CIRCULAR No. 7. 
 
 SURGEON GENERAL'S OFFICE, 
 
 Washington, July 1, 18G7. 
 
 A REPORT 
 
 ON 
 
 AMFUTATIOiNS AT THE HIP-JOINT 
 
 IN 
 
 ]MILIT^RY SXJPiaERY 
 
 • a * ■ • * 
 
 WASHINCtTOI^: ' 
 
 government printing office, 
 
 1 8 f i 7 .
 
 \
 
 Library 
 
 CIRCULAR No. 7. 
 
 WAR DEPARTMENT, 
 
 Surgeon General's Office, 
 
 Washington, July 1, 1867. 
 
 The following Roport, eml)0(lyiiig the experience of the War of the Rebellion in 
 
 relation to Amputations at the Hip-Joint, is puljlished for the information of the Medical 
 
 Officers of the Army. 
 
 JOSEPH K. BARNES, 
 
 Surgeon General. 
 
 4S1180
 
 ^ R E 1^ O PI T 
 
 ON 
 
 AMPUTATIONS AT THE IllP-JOINT 
 
 IN 
 
 MILITARY SURGERY 
 
 BY OKORrilO A. OTrS, 
 Assistant Surgeon and Brevet Lieutenant Colonel, II. S. Army. 
 
 Surgeon Generai/s Office, 
 Washington, D. C, 
 
 June 30, IS (J 7. 
 BREVET MAJOR GENERAL J. K. BARNES, 
 
 Surgeon General. U. S. Army. 
 
 General :■ — 
 
 In accordance with your instructions, I have examined how far the experience 
 acquired in the war of the rebelHon has augmented our data for estimating the A'ahie 
 of the operation of amputation at the hip-joint as a resource in military surgery, and 
 have embodied the results of that inquiry in the following report: 
 
 Compared with the immense aggregate of major amputations, the number of 
 amputations at the hip-joint during the war was not large; but considered with reference 
 to the previously recorded examples of this amputation as performed for gunshot injury,'-' 
 they constitute a great accession to the statistics of the operation. 
 
 *In Mr. Cox's table, {A Memoir on Amputations of the Thi;/h at the Bip-joint, London, folio, 1645,) thirty-two 
 .imputations at the hip-joint are recorded as having been perfonned on account of pnnshot injury ; but several of them were of 
 ihiubtful autlienticity. Of the ninety-eight oases enumerated in Dr. Stephen Smith's well-known statistical paper, published in 
 18r)2, (A'ofl York Journal of Medicine, Vol. IX, p. 184,) but twenty-three followed gunshot fractures. M. Legouest. in 18fi3, 
 ( Traiti de Chirurffit d'Armie. p. 699,) gave a carefully studied tabular statement of forty-four such cases as are in question. In 
 18G4. Dr. Deinnie {MUilUr Chinirrjigche StmVun. WUrzburg, 18C4, Vol. II, p. :i.")l) added eighteen cases to M. Legonest's list, 
 and made a table of sixty-two coxo-femoral amputations for gunshot fractures. He erroneously includes a successful operation 
 by M. Sedillot. which was done ioi- a compound fracture caused by a fall from a window. His total should be sixty-one cases.
 
 G AMPUTATIONS AT THE HIP-JOINT 
 
 It wouM be diffifult, imlood, to find in tlio annals of military snrgery a linndred and 
 twenty antlientie instances of amputation at the ln|i-i(>iiit for injuries inf^ieted by weapons, 
 or to produce half that nundjer in Avliich even meagre histories of the cases have been 
 preserved. With a few interesting exceptions, the operations of this character done during 
 the Crimean, Itahan, and Schleswig-Holstein wars are known to us only through numerical 
 returns. It is, therefore, the greater matter of satisfaction that in more than hfty instances 
 in whicli this operation was performed during the war of the rebellion, the more important 
 facts in relation to each case have been ascertained. 
 
 At the present day surgical statistics commonly encounter severe criticism, and the 
 results of the numerical method of medical and surgical investigation are viewed with distrust. 
 "Excellent in the hands of M. Louis," J\l. Vel])eau says of this method, "it is detestable 
 as manipulated by many of his followers.'' A recent writer* on the special point in 
 surgery under consideration has well discussed the causes that have led to this scepticism. 
 These are the magnitude and frecjuency of the errors propounded after a faulty application 
 of the statistical method; which are the more pernicious because a long j^eriod often elapses 
 before evidence can ho collected to refute conclusions derived from a large number of 
 defective observations presented with a great parade of rigid analysis; and when such 
 results are finally disproved, the greater discredit is thrown upon the numerical method, 
 which, when properly employed, is one of the most potent engines for the attainment of 
 truth and the elimination of error. 
 
 In the collection of surgical statistics there are several special sources of fallacy. The 
 desire for distinction of and)itious operators sometimes tempts them to report successful 
 results ]irematurely, and to fail to record unfortunate cases. Feverish partizans of particular 
 operative procedures, in accumnladug statistics, not unfrcquently evince an unpardonable 
 disregard for the fundamental rules of evidence, and admit testimonv aliounding in trans- 
 parent fallacies. Some writers, in their zeal to gather together numerous observations, 
 group those that are verv dissimilar, and deduce inferences from the collection that are 
 pertinent onlv to }iarticu]ar eases. In the liibliography of the operation under consideration, 
 for example, we find ;i juhnarv amjiutation at the hi]i-jnint |)erformed Ibr Iraumatic lesions 
 in a vigorous man cnllated with a case where the necrosed head and ti'ochanters of the 
 femur were enucleated fi-om tlie thigh stump of a strumous child. 
 
 When these and other sources of error are avoided, it ma}' reasonably be hoped that 
 the analvsis of large nuud)ers of surgical cases, diieiittention beingpald toes.sential pai'liculars, 
 nuist result in the establishment of rul(>s for the peribrmance of operations more nearly 
 ap})roacliing scientific method and accuracy than those that now prevail, and in the selection 
 of proper cases for operation at the stages and under the circumstances most conducive to 
 success. And when compilers of surgical statistics first carefully inquire into the reliability 
 of individual eases, and then into the soundness of tin' method of arranging them ami 
 reasoning on them, JMorgagni's aphorism, Ob.servalioncs perpemlendic nou numerandcc, 
 must be modified to express the proper order of inquiry, and to read : Observations of fact 
 must be well weighed and then counled.f and conlitlence in the numerical method as a 
 powerful aid to siu'gical itix'estigatioii will be restored. 
 
 " Mr. J. Samson Gamgee, of Birmingham, England, in liis excellent monograpli, entitled "-( Hwtory of a Successful Case of 
 Amputation at the flip-joint." Quarto. Londoii. JSfifi. 
 t OaMCKK. hir. rit.
 
 IN MILITARY SURGERY. 7 
 
 An endeavor has been made, in tlie examinntinn oftlie statistics of amputation at the 
 hip-joint in the war uf the rebelhim, to ennltirm to the priiicipL's al)ove indicated. In the 
 histories of the operations recorded farther on in this report, errors may be detected here- 
 after, and some of the histories are, of necessity, very incomplete. But their authenticity 
 has been scrutinized, and doubtful cases have been rigidly excluded; the cases have been 
 arranged in separate categories according to their clinical relations; and all the material 
 facts that have been ascertained in regard to the indi^'idual cases are set forth, to enable 
 the reader to judge of the correctness of the statistical conclusions. 
 
 The list of operations includes not only those that were performed in the army of the 
 United States, but those done in the Rebel army. In collecting the histories of the latter, 
 the most cordial and intelligent co-operation has been received from the distinguished 
 professor of surgery at ISFashville, Tennessee, I)r. Paul P. Eve. 
 
 In addition to the collection of cases in which ampiutation at the hip-joint was per- 
 formed during the war, an account will be given of a few cases in which conservative 
 measures were adopted under circumstances commonly believed to justify, or even demand, 
 exarticulation of the femur — cases illusti'ating, so to speak, the natural history of gunshot 
 injuries of the upper portion of the thigh.* And the matured opinions of several military 
 surgeons, who had large experience of the graver gunshot injuries of the upper portion of 
 the femur, treated either by amputation at the joint, or by excision, or by attempts at 
 conservation, will be recorded. 
 
 In order to show how far these contributions increase our means of judging of the 
 value of amputation at the hip-joint as a resource in military surgery, it is necessary to 
 review the history of the operation, and to determine the state of the question prior to the 
 war. This report will consecjuently be divided into an liistorical summary, an account of 
 individual cases, a citation of the opinions of surgeons, and a discussion of results. 
 
 * A full report on tins most interesting class of injurie.s must be deferred until tlie comidetion of the an;il_vsis of the immense 
 stutiBtieal material on gunshot fractures of the fenmr recorded in this oftice.
 
 AMPUTATIONS AT THE HIP-JOINT. 
 
 HISTOEICAL SUMMAEY. 
 
 Bauveur Fraiirois j\rorand, who stiulicd surgery in England in 1729, under tlie cele- 
 brated Glieselden, and subsequently became surgeon of the Hotel des Invalides, and a 
 professor at the Parisian hospital of La Charite, was the first practitioner who directed his 
 attention in a particular manner to amputations at the coxo-femoral articulation and pro- 
 claimed tlie practicability of this formidable operation. He studied different methods for 
 this disarticulation upon the cadaver, and reported instances of its successful performance 
 upon dogs and cats; and learned societies and academies were compelled by his great 
 authority to consider the subject. 
 
 In March, 1739, tAVO of Morand's pupils — Volher, surgeon to the horse-guards of the 
 Kino- of Denmark, and Puthod, a prac'titioner at Nyon, in Switzerland — communicated 
 memoirs to the Royal Academy of Surgery at Paris, in which the propriety of this operation 
 was formally advocated, and the various injuries and diseases for which it might be regarded 
 as the only resource were pointed out. Tliese pajiors were written with much ability, and 
 they were subsequently puljlished by ]\L:)rand in his works. ^ MM. Le Dran and Guerin 
 were appointed by the Academy to consider these memoirs, and, after many dissections and 
 long investigation, they made, July 26, 1740, a favorable report. 
 
 In 1743, Eavaton desired to perform the operation in the case of a gendarme of Louis 
 XV, with a complicated fracture through the trochanters, but was prevented by the oppo- 
 sition of his colleagues.^ 
 
 In 1748, Lalouette published a thesis strongly recommending a trial of the operation,^ 
 and the same year, Laeroix, of Orleans, completed an amputation which nature had nearly 
 effected, in the case of a child of fourteen with sphacelus of the lower extremities induced 
 by ergotism. Laeroix, in the presence of Le Blanc, divided with scissors the round ligament 
 and sciatic nerve and slnvds of tissue that (•oiin(M-tc(l the left thigh with the truid-c; and 
 four days afterwards he re[)eated this procedure and disarticulated the right femur. The 
 boy survived the second operation eleven days.* Many writers, among others Mr. W. 
 Sands Cox* and Dr. Stephen Smith,® cite this case as the first recorded example of amputation 
 at the lii])-ioint on the living human subject; but it assuredly cannot justly be considered 
 an operation of amputation. 
 
 ' opuscules de Chirurr/ie, par M. MORAND. Paris, 1708, pp. le'9 ami 199. 
 
 • Ravaton, Chiruryie d'Armec ou Traite des I'laies d'armes a feu, Paris, 1768, p. 331; and I'ratique Moderne de la Chirurgie. 
 Paris, 1770, Tome III, p. 458. 
 
 '' Al.UKHTl's Hai.LKH. Disputdtiones Chirurf)ie<E iSeleetcv. Lausamio, 1775, T. V, p. 205. 
 
 * RlcilKliAXD, Xosot/raphie et Tlieriipcutique Cliirurr/ieales, T. IV, p. 545, Paris, 18-il ; and A'f.i.I'KAI', Xouveaux KKmcns de 
 Mldlcinc Ojicnttoire. Paris, 1832, T. I, p. 513. M. Vt'lpeau says tlie right tliigli was roiiiovcd lirst. 
 
 ■'William Sands Cox, V. R. S. A Memoir on Amputation of the Thiijh at the Hip-joint, with a successful ease. London, 
 1845, folio, p. 40. 
 
 '•Stki'IIKX Smith, M. I). Slatisties of the Operation of Ampntation nt the Hip-joint. New Vorl: .lournal of Medicine, 
 Septeniliir, 1852, p. 93.
 
 HISTORICAL SUMMARY. 9 
 
 111 1756, Morand succeeded in liiiving tliis subject made the prize question for that year 
 liy the Academy of Surgery;^ but the twelve memoirs presented were adjudged unsatisfac- 
 tory, and the subject was again proposed in 1759, when thirty -four essays were offered, and 
 the academy appears to have given its sanction to the proposal by according the prize to 
 the essay of Barbet. 
 
 With eighteen others of the essayists, Barbet defended the propriety of amputating 
 at the hip-joint under certain conditions, and he specified some of the circumstances under 
 whicli he considered the operation justifiable. Thus, if the thigh was crushed by a cannon 
 ball in the neighborhood of the joint, and only a small portion of the soft tissues remained 
 to be divided by the knife, or if gangrene involved the circumference of the joint and 
 liad destroyed the greater portion of the flesh, he thought the disarticulation should be 
 undertaken; and he dwelt very much on Lacroix's case as an illustration. He gave 
 general rules for the performance of the operation, but wisely observed that the particular 
 plan must be varied according to the nature of the cases in which it was required.^ 
 
 In 1758, Goursaud, surgeon to the College of Paris, proposed a new operative pro- 
 cedure for amputation at the hip-joint. The following year Moublet,^ surgeon of the 
 hospital at Tarascon, in Provence, published a good essay in advocacy of the operation. 
 Shortly afterwards Puy, of the Hotel-Dieu of Lyons, and Lecompte, announced the suc- 
 cessful results of their disarticulations of the femur in the lower animals, and Lefebure 
 jiublished an essay in which the operation was considered in all its relations, and first sug- 
 gested the propriety of the ligation of the femoral artery as a preliminary step. 
 
 On the other side, Calliseu,* Richerand,^ Bilguer,® and Pott'' condemned the operation. 
 
 In 1773, Perault, a surgeon at Sainte-Maure, in the department of Indre-et-Loire, 
 imitated Lacroix, in the case of a man twenty-one years of age, named Gois, whose right 
 thigh was crushed between the pole of a wagon and a wall and was almost totally dis- 
 organized by the progress of gangrene.^ The patient recovered and lived for many years 
 as a cook at an inn in Sainte-Maure, where M. Velpeau saw his son and heard his history 
 in 1815.^ In Perault's case, as in that of Lacroix, the separation of all the parts which it 
 
 ' The question was propounded in the following form : " Dans le cas ou I'amputation de la cuisse dans I'article paroitroit 
 I'unique ressource pour sauver la vie a un malade, determiner si Ton doit pratiquer cette operation, et quelle seroit la methode 
 la plus arantageuse de la faire ?" Memoires sur les Prix de I'Acadhnie Royale de Chirurgie. T. IV, p. 41. 
 
 - Barbet's memoir is published in full in the Mimoires sur les Sujets pro-posh pour lea Prix de I'Academie Royale de Chirurgie. 
 Nouvelle Edition avec Notes. Paris, 1819. Tome IV, p. 41. 
 
 ■^Journal de Medecine de Paris, 1759. Tome IX, p. 40. 
 
 ^ Systema Chirurgicce Hodiernm in usum publicum atque privatum adornatum. Hafnife, 1815-1817. Vol. II, p. 418. 
 
 '' Xosographie et Thirapeutique Chirurgicales. Tome IV, p. 545. 5th ed. " Un chirurgien prudent doit s'abstenir de I'amputa- 
 tion de la cuisse dans I'articulation de la hanche, lorsque la nature ou I'aceident ne I'ont point commencee." 
 
 ^'' IJissertatio inauguralis Medi^'o-Chirurgii^a de menihrorum amputatione rarissime admiitistrandd aut quasi abrogandd, quam 
 pro gradu Doctoris Medicime et prcecipue Ckirurgice rite consequendo, die vigesima una Martii 1761, in alma. liegid Fridericiand, 
 speciminis loco, publicce eruditorum censurw submisit Johannes Ulricus Bilguer, Curia- Ehicttis, generalis prwfectus Chirurg- 
 orum exercitus Regii Borussici. Traduite en Fran(,'ois et augmentee de quelques remarques, par M. Tissot, Docteur en 
 Medecine, 1764. 
 
 • The Chirurgical fVorks of Percivai-L Pott, J^. R. S. Vol. II, p. 317. 1st Am. Ed. Strangely enough Pott quotes the 
 Prussian surgeon Bilguer and his French annotator Tissot as advocates of the operation, though Bilguers entire dissertation is 
 a plea for the abandoinnent of amputations, except in the rarest cases, and his strictures on this particular operation are so severe 
 that Murand (Opuscules dc-Chir., p. 232) felt compelled to reply tn them in an elaborate memoir. 
 
 'Sab.vtier. De la Medecine Opiratoirc. Nouvelle ed., 1832. T. IV, p. 673. 
 
 " M. Veli'eau. P.lim. dc Med. Operatoirc. Tome I. p. 513.
 
 10 AMPUTATIONS AT THE HIP-JOINT. 
 
 IS ( 
 
 angerous to divide lind lieen accomplished without the aid of the surgeon; and these 
 cases are justlv styled liv Henot^ mere simulacra of amjnitations at the hi[i. 
 
 In December, 1774, Kerr, of Northampton, in England, amputated at the right hip- 
 joint in the case of a consumptive girl of eleven or twelve years, who had coxalgia with 
 lumbar abscess and extensive caries of the acetabulum and of the adjacent parts of the 
 osinnominatum. The subject of this unjustifiable operation survived it seventeen days.^ 
 This is the first authentic instance of a true amputation at the hip-joint, and the result nf 
 the case was, in one respect, of great value, since it dispelled the exaggerated fears that 
 had been entertained of the immediate danger of the operation, and proved that in more 
 favorable cases an expectation of recovery after this mutilation might reasonably bo 
 entertained. 
 
 About this period, according to tradition, another amputation at the hip-joint was 
 performed in England by Henry Thomson, surgeon of the London Hospital.^ It is not 
 recorded, Mr. Curling states, on the books of the hospital.^ It is supposed to have been a 
 speedily fatal case, and the one probably witnessed by Pott, and which led to his emphatii/ 
 condemnation of this operation. 
 
