochanter major six inches 
long, passing through the wound of entranee and continued downward in the axis of the limb, turned out the shattered superior 
extremity of the femur and sawed the bone just below the trochanters. The fragments of the head and neck were then removed. 
There was more bleeding in this than in Dr. McNulty's other operations of excision of the head of the femur, yet the haemor- 
rhage could not be called profuse. The patient survived the operation fourteen hours. During this interval he appeared to be 
unconscious. 

Case 236. — It has not been possible to learn the name and military description of the subject of this operation. He was 
a private soldier of the First Corps, and a Frenchman, for the operator recalls the broken English in which he begged for the 
operation, and expressed his relief and thanks after it was performed. He had a terrible comminution of the upper extremity 
of the left femur, inflicted by a fragment of shell at the battle of Antietam, September 17, 186J. Surgeon John McNulty, U. S. V., 
excised the head and neck of the femur, five hours after the reception of the injury, through a vertical incision six inches long, 



EXCISION AT THE Hir AFTER .SHOT INJURY. 



99 



under chloroform. As in two other operations performed by Dr. McNulty, it was found that the lesions extended into the pelvis. 
Consequently there could be little or no liopo of a successful result. This patient survived the operation only ten hours. 

Case 237. — Private ■ , of the First Corps, was wounded at the second battle of Bull Run, August 30, 180:2, 

by a conoidal musket ball, which entered the left hip below and in front of the trochanters, and fractured the femur at the junc- 
tion of the head and neck. He was conveyed to the hospital of General King's division of the First Corps in the brick house 
which had been occupied as the rebel headquarters at the first battle of Bull Run. The prostration from shock was great, yet 
it was thought that cxurticulatiou of the femur was the only resource, and that excision would be less hazardous than amputa- 
tion. Accordingly, fifteen hours after the reception of the injury. Surgeon John McNulty, U. S. V., proceeded to excise the 
head and neck of the left femur through a vertical incision on the exterior of the limb about six inches in length, the patient being 
under chloroform. On dividing the round ligament to enucleate the head of the bone, it was discovered that the ball had pene- 
trated the pelvic cavity through the lower ]iortion of the acetabulum. The femur was sawn through at the junction of the shaft 
and neck by a narrow-bladed saw. After the removal of the shattered fragments of bone, the patient suffered much less pain. 
There were no symptoms of peritonasal inflammation at the date of the operation, but they were subsequently developed. The 
patient died August 31, 1862. 

Case 238. — Private , was wounded on August 28, 1802, in the engagement between General Rufus King's 

division of the First Corps and the advance of General Jackson's column on the Washington turnpike, near Gainesville. A 

conoidal musket ball had splintered the neck and trochanters of the left femur, and was supposed to have 

lodged about the acetabulum, though the operator discovered in the sequel that it had penetrated into the 

cavity of the pelvis. The symptoms of shock were very grave and the prognosis very unfavorable; hut 

the chief medical officer of the division, Surgeon Peter Pineo, U. S. V., determined to remove the upper 

extremity of the femur. The upper fourth of the femur was excised a few hours after the reception of the 

injury. The excision was done under chloroform, with little apparent loss of blood, through a vertical 

incision on the outside of the limb. The femur was sawn about two inches below the lesser trochanter. 

It was now discovered that the ball had passed through the innominatum, and that internal haemorrhage 

was going on. During the night of August 28th General King's division was driven back to Manassas, 

and this patient with other wounded fell into the hands of the enemy. It is probable that he survived 

but a very short time. Dr. Pineo secured the specimen, and it is preserved in the Surgical Section of the 

Army Medical Museum as No. 71. It is figured at page 233 of the Catalogue of the Surgical Section, and 

another view is given in the accompanying wood-cut (Fig. 50). The trochanter major is separated into 

live fragments, and a long oblique fissure produces a complete solution of continuity in the shaft of the 

femur.— (Circ. 6, S. G. O., 1865, p. 62, Case 5, and Circ. 2, S. G. O., 1809, pp. 21, 132.) 

The successful primary excision at the hip and thirty-two unsuccessful operations will 
now be concisely tabulated in alphabetical order for convenience of comparison and reference: 

Table XL 
Summary of Thirty-three Gases of Primary Excision at the Hip after Shot Injury. 




FIG. 50. — Perforation 
of trochanter and Assur- 
ing of tbo shaft of left 
femur. Spec. 71. 



No. 



NAME, AGE, AND MILITARY 
DESCRIPTION. 



Cannon, — , Pt., A, 49th May 5, 
Georgia, age 24. 1864. 



Date 

OF 
INJURY 



NATURE OF INJURY. 



Barber, P.M., Capt.,H, 16th 
Connecticut, age 32. 



Beard, C, Pt., 
sippi. 



12th Missis- 



Brown, E. T., Sergeant, C, 
21st Massachusetts, age 30. 



Cole, R., Pt., B, 29th Con- 
necticut. 



Coon, J., Pt., C, 60th Indiana, 
age 20. 



7 ' Dempsey, B., Pt,, Battery 
I, 4th Artillery. 



Epton, J. W., Pt., I, 5th S. 

Carolina. 
Goode, J. T., Pt., K, Cth 

Virginia, age 21. 



Sept. 17, 
180T 



Aug. 23. 
1864. 



July 23, 
1864. 



Oct. 27, 
1864. 



Jan. 11, 
1863. 



Feb. 25, 
1864. 



Aug. 16. 

1864. 
July 31. 

1864. 



Conoidal ball comminuted left 
femur one inch below trochan- 
ter major and lodged. 



Shot shattering trochanters and 
neck of right femur. 



Conoidal ball fractured head 
and neck of right femur and 
lodged in acetabulum. 

Fragment of bomb fractured 
upper extremity of left femur, 
five inches. 

Musket ball shattering upper 
oxtremity of right femur. 



Conoidal ball comminut'g neck 
and upper part of shaft of 
right femur. 

Fragment of shell crushing 
trochanters and neck of right 
femur. 

Conoidal musket ball wound of 

right hip. 
Conoidal ball fracture upper 

extremity of left femur. 



Date 

OF 
OPERA- 
TION. 



OPERATION AND OPERATOR. 



Mav 6, 
1864. 



Sept. 18 
1862. 



Aug. 23 
1864. 



July 23, 
1864. 



Oct. 27, 
1864. 



Jan. 11 
1863. 



Feb. 2f 
1864. 



Prim'ry. 

July 31, 
1864. 



Head. neck, and upper extrem- 
ity of shaft, through incision 
in wound six inches long, by 
Surg. J. J. Dement, P. A.C.S. 

Head, neck, trochanters, and 
tract, upper extremity, thro' 
straight incision four ins. long, 
by Surg. M. Storrs. 8th Conn. 

Head and femur, just above 
lesser troch., thro' angular in- 
cision, by Surg. A. A. White, 
8th Marj'land. 

Head and broken extremity of 
shaft, thro' longitudinal in- 
cision, by Surg. W.V. "White, 
57th Massachusetts. 

Head, neck, trochanters, and 
portion of shaft by longitudinal 
incision over troch. major, by 
Surg. C. M. Clark, 39th 111. 

Head and shaft below troch. 
minor, through semi-circular 
incis'n, by Surg. M. T. Carey, 
48th Ohio. 

Head, neck, and shaft an inch 
below trochanter minor, thro' 
longitudinal incis. five ins., bv 
Surg. N. W. Abbott, 8Cth III. 

Head and neck of right femur. 

IIead.neck,and nearly one-third 
of shaft, thro' linear incision, 
by Surg. G. S. West, C. S. A., 
and others. 



Result and Remarks. 



Recovered, February. 1865, short- 
ening three inches : limb useless 
for locomotion. Died Novem- 
ber 23, 1865, diphtheria. Circ. 
No. 2, pp. 26, 133. 

Surgical fever. Died September 
20, 1862. Circ. 2, pp. 22, 133. 



Died Aug. 25. 18G4. Spec. 1410, 
A. M. M. Circ. 2, pp. 31, 134, 
and Circ. 6, p. 70. 



Died July 27, 1864. 
30, 134. 



Circ. 2, pp. 



Died October 29, 1864. Circ. 2, 
pp. 33, 134. 

Died January 21, 1863. ClVc. 2, 
pp. 23, 133. 

Died Februarv 28, 1 864. Circ. 2, 
pp. 25, 133. ' 



Died September 2, 1864. Circ. 

2, p. 120. 
Died August 2. 1864, from shock 

of operation. Circ. 2, pp.30, 134. 



1 AimoTT (N. W.), Cases of Resection, in Chicago Medical Examiner, 1864, Vol. V, p. 612 



LOO 



INJUBIES OF THE I.OWKi; EXTREMITIES. 



xo. 



23 



24 



35 



27 
28 

29 

;w 
31 
32 

33 



Name, Age, and Miutabx 
Description. 



'Greely, T., Pt.,C, 71th New 
Yorfc, ago 20. 



Grimshaw, s.. Sergeant. II. 
6th X. V. Cavalry, ago 31. 



* Ilobson, r. ^., Pt.. II, 32d 
Tennessee, ago 23. 

Johnston. Jl. C, Pt., R, 5Gtb 
North Carolina, ago 26. 



McCulloch, .T., Recruit, ago 
35. 

McDonald. E. A., Ft., F, 
140th Pennsylvania, age 31. 



McGuire. J. A., Lieut.. I, 
148th Pennsylvania. 

Mayo. G. W., Pt., B, 25th 

Virginia Reserves. 



Melcar. I., Pt., A, 8th Mich- 
igan Cavalry, age 18. 

Morrison. C, Pt., C, 185th 
New York, age 21. 

O'Rourke. — , Pt., J 8th Mis- 
sissippi, age 24. 



Pease, T. G., Pt., B, 117th 
New York. 

Phillips, J. J., Pt,, G, 61st 
Virginia. 

Raines, C, Pt., E, 25th N. 
Carolina, age 23. 



Robeson, T. K., Capt., 2d July 3, 
Massachusetts, age 24. 1863. 



Date 

" OF 

IN.IUUV 



Oct. 5. 
1861. 



Oct. lit. 
1864. 



June 24, 
1664. 



Juno \~i 
1864. 



Aug. ;ju, 
1861. 

Aug. 20. 
1864, 



Xati'ki; or In.iukv. 



Round ball splintering neck of 
left lemur into articulation. 



I DATE 
OF 

, Opera 

I 'HON. 

Oct. 6, 
1861. 



Fragm'nt of shell shat'ing head Oct 10, 
and neck of left femur, fissures 1864 
extending four and a half ins. 
in shaft, lodged in acetahul'ni. 

Conoidal ball tract, neck and June 24 
trochanters of lemur, extend- 1864. 
into capsular ligament. 

Conoidal ball severing headJ.Jime 1" 
and portion trochanter major, 1864. 
right femur. 



Shot shattering upper part of Aug. 30, 
femur. j 1861. 



Conoidal ball splintered neck 
and lodged in head of right 
femur. 



May 12, Musket ball smashed truchaut- 
1864. ers and neck of right femur. 



May 12, Conoidal ball fractured neck 
1864. I and shaft of right femur. 



16,. 



Conoidal ball shattered head 
and upper part neck of left 
femur. 
Conoidal ball separated neck 
from shaft of left lemur and 
tract, trochanter major, and 
probably lodged in pelvis. 
May*.. Musket ball shattered neck of 
right femur and lodged. 



186: 



Mar. 29. 
1865. 



1864. 



Aug. 20 

1864. 



MavlS 

1864. 



Mav 13 

1864. 



Nov. m 
186:}. 



Mar. 29 
186.".. 



Mav 6, 

1864. 



Oct. 28, 
1864. 

May 6, 
1864. 

June 2, 
1864. 



Talman. J. M.. Sergeant, If, 
18th Wisconsin, age 30. 



Unknown, Pt., 1st Army- 
Corps (a Frenchman). 

Unknown, Pt., First Army 
Corps. 



Unknown, Pt., General R. 
King's division, First Army 
Corps. 

Unknown, Pt., Fifth Army 

Corps. 
Unknown. Pt., Eighteenth 

Army Corps. 

Unknown, Pt., C S. A 

Unknown, Pt., Ewell's Corps. 



Unknown, Pt., Kershaw's 
S. C. Rrigade. 



Mav 14. 
1863. 



Musket ball shattered trochant- Oct. 28, 

ers and ncek of right femur I J 864. 

and lodged in cotyloid cavity. 
Conoidal ball, extensive longi- May 7, 

tudinal splintering of shaft of 1864. 

right femur. 
Conoidal ball, extensive com- June 2, 

munition of shaft and upper 1864. 

portion of right femur within 

the capsule. 



OpEltATION AND Ol'EKATOK. 



Conoidal ball shattered head 
and neck of right femur, frac- 
tured the pelvis, and pene- 
trated its cavity. 

Conoidal ball comminuted head 
and neck of left femur, and 
lodged in neck ; fissures ex- 
tending down shaft. 



July 3, 
1863. 



Mav 15, 
1863. 



■Sept. 17, Fragment of shell comminut'g Sept. 1" 

1862. upper extremity of left femur, 186S 

| lesions extending into pelvis. 

Aug. 30,' Conoidal ball fractured the left 'Aug. 30. 

1862. I femur at junction of head and 1862. 

I neck, pen. pelvic cavity. 

Aug. 28, : Conoidal ball splintering neck Aug. 28 

1862. | and trochanters of left femur, 1 862. 
and pen. pelvic cavity. 






May 10, 



1864. 

June 3, 

1864. 



Musket ball fracturing trochan- 



teric portion of left femur. 
Fragment of shell comminuted 
trochanter major and neck of 
right femur. 
Dec. 13,1 Fragment of shell fractured 
1862. i trochanter major and neck of 
right femur. 
May 5, Conoidal ball fractured neck of 
1864. ' left femur, lodging. 



May 3, Musket ball shattered neck of 
1863. i femur. 



May 10, 
1864. 

June 3, 
1864. 

Dec. 13, 

1862. 

Mav 5, 

1804. 



Mav 4. 
1 863. 



Head and fragments of neck, 
through incision seven inches 
long, sect, thro' troch. maj. and 
base of neck, bv Ass't Surg. 
J. W. S. Gouley, U. S. A.. 
and others. 

Head and four and a half ins. 
of shaft, through straight in- 
cision seven inches long, by 
Surg. A. P. Clark, 6th New- 
York Cavalry. 

Head and shaft just below tro- 
chanters, through linear in- 
cision ten inches long, by 
Surg. J. F. Grant, P. A. C 8. 

Head and fragments, through 
curvilinear incision live ins. 
long, roughened projection of 
shaft cut off. by Surg. C. IT. 
Ladd, 56th N. C. 

Head, nock, and trochanters, 
through vertical incision, bv 
Prof. G. C Blackmao. 

Head, fragments of neck, and 
shaft, thro' trochanteric ridge. 
V -incision, by Surg. F. C. 
Reamer, 143d Peon. 

Head, neck, ami trochanters, 
thro' longitudinal incision, bv 
Surg. G.W. Snow, 35th Mass. 

Head and shaft, five inches be- 
low troch. minor, through 
straight incision, by Surg. C. 
It. Gibson. P. A. C. S. 

Head and nock, thro' incision 
ten inches long, by Surg. J. 
S. 1). Cullon, C. 8. A. 

Head and shaft, half inch be- 
low trochanter minor, thro* 
longitudinal ineis'n, bvSnrg. 
\V. Fuller, 1st Mich. 

Head, neck, and shaft, through 
trochanters, curvilinear incis. 
four inches long, by Surg. J. 
T. Gilmore, 0. S. A. 

Upper extremity of femur, by 
Surg. N. Y. Leet, 76th Penu. 

Head and up. extremity, thro' 
long vertical ineis'n, by Surg. 
C. B. Gibson, C. S. A. 

Head, neck, trochanter major, 
and three and a half ins. of 
shaft, thro' longitudinal incis- 
ion six inches long, by Surg. 
0. M. Clark, 39th 111. 

Head, neck, and shaft just be- 
low trochanters, thro' ineis'n 
six inches long, by Surg. J. 
McNulty, U. S. V. 

Head, neck, and shaft, twoand 
a half inches below lesser 
trochanter, curved incision, 
by Surgeon H. S. Hewit, 

u. s. v: 

Head and neck, thro' vertical 
incision six inches long, by 
Surg. J. McNulty. U. S. V. 

Head and shaft, at junct'n with 
neck, vertical incision six ins. 
long, by Surg. J. McNulty, 

u. s. V. 

Head and shaft, about two ins. 
below trochanter minor, vert- 
ical incision, by Surgeon P. 
Pineo, U. S. V. 

Head, neck, and trochanters... 

Head, neck, and trochanters. - . 



Head. neck. andtrochanters,by 
Surg. II. McGuire, P.A. C- S. 

Head and shafd fragments of 
neck and shaft, longitudinal 
ineis'n, by Surg. II. McGuire, 
P.A. 0. S. 

Head and neck, by Surgeon 
James, 16th South Carolina. 



Result anp Kemakks. 



Surgical fever, pyaemia. Died 
Oct. 12, 1861. Circ. 6, p. 02, and 
Circ. 2. pp. -Jl. 133. 



Died Nuvomborfi, 1864. Give. 2, 
pp. 32, 134. 



Reaction never complete. l)ied 
June 27, 1864. Circ. 2, pp. 30, 
134. 

Died August 1G, 1864. from ex- 
haustion, probably the result of 
caries and ill-judged diet. Circ. 
2, pp. 29, 134. KVB {I. c, p. 263) . 

Died August 30, 1861, four hours 
after operation. Circ. 2, pp. 
20, 132. 

Died September 4, 1864, of pyae- 
mia. Circ. 6, p. 70, and Circ. 
2, pp. 30, 134. 

Died May 15, 1864. Circ. 2, pp. 
L'8, 134. 

Died May 15, 1864, from shock. 
Spec. 5498, A. M. M. Circ. 2, 
pp. 28 134. 

Died December 2. 1863. Circ. 2, 
pp. 25. 133. EVE (/. c, p. 257). 

Haemorrhage. Died April 26, 
1865, irritation and profuse sup- 
puration. Circ. 2, pp. 33, 13-1. 

Didnotreact. Died May 9, 1864. 
Circ. 2, pp. 27, 133, and Eve 
(I. c. p. 257). 

Died Oct. 29, 1864. Circ. 2, pp. 
32, 134. 

Died May 11. 1864. Spec. 5499, 
A. M. M*. Circ. 2, pp. 27, 133. 

Died June 4, 1864, exhaustion. 



Didnotrally. Died July 3, 1863. 
Circ. 2, pp. 25, 133. 



Died Mav 19, 1863. Circ. 6, p. 
66. and Circ. 2, pp. 24, 133. 



Survived the operation ten hours. 
Circ. 2, pp. 22, 133. 

Died August 31, 1862, from shock 
of injury and operation. Circ. 
2, pp. 22, 132. 

Patient fell into the hands of the 
enemy, probably survived but 
a short time. Spec. 71, A.M. M. 
Phot. Ser., Vol. 1, p. 13, S. G. O. 
Circ. 6, p. 62; Circ. 2, pp. 21. 132. 

Died May 13, 1864. Circ. 2, pp. 

28, 133. 

Died June 6, 1864. Circ. 2, pp. 

29, 134. 

Died two or three days after 
operation, from shock. Circ. 2, 
pp. 23, 133. 

Died Mav 22. 1 864. pyaemia. Circ. 
2. pp. 36, 133. 



Died May 6. 1863. Circ. 2. pp. 
24, 133, and Eve (I. c, p. 257). 



'Calhoun (J. T.), Army Correspondence, in Med. and Surg. Reporter, 1862, Vol. VIII, p. 76. 

*EVE (P. F.). Contribution to the History of the Hip Joint Operations, etc., m Trans, of Am. Med. Ass., 1867. Vol. XVIII, p. 261. 



SECT. 11. 



RXCISIOS AT IIIK III1* AFTER SHOT KTTUBY. 



101 



01 the thirty-throe primary excisions at the hi}' seventeen were on the right side, 
thirteen on the left, and in three cases the side of the injury was not indicated. In 
twenty-two instances the straight, vertical longitudinal or linear incision, as variously 
termed by the different operators, was employed; in four instances the curvilinear; in one 
the V-shaped, and. in six cases the mode of incision was not indicated. In live instances 
the missile, either whole or in part, was excised with the injured bone. 

Intermediary Excisions. — Of twenty-two excisions classified as intermediary, two 
resulted successfully, a mortality rate of 90.9. Sixteen of the operations were practised 
on Union and six on Confederate soldiers. The shortest interval between the dates of 
reception of injury and operation was two days, the longest twenty-eight, the average 
interval being about thirteen days. .Details of the two successful intermediary excisions 
will be first noticed : 



Case 239. — Lieutenant James M. Ja/rrett, Co. C, 15tli North Carolina, a spare man, "28 years of age, of medium size, 
of fair complexion, of temperate habits, and good general health, was wounded at the affair at Bristow Station, Virginia, 
October 14, 1863, by a conoidal musket ball, which entered in front and a little to the outside of the median line of the left thigh, 
two inches below Poupart's ligament, shattered the femur, and made its exit posteriorly at the outer part of the limb, the wound 
of exit being on a rather higher level than that of entrance. The fracture was dressed 
with a straight splint, and the wounded officer was placed in an ambulance wagon and 
transported over rough roads to Richmond, a distance of one hundred and sixty miles. 
On October 20th, lie was admitted to hospital No. 4. at Richmond, in an exhausted 
state, and was placed in charge of Surgeon James ]?. Read, P. A. C. S. He complained 
of extreme pain upon any movement of the limb, and was unwilling to submit to an 
examination of the injury unless insensibility was induced. Chloroform having been 
administered, the splints and soiled bandages were removed, and the limb was p.laced 
in an easy position on pillows. Water dressings were applied to the wounds, and an 
opiate was administered. For the next three weeks, the progress of the case was very 
unfavorable. The wound of exit discharged copiously unwhole- 
some thin pus, mixed with blood and bubbles of fetid gas and 
small hits of dead bone. The pulse was quick and small, the 
tongue red and dry. There was a tendency to diarrhoea, and 
night sweats frequently recurred. On November 9th, as the 
patient was steadily growing worse, a consultation was asked 
for, and Surgeons C. 15. Gibson and M. Michel saw the case with 
Dr. Read. It was decided that the circumstances called for 
operative interference, and that an excision of the head of the 
femur offered the best prospect of recovery. On November 9th 
the patient was anesthetized, and then placed on his right side 
on the operating table. A straight incision was commenced two 
inches below the posterior or exit wound, and was carried through 
this to the great trochanter, and thence upward for two inches 
further, thus making a wound about seven inches in length. This 
incision being carried down to the bone, the upper end of the shaft 
of the femur was examined and was found to be jagged and 
pointed, thin layers of bone about three inches long being broken 
off from its anterior aspect. The lower fragment was projected through the incision by adducting the limb and pushing the 
knee upward, and it was sawn about two inches below its upper sharp extremity. The trochanteric portion of the femur was 
then sought for, and was found drawn upward by the psoas and iliaCHS interims. Its extremity was seized by the lion forceps 
and drawn downward, and the attachments of these muscles to the lesser trochanter were divided. To luxate the head of the 
femur so as to admit of the division of the round ligament was a work of great difficulty. It was finally accomplished, partially 
by twisting the neck of the bone, and the head was exarticulated. The appearance of the principal portion of this excised 
bone is shown in the annexed wood-cut (Fig. 51). Several large detached fragments and splinters were then extracted, and 
other closely attached bits of bone were enucleated by the finger-nail. The wound was cleansed and then closed by sutures and 
adhesive strips. Dry dressings were applied, and the thigh was fixed by a large straight splint. The patient was ordered two 
grains of opium and a drachm and a quarter of brandy every two hours. At bed-time the patient was quite comfortable, and 
could shift his position slightly without pain; his pulse was 120. On the following day, anodynes were given at greater inter- 
vals. On November 11th, they were omitted, except at bed-time, and nutritious diet was ordered. The next day the sutures 
were removed; the wound began to discharge laudable pus in small quantity. The case progressed without, any untoward 
complication. On December 9th the wound was healed, except at two points, connected by sinuses leading to the cotyloid 
cavity and the upper end of the shaft. The patient had gained flesh and strength; his pulse was full and strong at 76 ; his 




Fig. 51. — Shattered 

upper portion of the left 
femur. (From a weed- 
cut after Itli.ui. ] 




Fir.. 52. — Appearance of limb seven months 
after operation. [From a photograph. 1 



102 



INJURIES OF THK LOWER EXTREMITIES. 



[CHAP. X. 



appetite mid digestion were natural ; he slept well, was cheerful, and did not complain of pain. The limb was shortened five 
inches. The daily discharge of pus was less than half an ounce. Two weeks subsequently the wound was entirely united; the 
cicatrix was firm ; the patient could move about his bed without inconvenience ; there was no pain on pressure about the muscles 
of the injured part. The patient was now removed to his home in North Carolina, and was soon able to move about on crutches. 
In September, 1804, ten months after the operation, he reported that he was able to bear considerable weight on the limb, and 
that lie had discarded his crutches and walked about in a high-heeled boot with the aid of a cane. The appearance of the 
patient, seven months after the operation, is exhibited in the wood-cut on the preceding page (Fig. 52). copied from a photo- 
graph presented to the compiler by Assistant Surgeon Latimer, C. S. A. 

Case 240. — Private Hugh Wright, Co. G, 87th New York, aged 28 years, a robust, healthy man, was wounded on May 
5, 1864, at the battle of the Wilderness, by a conoidal musket ball, which entered the right thigh an inch within the track of 
the femoral vessels and two inches below Poupart's ligament, passed backward and outward, shattering the neck and trochanters 
of the femur, and, having been greatly flattened and distorted by the impact, it lodged amid the fragments of bone. The precise 

direction of the fracture is indicated in the accompanying wood-cut (Fig. 54). ' He stated 
that after being wounded, he was carried to the rear by a number of his companions, and, 
in the evening, was taken to the field hospital of the 2d division of the Second Corps. 
Here he remained for three days. He was then sent in an ambulance wagon to Fredericks- 
burg, and placed in a temporary hospital. He stated that his wound was repeatedly » 
examined by different surgeons, but that no treatment was instituted beyond the applica- 
tion of a compress dipped in cold water to the wound. He was transferred, after a fort- 
night, on a hospital steamer, to Washington, and on May 25th he was admitted to Stanton 
Hospital, then under the charge of Surgeon 15. B. Wilson, U. S. V. He was placed in Ward 
6, under the care of Acting Assistant Surgeon J. B. Garland, who communicated a special 
report of the case. The injured limb was swollen, everted, and shortened. Pus had 
accumulated in the tissues about the hip. Notwithstanding the gravity of the injury, the 
patient's constitutional condition is said to have been hopeful. On exploring the wound 
with the finger, the patient being under the influence of chloroform, detached fragments of 
hone could be felt. On consultation with Acting Assistant Surgeon George A. Mursick, 2 
an operation was decided upon, for the purpose of removing these loose fragments, and 
the missile, if it could be found. On May 27th, the patient was rendered insensible by 
sulphuric ether, and Dr. Mursick, assisted by Dr. Garland and 
others, made a straight incision, commencing above and behind the 
trochanter major and carried downward in the axis of the thigh. 
It was not in contemplation, at the beginning of the operation, Dr. 
Garland states, to exarticulate the head of the femur; but when the 
" muscular attachments were divided, and the full extent of the frac- 
ture was revealed, and the joint was found distended with pus, it 
was at once determined to make a formal excision. The fragments 
of the neck were extracted piecemeal. The ball was found lying 

behind the neck, and was extracted. The capsular ligament being 

' ^ ° Fid. 54. — Shotcommi- 

FlO. 53. — Appearance of limb two years freely inflised, a bistoury was inserted into the cotyloid cavity and nution of neck and tru- 

and five months after operation. [From a , , ,. , , , ., , , » ., - chanters of right femur, 

photograph.] the round ligament was severed, and the head of the lemur was s 3:i7 5 <* 

removed without difficulty. The jagged upper extremity of the 

shaft of the femur was then turned out of the wound by carrying the limb over the opposite knee, and was smoothed oif by a 

chain saw. There was but trifling haemorrhage, and no ligatures were required. The wound was carefully cleansed, dressed 

with dry lint, and left to heal by granulation. To keep the limb in position, long sand bags were laid on either side of it, and 

moderate extension was made by means of a weight attached to the leg and suspended from the foot of the bed. At night he 

took a grain of sulphate of morphia in a draught. The operation seemed to depress him very much, and reaction was slow. 

He passed a restless night, manifesting much nervous excitement. In the morning his pulse was feeble and frequent; his 

tongue dry and furred. He was ordered an ounce of brandy every three hours, a grain of opium every four hours, and as much 

beef tea and concentrated nourishment as he could take. On May 29th his general condition had much improved; the pulse 

was less frequent and stronger. There was free suppuration. The wound was dressed with a weak solution of permanganate 

of potassa. On June 1st he continued to improve, the wound looked well, and the character of the suppuration was good. 

The amount of brandy was reduced to four ounces daily. On August 1st he was still doing well. The wound was filled up 

with granulations from the bottom, with the exception of a sinus leading to the bone. It continued to suppurate quite freely, 

and some small pieces of dead bone had come away with the discharges. He had gained in flesh, and his health and spirits 

were good. On August 22d, he attempted, for the first time, to sit up in bed, but, owing to the rigidity of the parts and the 

agglutination of the muscles, the pain caused by the sitting posture was so severe that he was compelled to lie down again. 

Cold evaporating lotions were applied to the thigh. On August 23d the upper part of the thigh swelled and was painful, and 

the discharge was increased in quantity. On August 27th the swelling of the thigh had increased, the discharge from the 

wound was very free, thin, and flaky, and the surrounding surface was glazed and doughy to the touch. The wound of entrance 

had re-opened and discharged thin pus. An abscess formed on the inner side of the thigh, and about four ounces of thin flaky 





1 An anterior view of this specimen is printed in the surgical report in Circular No. G, S. G. O., 1865, p. 74, and in the Catalogue of the Surgica 
Section of the Army Med. Museum, 180*6. p. 246. 

2 MUIISICK (G. A.), A successful Case of Excision of the Head of the Femur for Gunshot Fracture, in New York Med. Jour., 1865, Vol. I, p. 424. 
See also Circular Xo. 6, S. G. O., 1865, p. 68, Circular No. 2, S. G. O., 1869, pp. 41, 135, Photographic Series, A. If. M., Vol. IV, p. 38. 



