"William
on the 24th September. lie had been tended "with the greatest care and skill, but his sufferings had been great, and the discharge very profuse, and he had required the use of frequent doses of opium. There had been considerable irritative fever, with occasional delirium, and consequent wasting and debility, on the
CASES FROM PRACTICE. GUNSHOT WOUND; AMPUTATION AT THE HIP-JOINT.
Fayrer, M.D., F.R.S.E., Surgeon, Bengal Army; l'rofessor of Surgery, Medical College of Bengal.
By J.
consultation was held at the the case of Lieutenant H., who had been accidently wounded, on the 12th of the same month, by a rifle shot, which had penetrated the gluteal region, and fractured the head and neck of the femur. The patient had been a passenger on board a'troopship, and met with the accident when out shooting at night, with a a friend, in the Island of Ceylon.' The circumstances were briefly as follows:? In pursuit of large game in the jungle' by moonlight, they had taken different paths, and believed that they were widely separated. About 2 or 3 in the morning, the attention of one of the gentlemen was called by his giiide to a herd of wild animals 40 or 50 yards distant. lie raised his rifle and fired, and to his horror found, on approaching the object, that he had wounded his companion, whom he believed to be' distant 'several miles. The injured man, when struck; was drCSsed in a grey shooting suit, and was crawling on all fours, probably to approach the without seen. The bullet from Snider rifle being game struck him just over the left tuber ischii, and lodged. lie lost a considerable quantity of blood whilst' being carried to the nearest habitation, some miles distant; and there, when the medical officers arrived, the nature of the wound was examined. It was found that the call had grooved the tuber ischii, of the femur, and there lodged. passed on towards the neck There was no evidence of its having entered the pelvis, aud the fracture of the neck of the lemur was not then detected, doubtless owing to the fact that the capsular ligament had not been much injured by the passage of the bullet. lie was taken on beard the ship, as, owing to the heat and damp of the climate, and fo.r other reasons, it was deemed better that he should go on to Calcutta; and after a stormy voyage he arrived at Fort Ox the 25th
September, 1867,
Officers' Hospital, in Calcutta,
on
a
passage. Some small iragments of bone, and the basal cone of wood of the Snider bullet, had been removed from the wound. I saw him first at 10-30 a.m. in consultation with several medical officers, and on placing him under the influence of chloroform, an exploration and thorough examination of the wound were made. His pulse was then 128 ; he was slightly delirious ; and the discharge from the wound was foetid and profuse. The constitutional disturbance was well-marked: the rapid pulse, profuse perspiration, and quickened respiration were suggestive of the commencement of pyremic mischief, though no rigors had as yet occurred. The respiration is said by the medical officers, who had seen him during the previous few days, to have been at times quick and catching. He had also a clay-colored diarrhoea. I observed, on exposing the limb, that the foot was everted, and the leg shortened about two inches, with a marked rounded prominence of the left hip about the trochanter; the skin was smooth and glazy, with the superficial veins well-marked. On grasping the head of the bone, and making extension and rotation the foot, creby pitation was apparent, and on introducing the finger into the wound, (now a large suppurating sinus), fragments of bone were detected, and the fractured neck of the femur, with part of its head, detached and left in the acetabulum, were apparent. The ischium was found to have been grooved by tbe ball. It is to be observed here that the state of matters had entirely changed since the wound was inflicted : the capsular ligament had given way in the suppuration and sloughing that occurred in the track of the ball, thus allowing the shortening of the limb to take place,?for there was none, it is reported, when the first examination was made,?and the portions of dead and comminuted bone to move more freely on each other, thus making the crepitus apparent. The wound also had become much enlarged by sloughing of the track of the ball, and allowed the finger to enter and examine freely. The nature of the injury having been so far determined, consultation was held as to the treatment, and it was decided that the only hope of saving life lay in an operation, which, considering the extent of injury, not only to the neck of the femur, but to the ischium, (the cancellated texture of which was opened,) and to the soft parts from sloughing and suppuration about the head and neck of the bone, and in the track of the ball, should be amputation at the hip-joint. As no pelvic injury seemed to have been inflicted, as his urine was natural, as no pyremic visceral complication had yet occurred, and considering his youth and previous healthy constitution,? he was only 20 years old,?it was thought that this operation offered the only chance of life, though it was admitted that it was at the best a poor one. His consent and that of his friends having been obtained, it was determined that the operation should be performed as soon as possible, and 3 p.m. was the time appointed. Accordingly at 3-30 p.m. he was brought under the influence of chloroform by Dr. Dale, Garrison Surgeon, and the operation performed. Entering the point of a long amputating knife, about two inches from the anterior superior spine of the ilium, in a line leading to the great trochanter, I transfixed the anterior and as it passed, part of the thigh, the point grazing the emerging about three inches from the anus. The artery was commanded by Professor Partridge, who, following the knife as the anterior flap was cut, seized and compressed