 For the next twenty years amputation at the hip-joint was commonly described in 
 sy.stematic books of surgery, and demonstrated on the dead subject by surgical lecturers; 
 but we find no instances of its performance on thr living. Tlie next example of tlu; 
 operation on record, and the first instance of its performance for gunshot injury of the 
 higher part of the femur, occurred in the Frencli army of the Rhine, in 1793. Tlu> 
 operator was the illustrious Larrey, then and thenceforward a zealous advocate of lln' 
 operation. The patient bore the operation well,' and several hours afterwards his condition 
 was most satisfactory ; l)ut it was then necessary tliat lie should follow the army in a- 
 precipitate march of more than twenty-four hours duration, in the depths of winter, and 
 lie died probably from the exposure and fatigue. It would be superfluous to recapitulate 
 the earnest arguments appended to his report of this case by Larrey, with which he insisted 
 upon the introduction of this operation into military surgery. They are referred to m 
 most modern surgical treatises, and are given in I'ull in Cooper's Surgical Dictionary, and 
 other readily accessible works. On their publication amputation at the hip-joint became 
 a recognized resource in military surgery. 
 
 It has been alleged that, in 1794, A. Blandin ainiuitated at tlie hip-joint three oi' foiii- 
 times for gunshot fracture of the upper part of the femur." M. Velpeau stales tlial ISlaiidlii 
 operated three times, and saved two of his patients, while llie lliird survived filty-eiglit 
 days ; and adds that another military surgeon. Ferret, in the same year, did a successful 
 
 ' liecucil dc Mim dc Mid. ik C/iir. ct dc I'liiir. Mil. Dcuxirmo Scrii'. Timir VI, |i. '.H. 
 
 " Duncan's .Mediml Commentaries. Edinburgh, 1799. Vol. VI, p. 'S.i7. 
 
 ^. John Thomson. Report of Observations made in the British Military Hosinlah in ll(h/iiiiii nflir the liatlk of Waterlno. 
 Eflinbiirgli, ISKi, p. SG4. 
 
 ■'.J. F. SoCTIl'.s Hotes to Chelius's Si/stem of Surrjenj. Am. cd. Vcl. 111. p. tsy. 
 
 ■• Mimoires de Chirur</ie Militaire. et Campaijnes de DoMl.N'KjCK .Ii:.\N J.Aintr.v. I'rcniiiT ('Inriirgicii dc la Ganlc, H.ii-oii 
 de I'Empire, etc.. Paris, 1812. Tome II, p. 180. 
 
 '■ il. VKI.I'KAf, Xovrcawx P.Um. dc Mid. Opir., Tome I, p. 514, ed. 1832 ; and Uockgkhy, Ironoijrophir d' Anatomic Chirur- 
 ffirale ct de Midirinc Opiratoire, Premier Division, p. 270. These statements are quoted liy tlie successive writers on the suliject, 
 eaeli eitini: his predecessor. Alexandre Blandin was "aide-major" to LaiTe,v. He wrote a Ihi'sis nn ainpulatiims. wlii.li I h;ive 
 not been able to procure. S e MaI-GAIGNK. Bulletin de I'Acadimic de Mid.. Aoiit. 8. 18.1"^.
 
 lIlSTOrjf'AL SITMMARY. 11 
 
 iunputation at tlie hip-jniul lor oimssliot injury. Bourgery says tlial Imt one of Blamlin s 
 patients recovered. Neither autlior gives any authority for his statement.-' 
 
 Dr. Wendelstaeclt, of Emerichof, near Limburg, on the Lahn, relates" that he had 
 examined an EncvHsh sailor whose thigh w.as carried away by a cannon ball at the naval 
 battle of Abouqyr, August 1, 1798, and who subsequently underwent amputation at the 
 hip, and who was in good health years after the operation. It is very singular that tliere 
 is no other record of the case. 
 
 Tn 1799, Larrey performed the operation twice at the siege of Saint-Jean d'Acre.'' 
 (-)iu' of his patients, an ofl&cer, M. Bonhomme, was in excellent condition on the seventh 
 day, when he was suddenly carried off by the plague. The other, a drummer boy, died in 
 an ambulance during the retreat of the army. 
 
 About this period it is alleged that Krimer amputated at the hip-joint for gunshot 
 fracture. The patient is said to have died of tetanus on the tenth day.* 
 
 At Wagram, July 6, 1809, Larrey operated at the hip-joint on two soldiers of the 
 imperial guard. These were intermediate amputations, and resulted fatally in a few hours.'^ 
 
 In 1811, Brownrigg amputated at the hip-joint unsuccessfully, at Elvas, in Spain.*^ But 
 he was more fortunate the following year, in a similar operation on a private of the 13th 
 British 'Dragoons. This man recovered and lived for many years afterwards at Spalding, 
 in Lincolnshire.'' This was a secondary operation, performed December 12, 1812, for 
 complications resulting from a gunshot fracture of the femur received at Merida, in Spain,^ 
 on December 29, 1811. It is the first successful amputation at the hip-joint recorded in 
 military surgery. Brownrigg also performed the operation in two other cases during the 
 Peninsular war ; these terminated fatally.* In this year also Guthrie performed the 
 operation unsuccessfully at the siege of Ciudad Rodrigo.^" 
 
 In 1812, Larrey also operated twice: first, on July 29th, at Witepsk, on a Russian 
 soldier, whose left thigh had been carried away by a cannon ball." Ribes assisted at this 
 operation. Larrey believed that the patient would have recovered had it been possible to 
 provide suitable nourishment for him. He died from dysentery on tlie twenty-fifth day, 
 the wound having nearly cicatrized. The other case was that of a French subaltern of 
 dragoons, whose thigh was terribly injui>ed by a cannon ball at the battle of Borodino, on 
 September 7th. He was removed to the abbey of Kolloskoi, and thence to Witepsk, 
 
 I I agree with M. Leoouest {Mem. de la Soc. dc Cliirurgie, T. V, p. 157 j that the proof tliat these operations were 
 performed is insufficient. And tlie same remark applies to the ease ascribed to Perret. They are not mentioned in any of the 
 systematic surgical treatises of tlie period, nor in P. F. Blandin's elaborate Essay on Amputations, (Dkt. de Med. et de Chir. 
 Pratiques. Tome II, ]>. 274.) 
 
 - Journal der I'rakt. He'dkund. VoN HuEELAND und HiMLY, 1811. IJand VI. ji. 110. 
 
 •' lielation Historique et Chiruryicale deVExpedition dc I'Armce d'Orient en Eiji/pte ct en Si/rir. par D. .J. Laurey. Paris, 
 1803, pp. 329, 332. 
 
 •■ Graefe und Waltheu. Zcitsrhriftfiir Chir. B. XII, p. 121. 
 
 '> Mini, de Chir. Mil. T. Ill, p. 349. Larreysays these patients were ''victims of the delay in ]ierforiiiiiif;; the operation." 
 
 '■ Commentaries on the Sunjenj of the War in Portni/al, S2)ain, Franre, and the Xel/irrlands. liy (!. .1. (IrTIIUII';. V. H. S. 
 Gth Am. ed., p. 77. 
 
 ' Avertll's Operative Surejery. 2d ed., p. 217. 
 
 " Diet. Pract. Surr/. By Samuel Cooi'KU. Am. <'d., p. 77. 
 
 ' AvERiix. Loc. cit. 
 
 '" A Treatise on Gunshot fVounds. By (i. J. (luTlirnK, l'\ R. S. 3d I.niiil. ed., ji. 33-2. 
 
 " Mini de Chir. Mil. T. IV, p. 20.
 
 12 AMPUTATIONS AT THE HTP-JOTNT. 
 
 where lie remaiiieil, under the care of Surgeon- jMaj or Bachelet, until he was nearly well. 
 He was then sent to Orclia, and the surgeon-major in charge there reported to Larrey, three 
 montlis after the operation, that he had entirely recovered.^ This case is cited as the second 
 successful amputation at the hip-joint in military surgery, and the first successful primary 
 amputation ; but, as the patient never reached France, and his death is not accounted for, 
 the adversaries of the operation will not admit the case as a success. 
 
 In the war of 1812, between the United States and Great Britain, no examples 
 occurred of the performance of this operation." 
 
 In April, 1814, after the unsuccessful assault on Bergen-op-Zoom, Cole performed this 
 operation by the circular method. A few days subsequently Samuel Cooper operated at 
 Oudenbosch on a soldier who had received at the same assault a dreadful fracture of the 
 upper part of the femur by a grape-shot. Both cases resulted fatally.^ 
 
 Dr. Emery operated, July 2, 1814, on a corporal whose left thigh had been fractured 
 by a musket ball a year previously in Spain. The patient died thirty days afterwards 
 frcjm secondary htemorrhage.^ 
 
 The third successful amputation at the hip-joint in military surgery was that performed 
 l)y Guthrie, on July 7, 1815, at Brussels, on the French soldier, Frangois Duguet, wounded 
 at the battle of Waterloo.' This man was living at the Hotel des Invalides in 1836. 
 
 On August 15, 1815, Air. Blicke ^jerformed the ojicratiou at Antwerp, on a soldier 
 with osteomyelitis of the femiu- produced by a contusion from a musket ball received at 
 Waterloo. The patient survived eight days." 
 
 Alcock relates' that he was informed by Dr. Belmunt that an accomplished Spanish 
 surgeon, educated at Barcelona, had twice amputated at the hip-joint during the Peninsular 
 war, and once with success. 
 
 For the next twelve years peace was maintaiiicil in Europe, and no instances are 
 recorded of amj^utation at the hip-joint for gunshot injury. 
 
 In May, 1827, during the siege of Athens by the Turks, Dr. Bryce, who accompanied 
 Lord Cochrane to Greece, reports that he amputated at the hip-joint in the case of a soldier 
 whose femur was badly shattered by a six-pound cannon ball. There had been copious 
 haemorrhage, yet the patient is said to have recovered rapidly, and to have been seen six 
 weeks subsequently at Paros, by the operator, perfectly cured.^ The history of this case 
 
 ' Larbey, Mem. de Cliir. J/tV., Tome IV. )). iJO; and Briot, Histoire de V IStat ct dcs Pro'jris dc la CJiirurr/ic MiUlnirc 
 en France, Besai)(;on, 1817, p. 182. 
 
 ■Medical Sketches of the Campaiffns of 1812. ]5y James Mann, M. D., Surfji'dii of tlic Arinv, &(.-.. ISIO. Oil:iV(), ]). :U8. 
 
 ■'CooPER'.s Surijical Dictionary, 8tli English «1., p. 116. Dr. Stkitikn Smith (A'chi York. Jour, of Med., Yo\. l\. Yi.'iOi) 
 nitlicr unreasoiialily oxcUules Cooper's case from Ijis statistics, because tlie jialieut died before the o|)erati<>n was com]>leted. 
 
 ■'GUTIIRIK, A Treatise on (lunshot Wounds. 3(1 London ed., p. 334. 
 
 ■'Guthrie, A Treatise on (lunsliot Jl'oimds, 3d London ed., p. 342; Lauuey, Clinique Chirunjicalc, Tonic \'. ji. 427; and 
 Hennen, Principles of Military Surijery, 3d London ed., p. 2C5. 
 
 ''TlIOM.soN, Report of Observations made in the Military Hospitals in Bel;/ium after the battle of Waterloo, l'.(linliurf,'li, 
 1816, p. 270; and Guthrie, Op. eit., p. 351. 
 
 'A'o<e» on the Medical History and Statistics of the British Leyion in Spain, comprisiny the licsulls of (lunshot ll'ounds in 
 Relation to important Questions in Suryery. By RUTHEKPORD AxCOCK, Deputy Inspector General of Hospitals. London, 
 1838, p. 78. 
 
 * Glasyow Medical Journal, 1831, p. 262; Brit, and Foreiyn Med. Chir. Review, Vol. XV, p. 512; C'OSTELLO, Cyclopcedia of 
 Prart.Sur(j.,\o\. I. p. 182 ; M. Velpeau, Op. cit., Tome I, p. .514 ; Cox, Op. cit., p. 11, etc., etc. Hut all the suoces.sive authors 
 take their account from Dr. Bryce's report in the Gla.sgow Journal.
 
 HISTORICAL SUMMARY. 1a 
 
 is traced for so sliort a poriod tliat it cannot be regarded as an auflicnticaled exa]ni)le ol 
 
 recovery. 
 
 ( )ii .luly 29, 1830, P. J. Koux, iierfoi'med tlie operation wilhuut success on a Swiss 
 subalternMvounded in the revolution in Paris. On November 10th, of (lie same year, Di-. 
 Clot Bey had an unsuccessful secondary operation at Marseilles." 
 
 In 1831,Demme, the elder, performed the operation three times dui-ino- the campaign 
 in P(jland. These were all unsuccessful intermediate amputatitms for gunshot fracture of 
 the femur.^ In the same campaign, M. Sedillot had an unsuccessful primary operation.^ 
 
 In 1832, at the siege of the citadel of Antwerp, LetuUe performed the operation 
 [irimarily on an artilleryman whose left thigh was badly shattered by a cannon ball. The 
 patient survived nine days.^ 
 
 Amputation at the hip-joint for gunshot injury was performed at least eight times in 
 tlie campaigns of the French in Algeria, from 1836 to 1840. Twice by Hutin'' unsuccess- 
 fully. Five times, primarily and unsuccessfully, by Guyon, Bertherand, and others.'' Once 
 successfully by Baudens,^ being the fourth authentic instance of the successful performance 
 of the operation in military surgery. 
 
 About this time Wedemeyer had a successful intermediate operation, and a primary 
 operation, which resulted fatally.^ Three fatal primary operations were recorded by 
 Jubiot;^" and Sir Benjamin Brodie operated unsuccessfully in a case of accidental gun.shot 
 fracture of the femur. •'^ 
 
 In the war between the United States and Mexico, in 1846 and 1847, there were no 
 amputations at the hip-joint.^^ 
 
 In the insurrection in Paris, in June, 1848, amputation at the liip-joint was performed 
 for gunshot injury five times by Richet," Baudens," Vidal,-^^ Robert,-''' and M. P. Guersant." 
 Richet's was a primary, the others were intermediate cases; all terminated fatally. 
 
 I Gazette des Sdpitawx, 1830, p. 392. 
 
 - Gazette des Hopitaux. Tome IV, p. 9G. 
 
 ^l")r. Hermann Demme, Militdr-CMrurgisdcc Studien, Zweite Abthcilunr/, p. 352. Wurzburg, 18(;4. 
 
 "■ Traite de Medecinc Ojieratoirc, par le docteur Ch. Skduxot, 3d ed., Paris. 18tiJ5, T. I, p. 455; and Jiundis dr CJiinirf/ir 
 I''ran(;aise et Etranycre, T. II, p. 279. LeooUEST (Chirurr/ic d'Armce, p. 699) credits Si'dillot ivitli five easi's ; Uut the iitl;cr 
 four were operations done in Algiers b_v Beitljerand :iiid otliers, and are simply referred to liy Si'dillot. 
 
 '■•HUtoire Chirurr/icalc du Siege de la Citadelle d'Anvers, par HiPPOLYTE L.^EKEY. Paris, lg33, p. 3(i7. 
 
 '^ M^ni. de Chiravffie Mil. 1^' Serie. Tome XLIV, p. 219. Botli were pi-im.iry operations. One patient lived ten day.* ; tiie 
 other died on the day of the operation. 
 
 ■ M. SiDII-I.OT, Ann, de Chir, Franc, et Etran;/., Tome II, )>. 279; LkgoUEST. Loro ritiito ; GUY'ON, E.TpcJilion de Chcrrlirll ; 
 Gazette Medicate de Paris, 1838,- jiledifo-Chiruri/ieal Jlcriew, Vol. XXXV, p. 214. 
 
 ** Cliniq2te dcs.Plaies d'Armes d Feu, par M. J. 13aiti>ENS. Paris, 1836, p. 513. The jialiiMit, a soldier, twenty-four years 
 old, was wounded at the Atlas, April 1, 1836, and was amputated at the hospital at Algiers on Ajiri! 7. He recovered rapidly. 
 and was for a long time afterwards an inmate of the Invalides. His stuni]! is figured in Bourgery's Plates. T. VI, Pi. 91, Fig. 9. 
 
 ■'Bulletin de M. le Baron Ferussac. Tome III, p. 161. 
 
 '" Theses dc la Faculte de Montpellier, 1840. I have not been able to refer to or to verity these cases. 
 
 " CoSTELLO. Cyclopwdia of Practical Surgery, Vol. I, p. 182. There is no question aa to the authenticity of these eases, 
 but I cannot find recorded any particulars in regard to them. 
 
 ' ■ Ha nd-look for the Military Surgeon, by ClIAItI.E.s S. TlUPLEH, A. M., M. D., Surgeon, U. S. Army, Ciniinnati. 18i;i, 
 p. .52; and Medical and Surgical Xotes of Campaigns in the War with Mexico, during the years 1845. 1846, 1847, and 1848, hy 
 John B. Porteu, M. D., Surgeon, U. S. Army. 
 
 '■'M. L. Legoxiest. Cfdrurgie d'Arme'e, p. 699. 
 
 '■' Recaeil de Mfin, de MM, et de Chir, Mil. 2" serie. Ton)e X. p. 130. 
 
 '"ViDAL. Traite de Pathologic Externe et de M^d . Opcr. Tome V. j). 703. Troisieme ed. 
 
 "M. L. Legouest. Loco citato. 
 
 '" Idem.
 
 14 AMPUTATIONS AT THE HTP-JOINT, 
 
 During the war in Schles-wig-Holstein, in 1S4S and 1849, this operation was performed 
 seven times: five times in 1S48 and twice in 18i9.' Five of the operations were done 
 bv I>r. B. Langenheek. and one of liis patients, a vouth of seventeen, recovered.^ 
 
 In 1849, after the riot in Astor Ph^ce, New York, an amputation at the hip-joint 
 was performed at the New York Hospital for a gunshot fracture of the neck of the femur 
 by a musket ball,^ the patient surviving the operation two days. This was the first 
 instance in which the operation was practiced in this country for gunshot injury. 
 
 In the war in the Punjaub, in 1848 and 1849, three primary amputations at the hip- 
 joint were performed for cannon-shot wounds, involving extensive lacerations of the thigh, 
 with comminuted fracture of the femur. Dr. James McRae states that the patients died — 
 one in six, one in twelve, and one in thirty-six hours, from shock.^ 
 
 Ill 1853, two amputations at the hip-joint for gunshot injury were performed at 
 Rangoon, in India. One, a jjrimary operation, was done on February 16th by Dr. J. 
 Fayrer ; the patient survived one raonth.^ The other was done by Dr. Beatson, six days 
 after the reception of the injury; the patient, a man of sixty-one years, died fi-om the 
 shock of the operation.*^ 
 
 In 1854 and the following year, in the war in the Crimea, this operation was performed 
 not less than forty-four times ; twice in the Sardinian, eight times in the Russian, fourteen 
 in the British, and twenty in the Frencli army. Porta mentions that the operations in 
 the Piedmontese army resulted fatally. PirogofT operated in the eight cases in the Russian 
 army. He describes his patients as in almost every instance ansemic and unfit to undergo 
 so grave a mutilation. Two survived five days; the others perished within two or three 
 days.^ All of the operations in the English army were primary. Five were performed 
 after Alma, Balaclava, and Inkermann. The director general, Thomas Alexander, did two 
 of these operations. His patients lived to reach Scutari; one, a man of the thirty-third 
 regiment, sm-vived three weeks, and the other, a Russian prisoner, lived a month. * Dr. 
 Richard McKenzie operated in another of these cases,^ and Assistant Surgeon Wyatt in a 
 fourth." Nine operations were performed during the siege of Sebastopol. Two of the 
 patients were officers and seven enlisted men." All of these cases ended fatally. Of the 
 twenty amputations at the hip-joint in the French army, twelve were done in the Crimea 
 and eight at the hospitals on the Bosphorus. Five primaiy and eight intermediate or early 
 secondary amputations were reported by the operators, ^TM. Paulet, Lustreman. Tliomas, 
 
 ^ Maximen dcr Krier/sheill-unst von Dr. L. STiiOMEYKii. llaiiovfr, ISCA, |i. .'iliS. 
 
