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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    tabular statement of thirteen alleged examples of this operation. I have elsewhere1 analyzed this table, and pointed out its mistakes and the fallacy of its conclusions Only seven of the cases, and but one of the five alleged successes, can be accepted.2 Dr. D. D. Saunders, of Memphis, Tennessee, has published3 a paper on excisions con- taining the following account of excisions of the head of the femur for gunshot injury: Casks.— Only three cases of excision of the head of the femur have fallen under my observation. Two of them were primary, and one was operated on twenty-eight days after the injury. The two primary operations proved fatal—one the twenty-second day, and the other the twenty-fifth day succeeding the operation—from exhaustive suppuration. In the case operated on twenty-eight days after the receipt of the wound, I was not present at the operation, which was performed after the battle of Gettysburg, by Dr. Asch, of Philadelphia. The head of the femur, neck, and trochanter were comminuted by a grape shot, which knocked off a portion of the superior rim of the acetabulum. About four and a half inches of the bone was removed, including the head. The subject of the operation was a healthy young man, of twenty-three years of age. I last saw this case eighteen months after the operation. He was walking about with a crutch, and could even walk pretty well with a stick ; the wound had entirely healed, and the limb was three inches shorter than the sound one. The upper end of the femur, with the new bony tissue which had been thrown out, was drawn up in contact with the acetabulum, and considerable mobility at the seat of the joint was retained, sufficient, at any rate, to make the limb very useful, much more so than commonly exists after this operation. Excision of this joint, when the blood vessels, nerves, and soft parts are not torn, is greatly to be preferred to amputation. It is certain that Dr. Asch did not excise the head of the femur after Gettysburg. He did, however, in a case of fracture near the trochanters, in the person of Private Dur- bin, 9th Alabama Regiment, extract detached fragments, and the patient recovered with a shortened limb, and was exchanged, and may, with the common exaggeration of wounded prisoners, have represented that he had undergone a formal excision. As to the other two cases mentioned by Dr. Saunders, it is impracticable to determine whether they are reported elsewhere in detail or not. These three cases are included in Dr. Eve's table. It also includes a case reported by Surgeon B. W. Avent, as follows: Case.— 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 spiculse removed with saw and forceps. He lingered for months, but finally recovered with a limb four inches short, but able to walk with the assistance of a cane. 1 Buffalo Medical Journal, Vol. VIII, p. 21, et scq., and American Journal of the Medical Sciences, Vol. LVI, p. 131. - The operations numbered in the Table 1 and 2, (Read), 4 (Ladd), 5 (Grant)', 7 (Cullen), 8 and 9 (Gihnore), are authentic, and correspond with Casks XLIIL LVIII, XXII, XXIII, XII, IX, and XVI, of this report. Case 3 of the Table was an example of consolidated gunshot fracture of the trochanteric region; it is proved by the report of Surgeon H. S. Hewit, U. S. V., and by a letter from Dr. Miltenberger, who is cited as the operator by Dr. Eve, that no operation whatever was performed. In Case 6 there is nothing in the report to indicate that the hip-joint was implicated. Assistant Surgeon M. J. Asch, U. S. A., cited as the operator in Case 10, positively disavows any knowledge of the operation. No names or dates are given in connection with Cases 11 and 12, and there is no reason to believe that they are not identical with cases reported elsewhere in detail. Case 13 is pronounced not to have been an excision of the head of the femur by the authority cited by Dr. Eve, as will be seen from the following letter: New CHILEANS, La., October 5th, 1868. Colonel: I have delayed answering your communication in consequence of a press of business for the last two or three days; but it gives me pleasure to furnish the information which Assistant Surgeon Otis desires. When Professor Eve wrote to me on the subject of gunshot injuries of the hip, I somehow conceived the impression that his object was to ascertain merely the percentage of mortality in cases where surgical interference had been attempted. One of my cases I thought illustrated this, though not falling strictly under the head of ' excisions of the head of the femur', but as his printed slip fa- analysis was small, I put it under this head as most convenient. The circumstances of the case were these: The patient had received a gunshot wound, from a minie ball, which had fractured the neck of the femur, the ball passing out near the ischiadic notch. An attempt was made at the time to remedy the injury as far as possible, but, after resecting the lower end of the femur, I desisted from further interference, as the hajmorrhage was very great, and I had no competent assistant at hand. Some ten days or two weeks after, as well as 1 can now recollect, the patient was laid on the table for the purpose of exsecting the head of the femur, for the examination had showed that it was extensively split up. After the primary incisions had been made, and several fragments of the neck had been removed, the operation was suspended, as the patient was suffering from the effects of the chloroform administered, and as the free explorations then made showed that the condition of the soft parts was such (from sloughing, burrowing of pus, ifcc.) that death was inevitable. As I am not a surgeon, and have never practised surgery, except for the exigencies of war, I had no vanities to gratify in the case, which was not a Uattering one, and should not have reported it if I had entertained any idea that a strict classification was desired. I am, very respectfully, your obedient servant, (Signed) J. DICKSON BRUNS. Bvt. Lt. Col. J. F. Randolph, Surgeon U.S. Army, Med. Dir. Dept. Louisiana. 3 Saunders, Excision or Resection of the Bones and Joints of the Lower Extremity. Memphis Medical Monthly, April, I860. Vol. 1, No. 2. 8 »