SECT. II.] EXCISION AT THE HIP FOR SHOT INJURY. 103 

pus was discharged. The patient was restless. He was ordered twenty drops of the tincture of the sesquichloride of iron 
every six hours, with stimulants and nutritious diet. On September 1st the swelling and inflammation of the thigh continued. 
He complained of nausea and want of appetite. An abscess formed on the outer side of the thigh. On September 5th the 
abscess was incised, and a large quantity of thin, flaky, and offensive pus was evacuated. He had an irritable stomach, and 
Hoffman's anodyne was administered. On September Gth the edges of the incision in the abscess were beginning to slough, and 
nitric acid was freely applied. On September 9th he had diarrhoea; ten grains of subnitrate of bismuth and a grain of opium 
were given every six hours. On September 13th the diarrhoea had nearly ceased. The patient's general condition had improved, 
and the wound looked well, though the suppuration was still copious, and had improved in quality. On September 85th a large 
ring-shaped exfoliation from the upper end of the femur was removed through the wound of operation. On September 26th 
another exfoliation was removed. On October Gth, 18G4, Private Wright was discharged from the military service on account 
of the expiration of his enlistment. On October 7th the swelling of the thigh had subsided; the discharge from the wounds 
had much diminished in quantity, and presented the appearance of laudable pus; the diarrhoea had ceased, and his general 
condition was much improved, he being able to sit up in bed. On October 30th. a sinus communicating with necrosed bone 
opened on the outside of the thigh. In the latter part of December, another abscess formed on the outer side of the thigh. 
When this was opened the swelling and inflammation subsided. He continued to do well until February G, 18G5, when another 
abscess formed in the lower third of the thigh, on the outer side. This was incised and the pus evacuated. Several pieces of 
dead bone came away with the discharges from the wound of operation. About the middle of March, 18G5, he was able to get 
out of bed, and to walk about the ward on crutches. Soon after, in getting out of bed, "he let his leg fall and hurt it." This 
accident was followed by inflammation and swelling of the thigh, and an abscess in the lower third of it, on the inner side. 
This was incised, and a small quantity of pus was evacuated. He was now attacked with erysipelas, which extended from the 
knee to the hip. This was combated with tonics and stimulants, such as iron and quinine, and rapidly disappeared. From this 
time he did well, taking daily exercise about the hospital on crutches. On April 17th, he was transferred to the Ward Hospital, 
at Newark, New Jersey. His general health was tolerably good. He could not bear much weight on his limb, and inflamma- 
tion and abscesses followed any unusual exertion. He remained at this hospital until May G, 18G5, when it was reported that 
he "eloped." As a discharged soldier, he was no longer under military authority, and was at liberty to go. For many months, 
though diligent inquiries were made, he could not be traced; but, in July, I860, Surgeon General L. W. Oakley, of New Jersey, 
transmitted a letter from Dr. W. Pierson, of Orange, New Jersey, which stated that Wright had entered the almshouse at that 
place in June, 1865, and had remained there until the following spring, under Dr. Pierson's professional care. At first, the 
mutilated limb had been enormously swollen from cedema, and there was an ichorous discharge from a sinus near the hip joint. 
With careful bandaging, the oedema gradually disappeared. In the spring of 1866, Wright left the almshouse, and engaged 
himself as a laborer on a farm. He wore, Dr. Pierson reported, a cork-soled shoe of his own manufacture. The limb was 
shortened precisely five inches. The circumference of the injured thigh at the highest part was one inch less than that of its 
fellow. He walked well without crutch or cane, bearing his full weight on the mutilated limb. There was quite free motion at 
the hip, but little at the knee. There were no open listules, and no tenderness about any of the cicatrices. Dr. Stephen Wickes, 
of Orange, reported, in the summer of 1866, that Wright was in good health, though somewhat intemperate; that he worked 
daily at light tasks, and was even able to mow grass. He commonly walked with a cane. According to the measurement 
of Dr. Wickes, the limb was shortened four and three-quarter inches. About this period, Dr. Mursick, the operator in the 
case, discovered his former patient, and examined him. He found the resected end of the femur firmly attached to the pelvis 
by ligamentous tissue an inch and a half long. The agglutination of the muscular sheaths had nearly disappeared. The limb 
was quite under control. The man could flex and extend it slightly, and adduct to a limited extent; the power of rotating and 
abducting was lost. Motion at the knee was quite restricted, on account of the thickening and consolidation of the surrounding 
tissues resulting from inflammation. He stated that latterly the improvement in his limb had been very decided; that when he 
first commenced to walk, the limb felt like a weight attached to the body; this sensation had entirely disappeared. January 
15, 18G7, Hugh Wright was found duly established at his residence in North Orange, Essex, New Jersey, receiving a pension 
dating from October, 1864, the date of his injury. The Pension Examiner, Dr. A. W. Woodhull, of Newark, reported "that 
at that date there was about six inches shortening, with no power of flexion or extension at the hip and the power of rotation 
to a very limited degree. All motion of the injured limb for progression was imparted by lateral swing of the body itself. I 
may add that the knee joint of the injured limb is stiffened." On October 19, 1867, Dr. Mursick again examined Wright, and 
took him to New York, and had his photograph taken. The negative is preserved at the Army Medical Museum, and is No. 
188 of the Surgical Series of Photographs, a reduced copy of the lower limbs as shown, in the photograph, is presented in the 
wood-cut (Fig. 53). At this period, Wright reported that his limb had given him no trouble since the sinuses healed, in May, 
1865, and that it sufficed for all purposes of locomotion. He stood on it very firmly, and could move it in any direction with 
an easy, swinging motion. He had been engaged for a year and a half as a farm hand, and was employed at that time as a 
wood-chopper. Ho had for a short time earned larger wages as a hod bearer, and had climbed high ladders with a heavy hod 
of bricks on his shoulders; but he found this avocation too fatiguing. His general health and physical condition were good. 
The knee joint continued quite stiff. It could be flexed to about quarter, perhaps, of the normal extent. When he walked, 
the rounded upper extremity of the femur played up and down on the dorsum of the ilium over a space of an inch and a half. 
In November, 1888, Dr. Mursick again examined Wright, and reported on his condition. The utility of his limb had augmented 
during the twelve months that had elapsed since the last examination. The attachment of the femur to the pelvis was strong; 
the cicatrices were firm and healthy. All the movements of the thigh were performed with almost as much facility as in the 
normal state; rotation, even, as well as flexion, extension, adduction, and abduction. His general health was good. On August 
3, 1872, Wright's pension was increased to $18 per month on account of increasing disability and because additional legislation 
permitted larger payment to the more gravely mutilated. In September, 1873, Pension Examiner A. W. Woodhull reported the 
local disability unchanged, and, on October 26, 1874, the sudden death of the pensioner, Hugh Wright, from supposed cardiac 
disease was reported. Unfortunately no autopsy was made and the valuable opportunity of examining the relations of tht 
resected joint was unimproved. 



101 



INJURIES OF Til!'. r.OWEI! EXTREMTTIE 



irnAP. x. 



In tlio twenty unsuccessful intormediarv excisions the average duration of life after 
operation was twelve and a half days. One patient (Cask 248) survived seventy-five days, 

ther than to the effects of the injury and 
three weeks with colliquative diarrhoea 
lesions seemed to indicate the operation, 
first category. The first was a solitary 



and apparently succumbed to climatic influences ra 
operation; another (Case # 251) died at, the end of 
and malarial complications. Four cases where the 
mad.' little or no recuperative effort, and form the 
instance of fracture by a shell fragment: 




FlO. 55.— Neck ami tro- 
chanters of right femur 

shattered by a fragment 
of Shell, anil excised. 
Spec.840. Sec.I, A..M.M. 



Cask 241. — Private Cornelius Callaghan, Co. G, 2d Delaware, was wounded in the left hip by a fragment of shell, at 
the battle of Antietam, September 17, 1802. On September 19th, he was admitted to hospital No. 3, at Frederick, Maryland. 
IIo was placed under the influence of chloroform, and an examination of the wound was made by Assistant Surgeons Bill and 
Colton, IT. S. A. The wound being enlarged sufficiently to admit of free exploration, the trochanteric region of the femur was 
found to be badly comminuted, the great trochanter entirely detached and drawn backward by the action of the gluteus, while 
fissures extended up the neck within the capsular ligament. No fissures extended below the trochanter minor. The patient's 
general condition was good, and all the circumstances being favorable to such an attempt, it was determined, in a consultation 
of the medical staff, and with the approval of Medical Inspector Coolidge and Surgeon Milhau, U. S. A., that the injured 
portions of bone should be excised. On September 20th, Assistant Surgeon J. H. Bill made an incision 
from the wound three inches downward in the course of the shaft, and another three inches long curving 
upward and inward from the wound to a point a little below the anterior superior spinous process of the 
ilium. The muscular attachments being dissected aside, a chain saw was passed around the shaft of the 
femur and made to divide it just below the trochanter minor. The head of the hone was then disarticu- 
lated. The edges of the wound were united by six sutures, and adhesive plasters anoVwater dressings 
were applied. The limb was kept in position by pillows, without the use of splints. A full dose of morphia 
was given, and light but nourishing food was directed. On the following day the patient was quite com- 
fortable. His pulse, which was 100 before the operation, now beat 120. He was ordered a diet of beef 
tea, eggs, and oysters, with a small amount of wine. At midnight he was sleeping quietly. On October 
1st he was still cheerful. His pulse was very compressible at 120, and he was sweating profusely. The 
thigh was swollen and painful. A draught of aromatic sulphuric acid with a little quiuia was added to his 
prescriptions, and the allowance of wine was increased. The prognosis was now v<-vy unfavorable. On October 2d the sweating 
was checked, but diarrhoea had supervened. The pulse was still softer and more frequent, and suppuration had commenced. 
At midnight the patient was attacked with vomiting and hiccough. On October 3d the vomiting persisted, and the sweating 
was renewed. This state continued through the day and night, the patient sinking gradually. He died at 3 o'clock P. M. of 
October 4, 18J2. The pathological preparation is deposited in the Army Medical Museum, and is numbered 840 of the Surgical 
Section. An anterior view of it is presented at page 247 of the Catalogue of the Surgical Section, and a posterior view in the 
accompanying wood-cut (FiQ. 55). 

Cash 242. — Private D. M. Noe, Co. C, 4Cth Ohio, aged 22 years, was wounded at the battle of Shiloh, Tennessee, April 
C, 18G2, by a conoidal musket ball, which shattered the neck of the left femur. The patient was placed on board the hospital 
transport steamer Lancaster, under the charge of Surgeon George C. Blackmail, U. S. V. On April 16, 1802, chloroform having 
been administered, Dr. Blackmail made a longitudinal incision four inches in length over the trochanter, and excised the head, 
neck, and trochanters, together with three inches of the shaft of the femur, the dinphysis being divided by a common amputa- 
ting saw. The patient reacted well after the operation, and for five days the symptoms progressed favorably. Pyaemia was 
subsequently developed, and death ensued on April 24, 1862, eight days after the operation. 

Case 243. — Private Marsclla Smith. Co. F. 38th Virginia, a robust middle-aged man, was wounded near Spottsylvania, 
early in the morning of May 10, 1804, by a conoidal musket ball, which entered at the upper posterior part of the left thigh, 
passed through the periiueum without injuring the urethra, and through the soft parts of the right hip. He was sent to Rich- 
mond by rail, and was admitted to hospital No. 0, otherwise known as the Eeceiving and Wayside Hospital, 
on the following morning. On May 12th he was placed under chloroform and the wound was thoroughly 
explored. The limb was everted and shortened and swollen; there was crepitus on rotation. The fracture 
appeared to be limited to the great trochanter and neck. It was supposed that the urethra was divided; but 
this was afterwards proved not to be the case. Surgeon Charles Bell Gibson, C. S. A., decided to excise 
the injured bone, and the operation was performed forty-eight hours after the reception of the injury, the 
head, neck, and two inches of the shaft being removed. It is stated that the effects of the chloroform were 
unfavorable. On the following day ''patient commenced sinking at an early hour, and continued growing 
Fig. 5G.— Oblique, more and more feeble until 3 o'clock p M.. when death ended his sufferings," May 13, 18G4. The excised 

sunshotfr.ictureoftlie portion of the femur was preserved by Dr. Richardson, and has been presented by him to the Armv Medical 

upper portion ot shaft ■ * J ^ * * 

of left femur. Spci;. Museum. It is represented in the accompanvina' drawing (Fig. 5G), and shows that the injury to the bone 

5500, Sect. I, A.M. SI. ,, t , , , , tl -u- ■ ■ t 

was altogether external to the hip joint. 

Cask 244. — A soldier of General Buell's army was wounded in a picket skirmish, about seven miles from Nashville, in 
March, 1832, by a conoidal musket ball, which shattered the neck and trochanters of the femur. He was immediately conveyed 
to Nashville, and placed in the College Hospital, under the care of Surgeon A. H. Thurston, U. S. V. Surgeon M. Goldsmith, 
U. S. V., saw him in two days after the reception of the injury, and deemed the case peculiarly well adapted for the operation 
of excision. The surgeon in charge concurring in this opinion, the patient was anaesthetized, and Dr. Thurston proceeded to 
excise the head and splintered upper extremity of the femur, through a long straight incision. The operation was accom- 




SECT. II. | 



EXOTSTON AT THE HIT AFTER SHOT INJURY. 



105 



pushed with but littla luEmorrhagi'. and although tin- patient wan much prostrated l>_\ the shock of t li<- injury and of (lie opera- 
tion, liu reacted and was in a comfortable condition for several days. But surgical fever and suppuration soon set in, and lie 

gradually sank, and died one week after the operation. There can he little doubt that the subject of this operation was Corporal 
Henry F. Smith, Co. B. 1st Wisconsin, who. according to the records of the Nashville Hospital, was admitted for a gunshot 
wound of the hip, and was the only patient who died from wounds in Dr. Thurston's wards, at the period referred to. 1 
Corporal Smith died on March 15, 1832. The operation was probably done on March 10th.- 

In the .second category of intermediary excisions arc grouped eight cases well adapted 
from the local lesions for the operation in which all the patients made a struggle for 
recovery, and two survived respectively five and eleven weeks : 

Case 245. — Private T. C. Christopher, Co. D, 18th South Carolina, aged 21 years, a robust -man, was wounded at 
Williamsburg, Virginia, May 5, 1832, by a conoidal musket ball, which entered about two inches below and behind the left 
trochanter major, and passed forward, upward, and inward. He was stooping at the time he received the injury. 1 Fe was made 
prisoner, and sent to York River, and thence on a hospital steamer to Washington, and placed in Cliff hnme Hospital, May 17th. 
His pulse was 100, and he complained of severe pain in the hip and knee. The tissues 
about the hip were much swollen; the limb was everted, and shortened one and a half 
inches. The opening made by the bullet was very small, and discharged a thin sanious 
pus. There was no orifice of exit. The patient was etherized, and careful exploration 
of the wound revealed a fracture of the inner portion of the neck and probably of the 
head of the femur. It was decided that excision should be performed, and the patient 
was placed upon a soothing and supporting regimen preparatory to the operation. May 
20th, Assistant Surgeon J. S. Hillings, IJ. S. A., made a curvilinear incision, four inches 
in length, one inch behind the great trochanter, that revealed the condition of the parts. 
Fragments of the inner extremity of the neck were removed piecemeal. The bead was 
then removed from the cotyloid cavity, except a small fragment which was extracted 
from an intermuscular space. The ball was now discovered lying in the obturator 
externus muscle, and extracted. Little blood was lost, and reaction took place. Water 
dressing was applied, and a grain of sulphate of morphia administered. E version of 
the foot was corrected by fastening the limb by straps of adhesive plaster to an upright 
piece of wood screwed to the foot of the bedstead, and, the latter being raised, adequate 
extension and counter-extension were secured. On May 21st, the patient reported a 
comfortable night, but now had a very irritable stomach, with frequent vomiting. His 
skin was cool and clammy ; his pulse small and feeble at 115. He was ordered aromatic 
spirits of ammonia in small doses, brandy, egg-nog, and beef essence, with sinapisms to 
the epigastrium. On May 23d, the irritability of the stomach had subsided. The 
patient was weaker; stimulants and concentrated nourishment were given. On May 
24th, the patient rapidly grew weaker. Capillary hemorrhage took place from the 
surfaces of the incision, but was readily checked by the application of a solution of persulphate of iron. Enemata of beef 
essence and brandy were administered, and these articles also by the mouth. Tin' patient sank rapidly, and died May 24th, 
five days after the operation. At the autopsy, twelve hours after death, the soft parts about the seat of injury were found dark 
in color and softened. The acetabulum was eroded. A clot of blood of three ounces was found between the peritoneum and 
iliacus externus muscle. The innominatum and superior portion of the femur were removed, and, together with the excised 
fragments, forwarded to the Army Medical Museum, and numbered 11) of the Surgical Section, having been mounted among its 
earliest specimens, and it is represented in the wood-cut (Fig. 57). — {Circ. 6, S. G. O., 18G5, p. 02, and Circ. 2, S. G. O., 1809, 
pp. 35, 135.) 

Case 240. — Private T. E. Foulke, Co. I), 2d Alabama, aged 17 years, was wounded and captured at Fort Blakely, 
Alabama, April 9, 1865. A conoidal musket ball entered posteriorly at the middle third of the left thigh, fractured the upper 
third of the femur, including the trochanters and neck, and was removed from above the anterior superior spinous process of the 
left ilium. The patient was then transferred to New Orleans, and, on April 15th, be was admitted to the St. Louis Hospital. 
On admission he was very much exhausted by profuse suppuration, the soft parts about the hip-joint being filled with unhealthy 
pus. On April 27th Surgeon A. McMahon, U. S V., excised the head, neck, trochanters, and two inches of the shaft of the 
left femur, the patient being under the influence of chloroform. He was placed on nourishing diet, with two bottles of porter 
daily, eggs, beef tea, and everything be desired. On May 23th he was transferred to the Marine Hospital at New Orleans. He 
was then doing well ; but hi? gradually failed, and died .lime 5, 1835, of exhaustion, thirty-nine days after the operation. 

Case 247. — Private Charles E. Marston, Co. F, 1st Massachusetts, aged 19 years, a pale and delicate boy, was wounded 
at the second battle of Bull Run, August 30, 1832. He was admitted to the College Hospital, Georgetown, D. C, on Septem- 
ber 0th, having laid on the battle-field several days, and then moved in an ambulance wagon thirty miles over very rough roads. 
An examination revealed a large bullet wound an inch anterior to and on a line with the right trochanter major, with great 
comminution of the bead and neck of the femur. The limb was shortened, and the foot was everted. The circumference of the 

1 The above account has been submitted to Dr. M. Goldsmith, who states that he thinks that the Identification of the case is complete. Surgeon 
Thurston died during the war. 

2 The report of the Adjutant General of Wisconsin for lSfio, p. 33. states that on March 8, 1862, five companies of the 1st Wisconsin Volunteers were 
sent out beyond Nashville on picket duty. They were attacked by a cavalry force, and Private Willett Greenly was killed — " the first Union soldier 
killed in Tennessee" — while Corporal II. F. Smith and one other were wounded, and were sent to Nashville. 

Surg. Ill— 14 




Flo. 57. — Transverse shot fracture of the 
anatomical neck of the left femur, with caries. 
Sjxc. 19. 



106 



INJURIES OF THE LOWER EXTREMITIES. 



[CHAP. X. 




FlO. ~>&. — Shot commi- 
nution of head and neck 
of ri^ht femur. Spec. '32B. 



limb exceeded that of its fellow by half. The pulse was 112, and of moderate volume. The tongue was rather dry. The 
patient suffered little pain. The general condition was not promising, and yet not very bad. Excision of the fractured bone 
was decided upon, and, on the '27th of .September, Assistant Surgeon B. A. Clements, U. S. A., assisted by Assistant Surgeon 
Charles II. Alden, U. S. A., and the surgical staff of the hospital, proceeded to perform the operation. Chloroform was 
administered, and a slightly curved incision five inches in length was made on the outside of the thigh, the shot hole in the 
middle of tin- incision, and the trochanters and neck were thus exposed. The neck was crushed into about forty fragments, 
which were extracted. The head was also much broken, and the round ligament was absorbed or destroyed, so that exarticula- 
tion was easy. The roughened portion of the neck, at its attachment with the trochanter, was sawn off with a small chain saw. 
The missile, a conoidal musket ball, wot found on the inner side of the thigh at the bottom of a large 
cavity, and was removed with difficulty. After thoroughly syringing the wound and removing the pow- 
dered bone, the wound was closed by silver sutures, except at the bullet hole, and sand bags were placed 
to keep the limb in position. Slight extension was made by a weight to the foot. The patient expressed 
himself as relieved by the operation, and he slept well that night. On the following day his pulse had 
risen to 128, and the discharge from the wound was very copious, thin, and brown. On September 29th, 
his pulse was still quick and feeble, and his tongue dry, and, though he took nourishment well, and was 
free from distress, he gradually sank, lie died on September 30, 1862, at half past 8 o'clock A. jr., three 
days after the operation. At the autopsy, on October 1st, made by Acting Assistant Surgeon G. K. Smith, 
the wound made by the operation was found to bo filled with very offensive pus. The upper end of the 
shaft of the femur was found to be diseased on its posterior surface near the trochanter minor, and the 
periosteum was loosened from the bone for some distance above and below this point. The fracture of the 
ischium, which was noticed at the operation, extended obliquely upward and backward from the lower 
border of the acetabulum, terminating in the sciatic notch, about an inch and a quarter above the spine of the ischium. The 
lower half of the acetabulum had been broken into several fragments, which were held in position by the cotyloid ligament. The 
excised portions of the femur were forwarded to the Army Medical Museum, and are numbered 328 in the Surgical Section. 
They are represented in the adjoining wood-cut (Fig. 58). 

Case 2-18. — Private John Miller, Co. E, lG2d New York, aged about 38 years, a robust, phlegmatic German, in good health, 
was wounded on June 14, 1833, in the assault on Port Hudson, Louisiana, by a conoidal musket ball, which passed through 
the upper portion of the thigh, breaking the neck of the left femur transversely, and splitting it longitudinally, but without 
great comminution. The pelvis was uninjured, and there was no serious damage to the soft tissues. The patient was conveyed 
to New Orleans on a hospital transport, and was placed in the St. Louis Hospital, on June Kith. It was determined that 
excision of tin; injured bone was advisable, and the officer in charge of the hospital, Surgeon F. Bacon, U. S. V., being confined 
to his bed by illness, the operation was performed on July 8th, by Assistant Surgeon George W. Avery, 9th Connecticut. The 
head, neck, and great trochanter were removed in the usual way, through a single straight incision of moderate extent over the 
trochanter and in a line with the axis of the femur. There was an immaterial loss of blood. The state of the tissues involved 
and the constitutional condition of the patient were as good as might be. Dr. Bacon remarked that the operation was well and 
rapidly performed. The patient rallied from it promptly, and afterwards received the most assiduous care. His progress was 
very favorable until the early part of September. The wound had nearly healed, and Surgeon Bacon and his assistants were 
very hopeful of the patient's recovery. But in September the weather became most oppressively hot, and the patient steadily 
declined. The wound assumed a bad appearance, discharging copiously, and despite sustaining measures, the patient sank and 
died from exhaustion on September 21, 1882, seventy-five days after the operation. Dr. Bacon examined the fragments of bone 
removed, and found the periosteum adherent throughout the larger pieces. 

Case 249. — Private Henry Phillips, Co. I, 140th New York, a robust man, aged 34 years, was wounded at the South 
Side Railroad, near Petersburg, on April 1, 1835, by a conoidal musket ball, which entered the left thigh and lodged against the 
anterior surface of the neck of the femur. The patient was conveyed to the field hospital of the 2d division of the Fifth Corps, 
and thence by ambulance and rail to City Point, where ho arrived on April 4th, and was transferred by steamer to Washington, 

and, on April 6th, was admitted into Douglas Hospital. He was much exhausted and had 
considerable fever, though in frequency the pulse and respiration were nearly normal. The 
wound was painful, and the beginning of its grave constitutional aspect was becoming man- 
ifest. There was no shortening or deformity of the limb. At a preliminary exploration the 
ball was found impacted near the anatomical neck, and was extracted. The limited nature 
of the fracture was also ascertained, and excision was decided on. On April 8th the patient 
was placed under the influence of ether, and Assistant Surgeon William F. Norris, U. S. A., 
excised the head, neck, and trochanter major through a curved incision six or seven inches 
in length with its convexity forward. About twelve or sixteen ounces of blood were lost 
during the operation. One small artery required a ligature. The ball had crushed in the 
laminated structure of the anterior face of the neck, and from this cup-shaped cavity a small fissure ran up the articular surface 
and a deep fissure nearly around the neck; but the separation between the head and neck was incomplete. During the opera- 
tion this fracture was converted into a complete one in rotating the bone to facilitate the exarticulation. The operation concluded, 
the limb was supported by pillows, and the patient was ordered beef tea and milk punch every three hours, and a full dose of 
opium at midnight. He had another dose of laudanum at four o'clock the next morning. On the 9th, 10th, and 11th, there 
was little pain, and anodynes were not required, but concentrated nourishment and stimulants were assiduously administered. 
It was thought the nurse exceeded his instructions in the amount of whiskey given, for on April 12th, the patient had hiccough 
and nausea, and his breath was redolent of alcoholic fumes. He was now transferred to the immediate charge of Acting Assistant 
Surgeon C. Carvallo. A laxative enema was administered, and, when the bowels were unloaded, a sinapism at the epigastrium, 
and small doses of creasote allayed the irritability of stomach. On April 13th the stomach was quiet, pulse 120, rather weak, 




FIG. 59.— Fracture of head and neck 
of left femur by a conoidal musket ball. 
Spec. IS235, Sect. I, A. M. M. J 



SECT, ii: 



EXCISION AT THE HIP AFTER SHOT INJURY. 



107 



and there was profuse perspiration. The patient was ordered a cupful of beef tea every two hours, one of milk punch every 
four hours, milk toast and soft boiled eggs at breakfast and dinner. No change the next day. On the 14th the wound 
looked well. Some shreds of disorganized connective tissue were removed by the dressing forceps. There was some pain and 
difficulty in micturition. Small doses of tincture of the sesquichloride of iron were directed thrice daily, and chicken broth was 
added to his dietary. No entry of importance appears on the ICth. On the 17th the pulse was 120, respiration 32. Slight pain 
on right side, and signs of pleurisy on auscultation. There was an erythematous blush about the wound, and, in the evening, 
there was diarrhoea, which was checked by pills of opium and nitrate of silver. On the 18th the pleurisy was worse, the 
breathing more rapid, and there was retention of urine, so that it was necessary after this to use a catheter. April 19th the 
countenance was sunken, and the wound was flabby. There was a sore on the sacrum. The patient was moved to a Crosby 
Invalid Bed. He had a draught containing ammonia and sugar, and a blister on his side. April 20th the nurse reported a chill 
during the night. The breathing was labored. There were sordes on the teeth. At the next morning visit the patient was 
very low. He died before noon, April 21, 1865, eleven days after the operation. The autopsy revealed dry pleurisy on either 
side; lungs healthy, somewhat congested posteriorly; heart and liver not abnormal. A large sub-peritoneal abscess in the 
course of psoas and internal iliac muscles, which appeared to originate in the obturator foreamen and ascend along the left iliac 
fossa, denuding the bone of its periosteum. No evidences of pyaemia were found, though it was strongly suspected after the 
occurrence of the chill on April 20th. The pathological specimen, contributed by the operator to the Army Medical Museum, is 
represented at page 24G of the Catalogue of the Surgical Section of 18f>0, and by the wood-cut (Fig. 59). 

Cask 250. — Captain John Phelan, Co. A, 73d New York, aged 22 years, received a compound comminuted fracture of 
the neck and upper extremity of the left femur at the battle of Spottsylvania Court House, on May 14, 18G4. On May 16th, he 
was admitted to Mount Pleasant Hospital. Washington. The rapid and incessant influx of wounded was such that the attention 
of the overworked hospital staff was not especially drawn to his case for some time after his admission, and the delay in 
minutely examining the case was extended by the uncomplaining fortitude of the sufferer, who expressed his wish that the more 
serious cases should first be attended to, and declared that his own sufferings were comparatively slight. When, however. 
Acting Assistant Surgeon Mulford, the ward surgeon, proceeded, on June 3d, to adapt apparatus to what he supposed to be an 
ordinary gunshot fracture of the upper third of the thigh, he was led to apprehend that the injury extended to the coxo-femoral 
articulation, and requested the opinion of the surgeon in charge of the hospital, Assistant Surgeon C. A. McCall, U. S. A., as to 
the diagnosis and treatment. Dr. McCall immediately visited the patient, and found him to be a large, muscular, finely formed 
man, whose previous health had been excellent. When lying quietly in bed, he suffered but little. His appetite was good; and 
his strength, so far, had diminished but little. Altogether, his general condition was extraordinarily good, in view of the gravity 
of the injury he had sustained. The ball had entered in front, just over the point at which the profunda is given off from the 
left femoral artery. The aperture of entrance was small and characteristic as an entrance wound of a conoidal musket ball. 
The missile had passed toward the great trochanter and shattered it. Further, its course could not be ascertained at the time. 
Any movement of the limb caused extreme pain. Though the femur was much comminuted, Dr. McCall was not positive that 
the hip joint was implicated, and, with a view to a full exploration of the injury, he directed Dr. Mulford to make a longitudinal 
incision three inches in length over the trochanter, to explore the parts thoroughly, and to ascertain by digital examination the 
condition of the articulation. If it was uninjured, Dr. Mulford was instructed to extract detached fragments of bone and foreign 
matters, to close the upper part of the wound, and to avail of the 
lower portion for drainage. In the afternoon the patient was ether- 
ized, and the exploratory incision was made, and it 
was found that the fracture extended to the head of 
the femur. It was then decided to excise the head. 
The patient was again rendered insensible by the 
inhalation of sulphuric ether, and Dr. McCall 
extended Dr. Mulford's incision upward an inch 
or more, and then made an oblique incision across 
its upper extremity, as represented in the accom- 
panying figure (Fig. 01). The two flaps thus 
marked out were reflected, and the joint was read- 
ily exposed, the round ligament divided, and the 
head of the femur exarticulated. The acetabulum 
was carefully examined and found to be uninjured. 
Seven large and numerous small fragments of the 
neck and trochanter major were then removed, a task requiring much time and patience, many fragments being driven into the 
gluteal muscles, or deeply retracted by the muscles attached to the great trochanter. The fractured upper extremity of the 
femur was then brought out at the wound, by adducting and pushing upward the knee of the injured limb, and all diseased 
tissue was removed. The periosteum was in a healthy condition quite up to the end of the bone. The wound was now 
thoroughly washed out, and approximated by three stitches, and by adhesive strips. A grain of sulphate of morphia was 
administered, and the patient was put to bed. The operation lasted three-quarters of an hour. Dr. McCall thinks that the ball 
was removed during the operation ; but is not positive on this point. The hospital report, which is quoted at page 69 of Circular 
No. 6, S. G. O., 1865, states that the patient's pulse was quick and irritable at the time of the operation, that he had a furred 
tongue and diarrhoea, and was reduced by suppuration. But Dr. McCall (letter of February 11, 1868; thinks that this report 
exaggerates the gravity of the constitutional symptoms, and is quite sure that the general condition was favorable. The patient 
rallied well from the operation. For two days the wound was dressed with lint. Suppuration then commencing, the limb was 
placed in Fergusson's apparatus for excision of the head of the femur, the counter-extension straps being left off. The wound 
was freely syringed with cold water containing a little permanganate of potassa. A nourishing diet was ordered, with tonics 





Fig. GO.— Excised 
head and fragments 
of neck of left femur. 
Spec. 2C18. 



rtuW 



A\^.vij\,;/f- ; 



Fig. 61. — Direction of (he incisions in case of excision of the 
head of the femur. [From a drawing by Dr. McCall.] 




108 INJURIES OK THE LOWER EXTREMITIES. ICHAP. X. 

and stimulants. For si week or ten days subsequently, the case progressed favorably. Suppuration was moderate in amount, 

and of a healthy character. About the middle of .1 the weather became intensely hot. The atmosphere of the wards, in 

which nearly every lied was occupied by a patient with suppurating wounds, became intensely oppressive. About this time, 
the patient began to grow worse. The cheerful resolution and .hopefulness he had hitherto evinced, gave way. Diarrhoea 
supervened, and he lost strength rapidly. The fatal event was thought to have been delayed by the plan which was pursued 
of daily removing the patient in bis bed at nine in the morning to a spot beneath the shade trees near the hospital, where he had 
pun; air and escaped the distressing scenes of the ward ; he remained each day until live in the afternoon. He died on June 21, 

1834. The portion of hone excised was forwarded at the time of tl peration to the Army Medical Museum. The preparation 

is No. 2618 of the Surgical Series. It is represented in the adjacent wood-cut (Fig. GOV 

Case 251.— A private soldier of General Pope's Army of Virginia, was admitted on September 2, 1802, to the Cliff'burne 
Hospital at Washington, D. C, with a gunshot fracture of the neck of the left femur, received at the second Bull Run battle, on 
August 29, 1802. A conoidal musket ball bad entered the left hip directly over the trochanter major and embedded itself in the 
neck of the femur. The trochanter major and the neck of the femur were split and comminuted, but the head was uninjured. 
The patient had suffered greatly from the journey from the battle-field to the hospital, and was prostrated by diarrhoea and 
malarial complications. The tissues about the hip joint were but slightly swollen, and the wound discharged healthy pus. It 
was decided that excision was the most hopeful resource, and on September 4, 1802, Assistant Surgeon John S. Billings,U. S. A., 
proceeded to operate. Chloroform was administered, and a straight incision was made over the trochanter major, and the head 
and fragments of the. neck were removed. The shaft of the femur was then divided by a chain sawat the level of the trochanter 
minor. ° The patient reacted well from the operation. He was placed on a fracture bed, and extension by means of a weight 
was made on the injured limb. The diarrhoea increased in severity despite all treatment, anil the patient succumbed, exhausted, 
on September 24, 1862, twenty days after the operation. 