the main trunk as soon as it was divided ; the limb meanwhile being depressed by Dr. Hume, C.B., V.C., no difficulty was found in passing the knife between the broken fragments of the neck of the hone, cutting out the posterior flap, and detaching the limb ; the proceeding occupying altogether between 20 and 25 seconds. There The large was considerable oozing from small arteries and veins. vessels, femoral and gluteal, were secured, and then the portion of the head of the femur, still attached by the round ligament, All was removed from the acetabulum. points having been secured, the flaps were brought together with silver-wire He became very low towards the latter part of the sutures. operation; the bleeding points being so numerous that many ligatures were required ; but under the influence of stimulants he rallied and was put to bed. His pulse rose, and reaction commenced; but although ho hot bottles and sinapisms applied to the was closely watched, limbs, and over the heart and stomach, and champagne and am-
bone^
(deeding
November 1,
CASES FROM PRACTICE.
1867.]
moniated stimulants given, he never thoroughly rallied. About hour and a half after being put to bed, his breathing became much accelerated, and he sank and died quietly at 6-40 p.m., about three hours after the operation. The quantity of blood lost during the operation was small, and he did not lose a drop after its completion. His constitutional powers were exhausted, and he never completely rallied from the shock. Death. I believe, was accelerated by the rapid formation of fibrinous coagula in the right side of the heart. I should note that, after removing the limb arid the fragment of the head of the bone left in the acetabulum, my finger entered a large sloughing cavity above, internal to, and behind the neck of the bone; from this, the bullet, split into three longitudinal pieces, together with some fragments of bone, was removed. Before bringing the flaps together, the remains of the sloughing capsular ligament, and some shreds of sloughing muscle, were also dissected away. The external portion of the margin of the acetabulum was found to be roughened and partially stripped of periosteum. The body was examined the following morning at 11-30 a.m.; decomposition had not perceptibly commenced. The thorax was opened, and the lungs were found to be partially collapsed. There were patches of lobular hypostatic congestion, but for the In the lower lobes most part they were pale and exsanguine. there were one or two small patches of commencing pyoemic but mischief, they had not advanced to disorganization. The pleurae and pericardium were quite healthy. Heart, natural in size and healthy in structure; valves, all competent. I5ut the right ventricle was nearly filled with a firm adherent fibrinous ante-mortem clot, and besides it there The fibrinous clots exwas a post-mortem colored coagulum. tended for into the pulmonary arteries. The right auricle also contained a small fibrinous clot. The left ventricle and its valves were quite healthy. Tne left auricle contained a small fibrinous clot. The exsanguine state of the lungs corresponded to the obstructed pulmonary circulation. Abdomen.?Liver healthy, pale, and rather fatty; spleen and kidneys quite healthy; intestines, healthy. The peritoneum covering the bladder and the pelvis had a darkened appearance, probably from decomposition; no trace of any injury in the pelvis. But, corresponding to the portion of the acetabulum denuded of periosteum, there was a small collection of pus in the subfascial areolar tissue of the pelvic cavity. In this situation the soft parts, external to the peritoneum, were matted together, as if by inflammation. I removed the left os-innominatum for more perfect examination, and found that the tuber ischii had been injured by the ball: it was grooved, and its cancellated tissue laid open. It was also broken across near the spine, and the ramus was also fractured: the fracture ran up to the top of the acetabulum, the outer portion of which was rough and denuded of periosteum. There was also a fissure in the acetabulum itself. These fractures were all fissures, and involved no separation of the fragments. an
Rem Ames. This is the only instance in which I have seen the cffects of the Snider bullet; and I should have expected, knowing the great force and velocity with which that projectile travels, that it would have passed right through the limb, struck at a distance of only 50 yards, notwithstanding the obstacle it met within the neck of the femur. The force of the ball, however, seems to have been spent in traversing the gluteal region, grooving the ischium, and breaking the head and neck of the femur into three pieces. The part of the neck actually traversed by the bullet presented a comminuted groove, and some small fragments knocked off lay in the wound, or in the foyer of pus and slougning tissue, from which the ball was removed after the amputation. With reference to the operation, and why amputation was preferred to excision. The soft parts were so much disorganized, the pelvic bones were so injured, and the patient's constitution had been so much tried already by suppuration and irritative with evident indications of incipient toxaemia, and fever, there is so great tendency in this place to the occurrence of osteoin divided myelitis bones, that it was considered that, if he could survive the shock of amputation, the subsequent chances of recovery were better than after excision, which would have left the ?suppurating cavity, and a divided long bone, as a probable source of future pysemic poisoning, should it. as was very probable, become the subject of osteo-myelitis. He bore the operation very fairly, and his condition, when it was undertaken, although low, was not by any means such as to render success impossible. The loss of blood was not very great, nor was there any difficulty or delay in the amputation.