 - Ueber Eesectionen nach Sckussimnden vonDr. FlilEDUlc.ll K.smaucii, KhI, 1s.")1. |), IJt ; Loxc.Moni:, in IIoIdus's Si/slem 
 of Surncry, Vol. II, p. 82 ; and Demme, Op. cit. 
 
 ^ Ttie Transactions of the Amcriam Medical Association. Vol. IV, p. oll>. 
 
 •' McRae, Jnrfian Annals of Medical Science, April, 1857, p. 053; and Mililarij Siirr/cri/, by Geouiji'. Wii.m.vm.son, 
 Surgeon-major, 64tli regiment, London, 1863, p. 202. 
 
 ■■ Clinical Surr/ertj in India. By J. Fayheh, M. D., p. GtW. 
 
 •' Indian Annah of Medical Science. October. 1854. 
 
 ' GrundzM'je dcr Allijemeinen Kricgschirur;/ie von N. PntOGOFE. Leipzig. ISiii, p. IKUi. 
 
 "LoNG^tORE. Loco citato. 
 
 ''Xotcs on the Svrr//r;/ of the War in the Crimea. Uy GeOKCK II. li. M.\< l.i:iil>, Jl, !>., 1". K. C. S., etc., etc. London. 
 1858, p, 369. 
 
 ^"Medical and Surf/ical Ilistory of the British Armi/ in the Crimea. Vol. I, p. 3. 
 
 " Staff-Siirgeon T. P. Matthew, in tlie Medical and Suri/ical Ilistorij of the British Arm}/ in the Crimea. Vol. II. |i. 371.
 
 HISTORICAL SUMMARY. 15 
 
 PerrilL AL)unier, Legouest, Lariviere, Mauger, and Salloroii.' Such particulars of these 
 thirteen operations as could be collected are presented in the tables in aimtlier part of this 
 report. Besides them, seven primary coxo-femoral amputations were done by the French 
 surgeons in the Crimea of which no memoranda were preserved. Three of these were 
 performed during or after the battle of the Alma, September 20, 1854, and three at 
 Inkermann, November 5, 1854. None of these patients survived the opertion twenty-four 
 hours, and, consequently, says M. Chenu, their names were not inscribed on the registers 
 of the field hospitals, and it is not known whether they were French soldiers or Russian 
 prisoners.^ 
 
 The Italian war of 1859 was the occasion of at least nine amputations at the hip-joint 
 for gunshot injury, or the complications consequent thereon. A iirimary operation after 
 the battle of Palestro, by the French surgeon Bertherand, on an Austrian soldier, whose 
 left thigh was shattered by a shell, terminated fatally in three hours.^ In two' primary 
 operations reported by Demme,'' death resulted from haemorrhage during the operation. 
 In two other cases the patients survived the shock of the operation but a short time. A 
 secondary operation by Isnard, at a hospital at Brescia, succeeded, and the patient was 
 able to get about on an artificial limb. Neudorfer also had a successful secondary operation 
 at the Santo Spirito Hospital at Verona.^ Two patients who were sent to Toulon wei'e 
 operated on by M. Jules Roux and M. Arlaud about sis months after the reception of the 
 injury in each case, and both recovered.*^ 
 
 Two unsuccessful primary amputations at the hip-joint were performed on account of 
 gunshot fractures in the French naval service during the Crimean or Italian wars. The 
 exact dates of these operations are not recorded.'' 
 
 Setting aside the doubtful or unauthehticated eases of Blandin, Ferret, Wendelstacdt, 
 Krimer, Alcock, and Bryce, there have been enumerated in the foregoing summary one 
 lumdred and eight amputations at the hip-joint performed on account of gunshot injuries 
 or their consecutive lesions. Admitting Larrey's case at Borodino to have begn successful,** 
 
 ' Rapport au Conseil de Sante des Armies sur les EestiUats du Service Medico- Ckirurgical anx Amlulances de Crimee et aux 
 Hi'ipitaux MilUaires Franqaise en Turqiiie, pendant la Campagne d'Orient, en 1854. 1855, 1856. P;ir J. C. C'hexu, Medecin 
 Principal, etc. Paris, 1865, p. 660. 
 
 " Chenu, Op. cit., p. 658 ; and ScRlVE, Relation Medico Chirurgicale de la Campagne d'Orient, Paris, 1857, pp. lOG, l'?5. 
 
 ^A. Bertherand. Campagne d' Italic de 1859, p. 37. 
 
 'Allgemeine Chirurgie dcr Kriegswunden nach Erfaltrungen in den A^orditalienisrhcn Hospitaclern von 1850. Von Dr. 
 Hermann Demme. Wiirzburg, 1861, p. 254. 
 
 '' Dr. Demme. Loc. cit. 
 
 '■ Dc V Osteomyclite et des Amputations Secondaires a la suite des Coups de Feu d'Apres des Ohservations recunllics d P Hopital 
 de la Marine de Saint- Mandrier sur des Blesses dc VArmcede V Italic. Par le Doctcur Jule.s Roux. Premier Cliirurgien on 
 Chef de la Marine, etc. Paris. Quarto, 1800, pp. 98, 99. From the title of M. Koiix's Memoir, and from the ninuerous 
 abstracts of it that have been published, it would be inferred that the six operations and four successes which Eoux reported 
 were all instances of amputation at tlie hip-joint for gunshot injury. This is only true, however, of the two cases of the series 
 noted above, in one of which M. Arlaud, the colleague of M. Koux, operated. The other operations were done on account of 
 lesions resulting from falls or other traumatic causes. 
 
 ' Desarticulation de la Cuisse, cVapres les Ohservations recucillies en 1859 sur des Marins dc la Flotte et des Blessed dc 
 I'Armce de I' Italic. Par le Docteur JuLES Roux, Premier Cliirurgien en Chef de la Marine. Comptes liendus Hcbdomadaircs des 
 Seances de VAcadimic des Sciences, Tome L, p. 752. 
 
 '* M. Legouest in his tables (Chirurgie d'Armee, p. 699) accredits Larrey with one successful case, and places it in the category 
 of intermediate operations. He counts six of Larrey's seven operations as primarj-. Now it is certain that Larrey's two opera- 
 tions after the battle of Wagrain were intermediate, for In? ascribed tlie fatal results to the delay in operating. It is equally clear 
 that the operation at the battle of ISorodiim or Mosjiisk, which is claimed as a success, was a primary one, for Lari'ey said be 
 perfonned it '"sur le champ de bataille." (Mihn. deChir. .MiL.T. IV, p. 51.) M. Legouest must either refuse to admit that any 
 of Larrey's operations were successfiil, or he must amend the proposition eiuuiciated in his ^fcinoirc sur le desartirnlation ro.ro- 
 fdmoraie an point de viic de la Chirurgie d'Armee, that primary amputations at the hip-joint have hitherto been invariably fatal.
 
 16 AMPUTATIONS AT THE HIP-JOINT. 
 
 the recoveries were ten in number — one after a jirimary, four after intermeiliate, and five 
 after secondary operations — a percentage of mortality of 91.66. 
 
 Except in the references to' the cases of Kerr, and the alleged cases of Lacroix, 
 Perault, and Thomson, introduced in tracing the early history of this operation, notice has 
 only been taken, in the preceding retrospect, of examples of the operation occurring in 
 the domain of military surgery. Yet the results of the amputations at the hip-joint done 
 in civil practice, especially for such as were performed on account of injury, uncjuestion- 
 ably exerted much influence upon the minds of military surgeons in their estimate of the 
 operation. The cases recorded in civil surgery are as numerous as those occasioned by the 
 accidents of war. The French boast of eight successes in civil practice, by Mulder,^ 
 Delpech,- M. Sedillot,^ Henot,^ M. Guersant,^ Foullioy," and ]\I. Jules Eoux,' andlament fifteen 
 failures, by Baffos,^ Pelletan,^ Dupuytren," Blandin," Gensoul,^" Delpech,i^ Gerdy," M. 
 Velpcau,!^ ^^^l j^j; j^j^g Roux.^^ 
 
 The German surgeons, if all their unsuccessful cases are reported, have been more 
 fortunate. The successes outnumber the reverses. In thirteen operations, Jaeger," 
 Hvsern,-'^ Textor,^^ and B. Langenbeck,^" each claim one success, and Heyfelder^' three; 
 while Von Walther,"^ Graefe,^^ DiefFenbach,^^ in two cases, and Heyfelder, also in two, 
 endured the mortification of failure. 
 
 Four amputations at the hip-joint for disease, by the Polish surgeons Peliken, Korseii- 
 iewski, and Porcienko, resulted fatallv.^ 
 
 ' In 1798, on a girl named Wiertz, aged eiglifeen. Velpeau, Op. rit., p. ril4. 
 
 ■ Hcruc Metlii-uh, 182,'), and Ann. de Chir. Franr. et Etramj. T. TI, p. 'Sll . 
 
 "Jiecueil de Mem. de Med. et de Chir. Mil. 1 surie. Tome XLIX. p. y77. 
 
 ■■ Idem. 2d serie. Tome VI, p. 93. 
 
 ^Jour. de Med. et de Chir. Prat. 1848. 
 
 "VlCiL. Traite de Path. Ext. et de Med. Op. ?,f\ ed. Tome V, p. 7(111. 
 
 "Two secondary operations, for clironic osteomj-elitis follow ini; injuries. Cninpfrs Rnidus nehdnmiidairts drs Seavees dr. 
 P Academic dcs Srienrci. T. L, p. 753. 
 
 "In 1812, in a child of seven year.* with coxalgia The cotyloid cavity was diseased and the child died in a few months 
 after the operation. Bulletin de la Faculte de Medicine. Tome VIII, p. 1 12. 
 ■'S. COOPKR'S Sur;/ical lyiftionary. 8th Lond. ed.. p. 117. 
 
 '"Six operations, si.x deaths. Lei;ons Oralcs de Clin. Chir. 2d eil. T. II. p. ")70. 
 
 " Transactions Mediralcs. Tome X, p. 353. 
 
 '- Laneette Fran<:aise. Tome 11, p. 220. 
 
 "Idem. TonieXIII, ]). 301. 
 
 ^^ Bulletin de la Thirap. Mddifo. Chir. Tome VIII, p. 318. 
 
 '■'' Op. cit. Tome I, ]). 515. 
 
 '*' Comptes Bendus dc V Acad, des Sciences. Tome L, p. 753. 
 
 '" Ilamburt/cr Zcitschriftfilr die (jesammte Med. Band III, Ileft. 1. 
 
 '" Opirations Generates par I!otIK(iKKV. Tome VI, p. 271. 
 
 ■'' Metz. Vebcr dc I./isunij des Oherschcnkels aus dcm UtifPiclenkc. Wnrzliiirj;. IHII. 
 
 ™ Stjw )MEVER. Max. der Krieiishcilkun.it, p. 277. 
 
 -' Deutsche Klinik. March, 1853. 
 
 -■-In 1824, for complicated fracture. The patient lived eleven ilays. (;i;.m:ii-. vsu Wai.toi'I!. /,it.tchrifl J'llr Chir. 
 Hand VI, p 1. 
 
 •■^ ^'ormcn fllr die AhlDsumj grOsscrcr Glicdmassen, p. 117. 
 
 ■'< Jour. Univ. dcs Sci. Med., Tome XLVUI, p. 381 ; and London Lancet, 1834, p, 908. One patient was a child with osleo- 
 sarcoma; the otlier was an a<lult with fracture through the trochanters. A secondary amputation was |)eiformed, which he 
 survived ten hours. 
 
 -'■• Acts of the Imperial Acadcm;/ at IVitna. (|Uoted l.y .M. \'el|ic.au, Mr. ( 'ox, and olIierB. I'elikan's opii-ation w.as on a man 
 of twenty-five, with fungus h.Tmatodes. Korseniewski o])erated (pii aeciiuiil of neuniiiia. I'orcienko hail two operalions: one in 
 1821, on a woman of fifty ; (jue in 1834, on a Jewess.
 
 HISTORICAL SUMMARY. 17 
 
 In tlie annals of British civil surgery not less than forty-seven of these operations are 
 recorded, with sixteen recoveries. The successful operators were A. Cooper,-^ Orton,^ Mayo,' 
 Macfarlane,' Mr. Syme,^ Mr. Cox," Mr. Wigstrom,' Mr. Whipple,^ Mr. Humphrey,' Mr. 
 Tatum," Mr. Gamgee," Mr. Hancock,'^ Mr. Holmes," Mr. Lee," and Mr. Godfray.^' In 
 four of the cases the thigh had previously been amputated in the continuity. In one case, 
 in a child of two years, the operation was done on account of injuries; in the remainder for 
 disease. 
 
 In the thirty-one unsuccessful operations, the operators were Kerr, A. Cooper,^" Brown- 
 low, Bromfleld," Carmichael,^* Mr. Syme, Liston," Smith,^" Handyside,^^ Mr. Jones,^ Mr. 
 Hancock,^ Dr. R. J. Mackenzie,^^ Mr. C. Guthrie,"-^ Mr. Wheatcroft,^'' Mr. Adams,^ Mr. 
 Erichsen,^ Stanley,^ Mr. Lane,=«' Badley,'^ Mr. Butcher,^ Mr. Young,=« Mr. Wells,=^ Mr. 
 Swain,^ and Mr. Curling.^ 
 
 ■ London Lancet. Vol. II, 1824, p. 96. 
 
 -In 1824, for caries. Medico-Chirurffical Transactions. Vol. XIII, Part I, p. 605. 
 
 ^ A reamputation for neuroma. Cooper's Sury. Dictionary. 8th Lond. ed., p. 117. 
 
 •• For compound fracture in a child of two years. Clin. Report of Glasijow Roi/al Infirmari/, 18:i2, p. 182. 
 
 •■* A reamputation, the first successful case in Scotland. Udin. ami Lond. Monthly Jour., 1848. 
 
 " A reamputation. See memoir already cited. 
 
 'At Lahore, India, for disease of the femur. London Lancet. Vol. I, 1850, p. 411. 
 
 * At Plymouth, for disease of the femur. London Lancet. Vol. II, 1846, p. 883. 
 
 '••Two cases: one of compound fracture, the other of chronic disease resulting from injury. 'EvE.'s Jiemarlcable Sargi»;al 
 Cases, p. 565. From Provin. Ass. Med. Jour., 1855. 
 
 '"In 1855, at St. George's Hospital, for malignant disease. London Lancet. Vol. II, 1855, p. 77. 
 
 " For malignant disease. See monogTaph already cited. 
 
 '- For necrosis, at Charing Cross Hospital. Med. Times and Gazette, January, 1857, p. 114. 
 
 " For fibroid disease of thigh. London Lancet. Vol. I, 1866, p. 367. 
 
 '■• For coxalgia. London Lancet. Vol. I, 1866, p. 386. 
 
 '" For extensive necrosis. Dublin Quarterly Jour. Med. Sci., November, 1866, p. 302. 
 
 "•CoSTELLo's CyclopcEdia of Surgery. Vol. I, p. 183. 
 
 " In Sir Astley Cooper's fiftieth lecture the cases of Brownlow and Bromfield are mentioned. London Lancet, 1824. 
 
 "On a girl of nineteen, with osteosarcoma. Trans. of Coll. of Physicians of Ireland. Vol. Ill, p. 8. 
 
 " "During my residence in Edinburgh the operation was done twice by Mr. Liston and twice by Mr. Syme. All the patients 
 died." Mr. W. Fergusson. A System of Practical Surgery. 4tli Lond. ed., 1867, p. 506. 
 
 -" On account of compound fracture. London Med. Gazette. Vol. XVI, p. 551. 
 
 ■-' On a boy with medullary sarcoma. Lond. and Edin. Monthly Jour., April, 1845, p. 254. 
 
 -- For haemorrliage from a lacerated wound of the thigh. Medical Times, March, 1854, p. 434. 
 
 -■"Two cases: one a reamputation, the other for compound fracture. London Lancet. Vol. I, 1860, p. 319; Idem, \ol. I, 
 1857, p. 31. 
 
 -■' For necrosis. Edinburgh Medieal and Surgical Journal, 1854, p. 117. 
 
 ^ For malignant disease. London Lancet. Vol. I, 1853, p. 405. 
 
 -'"'For coxalgia; fatal in four hours. London Lancet. Vol. I, 1853, p. 470. 
 
 °' For malignant disease. Medical Times, April, 1854, p. 349. 
 
 =« Two cases: one of compound fracture, the other of encephaloid. London Lancet. Vol. I, p. 363, 1855, and Vol. I, 1866, 
 p. 222. 
 
 -' For meduUary cancer. London Lancet. Vol. I, 1857, pp. 343 and 380. 
 
 ^o Three cases: two of malignant disease, one of injury. London Lancet. Vol. II, 1857, p. 443; Idem, Vol. I, 1865, p. 651; 
 Idem, Vol. I, 1865, p. 566. 
 
 3' In 1814, the patient, a boy, had his thigh crushed by machinery. Mr. W. S. Cox. Op. cit, p. 12. 
 
 ^- For osteosarcoma. Dublin Quarterly Journal of Medical Science. No. LXXXIV, p. 305, Nov., 1866. 
 
 *' For a bad fracture. London Lancet. Vol. I, 1865, p. 6.52. 
 
 ^^For maligriaut disease; the patient lived nearly a year. London Lancet. Vol. I, 1865, p. 652. 
 
 ■■'"For encephaloid. Dublin Quarterly Journal of Medical Science, November, 1866, p. 302. 
 
 * Two cases: one of medullary cancer, the patient survived ten months; one of necrosis, ending fatally in five weeks. 
 iMndon Lancet. Vol. I, 1856, p. 6, and Vol. I, 1865, p. 566. 
 