Case 252.— "Private Michael Welsh, Co. II, 10th Kentucky, aged 40 years, was struck by a conoidal ball in the region 
of the left great trochanter, at the battle of Ohickamauga, September 20, 1863, ami at once conveyed to a field hospital, which 
soon after fell into the hands of the enemy. Ten days subsequently, he was brought to Chattanooga; and during the period of 
his captivity the only nourishment that he received was a small portion of corn-meal gruel daily. Having lost his blankets, he 
also suffered much from cold, ami had contracted a rather severe bronchial inflammation. On the 1st of October, he was 
admitted into the general field hospital of the Fourteenth Corps, when a conoidal musket ball was removed from 
among a mass of small fragments of the neck of the femur, the ball having entered just anteriorly to the great 
trochanter. Two days subsequently, Surgeon F. II. Gross, IT. S. V., carried a curvilinear incision, with its con- 
vexity presenting forward, and including the opening made by tho ball, from above downward, and excised the 
head of the femur along with the attached greater portion of the lower surface of the neck of the bone. Many 
froctoreofneok fragments were removed with the forceps; but as the trochanters were not involved in the injury, the remaining 
s ,'°54 o' mm '' Bharp portions of the neck were trimmed off close to the inter-trochanteric lines, which completed the procedure. 
No ligatures were required. The man bore the operation well, and the limb was placed in a comfortable position. 
From the date of the operation up to October 20th, the man did very well, in spite of his enfeebled condition and bronchial 
trouble, when the discharge from the wound became sanious. On the same night he had a chill and was delirious, and the 
pulse was very feeble and frequent. On the 25th of October his condition is thus described : Pulse 125 and very feeble; tongue 
dry and red ; had a natural alvine evacuation. At 9 o'clock A. M. haemorrhage recurred from the wound, which was arrested by 
injecting a solution of sulphate of iron. Stimulants freely administered, but the man grew more and more feeble, and expired 
at 2 o'efock P. Jr. No post-mortem examination was held, but death was evidently due to pyremia. The specimen shows that 
about one-fifth of the head at its upper aspect has been shot away, together with the entire upper surface of the neck, about 
one-half of the anterior and posterior surfaces and the lower border of the neck remaining." The pathological specimen, illus- 
trated by the accompanying wood-cut (Fig. 62), was forwarded to the Army Medical Museum, June 3, 18G8, by the operator. 

The third category of intermediary excisions includes eight cases in which the con- 
ditions revealed on exploration offered little prospect of success. All of the patients were 
subjected to rough transportation. The first case was complicated with shot perforation of 
the elbow, the second was a man of sixty in poor health, the third a lad, rudely exposed 
in a wagon without springs; two others had wounds penetrating the pelvic cavity, and, in 
one of these cases, a splinter of the left innominate bone opened the internal iliac vein, and 
led to uncontrollable haemorrhage, while, in the other, hyperacute peritonitis supervened. 

Case 253.— Private G. TV. Brantley, Co. C, 2d Alabama, aged 18 years, was wounded and taken prisoner at Fort 
Blakely, Alabama, April 9, 1865. A conoidal musket ball bad passed through the left groin, fractured the neck of the femur, 
and emerged posteriorly at the apex of the left buttock. He also received a gunshot fracture of the external condyle of the 
right humerus. He was conveyed to New Orleans, and, on April 15th, he was admitted to the St. Louis Hospital. The thigh, 
groin, and surrounding parts were infiltrated with unhealthy pus, and the patient was very much exhausted. On April 28th, 
the patient was anaesthetized by chloroform, and Surgeon A. McMahon, U. S. V., proceeded to excise the head, neck, and 
trochanters of the left femur. No arteries required ligation. The patient did not rally very well. Stimulants were freely 
administered; but the patient sank, and died on May 2, 1865, of capillary haemorrhage. The condition of the patient did not 
admit of any operation on the elbow joint. 

Cask 254.— Private Peter Boyle, Co. D, 59th Massachusetts, aged 60 years, was wounded at Petersburg, July 30, 1864. 
A conoidal musket ball entered the left hip and passed antero-posteriorly through the soft parts and surgical neck of the femur, 



sect. ii,i 



KXiTSluN AT Till'', III!' AKTEK SHOT INJURY. 



100 



trochanter major. His entry at the base hospital at City Point and transfer to Washington are recorded on 
was conveyed to Washington on an hospital steamer, and on August 3d was admitted to Douglas Hospital. 



trough exploration 




Pig. 63.— Shot per- 
foration of neck of left 
femur. Spec. 30!«. 



and fractured III 

August 1st. If> 

His constitutional condition, on admission, was poor The wound, however, had an healthy aspect, and a tli 

si towed that the injury to the soft tissues involved no important part, and that the fracture at the junction of 

tin- neck and trochanter major was not accompanied by much longitudinal splintering in either direction. 

Assistant Surgeon William Thomson, U. S. A., decided that ail excision of the injured bone was expedient, 

and that the operation should be done as soon as the patient had rallied from the fatigue and irritability 

induced by his long journey. On August 5th. ether having been administered. Assistant Surgeon Thomson 

proceeded to excise the head, neck, and trochanters of the left femur, through a straight incision of sufficient 

length made over the trochanter major. The rotator muscles and the tendons of the psoas and iliacus being 

divided, the round ligament was readily cut and the head exarticulated. The section of the shaft was made 

by a chain saw at the level of the trochanter minor. The operation was rapidly accomplished, and there 

was no haemorrhage of moment. The wound was dressed with an antiseptic solution of one drop of creasotc 

to each ounce of water on charpie, and the limb was supported by a sand bag on either side. The patient 

reacted well after the operation; but at night there was profuse sweating and some nausea. On the following morning he ate a 

good breakfast. He still had a cool, sweating skin, and his pulse was at 128. He gradually sank, and died from exhaustion on 

August 7, 18o4. The pathological preparation, presented by Dr. Thomson to the Army Medical Museum, is figured by the 

accompanying wood-cut (Fig. 6:1). 

Case 255. — Private Charles C. Cleaver, Co. C, "2d Infantry, aged 18 years, was wounded at the battle of Spottsylvania, 
on May 12, 18iJ4, by a conoidal musket ball, which fractured the neck and trochanters of the right femur. He was transferred to 
Fredericksburg and thence to Belle Plain in a wagon, and thence on a steam hospital transport to Washington. On May 18th 
he arrived at Washington, and was admitted to Judiciary Square Hospital. The soft parts of the upper and 
outer part of the thigh were extensively lacerated, and pus of an ill-conditioned character was burrowing 
in every direction around the wound. The patient's condition was unfavorable; but it was decided that 
excision of the fractured portion of the femur afforded the only prospect of relief. Accordingly, on the 
19th, Assistant Surgeon Alexander Ingram, U. 8. A., proceeded to make a curved incision six inches in 
length, through which the head, neck, and four and a quarter inches of the shaft of the femur were removed. 
Carpie soaked with permanganate of potash was applied to the wound, and tonics and stimulants were 
freely given. Pyaemia supervened, and the patient died on May 2:i, 1804, four days after the operation. 
The pathological specimen, figured in the accompanying wood-cut (FlG. (>4), is in the Surgical Section of 
the Army Medical Museum. 

Cask 25(i. — Private Alexander Ewing, Co. A, 140th Pennsylvania, aged 30 years, was wounded at 
the battle of Spottsylvania, on May 12, 1864, by a conoidal musket ball, which comminuted the upper part 
of the left femur. He was taken to the hospital of the 1st division of the Second Corps, and on the follow- tare of the neck nnd 
ing day was sent to the rear in a wagon. Arriving at Belle Plain after a three-days' journey over rough m OT . Stow. 98&. 
roads, he was conveyed on an hospital steamer to Washington, and, on May 18th, he was admitted to 
Judiciary Square Hospital. There was considerable inflammation and swelling of the soft parts, and the patient was in poor 
health. On the following day he was anaesthetized, and Acting Assistant Surgeon J. F. Thompson made an incision five inches 
in length over the great trochanter, including in it the wound of entrance. The muscular attachments being divided, it was 
found that the neck was splintered, that fissures extended within the capsule, that the great trochanter was separated from the 
shaft, and the upper part of the shaft much comminuted. The head and fragments of the neck and trochanters were removed, 
and the shaft was sawn just below the trochanter minor. Ice was applied to the wound, and stimulants were freely administered. 
The wound assumed an unhealthy action, and the patient gradually sank and died from exhaustion on May 24. 18li4, five days 
after the operation. The pathological specimen was not received at the Army Medical Museum. 

Case 257. — Corporal Henry C. Sennett, Co. F, 122d New York, aged 27 years, was wounded in front of Petersburg. 
March 27, 1835, by a conoidal musket ball, which entered midway between the anterior superior spinous process of the ilium 
and the trochanter major, and lodged in the head of the left femur. The patient was removed to Washington, and, on April 2d. 
was admitted to Mount Pleasant Hospital. He was feverish and fretful, and his tongue was furred; but 
the wound bad a healthy aspect, and there was but little swelling or deformity of the limb. But explo- 
ration with the finger proved that the ball bad penetrated the hip joint. On April 4th the patient being 
anaesthetized by an equal mixture of chloroform and ether, Assistant Surgeon II. Allen, U. S. A., made 
a T-shaped incision, four inches by six inches, over the trochanter major, and excised the head and neck 
of the femur. The head was fractured into three pieces, and the ball was embedded in it. Violent 
hiccough came on immediately after the operation and continued through the night, but was finally 
arrested by the persistent use of antispasmodics. On April 5th and Cth there was great tympanitis, the 
bowels being obstinately constipated. An enema of castor oil was administered without effect, and in 
two hours another of molasses and water and salt, which induced a slight evacuation. Singultus again 
recurred. On April 7th the bowels moved freely. A chill occurred, lasting half an hour. There was 
great abdominal tenderness on pressure, and other well marked symptoms of peritonitis. On the 8th j,, I( . 
the hiccough continued; the abdomen became greatly distended; the countenance became pinched and try of the left femur, from 
ghastly, and the patient died at ten at night. At the autopsy, made twelve hours after death, the lungs conoidal hall in it, has 
were found healthy; the liver greatly hypertrophied; the lower fifth of the ilium inflamed and injected, been excised.— Spec. 103. 
The tissues surrounding the hip joint were in a sloughing condition, and were infiltrated with fetid pus, which had burrowed 
several inches under the gluteal muscles and two inches below the trochanter minor. The acetabulum was denuded and slightly 





110 INJURIES OF THE LOWER EXTREMITIES. |CHAr. x. 

fractured at its upper and posterior border. Two inches of the upper extremity of the shaft of the femur was denuded of peri- 
osteum. The specimen was presented by Dr. Allen to the Army Medical Museum, and is represented in the adjoining wood- 
cut (Fig. 05). The innominate bone was not removed ; but the upper fourth of the femur was sawn off after death, and mounted 
with the excised head to show how completely the injury to the femur was limited to the epiphysis. Had it not been for the 
fracture of the pelvis, it would have been difficult to have found a case better adapted for the operation of primary excision. 

Cask 208. — Private F. Machlin, 1 11th Pennsylvania, a robust man, was wounded at the second battle of Bull Run, 
August 30, 1862. He laid on the field several days, and was then transported thirty miles in a wagon to the Warehouse Hos- 
pital, Georgetown, D. C, where he was received on September 8th. A musket ball had entered the right buttock and emerged 
an inch and a half below and within the anterior superior spinous process of the ilium. The limb was shortened, and the foot was 
everted; any movement gave excessive pain. A thorough examination was made under the influence of chloroform, and showed 
that the neck of the bone was comminuted and the shaft uninjured. The case was considered to be a particularly favorable one 
for the operation of excision of the broken fragments, and the general condition of the patient was such as to offer some hopes 
of its success, and it was determined to do the operation on the following day. But the surgeon in charge of the hospital was 
confined to his bed by illness, and was unable to see the patient for five days. On September 13th the general condition of the 
latter was less favorable. His pulse was 130, quick and weak, and his tongue was dry. He was placed under very careful 
nursing, and beef essence, brandy, eggs, and milk, and other concentrated nourishment and stimulants were administered ad 
libitum. By September 20th this treatment had produced slight improvement, and though he was still in a very unfavorable 
condition for an operation, it was determined, on consultation, that an excision might afford the patient relief from 

©the constant pain he suffered, and that it could not greatly depress him. At noon on September 20th, accordingly 
Assistant Surgeon B. A. Clements, U. S. A., assisted by Dr. George K. Smith, of Brooklyn, and the surgical staff 
of the hospital, performed the operation. An incision five inches in length was made from a point two inches 
behind and an inch below the anterior superior process of the ilium, downward over the prominence of the 
Fig. 66.-Ex- trochanter major. The incision exposed the parts freely, and the muscular insertions being divided, and several 

cised head of small loose fragments of bone removed, the irregular broken extremity of the shaft, at its junction with the neck 

right femnr. ° ° J ' J 

Spec. 329. and the tip of the great trochanter, were excised by a chain saw. The remnant of the capsular ligament and the 

round ligament were now cut, the joint being opened from below and in front with a probe-pointed bistoury. 

A blade of a long bullet forceps was then introduced as a lever and the head was disarticulated by gently prying it out of the 

cotyloid cavity. These steps in the operation were facilitated by rotating the trochanter outward, and by lifting the extensor 

muscles by a metallic retractor. A small vessel was tied at the upper end and another at the lower end of the wound. The 

wound was well washed out by means of a syringe and a few stitches were applied, the middle portion of the wound being left 

open. The limb was suspended in a Smith's anterior wire splint. The patient appeared to rally from the operation satisfactorily. 

At 9 o'clock P. M. he was free from pain; his pulse was 136, and the skin was cool and natural. He had slept tranquilly. On 

the following day, September 21st, his pulse was 120 and very feeble. The discharge from the wound was dark and thin, and 

copious. His countenance was placid, the pinched, distressed expression it had worn having disappeared. But in the afternoon 

he sank rapidly, and died in the evening, thirty-six hours after the operation, September 21, 1862. The specimen is No. 329 

of the Surgical Section of the Army Medical Museum, and is represented in the accompanying wood-cut (Fig. 66). — (Circular 6, 

S. G. O., 1865, p. 64; Circular 2, S. G. O., 1869, pp. 37, 135.) 

Case 259. — Lieutenant D. N. Patterson, 46th Virginia, aged 31 years, was wounded at an engagement on the Boydton 
Plank Road, near Petersburg, March 29, 1865, and was captured and sent to City Point, and immediately conveyed on an 
hospital transport to Washington, and placed in Armory Square Hospital on April 2d. On examination, it was found that a 
conoidal ball had entered the left thigh behind the trochanter major, and had passed inward and forward, fracturing the trochan- 
ter, neck, and head of the femur, and the anterior border of the acetabulum. On the day after the patient's admission, five days 

subsequent to the reception of the injury, Surgeon D. W. Bliss, U. S. V., in charge 
of the hospital, decided that the case was one in which excision of the upper extrem- 
ity of the femur was applicable. The wounded man was anxious that an operation 
should be performed, and his general condition was very satisfactory. On April 3d 
he was placed under the influence of chloroform, and Surgeon Bliss exposed the 
fractured bone by a curvilinear incision with its convexity forward. The shattered 
fragments of the neck were extracted, the rent in the capsular ligament was enlarged 
and the round ligament was divided, and the head of the femur was exarticulated. 
It was found that the ball had not only comminuted the head, neck, and great 
trochanter, but that fissures extended down the shaft of the femur. The bone was 
divided by the chain saw two inches below the trochanter minor. The deep wound 
was now washed out, and small fragments of bone were removed, and search was 
made for the ball. It was finally detected by means of a NeTaton probe deeply 
buried in the obturator muscle near the posterior margin of the obturator foramen. 

The operation was accomplished with little loss of blood, and the patient reacted 
Flo. fi7.— Extensive fracture* of the shaft, tro- r v ' r 

chanters, head, and neck of the left femur, and of satisfactorily. The wound was lightly dressed, sufficient outlet for discharges being 
theosinnominatuin. Spec. 4048. left> fM q^ ]imb WM exten(led aud 8U pp rted by pillows. Careful nursing was 

provided, and such stimulants and concentrated nourishment as seemed best adapted to the patient's condition. For three days 
he progressed very satisfactorily. Notwithstanding the extensive lesions of the pelvis, which were not detected until after 
death, there was no indication of peritonitis or disturbance of the urinary organs. On April 7th, however, profuse haemorrhage 




■Bates (S. P.) {History of Pennsylvania Voluntetrt, 1861-5, Harrisburg, 1869, Vol. I, p. 30) records the name of this patient as Philip Mechling, 
Co. T, lHh Pennsylvania Volunteers. 



SECT. 1 1. 1 



EXCISION AT THE HIP AFTER SHOT INJURY. 



Ill 



took place, which could not be controlled, and the patient died on the morning of that day. At the autopsy it was (build that 
the bleeding had proceeded from the internal iliac vein, gradually worn away by a sharp bit of bone forced inward by the ball. 
The pathological specimen, represented in the adjoining wood-cut (Fig. 67), is also figured at page 246 of the Catalogue of the 
Surgical Section of the Army Medical Museum, where another view is given. 

Case 260. — "I have the honor to report," writes Dr. Hooton, "that I did not take charge of hospital 21 until March 10, 
1833, and did not treat the case referred to. I was somewhat conversant with its history, however, and will give it to you as I 
received it from Surgeon Sennet, 94th Ohio, whom I relieved. The wound was received at the battle of Stone River or 
Murfreesboro', the last of December, 1862, or January 1, 1863. Resection of the upper part of the shaft, including the shattered 
trochanters, was performed on the field. The head of the bone was left in the cotyloid cavity. A few days subsequently the 
patient was sent by rail to Nashville, a distance of twenty miles. Notwithstanding the fatigue of the long journey, his general 
condition was very satisfactory, and the wound looked well. Part of the incision healed; but there was a profuse discharge 
from the lower part, and gradually this discharge became thin and ichorous. About January 21st it was determined to reopen 
the wound. It was found that the head of the bono was carious throughout its whole extent. It was therefore removed. After 
this operation, which was accomplished without haemorrhage or other untoward circumstance, the limb swelled very much, 
irritative fever set in, and the patient died exhausted in a few days." [The records of the hospital identify this patient as 
Sergeant Dallas W. Hade, Co. H, 101st Ohio, wounded at Stone River, December 31, 1862; died January 31, 1863.] 

Of the twenty-two intermediary excisions at the hip, four were on the right side, 
sixteen on the left; in two cases the side of the injury was not reported. A straight 
longitudinal incision was made in nine instances, a curvilinear in seven, a crucial in one, a 
T-shaped in one, and in four operations the mode of incision was not stated. In five 
instances the missile was removed at the time of the operation. Twenty excisions were 
performed by Union surgeons and two by Confederate surgeons. Pathological specimens 
illustrating thirteen of the excisions are preserved in the Army Medical Museum, with 
photographs of the two survivors of intermediary excisions at the hip. 

Table XII. 
Summary of Twenty-two Cases of Intermediary Excision at the Hip Joint for Shot Injury. 



No 



Name, Age, and Military 
Description. 



1 Jarret, J. M., Lieut., C, Oct. 14, 
15th North Carolina, age 28. 1863. 



Date 
op 

INJURY 



1 



2 Wright, H., Pt., G, 8th N. 
Jersey, age 28. 



Boyle, P., Pt., D, 59th Mas- 
sachusetts, age 60. 



Brantley, O. W., Pt., C, 2d 

Alahama, age 18. 



Callaghan, C, Pt., G, 2d 
Delaware. 



Christopher, T. C, Pt., D, 
18th South Carolina, age 

21. 



Cleaver. C. C Pt., C, 2d 
Infantry, age 18. 



May 5, 
1864. 



July 30. 
1864. 



April 9, 
1865. 



Sept, 17. 
1862. 



May 5, 
1862. 



May U 
1864. 



Nature of Injury. 



Left femur shattered nt upper 
third by a conoidal ball. 



Conoidal ball shattered the 
neck and trochanters of right 
femur and lodged, greatly flat- 
tened and distorted, amid the 
fragments of bones. 



Conoidal ball perforated surgi- 
cal neck of the left femur and 
fractured trochanter major. 



Conoidal ball fractured neck of 
left femur ; also fract. of extl . 
condyle hum. 

Comminut'n of left trochanteric 
region, fissures extending up 
neck of femur, by a fragment 
of shell. 

Conoidal ball fractured head 
and neck of left femur and 
lodged in obturator cxtemus 
muscle. 

Neck and trochanters of right 
femur fractured by a conoidal 
.ball. 



Date 

OF 

Opera 

tion. 



Nov. 9, 
1863. 



May 27, 
1864. 



Aug. 5, 
1864. 



April 28, 
1865. 



Sept. 29. 
1862. 



May 20, 
1862. 



May 19 
1864. 



Operation and Operator. 



Result and Remarks. 



Excis'n of head, neck, trochant- 
ers, and a port'n of shaft of left 
femur; several large detached 
fragments and spirilla- rem'd, 
by Surgeon J. 13. Read, P. A. 
C. S.; chloroform ; straight I 
incision seven inches long. 

Head, neck, and both trochant- 
ers of right femur removed 
thro' Btraight incision ; missile 
extracted ; jagged upper ex- 
tremity of shaft turned out 
and smoothed off, by Ass't 
Surg. G. A. Mursick. U. S.V. 

Head, neck, and shaft of left ' 
femur at level of troch minor, I 
excised through straight in- j 
cision, by Ass t Surgeon W. 
Thomson, U. S. A.; ether. 

Head, neck, and trochanters of , 
femur excised, by Surg. A. I 
M. McMahon, U. "S. V. 

Head, neck, and portion of shaft 
of left femur excised, by Ass't 
Surgeon J. H. Bill, U. S. A.; 
curved incision ; shaft divided 
.just below trochanter minor. 

Shattered fragments of head 
and neck of left femur remo'd 
through a curvilinear incision 
four inches long, by Assistant 
Surg. J. S. Billings, U. S. A. 

Head, neck, and four and a 
quarter inches of shaft of right 
femur removed thro' a curved 
incision, by Ass't Surgeon A. 
Ingram, U. S. A. 



September, 1864. Recovered. 



Disch'd October 6, 1864. and pen 
sioned. Spec. 3375, A. M. M. 
Sept. 4, 1873, "Six and a half 
inches shortening." Pensioner 
died October 26, 1874, of heart 
disease. 

Died August 7, 1864, from ex- 
haustion. Spec. 3593, A. SI. M. 
Circ. 0, S. G. O., 1865, p. 70. 
Circ. 2, S. G. O., 1869, pp. 45, 
136. 

Died May 2, 1865, of capillary 
haemorrhage. Circ. 6. S. G. O., 
1865, p. 74. Circ. 2, S. G. O.. 
1869, pp. 47, 136. 

Died October 4, 1862. Spec. 840, 
A. M. M. Circ. 6. S. G. 0.,1865, 
p. 64. Circ. 2, S. G. O., 1669, 
pp. 37, 135. 

Died May 24, 1862. Spec. 19, 
A.M.M. Ci'rc.6,S.G.O., 1865, 
p. 62. Circ. 2, S. G. O., 1869, 
pp 35, 135. 

Died May 23, 1864, of pyaemia. 
Spec. 2819, A. M. M. Circ. 6, 
S. G. O., 1865. p. 66. Circ. 2, 
S. G. O., 1869, pp. 43, 135. 



1 RK.AD (J. B.), Resections of the Hip Joint, in Confederate States Medical and Surgical Jour., 1864, Vol. I, p. 5. Phot. Scr., A. M. M., Vol. I, p. 41 . 
Circular No. C, S. G. O., 1865, p. 06. Circular No. 2, S. G. O., 1869, pp. 39, 135. Eve (P. F.), A Contribution to the History of the Hip Joint Opera- 
tions, etc., in Trans, of tin Am. Med. Association, 1867, Vol. XVIII, p. 256. 

'MunsiCK (G. A.), A Successful Case of Excision of the Head of the Femur for Gunshot Fracture, in New York Med. Jour., 1865, Vol. I, p. 424. 
Circular No. 6, S. G. O., 1865, p. 68. Circular No. 2, S. G. O., 1869, pp. 41, 135. Surgical Photograph Series, A. M. M., Vol. IV, p. 38. 



IN.H'KIKS OK Till-: IAjWKR KXTRKM I TI K 



[CHAP. X. 



15 



L8 



20 



22 



Name, Age, ami Military 
Description. 



En-rag, A., Pt., A. 140tl 
Pennsylvania, ago 30, 



Fovlke, T. /,'.. Pt.. 1>, 2d 
Alabama! age 17. 



Hade, I). \V., Sergeant, H, 

101st Ohio. 



Marston, (*. E.. Pt., F, 1st 
Massachusetts, age 19. 



MachHn, P., Pt., I, 11th 
Pennsylvania. 



Miller, J., Pt., K, 162d N. 
York, age 38. 



Noe, D. M., Pt., C, 46th Ohi- 
age 22. 



Patterson^ D. N., Lieut., 

40th Virginia, age 31. 



Phelan, J., Capt., A, 73d 
New York, age 22. 



Phillips, II., Pt., I, 146th 
New York, age 34. 



Sennett, II. C, Corp'], F, 
122d New York, age 27. 



Smith, Jtf., Pt., F, 38th 
Virginia. 



Unknown soldier of General 
Buell's Army. [Probably 
Corporal II. P. Smith, 12th 
Wisconsin. | 

Unknown soldier, private of 
Gen'l Pope's Army. 



'Welsh, M., Pt., II, 10th 
Kentucky, age 40. 



DATE 

OF 
fKJUUY 



Mav 12 
18(14. 



April 9, 

1865. 



Dee. 31 
1862. 



Aug. 30 
1862. 



Aug. 30. 
1862. 



June 14 
1863. 



April 6 

1802. 



Mar. 29 
1 865. 



May 14. 
1864. 



April I. 
1865. 



Mar. 2' 
1865. 



Mav 10, 

1864. 



Mar. - 
1862. 



Aug. 29 
1862. 



Sept. 20. 
1863. 



Nature ok Injury. 



Conoidal ball splintered neck, 
separated the great trochanter 
from shaft, and comminuted 

upper part of the left femur. 
The fissure extended within 
the capsule. 

Neck, trochanters, and upper 
third of left femur fractured 
by a conoidal ball, which 
lodged above the ant. sup. 
spinous process of the left 
ilium. Missile removed. 

Shot fracture of the trochanters 

of femur; resection of the 

upper part of the shaft and the 
shattered trochanters on the 
field; head of bone left in 
cotyloid cavity. 

Neck of right femur crushed, 
and the head of the bone com- 
minuted by a conoidal ball, 
which lodged in the inner side 
of the thigh. 



Comminution of neck of right 
femur by a musket ball ; fis- 
sure extending into the head 
of the bone. 



Conoidal ball perforated upper 
portion of left thigh, breaking 
the neck offemur transversely 
and splitting it longitudinally, 
but without great comminut n. 

Neck of left femur shattered 
by a coiioidal ball. 



Conoidal ball fractured the tro- 
chanter major, neck, and head 
Of the left lemur, and anterior 
border of the acetabulum ; 
fissures extended down shaft. 
Missile lodged. 

Left trochanter major shattered 
and neck of femur fractured 
to the head by a conoidal ball, 
which lodged ; many fragm'ts 
driven into gluteal muscle. 

Conoidal ball crushed in the 
laminated structure of the an- 
terior surface of neck of left 
femur, where it lodged. Mis- 
sile extracted. 

Left acetabulum fract'd slight- 
ly at its up. and post, border 
by a conoidal ball, which also 
fractured the head of the bone 
and lodged in the same. 

Conoidal ball fractured the 
upper portion of the shaft of 
left femur, passed through the 
perineum without injuring 
the urethra, and through the 
soft parts of the right hip. 

Neck and trochanters of 

femur shattered by a conoidal 
ball. 

Conoidal ball split and commi- 
nuted the left trochanter ma- 
jor and neck of the femur and 
lodged in the latter. 

Conoidal ball fractured the 
neck and head of left femur 
and lodged. Oct. 1st, ball 
removed. 



Opera- 
tion. 



Mav 19, 
1864. 



April 2' 
1865. 



Jan. 21, 
1863. 



Sept. 27, 
1 862. 



Sept. 20 
1862. 



July 8 



April 16, 

1862. 



April 3, 
1865. 



•Tune 3, 
1864. 



April 8. 
1865. 



April 4 
1865. 



May 12 
1864. 



Two 
days 

after in 
jury. 

Sept. 4. 
1862. 



Oct. 3, 

1863. 



< iteration AMI i iterator. 



Removal of the head and frag- 
ments of the neck and tro- 
chanters through an incision 
five inches long, by A. A. 
Surgeon .1. r. Thompson. 

Excision of the head, nek, 
trochanters, and two inches of 
the shaft of femur, by Surg. 
A. M. McMahon, V. s. V. 



On reopening the wound the 
head of the femur was found 
carious throughout its entire 
extent; it was therefore re- 
moved, by Surg. E. Sennet, 
94th Ohio. 

Fragments of neck removed, 
head of hone exartieulated, 
the roughened portion of the 
neck at its attachment with 
the trochanter sawn off with a 
small chain saw. and the mis- 
sile removed with dillieulty at 
the bottom of a large cavity; 
slightly curved incision, by 
Ass't Surgs. B. A. Clements 
andC. II. Alden, U.S.A. 

Loose fragm'ts removed, irreg- 
ular broken extremity of shaft 
excised, and head of bone dis- 
articulated : incis'n live inches 
long; Ass'tSurg. B. A. Clem- 
ents, U. S. A., assisted by Or. 
O. K. Smith, of Brooklyn. 

Ass't Surg. G. W. Avery, 9th 
Conn., excised the head, neck, 
and great trochanter through 
a single straight incision. 

Excision of the head, neck, and 
trochanters, and three inches 
of the shaft of femur; incision 
four inches long, by Surg. G. 
C. Blackman, U. S. V. 

Shattered fragm'ts of the neck 
extracted, head of femur ex- 
articulated, and shaft divided 
two inches below the trochan- 
ter minor, through curvilinear 
incision; missile removed, by 
Surg. 1>. W. Bliss, U. S. V. 

Head of femur exartieulated 
and the fragments of the neck 
and trochanter major remoVd, 
thro' crural incision, bv Ass't 
Surg. C. A. McCalT, U. S. A. 

Head, neck, and trochanter 
major removed through a 
curved incision six or seven 
inches long, bv Ass't Surg. 
W. P. Norris, U. 8. A. 

Head and neck excised thro' 
a T-shaped incision, by Ass't 
Surgeon H. Allen, U. S. A. 



Head. neck, and two inches of 
the shaft of femur excised, by 
Surg. C. B. Gibson, C. S. A. 



Head and splintered upper ex- 
tremity of femur remov'd thro' 
a long Straight incision, by 
Surg. A. H. Thurston. U. S. V. 

Head and fragments of neck of 
the femur removed: the shaft 
of femur was then divided at 
the level of trochanter minor, 
straight incision, by Assistant 
Surg. J. S. Billings. U. S. A. 

Head of femur excised, together 
with the attached greater por- 
tion of the lower surface of 
the neck of the bone, fragments 
removed and remaining sharp 
portions of neck trimmed off; 
Surg. F. H. Gross, U. S. V. 



Result and Remarks. 



I tied May 24, 1864, from exhaus- 
tion. Circ. 6, S. G. O., 1865, p. 
C^. Circ. 2, S. G. O., 1869, pp. 
43, 135. 

Died June 5, 1865, from exhaus- 
tion. Circ. 6. S. G. O.. 1865. p. 
74 Circ. 2, S.G.O., 1869, pp. 
At i ■)*: 



Died Jamuuy 31, 1863. from ex- 
haustion. CtYc.2, S. G. O., 186!.), 
pp. 38, 135. 



Died Sept. 30, 1862. Spec. 328, 
A . M . M . Circ. 6, S . G . O . , 1 865, 
p. 64. Circ. 2, S. G. O., 1869, 
pp. 36, 135. 



Died Sept. 21, 1862. Spec. 329, 
A.M.M. Circ. 6, S.G.O., 1865, 
p. 64. Circ. 2, S. G. O.. 1869, 
pp. 37, 135. 



Died Sept. 21 , 1863, from exhaus- 
tion. Circ. 2, S. G. O., 1869, 
pp. 38, 135. 



Died April 24, 1862, of pya?mia. 
Circ. 2, S. G. O., 1869, pp. 34, 
135. 



Died April 7, 1865, from haemor- 
rhage. Spec. 4048, A. M. M. 
Circ. 6, S. G. O., 1865, p. 72. 
Circ. 2, S. G. O., 1869, pp. 45, 
136. 

Died .Tune21, 1864, from diarrhcea. 
Spec. 2618, A. M. M. Circ. 6, 
S. G. O., 1865, p. 68. CHre.% 
S. G. O., 1869, pp. 44, 136. 



Died April 21, 1865. Autopsy: 
Pleurisy on either side ; large 
subperiosteal abscesses. Spec. 
3235, A.M.M. Circ. 6, S.G.O., 
1865, p. 72. Circ. 2, S. G. O., 
1869, pp. 47, 136. 

