A report on excisions of the head of the femur for gunshot injury.

Date:
1869
Catalogue details

Licence: Public Domain Mark

Credit: A report on excisions of the head of the femur for gunshot injury. Source: Wellcome Collection.

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    to a permanent hospital; the local lesions were limited; the operation was rapidly accom- plished; and the fatal issue must be traced to the complications through which many of the best planned surgical manoeuvres are frustrated, the supervention of pyaemia: Case II.—Private Timothy Greely, Co. C, 5th Excelsior, (74th New York Volunteers.) aged 20 years, was wounded October 5th, 1851, by a round musket ball from a smooth-bore musket, which entered near the fold of the left nates, 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 pat ient congratulated himself on having escaped with what he regarded as a slight injury. A consultation of the surgical staff of the hospital having decided that an excision of the head of the femur was expedient, on the morning of the following day, 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 Surgeon H. C. Brown, of the Excelsior Brigade, 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 downwards 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; pyaemia 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. In the next case it is obvious that no operation could avail, and undoubtedly none would have been undertaken had the grave injury of the pelvic cavity involved by the wound been apprehended. Hence this case, like a number of others to be hereafter described, is not entitled to weight in estimating the utility of excisions in properly selected cases of injuries at the hip. The abstract is compiled from letters from the operator:* Case III.—Private ■, was wounded on August 23th, 1832, in the engagement between General Rufus King's Division of the First Army 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; but the chief medical officer of the Division, Surgeon Peter Pineo, U. S. Volunteers, 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 p. 233 of the Catalogue of the Surgical Sec- tion, and another view is given in the accompanying wood cut, (Fig. 3.) The trochanter major is separated into five fragments, and a long oblique fissure produces a complete solution of con- tinuity in the shaft of the femur. fig. ^-Perforation of the tro-. The account of the next case so closely resembles that of the chanteric region of the left femur J \L\h^s^\7^i&CA.ltvi. preceding, that, but for the unquestionable authority of the opera- tors, it would be inferred that they were identical. The descriptions of the injuries are very similar; but, in Dr. McNulty's operation, the section of the femur appears to have been made higher up than in the specimen forwarded by Dr. Pineo, and there is a difference of two days in the dates assigned to the operations. This, and the five succeeding cases, it is believed have not been heretofore published. * The case is No. 5, of the tabular statement of excisions of the head of the femur, in Circular No. 6, S. G. O., 1865, and is recorded also in Vol. 1, p. 13, of the Photographs of the Army Medical Museum.