271
Reaction commenced, but, as I believe, the rapid supervention of the formation of fibrinous coagula in the right sido of the heart, or rather the aggravation of this already incipient condition, prevented its perfect re-establishment; and he sank, as many other surgical patients do, not only from the shock and exhaustion, but from the sudden interruption in the pulmonary
circulation.
The medical officers who saw* the patient were :? Du. C. A. Gordon*, C.B., Deputy Inspector General. ditto. ditto Dr. Muuk, Du. Hume, C.B., Y.C., Surgeon-Major. Dit. Thompson, Surgeon, 76th Regiment. Du. Macnamaba, Stall' Surgeon. Du. Fayrer, Professor of Surgery, Surgeon, B.M.S. Du. Partridge, Professor of Anatomy, Surgeon, B.M.S. De. Dale, Garrison Surgeon, B.M.S. Dr. Powell, Garrison Assistant-Surgeon, B.M.S.
/
on the 24th September. lie had been tended "with the greatest care and skill, but his sufferings had been great, and the discharge very profuse, and he had required the use of frequent doses of opium. There had been considerable irritative fever, with occasional delirium, and consequent wasting and debility, on the
CASES FROM PRACTICE. GUNSHOT WOUND; AMPUTATION AT THE HIP-JOINT.
Fayrer, M.D., F.R.S.E., Surgeon, Bengal Army; l'rofessor of Surgery, Medical College of Bengal.
By J.
consultation was held at the the case of Lieutenant H., who had been accidently wounded, on the 12th of the same month, by a rifle shot, which had penetrated the gluteal region, and fractured the head and neck of the femur. The patient had been a passenger on board a'troopship, and met with the accident when out shooting at night, with a a friend, in the Island of Ceylon.' The circumstances were briefly as follows:? In pursuit of large game in the jungle' by moonlight, they had taken different paths, and believed that they were widely separated. About 2 or 3 in the morning, the attention of one of the gentlemen was called by his giiide to a herd of wild animals 40 or 50 yards distant. lie raised his rifle and fired, and to his horror found, on approaching the object, that he had wounded his companion, whom he believed to be' distant 'several miles. The injured man, when struck; was drCSsed in a grey shooting suit, and was crawling on all fours, probably to approach the without seen. The bullet from Snider rifle being game struck him just over the left tuber ischii, and lodged. lie lost a considerable quantity of blood whilst' being carried to the nearest habitation, some miles distant; and there, when the medical officers arrived, the nature of the wound was examined. It was found that the call had grooved the tuber ischii, of the femur, and there lodged. passed on towards the neck There was no evidence of its having entered the pelvis, aud the fracture of the neck of the lemur was not then detected, doubtless owing to the fact that the capsular ligament had not been much injured by the passage of the bullet. lie was taken on beard the ship, as, owing to the heat and damp of the climate, and fo.r other reasons, it was deemed better that he should go on to Calcutta; and after a stormy voyage he arrived at Fort Ox the 25th
September, 1867,
Officers' Hospital, in Calcutta,
on
a
passage. Some small iragments of bone, and the basal cone of wood of the Snider bullet, had been removed from the wound. I saw him first at 10-30 a.m. in consultation with several medical officers, and on placing him under the influence of chloroform, an exploration and thorough examination of the wound were made. His pulse was then 128 ; he was slightly delirious ; and the discharge from the wound was foetid and profuse. The constitutional disturbance was well-marked: the rapid pulse, profuse perspiration, and quickened respiration were suggestive of the commencement of pyremic mischief, though no rigors had as yet occurred. The respiration is said by the medical officers, who had seen him during the previous