Died April 8, 1865, from peri- 
tonitis. Spec. 153, A. M. M. 
Circ. 6, 8. G. O., 1865, p. 72. 
Circ. 2, S. G. O., 1869, pp. 46, 
136. 

Died May 13, 1864. Spec. 5500, 
A.M.M. t'irc.2, S.G.O., 1869, 
pp. 43, 135. 



Died one week afteroperat'n, from 
surgical fever and suppuration. 
Circ. 6.S.G.O., 1865, p.62. Circ. 
2, S. G. O., 1869, pp. 34, 135. 

Died Sept. 24, 1862, from exhaus- 
tion. Circ. 6, S. G. O.. 1865, p. 
64. Circ. 2, S. G. O-, 1869, pp. 
36, 135. 



Died October 25, 1863. Spec. 
5442, A. M. M. 



1 GROSS (S. W.), Head of the Thigh Bone removed by Excision on account of Gunshot Injury, in Am. Jour. Med. Srf., 1868, Vol. LV, p. 410. 
Oris (G. A.), Observations on some Recent Contributions to the Statistics of Excisions and Amputations at the Hip for Injury, in Am. Jour. Med. Sci.* 
1868, Vol. LVI, p. 130. Circular No. 2, S- G. O., 1869, pp. 39, 135. 



sect, ii.; 



EXCISION AT THE HIP AFTEE SHOT INJURY. 



113 



Secondary Excisions. — Thero wore reported eleven secondary excisions at the hip 
practised on nine Union and two Confederate soldiers, resulting in three recoveries and 
eight deaths, a mortality rate of 72.7 per cent, 1 The shortest interval between the recep- 
tion of the injury and the operation was thirty-one days, and the longest eight years and 
four months. Two of the survivors of secondary excision at the hip are still pensioners in 
comparatively good health, at a period remote from the date of operation. 

Case 261. — Private Joseph Brown, Co. I, 3d Michigan, aged 38 years, was wounded at the second battle of Bull Run, 
August 29, 1832, by a musket ball, which passed through the left thigh, fracturing the femur just below the trochanter minor, 
lie laid on the battle field three days, and was then removed to Centreville. On September 11, 18G2, he was admitted to 
Fairfax Seminary Hospital, near Alexandria. The limb was kept in position by appropriate apparatus; but suppuration was 
profuse, and, on two occasions, fragments of bono were removed from the wound. Early in March, 1833, there was great 
swelling of the thigh, the discharge became scanty and fetid, and pus burrowed amid the muscles. On March '-1st, an explo- 
ratory incision was made from three inches above to five inches below the prominence of the great trochanter. The neck and 
upper extremity of the shaft of the femur were found to be extensively diseased, and excision was decided on. Surgeon D. P. 
Smith, U. S. V., performed the operation. Difficulty was experienced in separating the mus- 
cular attachments from the trochanters, on account of the foliaceous masses of callus that had 
been thrown out. When this dissection was accomplished, many necrosed fragments were 
extracted, and the periosteum and now bone were separated by the handle of the scalpel and 
preserved as far as practicable. The shaft of the femur was then divided by powerful cutting 
bone forceps, about six inches below the tip of the great trochanter. A screw was driven into 
the mass of callus, below the trochanters, to be used as a lever in disarticulating the head, but 
it would not hold, and the bone was seized with large forceps and rotated, so as to facilitate 
the division of the capsular and round ligaments. The head, neck, and trochanters, and the 
masses of callus adhering to the trochanters, were then removed. The operation was accom- 
plished with but very trifling haemorrhage, yet great prostration followed, and the patient 
rallied slowly. As the anaesthesia passed off, he had much nausea and vomiting. As soon as 
this subsided, he was given a very full allowance of concentrated nourishment, such as strong 
beef-tea, eggs, milk, etc, with half an ounce of brandy every two hours. The wound was par- 
tially closed; the limb was supported on pillows until the third day, when it was dressed in a 
Smith's anterior splint. About forty-eight hours after the operation, an erysipelatous blush 

pervaded the limb, and the constitutional symptoms assumed a typhoid 

character. A female catheter was passed through the middle of (he 

wound and another at its lower extremity, through which much offensive 

decomposed serum and grumous blood escaped. The wound was 

thoroughly washed out through the catheters with warm water impreg- 
nated with chlorinated soda. On the fifth day there was a rigor, and 

haemorrhage to the extent of six ounces. As the anterior splint did not 

permit convenient access to the limb, it was removed, and the leg and 

thigh were suspended in a canvas hammock, the leg being horizontal 

A piece of soft toweling 

femur, with foliaceous extending from the perineum to the popliteal space, and, connected by 
callus. Spec. 11 S3. .75 ■ , , , , J I , , f , , , 

cords with an upright post at the head of the bed, supported the muscles 

on the sides and under surface of the thigh. The wound freely discharged synovia, bloody serum, and thin pus, until the seventh 
day, when healthy suppuration was fairly established. During April, 1863, the patient's progress was satisfactory. He was 
supplied with very nutritious diet, with porter, and cod-liver oil. He took for a time as much as a half a pint of oil daily. 
During May, the case continued to progress favorably. It was necessary to keep a tube in the wound until June 1st. Pre- 
viously, whenever it was removed pus would accumulate and burrow. A mesh of suture wire was finally substituted for the 
tube. This was retained until June 20th, when the patient began to get about on crutches. In the latter part of July the wounds 
closed. In August, Brown was reported as "well," and on August 23, 1833, he was discharged from the hospital and from 
the military service of the United States. On March 21, 1831, he wrote from his homo in Coopersville, Michigan, that his health 
was good; that he could get about and attend to home business ; could saw and split a little wood for fuel, though his knee was 
stiff and his leg painful. On the whole, there had been steady improvement, In September, 1835, he again wrote, and stated 
that his general health was good; that he had some control over the movements of the thigh, being able, when standing on the 
right foot, to swing the left backward and forward, and to adduct the thigh enough to carry the injured limb across the other. 
He could bear some weight on the limb, and use but one crutch, with a stirrup for the foot. There had been no fistulous orifices 
since March 1834, and there was no soreness about the cicatrices. In November, 1835, in accordance with a request from the 
Surgeon General's Office, Mr. Brown had a photograph (FIG. 69) taken to represent the amount of deformity in his limb. This 
picture is numbered 110 in the Photograph Series of the Army Medical Museum. It is carefully copied in the accompanying 
wood-cut. The excised bone is preserved at the Museum, and is numbered 11D2. Section I. It is represented in the adjacent 
wood-cut (Fig. 68). On February 12, 1868, he wrote to the compiler of this report : " I take pleasure in informing you that my 

1 Besides the nine cases recorded in the Report on Excisionx of the Hrad of the Femur for Gunthot Injury, S. G. O., 1869, a successful example has 
been reported by Dr. E. STKltLINO, of Cleveland, Ohio, and another successful operation was performed in 1871, by Dr. J. Ii. BlGKLOW of Indianapolis. 

Surg. HI— 15 




and I Tru?han" e r a s d of Teft aud the thi S h '" an almost vertical position 




Flo. 09. — Appearance of limb three 
years after the operation. [From a 
photograph.] 



114 [NJURIES OF THE LOWER EXTREMITIES. |CHAP. s. 

limb is in as good condition as when I lust wrote von ; but think there is no improvement, except that it is not as tender. There 
have been no abscesses, nor any pain in the limb, excepting slight pains about the knee, just before storms About two years 
ago, I slipped and fell upon the ice, injuring the limb severely about the knee, and was thereby confined to the house for about, 
three weeks. In March last I had a severe attack of ague. The limb swelled quite badly at this time, and was much inflamed for 
about ten days. I applied cold water and a bandage to reduce the swelling. I had to keep it bandaged about two weeks after 
the inflammation was removed. Since that time the limb has given me no more trouble than usual. Since I was discharged J 
cannot see that there is any lengthening of the limb. I have to use a crutch and cane all the time when moving about, and 1 
think I shall always have to do this. The injured limb has wasted away somewhat since I last wrote. The circumference of 
the well limb at the upper extremity is 22 inches, and the injured limb measures at the same place 19.} inches. The knee of the 
well limb measures around the centre of the knee-pan 15J inches; the injured limb measures at the same place 17 inches. The 
above measurements were made in the evening; 1 think that in the morning the measurements of the injured limb would be 
less. The knee still remains quite stiff, and gives me about all the pain there is anywhere in the limb. 1 have been troubled 
during cold weather by coldness of the outer side of the leg, and I have to warm it, by the fire before going to bed nearly every 
night when I have been out." On November 19, 1863, another letter was received from Mr. Brown, from which the following 
extract is made: "I take pleasure in informing you that my limb is in as good condition as it has been at any time since it was 
entirely healed, and, if anything, in better condition. It does not pain me about the knee as much as it did one year ago. It 
does not have any spell of swelling at the knee as it did for the first two years after my discharge, and there is less soreness 
about the limb than there was even one year ago. I can get around without hurting it as much as formerly. I can bear some 
weight upon it. I have walked across a room without the aid of crutch or cane, by stepping very quick with the well limb; 
but it is more like hopping than walking. There have been no abscesses in the limit I think that it is gradually improving, and 
hope that I may yet see the day that I can go without a crutch. My general health is good. I have not been sick a day for a 
year and a half, and then only a few days with ague. My weight now is 1G7-J pounds. Before I entered the army my weight 
was never quite up to those figures, but within a few pounds of it. I have been postmaster at this office over a year, and have 
attended to all the business of the office almost entirely without assistance, and it gives me pretty good exercise." On Septem- 
ber 0, 187o, the date of his last examination for pension, the Grand Rapids Examining Board stated: "There is now a false 
joint with shortening of the limb." Since then this pensioner has been exempted from further surgical examinations. He was 
paid September 4, 1877, remaining in comparatively good health more than fourteen years after the operation. 

The next successful secondary excision at the hip after .shot injury was tiot identified 
at the Surgeon General's Office until alter the puhlication of Circular 2, in 1869. 

Case 26i. — G. W. Tilliston, Co. D, 1st Ohio Artillery, aged 44 years, was wounded at Laurel Hill, July 7, 1801, by a 
rifle ball, which entered the right groin, passing backward through the neck of the femur and lodging in the large muscles of 
the buttock. Two weeks after the reception of the injury he was mustered out by reason of expiration of service, and subse- 
quently he was admitted on the Pension Rolls. Dr. E. Sterling, of Cleveland, who was the regimental surgeon and treated the 
wounded man in the field, subsequently certified to the nature of the injury and reported the following: "Extraction of the 
ball was impossible. The wound was dressed, and within a few days the patient was removed to his home iu Cleveland. On 
or about the 20th of September following it became necessary to remove that portion of the bone traversed by 
the ball, and I performed the operation of excision at the hip joint." Examiner J. Laisy, of Cleveland, on 
July 17, 1857, certified to resection of the head and part of the neck of the femur, and stated: "A fistulous 
opening has formed six inches below the anterior superior spinous process of the ilium, which is keeping up 
a constant and profuse discharge of purulent matter. The right leg, in consequence of the operation, is short- 
Fio. 7o'— Shat- enu d about three inches. He is unable to bear any weight on the injured limb, and obliged to walk on crutches." 

tcrcd head of right Two years later, in August, 1809, the excised head of the femur,, represented in the wood-cut (Fig. 70), was 

lemur. Spec.oo'JO. - _ -- , , i i i -i -i i » £ i . ,. , , , -, 

transmitted to the Museum by the operator, who deplored the loss <>t the other portion ot the resected bone, and 

described the case as being attended with "perfect recovery and a good limb, the pensioner being able to go up and down stairs 

with ease."' Dr. N. M. Jones, attending physician of the pensioner, certified that he died September 0, 1871, and added that a 

post-mortem examination, held by himself, revealed "extensive necrosis of the upper third of the femur * * * an d f the 

ilium, having entirely destroyed the acetabulum and penetrated the pelvis." He also stated that he found an enormous abscess 

covering the entire right ilium and sacrum. 

The third successful secondary excision at the hip was practised, in 1871, for ostitis 
and coxitis, eight years and four months subsequent to the reception of the shot injury. 

Case 283. — Private T. W. Pease, Co. II, 19th Indiana, aged 26 years, was wounded at Gettysburg, July 1, 1863, by a 
conical musket ball, which entered the anterior aspect of the right thigh three inches below Poupart's ligament, passed back- 
ward and outward, and lodged just behind the trochanter major, having fractured the upper third of the femur and passed 
through the trochanter. The wounded man remained for several months at a Corps hospital at Gettysburg, where merely a 
"shot wound of right thigh" was noted, but no progress of the case recorded. According to his statement, the missile was 
extracted by incision three days after the injury, and on July 9th, while under the influence of ether, nearly three inches of bone 
was removed in fragments. Extension and counter-extension were applied, but the latter caused so much pain that it was discon- 

1 Professor II. CulrertsOX, M. D. (Excision of the Larger Joints of the Extremities, Prizo Essay, Trans. Am. Med. Assoc.. Vol. XXVII, Supple- 
ment, 1876, pp. 5 and 50), reports this operation as practised "August 20, 1861," which would make it the first excision at the hip after shot injury 
performed in tho United States, tho primary excision practised by Professor Blackman, on Private J. McCulloch (Case 230, p. D7, ante) having been 
done August 30, 1861. Dr. E. Sterling in his letter transmitting the specimen (3590) also asserts that his excision of the head of the femur in Tilliston's 
case was the first during tho war. Pension Examiner LAISY also states that the patient was wounded July 7, 1861, and that resection was performed six 
weeks afterwards; but, in bis official report to the Pension Office, Dr. STERLING states that the operation was performed " on or about the 20th of September." 




SECT. II. J 



EXCISION AT THE HIP AFTER SHOT INJURY. 



115 



tinued at the end of twenty-four hours. Smith's anterior splints were applied on July 20th, and cold-water dressings were used. 
The patient also stated that the limb was swollen and painful, the discharge of pus profuse, and his general health bad. For 
the first two weeks he suffered from constipation, after which, having taken a laxative, diarrhoea set in and troubled him, with 
short intermissions, for about three months. . The records of Camp Lettcrman Hospital show that the patient was admitted there 
on September 5th, also that Acting Assistant Surgeon E. A. Koerper took charge of the case on October 6th, who opened a large 
abscess on the inner side of the thigh on November 3d, and removed the splints several days afterwards, the fracture having 
become united and the patient's health improved. The subsequent progress of the case was recorded by Acting Assistant Surgeon 

11. L. Smyser, at the York Hospital, where the patient was transferred on November 14th. The wound of entrance and exit 
at that time had closed, but there was still discharge from an opening on the middle and external part of the thigh, and the 
limb was swollen and curved outward, with three inches shortening. After this a steady improvement followed until January 

12, 1334, when the patient was seized with a chill, followed by fever, and a deep seated abscess began to form on the anterior 
part of the thigh, which was opened four days afterwards. Abscesses continued to form at intervals and suppuration was more 
or less constant, causing the cicatrices of the wound to be reopened. On February 29th, symptoms of tetanus appeared, being 
exhibited by stiffness of the muscles of the neck and inability of the patient to open his mouth more than half an inch. This 
attack was subdued, by the administration of pills of camphor and opium, after several days' duration, and during the succeed- 
ing night and morning it was followed by an almost constant hiccough, after which another attack of diarrhoea came on. In 
April following the wound had again healed, and the patient had so far amended as not to require any more medicine. On July 
3d, he was able to walk about on crutches for the first time. His term of service having expired, he was mustered out August 
8, 1834, and pensioned. Examiner (}. YV. Clippinger, of Indianapolis, certified, October 17, 1833: 

* * * "Almost total anchylosis of knee joint, with foot turned inward at the toes; extensive 
necrosis of entire shaft of bone, with discharge at three points. * * * Discharge offensive and 
exhaustive. Is feeble and emaciated, has frequent night sweats, and requires constant aid and 
attendance." Dr. A. L. Lowell, of the Pension Office, who made a special examination of the pen- 
sioner on July 20, 1838, reported the following: * * * "The wound is still discharging from 
its anterior opening and the process of exfoliation is still progressive. The eoxofemoral articulation 
is firmly fixed and immovable. * * * The subject travels with the assistance of crutches. II is 
general health is good." Dr. J. K. Bigelow, attending physician of the pensioner and late Surgeon 
of the 8th Indiana, reported that he, being aided by Surgeon J. S. Bobbs, "on September 2, 1808, 
removed ten and a half inches of the necrosed shaft of the femur, said necrosed hone having kept 
up a constant and exhaustive discharge from three or four large sinuses at various places along the 
inner and posterior part of the thigh," etc. The Indianapolis Examining Board certified, February 
8, 1870: "The pensioner is very obnoxious to erysipelas, which frequently causes large inguinal and 
popliteal abscesses," etc. Two years afterwards the same Board reported that "the operation for 
removal of necrosed bone two years ago, apparently resulted in good recovery. * * One year 
after said operation erysipelas of the limb, with ulceration, etc., again ensued, and on October 20, 
1871, he was again attacked with large abscesses, and several sinuses made their appearance. Upon 
careful examination it was found that the new bone was necrosed and 
necessitated coxo-femoral exsection, which was performed on the 8th of 
November, 1871. There is ten inches shortening. He requires the con- 
stant attention of a nurse," etc. In a report recapitulating the history 
of this case, transmitted by Dr. Bigelow, in September, 1877, he describes 
the operation of exsection as follows: "While under the influence of 
chloroform, an incision was made from the middle of the dorsum of the 
right ilium down the outer aspect of the thigh to within two inches of 
the knee joint. The femur was exposed and divided five inches below 
the trochanter with Hoy's saw, and on account of the extensive perfora- 
tions of the muscles surrounding the bone by osteophytes (Fig. 71) the 
epiphysis was with difficulty and considerable hemorrhage, enucleated 
and unjointed from the acetabulum. It was found to consist of a very 
large dead involucrum, filled in all its aspects with sharp projecting spicule. A portion of the leaden ball was found embedded 
in the cancellous structure near the trochanter. The wound healed kindly, and was entirely closed in twenty-eight days. In 
three months a cartilaginous union had taken place, and now— -in September, 1877 — with the assistance of a ' six-inch lift' on 
the right boot the man can walk quite well with a cane, having nearly a perfect arthrodial joint at the hip, and being able to 
attend to the ordinary duties of a Deputy United States Marshal." In 1873, in visiting the Surgeon General's Office, Dr. J. K. 
Bigelow contributed a photograph of the excised epiphysis, which is copied in t lie wood-cut (Fig. 71). In 1877, Dr. Bigelow 
contributed to the Museum another photograph representing the cicatrix and appearance of the injured limb, which is copied in 
the right hand wood-cut (Fig. 72). This pensioner was paid September 4, 1877. 

The number of patients who survive shot injuries involving the hip joint until the 
secondary period without operative interference is small ; but such cases may be regarded 
in reference to their ability to sustain excisions as becoming analogous to the subjects of 
excisions at the hip for pathological causes. Now we learn from the experience of civil 
practitioners that excisions at the hip for disease have a mortality rate in children aver- 
aging perhaps below 45 per cent., yet in adults of the military age rising to an average 




FIG. 71. — Shot fracture of tro- 
chanter major of right femur. 
[From a photograph furnished 
by Dr. Bigelow.] 




Fig. ~~. — Appearance of the 
limb six years after the opera- 
tion. [From a photograph.] 



116 



INJURIES OF THE LOWER EXTREMITIES. 



[CHAP. X. 



of over 60 percent. It is found on examination, that, as might be anticipated, the second- 
ary excisions at the hip for traumatic effuse attain a mortality rate approximating that of 
excisions for disease in adults of about the same age. The three survivors of secondary 
excisions at the hip after shot injury were robust mature men of 26, 34, and 44 years of 
age. In the eight unsuccessful cases the ages varied from 18 to 43 years. In seven of 
the eight unsuccessful operations the patients succumbed in from one to eight days from 
the dates of operation, a mean of a little over four days, while the eighth lived over a 
hundred days after the operation, and succumbed apparently to unfavorable climatic influ- 
ences and only in part to traumatic causes. 

Cash 264. — Private Hugh Fiain, Co. G, 31st Massachusetts, aged 22 years, was wounded February 1. 1865, by a 
conoidal musket ball, which entered the anterior surface of the middle third of the left thigh, ranging upward, and making its 
exit above the left gluteus, fracturing the neck of the femur in its course, lie was on horseback, his regiment serving at the 
time as mounted infantry. He was treated in the regimental hospital for several days, and then, on February 13th, he was 
admitted to the St. Louis Hospital, at New Orleans. When admitted, he stated that the surgeon of his regiment had given him 
chloroform, and examined the wound, and that the bone was not touched. He had walked upon the limb, and there was then 
no evidence of fracture. His general health became poor. He had night sweats. His tongue was cleun and moist, and his 
appetite was good. The whole thigh gradually became dissected with pus of an unhealthy character. Abscesses discharged 
through fistulous openings in the groin. The limb was inverted and shortened, and was drawn over to the right. It was 
decided that an excision of the head of ihe femur was expedient. On March 24th, Surgeon A. McMahon, IT. S. V., proceeded 
to perform the operation. An incision four inches in length was made over the great trochanter, the soft part..; were dissected 
up, and the femur was divided by the chain saw just below the trochanter minor. The ligameutum teres was softened, and the 
head of the femur was removed without difficulty. The wound was filled with lint, and the patient was ordered porter, chicken 
broth, eggs, stimulants, and everything necessary to sustain the drain upon his system. He felt easier for a few days after the 
operation, but he gradually sank, becoming very much emaciated, and died March 30, 1885, six days after the operation. The 
ball had injured the neck of the femur, and the subsequent caries had caused the destruction of the head and the disorganisation 
of the surrounding tissues. 

Case 2,>5. — Private Edward Hunt, Co. D. 71st Pennsylvania, aged 24 years, was wounded at the battle of Antietam, 
September 17, 1863, by a conoidal musket ball, which entered about two and a half inches above the trochanter major, and 
grazing the neck of the right femur, passed out at the nates. Shortening and eversiou were not present, and it was thought 
that there was not a complete fracture. After the battle, he was removed to a barn near the battle-field, where he was treated 
with cold-water dressings for eleven days. He was then removed to the City Hotel at Frederick, 
Maryland, and the cold applications were continued up to November 19th. During this period the 
wound was discharging healthy pus profusely. As pus was burrowing in the muscles, a seton was 
run through the wound and six inches down the thigh. On November 19th, he was removed to Jail 
Street Hospital, and about the last of December he was transferred to the U. S. Hotel Hospital, and 
thence, on January 20, 1833, to hospital No. 5, at Frederick, Maryland. On January 31st, an 
abscess formed on the anterior internal aspect of the thigh, which was opened, and discharged nearly 
a quart of laudable pus in twenty-four hours. On February 2d, the opening on the posterior aspect 
of the thigh was enlarged and the wound syringed out with warm water. Erysipelas attacked the 
wound, but it was not of an intense character, and by February 10th, it had subsided, and the patient 
was in good condition comparatively. On February 23d, he had become more emaciated and had 
night sweats, but his strength continued good. • On exploring for the ball with the finger, in the 
opening on the inner, side of the thigh, a round, smooth surface was felt, which was thought at first 
to be a piece of a conoidal ball, but was ascertained to be the head of the femur just outside of the 
acetabulum. Excision of the hip joint was now decided upon, and Assistant Surgeon Henry A. 
Dubois, U. S. A., operated, the patient being under chloroform, by enlarging the opening on the 
inner side of the thigh, cutting the capsular ligament, and removing the head of the femur. The 
Heck was divided by the lion-jawed cutting forceps. A small quantity of pus was found behind the head of the bone. But 
very little blood was lost during the operation, and the patient rallied partially, but he never fully recovered from the shock, 
and died February 25, 1833, two days after the operation. At the autopsy the neck of the femur was found rounded off, and 
formed a false centre of motion on the inner side of the acetabulum. The rounded extremity of the neck and the acetabulum 
were carious. The cut (FlG. 73) imperfectly represents the specimen, which was sent to the Army Medical Museum. 

Case 266. — Ensign TV. J. Henry, 21st Mississippi, aged 22 years, was wounded near Petersburg, on June 21, 1864, by 
a conoidal musket ball, which entered the upper third of the left thigh anteriorly and made its exit at the opposite side of the 
limb, having badly comminuted the femur, without injuring the principal vessels or nerves. The wounded man was conveyed 
to Richmond, and was admitted to hospital No. 4, on June 28th. The injured limb was suspended by Smith's anterior splint, 
the wound was dressed with water dressings, a nourishing diet was ordered, with an opiate at bed-time. Under this treatment 
the case progressed satisfactorily until August 2d, when the copious suppuration and wasting of the patient excited so much 
anxiety that a consultation was held, at which Surgeons C. B. Gibson, M. Michel, and J. B. Read assisted. After a careful 
exploration of the injury under chloroform, it was decided that an excision of the upper extremity of the femur was expedient, 
and the operation was at once performed by Surgeon J. B. Read, P. A. C. S. An incision seven inches in length was made, 




FIG. 73. — Caries of the ace- 
tabulum, neck, and trochanters 
of the right femur, following 
an excision for shot fracture. 
Spec. 3907. J 



SECT. ii. J EXCISION AT TIIF, HIP AFTER SHOT INJURY. 117 

commencing above the trochanter anil curried downward In the axis of the thigh. The joint was opened and the head of the 
hone oxarticulatod. The shaft was sawn below the trochanter minor, about six inches of the hone being removed. The wound 
being thoroughly cleansed, was approximated and kept in position by sutures and adhesive strips. A lung straight splint was 
then applied on the outside of the limb. An ounce of brandy and thirty drops of tincture of opium was ordered to be admin- 
istered every hour until reaction should be fully established. August 3d, the patient had reacted and had passed a comfortable 
night. The pulse was at 13(3; there was no pain, except in the left knee, which was swollen, but without increased heat or 
redness. The appetite was poor but improving. A nourishing diet was directed, and half an ounce of brandy every two hours 
with a grain of opium every three hours. 4th, the patient had rested well, had a good appetite, the tongue was clean, the skin 
moist, the bowels had been moved naturally, the pulse was at 12'J, the countenance was cheerful. The treatment was continued 
with the addition of porter thrice daily. 5th, the pulse was stronger at 120, the countenance was cheerful ; the treatment was 
continued. Cth, the patient was reported to have passed a bad night. He complained of acute pain in his left knee and in the 
right side of his chest. The pulse was 133 and weak. Incipient pneumonia was detected in the right lung. He had vomited 
the porter, and it was discontinued; the brandy and opium were continued as before. The wound was suppurating profusely. 
The sutures were clipped, and the wound was kept together by adhesive strips. The bowels were constipated. An enema of 
warm soap and water was administered, which procured a normal dejection in a few hours. Sinapisms were applied to the chest. 
7th, he had rested tolerably well, but breathed badly. He was sweating profusely, and complained of much pain in the chest. 
The pulse was at 140, and was very weak. He was ordered an ounce of brandy every hour and a grain of opium ever3' four 
hours. 8th, he was reported as having passed a very restless night. He was too weak to expectorate; the pulse was very 
feeble at 148. He was evidently sinking. He died at 3 o'clock P. M., August 8, 1834, six days after the operation, and forty- 
nine days from the reception of the injury. The report gives no account of the post-mortem appearances. 

Case 2G7. — Private John W. Nelling, Co. K, 1st Massachusetts, aged 25 years, was wounded on June 30, 1862, at the 
engagement at White Oak Swamp, by a musket ball, which entered his right groin, passed horizontally backward, comminuted 
the neck of the femur, and emerged posteriorly. He was abandoned with other wounded in the retreat of General McClellan's 
army. Being made a prisoner, he was confined in Richmond for three weeks, and was then released and sent by water to 
Baltimore, where he was admitted to the National Hospital, on July 25th, in a very depressed condition. There was copious 
suppuration, and through the large orifices of entrance and exit it was easy to explore the extent of the injury to the bone, and 
to determine that the comminution was limited to the epiphysis. It was deemed advisable to excise the shattered extremity of 
the bone as soon as the patient could acquire, by a tonic treatment, strength to undergo such an operation. In a few weeks his 
general condition was much improved, though he was still anaemic and feeble. On August 21st, Assistant Surgeon Roberts 
Bartholow, U. S. A., in charge of the hospital, proceeded to perform the operation. The patient being placed under chloroform, 
Dr. Bartholow made a vertical incision, commencing a little above and behind the great trochanter, continued downward into 
the axis of the limb four inches, and carried it down to the bone. The head of the femur was found to be entirely separated 
from the neck, and was retained in the acetabulum only by the round ligament. 
This was divided, and the head was removed. Several necrosed fragments were 
then extracted, and the jagged extremity of the neck was smoothed by an osteo- 
tome. But little blood was lost in the operation, and the patient rallied promptly 
from the effects of the anaesthetic. After he was put to bed, the limb was 

suspended by Smith's anterior splint, and (lie patient's condition was rendered ^Kf^fijplS* *^ 

comparatively comfortable. The case progressed favorably ami without an ^B^s*flgEP^ ■ l >^* 

untoward symptom till the afternoon of August 25th, when a sudden and very "^■iw-^p- 

,*,,,,,,„ , . „. . . , , , ,, Fig. 74.— Head urnl fragments of the neck of right 

profuse gush ot dark blood from the wound of incision and the entrance bullet femur, excised for gunshot fracture. Spec. 400, Sect. 

wound took place, and the patient expired before the haemorrhage could be con- '• A ' M- JI - * 

trolled. At the post-mortem examination, the soft parts in the vicinity of the wound were found to be in a softened and semi- 
gangrenous condition. The end of the excised neck was denuded of periosteum and was necrosed. The external iliac and 
femoral arteries were traced some distance above and below Poupart's ligament, and were found to be in a normal condition. 
The femoral vein was softened, and near the track of the ball appeared to be broken down so as not to be distinguished from the 
surrounding tissues. A quantity of dark fluid blood was found under the integuments. The excised head and neck were 
deposited in the Army Medical Museum by the operator, and are represented in the cut (FlG. 74). 

Case 2C8. — Private Joseph Roth, Co. B, 188th New York, aged 25 years, a large robust man, was wounded in the 
engagement at Hatcher's Rim, near Petersburg, on February C, 18C5, by a round musket ball, which entered a little below 
Poupart's ligament, an inch external to the course of the vessels, and lodged in the neighborhood of the hip joint. He was 
received at the field hospital of the 1st division of the Fifth Corps, and thence conveyed to the base hospital at City Point, and, 
as there was no pain or deformity, the case was regarded and treated aa a flesh wound, and a week subsequently the patient 
was sent in the hospital transport steamer State of Maine to the General Hospital at Point Lookout. After a short time, Roth 
began to complain of great pain in the knee and leg of the wounded limb, which aroused suspicion that the hip joint was impli- 
cated. The symptoms becoming aggravated, and pointing clearly to some injury of the joint, Surgeon John Vansant, U. S. A., 
in charge of the hospital, determined to make an exploratory incision, and to ascertain the true condition of things. The patient 
being anaesthetized by a mixture of chloroform and ether on March 9th, an incision was made, commencing at the wound of 
entrance, and continued downward three inches or more. The ball was now found impacted in the head of the femur, the 
anterior part of wdiich was shattered, while the posterior two-thirds of the head was intact. The muscular attachments being 
divided, and the capsular ligament freely opened, the round ligament was severed, and the head was exarticulated. A chain saw 
was then passed around the neck, which was divided near to the head, and the latter, with the ball inserted in it, was removed. 
Some sharp projecting portions of the neck were smoothed off with bone forceps. There was very little haemorrhage. The 
wound was drawn together and treated by water dressings, and the limb was kept in suitable position by pads and pillows. 
The patient seemed to do well for several weeks, but gradually became feeble and emaciated, losing all appetite. There was 





118 



IX.TUPJES OF THE LOWF.R EXTREMITIES. 



[CIIAIV X. 



but a slight discharge. In May. the patient became quite yellow, and apparently suffered from malarial complications. In spite 
of a careful tonic and sustaining regimen, mid the bracing, wholesome salt air of Point Lookout, lie gradually declined, and 
died June 17, 18!i5. The pathological specimen was not forwarded to the Museum, and no account of an autopsy was rendered. 
an annoying omission, since it would have been interesting to have learned what reparative action had taken place during the 
throe months after the operation which this patient survived. 