 3
 
 6 
 
 18 AMPUTATIONS AT THE IIIP-JOINT. 
 
 Ill American civil practice, twenty-four examples of amputation at the hip-joint are 
 recorded. Fifteen successful cases are reported ; so large a preponderance as to lead to the 
 suspicion that all the unfortunate cases have not been published. The operators in the 
 successful cases were Brashear.^ Mott," Duffee,^ Dr. Van Buren/ Dr. May,^ Dr. Bradbury,*' 
 Dr. Potter," Dr. Blackman,*^ Dr. J. Mason Warren," Dr. Buchanan," Dr. Pancoast," and 
 Dr. Gross.^= 
 
 In the nine unsuccessful cases, the operators were Brainard,'^ Buel," Clark,'" Dr. Van 
 Buren,'" Dr. J. ^Mason Warren.'" Dr. Hachenburg,'* and Dr. Hewson." * 
 
 Of the one hundred and eleven amputations at the hip-joint in civil practice here 
 recorded, forty-six succeeded and sixty-five ended fatally: a mortality rate of 58.56. 
 
 All of the facts here recapitulated were not known to our surgeons at the commence- 
 ment of the war of the rebellion. Some of them, indeed, have transpired during its 
 progress, or since its termination. But a large proportion of them were well known, and 
 the conclusions deduced from these were not materially modified by the additional cases. 
 It was considered well established, that in amputation at the hip-joint for chronic disease, 
 the mortality was less than in several other major operations in surgery; that the mortality 
 had lessenecl since the introduction of antesthetics had furnished the means of diminishing 
 
 ' In 1806. Moll's Vclpeau's Surr/rri/. Vdl. III. Eve's Bcmarkablc Cases !ii Surgery, p. 362. 
 
 - In 1824, for caries following fractui-o. I'hilndeljihia Journal of Medical and I'hi/siral ,Scienres. 1827. Vol. V, )>. 1(11. 
 
 ' In 1840, for coxalgia. Institutes and Practice of Surger;/. By William Gibsox. 7th ed. Vol. II, p. 4til. 
 
 ^ In 1850, a reamputation for osteochondroma. Contributions to Practical Sunjcnj. By W. H. Why. BuKEN, M. 1). Pliihi- 
 delphia, 1865, p. 10. 
 
 "• In 1850, for scrofulous degeneration. Am. Jour, of the Med. Sci.. October, 1851, p, 313. 
 
 '■ In 1851, a reamputation of a thigh stump of a strumous child. Boston Medical and Surr/u'al Journal. Vol. XLVI, p. 349. 
 
 ' Two cases : one in 1853, for caries, N. T. Jour, of Med., 1854 ; and another in 1860, for diiiease of the fi-nmr resulting from 
 the kick of a horse. Am. Med. Times, Vol. I, p. 309. 
 
 "In 1855, for osteocephaloma. Il'esturn Lancet, 1857. Vol. XVIII, p. 7. 
 
 "In 18.59, for osteosarcoma. Boston Med. and Sure/, Jour., 1859. Vol. LX, p. 329. 
 
 '" In 1859, on a boy of fourteen years, for necrosis. Boston Med. and Sunj. Jour. Vol. LXI, p. 227. 
 
 " Two cases. One in 1880, for meciullary sarcoma; the patient died two years subsequently from recurrence of the disease 
 in the trunk. Am. Jour. Med. Sci. Vol. LII, p. 23. The other in 1855, for osteochondroma. Op. cit. Vol. LII, p. 28. 
 
 '-Two cases. One in 1862, on a child of nine years, for deformity following a hurn. Am. Jour. Med. tici. Vol. XLVIII, 
 p. 105. The other in 1865, for encephaloid. Op. cit. Vol. LII, p. 31. 
 
 ' ' In 1837, for a tumor involving the femur. Am. Jour. Med. Sci. Vol. XXII, 1838, p. 372. 
 
 " In 1847, for a railroad accident. Am. Jour. Med. Sd. N. S. Vol. XVI, p. 34. 
 
 '" In 1853, for medullary cancer. Peninsular Journal of Med. Vol. I, p. 59. 
 
 "'Two cases: one in 1853, one in 1855 ; both for railroad accident.s. \. 1'. ,/o«r. n/.l/ic/.. Vol. Xll. p. 151. and Contrilintions 
 to Prac. Sunj., p. 33. 
 
 '■ In 1858, for compound fracture in a hoy of si.x years. Boston Med. and Sury. Jour. Vol. LIX, p. 281. 
 
 '" In 1861. Boston Medical and Sunjical Journal. Vol. LXVI, p. 150. 
 
 '■' Two cases: one in 1864, for a railroad accident; another in 1865, for enchondronia. Am.Jour.M(d. Sci. Vol. LII, |ip. 28-31. 
 
 " I have omitted the sixth, ninth, and eleventh cases of Dr. Stephen Smith's tabular statement of eleven amputations at the 
 hill-joint in American practice. The si.\th case has already been enumerated among the amputations for gunshot fracture. In 
 the ninth case the operation is said to have been done successfully liy Drs. Kichardsand C'l.aggett, in Washington county, Mary- 
 land. (Transactions of the Am. Med. .-Issoe., Vol. IV, p. 269.) The eleventh case consists of a statement of IJr. Willard I'arker, 
 that he had heard that the operation had been successfully performed by Dr. KuUer, of Norwich. Connecticut. These two cases, 
 reported on the basis of the merest rumors, are unfit for statistical purposes. It is (|Uestionable if the first case, also, should not be 
 set aside, since the operator, Hrashear, did not repoi-t the operation until forty yeai-s after its |ierformance, and then declined to 
 state the causes that necessitated it. (New Orleans Mttl. and Sur;/. Jour.,V<i\. II., and .l/o«'.< Velpeau, Vol. III.) I have also 
 <lisrarded fnmi the lists of European cases the operations of Lacroix and I'erault, the two ]iretended successes of Millingen. 
 (Jour, dc Med. dc Vartermondc, T. II. p, 2-10,) the ca.ses ascribed to Thomson, liruol;.', Havaton. (ioursaull. 1 )el.iiiniy. Kerst, 
 Kossi, and Cherubini, being unable to find evidence of their authenticity.
 
 HISTORICAL SUMMARY. 19 
 
 the shock of the operation ; and it was hoped that the methods recently proposed for 
 controlling the circulation in the thigh by compressing the aorta might remove another of 
 the great dangers of the operation. It was admitted that, in cases of injury, the results of 
 the operation were very unsatisfactory, and the experience reported from the Crimean 
 war had led to the conviction that, in military surgery, the results were especially 
 discouraging and deplorable. 
 
 With such impressions, few of the practitioners who engaged in the surgery of the 
 war looked forward to such exigencies as might require amputations at the hip-joint with 
 hopeful anticipations. Many believed that as patients with terrible gunshot injuries of the 
 upper part of the thigh often lingered for a long period, it was more humane to abandon 
 them to inevitable death than to subject them to a mutilation which was so rarely successful, 
 and such practitioners were willing that the operation should be discarded altogether from 
 military practice. The majority contended that the results had not been so hopeless as to 
 lead us to abandon the operation. Dr. Chisolm, who prepared a manual of military surgery 
 for the use of the Southern medical officers, observed "an unfortunate ambition — we might 
 even use a stronger term for it — a criminal desire, to have an amputation at the hip-joint in 
 the list of operations performed, which misleads many surgeons to perform this disarticu- 
 lation, when their better judgment teaches them that it must be a useless mutilation."^ But 
 manifestations of this criminal spirit were certainly uncommon, for the great body of 
 surgeons were earnestly and conscientiously seeking for the best solution of the grave 
 problem of how to deal with the severer gunshot injuries of the upper part of the thigh. 
 There was a disposition on the part of the leading surgeons to give conservative surgery a 
 very fair trial, and the operation of excision of the upper extremity of the femur in such 
 cases as had formerly been treated by extirpation of the thigh was advocated by many. 
 
 ' A Manual of Military Suvfjery, for the use of Surf/eons in the Confederate States Army. By J. Julian Chisolm, M. D., 
 Professor of Surgery in the Medical College of South Carolina, etc., etc. Third od., p. 483.
 
 20 AMPUTATIONS AT THK TIIP-.IOINT 
 
 HIP-JOINT AMPUTATIONS IN THE WAR OF THE REBELLION. 
 
 There oci'iirrctl, in tlic war of the rebellion, fii'ty-three aiitlienticated instances of 
 amputations at the hiii-joint, performed on account of injuries inflicted by weapons or of 
 lesions consecutive thereto. Thirty-four of these operations were performed in the armies of 
 the United States, and nineteen in the rebel armies. There have been reports or rumors of a 
 number of other examples of the operation. Some of these, upon investigation, have been 
 proved to 1)0 altogetla'r unfounded, and others too uncertain and indefinite to lie admissible 
 ibr statistical purposes. 
 
 Surgeon H. Z. Gill, U. S. Volunteers, has communicated to this oflice a statement that, 
 in the autumn of 1861, Surgeon J. Frank Gabriel, 11th Ohio Volunteers, in charge of the 
 hospital at Gallipolis, Ohio, amputated at the hip-joint in the case of a soldier whose thigh 
 had been frightfully crushed by a cannon shot. Dr. Gabriel, however, states that although 
 he considered the case to be one in which the operation would have been indicated had it 
 come under his care in season, he did not operate, because the j^atient was nearly moribund 
 when he reached the hospital. 
 
 A successful secondary amputation at the left hip-joint was reported from Armory 
 Square Hosjjital in the autumn of 1862, and an intermediate amputation at the right hip- 
 joint, in the case of Corporal R. A. Whitworth, Co. E, 64th Georgia (Rebel) Regiment, 
 was mentioned in the surgical report of the hospital at Fort Monroe, for the third quarter 
 of 1864. But it was ascertained by inquiries addressed to Surgeon D. W. Bliss, U. S. 
 Volunteers, and Assistant Surgeon E. McClellan, U. S. Army, in charge, respectively, of 
 these hospitals, that these cases were both instances of amputation in the upper part of the 
 continuitv of the thigh, and that the mistakes arose from clerical inaccuracies in making up 
 the returns from these very large establishments. 
 
 A statement that he had performed during the war an unsuccessful amputation at the 
 hip-joint for gunshot injury has been received from Surgeon 0. C. Co.x, U. S. Volunteers, 
 with an assurance that he would forward the details of the case; but as yet no account of 
 it has reached this ofHce. 
 
 Surgeon T. H. Squire, 89th New York Volunteers, and Surgeon J. A. Bigelow, 1 Itli 
 Connecticut Volunteers, report that Acting StaflF Surgeon M. Storrs amputated at the hip- 
 joint after the battle of Antietam. Dr. Storrs declares that this report is an error, arising 
 probably from the fact that he performed an excision of the head of the femur on that 
 occasion. 
 
 Surgeon Bigelow also reports that a primary exarticulatioy at the hip was performed, 
 in September, 1864, at the 18tli Corps Hospital, before Petersburg, by Surgeon P. J. 
 D'Avignon, 96th New York Volunteers, on a soldier whose thigh was carried away by a
 
 IN THE WAR OF THE REBELLION. 21 
 
 shell, who died during the night succeeding the operation. The case is not mentioned in 
 the casualty lists of the 18th Corps, and it has been impracticable to obtain any confirma- 
 tion of the report. 
 
 In the register of the Convalescent Camp Hospital, near Vicksburg, Mississippi, 
 there is an entry of the case of "Private Andrew M. Jackson, Co. C, 41st Illinois Volun- 
 teers, wounded July 23, 1863, in the left hip, amputated and died July 29, 1863." There 
 are no quarterly reports from this hospital, and all attempts to obtain further information 
 respecting this case have been unsuccessful. 
 
 It has been alleged that Surgeon Charles J. Nordquist, 83d New York Volunteers, 
 amputated at the hip-joint, in May, 1864, during the battle of Spottsylvania, in the case 
 of private J. W. Dadds, Co. B, 4th Maryland Volunteers. The facts of this case are still 
 under investigation; but it is believed that the operation was an excision of the head of 
 the femur. 
 
 From the difficulty of collecting information from the rebel armies, vague and 
 unreliable reports from that source are still more numerous. 
 
 Mr. W. L. Henderson, a medical student under Professor F. H. Hamilton, reported 
 to his preceptor that he had witnessed an amputation at the hip-joint, performed in March, 
 1862, at Memphis, Tennessee, by Dr. E. S. Fenner, and that he subsequently saw the 
 fatient in perfect health as late as four months after the operation.^ There can be but 
 little doubt that this statement is entirely erroneous,^ and it is much to be regretted that 
 it has been widely disseminated. 
 
 Dr. J. W. Clift, of Savannah, Georgia, reports that Dr. Cullen, a surgeon of General 
 Long-street's Corps, performed an amputation at the hip-joint for gunshot injury, and the 
 editors of the Eichmond Medical Journal record that Dr. Cullen mentioned to one of them 
 two successful coxo-femoral amputations within liis knowledge.^ 
 
 Professor Paul F. Eve, has communicated the fact that a case-book of the late Dr. 
 Hargrove Hinkley, surgeon of a rebel regiment, contained entries of three amputations at 
 the hip alleged to have been performed at Jackson, Mississippi, in the summer of 1863. 
 But Dr. John Pugh, of Pinecourt, writes that he was intimately associated with Dr. 
 Hinkley throughout the war, and that he can positively assert that Dr. Hinkley never 
 exarticulated the thigh. 
 
 Professor Eve also mentioned that he had been informed, and believetl, that Surgeon 
 Cowan, of the staff of the rebel General Forrest, twice amputated at the hip-joint during 
 the war. 
 
 ' See Cirmlar No. 6, S. G. <)., 1865, p. 49, and A Treatise on Military Surgery, by F. H. Hamilton, pp. 423 and 482, 
 = Dr, C, H. Mastin, of Mobile, Alabama, who was inspector of the rebel hospitals at Memphis in 1802, is positive that Dr. 
 Fenner performed no such operation there, Dr, Fenner, of Memphis, called at this office in the summer of 1865, with Dr, Nott, 
 of Mobile, and denied any knowledge of such a case, lie suggested that the operation might have been done by Professor E. 
 D, Fenner, That eminent practitioner is dead ; but his colleague, Professor D. \V. Brickell, states positively that he never 
 attcmjited the operation of amputation at the hip-joint. Assistant Surgeon W, S. Tremaine, II, S, Army, stationed at Memphis, 
 Professor J, J, Cliisolm, of Charleston, and Professor Paul F, Eve, of Nashville, have made diligent impiiries in relation to this 
 alleged oi)cration, and have arrived at the conclusion that the report of it is altogether apocryphal. 
 
 ''The liirhmond MeilicaJ Journal. Vol, I, p, 11, January, 1866. Dr, Gilmore writes that Dr, Cullen excised the head of 
 the fenuu-, in November, 1863, in the ease of a prisoner, a Michigan cavalry soldier, who survived tlie operation a few days. 
 This exarticulation may probably have been confounded with an extiiiiation of the thigh.
 
 22 AMPUTATIONS AT THK IIIP-JOINT 
 
 Professor J. J. Chisolm, of the Mediciil College of South Carolina, has communicated 
 a report that Surgeon Myddleton Michel had amputated at the hip-joint several times, 
 and that Professor P. F. Eve had performed the operation once at least. Dr. Eve has 
 contradicted this report, so far as it relates to himself. It is unnecessary to recapitulate 
 more of these indefinite statements. 
 
 The tifty-three authenticated operations now to be described are divided into four 
 categories : primary, intermediate, and secondary amputations, and reamputations. Practical 
 surgeons are very generally agreed at the present day that amputations for injury should 
 be classified in at least three categories, according to the period at which they are performed, 
 and that the old division into primary and secondary operations is insufficient.-' Beyond 
 question there are three distinct, successive, and easily apjareciated periods in which 
 amputations are performed: the period between the reception of the injury and the 
 appearance of the inflammatory symptoms; when inflammatory action has commenced 
 and is more or less capable of disturbing the animal economy ; and when the violence of 
 the inflammatory symptoms and symptomatic fever have abated and the suppurative stage 
 is fully established. Operations done in either of these periods differ widely in th(>ir 
 attendant circumstances and in their results. It is important therefore that they should 
 l>e grouped in separate classes. 
 
 Some authors subdivide still further, and separate tlie first class into immediate 
 amputations, or amputations sur le champ, performed, without awaiting reaction, at the 
 earliest possible moment after the reception of the injury, so that the shock to the system 
 from the operation may be confounded, so to speak, with that from the injur;;^, and primary 
 operations performed after reaction and previous to the accession of the inflammatory 
 stage.^ M. Legouest would separate the third class into consecutive amputations, done 
 during the suppurative period after the acute inflammatory symptoms have subsided, and 
 ulterior amputations, performed when the traumatic phenomena have entirely disappeared 
 and the case has become assimilated to a case of chronic disease.^ These refinements 
 could hardly be adopted in dealing with extended statistics. 
 
 It is greatly to be desired that a uniform system of classification of amputations and 
 of their nomenclature should be adopted by surgeons, in order that the results of operations 
 performed at different periods should be compared with precision. At present, authors 
 refer to the first class as immediate or primary; to the operations done in the middle 
 })eriod as delayed, tardy, mediate, intermediate, intermediary ; to those of the third period 
 as consecutive, ulterior or secondary amputations. And there is great confusion in the 
 definition of these epithets.^ ^^An<^ surgeons mean by primary amputations those done 
 
 ' Bkkakd, De.nonvilliers, and Go.sselin, in Compendium dc Cliirnrgie Pratiiiue, T. II, p. 504. Baron Hippolvtk 
 Larrey. IluUetln de U Amdimie Impiriah de Medecinc, Tome XXV, p. 647. Dr. Ha.mii.ton, A Trcat'iae on Military Surgery, 
 p. 428. Mr. Fkrgc.sson, A St/atem of I'ractkal Suri/cry, 4Ui Loiulon cd., p. 197. Ai.cocK, Xotcs on the Medieal Uistori/ and 
 Stntistiei of the lirithh Legion in Spain, p. 07. M. J. Roux, De V Ostcomijeliie , etc., p. 109. B.VLLINGALL, Outlines of Military 
 Sun/ery, 5th ed., p. 424. Mr. EuiCllSEN, liowever, (Science and Art of Surgery, 2d Loud. ed. ji. 22,) dcclaros tliiit"tlii8 
 distinction is a uomewliat trivial one." M. LEGOUF..ST (Diet. Encyclopid. des Sciences Med., 1865, T. Ill, AuT., Ani|)utalion) 
 advises five divisions. , 
 
 -BOYEK, Train des Maladies Chirurgimhs et des Opirationa qui leur conviennent, 5tli cd., Tome IV. HliTcnisoN, 
 Some Practical Observations in Surgery, p. C. Dr. Hamilton, Loco citato. GuTHRlE, Commentaries, ifcc 
 
 "M. L,EQOilE.ST. Diet. KncyclopM. des Sciences M6d. Paris, 1865. Tome III. Art., Amputations. 
 