few days, to have been at times quick and catching. He had also a clay-colored diarrhoea. I observed, on exposing the limb, that the foot was everted, and the leg shortened about two inches, with a marked rounded prominence of the left hip about the trochanter; the skin was smooth and glazy, with the superficial veins well-marked. On grasping the head of the bone, and making extension and rotation the foot, creby pitation was apparent, and on introducing the finger into the wound, (now a large suppurating sinus), fragments of bone were detected, and the fractured neck of the femur, with part of its head, detached and left in the acetabulum, were apparent. The ischium was found to have been grooved by tbe ball. It is to be observed here that the state of matters had entirely changed since the wound was inflicted : the capsular ligament had given way in the suppuration and sloughing that occurred in the track of the ball, thus allowing the shortening of the limb to take place,?for there was none, it is reported, when the first examination was made,?and the portions of dead and comminuted bone to move more freely on each other, thus making the crepitus apparent. The wound also had become much enlarged by sloughing of the track of the ball, and allowed the finger to enter and examine freely. The nature of the injury having been so far determined, consultation was held as to the treatment, and it was decided that the only hope of saving life lay in an operation, which, considering the extent of injury, not only to the neck of the femur, but to the ischium, (the cancellated texture of which was opened,) and to the soft parts from sloughing and suppuration about the head and neck of the bone, and in the track of the ball, should be amputation at the hip-joint. As no pelvic injury seemed to have been inflicted, as his urine was natural, as no pyremic visceral complication had yet occurred, and considering his youth and previous healthy constitution,? he was only 20 years old,?it was thought that this operation offered the only chance of life, though it was admitted that it was at the best a poor one. His consent and that of his friends having been obtained, it was determined that the operation should be performed as soon as possible, and 3 p.m. was the time appointed. Accordingly at 3-30 p.m. he was brought under the influence of chloroform by Dr. Dale, Garrison Surgeon, and the operation performed. Entering the point of a long amputating knife, about two inches from the anterior superior spine of the ilium, in a line leading to the great trochanter, I transfixed the anterior and as it passed, part of the thigh, the point grazing the emerging about three inches from the anus. The artery was commanded by Professor Partridge, who, following the knife as the anterior flap was cut, seized and compressed the main trunk as soon as it was divided ; the limb meanwhile being depressed by Dr. Hume, C.B., V.C., no difficulty was found in passing the knife between the broken fragments of the neck of the hone, cutting out the posterior flap, and detaching the limb ; the proceeding occupying altogether between 20 and 25 seconds. There The large was considerable oozing from small arteries and veins. vessels, femoral and gluteal, were secured, and then the portion of the head of the femur, still attached by the round ligament, All was removed from the acetabulum. points having been secured, the flaps were brought together with silver-wire He became very low towards the latter part of the sutures. operation; the bleeding points being so numerous that many ligatures were required ; but under the influence of stimulants he rallied and was put to bed. His pulse rose, and reaction commenced; but although ho hot bottles and sinapisms applied to the was closely watched, limbs, and over the heart and stomach, and champagne and am-
bone^
(deeding
November 1,
CASES FROM PRACTICE.