Case 209. — Private Alfred Toney, Co. A, loth North Carolina, aged 4.i years, a farmer by profession, was wounded 
June 30, 1803, and admitted to hospital No. 4, Richmond, on the same day. A conoidal musket ball had entered the left buttock 
and lodged. No particular attention was called to this case for some time. The patient seemed to be doing well. On August 
11th, however, he complained of great pain in the knee and ankle; the slightest touch caused great anguish. The foot was 
oedematous. Chloroform was administered, and digital examination of the wound was made. The finger could pass but half 
an inch into the wound until the limb was carried forward; it then could he passed into the cotyloid cavity, and the ball was found 
in the acetabulum. The round ligament was severed and the head of the femur was ascertained to be slightly fractured ami 
deprived of its cartilage. Excision of the head of the femur was decided upon, and on August 12th, Surgeon James 15. Read. 
P. A. C. S., proceeded to operate. The patient was laid on his face, and his buttocks were brought to the edge of the table. A 
straight incision was commenced two inches below the anterior superior crest of the ilium and carried downward to one inch 
below the trochanter major. The muscles were then separated, and the joint exposed. The head was then dislocated by forcibly 
bringing the leg under the table. The soft parts were protected by a spattda and the head was sawn off. The ball was removed 
from the cotyloid cavity, which was found to be broken across and the cartilage loosened. The wound was then closed by 
sutures and the patient was removed to his bed. He suffered no pain, and in twenty-four hours the swelling had subsided. His 
general condition was very feeble, and ho was freely stimulated during the after-treatment. lie died August 19, 1833, eight 
days after the operation, exhausted by hectic fever. There is no account of any abdominal disturbance or pyacmie symptoms 
resulting from the fracture of the acetabulum. 

CASE 270. — Private Henry Woodworth, Co. A. 4th Vermont, aged 18 years, was wounded at the battle of Spottsylvania 
Cowl House, on May 11, 1834, by a. conoidal musket, ball, which entered the left thigh, just below the trochanter major, passed 
inward and forward, grooving the femur anteriorly at the level of the lesser trochanter, and lodging under the sartorius muscle. 
The patient was conveyed to the field hospital of the 2d division of the Sixth Corps, where the ball was 
removed through an incision at the edge of the sartorius. A week subsequently, he was placed on one of 
the trains for the Rappahannock, and was transferred from Fredericksburg to Washington, where, on May 
25th, he was admitted to Ilarewood Hospital. His condition on admission was very unpromising; his pulse 
was quick and feeble; he was anaemic, and without, appetite. He was placed upon a tonic regimen, but he 
did not improve. The wound discharged profusely; there was much pain in the joint, pain aggravated by 
the slightest movement, and pus had burrowed in every direction about the articulation. Surgeon R. P>. 
Bontecotl, 1*. S. V., in charge of Ilarewood Hospital,' decided that an excision of the head of the femur 
offered the only possible chance of saving life, and, on July 1st, the patient having been anaesthetized by 
sulphurie ether, Dr. Bontecou proceeded to pel form the operation. A curved incision, with its concavity 
forward, embracing the trochanter, readily exposed the joint. The muscular attachments were divided, and 
the head was easily disarticulated, the joint being disorganized and the round ligament destroyed. The continuity of the 
bone being uninterrupted, the upper extremity was readily turned out and sawn just below the point of impact of the ball. On 
examination of the portion of bone removed, it was found that much of the head had been absorbed, and that the remainder 
was carious. The specimen is represented in the accompanying wood-cut (Fig. 75). The neck and trochanters are covered 
with traces of the effects of periostitis. The cotyloid cavity was ulcerated. The wound was drawn together by adhesive strips, 
and the limb was dressed in a fracture apparatus with moderate extension. Every means of supporting the patient's strength 
was adopted, but he did not rally from the operation, and, sinking gradually, expired on July 2, 1864. 

Case 271. — Private John Zaborowski, Co. H, 7th Connecticut, aged 33 years, was wounded at the engagement at Deep 
Bottom, Virginia, August 1(5, 1834, by a conoidal musket ball, which entered just below the right trochanter major, and passing 
upward and inward, fractured the neck and slightly injured the head of the femur. The patient was conveyed to the field 
hospital of the Tenth Corps, where his wound was dressed, and he was then sent to City Point and transferred to the hospital 
transport steamer De Molay, and conveyed to the U. S. Hospital, at Beverly, New Jersey, where he was admitted on August 
22d. His condition at this period is not described, and it is not stated whether the ball had boon 
extracted. From the subsequent history, it would appear that there was profuse suppuration about the 
joint, since a free transverse incision was practised to give free escape to the discharge. On September 
27th it was determined to excise the head of the femur. The patient had greatly lost in flesh and strength 
since his admission, and seemed to be rapidly failing from the exhaustive suppuration; extensive slough- 
ing of the soft parts had supervened, and, upon the whole, the case was unfavorable and unpromising. 
Chloroform having been administered, and the patient being placed on his sound side, Assistant Surgeon 
C. Wagner, U. S. A., made an incision four and a half inches in length, extending from jjst below the 
Fio. ?G.-Heau of riMit anterior superior spinous process of the ilium toward the tuberosity of the ischium, crossing the trans- 

femurexclnedforcariesfol- verse incision previously made over the trochanter major to permit free exit of pus. The thigh was 

lowing' a gunshot fracture n ji i . ii j p i t • i •> t i • 

Spec, wt in. Sect. I, a.m. M. flexed and rotated inward, the tendons of the muscles were divided, and a chain saw was passed under 

4 and between the head of the femur and the trochanter major, and the bone was sawn through the neck, 
the soft parts being protected by spatulas. About one inch of the trochanter major was found to be necrosed, and was removed 
by a small saw. No blood was lost during the operation. The patient sank rapidly, and died September 28, 1834, of exhaus- 
tion. X post-mortem examination revealed nothing of note, except slight caries of the acetabulum. The carious head of the 
femur was sent to the Army Medical Museum, and is represented in the adjacent wood-cut (FlG. 70). The fragments of the 
neck and the necrosed trochanter major were lost. 




Flo. 7 j.-Exciscd up- 
per extremity of left 
femur with a conoidal 
ball. Spec. 3049. £ 




SECT. II. I 



EXCISION AT THE IT II* AFTER SHOT INJURY. 



119 



Of the eleven secondary excisions at the hip five were on the right and six on the 
left side. The pathological specimens were preserved in six instances. 



Table XIII. 
Summary of Eleven Cases of Secondary Excision of the Head of the Femur for Shot Injury. 



N Name, Age, and Military 
m i description. 



10 



Date 

OF 
IXJUKY 



1 'Brown, J., Pt M I. 3d Mich- 
igan, ago 38. 



Tilliston, G. W., Pt., D, 1st 

Ohio Light Artillery, ago 
44. 



Pease, T. W.. Pt., II, 19th 
Indiana, age 2o". 



Aug. 2«>. 
1862. 



.Julv 7, 
1801. 



Julv 1, 
I8ti3. 



Frain, H., Pt., G, 31st Mas- 
sachusetts, age ££. 



Henry, W. J., Ensign, 21st 
Mississippi, age 22. 



Hunt, E., Pt., D, 71st Penn- 
sylvania, age 24. 



Nelling, J. W., Pt., K, 1st 
Massachusetts, age "2o. 



Roth, J., Pt., B, lS8th N. 
York, age 25. 



■Tone?/, A., Pt., A, lGth N. 
Carolina, age 43. 



Woodworth, H„ Pt., A, 4th 
Vermont, age 18. 



3 Zaborowski, J., Pt.. H, 7th 
Connecticut, age 33. 



Nature of i .jury. 



Musket ball perforated Hie left 
thigh, fracturing femur just 
below the trochanter minor. 



Ttifle ball entcr'd the right groin, 
passed back ward, fractured 
the head and neck of femur, 
and lodged in large muscles 
of buttock. 

Conoidal ball fractured upper 
third of right femur, passed 
thro 1 trochanter and lodged 
behind trochanter major, fol- 
lowed by chronic ostitis and 
coxitis. 



Date 

of 
Opera- 
tion. 



Mar. 21, 
1863. 



Sept. CO, 
1801. 



Nov. P. 
1071. 



Feb. 1 , 
1805. 



Mine 21 
1864. 



Sept. 17, 
18<!2. 



June 30, 
18(>2. 



Feb. fi, 
1805. 



June 30, 
I8b3. 



May 1 1 
lb'64. 



Aug. 1G. 
LS64. 



Left thigh perforated by a co- Mar. 24 
noidal ball; the neck of the | 186." 
femur was fractured. 



Comminuted shot fracture of 
upper third of left femer by a 
conoidal musket ball. 



Conoidal ball grazed the neck 
of the right femurand passed 
out at the nates. 



Musket ball comminuted neck 
of right femur; head of bone 
entirely separated. 



Anterior part of head of left 
femur shattered by a round 
ball, which lodged in same. 



Head of the left femur slightly 
fractured by a conoidal ball 
that lodged in acetabulum. 



A conoidal ball grooved the 
left femur anteriorly at the 
level of the lesser trochanter 
and lodged under the sartorius 
muscle and was removed. 



Conoidal ball fractured the 
neck and slightly injured the 
head of the right femur. 



The femur was divided by the 
chain saw just below the trc 
chanter minor: the head of 
the femur was removed with- 
out difficulty; Surg. A. M. 
McMahon, U. S. V. Incision 
tour ins. long 

Head of femur exarticnlatcd 
shaft sawn below trochanter 
minor, six inches of bone re- 
moved, by Surg. J. 11, Head 
C. S.A. Ineis. seven ins. long. 

Opening on inner side of thigh 
enlarged, neck of the femur 
divided with lion-jawed for- 
ceps and head of bone re 
moved, bv Ass't Surg. U. A 
DuBois, U. S. A. 

Head (if bone removed, several 
fragments extracted, and the 
jagged extremity of the neck 
smoothed by an osteotome. 
by Ass't Surg. U. Bartholow 
U. S. A., thro' vertical incis 

The neck of the femur was 
divided near the head of the 
bone by a eh ain saw; the head 
of the bone with the ball in 
sorted was then removed 
straight incision, by Assistant 
Surg. J. Vansant,TJ. S. A. 

Head of femur sawn off and 
the ball removed from tho 
cotyloid cavity, bv Surg. J 
P. Bead, P. A. C. S.j straight 
incision. 

Head of femur disarticulated 
and upper extremity of bone 
rca dily turned out and sawn 
just below the point of impact 
of the ball, by Surg. It. B. 
Bjntocou, U. S. V.; curved 
incision 

Chain saw passed under and 
between the head of femur 
and trochanter major and the 
bon e sawn through the neck 
an inch of trochanter major, 
fou nd to be necrosed, removed 
by small saw, by Ass't Surg, 
C. Wagner, U. S- A.; crucial 
incision 

l_ 

■SMITH (D. P.), Gunshot Wounds of the Great Trochanter, in Am. Med. Times, 18C3, Vol. VII. p. l ~- Circular No. 6, S. O. O.. 1865, p. GS. 
Circular No. 2, S. G. O., 186'.), pp. 50, 137. 

2 Read (J. B.). Resections of the Hip Joint, in Confederate States Med. and Surg. Jour., 16(54, Vol. I, p. G. Eve (P. P.), A Contribution to the 
History of the Hip Joint Operations performed during the late Civil War, in Transactions of the American Medical Association, Vol. XV11I, p. 256. 
Circular No. 2, S. G. O.. 18G9, pp. 51, 137. 

3 WAGNER (C.)j Report of Interesting Surgical Operations performed at the U. S. Gen. Uorp., Beverly, X. J., 1PG4. pp. 14. 15. Circular No. G, 
S. G. O.. 18C5, p. 70. Circular No. 2, S. G. O., 18G9, pp. 53, 137. 



Aug. 

IB* 



Feb. 23, 
1863. 



Aug. 21 
1862. 



Mar. 9, 
1865. 



Aug. i; 
1863. 



Julv 1, 
1864. 



Sept. 2^ 
18G4. 



Operation and Operator. 



Necrosed fragments extracted ; 
shaft of lemur divided six ins. 
below tipoftroeh. minor. '1 he 
head, neck, and trochanters, 
and (lie masses of callus ad- 
hering to tho trochanters were 
then removed, straight ineis. 
eight ins. long, by Surgeon 
D. P, Smith, II. S. V. 

Head and neek of femur ex- 
cised, bv Dr. P.. Sterling. 



Femur divided live ins. below 
the trochanter and unjointcd 
from acetabulum, by Dr. J. 
K. Bigelow, late Surgeon 8lh 
Indiana. 



ItKsiLT aki) Remarks. 



Diseh'd Aug. 23, 18G3, and pen- 
sioned. Appointed postmaster 
in 1807, at (Joopcrsville, Mich. 
Able to attend almost entirely 
without assistance to the busi- 
ness of the office. Paid pen- 
sion March 4. 1876. Spec. 1192, 
A.M. SI. I'hot. Ser. 110.A.SI.M. 

(Diseh'd July 21. 18G1.) July, 
1867, fistulous opening discharg- 
ing purulent matter. 'I hree ins. 
shortening. Pons'ncr died Sept. 
G. 18/1. of as'henia. Autopsy. 
Spec. 559(1. A. SI. SI. 

Portions of femur had been pre- 
viously removed. Patient had 
been diseh'd Aug. 8, 18G4. In 
Sept., 1877. tho pensioner had 
"nearly a perfect urthrodial. joint 
at hip. and was able to attend to 
tho ordinary duties of u deputy 
marshal.' 

Died Slarch 30. 18G5. Circ. 6, 
S. G. O., 18G5, p. 72. Circ. 2, 
S. G. O., 18U9, pp. 54, 137. 



Died August 8. 18G4. Circ. 2, S. 
(1. ().. 181,9, pp. 52. 137. 



Died Pcb. 25, 18G3. Spec. 3907, 
A.SI.M. Circ. G, S. G. O., 1865, 
p. 66. Circ. !!, 18G9, S. G. O., 
pp. 49, 137. 

Died August 25. 1862, of haemor- 
rhage. Spec. 400, A. SI. SI. Circ. 
0. S. t;. O., 1865. p. 62. Circ. 2, 
8. G. O., 1869, pp. 48, 137. 



Died June 17, 18G5. Circ. 6, S. 
G. O., 1865, p. 74. Circ. 2, S. 
G. O., 1869. pp. 53, 137. 



Died August 19, 1863, from ex- 
haustion, of hectic fever. 



Died Julv 2. 18G4. Spec. 3049, 
A. SI. SI. Circ. G, S. G. O., 1865. 
p. 70. Circ. 2, S. G. O., 1869, 
pp. 52, 137. 



Died September 28. 1864, from 
exhaustion. Spec. 3716, A. SI. SI. 



120 



INJURIES OK THE LOWER EXTREMITIES. 



[CHAP. X. 



Since the termination of tlie civil war the operation of excision at the hip for shot 
injury lias been practised five times in the service of the United States Army and once 
in the service of the United States Navy, and this aggregate of six excisions 1 gives the 

1 Four of the operations arc described at length in A Iteport of Surgical Cases treated in the Army of the United States from 18G5 to 1871, Circular 
No. H, War Department, Surgeon General's Office, Washington, 1871, pp. 228-234, and the facts regarding them will be here briefly recorded, two of the 
cases are hitherto unpublished, and will be narrated more in detail. Two of the excisions were primary, one intermediary, and three secondary opera- 
tions. The first case was that of Private Hubert Erne, Co. D, 4th Infantry, aged 48 years, wounded December 2, 18G9, while acting as one of a corpo- 
ral's guard of the mail wagon from Fort Laramie to Fort Fet terra an, in an attack by a band of Indians, lie was struck in the left buttock by a round 
carbine ball (cal. 4.1, weight 22fi grains), aud fell to the ground. His cmnrades placed him in a wagon and drove rapidly to Laramie, over a very rough 
road ; he was struck at two in the afternoon and was placed in bed in the hospital at half-past seven, much exhausted, having driven thirty-two miles in 
five and a half hours. He had lost blood copiously. His extremities were cold, pulse almost imperceptible, and his countenance was pallid and covered 
with clammy sweat. The left lower limb showed shortening with eversion, the thigh arched with an anterior convcxit}-. The entrance wound was an 
inch and a half behind the trochanter major on a slightly higher plane ; the exit aperture was near the centre of the groin just below Poupart's ligament, 
directly over the axis of the femoral artery. The diagnosis of Assistant .Surgeon F. MeaciiaM, post surgeon, was that there was fracture of the shaft, 
neck, and trochanters of the left femur. As he had not rallied from the shock, it was thought best to defer surgical interference until morning, and 
the limb was placed in a comfortable position, and the patient allowed half an ounce of brandy every half hour, while external applications of heat were 
made by hot blankets, heated sad-irons, and bottles of hot water. At midnight the patient had fairly reacted ; but complained of great pain in the 
middle of the injured thigh. He was ordered a fourth of a grain of morphia to be repeated in two hours if needed. At 7..30 A. M., December 2d, the 
patient was comfortable : pulse at 9". No appetite and little sleep during the night- Temperature in axilla 99° F. Cold-water dressings to wound were 
applied, milk punch given freely, and an eighth of a grain of sulphate of morphia every two hours. At 1 P. M. Dr. MEACIIAM, assisted by Assistant 
Surgeon J. B. GlUARD, U. S. A., placed the patient under chloroform and thoroughly explored the injury, after enlarging the entrance wound to admit 
the finger to ascertain the extent of shattering of the neck, trochanters, and shaft. No important vessels or nerves were involved. The patient was 
an old soldier; he had been a hard drinker; during the civil war had been more than once wounded, having on one occasion suffered a shot fracture < f 
the lower jaw. After careful consideration of the heal and constitutional conditions it was determined that excision of the upper extremity of the femur 

would afford the patient the best chance of life. Dr. Meaciiam made a curvilinear incision seven inches in length, 
beginning an inch and a half above the trochanter major, traversing the entrance wound and extending downward in 
the axis of the shaft. Exposing the bone by rapid division of the muscular attachments, the fragments of the shaft 
were first removed and the pointed upper extremity of the shaft was then divided by the chain saw; then, with 
some difficulty, the head of the bone was exarticulated, aud the operation completed. The exploratory incisions, 
consultation, and final excision occupied nearly an hour. Tattle blood was lost, and the patient promptlj 7 rallied, with 
little sign of shock. The upper part of the incision was united by sutures and adhesive strips. The man was put to 
bed with the injured limb extended, and a weight of four pounds attached by Buck's method. The wound had cold- 
water dressings, and the patient had an ounce <5f brandy every hour when awake, and a quarter of a grain of sulphate 
of morphia every two hours. December 4th, the patient had passed a good night, and had a full pulse at 90. During 
the day he had nutritious diet, a half ounce of brandy hourly if awake, and two grains of quinia and an eighth of a 
grain of sulphate of morphia every four hours. Excised fragments of bone were cleaned and sent to the Army 
Medical Museum and preserved as Specimen 5u'58, of the Surgical Section, which are represented one-fourth the size 
of nature (Fig. 78). On December Gth, in the early morning, 
there was little cliango in the constitutional symptoms. The 
patient had slept four hours during the night. He was troubled 
with hiccough. He had partaken freely of freshly prepared 
essence of beef. At the surgeon's morning visit, at half past 
seven, twenty -grain doses of bromide of potassium were substi- 
tuted for the morphia, and the other treatment and diet were 
continued, with the addition of canned oyster soup. At the 
evening visit, at nine, the hiccough had nearly ceased, the 
wound had begun to suppurate, the pulse was 100, the tongue 
was moist, and the thirst diminished. The dose of bromide of 
potassium was reduced one-half; the other treatment was con- 
tinued. On the morning of December nth he was found to have 
passed a restless night, annoyed by hiccough when awake. He 
complained of the extension, and the weight attached to his 
foot was diminished one-half. Whiskey was substituted for the -Anterior and posterior views of head and 





FIG. 77. — Cicatrix in Meaeham's 
case of successful excision of the 
left hip. [From a pl u|t,, graph.J 



phate of quinia every four hours. 



FIG. 78 

_ trochanters of left femur excised for shot perforation, 
brandy which he disliked, and a tincture of sesquichlonde of gp eCt 5^53 ^ jf t jr # 

iron was given in twenty-drop doses, with two grains of sul- 

One-fourth of a grain of sulphate of morphia was ordered to be given when the pain demanded it. The patient 

was removed to a water-bed. On December 7th the patient was more comfortable and had slept well. He was annoyed by flatulence, the bowels not 

having moved since the reception of the injury. He was ordered a tablcspoonful of castor oil and twenty drops of turpentine, and an enema of soap 

and water. The suppuration from the wound was quite copious. On the following day it was practicable to omit the anodyne, and the patient had a free 

evacuation of the bowels, with great relief. The patient was allowed a small piece of beef-steak for his breakfast, and chicken for dinner. The discharge 

from the wound was profuse, and the integument over the hips and nates was somewhat abraded from heat and moisture. The weight attached to the 

foot was removed altogether. The patient was transferred from the water-bed to a mattress, in the middle of which was a movable portion corresponding 

with the pelvic region. This arrangement greatly facilitated the application of dressings and the use of a bed-pan. The patient was ordered three 

ounces of beef essence thrice daily and as much milk as ho should relish. On the 9th, he was found to have slept well without taking an anodyne. The 

suppuration was profuse. The pulse was at 100. The appetite was abundant. Hiccough was again quite troublesome. The bowels had not been 

moved since the 7th, and an enema of castile soap and warm water was ordered to be given daily, unless there should be an alvine evacuation before 

nine in the morning. During the next fortnight there were no symptoms of especial interest. The wound continued to suppurate, but less copiously, and 

was rapidly filling up with granulations. On December 22d the patient passed a very restless night. The surface was hot, and the pulse at 100; the 

appetite was gone; the abdomen was tympanitic. On December 2:id, he had several dejections, and had slept soundly during the previous night, and 

was in every respect much better. On January 1, 1870, his bowels were again obstiuately constipated. Cicatrization of the wound was rapidly going 

on. Citrate of iron and quinine was substituted for the sesquichloride of iron. Laxative enemata were required daily, and whiskey was still given. The 

obstinate hiccough ceased about the middle of January, at which date the pulse had fallen to an average of 90, and the wound had far advanced toward 

healing. For the next six weeks there was very little change in the daily record. The patienfs convalescence progressed favorably, and by February 

28th the wound was open at two points only. Constipation was still a troublesome complication ; the patient being annoyed by injections he was ordered 

to take a three-grain compound cathartic pill nightly. By the end of March the patient was able to sit up. There were still two fistulous sinuses leading 



SECT. II. | 



EXCISION AT THE HIP FOR SHOT INJURY, 



121 



gratifying result of four recoveries. Adding to tlie sixty-six cases of excision at the hip 
for shot injury performed during the War of the Rebellion the ninety-nine cases referred 
to in Note 1 on page 90 ante, and the six cases detailed in Note 1 commencing on page 



toward the cotyloid cavity. About on ounce of pus was discharged daily. The limb was about live inches shorter than the other. On April 10th the 
patient got on crutches, but could nut walk far without fatigue. For the next twenty days he seemed disinclined to exert himself but was taken out 
every day in a wheeled litter. One of the sinuses had closed. By July 8th the patient had gained in flesh and strength, and the purulent discharge had 
diminished to a few drops daily. The limit was swollen considerably and there was an erysipelatous blush extending below the knee. At this date Dr. 
MEACHAM was ordered to Omaha, and the patient passed into the hands of Acting Assistant Surgeon L. S. TESSOX, who, on July 29th, wrote to Dr. 
MEACHAM that quite a large abscess formed in the muscles of the thigh. On August 9th, Dr. TESSON again wrote that it had been necessary twice to 
make incisions to evacuate abscesses in the thigh. Again, on March 9. 1871, Acting Assistant Surgeon A. J. Ilooo writes that the man is entirely well, 
the cicatrix being perfectly sound ; but the man persisted in lying in bed. On April I, 1871, Dr. MEACHAM reports that ho had succeeded in getting his 
patient again under his personal observation, previous to which he had borne transportation hi an ambulance for ninety miles, and appeared in better 
spirits at the end of the journey than when he set out. The wound had entirely healed, leaving a firm and sound cicatrix three inches in length. The 
patient was able to walk comfortably on crutches and had slight control over the limb, which admitted of a to-and-fro motion, with rotation inward. The 
upper end of the femur rested on the dorsum of the ilium, about one inch above the acetabulum, and was movable in that position. There was six and a 
half inches shortening. Tiie patient was somewhat hypochondriacal, being greatly troubled with indigestion and irregular bowels. A photograph of 
the patient, taken at Omaha, March 30, 1871, is copied in the wood-cut <FlG. 77). Private Hubert Erne was discharged from service May 18, 1871, 
and by an order dated A. G O., June !), 1671, was sent to the Soldier's Hume, near Washington. In answer to an enquiry from this Office, Surgeon C. 
H. Lauii reported : ''Hubert Erne, late of the 4th Infantry, was received in hospital at Soldier's Home on July 1G, 1871, in a very emaciated and feeble 
condition, the result of chronic diarrhoea. Having during his residence here exhibited symptoms of partial insanity, and having no facilities for the 
proper care of such cases, he was transferred to the Government Insane Asylum, near "Washington, August 20, 1871 , at which place it is reported that he 
died a short time after his admission." Then Dr. C- II. NICHOLS, Superintendent of the Government Hospital for the Insane, reported that the patient " was 
admitted August 19, 1871, to be treated for acute insanity, and that he died Nov. 7, 1871, from exhaustion, of acute mania. No autopsy was made in the 
case." Another primary excision at the hip for shot fracture of the upper extremity of the femur was practised at Tort Concho, Texas, hi 1874, by 
Assistant Surgeon W. F. BUCHANAN', U. S. A. The fracture was attended with very extensive longitudinal splintering, and it would appear that such 
conditions involve incisions of such perilous magnitude as to afford the slightest prospects of success even under the most favorable attendant circum- 
stances. The abstract of this case has not, at this date, (June 1, 1878), been published in print. — Sergeant T. Duncan, Co. K, 25th Infantry (Colored), 
aged £7, was shot in the left hip while a prisoner and attempting to escape from his guard at Fort Concho, Texas, on the morning of November 
24, 1874. On receiving the injury, which was produced by a conical rifle ball at u distance of about sixty yards, he fell to the ground, when he was 
placed on a wheeled litter and was conveyed to the Post Hospital. At D.20 A. M. an ounce of brandy with half u grain of morphia was administered. 
An examination externally exhibited a wound of entrance in the gluteal region, on a line with the lower border of the great trochanter, and about mid- 
way between the trochanter and the tuberosity of the ischium; the wound of exit existed in the 
anterior part of the thigh, same side, about an inch and a half below I'oupnrt's ligament and one 
inch external to the femoral vessels. The mobility, crepitus, probing, etc., proved that the upper 
port of the shaft of the femur had been shattered; a compound comminuted fracture, doubtless 
extending within the capsule. Venous haemorrhage was taking place from the wound in the gluteal 
region, and great pain was felt in touching the great trochanter and In the knee. There was also 
great nervousness, and quick and feeble pulse. lie was placed on his right side, the injured leg 
supported, the body bolstered, and the hemorrhage controlled by pledgets of lint saturated with a 
solution of persulphate of iron. Cold-water dressing was applied, a tin wanner filled with hot 
water applied to the feet, and a quarter of a grain of sulphate of morphia together with an ounce of 
brandy was given every two or three hours. On the following day, at 11.30 A. M., the patient was 
quite nervous, suffering great pain, and only relieved by the full effects of the anodyne, having 
slept little during the night and eaten nothing but a little beef essence ; pulse 100 and small ; tem- 
perature normal. It was decided that resection offered him the only chance to survive. lie was 
therefore placed on the operating table and brought under the influence of the anaesthetic, consist- 
ing of one part of chloroform and two of ether, when n longitudinal incision about eight inches in 
length was made, commencing just above the trochanter und extending in the axis of the head and 
neck of the bone, and the soft parts were dissected away. The upper end of the shaft being found 
much shattered and the fracture extending within the neck, the head of the bone was cxarticulated 
and the fractured extremity removed with the chain saw. About five inches of the shaft, with the 
head and neck, were exsected. No arteries were cut, and but one small vein was ligated. All the 
fragments of bone, about forty, were removed, the parts washed out and a weak solution of per- 
manganate of potassa applied, the sides of the wound being united with interrupted sutures sup- 
ported by adhesive straps. The patient was then placed in bed, position maintained by sand bags, 
and cold-water dressings instituted. As soon us he had recovered consciousness, brandy and 
morphia were given ami repeated frequently. Warmth was applied to the feet. The patient was of great muscular development, and the incision 
required t:> bo lengthened an inch or bo to allow of necessary retraction. His pulse was about the same as before the operation, rather full. Although 
relieved of the pain he had suffered previous to the operation, he continued restless, constantly trying to change his position, groaning, etc., nnd died on 
the morning of November 26th, about fourteen hours after the operation." The excised portion of the fractured femur, represented in the wood-cuts 
(FIGS. 71), 80), with the history, was contributed to the Museum by the operator, Assistant Surgeon W. F. Buchanan, U- S. A. Of the excisions at the 
hip after shot injury, practised since the close of the civil war in the United States Army, one was an intermediary operation performed by Surgeon 
GtOVBS PERIN, U- S. A., at Newport Barracks, Kentucky, in August, 1867 : CASE. — Private Francis Abeam, aged 30 years, U. S. General Service, was 
wounded at Newport Barracks, Louisville, on July 31, 18G7. Ho was a prisoner in the guard-house, and was shot by a sentinel while attempting to 
escape. The ball entered behind and below the prominence of the right trochanter major and passed inward and upward, emerging on the anterior 
part of the thigh, two inches below Poupart's ligament, a little to the outside of the course of the femoral artery, having shattered the upper part of the 
femur, the fissures extending within the joint. The wounded man was immediately taken to the Post Hospital, and was examined by Colonel PEP.IN, 
the surgeon in charge. The patient had been an habitual drunkard for years and had mania apotu when shot. The shock of the injury was so great 
that an operation was not considered advisable. It was determined to adopt a supporting treatment, and to endeavor to build up the general health, 
with a view of operating at the first favorable moment when a good result could be reasonably anticipated. On August 26, 1867, the patient was in a 
better condition than at any time subsequent to the reception of the injury. The pulse was at 90 j there had been troublesome diarrhoea, but it was some- 
what abated; the injured limb was much wasted, except at the upper part of the thigh, where it was greatly swollen ; the discharge from the wound 
was very copious, and there was extreme pain on the slightest movement. There were abscesses about the joint communicating with its cavity. 
Excision having been decided upon, Surgeon PEED*, assisted by Assistant Surgeon T. E. Wilcox, U. S. A., proceeded with the operation. The 
patient being rendered insensible by a mixture of chloroform and ether, the entrance wound was enlarged by a straight incision downward and three 

Surg. Ill— 16 




Fin. 7'.). — Shattered 
upper extremity of the 
left femur. Spec. Gol3. 




I-To. 80. — Posterior view 
of the same specimen. 



12: 



INJURIES OF THE LOWER EXTREMITIES. 



[CHAP. X. 