 ■' " L'exactitude dans la denomination des amputations suivant le moment oil elles sont prali<]uees est uii des desiderata 
 iniporlants dc la science; o'est un element capital a la determination de repoque oil i! eonvient d'operer dans le cas di' lesions 
 lraniiiati(|ues." M. I,E(;<)t!E.ST. Locn citato.
 
 IN TlIK WAR OF THE REBELLION. 23 
 
 within a few hours after the reception of the injury; others extend the primary period to 
 several days. Of late, many designate as secondary amputations only those in which a 
 previous amputation lias been performed on the same limb. Baron H. Larrey is a 
 strenuous advocate of this discrimination. 
 
 I have placed in the class of primary amputations those performed in the interval 
 between the recejstion of the injury and the commencement of inflammatory symptoms, 
 and I believe that, in cases of gunshot injury, the duration of this period will very rarely 
 be found to exceed twenty hours. I have selected the epithet intermediate for the 
 operations of the second class as being more conformable to our idiom than mediate or 
 intermediary, and I have included in this category those amputations performed during the 
 persistence of the inflammatory stage, a variable period, usually included between the day 
 after the reception of the injury and some time in the second or third month. The 
 secondary amputations comprise those jaerformed at a period when the inflammation had 
 abated and the lesions had become, in a measure, local and analogous to chronic disease, 
 excluding the cases in which amputation had been previously performed in the continuity. 
 I have placed those cases in which an amputation in the continuity has preceded the 
 amputation in the contiguity in a fourth category, and have designated such operations 
 r earn j)utat ions. It appears to me impracticable, even were it desirable, to restrict the 
 term secondary, which has been so long used in a more general sense, to these operations. 
 And yet it is important that they should be separated into a distinct class, because they 
 are cjuite numerous and widely differ in the risk attendant upon them from other secondary 
 operations. The term ream/putations, if awkward, is not likely to be misunderstood. 
 
 The histories of the cases in each category are arranged in chronological order. 
 
 PRIMARY AMPUTATIONS. 
 
 In each of the nineteen cases included in this category, amputation was performed 
 within twenty hours of the infliction of the injury. Several of the operations were 
 immediate amputations in the strictest construction of that term. The average inteiwal 
 between the reception of the wound and the operation was seven hours. Eleven of the 
 patients succumbed to the direct shock of the operation, surviving from a half hour to ten 
 hours. Three lingered for two days, and two for eight or ten days. One has survived 
 the operation over four years, and is now in excellent health. Two so far recovered that 
 they were known to be in good condition, in one case two months, and in the other six 
 months from the dates at which the operations were performed. It is to be hoped that the 
 subsequent histories of these men may be traced, and that it may be proved that the 
 operations had permanently successful results. At present, these cases cannot be regarded 
 as recoveries authenticated beyond all question. Excluding these cases, the percentage of 
 mortality in the primary amputations at the hip-joint was 94.73. Including them, the 
 mortality rate is reduced to 8-4.21. Eight of the operations were performed by surgeons in 
 the armies of the United States, one was done by a medical officer of the U. S. Navy, and 
 ten were performed by surgeons in the rebel armies. 
 
 The imperfect abstract of the first case is compiled from letters from Surgeon G. C. 
 Harlan, 11th Pennsylvania Cavalry- Surgeon R. B. Bontecou, U. S. Volunteers, Dr. R. K.
 
 24 AMPUTATIONS AT THE HIP-JOINT 
 
 Browne, and Dr. L. McLean, the operator. Dr. McLean's memoranda of the case, together 
 with the pathological specimen, were unfortunately destroyed, August 30, 1862, at the 
 second battle of Bull llun, Ijy the burning of an hospital train. 
 
 Case I. — On March 9. 1862, in the engagement between the U. S. frigate Congress and the rebel iron-clad Merrimac, a 
 private of the 99th New York Volunteei-s, 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 tlie 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 reception of the injury, reaction having taken place to a considerable degree, the patient was placed under the 
 influence of chloroform by Surgeon R. K. Browne, U. S. Volunteers, and Surgeon Leroy McLean, 2d New York Volunteers, 
 amputated the injured limb at the hip-joint by the lateral double-Hap method of Baron Larrey the elder. His principal assistants 
 were Dr. Evarts, Dr. K. K. Browne, and Brigade Surgeon J. Curtis, U. S. V'olunteers. The operation was rapidly accomplished, 
 with the loss of but little blood. Six arteries required ligature. Tlie patient did not rally from the shock of the operation, and 
 died in less than two hours after its completion. 
 
 ]\Iemoranda of the next seven cases, all of which occurred in the rebel armies, were 
 communicated to this office by Professor Paul F. Eve, of Nashville. It is believed that 
 none of these cases have been published hitherto. Li a few instances the operators or 
 surgeons who witnessed the operations liave reported some additional details; yet the 
 histories of several of the cases are still very incomplete. 
 
 C.\.SE II. — A private in General A. S. Johnston's, army was wounded on the morning of Sunday, April 7, 1862, at the battle 
 of Shiloli, by a fragment of shell, which shattered the upper extremity of the left fenuir. The comminution extended to the 
 neck and head of the heme, and the soft jiarts at the upper third of the thigli were torn into shreds. Notwithstanding the 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. AV. Yandell, Medical Director. The operation was well 
 borne ; but about three hours after its completion symptoms of exhaustion were manifested, and the case terminated fatally seven 
 hours after the operation, at two o'clock of the morning of April 8, 1662. 
 
 Dr. J. T. Gilmore, of Mobile, Alabama, has courteously furnished such particulars of 
 the tliree following cases as his memory retained. Full notes of the cases, which he liad 
 preserved with a view to publication, were unhappily lost at the battle of Cedar Creek, 
 October 19, 1864. The case of Williamson, in all probability a successful one, is of great 
 interest, and it is to be hoped that its ulterior history may be hereafter traced : 
 
 Case III. — Private Williamson, 13th Mississippi (Rebel) Regiment, was woimded at an advanced picket station near Seven 
 Pines, on June 4, 1862. A conoidal nuisket-ball entered the posterior jiart of the right tliigh about two inches below the 
 trochanter major, and, passing forwards and downwards, 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, 
 located in a church buihiing on the "Nine-mile Road" to Richmond, and was tliere placed under the influence of chloroform 
 about two hours after the reception of the injury. After an explor.ation of the wound, it was decided that amputation should be 
 perfoi-med. Dr. Gilmore liegan the operation with the belief that the conuninution of the femur was maiidy below the entrance 
 wound, and that by making a long anterior flap the bone might be sawn at least through tlie trochanters; but when the anterior 
 flap was reflected, and the fracture was exposed, it was found that fissures extended u]nvard into the neck tjuite within the 
 capsular ligament, and that disarticulation must be resorted to. A ligature was first placed upon the femoral artery, and the 
 incisions were then extended upwards, the joint opened, the round ligament divided, and a slu)rt posterior flap formed by cutting 
 downwards and outwards. 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 wluch 
 suppuration was not excessive, and tlie healing of the wound progressed favorably. He was then pl.-iced 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. (iilmore learned that he arrived there in safety; but no intelligence 
 was subsequently received from him. 
 
 In explanation of the omission of this and tlie two following cases in the published 
 official return of wounds and operations in the Army of Northern Virginia for 1862,'-' Dr. 
 
 • Published in the Confederate Statea Medical and Surriiral Journal. Vol. I, p. 155.
 
 IN THE WAR OF THE KEBELLloX. 25 
 
 Gilraore writes that, "until General Lee took command of the army, battle-field reports of 
 casualties were not required. During and after tlie battles about Richmond, in consequence 
 of the scarcity of hospital accommodations, the men were transferred or furloughed with 
 no other requirement than a wound to exhibit to the provost-guard. The almost total 
 absence of organization in the medical department at that period sufficiently explains why 
 no mention is made in the official reports of many important operations performed in the 
 early part of the war:" 
 
 Case IV. — A private of tlie 18th Mississippi (Rebel) Regiment, of Bai-ksilale's Briirnile. a robust iiiaii. urnler thirty years 
 of age, received a gunshot fi'acture of the upper extremity of tlie li-ft femur, at tlie battle of Malvern Hill, on the atternoou ot 
 July 1, 1862. The injury was probably caused by a conoidal musket ball, and there was great splintering of bone, extending to 
 the neck. Early on the moniing of July 2d the patient inhaled chloroform, and amputation at the hip-joint was performed by 
 Surgeon J. T. Gihnore, P. A, C. S., by forming anterior and posterior flaps by transfixion. There was no reaction, and the patient 
 died from the shock of the operation an hour or two atler its completion. 
 
 Dr. Gilmore, formerly Surgeon-in-chief of McLaws" Division of Long-street's Corps, 
 reports the fifth case also: 
 
 Case V. — A private of the 21st Mississippi (Rebel) Regiment, a young, healthy man, was wounded at the battle of Malvern 
 Hill, July 1, 18152, by a conoidal musket ball, which fractured the left femur through the trochanters and neck. Twelve hours 
 after the reception of the injury he underwent amputation at the hip-joint. The operation was performed under chloroform by 
 Surgeon .J. T. Gilmore, by the antero-posterior flap method, the flaps being formed by transfixion. The patient only partially 
 reacted after the operation, and though he lingered until the morning of July 4th, he died apparently from the shock of the 
 operation. 
 
 Dr. William M. Compton, of Holly Springs, Mississippi, has communicated the 
 particulars of the sixth case and of two others in which he amputated at the hip-joint: 
 
 Case VI. — A lieutenant in an Arkansas (Rebel) Regiment in Cabell's Brigade, aged twenty-eight years, was wounded at 
 the attack on Corinth, Mississippi, October 3, 18G2. A solid cannon-shot 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 liead 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 
 reception of the injury, by Surgeon W. M. Compton. 2d Texas (Rebel) Regiment. 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 fonning a large and long antero-internal flap. The patient was under the influence of chloroform. There was but little 
 hfpmorrhage. 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 iuHammation was not intense, appetite returned, 
 and strong hopes of the jiatient's recovery w ere entertained. But, on the seventh (\a.y, erysipelas invaded the stumjj 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 tenninated fatally on October 12, 1862, thirty-six hours after the invasion of erysipelas. 
 
 A report from Professor Paul F. Eve, with a copy of a letter from Dr. J. Grant, of 
 Pulaski, Tennessee, furnishes the scanty details of the next case : 
 
 Case VII. — A private soldier of Major Douglass's (Rebel) Cavalry was accidentally wounded by a comrade near Lavergne, 
 Tennessee, on October 19, 1862. The injury was inflicted by a round ball, with buckshot, fired from a fowling-piece, the 
 muzzle being within a few inches of the person of the man who was w<mnded. The charge passed directly tlirough the thigh. 
 Just below the trochanters, comminuted the femur and extensively lacerated the soft parts. The operation was performed eight 
 hours after the reception of the injury. Chlorofonn was administered until ansEsthesia was complete. Then an assistant 
 controlled the femoral at the groin, and the operator, Dr. J. F. (Sraiit, entered the pomt of a knife twelve inches long an inc'h 
 below fhe anterior superior spinous process of the ilium and transfixed, according to Lisfranc's method, on the outer side of the 
 femur, bringing the point out near the tuberosity of the ischium, and cutting an external and posterior flap five inches long. The 
 gluteal and sciatic aiteries were then tied ; then an antero-internal flap was cut and the head of the bone was disarticulated. 
 The patient bore the operation satisfactorily. He was taken to the neighboring house of a widowed lady on the Murfreesboro' 
 pike, between Lavergne and Nashville. Here he was seen by Dr. Grant on October 22d. and seemed in every respect to be 
 doing well. On this day that locality was occupied by United States troops, and Dr. Grant did not see his patient again. He 
 received a. message from him on October 30th. but no subsequent information. It is altogether probable therefore that the 
 patient died.
 
 26 
 
 AMPUTATIONS AT TIIK HU'-.lolXT 
 
 KJi-itii's fur llic lollowins: very rernarkahle case are Professor Tan 
 
 F. Eve, 
 IS, of St. Louis, ]\Iissouri, fonuerly a svirgeon in the Eel.icl Army, the 
 
 The an 
 Dr. G. M. B. Mau^, 
 
 operator, I>r. W'ilhani i\l. (Vmipton, of Holly Springs, Mississippi, and Dr. ,J. M. Green, 
 who directed tlic after-treatment. It can hardly be doubted that the case liad a successful 
 issue; but like one of Dr. Gilniore's cases, (Cask III,j its later history is involved in 
 obscurity, and it is greatly to be desired that it may be hereafter traced and authenticated 
 liiA'ond cavd : 
 
 Case YIII. — Private Robinson, of a Louisiana (Rebel) Regiment, aged tliirtv-five year?, \va.s ivonnded at Battery Peniber- 
 tiin. at the continence of the Tallaliatcliie and Valabuslia Rivere. on March Hi. IStjo. by a ir,agment of a twenty-fonr ponnder 
 .■^liell, fired from one of the United States gunboats attacking the work. Surgeon William M. Compton, ill Texas (Rebel) 
 Regiment, was standing near the wounded man when he fell, and ran to his assistance. Hastily exposing the wound. Dr. 
 ('om|itoii found that the inuncnse projectile, consisting of nearly half of an elongated shell, had buried itself in the upper part of 
 the left thigh, smashing the troclianters and neck of the femur and wounding the femoral artery. An assistant compressed the 
 ' artery at the crui'al arch, ^vhile the nece.'?sary preparations for an amputation were made on the spot. Chloroform was admin- 
 istered, and then ))r. Compton ni.Tde an irregular circular incision through the integuments just above the margin of the huge 
 lacerated wound, dissected nji and retracted tile skin, trimmed away the lacerated uniscles and divided those that w^ere intact, 
 and exarticulated the head of the femui', making, as Dr. Compton described it, an awkward circular amputatifm. The arteries 
 were now rapidly secured and the wound dressed. Strange to say, the patient I'cacted with scarcely a sym]itoni of shock. 
 When the influence of the ana.'Stlietic jiassed aw.ay, he was cheerful and even jocidar. He was moved to a field hospital and 
 was treated under Dr. Com|iton's inunediate supervision until March l*th. The febrile reaction was very slight ; the a|ipetite 
 never failed : the wound liad as healthy an appearance as could be <lesire(l. On the fifth day the patient was sent on a steamer 
 to the large general hospital at Y.'izoo City. The surgeon in charge of that liosjiital. Dr. J. M. Green, writes that the ease 
 presented a most extraordinary e.xatiiple of union by the first intention throughout almost the entire extent of the vast wound. 
 The patient left the liospital on April 20, USO:!, in fine health and excellent spirits. Dr. Green received direct intelligence from 
 him near the close of the ensuing Septemliir, more than six months suliseiimnt to tlie t)jieration, and he tlieii reported himself in 
 good condition. 
 
 The next ease is already well known to surgeons.* 
 the patient still li\cs ami riijovs comfortable lirallb. 
 h'diu hini at this ofhce complaining uf tlic msufticieiicv ol 
 
 It is satisfactory (o record that 
 Letters arc frcquciith- receiverl 
 his itension, but rc'iuii-ing in his 
 
 physical condition : 
 
 l*"ri;. 1. Fnicturc of the femur liv 
 Miuskct bull. Xpec. 114*1, A. M. M. 
 
 C.\SK I.\,— Private .lamis K. Kelly. Co. li, .'(Itli Penn- 
 sylvania \'olMnteeis. aged twenty-eight yeai-s, was wounded 
 at about nine o'clock of the morning of April yi) IStiM, in a 
 skirmish of the First Division, First Corjis. on tin- l{:ippa- 
 liannock, nearly opposite Pratt's house, two nules lielow 
 Fredericksburg. A conoid.al musket ball, fired from a distance 
 of about three hundred yards, entered the upjier ]iarl of liis 
 lilt tliigli in front, fractured the femur, and passed out at lire 
 posterior part of the thigh. The ball struck the femur four 
 inches lielow the great trochanter and fractured it somewhat 
 oblifjuely. but with less conunimition than is usual. A long 
 fissure extended however to the level of the trochanter minoi-. 
 (See f'if/urc I J.) The important vi'ssels and nervi's were unin- 
 iured. Siugeon Edward Shipjjeii, U. S. Volunteers, Surgeon- 
 in-chief of tlie First Division, considted the senior medical 
 olHcers of the brigades attaclicd to the division, aiul it w-as 
 decided that in order to give the man a chance for his life 
 amjiutation at the hip-joint should be peri'ornied. At four 
 o'clock, seven liours after the reception of the injury, the 
 patient was |ilaced fully under the iidluenee of chloroform, 
 and Surg.'on Sluiipen commenced the oi)eration, as.sist<'d by 
 Surgeons (i. W. New, A. W. Preston, Hrowne, and Murdoci^. 
 Tlie patient's nates were brought well over the edge of the 
 operating table, and the femoral artery was conipresseil at the 
 
 I'm. II. I'o.^ilerior vicwof thosnine 
 sjioeiiiK'n. e.\hibitinir a fissure 
 ruiiniiii; t(i the trorhiinter minor. 
 
 * See Cirrular Xo. 0, ,S'. O. ().. 1H6.''), p. 48. A Treatise on MUitarij ,S„r;/-ri/. by F. II. Hamilton. M. D., New York. ISfi,"), 
 p. .182. Confederate States Mcdmtl ,ind Sur;/u;il Journal. Vol. I. p. 1.S3. Tlie Ihihlin (Jmirttrh/ Journal of Medical Sciciwe, No. 
 I>XX.\I\'. p. :!()!. .tiinalea d' lliiiiienc I'nhi;,/,,, . DiMixieme Serie. T. X.WI. |.. '..'7(1.
 
