BUFFALO

Medical and Surgical Journal.

VOL. V.

MAY, 1866.

No. 10.

ART. I.—Gin-shot wound, with removal of rim of acetabulum and dislocation of femur-Recovery. BY J. F. MINER, M. D.

The following remarkable and interesting case of recovery after gun shot wound involving the hip joint is so rare, and in result so unusual, that an account of it may be interesting and valuable as an additional case of recovery among the rare ones which have been observed by military surgeons. Perhaps the whole surgical history of the Rebellion will not furnish a parallel.

Lieut. Col. James Strong of the 38th N. Y. V., now Brigadier General of the Veteran Reserve Corps, was wounded May 5th, 1862, at the battle of Williamsburg, Va. The ball entered a little below the anterior superior spinous process of the illium, and made its exit near the outer margin of the sacrum. The ball passed deeply, and fractured in its course the rim of the acetabulum, which was removed an inch and a half in length and of a diameter sufficient to show that the whole upper rim had been carried away.This fragment of bone was removed from the wound at the dressings made while in the hospital, where he was carried after having lain on the field for some hours. Surgeon A. J. Berry first dressed the wound and removed fragments of bone and portions of pants and drawers. The wound was very large, and a thorough examination could be made by the easy passage of the finger. After a stay in military hospital of eight days, he was placed on board ship and taken on his way home by his brother and assistants, coming the whole distance upon a stretcher made for the purpose, and suffering the greatest pain from every motion of the boat or By force of great resolution and courage his home in Buffalo, VOL. 5, NO. 10-51.

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situated upon the bank of the Niagara, was reached after a painful journey of five days. The belief that recovery would be impossible in a military hospital or even in a warm climate, under most favorable circumstances, prompted an undertaking which could never have been made from less urgent inducements. On his arrival the wound presented a healthy appearance, and the constitutional disturbance was slight, considering the nature of the injury. The leg was partly flexed upon the thigh, and the thigh upon the body, the whole drawn internally to considerable extent. In this position it was fixed; it could not be moved in the slightest degree without producing pain, which was absolutely unindurable. The constitutional disturbance at length became very great, and the question of life rather than position of the leg engrossed all attention. Fragments of clothing and speculæ of bone were at various times extracted or washed from the wound, while great quantities of pus constantly issued. Chills, profuse perspiration, rapid pulse, great prostration, with total loss of appetite, make up the main features of the case, the severe and continual pain overshadowing and covering all other symptoms-pain which it was impossible to allay. In this condition of extreme distress. and uncertainty of life he continued without great change for about eight or ten weeks, when he gradually and very slowly commenced to improve, both in his general condition and in the appearance of the wound, until after a few weeks more he could be moved from one side of the bed to the other, and his comfort promoted by change of position.

When at length it became apparent that his recovery was probable, the question of the condition of the leg was again agitated, and efforts were early made to extend it, and obtain motion in the knee-joint. Extension and counter-extension under the influence of chloroform was adopted, and persevering efforts made to obtain as favorable results as possible. Nothing, however, can be said to have been gained by these efforts other than to have obtained greater motion in the knee-joint, the hip being made neither better or worse. Abscesses occasionally formed in the site of the old wound, and continued to do so for eighteen months or two years, each time inducing great constitutional disturbance, sometimes so great as to excite fears of his life.

The General has been on duty for the last two years, and for most of the time has enjoyed a comfortable degree of health. The present condition of the thigh will complete the main features of a case, which, to avoid being tedious, has been recited more in aggregate than in detail.

The thigh is shortened three and a half inches; the head of the femur rests upon the illium above the acetabulum, and a complete and bony anchylosis exists; the knee is drawn inwards and the joint has good motion. The weight of the body can be borne upon that leg with comfort, and the twisting of the pelvis and the extension of the toes compensates for the shortening and stiffening in a wonderful degree, so that he walks with, or without a cane, with but slight disability, considering the severity of the injury and the unnatural condition of the articulation.

The gravity of gun-shot wounds involving the larger joints has been observed by physicians, both civil and military; the danger from such wounds varying with the extent of injury, the destruction of the tissues, size and kind of joint, and state of health and circumstances of case after injury. It was formerly supposed that injury admitting air to the synovial structures was very dangerous, but this view is not now so universally adopted, and probably the air thus admitted is not of itself so important. Such injury of the small joints are not very dangerous, but of 65 cases of gun-shot wounds of different joints related by Alcock, 33 only recovered, 21 of these with loss of limb, leaving only 12 recoveries without amputation out of the 65 cases. Gun-shot wounds involving the hip-joint have always been regarded as fatal, and very few cases can be cited as exceptions to this general rule. Gun-shot wounds of all large joints are dangerous to life and limb, especially so when the articular extremities of bones are involved in injury; the knee-joint is scarcely less important in results of injury than the thigh, and the most experienced military surgeons have not seen a case of recovery without amputation, when attended with severe injury of the bones.