120, we have a total of one hundred and seventy-one instances of excision at the hip for 

shot injury, of which one hundred and forty-eight, or 86.5 per cent, proved fatal. Forty- 
three of the operations were primary, witli forty deaths, or 93 per cent.; sixty were inter- 




no. 81. — Shattered upper 
extremity of right femur, 
excised for curies following 
shot fracture. Sj>ec. 548<). " 




FIG. 8^. — Posterior view 
of the same specimen. 



inches in length. The head of the bone was disarticulated, and the shaft was sawn several inches below the lesser trochanter. The wound was then 
cleansed and approximated. Scarcely any haemorrhage took place, no ligatures being required. On recovering from the anaesthetic, the patient com- 
plained of great pain and nausea. Brandy was administered, and half a grain of sulphate of morphia ; but there was such irritability of stomach that 
everything was rejected. A quarter of a grain of sulphate of morphia was then administered hypodennieally, and this relieved the pain. But there was 
no decided reaction, and. sinking gradually, the patient died from the shuck of the operation 
twenty hours after its completion. No autopsy was made. The shattered excised bones were 
sent to the Army Medical Museum, and arc represented in the adjoining woodcuts (Fl<;s. 81 , 82). 
Many of the fragments were carious. Of the six eases of excision at the hip joint practised on 
account of shot injury in the I'nited States since the civil war, three were successful secondary 
operations. Two occurred in the I'nited States Army and one in the United States Navy. The 
firstof the ojirrations was performed by Assistant Surgeon J.H. GIBBON, in August, 18(>8. The 
patient recovered with a very satisfactory control of the functions of the articulation and limb. 
A detailed report of the case was published in Circular Xo. 2, S. G. O., 1869, pp. 117-120, and 
in Circular No. 3. S. G. O., 1871, p. 228, an account of the pensioner's progress was given, wilh 
a lithograph plate showing the appearance of the injt.rcd limb three years subsequent to the 
operation. The following is the condensed abstract of the ease as published in Circular No. 3: 
" Private Charles F. Kead, Co. I, 37th Infantry, while in a stooping posture, and distant about 
one hundred feet, was shot by a sentinel at Missouri Bottom, New Mexico, on June fi, 18GS. 
The ball struck about the middle of the posterior aspect of the left thigh, causing an injury to 
the bone, the nature of which is shown in the accompanying wood-cut {Fir., 84), illustrating 
the specimen contributed to the Army Medical Museum by the operator. Assistant Surgeon J. 
R. GIBBON", U. S. A. The case being fully detailed in Circular No. 2, S. G. O., 1S(H>, page 
117, reference will only be made to the more salient points, and to information received since 
the publication of that report. After weeks of temporization, during which the pntient, a young 
man in the prime of life, had become much exhausted from numerous and futile searches after the missile, from bedsores, 
profuse suppuration, an irritable diarrhoea, and pain so intense as to require the administration of an anaesthetic previous to dressing the wound, the 
choice lay between a lingering death or excision of the head of the femur, or the more fearful and precarious alternative of amputation at the joint. On 
August 14th the patient expressed willingness to submit to any operation that would afford relief, when he was anu'sthotized for the purpose of again 

freely examining the parts, and performing such operation as should be considered necessary. Upon explorations of 
the wound with the probe and linger, the ball was discovered in the head of the femur, a T-shaped incision was 
made over the joint, the head of the bone was turned out of the acetabulum, and was sawn through the neck, just 
within the greater trochanter. The incisions were closed with metallic sutures, and the limb was temporarily 
placed between splints, with a pilttrw under the knee. A Smith's anterior splint not being on hand, nor the material 
procurable for making one, a long external splint, made in two parts, and connected by iron braces, was devised and 
put in course of construction. The jtfter treatment consisted in carbolized dressings to the wound, the administra- 
tion of antiperiodics to control a fever of a remittent type (at one time supposed to be the precursor of erysipelas 
or pyaemia), and a plain nutritious diet. Notwithstanding frequent displacement of the limb from occasional attacks 
of diarrhoea, and the absence of a proper apparatus to secure immobility, the performance of this formidable opera- 
tion seemed to have imparted a new tenure of life. By November 20th the patient was able to walk about the 
hospital, and the further progress cf the ease was as rapid as it was favorable. On May 10, 186*9, this soldier was 
discharged the service and pensioned for total and permanent disability, the injured member being shortened one 
inch and three-quarters. He came across the plains by the next train, and, in September, 1869, reported at the 
Surgeon General's Office, where a photograph was taken. At that time the patient's general health was excellent; 
the cicatrix was perfectly firm and sound, and the strength of the ligamentous. attachments and the amount of 
control over the movements of the limb were very remarkable. He could bear much weight on the limb. He was 
supplied with a prothetic apparatus and advised not to use it straightway, but to continue exercising the limb 
continuously for some months, thereby increasing the strength cf the muscles and ligamentous attachments, and the 
freedom of the newly-formed joint. The next week Head went to New York, where the pro- 
posed apparatus was ingeuionsly applied by Dr. E. D. Hui'SOX. In the summer of 1870, it was 
reported that this man could walk very comfortably with a cane either with cr without appa- 
ratus. The appearance of the patient is shown in the accompanying wood cut (FlG. 83.) In 
June 1671, three years after the operation, the man was in very good health, and could walk 
almost as well as ever." He was lastpaid on September 4, 1&77. The next secondary operation 
was pcrf irmed by Surgeon W. E. Taylor, U- 8. Navy. A report of the case was published 
in Circular No. 3, S. G. O., 1871, p. 232: Charles B. Scott, a seaman of the V. S. Navy, aged 
34, of fair general health, was wounded in an attack on a piratical vessel in Tecapan Tliver. west 
coast of Mexico, June 17, 1870, by a rifle ball, fired at a distance of about eighty yards. He 
was conveyed a distance of seventy miles to the U. S. ship Mohican, on board of which he was 
treated for several days, and finally transferred on July 12th to the Naval Hospital, Mare Island, California. The wound of entrance was small, and 
situated a little below and about two inches posterior to the top of the left great trochanter. He rested entirely on the right side, with the injured limb 
partially flexed and resting on the sound one, the whole limb being inverted and shortened about one inch. Cold-water dressings had been applied to the 
wound and anodynes administered when required. His general condition was decidedly below par. The least movement in the injured joint caused severe 
pain ; he did not sleep well, and his appetite was poor. Full diet, with milk and an anodyne at night, were ordered. On July 14th an examination of 
the wound was made. No anaesthetic was used, and the result was unsatisfactory. However, appearances led to the belief that the neck and probably 
the head of the femur were fractured; the ball could not be felt. The joint was not swollen but was very sensitive, and there was a scanty sanious 
and fetid discharge from the wound. On July S.r#t Ii the patient was chloroformed, and Surgeon W. E. TAYLOR, U. S. Navy, made a single straight 
incision, seven or eight inches long, and found the neck and head extensively comminuted; he then sawed off the bone just below the trochanter minor, 
and removed the fragments, some twelve or fourteen in number, as also the ball, which seemed to have struck the neck obliquely, breaking it into three 
pieces, and then passed into the head, shattering it into nearly a dozen pieces. Very little blood was lost, two small arteries only requiring to be secured. 
After syriuging the wound with a weak solution of permanganate of potash, it was partially approximated by four sutures, and the limb was placed in 
an ordinary fracture box, and dressed with oakum. The operation was well borne, and reaction prompt. Stimulants, with nutritious diet, were ordered, 
and rigid cleanliness was enforced. On the 27th the patient began to suffer from decubitus. On the evening of the 29th he became delirious ; pulse 130 





Fig. 63. — Appearance cf the limb 
fifteen months after the operation. 



Fic..84.-Excised 
head cf left femur 
with impacted 
musket ball. Sp. 
5576. 



SECT. II.] 



EXCISION AT THE HIP FOR SHOT INJURY. 



123 




PIG. 85. — Anterior and posterior views <>f the 
upper extremity of the left femur. Spec. 5884. 




FlO. 86. — Appearance of limb 
seven months after operation. 



mediary, with fifty-eight deaths, or [)6.6 per cent.; forty-one, with twenty-six deaths, or 
63.4 per cent., were secondary; and, in twenty-seven instances, with twenty-four deaths, 

anil irritable. Hydrate of chloral being substituted fur morphia, lie went to sleep in a few minutes, and next morning awoke refreshed and feeling better 
than at any time since the accident. The pulse fell to 100. On the 31st, the sutures were removed. The good effect of the chloral was very marked, 
but. by August 0th. it seemed to have lost some of its effect : whereupon morphia was combined with the usual dose, 
and he slept well. The discharge from the wound was small in quantity and laudable. On August 8th, some exten- 
sion of the limb was made, but was badly borne. By the 14th, the patient was doing well in every respect. On the 
21st, all dressings being removed from the limb, it was thoroughly bated and rubbed, after which it was replaced in the 
fracture box. when extension and counter-extension were made by means of the ordinary perineal band and screw. 
This was discontinued on the 2<ith, owing to enlargement of the inguinal glands and the general malaise and discom- 
fort experienced by the patient. On the 30th, the use of anodynes was discontinued, as he could sleep without them. 
September 1st, found the patient improving, the discharge from the wound being moderate, with an entire absence of 
inguinal trouble, bedsores, and excoriations. Slight passive motion was commenced in the limb, and it was allowed 
to rest lightly on a pillow for several hours. On the 7th, he was able, for the first time, with assistance, to leave his bed. 
After this he continued to sit up several hours daily, and. gaining in flesh, was able, by the 18th, to walk on crutches. 
He continued to take daily a moderate amount of out-door exercise, the limb meantvbile being supported and steadied 
by mcans'of a wire splint, and his general condition became excellent. On December 27th. he went by steamer to 
San Francisco, a distance of fifty miles, and returned in the evening, having borne the journey well. On January 20, 
1871, a prothetic apparatus was adjusted to the limb, which, at the beginning, proved highly useful. On February 1st, 
the patient was transferred to the new Naval Hospital. At this time his general health was excellent. The left buttock 
was somewhat flattened, and there was a small opening about the centre of the line of incision, which discharged a 

small quantity of pus; the limb was about three and a half inches 
Shorter than its fellow, the knee being quite stiff and foot everted 
(FlO, 8(1). The patient had gained about thirty pounds since the 
operation of excision, and there was a probability of his being able to 
walk quite well without the aid of crutches. Scott was discharged 
April 18, 1871. at Marc Island, California, and pensioned. Drs. R. V. 
WAl.SM and J. S. Gunmni;, of Enniskillen, Ireland, certified, Sep- 
tember 4. 1875: "There is a fistulary opening connected with the 
bone. The leg is greatly wasted, being one-third the size of the sound 
leg." Or. JOHN ST. CLAIR Cunning certified, October, 17, 187' 
"Charles 11. Scott, who died at Oniagh, Tyrone Count) - , Ireland, on 
the 1st day of July, 1877, was under my professional care, and his death was caused by chronic cystitis, the result of a very extensive and severe injury 
to his hip joint. 1 ' The specimen f>884 is preserved in the Museum and shown in the accompan}-ing wood-cut (Flo. 85), The third of the secondary 
operations of excision at the hip joint for shot injury was praetised at Fort Fetterman, Wyoming Territory, in September, lfc77, by Assistant Surgeon 
JOHN V. It. HOFF, U. S. A., who lias famished a detailed report of the ease, from which a condensed abstract is made: Sergeant William J. Linn, Co. 
M, 4th Cavalry, aged 22 years, was wounded in a fight with Cheyenne Indians during the Powder River Expedition, November 25, 187fi. The bullet 
(probably conoidnl, calibre .50 inch, weighing 412 grains) entered the right groin three 
inches below and slightly internal to the anterior superior spinous process of ilium and two 
and three-fourth inches externa! to the symphysis pubis, passed obliquely backward through 
the hip joint, fractured the neck of the femur, notched the posterior segment of the rim of 
the acetabulum, and emerged at a point about one inch posterior and exterior to the notch 
in the acetabulum. The wound nas received while the soldier was resting on his right knee 
and left foot in the act of discharging his carbine. The patient was immediately carried to 
the rear and a plaster of Paris badge applied. He was moved on a travois over an almost 
impassable country, during weather so cold that mercury froze, and reached Supply Camp 
on the third day. Here the plaster bandage was reapplied and the patient was placed in an 
ambulance and carried to Cantonment Reno, reaching the latter place after a five days' jour- 
ney over a country where roads arc unknown, in weather of the utmost severity, and under 
circumstances of hardship which skillful care and unremitting attention could but little 
alleviate. A week after his arrival at Reno, the plaster baudage was removed, the limb was 
elevated, and the wounds of entrance and exit, which were discharging pus freely, were 
treated with simple dressings. The wound of entrance closed in four weeks, and, though 
the wound of exit was still discharging, an immense abscess formed in and about the joint, 
which pointed in anterior cicatrix, finally opened spontaneously, and remained so for several 
months. A light extending weight was used for a short time, no medicine given except 
morphia occasionally for pain and physic for constipation. On March 24, 1677, the patient 
was transferred to the post hospital at Fort Fetterman. The journey was accomplished in 
five days on a stretcher slung in an army wagon. When admitted he was very emaciated, 
pale and pain-worn, and weighed about 100 pounds, having lost 80 pounds since the recep- 
tion of the injury. Two suppurating sinuses led into the articulation and there was fibrous 
anchyh sis of both hip and knee joints. The patient had not moved from a recumbent ir f^. 
position since he received the injury, and could not even be raised upon a bed-pan without ] 
great pain. Tonics and a generous diet were ordered, the wounds were dressed with earbolit 
acid solution. The bowels were freely opened and kept regular. When the patient had fairly 
recovered from the exhausting effects of the journey a side splint was npplied whieh enabled 
him to be moved without pain. Notwithstanding the most careful attention the patient 
gradually failed, and grew so feeble and complained so much of pain that it seemed but a 
question of weeks between an operation or death. On September 28th, Assistant Surgeon 
J. V. R. HOFF, TJ. 3.' A., excised the hip joint after Semixott's method. A circular 
incision was made to include the great trochanter and opening into the joint, the capsular ligament was severed, the head of the femur was thrown 
out and removed by the chain saw at a point just below great trochanter. The head of the femur (proper), which had been severed by the bullet at its 
neck, was found lying loosely in the acetabulum partially absorbed, and was easily removed by forceps. Ether was used; insensibility induced in 
seventeen minutes and maintained one hour and ten minutes; reaction was rapid and satisfactory. Antiseptic dressings were used. A double splint to 
fit both legs, made of light iron, reaching to the waist and there secured by a belt, was applied. This proved most useful in enabling the patient to be 
moved with comparative ease, and, at the same time, keeping the wounded parts measurably immovable. Extension was applied by means of tin plates 




^ 



Fin. 87. — Appearance of 
limb ten months after oper- 
ation. Side view. 




Fig. 88. — Anterior view of 
the same. 



124 INJURIES OF THE LOWER EXTREMITIES. [chap. x. 

or 88.8 per cent., the period of the operation was not stated. Grouping the one hundred and 
seventy-one cases of excision at the hip, according to the time or the occasions on which 
the injuries were received, we find that of sixteen operations performed before the American 
war, 1860-65, one proved successful, and that in a second the patient survived after con- 
secutive amputation; that four fatal operations were performed during the insurrection in 
Poland, 1863, and the campaign in Schleswig-Holstein, 1864; that six excisions at the 
hip with two successes were performed during the Austro-Prussian War of 1866; that of 
seventy-one operations done in the Franco-Prussian War of 1870—71, eight were success- 
ful; that once, at least, excision at the hip was unsuccessfully performed during the Russo- 
Turkish War, 1876—77, and that in one instance the hip joint was successfully excised for 
shot injury in 1876, in California; that of the sixty-six cases of excisions at the hip per- 
formed for shot injury received during the American civil war, six proved successful; and 
that finally, of the six cases performed in the service of the United States since the close 
of the American war in 1865 to the present time (1879), four were attended with success. 
Of the six survivors of excision at the hip performed on patients wounded during the 
American civil war, two oidy were living in the early part of 1879: Brown, of Grand 
Papids, Michigan (Case 261, ante), and Pease, of Indianapolis, Indiana, (Case 263, ante); 
both were examples of recovery from secondary excision. Brown can bear his weight 
upon the injured limb, can walk across a room without the aid of crutches or cane, but 
ordinarily uses a support. Pease, with the assistance of a "six-inch lift," can walk quite 
well with a cane. Tilliston, the third survivor of secondary excision, lived until Septem- 
ber 6, 1871, ten years after the operation. He was unable to bear any weight on his 
limb, and was obliged to wear crutches. He succumbed to most extensive necrosis of the 
pelvic bones and femur, with huge recurring abscesses. In the case of Cannon, the sur- 
vivor of primary excision (Case 206, ante), the limb was useless for purposes of locomo- 
tion. He died of diphtheria in 1865, eighteen months after the injury and operation. 
Of the two survivors of intermediary excision, Lieutenant J. M. Jarrett (Case 239, ante) 
went to his home in North Carolina, and was reported as doing well in September, 1864, 
ten months after the operation; walking about with a high-heeled boot and the aid of a 
cane. Persevering attempts to obtain further information regarding the ulterior history of 

three inches wi'le by twelve inches long, secured to the leg by adhesive straps ami connected through eyes, at their extremities, by elastic tubing, to a 
twenty-one pound weight, playing over a pulley. The tubing passed through a piece of board twelve inches long, secured below the foot piece, thereby 
preventing pressure on the malleoli. This arrangement answered the purposes of extension admirably, while counter-extension was effected by elevating 
the foot of the bed. The patient's convalescence was very tedious. He suffered from 
bed-sores and almost continuous pain, requiring the constant administration of opiates and 
anodynes : but gradually improved, and, on December 9th, Dr. HOST notes : " From this 
date there was scarcely an uutoward symptom. Convalescence progressed slowly but 
surely: stiluiess of the muscles disappeared entirely about the 15th instaut. Tympanitis 
lasted three days. Spasm persisted, but with greatly reduced violence, nearly two weeks 
after the extension-weight was removed, December 27th. The patient had daily exercise, 

FIG. 88a. — Excised uppcrcx- and, on Januarv in, 1878, took his first walk in the opes air. The discharge grew less in T .,.„ aQ i ««.*«i«—i r 

Iremity of right femur; anterior , ' , ... „ , '. , . ... n _,. ., !• IG. 8Bo.— Posterior \ lewot 

view Soec 6787 amount, and, on January loth, the dressings were entirely removed. 1 ebruary 17th, the the same. 

partial anchylosis of the right knee joint not having been full}- overcomo by passive motion 
and mechanical appliance, ether was administered and the adhesions thoroughly broken up. There was partial bony anchylosis, the patella at portion of 
superior external border was firmly joined to femur, and in the breaking down suffered fracture. The limb was placed in a straight splint, and on the 
third day passive motion was instituted. March 18, 1878, the patient was ordered to join his regiment. The false joint at the hip had all the motions of 
its predecessor in a somewhat limited degree, and, though capable of sustaining the patient's weight while walking, was not yet equal to any great exer- 
tion, but daily gained in strength. In other respects the patient's health was in admirable condition. Apparent shortening of the limb one inch. The 
resected upper extremity of the femur was contributed to the Army Medical Museum by the operator, and is numbered C787 of the Surgical Section. It 
is shown in the wood-cuts (FIGS. 88a, 8S6). In a letter to Dr. IIoiT, dated Fort Clark, Texas, April 3(', 1878, Sergeant Linn writes : " Dear Sir: I write 
to you according to promise to let you know how 1 am getting along. I am feeling just as well as ever I did. My leg is improving in size and strength, 
but the hip joint is just about the same as when I left you. 1 weigh one hundred and fifty pounds now and am still improving." On July 10, 1878, 
Surgeon JOHN MOOKE, U. S. A., Medical Director Department of Texas, forwarded to the Surgeon General two photographs showing the appearance 
of the limb ten months after the operation. They are copied in the wood-cuts (Flos. 87, 88) on the preceding page. In a letter from Fort Clark, Texas, 
October, 1878, I.inn states that he "don't use a crutch ut all, and only uses u cane when he goes to walk a long distance." 





SECT, n.] EXCISION AT THE HIP FOR SHOT INJURY. 125 

this officer were unavailing. The second survivor of the intermediary operation, Hugh 
Wright (Case 240, ante), excised May 27, 1864, walked well without crutch or cane, 
bearing his full weight on the mutilated limb. He lived until October 26, 1874; his 
death was ascribed to cardiac trouble. 

Of the six patients submitted to excision at the hip in the United States Army and 
Navy since 1865, four recovered. Assistant-Surgeon F. Meacham's primary case of Erne, 
4th Infantry, aged 48 (Note 1, p. 120, ante), operated on December 3, 1869, lived until 
November, 1871. The patient walked comfortably on crutches and had slight control of 
his limb. Recovering thoroughly from the coxo-femoral lesions, he became a great sufferer 
from chronic diarrhoea, and, at last, was attacked with acute mania. The other three cases 
were examples of successful secondary excision. In the case of Charles F. Read, 37th 
Infantry (Note to p. 122, ante), wounded June 6, 1868, and successfully excised by Assist- 
ant Surgeon J. R. Gibson, August 14, 1868, the result was exceptionally gratifying. In 
a letter from his home at Thornton's Ferry, New Hampshire, dated July 1, 1878, nearly 
ten years after the operation, Read was able to write that he thought he had a very good 
leg under the circumstances, and used no artificial appliance. His crutches he had laid 
aside since 1871, relying altogether on his cane, with which he "could get along very 
handily." He adds a minute account of the condition of the injured limb, showing indis- 
putably an extraordinary restoration of the functions of the articulation. "I can use it 
so well," says Read, "that some think me falsifying when I tell them that the head of the 
bone is lost." In the secondary case of the seaman, Charles B. Scott, wounded June 17, 
1870, on whom Surgeon W. E. Taylor, U. S. N., successfully excised the head of the femur, 
July 25, 1870, there was temporary relief. The patient regained comparative health and 
flesh, and partial use of the limb, exchanging his crutches for a cane; but necrosis invaded 
the articulation, and the patient succumbed July 1, 1877, while on a visit to his friends 
in Tyrone County, Ireland. In the case of Sergeant W. J. Linn, 4th Cavalry, wounded 
November 25, 1876, who underwent excision at the right hip by Assistant Surgeon J. V. R. 
Hoff, U. S. A., September 28, 1877; a year after the operation the patient's health was 
in admirable condition, and there was every prospect that the mutilated limb would regain 
as great a measure of utility as can be hoped for, under such circumstances. In October, 
1878, he had discarded the crutch, and only used a cane when he walked long distances. 

Of the sixty-six excisions at the hip performed during the American civil war, forty- 
five were practised on Union and twenty-one on Confederate soldiers. Of the forty-five 
Union soldiers, four recovered, a mortality rate of 91.1 per cent.; of the twenty -one 
Confederates, two recovered, a fatality of 90.5 per cent. 

The side on which the excision was practised was recorded in sixty-one of the sixty- 
six cases, twenty-six being on the right and thirty-five on the left side. Three of the 
former, or 88.4 per cent., and also three of the latter, or 91.4 per cent., proved fatal. 

Six operations, viz: one primary, four intermediary, and one secondary, performed 
on patients under the age of 20 years, terminated fatally; twenty excisions, viz: nine 
primary, six intermediary, and five secondary, on patients, between 20 and 29 years, 
inclusive, presented three recoveries, one after a primary, and two after intermediary 
operations; of thirteen operations on men between 30 and 39, six were primary, four 
intermediary, and three, with two recoveries, were secondary; four excisions were per- 
formed on patients over 40 years, two being fatal intermediary, and two, with one recovery, 



126 INJURIES OF THE LOWER EXTREMITIES. [CHAP. x. 

secondary operations. In twenty-three of the sixty-six excisions the ages of the patients 
were not ascertained. 

According to the statistical arrangement of the eases of excision at the hip lor shot 
wounds in the American civil war, as given in Table X, p. 89, ante, the mortality of the 
primary operations was 96.',) per cent., that of the intermediary 90.9 per cent,, while 
the fatality of the secondary operations was only 72.7 per cent. The results of the six 
excisions at the hip in the American Army and Navy since the civil war gave a mortality 
of 50.0 per cent, for the primary operations, of 100.0 per cent, for the intermediary, while 
the three secondary operations were all successful. Of the ninety-nine other cases of 
excision at the hip after shot injury, cited in Note 1, page 90, ante, of primary cases, 87.5 
per cent, proved fatal; of the intermediary all perished, while, of the secondary, only 66.6 
per cent, had a fatal termination. Aggregating all cases of excision at the hip for shot 
injury in which the results have been ascertained, we have a mortality rate of 93.0 per 
cent, for the primary, of 96.6 per cent, for the intermediary, and of 63.4 per cent, for the 
secondary operations. This result confirms what we have already stated on page 610 of 
the Second Surgical Volume, that the "excisions and amputations practised during the 
intermediary or inflammatory stage are by far the most dangerous, and should never be 
performed except as compulsory operations." The ratio of mortality in the secondary or 
ulterior operations is considerably less than that in the primary operations. But this fact 
should not lead to the conclusion that the primary operation is to be avoided. The dis- 
astrous results attending cases of indubitable shot fracture at the hip treated by tempor- 
ization, as pointed out on page 88, ante, must induce the surgeon to desist from such an 
experiment, and to excise primarily rather 1 than submit the patient to the danger of the 
inflammatory period. - 

In nine 3 of the sixty-six cases of excision of the head of the femur performed for 
shot injuries received during the American civil war, the acetabulum was involved, and, 
although these nine cases terminated fatally, the successful operations of Assistant Surgeon 
J. V. R. Hoff, U. S. A., in the case of Linn (Note on page 123, ante), and of Drs. Schon- 

1 Dr. Johx A&HHUBST, jr. (Print, and Pract. of Surgery, 1671, p. 165), declares tluit : "Gunshot injuries of the hip joint are universally regarded 
as among the gravest injuries met with in military practice, '' and, after reviewing the statistical and other evidence on the comparative advantages of 
expectant treatment, excision, and amputation, asserts that : " From these facts the conclusion is fairly drawn, that in any case of gunshot injury of the hip 
joint, primary excision should he preferred to any other mode of treatment, and this simply to increabe the chance of life, without reference to the utility 
of the preserved limb. Of course there may he such extensive destruction of ['arts as to put excision out of the question, and in such cases the surgeon 
must still have recourse to what IIennkx calls the ' tremendous alternative ' of hip joint amputation, an operation which may also be required secondarily, 
after an unsuccessful attempt to save the limb." Dr. "WILLIAM THOMSON', formerly Brevet Major and Assistant Surgeon, U. S. A., who, as Acting Med- 
ical Inspector of the Army of the Potomac and Surgeon-in-eharge of Douglas Hospital, Washington, had excellent opportunities to investigate the subject 
of shot fractures at the hip joint, wrote to the compiler in 1868 : * * " From a study of these cases, and others similar in character, it would appear that 
the fatal terminations, under expectant treatment, are due to the following causes : the joint becomes inflamed primarily or secondarily ; the capsule becomes 
distended by tiie products of inflammation, gives way, and the contents escape into the neighboring parts, and give rise to those extensive dissecting 
abscesses which are found at the autopsies, and which account so entirely for the fatal results. If these views should be accepted, a full and free incision 
into the joint, at an early period, would be the proper surgical procedure, and this is accomplished by its excision. The removal of the head of the bone 
severs, to that extent, the connection between the body and the lower extremity, prevents that constant disturbance at the joint that follows every 'motion 
of the body, and thus places the seat of injury at comparative rest. The division of the bone through its cancellated structure may increase the risk of 
osteomyelitis with its purulent infection, and experience may yet demonstrate that a full and free incision alone, in the primary stage, may be the best 
resource of surgery." — (Circular No. 2, S. G. O., 1869, p. 114,) 

2 LOSSES' (1.) (Kriegschir. Erf. aus Mannheim, Heidelberg und Carlsrtihe, in Deutsche Zeilschr. fur Chir., 1873, 15. II, p. 64) cites a fatal case of 
shot fracture of the neck of the femur and great trochanter, and remarks : "A primary resection of the joint, with removal or gouging of the trochanter 
major, might in this case have offered a chance for recover}'. But it was probably difficult to ascertain immediately after the injury how far the joint was 
involved. A secondary excision, from the general appearances (post-mortem) cited, gave very little prospect of success." FISCHEK (H.) (Kriegschirur- 
gische Erfahrungen, Erlangen, 1872, p. 201) remarks of shot fractures of the hip joint : " All well-timed operative interference miscarries on account of 
the difficulty of the diagnosis. . . I lament this difficulty and impossibility of exact diagnosis, because I believe that the best mode of treatment of 
shot fractures of the hip joint is the primary resection of the joint, however difficult the execution of the operation might he." 

3 Case 209, p. 93, Private Charles Beard, 12th Miss.; Case 224, p. 95, Sergeant S. Grimshaw ; Case 235, p. 98, Captain T. K. Robeson; CASE 
236, p. 98, Unknown private of the F'irst Army Corps; CASE 237. p. 99, Unknown; CASE 247, p. 105, Privato C. E. Marston, 1st Massachusetts; CASE 
257, p. 109, Corporal H. C. Sennett, 122d New York ; CASE 259, p. 110, Lieutenant D. N~. Patterson, 46th Virginia; Case 269, p. 118, Private A. Toner/, 
16th North Carolina. 



SECT. II. 



AMITI ATlONs AT THE II I I' JOINT. 



27 



born 1 and. Liupedeu, 2 prove conclusively that an injury of the margin of the acetabulum 
does not preclude the operation of excision at the hip. 

When we consider the evidence adduced in the foregoing pages, and especially the 
fad thai of one hundred and seventy-one patients on whom excision at the hip for shot 
injury is known to have been performed to the present date, twenty-three survived the 
operation, although in one instance the excision was followed by amputation at the hip 
(Xeudorfer's case of Schranz, Note 1, on page 90, ante), and that the remaining twenty- 
two survivors had more or less use of the injured limbs, it must be admitted that the results 
of this operation, so far, have been encouraging, in an almost hopeless class of cases. 

AMPUTATIONS AT THE HIP JOINT. -In 1867, in a monograph on amputa- 
tions at the hip joint, 3 it was stated that "fifty-three authenticated instances of amputations 
at the hip joint, performed on account of injuries inflicted by weapons or of lesions con- 
secutive thereto," had occurred during the American civil war. Since that time, data of 
thirteen additional cases of this operation have been obtained, making, at the present time, 
a total of sixty-six cases of coxo-femoral amputations to be considered here: 

Table XIV. 

Numerical Statement of Sixty-Six Canes of Amputation at the Hip Joint. 



AMl'l lATlOXS. 



Primary 

Intermediary 

Secondary 

Reamputations . 



Aggregate. 



Total casks. Recoveries 



Deaths. 



55 



Ratio of 
Mortality. 



88.0 

100.0 

77.7 

33. a 



83.3 



1 have continued to divide these sixty-six operations into primary, intermediary, 
secondary, and reamputations, according to the plan adopted in the monograph of 1867, 
and the relative percentage of fatality of the secondary operations and of reamputations 
confirm me in the opinion expressed at that time, that the reamputations "should be sep- 
arated into a distinct class, because they are quite numerous and widely ditl'er in the risk 
attendant upon them from other secondary operations." Of nine cases of reamputations 
at the hip three only, or 33.3 per cent., were fatal; of nine secondary operations six, or 
77.7 per cent., terminated in death. The subjects of the twenty-three intermediary 
exarticulations at the hip all perished, and of twenty-five primary amputations probably 
three were successful. 

As indicated in Table IX, page 65, ante, in twenty-seven of the sixty-six exarticu- 
lations the injury directly involved the hip joint. In thirty-two instances, the operations 
followed shot fractures which did not extend beyond the diaphysis of the femur. In two 
of this scries and in seven examples in which the primary lesion implicated the knee joint, 
amputations in the continuity of the thigh had preceded the exarticulations at the hip. 

1 SeeLANGEXRECK (B. von), TJcber die Schiissfracturen der Gclcnke und Hire Bcliandlung, IJcrlin, 1868, p. 10, nnd Cask 24 of Note 1 , on page HO. ante. 

*See DKININ'UK!:, Beitrdge zu den Schiissfracturen des Hiiftgehnks unter besonderer Berilcksichtigung der Erfahrungen aus dem Feldzuge 1870-71 
und Benutzung der Aden des KoniglicJien Kriegsminislcriums, in Deutsche Militairurztlichr. Zcitschrift, 1874, U, III, p. 300, CASE No. 37; and Case 
No. 63, in Note on page 91, ante. 

3 OTIS (G. A.), A Report on Amputations at the Hip Joint in Military Surgery, Circular No. 7, War Department, Surgeon General's Office, July 
1, 1807, Washington, p. 20. 