 IN TIIF. WAK OF THE KKRKLUOX. Z( 
 
 groiii. A teu-inoii catling was then introtUiucd aixnit miilway lu'twccn tlu' ti'OcliantiT major anil the antcrinr Htipei'iftr spinous 
 j)rocess of tli« ilium, tlie point at Kist diructcil slightly upwards in order to open the ca])sule of the joint ; then tlie handle was 
 raised and the point made to come out about an inch in advance of the tuberosity of the ischium. A large flap was then cut from 
 the anterior and inner side of the thigh, about six inches in length; the haemorrhage being controlled by Surgcoiv James 15. 
 Slurdock. 124tli New Yoi k Volunteers, who grasjied the Hap and compressed the femoral artery before it was cut. The heel of the 
 knife was then placed where the point came out, and the points of entrance and exit were connected by an Incision cutting to the 
 bone. Part of the capsule being opened by the first incision, the remainder of it was divided, the round ligament cut, and 
 the head of the femur removed from the acetabulum. The hiemorrhage w as then arrested, the femoral artery being tied last- 
 The loss of blood was very slight, less even than in an ordinary am])utation of the thigh. The stump having been dressed, the 
 patient was placed in an hospital tent, and remained under Dr. Shippen's charge for three days. The operation was admirably 
 borne, and the case was progressing most favorably on May *Zi\, when the patient was transferred to the Corps Hospital at the 
 Fitzhugh House, under charge of Surgeon A. W. Whitney, 13th Massachusetts Yolunteers, in consequence of the movement of 
 the First Division to the battlefield of Chancellorsville. No unfavorable symptoms occurred. The patient improved dailv, 
 the stmnp granulating finely. He had an excellent aii]>etite. and was quite content with the soldier's ration. But Dr. B. .\. 
 Clements, Assistant Medical Director and Dr. Taylor, Medical Inspector, visited him and pro^Mded that he should lie furnisheil 
 with such delicacies as the resources of the hosjiital coidd not sujiply. In the latter part of Maj', Surgeon Shippen haviii" 
 returned from Chancellorsville, saw the patient frequently and removed the ligatures until, on May 28tli, the last had come 
 away. The case continued to progress favorably until June l.'jth, when the greater portion of the Army of the Potomac having 
 moved northward, the wounded and sick at the Fitzhugh House were captured by the rebels. Kelly was taken to Fredericks- 
 burg in a wagon, and thence to Richmond by rail, and was incarcerated in Libby Prison. The exti'aordinary nature of his 
 case appears not to have procured for him any modification of the amenities of that place of confinement. According to his 
 report, he lay upon the floor on his blanket, and received a diet of diluted tea and corn bread, and twice a week a bowl of sou)). 
 He was not subjected to any surgical attendance. Alter a week of the prison regimen, the wound became gangrenous and a 
 troublesome diarrhoea supervened. On July 14th, the prisoner was exchanged. He was sent to Aimapolis, and entered the 
 hosiiital there in an exhausted state. His normal weight before the removal of the limb was one hundred and fifty-five 
 pounds ; he now weighed sixty-three pounds. There was a sloughing sore extending from the upper outer angle of the wciunil 
 downwards over a space larger than the hand. There was profuse diarrhea. He \\ as ordered to take pills of opium and 
 bismuth, with tincture of sesquichloride of iron, and beef essence and rice jelly for nourishment Bromine was applied to 
 the sloughing parts on three successive days, but without apparent benefit. A dilute lotion of chlorinated soda was then 
 substituted. On July 24th the slough separated, leaving a clean, healthy, gramdating surface. On Aug-ust 19th, Acting 
 Assistant Surgeon Stovell, who had immediate chijrge of the case, reported that the patient had steadily improved since his 
 admission and might be considered out of danger. On September 17th, Surgeon T. A. McParlin, U. S. A., reported that 
 Kelly was rapidly improving; that the wound was healed, except at a point where there was a slight purulent discharge 
 and over an ulcerated space as large as a walnut, which was granulating kindly. The patient had been removed to the tent 
 colony or camj) of convalescents. On December 23, 1863, the wound had entirely healed, and Kelly visited Washington 
 and obtained his discharge from service and a pension of one hundred and eighty dollars a year. He then went to his home 
 at Blairsville, near Black I^ick post office, Indiana county. Pennsylvania. His general health was then good and his weight 
 had increased to one hundred and twenty-four pounds. In the autumn of 16()3, before the wound had completely cicatrized, an 
 excellent picture of Kelly, in water color, was made by Mr. Stanch, under the direction of Surgeon J. 11. Brinton, Curator of 
 the Army Medical Museum. In December, 18G4, Lieutenant Colonel G. K. Johnson. Medical Inspector U. S. A., procured a 
 very satisfactory photograph of Kelly's stump. From these two pictures the plate which accompanies this history was 
 prepared. Kelly still resides at Blairsville, and his general health continues good. 
 
 . The next is one of tlie three cases reported by Dr. AV. M. Compton: 
 
 C.\SE X. — Private Cooper, of an Alabama (Rebel) Regiment, aged twenty years, was wounded at the siege of Vicksburg. on 
 May 22. 18G3, by a fragment of shell, which infiicied a terrible laceration of the upper exterior part of the right thigh, com- 
 minuted the upper third of the femin-, and fractured the tuberosity of the ischium. There was profuse haemorrhage. Surgeon 
 W. M. Compton, 2d Texas fRebelX Regiment, 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 Hap and dividing the soft 
 parts jiosteriorly 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. 
 
 Professor P. F. Eve and Dr. S. L. Nidelet, of Mobile, Alabama, formerly Surgeon-in- 
 chief of General Maury's (Rebel) Division, communicated the facts of the following case. 
 AVhile this report was in the printer's hands a letter was received from the operator, Dr. 
 Benjamin D. Lay, now of Paducah, Kentucky, giving some additional particulars respect- 
 ing tlie operation : 
 
 Ca.se XI. — A private of the :!d Missouri (Rebel) Regiment was wounded at the siege of Vicksburg, in June, 18()3, by a 
 large fragment of shell. The projectile produced a frightful laceration of the tissues on the inner and postericir parts of the
 
 28 
 
 AMPUTATIONS AT TIIK IIU'-.IOINT 
 
 ri.'ht tlii^li <-on.pK't.-lv aivi.liMl llu- frinoral -.n-tory. ;in.l .•ommlmited tin- tViiiur tlirnugh an extent of eight or nnie niel.es. A 
 
 surgeon in tlie trenei.es pnt a li-atni-. the feuH.Vi.l artery, and the «,.nn,U..I man was eonveyed to the City Hospital, aiul was 
 
 plied with eoi-tlials. The sufterer had hut recently recovered from an attack of illness ; the primary hjcinorrhage had heen 
 coinous and reaction was very imperfect. A consultation of surgeons decided that amputation at the hip-joint should he 
 practised, and the wounded man expressed a desire to have the henefit of this forlorn chance. Surgeon B. D. Lay r.ndertook the 
 operation with great reluctance, fearing that the patient might die under the knife, he was so very feehle. Stimulants were 
 treely administered and nior|ihia ; hut it was decided that the operation should be done without anjesthetics. The nature of the 
 wouiid determined the direction of the incisions. There was a rent in the soft parts laying bare the tuberosity of the ischium, 
 and another extending nearlv to Poupart's ligament, in which the ligated femoral artery w as hanging. Dr. Lay commenced the 
 operation, in the presence of'surgeons Tiritts. McDowell, Nidelet, an<l others, by making a clean circular cut through the inner 
 and posterior parts of the thigh, dividing all the soft parts down to the articulation ; a semilunar flap was then obtained from 
 the outer and anterior part by cutting from. without inwards; the head of the fenuu-was then disarticulated. Eight ligatures 
 were required. The flaj) fitted well. The operation was well supported, and the ]iatient said that he felt more comfortable affer 
 than before it. However, reaction was never fully established. Ur. Nidelet relates that the patient died upon the table within 
 an hour and a half after the completion of the dressing. Dr. Lay"s recoU.-ction is that he survived the operation some fourteen 
 or sixteen hours. 
 
 a consultation was held in the case, at 
 others assisted. It was 
 
 Special reports from the operator, Assistant Surgeon Benjamin Howard, U. S. Army, 
 and Surgeon Thomas M. Flandreau, 146th New York Vokmteers, have furnished Uk' 
 particulars of the next case;-' 
 
 C.1SE XII. Private James Martin, Co. I, 146th New York Volunteers, aged twenty years, was wounded on the afternoon 
 
 of Julv 13, 1363, in one of the reciumoissances of General Lee's positicjn near Willianisport. He was carried to the rear and 
 placed in a barn by the roadside not far from Willianisport. On the following nioi 
 which Assistant Surgeons Howard, C. W^agner, and Colton, U S. A., and Drs. Stearns, Lord. Dean, 
 found that a conoidal musket ball had passed through the upper part 
 X ^ 1^ of the left thigh from before backwards, and had struck the femur a 
 
 / ^ CT^'V little below the great trochanter and produced a comminuted fractuu 
 
 1 _,^'^'^^S^ "'^■' ■% It was believed that the fracture extended into the coxo-femoi il 
 
 V ..juSsSJ -sS articulation, and it was decided that no operative procedure could li 
 
 advantageously practised except an amputation at the hip-joint. Di 
 Howard was invited to operate. Chloroform having heen _a<lminis 
 tered, he removed the linil) by a douhle-fla]) operation. He describes 
 the operation as performed by "entering the knife about four or fiM 
 inches below the anterior superior sjiinous jn'ocess of the ilium, and 
 causing it to emerge liy transfixion an inch ami a half to the inside of 
 the course of the femoral vessels. The operation was completed m 
 the ordimuy manner of flap amputations. By transfixing at the points 
 desi'ribed, the mouths of the divided vessels were so near the margin of 
 the anterior flap as to be readily seized imiuediately after division 
 
 "lo. III. Coniniinuiia (runsliot aiul bv the external obliquity of the plane of incision, drainage of pus 
 fracture of Hit* femur in a * ... ^ , ^i i* *i i- i • * i * * • 
 
 vcinuc iiubject. Spec. t37U, "'"s facditated more than by the ordmary liorizontal antero-postcrior 
 
 ■\- "■ *'• flaps." It appears that the disarticulation was rapidly accomplished. 
 
 1 1< . I^ . IN bferioi view of Sprri- 
 men 13T.I, A. M. M. 
 
 and that very little blood was lost. The shock was great, but the patient is reported to have rallied so fai' that it was 
 considered safe to move him. On July 11, 18G'.), he died on the road to Sharpsburg, about forty-eight hours stdiseipient to 
 llie oper.ation. An examination of the pathological specimen from this case, which was forwarded by Assistant Surgeon 
 Howard to the Army Medical Museum, where it is numliered Spcrimrn 1379. justified the oi)inion formed before tin? operation, 
 that an exci.sion of the hi'ad of the fenuir was impracticable; for besides the conuuinntion about the lesser trochanter and the 
 fi.ssin-es towards the neck, fissures ran ilowii the .shaft of the hone for a long distance. 
 
 A letter I'roiii tlie operator, Surgeon Albert C. (Jorgas, U. S. Navy, and a iiniiioraiidiiiii 
 from Surgeon 1'. .1. llorwitz, Chief of the J)ureau of Medicine and Surgery of the Navy 
 Department, have furnislied the dtita from which the abstract of the lollowing case is 
 compiled :" 
 
 C'a.SE XIII. — Seiunan (ieorge Cook, aged twenty-one years, an Knglishuian by liirlli. was \vc>UTi<led on I'clirnary 1. 1864, 
 in an engagement of a gunh()at with a battery sujijMU'tt-d by sharpshooters, at Smithlieltl, \'ii'ginia. A rille hall grazed his 
 
 ' See Circular No. (i, <S. 0. O., ISfio, p. 50, Case 5. 
 
 "■ See Circular Ko. 6, S. G. 0., 1865, p. 50, Case 13.
 
 IN THK WAR OF THE REr:ELLTOX. 
 
 29 
 
 rin. V. Coiimiimition <if fettulr 
 l>y u rifle bull- .Spec, 2'^7:j, 
 A. M. M. 
 
 ii;,'lil tliigli. pasai'il thro'isli Imtli tcsliclcs ami ciiti'i'i'il the left tliifrli. 
 IVacl'U-tMl the femur, and past-eil out at the ]iristeii(H- ami outer portion 
 of the linili. The wounded man was taken to the Naval Hospital, 
 at rortsniouth, Virginia, not many miles distant, and Surgeons 
 Solomon Sharp, A. C'. Gorgas. Jolin Paul Qiiinn, and Assistant 
 Surgeon G. S. Franklin, U. S.Navy, lielil a consultation, at whieh it 
 was decided that the femur was extensively shattered, and that an 
 amputation at the hip-joint presented the only chance of saving the 
 patient's life. On tlie morning of February Sid, the patient was 
 placed under the influence of chloroform, the femoral artery was 
 compressed at the groin, and Surgeon Gorgas, assisted by his col- 
 league, proceeded to remove the limb. The operation was performed 
 bv transfixing and forming an anterior flap, disarticulating, and then 
 making a posterior flap by cutting from within outwards. Very 
 little blood was lost ; yet the patient never reacted, but succumbed 
 about two hours after the completion of the operation. The patho- 
 logical preparation from the case was forwarded by Surgeon Gorgas 
 to the Army Medical Museum. It is numbered Specimen 'iS/'^i. 
 It is a very strong and compact bone. The ball has separated five 
 large ft-agnients, and has produced fissures extending from above 
 the level of the trochanter minor a little over four inches down 
 the shaft. 
 
 Fk;. 'VI. Posteriur view of Sjirri 
 men 2S73, A. M. M. 
 
 6, Surgeon 
 
 A brief memorandum of the following case appeared in Circular No 
 General's OfHce, 1865, at page 50, whereupon Dr. James Chapman, of Medina., New York, 
 formerly surgeon of the 123d New York Volunteers, wrote and contended that the record 
 was erroneous, and that no such operation had been performed. Dr. Chapman argued 
 that as he was the chief operator of the field hospital of the First Division of the Twentieth 
 Corps, and was present at the Division Hospital at every battle and skirmish in which 
 the corps was engaged, from its organization to its disbandment, and that an operation 
 of the magnitude of an amputation at the hip-joint could not \vd\c been performed at 
 the hospital without his knowdedge. But it appears from the reports to this office that the 
 patient was not treated at the First Division Hospital, but at that of the Second Division, 
 where Dr. Chapman was not employed. The surgeons-in-chief of the two divisions, 
 Surgeon A. L. Cox, U. S. Volunteers, and Surgeon A. Ball, 5th Ohio Volunteers, report the 
 facts of the case in terms which accord entirely. The medical director of the corps. 
 Surgeon H. E. Goodman, U. S. Volunteers, writes, in a letter dated April 30, 18()7, 
 that the case was described to him at the time, and that he was told that it was one 
 very unfavorable for an operation. Other evidence is available ; but sufficient has been 
 adduced to show that there is no reason to question the authenticity of the case: 
 
 Case XIV. — Private William Waters, Co. K, 123d New York Volunteers, was wounded at the battle of Resaca, Georgia, 
 on May 15, 18G4, by a large fragment of shell, wliich com|iletely carried away his left thigh and fractui'ed both the tibia and 
 fibula of the right leg. He was carried to the Field Hosjjital of the Second Division of the Twentieth Corjis, and as soon as he 
 had partially rallic^d from the shock of liis frightful injuries chloroform was administered, and Surgeon J. W. Brock, Clith Ohio 
 Volunteers, amputated at the left hip-joint ; and then removed the right leg at the place of election. The patient survived the 
 double operation hut a sliort period. The exact length of time is not stated ; but he died in the afternoon of the day on which 
 he was wounded. May l.'i, 1864. 
 
 The history of the next case has been published by the operator,'^' to whom, however, 
 the patient's name was unknown. By the casualty list of the Third Division of the Ninth 
 Corps for Spottsylvania, the patient has been identified beyond a doubt, and Surgeon 
 
 * A Treatise on Militarn Surr/eri/, by F. TI. n.vini.TON, M. D.. etc. pp. 48.5, fi-27. See also Circular Xo. G. *'. (!. 0.. ISfi.'S, p. 
 TiO, Case *.
 
 30 
 
 AMPUTATIONS AT TTIK HIP-.IOIXT 
 
 Henry W'licatun UiviTs ami Assistant 8nrg(.'on A. d. Sjirague, of Rhode Island, and 
 Surc'i'iin M. K'. llogan, U. S. Volunteers, have furnished some additional particulars 
 relative to the case: 
 
 Case XV. — Pi'ivate Kiehard Gordon, Co. H, 7th Rhode Island VoUuitei'rs. a stout and apparently healthy man, of about 
 twenty-eight yeai's of age, was wounded at about eight in the morniiif; of the 18th of May, 1864. in one of the assaults on the 
 lines at Sjiottsylvania, and was carried on a stretcher, two or three miles to the rear, to the Field Hospital of the Third Division 
 of the Ninth Army Corjis. A fragment of shell had completely shattered the left thigh, leaving the lower part of the limb 
 attached to the ujiper by shreds of integument and muscles only. There had been but slight primary hiemorrhage. He was 
 conscious and his jiulse was ]ierceptible ; but he was in extreme collapse. A consultation was held, at wliich the Surgeon-in-chiet 
 of the division. Surgeon P. .\. O'Connell, Surgeon James HaiTis. 7th Rhode Island Volunteers, and others, assisted, and it was 
 <lelermined to give the njan the chance of an operation rather than to allow him to die without an effort to save him, and 
 Dr. J. M. Carnochan. a civil surgeon, 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 Pouparfs ligament, and then proceeded to amputate at the hiii-joint by a modification of the oblique method of 
 Outline. A vertical incision three inches long, commencing an uich above the great trochanter was made, the soft jjarts being 
 divided down to the bone. From the lower third of this incision, two oblique incisions, one before and one behii.id, 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, iuid the kiufe being carried to the inner side of the neck the operation was finished by dividing the soft parts 
 on that side b.v a single swee]) of the instrument. The operation, including the ligation of the femoral, was completed in two 
 niimites. The ]iatient recovered kindl.v fi'om the influence of the ana'sthetic. He was placed in a shelter tent and took a dose of 
 opium. He died ten boiu's after the operation, no reaction having taken place, 
 
 • The operator, Surgeon 0. (J. Jewett, 16tli Massachusetts Volunteers, has transmitted- a 
 
 '■ly 
 
 full account of the following case, and Surgeon Henry F, Lyster, Hth Michigan 
 
 \"olunteers, and Assistant Surgeon J. J). Stewart, 74th Xew York \^jhinteers, have 
 cuniinunicated facts regarding it: 
 
 Case XVI. — Private .Jacob Barger, Co. B, 26th Pennsylvania Volunteers, aged twenty-two years, of robust constitution 
 and sanguine leniperament, was wounded on the morning of May 18, 18fj4. in the attack of Birney's Division of the Second 
 Army Corps upon the intrenchments before Spottsylvania Court House. He was struck by a 
 fragment of sliell, which shattered the fennu' from a little above the trochanter minor for nine 
 inches downwards, and tore' and mangled the soft parts on the anterior and lateral aspects of the 
 tlugh, leaving uninjured a V-shaped portion of integument and subjacent tissue on the antero- 
 iiili-rnal femoral region, seven inches wide at the base aiul ten inches in vertical length. He was 
 carried to the Field Hospital of the Third Division of the Second Corps and was examined about 
 two hours iifter the reception of the injury. 'I'bere \vas no a])parent shock, and there had been 
 very little haemorrhage. 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 \va,s 
 one of the few cases 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 
 opiiation should be practised. He was of a hopeful, buoyant nature, and was sanguine of a 
 favorable issue. Amputation having been deci(h?d upon,, chloroform was administered by Surgeon 
 .John Wiley, Gth New Jersey Volunteers, a medical ofiicer of great experience and caution in this 
 duty. Only two drachms of tlu' ana?sthetic w.is used, given fi'inn a na|)kin, with great regard to 
 a ilue adnn.\ture of atmosplieric air. SiU'geon C, C, Jewett, Kith Massachus(^tts, perlbrmed the 
 anqnitation, liy making a single antero-internal flap. Assistant Suigeon J. T. Calhoun, U, S, 
 Army, and others present on the occasion, have described the admirable dexterity and skill 
 manifested in the operative procedure. The disarticulation was completed in less than forty 
 seconds. Surgeon C, H, Irvine, 72d New York Volunteers, compressed the crural artery at the 
 groin ; Surgeon F, Prentice, 73d New York Volunteers, grasped the flap and secureil the cut end 
 of the femoral; Surgeon James Ashe, 70th New York Volunteers, had charge of the limb; 
 Surgeon Evarts, 20th Indiana Volunteers, Surgeon F, A, Winston, 1st Massachusetts Volunteers, 
 and Assistant Surgeon J, T, Calhoun, U. S, Army, also aideil in the operation. The flaji, the 
 form and location of which were detenniue<r by the wound, was made by cutting from without 
 inwards, Inunediately after the head of the bone was freed from the acetabulum a spasmodic 
 catch was heard in the patient's respiration, and an assistant exclaimed; ''Stop the chlorofoi-m !" 
 Surgeon Wiley promptly responded: "He is not t.aking any," The next instant an assistant at 
 the wrist reported that the pulse was tailing. The arteries were now ra])idly secured, Tlie loss 
 of blood was estimated not to exceed a single ounce. But the patient was insensil)le, the respira- 
 I'lo, VIl, Coiniintnilion nf fcinur tfon laboi'ed, the pulse very slow and feeble. The usual restorativi'S were emjiloyed without eflect. 
 The patient did not rally; lie lingered for about two hours, and <lied a little after noon. May IS, 
 
 l.y 11 alien. Sin. :ill80, A. .M, M.
 