A gun-shot wound such as related, carrying away the rim of the acetabulum and allowing the muscular contraction to dislocate the femur, drawing the head upwards and backwards, must be a very severe and dangerous injury. If such cases have occurred they

have more generally died from either shock, hemorrhage, or inflammatory action and traumatic fever, within a few days — have rarely continued under observation long enough to accurately determine their nature, or the results of imperfect recovery. That gun-shot wound of the head of the femur would be more serious than of the rim of the acetabulum is not improbable, but recovery from either is sufficiently infrequent to make every case which does occur, of the greatest importance in determining probable results of similar injuries.

ART. II.-Abstract of Proceedings of Buffalo Medical Association. TUESDAY EVENING, March 5th, 1866. The Association was called to order at 7 o'clock by the President. Present-Drs. Ring, Gay, Cronyn, Strong, Eastman, Samo, Wetmore, Gleason, Little, Gould, Congar, Boardman and Johnson.

DR. JOHNSON moved that Dr. Abbott be invited to attend the meetings of this Association until he becomes eligible to membership. Carried.

DR. EASTMAN made a like motion in favor of Dr. H. S. Tafft, which was carried.

The minutes of the last meeting were read and adopted.
Voluntary communications being in order-

DR. GAY reported a case of diphtheria of unusual severity. The patient was a robust man of 26 years. On the first day of the disease all the usual general symptoms of the disease were present with no local disturbance until the second day, when he found a thick, firm exudate, complicated with abscess of the tonsil. The exudate came off and re-formed, dipping down into the larynx, making deglutition very difficult; most of the food consisting entirely of fluid, was returned through the nares. The abscess opened spontaneously, and healed two or three days after.

Treatment consisted of sol. subsulphate ferri xx, minims aqua mentha, syp. simplex aa 3ss, in teaspoonful doses every 2 hours. Gave also chlorate potassa in sat. sol. Gave neither whisky or quinine. Believe the good results in this case due to the sol. subsulph. ferri, and that the remedies of greatest value in such cases are, first, the aqueous vapor; second, subsulphate ferri.

DR. STRONG remarked, that we are too apt to attribute the good effects of alcoholic stimulants to systemic affects. He believes that the local effects of alcoholic stimulants are valuable in diphtheria. Dr. S. related the case of a patient with diphtheria with but a small amount of exudate and constitutional symptoms well marked; pursued his usual plan of treatment until the fourth day, when he applied four leeches over the larynx with excellent effect, the patient convalescing rapidly. He also said that his experience had taught him that local depletion, and at the same time stimulants should be resorted to in many cases of inflammatory disease.

DR. EASTMAN had not used sol. subsulph. ferri in diphtheria. Believes that aqueous vapor in many cases a very useful remedy. He related a case in which there was total loss of voice, used aqueous vapor and made application of ice over the larynx for twelve consecutive hours, when the patient was much better and recovered rapidly. Had also recently seen a case treated by another practitioner' in which the patient seemed convalescing favorably, when edema of the glottis supervened, and death occurred in about ten minutes from the commencement of the edema.

DR. WETMORE remarked that he employs the vapor from a saturated sol. of carbonate of soda, and thinks it superior to aqueous vapor. Often paints the membrane with this solution, and sometimes uses carb. soda in fine powder, directing the patient to inhale it. Has often seen neuralgia follow diphtheria, but thinks paralysis follows it very infrequently. Should hardly know how to treat diphtheria without iron, quinine and whisky.

DR. STRONG Spoke favorably of aqueous vapor in croup, but remarked that he believed true croup almost always fatal.

DR. BOARDMAN reported a case of pleuro-pneumonia in a robust man, with pulse at 120, and short, painful respiration and slight cough and severe headache. Gavegr. morphia by hypodermic injection, and gr. morphia four hours after in conjunction with mustard poultice. Slept quite well through the night. In the morning found the pulse 100, and much less pain; headache gone. Treatment continued through the day. Sputa rusty and heavy. Next day found pulse 86; sputa lighter, but little pain; frebrile excitement nearly ceased. Patient convalesced rapidly. Believe the subcutaneous injection of the morphia very useful in this case.