128 



INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 



In the subjoined foot-note 1 an endeavor is made to compile a correct record, in chrono- 
logical order, of the published authentic examples of amputation at the hip joint in military 

■LARREY (D. J.) (Mem. dt Chir. mil. et ('amp., Paris. 1812, T. II, p. 180), A soldier of the French army of the Ithine, in 1793. Primary operation; 
died within a week. — 2. WEXDELSTADT (Keminzscenztn, in IlUFELAXi>"s Xeues Journal der Practischen Arzneyl m unde, Berlin, 1811, B. XXVI, Stack 
IT, p. 110) relates: " I have seen and examined an Englishman, who served as a sailor in the British Navy, and who had lost at the bloody battle of 
Aboukir, August 1, 1798, the thigh from a cannon ball, and who had undergone, the amputation of the probably splintered stump out of the acetabulum, 
and who survived the operation want/ years." — 3. LARREY (D. J.) {Rel. chir. de VArmee d' Orient, Paris, 1803, p, 329), Bonliomme, officer of the 16th 
Demi-Drignde, Army of Egypt, 1709. Primary exarticulation at right hip; died of the plague on the eighth day. — 4. LARREY (D.J.) (Eel. chir. de 
VArmee d' Orient, 1S03, p. 332), Drummer of 2d Light Demi-Brigade, Army of Egypt, in 1799, aged 20. Primary amputation at right hip ; died in a few 
days. — 5. LARREY (D. J.) (Mem. de Chir., etc., 1812, T. Ill, p. 350), A French soldier at Wagram, July C, 1809. Primary operation; died in three 
hours.— 0. Larrey (D. J.) (Mini, de Chir., etc., T. Ill, p. 331), A French soldier at Wagram, July fi, 1809. Primary operation; died within twenty-four 
hours. — 7. BRO\v\Rir;c. (GUTHRIE'S Commentaries, (1th ed., 1855, p. 62), A soldier at Elvas, 1811. Secondary operation ; died in eight days. — 8- LaRREY 
(D. J.) (Mem. de Chir., etc., 1817, T. IV, p. 26), A Russian soldier, in 1812. Primary amputation at left hip ; died on the twenty-ninth day from dysen- 
tery. — 9. LARREY (D. J.) (Mem. de Chir., etc., 1SI7, T. IV, p. 50), Lieutenant of Dragoons, Borodino, September 7, 1812. Primary; alive and well at 
Oreha three months after. — 10. BROVv'XklCO (AVEBILL (C.) (A Short Treatise on Operative Surgery, London, 1825, p. 217). Private 13th British Light 
Dragoons, December 29, 1811. Secondary operation December 12. 1812; recovery. — 1 1. BttOWXBIGG (Averii.t., loc. cit.), Particulars not recorded : fatal. — 
12. GUTHRIE (O. J.) ( Treatise, on Gunshot Wounds, 1827. p. 332), Private Mason, 23d British Infant ry, in 1812. Secondary re-amputation ; death in seven 
hours.— 13. CoorEit (SAMUEL) (Diet. Pract. Surg., 8th London ed., 1861, Vol. I, p. 110), A British soldier at Oudcnbosch, in Holland, in 1814. Inter- 
mediary operation; died in a few minutes. — 1-1. CORK (CI. J. GUTHKIE, loc. cit., p. 351), A soldier at Bergcn-op-Zoom, 1814. Secondary operation; died 
in twenty hours. — 15. Emery (GUTHIHG, loc. cit., p. 334), Sebastian de l'Amour, Corp. Chass. Britt., Spain, August, 1813. Secondary operation July 
21, 1814 ; death in thirty days.— 10. GUTHRIE (G. J.) (A Treatise on Gunshot Wounds, London, 1827, p. 342), Duguet, 45th French Regiment, aged 25, 
Waterloo, June 1H, 1815. Intermediary operation July 7th: reeoverod. Duguet died in 1840 (GUYOX, Stat, des amputations pratiqucrs a VArmee 
d'Afrique, etc., pendant tes annees 1837, 1838, rt 1839, in Gaz.Mcd.de Paris, 1841, T. IX, p. 106).— 17. Mr. BEICKE (J. THOMSON, Obs. after the Battle of 
Waterloo. Edinb., 1810, p. 270), A British soldier, Waterloo. 1815. Secondary operation; died in eight days. — 18. B. Broi>IE(G. J. GUTHRIE, On Gunshot 
Wmtnds of the Extremities, London, 1815, p. 110) operated, in 1814, unsuccessfully in a case of accidental shot wound. — 19. QUARR1ER (D.) (Med. Chir. 
Trans., 1820, Vol. VIII. p. 3), Seaman T. Sullivan, Algiers, 1810. Primary operation; death in fifteen minutes. — 20. KREMER (Exarticulation des 

Oberschenlels aus dem Huftgelenlc, in Journal der Chiritrgie, von C. F. von GRAEFE und Ph. v. WALTHER, Berlin, 1828, B. XII, p. 121), J. S. C , 

aged 38, Waterloo, 1815. Exarticulated in 1822; died on the tenth day. — 21. Pr. Sl'ER (ROUX (J.), Disarticulation de la cuisse d'apres des observations 
rec. a Saint Mandricr, Paris, 1800, p. 4), A galley prisoner at Toulon, in 1825; fatal. — 22. DEEEFEXEACH (J. F.) (Mag. fur die gesammte Ileilkunde, B. 
X XIV, 1 1, S. 335), A Baron, aged 22. Secondary operation in 182G ; died in ten hours. — 23. Dr. BUYCE { Glasgow Med. Jour., 1831, p. 262), Soldier, aged 
23, at the siege of Athens, May, 1827. Recovery in six weeks. — 24. ROVX (P. J.) (Gaz. des Bop., 1830. p. 392), A Swiss subaltern, in 1830. Primary 
operation ; died the same day. — 25. CLOT Bey (Gaz. des Hop., 1830, T. IV, p. 96), Ali Homer, an Arab, aged 26. Secondary operation in 1830 ; died 
November 17, 1830.— 26. Seiheeot (C.) (Ann. de la Chir. Franc, et Et., 1841, T. II, p. 279), A'Russian prisoner; Poland, 1831. Primary; died soon 
after the operation. — 27. The elder DEMME (VERDAT, These inavg., Berne, 1846, and A. LOxixo, ijber die Blutung bei der Exarticulation des Ober- 
schenlcels, Zurich, 1877, p. 69), Polish solder, in 1831. Intermediary operation ; death in thirteen days. — 58. Surgeon AUXOLD (A. LUxiXG, loc. cit,, p. 69, 
and VERDAT, These inaug., Berne, 1846), Russian soldier in Polish War, 1831. Ligation of common iliac by Dr. DEMME. Intermediary exarticulation 
at hip; death on the third day. — :?. Dr. FRANCKE (A. LOxiXC, loc. cit., p. 69, and FRAXCKE, Diss., Leipzig, 1835), Russian soldier, A. Pasgczuk, aged 22, 
Warsaw, Sept. 7. 1831. Operation Sept. 23, 1831 ; death in two days.— 30. The elder DEMME (A. Luxixo, loc. cit., p, 08, and Verpat, These inaug., Berne, 
1846), Polish soldier, in 1831. Intermediary operation; death from gangrene on fifth day. — 31. LETULEE (H. LARREY, Hist. chir. du siege de la Cit. 
d'Anvcrs, 1803, p. 307), A French cannonier of tlie 11th regiment of Artillery. Siege of Antwerp, 1832. Primary operation December 13th; died Decem- 
ber 22, 1832. — 32. 33. During the campaign in Syria, in 1832, two exarticulations at the hip were performed, one by VOX WELZ, the other by ClIEEUKiXi. 
Both were fatal (M. JJEdFAi in Dr. W. Waltiier's Handwortcrbuch der Gesammten Chirurgie, Leipzig, 1836, B. I, p. 409). — 34, 35. AECOCK (R.) 
(Notes on the Med. Hist, and Stat, of the British Legion in Spain, London. 1838, p. 78) relates that he was informed by Dr. BEEMUXT that an accom- 
plished Spanish surgeon had twice amputated at the hip joint during the Peninsular War of 183" — once with success. — 36. HUTIK (F.) (Rec. de Mem. de 

Med. de Chir., etc., l rc s6rie, T. XLIV, p. 219), M , a soldier of the 1st Light Battalion, C'onstantine, 1836. Primary amputation ; Manec's method; 

died December 13, 1836 —37. Ilunx (F.) (Bee. de Mem. de Med. de Chir., etc., T. XLIV, p. 220), L , 2d Regiment of Engineers, Constnntine, 1836. 

Primary operation ; died December 4, 1836. — 38. BAL'DEXS (L.) (Clin, des plaies d'armes a feu, Paris, 1836, p. 517), C . a soldier in the Battalion 

d'Afriqne, 24 years old, Algiers, 1836. Intermediary operation; recovered, and was an inmate of the Hotel des Invalides in 1840 (SEDIEEOT, Amp. coxo- 
femorale, in Bee. de Mem. de Med., 1840. T. 49, p. 276). — 39^11. From the tabular statement of Dr. Gt'YOX (Statistique des amputations pratiquies d, 
Varmee d'Afrique, etc., pendant les annies, 1837, 1838, et 1839, in Gaz. Med., 1841, T. IX, p. 105) it appears that no exarticulations at the hip were per- 
formed during these years j but Dr. GuYOX states (loc. cit., p. 106) that three unsuccessful amputations at the hip were performed in 1841. — 42. IlAUDEXS 

(L.) (Bee. de Mem. de Med. de Chir., etc., 1853, 2 mc se>., T. X, p. 130), X , a soldier of the 18th Light Infantry, Paris. 1848. Primary operation ; 

death on the second day. — 43. VlDAE (Alt..) (Traite de Path. ext. et de MM. op., 5 me 6d M Paris, 1801, T. V, p. 731), A French student of medicine, 
insurrection in Paris in 1848. Secondary exarticulation ; fatal. — 44-46. During the same revolution RlCHET (M. E. IIervieux, Compte rendu des blessis 
rectus a I ambulance des Tuileries. in Gaz. Med. de Paris, 1848, p. 712) performed a primary operation which proved fatal ; and P. C.UERSAXT and UOUERT 
(L. LEGOUEST, Traite de Chir. d'Armde, 1863, p. 700) had each an unsuccessful intermediary operation. — 47. RESTELLI (F. BAROEFIO, Belle Ferite dVarma 
da fuoco, Torino, 1862, p. 284) performed a successful exarticulation in 1818, after the insurrection in Lombardy. — 48. Trezzi (GrITTI ROCCO, Delle 
Fralture del Fcmore par arma da fuoco, Milano, 18G6, p. 80) operated unsuccessfully on an insurgent at Milan in March, 1848. — 49. C. TEXTOlt (G. B. 
Gl t EXTIU-:r, Die Blutigen Operationen, Leipzig, 1859, Abschmitt VIII, p. 180), Exarticulation for shot fracture of the neck of the femur in a patient aged 
32, in 1848; death from pya?mia. — 50. TEXTOR, the younger (GtixTHER, loc. cit., p. 180), performed an intermediary operation in 1848; death on the 
fourth day. — 51. ltoi'X (P. J.) (Des plaies d'armes a jeu. Communications faites, etc., par BAUPENS, ROUX, etc., Paris, 1849, p. 38, and Gaz. des Hop., 
1848, p. 513) had, in June, 1818, a secondary fatal operation. — 52. LlXHART (W.) (A. LOxiXG, loc. cit. t p. 75, and EsCHE, Diss, inaug., Wtlrzburg, 
1863, p. 11), in 1848, in a case of shot comminution of the trochanter, ligated the femoral, and afterwards exarticulated at the hip. The patient died 
shortly after the operation. — 53-59. During the Sclileswig-IIolstein War, 1848-50. seven exarticulations at the hip were made. Prof. B. von Lanoexbkc'K 
(tjber die Schussfracturen der Gelenlce, Berlin, 1868, p. 19) performed four of the seven operations : J. Seibold. drummer in Tann's corps, aged 18, 
wounded at Hoptrup. June 7, 1848 ; operation June 8th; patient hale and hearty in 1856. Anders Nielson, 2d Danish Jaegers, aged 26, Sohleswig, April 
23,1848; operation April 24th; death May 21st. Niels Andersen, 4th Danish Infantry, Schlcswig, April 23, 1848; operation May 14th; death May 20, 
1848. Danish soldier, wounded at Ban, April 9, 1848; operation June 20th : death June 21, 1848. The other three operations of this campaign proved 
fatal; no further data are noted (L. Sti;omeyer, Maximem, 1861, p. 53J). — 60. LEXTE (F. D.) (Transactions Am. Med. Association, 1848, Vol. IV, p. 
316), J. Dalzell, aged 23. Astor Place Riots, New York, 1849. Primary operation; died May 12, 1849.— 61-63. In the War in the Punjaub, 1848-49, 
three primary operations were performed. Dr. McRae (Indian Annals of Med. Sci., 1857, p. 663) states that the patients died — one in six, one in twelve, 
and one in thirty-six hours, from shock. — 64. BKC'K (I>.) (Die Schusswunden, Heidelberg, 1850, p. 315), Soldier of the 2d Baden In&ntry, wounded June 
29, 1849, in battle, at the Murg. Secondary operation: death six days after operation. — 65. FAYREU (J.) (Clinical Surgery in India, London, 1866, p. 
630), Moting Schwe-Mo, a Burman, aged 30. Rangoon, Bengal, February 15, 1853. Primary amputation at left hip February 16th ; death March 17, 
1853. — 66. Dr. Beatsox (Uaxkixg's Abstract, 1855, No. 21, p. 182). Thomas Lisbey, aged 61. Conductor in the Ordnance Department, Donnabew, 
March 19, 1853. Exarticulation of left hip March 25th; died March 25, 1853. — 67-110. Of the forty-four exarticulations at the hip performed during the 



SECT. n. j AMPUTATIONS AT THE HIP .TOTNT. 129 

surgery aparl from the sixty-six cases that pertain to the American civil war. This cate- 
gory comprises one hundred and eighty-four cases, of which the results are ascertained in 

Crimean War. two were done in the Sardinian army, eight by Professor N. Pirouoff (Grandzugc der Allgamciucn Kriegsch., Leipzig. 181.1. p. 1137), in 
the Russian tinny, fourteen in the British army (MATTHEW, loc. cit., p. 374), and twenty in the French army (J. C. CHEXU, Rapport med. chir. dc Camp, 
d'Orient, 1805, p. 658), POKTA states that the two eases in the Piedmontese army were fatal. Of PlKOGOFF'fl eight cases two survived five days and 
the others perished within two or three days. The operations in the English army were all primary and resulted fatally. The results of the operations 
in the French army were equally unfortunate; all the patients died. Of twenty-two of the forty-four eases it is only recorded that they had a fatal 
termination. The particulars of the other twenry-two will hero be cited: Alexander (T.) (Gl-THKIE's Comment., 6th cd., p. 620) disarticulated at the 
hip. in the case of Peter Cleary, 23d Fusileers, for gunshot fracture of femur, Alma, Sept. 20, 1854. Operation Sept. 21st ; patient died on the passage to 
Scutari. ALEXANDER (T.) (G. J. (iL liiltlE. Commentaries, 6th ed., 1855, p. 620), A Russian prisoner, Alma, Sept. 20, 1834. Primary operation Sept. 
2£d, died Oct. 22, 1834. Alexander (T.) (G. J. Gethrie, Inc. cit., p. 620), Peter Sullivan, 33d British Infantry, Alma, Sept. 20, 1854. Primary opera- 
tion Sept. 21st; died Oct. 11, L854, McKEXZIE (II.) {.MacLeod, Notes on Surgery in the Crimea, London, 1858, p. 369), Soldier, Alma. Sept. 20, IP54. 
Primary operation ; died. Assistant Surgeon WYATT (T. 1*. MATTHEW, Med. and Surg, Hist, of the British Arm;/ in the Crimea, London, 1858, Vol I, 
p. ill), An officer of the Coldstream Guards, Inkermaun, Nov. ,*i. 1854. Primary operation; died immediately after the operation. Mounter (in C hem's 
Rapp. med, chir. sur. la Camp. d'Orient, I.8C5, p. 660), GarassiwofT, a Russian prisoner, Alma, Sept. 20, 1854. Intermediate operation Sept. 27th ; died 
Sept. 2iv 1834, two days after the operation. Le<;oee>t (L.) (M6m. de la Soc. de Chir., 1803, t. V, p. 157), Ignatius Wolokenski, 5th Russian Infantry, 
aged 30, Alma. Sept. 20, 1854. intermediary amputation at left hip October 3d; died Feb. 1), 1855. MOUNIER ((.'MENU, loc. cit., p. 660), Chiflttzoff, a 
Russian prisoner, Inkermaun, Nov. 5, 1854. intermediary operation November 5th; died December 2, 1854, one week after the operation, Paulet 
(CHENir, Joe. cit., p. 661), Soldier. Primary operation in 1855; died one hour after the operation. Lestremax (Chene, loc. cit., p. 661), Soldier. 

Primary operation in 1855; died five hours after tl Deration. Thomas (Chexu, Joe. cit., p. 661), Soldier, gunshot fractureof the femur, 1855. Primary 

operation : died five hours after the operation. Thomas (( hem. toe. cit., p. 661), Soldier, 1855. Primary operation ; died eleven hours after operation. 
I'kkimn (CllKNU, !<>r. rit.. p. 660), A private of the 33d French Infantry. Fracture of left femur July 5, 1855. Primary operation a few hours after 
injury; died in one or two days. Fraxki.yx (T. P. MATTHEW, Joe, cit, Vol. I. p. 377), A private of the 77th British Infantry. Sevastopol. August, 1855. 
Primary operation; died twenty-two hours after the operation, from exhaustion. Dunloe (T. P. Matthew, loc. cit., Vol. I, p. 403), A soldier of the 
88th Regiment Connaught Hangers. Primary operation ; died soon after the operation, in November, 1855. Surgeon-Major Tltoi'SDELL (It. Dltl ill. 
Surgeon's Vade Mecum, 1805, 9th ed., p. 160), A private of the 50th British Regiment, Sevastopol, 1855. Primary operation; died the day after the 
operation. Mounter (Chexu, loc, cit., p. 660), Pietrow, a Russian prisoner. Inkermann, Nov. 5, 1855. Secondary operation Dec. I'.th; died Dec. 29, 
1854. Lauiyierk (ClIEXU, loc. n't., p. 660), Kerigla.a Russian prisoner, Traktir Bridge, Aug. It), 1855. Intermediary operation Aug. 23d ; died August 
2:!. 1865, during the operation. Mae<;ee (CHEXU, loc. cit., p. 661), A Russian prisoner, Traktir Bridge, Aug. 16, 186-7. Intermediary operation; died 
soon after the operation. SALLERON (Mem. de Med., de Chir. et de J'har. Mil., 2 m8 ser., T. XXI, p. 317), A soldier. Sevastopol, 1855. Intermediary 
operation (1); died twenty hours after the operation. Sallerox (Mem. de Med., dc Chir. et de 1'har. Mil., 2"" s6r. t T. XXI, p. 317), A soldier, Sevasto- 
pol, 1855. Intermediary operation (.'); died sixty hours after the operation. Chief Surgeon Marroin, of the French Navy (J. RoEX, Disarticulation dc 
la cuisse, Paris, 1860, p. 4), disarticulated, in the case of a soldier of the Crimean army, for fracture of the greater trochanter. The jiatient died shortly 
after the operation. — U 1-112. Professor J. F. HEVEELDER, chief surgeon of the Russian army in Finland, in 1855 (Die Vcrwundungcn itnd Operational 
in Folge des Bombardcments von Sccaborg vom 9-11 Aug.. in Deutsche KUnilc, 1855, II. 7, pp. 530-533) exarticulated twice at the hip. A Finnish soldier, 
wounded at Sveaborg, August, 18;">5; primary amputation at left hip; died in two hours. Stanislaus Mulct zki, 8th Finnish Bat., shot fracture of neck of 
left femur, Sveaborg, Aug. 9-11, 1855; primary operation; patient died in less than an hour. — 113-115. BEBTREEAKl) {Camp, dc Kabylic, Paris, 1662, 
pp. 145, 238, and 380) gives three examples of disarticulation at the hip: A , 60th Line, wounded June 20, 1854 ; fracture of neck of femur, disartic- 
ulation, by Dr. GlLGENCKANTZ, July 14, 1854 : death on the same day, before recovering from the effects of the chloroform. C , 90th Line, shot frac- 
ture of neck of femur, Algiers, May 21, 1857 ; secondary disarticulation ; died on the day of the operation. W , 2d Legion ctrangerc, shot fracture of 

neck of right femur; disarticulation by Dr. TabouKET; fatal. — 116. BERTH ER AND (A.) (Camp. & Italic, de 1859, Paris. I860, p. 37), An Austrian soldier, 
a prisoner after the battle of Palestro, June 4, 1859, Intermediary operation ; died three hours after the operation. — 117. Arlaed (J. C. CllENU, Camp, 
d'ltalieen 1859 et 1860, T. II, p. 697), Lotus Legallo, Fusileer, 84th French Regiment, age 25, Montebello, May 20, 1851V Secondary cxarticulution at 
right hip; recovered. — 118. IsSARD (J. C. CHENE, Ux: cit., p. 694), Captain Deshayes, 73d Regiment, Solferino, June 24, 1859. Secondary exartieula- 
tion at left hip; recovery. — 119. ROUX (Jills) (Ciienl, Camp, d' Italic, en 1850 et 1860, T. II, p. 097), Lieutenant Joseph Vitarel, 65th French Infantry, 
aged 24, Magenta. June 4, 185!'. Secondary amputation at left hip ; recovered. — 130. NeudoreeR (J.) (Handbuch der Kricgschir., 1872, B. II, Abth. II, 
S. 1468), Johann Sehranz. 7th Jaeger. Neck of femur, Palestro, May 30. 1851V November 27th. excision at left hip joint. December 1st. amputation 
at hip joint. Neudorfer saw the patient in 1868.— 121. NEEDOREER (J.) (loc. cit., p. 1467), Jurko Katseh, of Inf. regiment K. II. Stephan, Solferino, 
June 24, 1859. Right trochanter. Operation, August 8th, seventy-six days after the injury ; died August 25, 1851V — 122. NeedoREEU (J.) (toe. cit., p. 
1468), Walland Waskanodor, Co. 13, of Baron Rossbaeli's Regiment, Solferino, June 24, 1850. Fracture of upper third of femur. Disarticulation Dec. 
31st (one hundred and ninety days after injury); died four months later. — 123. ScOTTI (G. B.) (GBITX1 ROCCO, Frat. del fern, per arma dafuoco, Milano, 
1866, p. 80), An Italian soldier. Gunshot fracture of femur, Solferino, June 24, 1859. Intermediary exarticulation in July, at Ospitale San Francesco, 
Brescia; died. — 124. TASSAXI (GeMTI ROCCO, loc. cit., p. 80), An Italian soldier. Shot fracture of femur, Solferino, June )>4, 1859. Intermediary ampu- 
tation at hip at Ospitale Maggioro, Milan, July, 1859; died. — 125. (iHERlNI (GlUTTI Rocco, loc. cit., p. 80), An Italian soldier. Gunshot fracture of the 
femur, Solferino, June 24, 1859. Disarticulation about July 26th, at Ospitale San Filippo, Brescia ; died. — 126. JOHNSON (T. D.) (Amputation at the Hip 
Joint, Recovery, in Pacific Med. and Surg. Jour., N. S., Vol. IT, 18C8-69, p. 305), A man of San Juan, Monterey Co., received a shot from a Colt's revol- 
ver, in July, 1862; ball shattered the entire shaft of femur. Dr. JOHNSON" exarticulated two days after the injury. The patient recovered, and was still 
living, in 1868, at the New Almaden mine, in Santa Clara County. — 127. VlLLACRAX (J. M. B. de) (Observacion dr. una hcrida de arma defuego situada 
en el 7nuslo izquicrdo complicada con fractura comminutiva del femur: dcsarticulacion coro-femoral a los 180 dt'as, y muerte del enfermo a los 259, in 
Gaccta Medica de Mexico, 1865, Vol. I. p. 161), Roman Medina, age 26, shot Nov. 2, 1863, in the left thigh, and admitted to hospital at San Pablo, Nov. 8, 
1863. Disarticulated May 11, 1864; death July 29, 1804.— 128-129. Laxoexreck (B. von) (Schussfracturen der Gelenhe, Berlin, 1868, p. 20), Danish 
soldier, wounded at Alsen, June 29, 1864; disarticulation July 1st; died July 8, 1864, of septicaemia; and Danish soldier, wounded at Alsen, June 29, 
1864 ; disarticulated at right hip June 30th ; death July 5, 1864.— 130-131. LAXGEXBKCK (B. von) (Die Schussfracturen der Gelenhe, Berlin. 1868. p. 21), 
Austrian soldier, wounded at Koenigsgratz, July 3, 1806; exarticulated at left hip July 10th; death July 14, 1866, of septicemia. Austrian soldier, 
wounded at Koenigsgriitz, July 3, 1866; amputation at right hip July 17th ; death July 24, I860.— 132. LlNHART(W.) (BECK. B., Kricgschir. Erf., 1867, 
p. 340) performed secondary disarticulation at the hip in 1806, at Wurzburg, for comminution of upper part of femur. Patient died a few hours after the 
operation. — 133. FISCHER (K.) (Militairdrztliche, S/cizzcn, Aran, 1867, p. 78) mentions a case in which disarticulation at the hip was performed unsuc- 
cessfully for haemorrhage, in the Austro-Prussian campaign of J 866. — 134. IlEYFELDER (J.) (Gaz. med. de J'aris. 1867. p. 511) states that an unsuccessful 
disarticulation at the hip was performed at the hospital at Nedclischt. in charge of Dr. WlLDE, after the battle of Koenigsgratz, July 3. 1866.— 135. 
MaNNEL (OTTO) (Kricgschirurgische Iieobachtungen im, Cadetenhaus Kriegslazareth zu Dresden, in Allgemeinc Wiener Med. Zcituug, 1867, Jahrg, XII, 

p. 403), Musquctier B , 1st Thiiringian Infantry, No. 31, wounded July 3, 1866, near Hradeck, in the left femur. Kxarticulation October 4. 1866. by 

Stabsarzt Dr. KUHXK; died October 8, 1866.— 136. Dr. J. Heyfelder (Gaz. Med. de Paris, 1867, p. 540) reports that a second amputation at the hip 
was performed at the hospital at Hradeck, in 1866, which proved fatal in ubout forty-eight hours. — 137. Fayrer (J.) (Gunshot Wound ; Amputation at 

the Hip Joint, in Edinburgh Med. Journal, 1808, Vol. XIII, II, p. 793), Lieutenant H , shot accidentally, on the Island of Ceylon, Sept. 12, 1867, over 

the left tuber ischii, ball lodged ; fracture of neck of femur not detected. Exarticulation at left hip Sept. 25th ; died three hours after the operation. — 
138. ASHIIL'EST (JOHN, jr.) (Case of Amputation at the Hip Joint for Gunshot Fracture of the Head and Neck of the Femur, in Am. Jour. Med. Set., 1869, 

Surg. Ill— 17 



130 INJURIES OF TIIK LOWER EXTREMITIES. [CHAP. X. 

one hundred and eighty-three, presenting sixteen recoveries. We thus arrive at an aggre- 
gate of two hundred and fifty eases of exarticulation at the hip as the present status of 
This grave mutilation in military surgery, with twenty-seven recoveries, two hundred and 
twenty-two deaths, and one example with unknown result, or a mortality rate of 89.1 per 
cent. We will next notice the details of the sixty-six cases of hip joint amputations of 
the American civil war as classified in Tabu-: XIV. _ 

Vol LVII p. 94), E. 11 , Irish worn™, aged 23, shot in the right hip. in Aug., 1867, at Taeony, Pennsylvania. Exarticulation on Jan. 14, 1868, death 

in three hours.-139. Cabothebb (A. B.) t Amputation at Ike Hip Joint, in Am. Jour. Med. Sci, 1873, Vol. LXV, p. 92). Juan Bianco, aged 14 ; Salnllo, 
Mexico, Dec-. 5, 1871. Intermediary operation Dec. 15th; recovery.-At lot fortyfour exarticulation. at the hip were performed during the Franc,, 
Prussian War 1870-71 .-1 40. Dr. ROlTBL (Deinlngf.r, Bcitragc. zu den Schussfracturcn des Buftgelenks, etc., in Dent. Mil.-arztl. Zeitschr 18,4 B. II I, 
p. 304), Cbr. Lucia. 3d Brandenburg Field Art., shell laceration, received at Ar.enay, Dec. 3, 1870. Eolation at right hip Dec. 4th, d.edshort.y after 
theo,*mtion Dec. 4,1870.-141-143. GeneraloBtDr.BBBCH (Zweiter CangratderDeuts^GamiChitftM^r^oBerXtnKltn.Wmhemch^S^.X, 
p "73 and DKSKOEE, f«c. c«., p. 30C) performed three cxarticulations at the hip , Aug. Hensel, 2d Pomm. Grenadier Iieg't , fracture of right femur, Mete, 
Oct 14 1870; operation Oct. loth, death immediately after operation. No particulars of the other two unsuccessful cases arc M-ecorded -144-14, MAC- 
COBMAC (W.) (Xotesand Recollection* of an Ambulance Surgeon, etc., London, 1871, pp. 78, 79), Guerieri, 4th Marines, wounded at Sedan, Sept. 1. 1870. 
Left tibia and upper partof left femur smashed. Admitted to Asfeld hospital Sept. 10th , operation Sept. 18th , death shortly after the opera,,™ "P^nde 
wound of back par, of ieft thigh by explosion of .hell. Admitted to Asfeld hospital Sept. 10th , operation Sept. 15th ; death in six days. Dr. MacCokmac 
(for cit., p. 80) s'a.es that Mr. BLBWTTT disarticulated the hip at Balan, "but with no better result than our two cases," and, on page 123 enumeratesamong 
the operations at the field hospital at Floing, under Generals.absarz, STBOMETEB, another hip join, exarticulation w„h m *»°J™^„£;J^"™ 
also refers to twoexarticulations by Dr. Frank, and cites MacCORMAC as authority. The latter (loc. cit,, p. 46), however, only states that he Dr.FBAKK 
crwal o me there were twocascs where operations should have been performeda, ,he hip join,, hut this had .0 be leftundonofor want o, assistance,' 
H8 Ober-Stabs-arz, NBUBBB (Dein.ngfr, loc. cit.. p. 308) exarticulated in the case of August Schmidt, 70th French Line, shot fracture of femur Aug. 
18 1870 ■ died .Sept. 7 1870.-14!). Ober-Stab.-a.xt Dr. LlPPFL (DEINI.NGEK, loc. cit., p. 308), at the 8th field hospital of the Tenth Army Corps, a . Pont 
a Mousson, exarticulated for gangrene in the case of Louis I.ecoque, shot in the soft parts of the leg; death four hours afterthe operation.-loO. Dr KO, , 
(DBffl^ lor. cit., p. 308), at the hospital at Maizcry, Private Andreas WUcsynski, 44th Infantry, shot fracture of the nght femur immod.a.clj 
below the trochanter, August 31, 1870. Exarticulation October 23, 1870 ; died of dysentery October 31, 1870.-151. Dr. SACHS Deininger, loc. cit.. „ 
306) at the 9th field hospital of the First Army Corps, at Ees Etanges, case of J. Nikelski. private, 12th Co.. 43d Infantry; shot fracture of nght femur , 
baU lodged. Metz, Aug 14, 1870. Exarticulation Sept. 20, 1870; death, from pyemia, Sept. 25, 1870.-152. Dr. HBAXIBH, at th. -hospital a Neudo rf 
Dr ,v,m,fb loc cit. p 306), disarticulated in. the case of Private II. Malton, 66th French line, shot in the left femur August 0, 1870. Operation Sep,. 
7th • death on day of operation .-153. Generalarzt Dr. Wagner (DELNLnger, loc. cit., p. 306), at the 8th field hospital, First Army Corps, at Gras, I nva e 
M. Buddrus, Co. 2. East Prns. Often., No. 1 , shot fracture of right femur near trochanter major, with extens.ve ■"WJ>f_*l>° «°? P arts '.f ^'^ at J ?« ^ 
Sept. I, 18 

::r::;::,;:^;=^ 



m Exarticulation Sep,. 17th ; died upon the operating tahle.-154. Assistant Surgeon TrendelesbERG (DBKWOBB, loc. cit p. 306) of the 
,spi,al Third Army Corps, at Vionville. case of Adolph Marshall, private, 52d Infantry. Shot fracture of left knee joint August 16, 1870 ; 
e suppuration. Exarticulation August 28, 1870 ; death on the same day.-155. Dr. Metzler (DEININGER, loc. cit., p. 300) at the Hesrian fie ,1,1 
ho:;,:, No." aLux la Grange, emulated at the hip in the case of L. Xouveau, 73d French line, wounded Angus, 18 18 Operate Au* 19,1, : 
death two hours after opera.ion.-150. Dr. Raynaud (Gillette, Remarque, sur les blessures par armes a feu observe pendant la siege de Metz (18,0), H 
celui de Pari, (1871) in Arch. qin. de Mid., 1872, T. XX, p. 571, and CH. PILLET, De la suppression de la compression digitate prehminaire etc., 1 aris, 
,873 p. ,14, exarticulated at the left hip in a young garde nationale, aged 19 ; death in a fewhours.-157. Dr. WtESEMES (B. BECK, Chir. dcr Scau^crM- 