 IX THK WAR OF THK KEBELLION. 31 
 
 1861. At tliis jiiiictuiv, ill cunspquence of an mivaiice of Rliodes's Division of Ewell's Corps, the Fit-Id Hospital was hastily 
 broken uj). Surgeon Jewett was under the impression that the specimen was lost. This, however, was not the case. Some 
 one fastened a label with the names of the patient and operator to the mangled limb, and it was forwarded, with other 
 liathological specimens, from Spott.sylvania to the Ai-my Medical Museum, where it arrived Siifely, and furnished the preparation 
 numbered 3080, which is figured on the jjreceding page. 
 
 The casualty list of the Third Division of tlie Twenty-third Army Corps, and the 
 reports of Surgeon A. M. Wilder, U. S. Volunteers, Acting Medical Inspector of the Army 
 of Ohio, and of Surgeon C. S. Frink, U. S. Volunteers, Surgeon-in-chief of tlie Tliird 
 Division, Twenty-third Corps, have furnished the facts of the next case :* 
 
 Ca.se XVII. — Private Jeremiah M. Brown, Co. H, 63(1 Indiana Volunteers, was wounded on June 16. 1861. in the attack 
 of the 23(1 Cor|is ujion the earthworks at Lost Mountain, near Marietta, Georgia. A conoidal musket ball struck his right thi'di 
 and shattered the upper extremity of the femur, fissures extending through the trochanter major. He was conveyed to the Field 
 Hospital of the Third Division, Twenty-third Corps, and early on the morning of June 17th, about fourteen hours after the 
 reception of the injury, he was placed under the influence of chloroform, and after a careful examination of the injury, it was 
 decided to amjiutate at the hip-joint. The operation was performed by the Medical Director of the Corps, Surgeon Edward 
 Sliippen, U. S. Volunteers. The operative method was similar to that adopted by Dr. Shippen in his successful operation, 
 (Case IX.) Comparatively little bhjod was lost, but the patient succumbed to the shock of the o])eration aud died upon the 
 operating table very soon after the completion of the disarticulation. 
 
 Professor Paul F. Eve and the operator. Dr. J. P. ]juist, of Nasliville, Tennessee, 
 have furnished the facts of the following case: 
 
 Case XVIII. — A private of the STth Tennessee (Rebel) Regiment was wounded at the battle of .Jonesboro', Georgia, 
 August 31, 1864, by a cannon-shot, which frightfully lacerated the s(ift parts on the upper and outer part of the thigh, and 
 shattered the femur, the sjilintering extending quite to the neck of the bone. Six hours after the injury. Surgeon J. R. Buist, 
 1st Tennessee (Rebel) Regiment, Chief Surgeon of Maury's Brigade of Che.itham's Division, removed the limb at the hip joint 
 by the antero-])osterior flap method by transfixion. The patient was rendered insensible by chloroform. He rallied ]iromptly 
 from the anaesthetic and from the shock of the operation. Cold water dressings were applied to the stum]), and stinudants and 
 concentrated nourishment were administered. After about eight hours tlie patient began to sink, and he died thirty-six hours 
 after the operation, September 2, 1864. 
 
 The abstract of the nineteenth case is compiled from the reports 
 of the First Division, Twentieth Army Corps, and from two letters 
 fi-om the operator. Dr. H. Z. Gill, of Ptichboro', Pennsylvania: 
 
 Case XIX. — Private James A. Ailing, Co. D, 3d Wisconsin Volunteers, was wounded im 
 March 16, 1865, at the battle of Averysboro', North Carolina, by a conoidal musket ball, which 
 entered the ujiper part of the left thigh in front, and ]iroduced a comminuted fracture of the femur 
 through the trochanters, with longitudinal splintering extending a short distance down the shaft 
 and upwards within the capsular ligament. The wounded man was conveyed to the Field Hospital 
 of the First Division of the Tw'entieth Corps. Chloroform was administered and the wound was 
 thoroughly explored, and it was determined to amputate at the hip-joint, because it was imperative 
 to move till! wounded on the following day over rough roads, and either an excision of the 
 head of the femur, or an attempt at conservation of the limb, offered, under the circumstances, 
 less chance of a favorable result than the removal of the limb. Five hours after the reception of 
 the injury. Surgeon H. Z. Gill, U S. Volunteers, performed tlie amputation by the double Hap F":. VIII. tiimsiiDt frat^uire 
 method. The patient reacted well after the operation, but the amendment was of brief duration. ij,ft femur. Fnim a dntwing- 
 He died seven hours after the completion of the amputation, March 17, 1865. ^J' Surgeon H. z. Gill, U.S. v" 
 
 Peviewing the foregoing nineteen cases of primary amputation at the hip-joint, it 
 appears that the operation was one of absolute urgency in Cases VIII and XI, in which, 
 together with great injury to the head and neck of the femur and the contiguous soft parts, 
 the femoral artery \\^s wounded, and amputation or the abandonment of the patients to 
 ccrlniii death were the only alternatives. As much may be said, perhaps, of Case XV. in 
 wliicli. if the account of the lesions is not exaggerated, the entire thigh was nearly torn away 
 by cannon-shot. In Case XVI the operation was obligatory almost, on account of the 
 extraordinary extent of the injury to the femur, and because an attempt at conservation 
 
 *See lieport of the Adjutant General of the State of Indiana, Vol. VI, p. 31, and Circular Xo. 6, S. G. 0., 1865. p. 50, Case 8.
 
 32 AMPUTATIONS AT THE Hir-JOINT 
 
 involved tlir tmusportatioii ol' the wouudi'd luau tt) the depots at FrediTieksljurg or Belle 
 Plain, a three days' ambulance journey, in which it is almost certain he would have 
 succumbed. In Case XTX also the consideration of trans|)ortatioM had decisive influence. 
 Surgeon Gill, the operator, observes that he would have excised the' upper extremity of the 
 femur in this case in preference to amputation, had he possessed any means of securing 
 subsequent immobility of the limb, had he been able even to procm-e plaster of Paris 
 for an immovable dressing. Cases I, TI, VI, X, and XVIII, in wliich Drs. McLean, 
 Yandell, Compton, and Pniist operated, were examples of extensive lacerations by shells 
 or other large projectiles; cases in which but faint hope of success under any treatment 
 could be entertained, in which the operation at least mitigated the patient's sufferings. 
 Cask XIV, in which a double amputation of the lower extremities was performed, was 
 plaiidy a hopeless one, and the operation must be condemned. In regard to the eight 
 remaining cases in which amputation was done for injuries to the upper extremity of the- 
 femur by musket balls, notwithstanding the one or two successful results, surgeons will 
 not fail to discuss whether an ef[ual or greater saving of life might not have been attained 
 liv an expectant or temporizing plan. Dr. Gilmore, wlio operated in three of these cases, 
 and subsccjuentlv twice excised the head of the femur, and also treated a comparatively 
 large number of similar injuries by the conservative method, declares, as the result of his 
 unusually extended observation, that recovery ensues in a far larger proportion of gunshot 
 injuries of the u]iper extremity of the femur left to the efforts of nature than in such 
 nijuries ti'cafcil bv piT.narv amjnitation or excision. 
 
 INTERMEDIATE AMPUTATIONS. 
 
 The eighteen operations included in this category resulted fatally. They were all 
 dniie. (if course, during the inthnnmatory period, ami without e,\cepli(.)n upon patients who 
 from unavoidalde negleet ami exposure were ill lltted to undergo operations. The interval 
 I'rom the reception of the injury to the date of tlu' operation in these cases varied from 
 twentv-ibur hours to one month; its mean length was a little over ten days. Though all 
 the patients died, t\\c one who survived longest living but eight days, yet a far less propor- 
 tion succumbed to the iiumeiliate shock of the operation than in the series of primary 
 cases. Of the sixteen fatal primary cases, eleven died from shock; and the average 
 duration of life after the completion of the operation was but thirty-eight hours. Of the 
 eiirhtcen intermediate cases but five died i'rom shock; and the iiatients ot this series 
 sur\ivc'(l the operation on an average fifty-two hours. One died of pyaania; two from 
 rapidly spreading gangrene; two, probably, from the effects of ha?morrliage at the time ot 
 the operation; and eight from the exhaustion conserpient u])on the surgical fever, supjiura- 
 tion, ami <jther disorders attendant upon so grave a mutilation. Ten of the operations were 
 performed liv medical officers of the U. S. Army; eight were done by surgeons ol the 
 Ivelx'l Army — four upon their own men, four upon ])risoners. 
 
 The first intermediate amputation at the hip-joint of the war was jieiiormed at a. 
 hospital in Pvichmond, upon a prisoner taken at the battle of lUdl Pun. The lact that 
 this operation was performed was comniuniciiteil by Professor Paul F. Eve, of Nashville, 
 and tJie scautv details of the case recorded here were sup]>lied I)y Prolessor T. C 
 Pidianlsoii, of New ( )rleans, who was present at the o|')erafiou:
 
 IN THE AVAR OF THK REBELLION. ' 33 
 
 Cask XX. — \ private .folilicr <if the U. S. Army was wouimIciI at the first hatlh> of Hull Kiiii, July 21, isiil, hy a iniisket 
 hall, wliieh fraetured the lower third of the ri{;ht femur. He fell into the hands of the enemy, and. on the following day, was 
 conveyed in an army wagon to Manassas Junction, and thence hy rail to Kiehmond, where he was admitted to the Alms House 
 Hospital. One week after the reception of the injury there was extensive purulent infiltration in the muscles of the thigh and 
 iuci]iient gangrene of the leg. Under these circumstances Drs. St. George Peachy and Charles Bell Glhson decided to amputate 
 at the hill-joint. On July 29th, the operation was performed by Dr. Peachy, in the presence of Drs. Gibson, A. E. Peticolas. 
 liichardson, and others. A preliminary ligature was placed upon the femoral artery at the beginning of the operation, which 
 was probably done according to Larrey's method. The patient is believed to have survived the operation two or three days. 
 
 It appears that this case was iieitlier published nor reported, as it is uot inckuled in 
 the statistics of the southern hospitals for the first year of the war, as recordi'd in the 
 "Confederate States Medical and Surgical Journal." Both Dr. Peachy and his principal 
 assistant, Dr. Gibson, died before the conclusion of the war. In view of the meagre history 
 <if the case that is accessible, criticism may be omitted. 
 
 The nest case is alluded to by Dr. A. M. Fauntleroy in his paper on amputation at 
 the hip-joint.* The particulars related were communicated by Professors J. S. Davis and 
 J. L. Cabell, of the University of Virginia, to Professor Paul F. Eve, by whom they were 
 transmitted to this office : 
 
 Ca.se XXL— Private J. H. AA'olf, Co. D, 4th Virginia (Kebel) Regiment, had his femur fractured at the battle of Bull Run, 
 July, 21, 1861, by a musket ball, which traversed the upper part of the thigh in an antero-posterior direction, and striking the 
 lemur four inches below tlie trochanters, shattered it quite up to the neck. The patient was removed to Charlottesville, Virginia, 
 and was received in the General Hospital at that place on July 24th. The fracture was treated by Smith's anterior suspensory 
 splint, and this mode of dressing proved very serviceable for a time. The inflammatory phenomena did not abate however, 
 and after four weeks it was decided that removal of the limb at the coxo-femoral articulation alone afforded a hope of pi'eserving 
 the patienfs life. On August Slst. the operation was performed by Brigadier General Edward Warren, Surgeon General of North 
 Carolina, and was rapidly executed by the double-flap method, with inconsiderable ha3inorrliage. On the following day there 
 was slight hfpmorrhage. Death from exhaustion ensued on August 23, 18fil. thirty hours after the ojieration. The constitutional 
 condition of the patient was unfavorable, and he was suftering from colliquative diarrha?a. 
 
 The particulars of the next case were also communicated by Professor Paul P. Eve, to 
 whom they were furnished by Dr. Charles H. Mastin, of Mobile, formerly medical inspector 
 of General A. S. Johnston's army, and l)y Dr. D. D. Saunders, of .Memphis: 
 
 Case XXII. — Private Jackson, aged twenty-one years, of Colonel Tappan's (Rebel) Brigade, was woiuided at the battle of 
 ISelmont, Missouri, November 7, 1861, and was conveyed on a steamer to Memphis, and admitted to the Marine Hospital. He 
 had a badly comminuted fracture of the upper extremity of the femur. On November 15th, Dr. Richard Potts proceeded to 
 amputate at the hip-joint by the antero-posterior flap method. The patient succumbed promptly to the shock of tlie operation; 
 dying, indeed, before its completion, according to Dr. Mastin, or, according to Dr. Saunders, ten hours after its completion. 
 
 The next three operations were performed upon men wounded at the battle of Shiloh. 
 The condition of all three of these patients was probably very unfavorable, on account of 
 their long exposure on the battle-field. The particulars of Dr. D. P. Smith's case were 
 reported by Brevet Colonel Thomas W. Fry, late Surgeon U. S. Volunteers, and Assistant 
 Surgeon M. C. Tolman, 2d Minnesota Volunteers, who assisted at the operation, f 
 
 * The Bichmond Medical Journal, January, 1866. Vol. I, p. 9. 
 
 t The case is described by Surgeon D. P. Smith in the Amcrk'in Medical Times, Vol. IV, p. 332, June, 1862, as a possibly 
 successful one. It is also alluded to in his " Narrative of Services," in response to a circular from the Surgeon General's Office, 
 of May 1, 1863. On receiving an application for the details of the case, Surgeon Smith replied that he had kept no notes of it.
 
 34 
 
 AMI'UTATIONS AT THE IIIl'-.IOINT 
 
 Case XXIII. — I'livnti' llonrv H. Halo. Co. G, 14tli Illinois Vohmteer.s, twenty-one years of age, was wouikKmI at the liattle 
 of'Sliiloli, April 0. lt-'<W. A iVagnient of sliell* shattered the u)iper portion of his lei^ femur, so that fissures extended to the neck 
 and far down the shaft. The soft parts on the outer aspect of the thigh were extensively lacerated and contused; the femoral 
 vessels and nerves Avere uninjured. On April 9th, with four hundred and sixty other wounded brought from the field, he was 
 l)laced ou the hospital trans])ort steamer Crescent City, to he conveyed to iSt. Louis. On Ajiril lj!th, Brigade Surgeon X>. P. 
 Smith, U. S. Volunteers, assisted by Brigade Surgeons Thomas W. Fry aiul H. P. Steanjs, U. S. A'oluntcers, and Assistant 
 Surgeon M. C. Tolraan, 2d Minnesota Volunteers, peribrined amputation at the liip-joiut. The patient being m.ade insensible by 
 chlorofonn, a long anterior flap was made by transfixion. Surgeon Stearns, following the knife with his fingers, compressed the 
 vessels in the fiap, and completely controlled the hiemorrhage. The head of the femur was rapidly disarticulated and tlie soft 
 jiarts posteriorly were divided by a straight incision. The art(!ries of the posterior portion of the wound were first secured, and 
 then those of the anterior Hap. It was estimated by the operjitor that the bleeding did not exceed six ounces. The shock was 
 slight and the patient reacted fairly, and for a sliort period after the operation the case wore an hoi)eful aspect. On A|)ril 14th, 
 the hospital transport arrived at St. Louis, and the wounded were transferred to hos|iitaIs in that city. Shortly after Hale's 
 admission to hosjiital liis stump began to look badly, the vast wound suppurateil profusely, gangrene supervened, and he sank 
 and died, on April 2(1, 18(i2. 
 
 A inomoraiidnm of the next case was joublislied in Circular No. 
 (-1 . (>., ISHo. J I. ")(). Adtlitionul details respecting it iiave 
 been coinmunicatiMl by tlie operator, Pruiessor George 0. Black- 
 of C'incimititi : 
 
 (1, 'V. 
 since 
 I nan. 
 