1867.]
moniated stimulants given, he never thoroughly rallied. About hour and a half after being put to bed, his breathing became much accelerated, and he sank and died quietly at 6-40 p.m., about three hours after the operation. The quantity of blood lost during the operation was small, and he did not lose a drop after its completion. His constitutional powers were exhausted, and he never completely rallied from the shock. Death. I believe, was accelerated by the rapid formation of fibrinous coagula in the right side of the heart. I should note that, after removing the limb arid the fragment of the head of the bone left in the acetabulum, my finger entered a large sloughing cavity above, internal to, and behind the neck of the bone; from this, the bullet, split into three longitudinal pieces, together with some fragments of bone, was removed. Before bringing the flaps together, the remains of the sloughing capsular ligament, and some shreds of sloughing muscle, were also dissected away. The external portion of the margin of the acetabulum was found to be roughened and partially stripped of periosteum. The body was examined the following morning at 11-30 a.m.; decomposition had not perceptibly commenced. The thorax was opened, and the lungs were found to be partially collapsed. There were patches of lobular hypostatic congestion, but for the In the lower lobes most part they were pale and exsanguine. there were one or two small patches of commencing pyoemic but mischief, they had not advanced to disorganization. The pleurae and pericardium were quite healthy. Heart, natural in size and healthy in structure; valves, all competent. I5ut the right ventricle was nearly filled with a firm adherent fibrinous ante-mortem clot, and besides it there The fibrinous clots exwas a post-mortem colored coagulum. tended for into the pulmonary arteries. The right auricle also contained a small fibrinous clot. The left ventricle and its valves were quite healthy. Tne left auricle contained a small fibrinous clot. The exsanguine state of the lungs corresponded to the obstructed pulmonary circulation. Abdomen.?Liver healthy, pale, and rather fatty; spleen and kidneys quite healthy; intestines, healthy. The peritoneum covering the bladder and the pelvis had a darkened appearance, probably from decomposition; no trace of any injury in the pelvis. But, corresponding to the portion of the acetabulum denuded of periosteum, there was a small collection of pus in the subfascial areolar tissue of the pelvic cavity. In this situation the soft parts, external to the peritoneum, were matted together, as if by inflammation. I removed the left os-innominatum for more perfect examination, and found that the tuber ischii had been injured by the ball: it was grooved, and its cancellated tissue laid open. It was also broken across near the spine, and the ramus was also fractured: the fracture ran up to the top of the acetabulum, the outer portion of which was rough and denuded of periosteum. There was also a fissure in the acetabulum itself. These fractures were all fissures, and involved no separation of the fragments. an
Rem Ames. This is the only instance in which I have seen the cffects of the Snider bullet; and I should have expected, knowing the great force and velocity with which that projectile travels, that it would have passed right through the limb, struck at a distance of only 50 yards, notwithstanding the obstacle it met within the neck of the femur. The force of the ball, however, seems to have been spent in traversing the gluteal region, grooving the ischium, and breaking the head and neck of the femur into three pieces. The part of the neck actually traversed by the bullet presented a comminuted groove, and some small fragments knocked off lay in the wound, or in the foyer of pus and slougning tissue, from which the ball was removed after the amputation. With reference to the operation, and why amputation was preferred to excision. The soft parts were so much disorganized, the pelvic bones were so injured, and the patient's constitution had been so much tried already by suppuration and irritative with evident indications of incipient toxaemia, and fever, there is so great tendency in this place to the occurrence of osteoin divided myelitis bones, that it was considered that, if he could survive the shock of amputation, the subsequent chances of recovery were better than after excision, which would have left the ?suppurating cavity, and a divided long bone, as a probable source of future pysemic poisoning, should it. as was very probable, become the subject of osteo-myelitis. He bore the operation very fairly, and his condition, when it was undertaken, although low, was not by any means such as to render success impossible. The loss of blood was not very great, nor was there any difficulty or delay in the amputation.
271
Reaction commenced, but, as I believe, the rapid supervention of the formation of fibrinous coagula in the right sido of the heart, or rather the aggravation of this already incipient condition, prevented its perfect re-establishment; and he sank, as many other surgical patients do, not only from the shock and exhaustion, but from the sudden interruption in the pulmonary
circulation.
The medical officers who saw* the patient were :? Du. C. A. Gordon*, C.B., Deputy Inspector General. ditto. ditto Dr. Muuk, Du. Hume, C.B., Y.C., Surgeon-Major. Dit. Thompson, Surgeon, 76th Regiment. Du. Macnamaba, Stall' Surgeon. Du. Fayrer, Professor of Surgery, Surgeon, B.M.S. Du. Partridge, Professor of Anatomy, Surgeon, B.M.S. De. Dale, Garrison Surgeon, B.M.S. Dr. Powell, Garrison Assistant-Surgeon, B.M.S.
/