~un.cn Freiburg 1 872, p. 855). W . 67th Infantry, wounded before Taris, December 21, 1870, by a shell, fracturing femur to neck. Primary operation ; 

death in twenty four hour S ._158. HUETER (Berlin. Klin. Wochenschrift, 1873, p. 250) operated on a French soldier for extensive fracture of femur. The 
patient died suddenly on the following day from venous luemorrhage.-159, 100. IKehiib ( Verhandl. dcr mil.-arztl. Gesellschaft m Orleans 18,0-71, in 
Pent m-arzll Zeitschrift, 1872, B, I, p. GO), Fracture of femur just below trochanter, arterial bleeding; ligation of iemoral ; secondary hemorrhage , 
exarticulation ; died during ,he operation. Another case proved fatal in a few day.,-161. OTT (Kriegsclnr. Mittheil. aus dem Reserve La*. £*"£»» 
1871 p 52) Hailes, a French soldier, wounded a, Vionville, Aug. 16. 1870, in right femur close to trochanter. Exarticulation Sept. 24 1870 ; death a 
few hour, after the operation.-162. Simon (G.) ( Verhandl, des Zioeiten Congress dcr Deut. Gesellshaflfur Chir., in Berl. Khn. ^hensdir 18,3 B. X, 
n 261) French officer; fracture of femur-osteomyelitis. Secondary exarticulation, fatal in three day s.-l 63-107. Rbppbecht (L.) (Mil. arztl hrf 
etc im Jahre 1870-71, Wilrzburg, 1871, p. 75) states that four unsuccessful exarticulations at the hip-three primary, one intermediary-were performed 
a, ','he Bavarian fie.d hospi.al No. 8, during September and October, 1870. and that a later operation at Veneres also resulted W~£«jM"K 
(flapper, sur Vambulance de Vancien corps legislat. du, 19 Sept., 1870, .. 31 Janv., 1871) oxart.cula.ed on December 2, 1870, in the case of D.schamp, d 
Zouaves for shot fracture of the right femur with injury of th. large veins and of the hip joint; fatal.-lfiO. Dr. J. AHHOLD {Anat. Beilrage zu *» 
Schusswunden, Heidelberg. 1873, p. 97) gives the case of H. Moulin, wounded at Worth, August P, 1870; shot wound of nght femur, wMh assure; os.o,.- 
myelitis and necrosis extending ,0 neck of femur. Exarticulation at the hip ; death Sep.. 22, 1870.-170. Dr. ML (BfollU.. » *— **! 
fractures des membres, etc.. in Archive, gin. de mid.. 1871, VI- serie, T. 17, p. 421) performed a secondary fatal exart.culat.on at the bip.-17 -183. (men I 
(TO (Avcrcu hist. stat. et din., etc., pendant la guerre de 1870-71 , Paris. 1874, T. I, p. 493) tabulates twenty-three exarhculahons a, the hip performed 
on French soldiers. Some details of ton of these cases have just been noticed; of the remaining thirteen cases it is only recorded that all the patients 
peri.hed.-184. Morton (T. G.) ( The Cincinnati Lancet and Clinic, Cincinnati, Jan. 4, 1879, N. S., Vol. II, p. 9), ^^"^f^^™'™™*** 
at Sedan, September 1, 1870; amputation of thigh ; admitted ,0 Pennsylvania Hospital Nov. 24, 1878; reamputat.on at h,p December 14, 18,8 In a letter 
dated Febmnrv 19, 1879. Dr. MORTON reports that the » patient is up and about, and would be discharged, but ho has no home to go to. Of the 184 
cases of exarticulation at the hip here cited, one (STROMEYER's case, reported by MACCORMAC, must be set aside, since its result was unknown Of the 
remaining 183 cases, 16 recovered and 167 proved fatal, a mortality of 91.2 per cent. Of the 53 primary operations, 50, or 94.3 per cen were fatal n,c 
three recoveries were; LarREY'8 sub-Iieu.enan, of dragoons, wounded September 7. ,812. and seen a, Orcha three months afterwards; LANGEMU CK « 
operation on J Siebohl. June 8, 1848 , T. D. Johnson's operation on the California miner, July. 1862. Of the 32 intermediary cases, 29, or 90.6 per cen, 
wTre fatal The three successful instances were: G. J. QUTHBlrt Waterloo case of Duguet, in 1815; L. Baudjhb'b Algerian case : m 1836; and 
CARO rBBB'B case of the Mexican lad, in December, 1871. Of the 31 secondary operations, 26, or 83.8 per cent., had a fatal termination. I he five success- 
ful cases were • BROWvrigg's British dragoon, wounded at Merida, December, 1811, and amputated in 1812, who was living, long afterwards, at Spalding, 
" ,1 s, re. EngL'nd; AblaU 2. of the fusileer, in the Italian War of 1859; WABBl case of the officer wounded at Solferino; Dr. Joles 
KOUrt case of the Magenta soldier, in 1859; and XeUdorfer's ease of the soldier wounded at Pales.ro, May 30. 1859, who underwent secondary 
excision and amputation in December following. Of two rcamputations at the hip (Cases 12 and 184), T. G. Mobtos s operation in 1878, on a French 
soldier wounded in 1870, had a successful issue. Of the 66 exarticulations in which the period of operation was unknown 4 recovered, giving a mortality 
of 93 8 per cent. The operators in the four successful cases were : The unknown operator, who, in 1798, operated on the English sailor who was examined 
by Dr Wevdflbtadt, Dr. Charles BRYCE. in the case of the British soldier wounded at Athens, in 1827; the Spanish surgeon reported by Dr. 
Bflml-nt to Mr. Alcock, who successfully disarticulated in 1835; and Restelu, in the Italian revolution in 1848. Of the 16 8 ucce SS ful operates, 5 
were performed by French surgeons. 4 probably by English. 3 by American, 2 by German, 1 by an Italian, and 1 by a Spanish surgeon. 



SECT. II. 



PRIMARY AMPUTATIONS AT THE HIP JOINT. 



131 



Primary Operations. — Of twenty-five well authenticated primary amputations at the 
hip joint practised during the American civil war, one was completely successful. The 
pensioner, Kelly, whose left lower limb Surgeon Edward Shippen disarticulated more than 
fifteen years ago, still survives in comfortable health. A brief review of the case will be 
given, with references to a few of the numerous accounts of it that have been published: 1 



Cask 272. — Private James E. Kelly, Co. B, 56th Pennsylvania, aged 28 years, was wounded, about 9 o'clock of the 
morning of April 20. 1863, in a skirmish of the 1st division, First Corps, on the Rappahannock, nearly opposite the "Pratte 
House," below Fredericksburg. A conoidal musket ball, fired from a distance of about three hundred yards, shattered his 
left femur. A consultation of the senior surgeons of brigades decided that exarticulation of the femur was expedient, and the 
operation was performed, at four in the afternoon, at the 
"Fitzhugh House,'' by Surgeon Edward Shippen, U. S. V., 
siirgeon-in-chief of the 1st division. The single flap method 
was adopted, and the amputation was accomplished with 
slight loss of blood. The patient was at first placed in a 
hospital tent, and was transferred, May 22d, to the Corps 
Hospital, progressing favorably . By May 28th, all the liga- 
tures had been removed. On June 15, 1863, the patient was 
captured by the enemy, and was removed to ihe Lihhy Prison. 
in Richmond. Up to this date there had been no bad symp- 
toms. On July 14th, Kelly was exchanged, and was sent to 
the Annapolis U. S. A. General Hospital. On his admission 
he was much exhausted by profuse diarrhoea. The internal 
portion of the wound had united, but the external portion 
was gangrenous. Applications of bromine were made to the 
sloughing surface without amelioration. A chlorinated soda 
lotion was substituted, and in the latter part of July there 
was a healthy granulating surface. On December 23, 1863, 
the wound had entirely healed, and Kelly visited Washing- 
ton, and obtained an honorable discharge from service, and a 
pension. Kelly then went to his home, near Black Lick P. 0.. 
Indiana County. Pennsylvania. A letter, dated January 12, 
I8ti5, was received from him at this Office, and represented 
him as in excellent health and spirits at that time. In the 
spring of 1868. Kelly went to New York and had an artificial 
limb adapted by Dr. E. D. Hudson. At that time a photo- 
graph was taken representing the appearance of the cicatrix 
and of the prothetic appliance. A reduced copy of this pic- 
ture is presented in the accompanying wood-cut (Fig. 89). 
Front and posterior views of the upper half of the shattered 
exarticulated femur are introduced among the accessories in 
the picture. In a pamphlet on Mechanical Surycry, New 
York, 1878, page 31, Dr. E. D. Hudson prints an excellent 

wood-cut displaying the appearance of the cicatrix and the artificial stump. By this simple and excellent expedient of a padded 
gutta-percha artificial stump secured to the pelvis by a broad chamois-lined canvas band, Dr. Hudson succeeded in applying 
satisfactorily and comfortably the ordinary artificial limb for thigh amputations, not only in Kelly's case hut in the case of Pt. 
George W. Lemon, Co. C, 6th Maryland. The specimen of the fractured exarticulated femur is preserved at the Army Medical 
Museum, as No. 1143 of the Surgical Section. Kelly's disability was rated, March 4, 1874, as total. His pension of $24.00 
monthly, was paid in March, 1878, and he was then in tolerably good health, nearly fifteen years after his terrible mutilation. 
He remains an irrefragable demonstration of a successful primary amputation at the hip after shot injury. There was nothing 
additional recorded at the Pension Office at the above date. 

Although in the next two instances of primary amputation at the hip it was found 
impracticable to trace the ulterior histories of the patients, it is known that Surgeon W. M. 
Compton's patient, Robinson, aged 35, was alive and well six months after the exarticula- 
tion, and that Private Williamson, the subject of Dr. J. T. Gilmore's operation, reached 
his home in Mississippi, after two months, with his stump fairly cicatrized. 

■HAMILTON (F. H.), A Treatise on Mil. Surg., 1865, p. 482. SORREL (F.), Gunshot Wounds — Army of Northern Virginia, in Confed. States 
Med. and Surg. Jour., 1864, Vol. I, p. 153. BUTCIIF.lt (R. G.), On amputations at the hip joint, in Dublin Quar. Jour, of Med. Sci., 180fi. No. LXXXIV, 
p. 301. Lkgocest (M. L.), he Service de Santides Armies Amiricaines, etc., in Annates D' Hygiene Publiqut, 1866, Douxieme s6rie, T. XXVI, p. 270. 
Circular No. 6, S. G. O., 1863, p. 48. Circular No. 7, 8. G. O., 1867, pp. 2C, 58. LUxiXG (A.), Ueber die Blutung bei der Exarticulation des Ober- 
schenkds, Zurich, 1877, p. 93. Hudson (E. D.), Mechanical Surgery: Prothetic Appliances and Apparatus. New York, 1878, p. 31. 




Fig. 89. — Appearance of stump five 
photograph.] 



yours after tho operation. [From a 



132 INJURIES OF THE LOWER EXTREMITIES. [chap. x. 

CASE 27:!. — Private Kobinsmi, of a Louisiana Regiment, aged ll"> years, was wounded at Battery Pemberton, at the con- 
fluence of the Tallahatchie ami Yalabusha Rivers, on March 13, 18fi3, by a fragment of a twenty-four pounder shell, fireil from 
one of the United States gunboats attacking the work. Surgeon William M. Compton, 2d Texas, was standing near the 
wounded man when he fell, and ran to his assistance. Hastily exposing the wound. Dr. Compton found that the immense 
projectile, consisting of nearly half of an elongated shell, had buried itself in the upper part of the left thigh, smashing the 
trochanters and neck of the femur and wounding the femoral artery. An assistant compressed the artery at the crural arch, 
while the necessary preparations tin- an amputation were made on the spot. Chloroform was administered, and then Dr. Comp- 
ton made an irregular circular incision through the integuments just above the margin of the huge lacerated wound, dissected 
up and retracted the skin, trimmed away the lacerated muscles and divided those that were intact, and exarticulated the head of 
the femur, making, as Dr. Compton described it, an awkward circular amputation. The arteries were now rapidly secured and 
the wound dressed. Strange to say, the patient reacted with scarcely a symptom of shock. AVhen the influence of the anaesthetic 
passed away, he was cheerful and even jocular. He was moved to a field hospital, and was treated under Dr. Compton's 
immediate supervision until March 17th. The febrile reaction was very slight; the appetite never failed; the wound had as 
healthy an appearance as could be desired. On the fifth day, the patient was sent on a steamer to the large general hospital at 
Yazoo City. The surgeon in charge of that hospital, Dr. J. M. Greene, writes that the case presented a most extraordinary 
example of union by the first intention throughout almost the entire extent of the vast wound. The patient left the hospital on 
April 20. 1863, in fine health and excellent spirits. Dr. Greene received direct intelligence from him near the close of the 
ensuing September, more than six months subsequent to the operation, and he then reported himself in good condition. 1 

Cask 274. — Private WiUiumnnti, 13th Mississippi, was wounded at an advanced picket station near Seven Pines, on June 
1. 1862. A colloidal musket ball entered the posterior part of the right thigh about two inches below the trochanter major, and, 
passing forward and downward, made its exit at the middle third of the thigh in front, having badly shattered the femur in its 
course. The wounded man was carried to the field hospital in charge of Surgeon J. T. Gilmore, C. S. A., in a church building 
on (he road to Richmond, and there placed under the influence of chloroform about two hours after the reception of the injury. 
After an exploration of the wound, ii was decided that amputation should be performed. Dr. Gilmore began the operation with 
the belief that the comminution of the femur was mainly below the entrance wound, and that by making a long anterior flap the 
hone might be sawn at least through the trochanters; hut when the anterior Map was reflected and the fracture exposed, it was 
found that fissures extended upward into the neck quite within the capsular ligament, and that disarticulation must he resorted 
to. A ligature was first placed upon tin; femoral artery, and the incisions were then extended upward, the joint opened, the 
round ligament divided, and a short posterior Hap formed by cutting downward and outward. Assistants compressed the 
bleeding orifices of the arteries, which were then rapidly picked up and tied. The amount of blood lost was small. The wound 
was dressed, and the patient was comfortably in bed within three hours after the reception of the injury. He was put upon a 
very nutritious regimen, a messenger being sent daily to Richmond for eggs, milk, and other delicacies which could not be 
procured in camp. Dr. Gilmore attended him for two weeks, during which suppuration was not excessive, and the healing of 
the wound progressed favorably. He was then placed under the charge of Acting Assistant Surgeon Spinks. Early in July, 
he was carried to Richmond upon a hand-litter to a private house, at which he received every attention. In the middle of July, 
six weeks subsequent to the amputation, the wound had entirely healed, and he was allowed to start for his home in Mississippi. 
Dr. Gilmore learned that he arrived there in safety; but no intelligence was subsequently received from him. 

Of twenty-two primary coxo-femoral amputations that resulted fatally soon after 
operation, the following series of thirteen cases is composed of instances in which the 
wounds were inflicted by cannon shot, shell fragments, or other large projectiles: 

CASE 27;">. — Private Jacob Barger, Co. B, 26th Pennsylvania, aged 22 years, of robust constitution and sanguine temper- 
ament, was wounded on the morning of May 18, 1S64, in the attack of Birney's division of the Second Corps upon the intrench- 
ments before Spottsylvania Court House. He was struck by a fragment of shell, which shattered the femur from a little above 
the trochanter minor for nine inches downward, and tore and mangled the soft parts on the anterior and lateral aspects of the 

1 "Mississippi State Lunatic Asylum. Jackson. Mississippi, January 1, 1S78. Mv DEAR DOCTOR: I herewith enclose a letter from Dr. GREENE, 
of Aberdeen, Mississippi, the surgeon who treated the ease of amputation at the hip joint in the Yazoo City hospital. To explain to you what may appear 
to bo my want of attention in keeping- the track of so interesting a ease. I will remind you that the operation was performed in the field. The patient 
wjis at onee conveyed to a steamboat, and as soon as it was full of siek and wounded (a few days) the boat was sent to Yazoo City. Soon after the date 
of the operation, I was ordered to Vicksburg. where I remained until after the surrender of that city, and for a long time was shut up by the siege from 
all communication with the outside world. The fall of Vicksburg, in July, was succeeded by the rapid evacuation of Yazoo City, and it was nearly a 
year before I met Dr. Greene, in Alabama, who informed me of the recovery of my patient. I had not heard of him after the departure of the steam- 
boat from Port Pemberton, and did not know that he had fallen into the hands of Dr. GREENE until the doctor informed me himself. I lost my note-book 
and other papers at Vicksburg and have never had any means of tracing the patient. I will say, however, for Dr. J. M. GREENE, that he stands at the 
head of hta profession in Mississippi, and is in every respect a highly esteemed christian gentleman, and his word in any statement of fact where he is 
known is received as solid truth. Very respectfully, your obedient servant, (signed) \VM. M. COMPTON." "Aberdeen, Mississippi, December G9, 1877. 
DEAR DtvCTOR: At the request of Dr. WM. M. COMPTON, of Jackson. Mississippi, I again write to you in regard to the hip joint amputation which he 
performed at Fort Pemberton, in 18*}:). I greatly regret my inability to furnish any facts in addition to those contained in a letter which I wroto to you in 
1867. I nclieve I therein told you that the subject of the amputation was received by ine in hospital at Yazoo City, Mississippi, in a few days after the 
operation. So skilfully were the flaps made and so perfect was the coaptation throughout the vast extent of cut surface, that the fibrinous agglutination 
followed at onee, and resulted in union by first intention in all parts except the tracks of ligatures and sutures. lam positivo in my recollection that 
within six weeks from the time of the operation the patient was dismissed from the hospital with the stump healed. Information of him reached me some 
months — T believe about five — afterwards, which I then regarded as entirely authentic. It was probably m the form of an application for ' Certificate of 
Disability ' upon which to be 'retired' or 'discharged' from service. At any rate, I am certain that it thoroughly satisfied me of the life and well-doing 
of the patient. It is to be deplored that iu a matter of so much interest to the profession, complete documentary evidence cannot be obtained; but yet I 
feel assured, from my point of view, that the cause of surgical history can sustain no detriment from placing Dr. COMTTON'B case in the same catalogue 
as that of Dr. SmrPEN. Very sincerely, your obedient servant, (signed) J. M. GREENE." 



SEC 



II i 



PRIMAKY AMPUTATION AT THE III]' JOINT. 



1 <?<"> 




thigh, leaving uninjured a V shaped portion of integument and subjacent tissue cm the antero -internal femoral region, seven 
inches wide at the base and ten inches in vertical length. lie was carried to a held hospital of the .Second Corps and examined 
about two hours after the injury. There was no apparent shock, and there had been very little hemorrhage. The pulse was 
full and calm, and the surface of the body was of a natural temperature. The senior surgeons of the division concurred in the 
opinion that this was one of the few eases of extensive gunshot injury of the femur in which a successful 
result might reasonably be anticipated from an amputation at the hip joint. The patient was desirous that 
an operation should be practised. ITe was of a hopeful, buoyant nature, and was sanguine of a favorable 
issue. Amputation having been decided upon, chloroform was administered by Surgeon John Wiley. 6th 
New Jersey, a medical officer of great experience and caution in this duty. Only two drachms of the anaes- 
thetic was used, given from a napkin, with great regard to a due admixture of atmospheric air. Surgeon 
C. C. Jewett, 16th Massachusetts, performed the amputation by making a single antero-internal Hap. 
Assistant Surgeon J. T. Calhoun, U. S. A., and others present on the occasion, have described the admirable 
dexterity and skill manifested in tin! operative procedure. The disarticulation was completed in less than 
forty seconds. Surgeon C. K. Irwine, 72d New York, compressed the crural artery at the groin : Surgeon 
P. Prentice, 73d New York, grasped the flap and secured the cut end of the femoral; Surgeon James Ashe, 
70th New York, had charge of the limb ; Surgeon Everts, 20th Indiana. Surgeon E, A. Winston, 1st Massa- 
chusetts, and Assistant Surgeon J. T. Calhoun. U. S. A., also aided in the operation. The Hap. the form 
and location of which were determined by the wound, was made by cutting from without inward. Imme- 
diately after the bead of the bone was freed from the acetabulum a spasmodic catch was heard in the patient's 
respiration, and an assistant exclaimed : " Stop the chloroform 1" Surgeon Wiley promptly responded ; "He 
is not taking any." The next instant an assistant at the wrist reported that the pulse was failing. Tie- 
arteries were now rapidly secured. The loss of blood was estimated not to exceed a single ounce. But the 
patient was insensible, the respiration labored, the pulse very slow and feeble. The usual restoratives were 
employed without effect. The patient did not rally; be lingered for about two hours, and died a little after 
noon, May IS, 1S04. In consequence of an advance of Rhodes's Division of Ewell's Corps the field hospital 
was hastily broken up. Surgeon Jewett was under the impression that the specimen was lost. This, 
however, was not the ease. Some one fastened a label with the names of the patient and operator to the 
mangled limb, and it was forwarded, with other pathological specimens, from Spottsylvania to the Army Medical Museum, where 
it arrived safely, and furnished the preparation represented in the adjoining wood-cut (FlG. 90).' 

Case 276. — On March 1), 18C2, in the engagement between the U. S. frigate Congress and the rebel iron-clad Memmae, 
Private J. Busb.mil, 00th New York, or Union Coast Guard, detailed as a seaman on the Congress, was wounded by a piece of 
shell, which tore away the muscles on the outer side of the left thigh so as to expose the bone, and comminuted the neck and 
trochanters of the femur. He was immediately conveyed to the military post hospital at Newport News, Virginia, which was 
distant but a few hundred yards from the anchorage of the Congress, and restoratives and stimulants were administered. Eight 
hours after the injury, reaction having taken place to a considerable degree, the patient was placed under the influence of chlo- 
roform by Surgeon R, K. Browne, U. S. V., and Surgeon Eeroy McLean, 2d New York, amputated at the hip joint by the 
lateral double-flap method of Larrey. His principal assistants were Dr. Everts. Dr. ]{. K. Browne, and Surgeon J. Curtis, 
IT. S. V. The operation was rapidly accomplished, with the loss of but little blood. Six arteries required ligature. The patient 
did not rally from the shock of the operation, and died in less than two hours after its completion. : 

The details of the next primary amputation tit the hip (Case 277), communicated by 
Dr. P. J. Bancroft, of Denver, Colorado, have not been heretofore published: 3 

Cash 277. — "Captain Ralph Carlton, Co. I, 3d New Hampshire, received a severe wound in the left bin and thigh from a 
cannon ball or a fragment of a shell at the battle of Secession ville, on James's Island, June 16, 1862. The trochanters were 

fractured and the femur was shattered and laid bare for several inches below. The gluteus maximus muscle was severed from 
its insertion, and the biceps and semi-inembranosus were torn asunder. Amputation at the hip joint was performed about two 
hours after the reception of the injury by some surgeon whose name I have forgotten, assisted by myself. The anterior flap was 
made by transfixion and carried well down the limb. The posterior one was short and made by paring the torn ends of muscles 
and the skin. The patient did not rally, and died about two hours thereafter, although he possessed, apparently, a strong will 
and a good constitution, and was suffering but moderately from shock at the time of the operation. When told of the dangers 



I'l'.. '.in. — Commi- 
nution of JV'imir by a 
shell. S]»c 3060. 



1 The abstract of this case is compiled from a fall report by Surgeon C. C. JBWKTT, Kith Massachusetts, of Hollistou. and from communications by 
Assistant Surgeon J. C. CALHOUN, Surgeon 11. 1". LYSTER. U. S. V., Assistant Surgeon J. I). Stewart. 74tli New York. Major S AMI' EL UltKCK, A. A.G. 
See Catalogut of Surg. Sect, of A. M. M. of 18fifi, p. 234, Spec. 3080 of Sect. I. See Circular 7, S. G. < >.. 1HCT, pp. :10 and 39, and I.f'iNisu (A.), Ubtr 
die Blotting bei tier Exarticulation dtt OberscftenLrln, Ziirieh, 1877, CASE 324, p. 9li. 

2 The imperfect abstract of CASE 1276 is compiled from letters from Surgeon O. C. IlARt.AN, 11th Pennsylvania Cavalry, Surgeon R. 11. Bontecoit. 
II. S. V., Dr. KUFU8 KING Browne, and Dr. L&ROT MCLEAN, 2d New York. See Circular 7. S. G. ()., 1867, pp. 24 and 57, and Ltixtxo (A.); Vber 
die Blutung bei titr Exarticulation drs Obertchenkels, Zurich. 1877, p. 90, Case 291. 

3 The particulars of this ruse were first communicated to the Surgeon General's Office by I>r. V. J. BANCROFT, of Denver, Colorado, formerly 
.Surgeon of the 3d Pennsylvania Artillery, November 26, 1875. Captain Caiu.ton's regimental surgeon, I >r. A. A. MOUI.TOX, 3d New Hampshire, wrote 
to the Surgeon General's Office from Tilton, New Hampshire, December 9, 1875, that he "did not see Captain Caiu.ton, bat heard that his limb was 
amputated at or near t lie hip joint."' A search at the Pension Office corroborates the dates of the injury as reported by Dr. Bancroft. On June Kith, 
the 3d New Hampshire was in a brigade comprising the 97th Pennsylvania, 7th Connecticut, and :id Rhode Island Artillery. Enquiries regarding tin* 
case were addressed to Surgeon ,T. R. Everiiart, 97th Pennsylvania, to Assistant Surgeon H. P. POKTEK. 7th Connecticut, and Surgeon II. G. STXCKNEY, 
3d Rtiode Island Artillery, medical officers of the brigade of General I. T. Stephens, and also to Surgeon E. Ij. Dimit.K. 6th Connecticut, and Surgeon 
P. A. O'COSNEtX, 281h Massachusetts, New England medical officers who were present at the engagement on James Island, on June 1G, 1862; but no 
further information cotdd be elicited from any surgeon present at this operation in addition to the details recorded by Dr. K. J. Bancroft, formerly 
surgeon ;kl Pennsylvania Artillery. 



13 i INJURIES OF THE LOWER EXTREMITIES. [CHAP. X. 

■ 
attending and following the amputation, I well remember how earnestly and energetically he said: 'I desire it. I must live. I 

will live. I have a wife and five children to provide for.' Yet in two short hours all earthly ties were severed." Surgeon A. 
A. Moulton, 3d New Hampshire, reported that Captain Carlton died on June 16, 1662, of "gunshot wound," and in the military 
history of the regiment, published hy the Adjutant General of the State in 1866, he is mentioned as "a gallant and promising 
officer," who during said engagement "was hit in both legs by a solid shot, and died the same day." 

Case 278. — Private Cooper, of an Alabama Regiment, aged 20 years, was wounded at the siege of Vicksburg, on May 
22, 1863. by a fragment of shell, which intiieted a terrible laceration of the upper exterior part of the right thigh, comminuted 
the upper third of the femur, and fractured the tuberosity of the ischium. There was profuse haemorrhage. Surgeon W. M. 
Compton, 2d Texas, decided to operate, because the wounded man most earnestly begged that an attempt should be made by 
amputation to save his life. A few hours after the reception of the injury he was placed under chloroform, and amputation at 
the right hip joint was rapidly performed by making a large anterior flap and dividing the soft parts posteriorly by a circular 
sweep of the knife. The stump was dressed and the patient actively stimulated, but he never rallied from the shock of the 
operation, and died in less than an hour after its accomplishment. 1 

Case 279. — Private Isaac C. Fulton, Co. I, 4th New York Heavy Artillery, was wounded, on October 1, 1864, in the 
trenches before Petersburg, by a fragment of shell, which shattered the upper extremity of his left femur and lacerated the soft 
tissues on the outside of the thigh, without, however, implicating any important vessels or nerves. He was immediately carried 
to the Second Corps field hospital, under the charge of Surgeon F. F. Burmeister, 69th Pennsylvania, and a consultation was 
held, at which it was determined that an amputation at the hip joint was the only resource that could possibly preserve life. 
The wounded man was, therefore, immediately placed under the influence of chloroform, and Surgeon J. W. Wishart, 140th 
Pennsylvania, did the operation. The ordinary method by anteroposterior flaps formed by transfixion was employed. The 
operation was rapidly performed and but a trifling quantity of blood was lost. The patient survived the shock of the injury 
and operation but a few hours, and died at City Point, October 1, 1864. 

Case 280. — Private Richard Gordon, Co. H, 7th Rhode Island, a stout and apparently healthy man, aged 28 years, was 
wounded May 18, 1861, in one of the assaults on the lines at Spottsylvania, and was carried on a stretcher, two or three miles 
to the rear, to a field hospital of the Ninth Corps. A fragment of shell had completely shattered the left thigh, leaving the 
lower part of the limb attached to the upper by shreds of integument and muscles only. There had been but slight primary 
haemorrhage. He was conscious and his pulse was perceptible; but he was in extreme collapse. A consultation was held, at 
which the Surgeon-in-chief of the division, Surgeon P. A. O'Connell, Surgeon James Harris, 7th Rhode Island, and others, 
assisted, and it was determined to give the man the chance of an operation rather than to allow him to die without an effort to 
save him, and Dr. J. M. Carnochan, who had volunteered his services at the hospital, was selected to operate. Chloroform was 
carefully administered by Surgeon Harris, and Dr. Carnochan, as a preliminary step, tied the femoral artery three-quarters of 
an inch below Poupart's ligament, and then proceeded to amputate at the hip joint by a modification of the oblique method of 
Guthrie. A vertical incision three inches long, commencing an inch above the great trochanter, was made, the soft parts being 
divided down to the bone. From the lower third of this incision, two oblique incisions, one before and one behind, were made 
to diverge and then to reunite about two and a half inches below the level of the ischiatic tuberosity. The head of the femur 
was then disarticulated, and the knife being carried to the inner side of the neck the operation was finished by dividing the soft 
parts on that side by a single sweep of the instrument. The operation, including the ligation of the femoral, was completed in 
two minutes. The patient recovered kindly from the influence of the anaesthetic. He was placed in a shelter tent and took a 
dose of opium. Ho died ten hours after the operation, no reaction having taken place. 

Case 281. — Brevet Lieutenant-Colonel J. H. Janeway, Assistant Surgeon, U. S. A., learned that Dr. Hunter McGuire, 
Surgeon-in-chief of Ewell's Division, performed a primary amputation at the hip after the engagement at Ball's Bluff. October 
21, 1861, upon a Union prisoner of war, with a frightful injury of the upper part of the femur, caused by a large projectile, and 
that the patient succumbed to the combined shock of the injury and operation soon after the completion of the latter. 

Case 282. — A lieutenant in an Arkansas Regiment in Cabell's Brigade, aged 28 years, was wounded at the attack on 
Corinth, Mississippi, October 3, 1862. A solid cannon ball struck the right hip and made a formidable wound, tearing up the 
soft parts of the buttock and shattering the upper extremity of the femur. The trochanters and about five inches of the shaft of 
the femur were comminuted; the head of the femur was exposed and was split across. It was decided that amputation at the 
hip presented the only possible surgical resource, and the operation was undertaken, two hours after the injury, by Surgeon W. 
M. Compton, 2d Texas. The operation consisted in paring into shape the lacerated soft parts at the posterior part of the thigh, 
completing the disarticulation already partly effected by the projectile, and forming a large and long antero-internal Hap. The 
patient was under the influence of chloroform. There was but little haemorrhage. The flap covered the immense wound and 
was adjusted with tolerable accuracy to meet the incision at the gluteal region. The combined shock of the injury and operation 
was very great, and the patient reacted slowly and with difficulty. But he rallied finally, and progressed very favorably for 
several days. The inflammation was not intense, appetite returned, and strong hopes of the patient's recovery were entertained. 
But, on the seventh day, erysipelas invaded the stump and extended rapidly, in spite of the use of tincture of iron and such other 
treatment as it was thought proper to institute. The case terminated fatally on October 12, 1862. 3 

Case 283. — A private in General A. S. Jolmstou's army was wounded on the morning of Sunday, April 7, 1862, at the 
battle of Shiloh, by a fragment of shell, which shattered the upper extremity of the left femur. The comminution extended to 
the neck and head of the bone, and the soft parts at the upper third of the thigh were torn into shreds. Notwithstanding the 

1 EVE (P. F.), A Contribution to the History of Hip Joint Operations performed during the late civil war, in Transactions of the Am. Med. Ass'n, 
1867, Vol. XVIII, pp. 255, 263. Circular No. 7, S. G. O., 1867, pp. 27, 58. 

"Hamilton (F. II.), A Treatise on Mil. Surgery, 1865, pp. 485, 6X7. Circular No. 6, S. O. O., 1865, p. 50. Circ. No. 7, S. G. O. 1S07, pp. 30, 59. 

3 EVE (P. F.), A Contribution to the History of the Hip Joint Operations performed, etc., in Transactions of the Am. Med. Ass'n. 1867, Vol. XVIIi 
pp. 255, 262. Circular No. 7. S. C. O.. 1867. pp. 25, 58. 



SECT. n.| PRIMARY AMPUTATIONS AT THE HIP JOINT. 135 

terrible nature of the injury the patient reacted, and it was thought, in the evening, that his condition justified amputation. At 
seven in the evening disarticulation at the hip joint was performed by Dr. D. \V. Yandell, Medical Director. The operation was 
we