 Case XXIV.- 
 
 I 
 
 -A private soldier of an Ohio regiment, about thirty-five j'ears of age, was 
 wounded on the first day of the battle of Shiloh. A]iril 6. IStiS, by a fragment of shell, which 
 extensively comminuted the shaft, trochanters, and neck of the right fennir, as illustrated in the 
 accompanying wood-cut. The patient was left on the battle-field during the tempestuous night of 
 April 6tli. and until late on the folhnving day. He was then removed to a temporary hospital, and 
 thence to the steamer Lancaster, to be transported to Cincinnati. On April Ifitli it was decided to 
 remove the limb, and the patient being rendered insensible by chloroform, amputation at the hip-joint 
 was performed by Brigade Surgeon G. C. Blackman, U. S. Volunteers, by the antero-posterior flap 
 method. The shock and hannorrhage were inconsiderable, and the patient rallied satisfactorily 
 from the operation. On April Itth. the hospital transport arrived at Cincinnati, and the patient 
 was transferred to St. John's Hospital in that city. Dr. C. X>. Palmer, house-surgeon at St. John's, 
 who was idaced in charge of the case, re]iorts that soon after the jiatient's adnussion to hospital 
 the flajis began to slough badly, and that symptoms of jiyipmia then supervened. Death ensued 
 on Ajiril 2'^, lHii2. six days fi-oni the date of o|)eration. 
 
 frncturc of the lemur. I'-roni Mh' aljstract ot tlic iicxt cuscwas lumislieil liy tlie operator, 
 
 a tlriiiuMj,' fiimisliett hy Dr. i t I ri 1 I'll 1 • " ' c T i "11 
 
 •"■"■k'"»"- bir. J. I. b'e hriiler, ;i lugiiiy esteemed jiractitioner ot Jivausville, 
 
 bidiaiin, who, at the time, was an acting assistant surgeon in clmrge of the military 
 hospital at that ]ilace: 
 
 Ca.se XXV. — Private Peter Pausbeck. Co. K, 43d Illinois Volunteers, w.as admitted on April 2(1, 18(!2, with nearly three 
 hundred other wounded men from the battle-field of Shiloh, to Hospital No. 2, at Evansville. He had been wounded nn 
 April *th, |irobably by a conoidal musket ball. The projectile had entered the front of the left thigh, about au inch below the 
 level of the trochanter major, and langing a little upwards had emerged from the gluteal region opposite. The ujiper ))ortion 
 of the fennir was crushed and almost powdered, and so extensive was the injury to the soft parts that some doubt was entertained 
 as to the nature of the missile, several surgeons suggesting that it might have been a gi-ape-shot. A consultation, at which the 
 entire surgical stall' of the hospital assisted, was held on the morning of April 21st, and every surgeon present concurred in the 
 
 * In Cirritfttr Xit, (i, S. (1. (>., IHlif), p. .",0, it is stated that tlie wound was caused by canister-shot, on the authority of 
 Surgeon ,Iohn II. Urinton's careful report of the wounded at Shiliili. I Ir. Smith states (Am. Mid. Times, lor. rit.) that a Minic 
 ball inllicltd the injury. Dr. Fry's account, copied from the orignial eiilry made at the time in his note-hook, is mo.st probably 
 correct. 
 
 t In the Cincinnnii Jovrnnl of Medicine, Vol. I, p. 101, February, ISIiti, Dr. Blackman has imlulged in some acrimonious 
 reflections upon the value of the statistics of Circular Xo. 0, IHtl,'), on the ground that the date of the fatal result in his auiputa- 
 tion at the hip-joint after Shiloh is I'rroneously reported in that circular. It is therefore proper to state that Dr. Blacl;niaii 
 omitted to make a report of his operations af>er Shiloh, and that before the statement in Cirrular Xo. (1, the ;iuthority for wlii<'h 
 is there given, was published, three distinct applications wvrr made to him tor the particulars of his case, which applications 
 were disregarded.
 
 IN THK WAR OF THE REHELLrON. 
 
 85 
 
 opiiiiim tliat am|>iit;iti(]n ;it tljc liip-jiiiiit atronli'd tlio only possible ohiincu of pri'servinf; thf palicnt's litV. Af(.-ur(linf,'Iy no time 
 was lost. Chlorntorm was administcreJ by a cai-et'nl assistant, who liabitiially disi^havged this duty at the liospital. Tlie 
 anmsthetic acted kindly, and an unusual amount was not required. Di-. ]JeI{iiiler operated, assisted by Dr. T. N. Myers 
 and others. In conseciuence of the position of the wounds of entrance and exit tlie amputation was executed by making- 
 external and internal Haps after Lisfrane's method. The los.s of blood was very triHing. After the completion of the operation 
 the pulse, which had been carefully watched, was observed to fail ra|iidly. Unavailing attempts were made to give brandv and 
 other restoratives. In a few moments the man was dead. There was no reason to lielieve thtit tlie use ot chloroform had any 
 connection with the fatal result, which was apparently due solely to the shock of the o)ieration. Such was the opinion of the 
 eminent professor of surgery of Jefferson College, Dr. S. D. Gross, who happened to visit the hospital half an hour after the 
 operation. Professor Gross expressed his approbation of the course that had been adopted, since, although it had resulted 
 unfortunately, it aflbrded the only hope of saving the patient's life. 
 
 of Nashville, 
 
 The next case was first reported to this office by Professor Paul F. Eve, 
 ami additional particulars in relation to it were communicated by T)r. James D. Wallis, of 
 Franklin, Tennessee, formerly surgeon of the 1st Missouri (Pbebel) Regiment, who 
 witnessed the operation. The operator, Dr. Felton, died in the summer of 1863: 
 
 C.v.seXXVI. — A private of Colonel Dockeray's Arkans.as (Rebel) Regiment of Cabell's Brigade was wounded at the 
 battle of Corinth, Mississipjii, October 3, 18(i2, by a conoidal umsket liall, which shattered the neck of his right femur. He was 
 convej'ed to an hospital at luka, where, on November 3d, Ins thigh was amjiutated at the hip-joint by his regimental surgeon. 
 Dr. R. A. Felton. The patient died ujion the table before the dressing of the stump was completed. The operation was done 
 under chloroform, and it was the general impression of the surgeons present that the ana;sthetic was administered too freely. 
 
 T'he abstract of the twenty-seventh case is compiled from a 
 letter from Lieut. Colonel Pineo, Medical Inspector, U. S. Array, 
 of December 26, 1864, and a memorandum accompanying Specimen 
 No. 710 of the Army Medical Museum. The case is briefly noted 
 in the register of Douglas Hospital;* 
 
 Case XXVII. — Private P. Johnson, Co. C, 2d Delaware Volunteers, was wounded at 
 the battle of Fredericksburg, December 14, 1862, by a conoidal Uiusket ball, which entered 
 the upper part of the right thigh in front and passed out at the nates, having, in its course, 
 divided the femoral artery and perforated the great trochanter. Except that the primary 
 haemorrhage was slight, little is known of the early history of the case. On December 25th, 
 the wounded man was conveyed to Washington, and placed in the Douglas Hospital. On 
 admission, nearly the entire injured limb was gangrenous, and it was believed that the fracture 
 extended into the hip-joint. Brigade Surgeon P. Pineo, U. S, Volunteers, in charge of the 
 hospital, decided to amputate at the hip-joint, "with no hope of a favorable result, but to 
 mitigate patient's distress in the last moments of life." On December 27th, anfeesthesia being 
 induced by ether, the operation was performed. The patient survived it only a few hours. 
 The pathological specimen was sent to the Army Medical Museum, and exhibits a perforation 
 of the great trochanter, with radiating fissures, which separate the trochanter and neck into 
 four ii'agments, and run obliquely down the shaft. Traces of the results of periostitis are 
 visible along the shaft. 
 
 Fig. X. PerfnrtitioTi iif tlie ri(;ht 
 fetnur by a musket ball. Spee. 
 710, A. M. M. 
 
 The four following cases were reported to this office by Professor I'aul F. Eve, 
 Additional particulars regarding cases XXVIII and XXIX wore communirated bv the 
 operators, Drs. Crymes and Kiuloch : 
 
 Cask XXVIII. — A private of General Bnagg's army, whose name and military description are not recorded, a larsje man, 
 six feet high, of fair complexion, about twenty-six years of age, was wounded on Deeember 'JS, 18fi2, in a skirmish prior to the 
 battle of Mm-freesboro'. A conoidal musket ball produced a fracture of the trochanter major and neck of the fenmr, with fissures 
 e.\temling within the capsular ligament. The wounded man was placed in a field hospital, and his injured limb was stipporleil 
 in a [iroper position ; but the local inflammation and constitutional disturbance that ensued were intense, and, on Januarv •'>, 
 1863, it was determined to amputate at the hip-joint. The patient being placed under chloroform, tlie operation was performed 
 
 ' See Cirrulitr No. 6, .S. O. ().. 186,'), p. .')l». Case 10.
 
 36 AMPUTATIONS AT THE HIP-JOINT 
 
 liy tlic :iiiliT(i-|insleii(ir fl:ip irHlliiiil liv Assistant Siir<jouii A. C. Crymcs, :VMh A1:iliiinia (Kcbel) Rei,'iiiicnt. On being n hiiuimI 
 to his l)i'(l. the patii-nt niaiiifestotl extiviiie prostration, anil stimulants were freely administered. After a few hours he was able 
 t(j take nutrimi'iit in a c-oneentrated fonu. and. a supporting aud stimulating treatnjent was jierseveringly pursued. In a Tery few- 
 hours aft( r the operation, however, the stiunp evinced a tendency to inihealtliy action, and the patient sank into an adynamic 
 condition, and died on tile morning of January 8th, three days after the operation. 
 
 iJctuils of the foregoing case were communieateJ to l)r. Eve by Dr. Caleli Tosey, 
 formerly surgeon of the 19th Alabama (Rebel) Regiment, and to thi.s office by the ojierator, 
 I)r. Crymes, of Fort Browcler, Alaljama. In his letter relative to the case, Dr. Crymes 
 observes that the mortality among the ■ wounded of General Bragg's army after Mur- 
 freesboro' was fearfully great, in consequence of the unavoidable confusion in the hospital 
 arrangements, the ov(>rcrowding of patients, the inevitable omission of adequate hygienic 
 regulations, the mental dejirt'ssion resulting from defeat, the want of ,suital;ile medical 
 supplies, and hasty and rough transportation. All of these causes operated to the disad- 
 A'antagc of the patient wliose histdry has been related. 
 
 Case XXIX. — A private of Co. C, .'i4th Massachusetts Voliniteers, a colored man, was wounded and made a prisoner in 
 the assault on Morris Island on the morning of .luly 11. 18(i:'>. A fragment of a shell from Fort Wagner struck the upper and 
 outer part of his right thigh, and fractiu'ed the neck and head of the fenuu' and the rim of the acetabulum, and extensively 
 lacerated the soft parts in its exit through the posterior part of the thigh. The patient was conveyed to Charleston on the 
 afternoon of July 12th, and was placed in an hospital hastily prepared for the reception of wounded colored prisoners. The 
 contract surgeon in charge of the hosjiital reports that the patient's condition, in view of the terrible wound he had suffered, was 
 rem,arkably good, and that the symptoms of shock were unusually slight. On July 13th, the third day after the reception of the 
 injury. Surgeon K. A. Kiuloch, 1'. A. C. S., saw the case, and amputated at the hip-joint by Manec's method. The knife, being 
 {■ntered midway between the anterior superior spinous process of the ilium and the great trochanter, and canned downwards and 
 inwards until its point emerged just in front of tlie ischium, was made to form a large antero-internal Hap ; the soft parts on the 
 outer and posterior part of the thigh were then divided by a semi-circular incision from without iuwards. and the head of the 
 femur was then disarticulated. The patient bore the operation well, but a few' hours subsequently there was extreme depression, 
 aud the case terminated fatally on the followuig nniruing, Jidy 14th, twenty hours after the operation. 
 
 It is probable that the fnicture of the pelvis was not recognized in this case until the 
 disarticulation was effected, else an operation would hanlly have been undertaken. In liis 
 narrative of the case. Dr. ]vinloch mentions that a surgeon of the U. S. Navy, a prisoner, 
 was present at the operation, and subsecpiently requested him to operate upon several 
 United States officers who required amputation. No pathological preparation was preserved 
 from the case of amputation at the hip-joint. 
 
 Ca.se XXX. — Private .John Chamberlain, of one of the United States regiments engaged at the battle of Chickamauga. was 
 wounded on the morning of the second day of that battle, September 20, 1.^03. A conoiihd nuisket ball passed through thi' 
 upper part of the thigh, and jiroduced great conuninution of the upper extremity of llie femur, tiie fissures extending to the neck 
 of the boiu'. The wounilcd nian was left ujion the field when the United States forces were driven back, and fell into the hands 
 of the enemy. On September X!lst. he underwent amputation at the lii]i-joint, the opei'iation being performed by Surgeon R. P. 
 liateman, P. A. C. S., now a |iraetitioner of Memphis, Tennessee. The man survived the ojieration lliirty-six h(jiu-s, and died 
 September 23, 18IJ3. 
 
 Ca.se XXXI. — Private .lames C'arden, of tlie army of Majoi- (ieneral Kosecrans, was ^vounded at tiie battle of Chickamauga. 
 in the second day's fight, Septendier 20, 1S(J3, by a fragment of shell, \vhich caused great laceration of the sof^ parts at the upi>er 
 part of the thigh, with conuninuted frjicture of the f'enuir. lie was left nium the fielil. and was made a jirisoner. On the evening 
 of September 21st, Surgeon K. P. BateiEian amputated his thigh at the hip-joint, lie died (m September 27, 1863, six days afler 
 the operation. 
 
 A letter addressed to Dr. Batcman requesting him lu supjily hirther details of the 
 two preceding cases has received no response.
 
 IN THE WAR OF TfTR REBELLION. o7 
 
 Casf, XXXn. — Private Sullivan Gaines, Co. M, 'id Micliigan Cavalry, was wounded im .Janiiar_v :!1, Wf'A. near Kmi-xville, 
 Tennessee, by a conoidal musket ball, which shattered tlie neck and head of tlie right feiuur. On the following day the patient 
 was admitted to Hospital No. 4, at Knoxville. He was greatly prostrated, and his constitutional condition was considered 
 unfavorable. On February 3d, Surgeon Edward Shippen, U. S. Volunteers, amputated at the hip-joint in the presence of 
 Surgeon Henry S. Hewit, Medical Director, and others. The patient being placed under the influence of chloroform, a long 
 double-edged knife was introduced about an inch above the trochanter major ; the point was first directed inwards and slightly 
 upwards, so as to divide the capsule freely, and was then depressed and brought out near the tuberosity of tlie ischium ; a large 
 antern-iiitemal tlap was then formed, an assistant having passed his hands into the incision and compressed the femoral artery 
 in the flap before it was cut. The flap was now raised, and the heel of the knife was placed at the inner angle of the wound, 
 and a sti-aight incision was made connecting tliis point with that at whicli the knife first entered, and dividing the tissues on the 
 back of the thigh down to the bone. Disarticulation was then eft'ected. The gluteal, sciatic, obturator, and other arteries in 
 tlie p<isterior jiortion of the wound were secured first; the femoral was the last vessel tied. The patient never rallied from the 
 shock of the operation. He died in about one hour. 
 
 This account of the case of Gaines is compiled from the register of Kuoxvilli' 
 Military Hospital No. 4, and from a letter from Dr. Shippen of February K), 1867. '■•' 
 Though the injury to the thigh bone appears to have been limited to the epiphysis, neither 
 report discusses the reasons for preferring the operation of amputation at the hip-joint to 
 that of excision of the head and neck of the bone. 
 
 C-\SE XXXIII. — Private Charles Lackey, Co. E, 7th Wisconsin Volunteers, thirty years of age, was struck, at the battle 
 of Spottsylvania. May 1"2. 1864, by a conoidal musket ball, which entered in front at the upper part of the right thigh and 
 produced a comminuted fracture of the femur through the trochanters and extending downwards nearly half the length of the 
 shaft of the bone, and then lodged in the muscles at the posterior part of the thigh. After the fatiguing journey to Belle Plain, to 
 whicli most of the wounded from Spottsylvania were unavoidably subjected. Lackey was conveyed on a hospital steamer to 
 Washington, and was received at Judiciary Square Hospital on May 18th. The wounded limb was much swollen. The sharp 
 extremity of the lower fragment of the femur had lacerated the muscles, and there was profuse suppuration with burrowing of 
 pus throughout the thigh. The fi'acture was believed to extend into the joint. The patient earnestly demanded that an 
 operation should be performed for his relief His condition was unpromising, for he was sufl'ering from surgical fever of an 
 intense character. A consultation of surgeons decided however that, without operative interference, the case would prove 
 inevitably and speedily fatal ; and as the extensive ft-acture of the shaft of the femur and the purulent infiltration of the thigh 
 precluded excision, amputation at the lup-joint was determined on. On May 21st, aniEsthesia was induced by sulplmric ether, 
 and Assistant Surgeon Alexander Ingram, V. S. Army, peiformed the operation by the antero-posterior flap methcjd. After the 
 operation the patient reacted but partially. After removal to the ward he was plied with beef-tea and stimulants and restoratives; 
 but he continued to sink, and died on the following day, May 22, 1864, twenty hours after the operation. 
 
 The history of the foregoing case is comjnled from the register of Judiciary Square 
 Hospital, and that which follows from the register of Chesapeake Hospital, and from letters 
 from Assistant Surgeon E. McLellan, U. S. Army, and Acting Assistant Surgeon George 
 Bayles. Both cases are reported in brief at page 50 of Circular No. 6, S. G. O., 1865. 
 
 C.\.SE XXXIV. — Private Levi Eckley, Co. A, G7th Ohio Volunteers, was wounded May 2U, 1864, in the as,<ault upon Major 
 General Butler's entrenchments near Bermuda Hundred. A conoidal musket ball passed through the left thigh, shattering the 
 upper extremity of the femur and wounding the sciatic nerve. The patient was couvej'ed on an hospital transport to Fort 
 Monroe, and was admitted to Chesapeake Hospital on May 22d. A consultation was held, at which it was decided that amputation 
 at the hip-joint presented the only chance of preserving life. The patient's condition was unfavorable ; he was greatly prostrated. 
 On May 24tli, the operation was performed by Assistant Surgeon H. C. Roberts, U. S. Volunteers, by forming antero-posterior 
 Haps by transfixion. The femoral artery was compressed at the groin by Surgeon D. G. Rush, 101st Pennsylvania Volunteei's, 
 and Acting Assistant Surgeons Bayles, Frick, and others aided in the operation. The hieniorrhage was excessive. Notwith- 
 standing, the patient reacted fairly, and when removed to his bed, he partook of nutritious food and stimulants. He dietl from 
 exhaustion four days after the operation, M.ay 24, 1864. 
 
 The facts given in regard to the next case arc derix'cd Imui Idlers from l)r. Samuel .1. 
 
 *Sce also Report of Adjutant (iincral uf M!iiil</an. for 1864, p. 1)8, and llauiillon's Treatise on Mililarn Smyery, p. 48."), and 
 Circular No. 6, S. G. ().. 1865, p. .50. (^ase No. !). 
 
 431180
 
 38 
 
 AMPUTATTOKS AT THE HIT-JOINT 
 
 Allen, Ibnaerly Surgeou-in-cliief of the Second Division of the Sixth Corps, and Dr. David 
 M. Goodwin, late Surgeon 3d Vermont Volunteers. The operation is briefly noted in the 
 register of the Field Hospital of the Second Division, Sixth Corps: 
 
 Cask XXXV. — Private Joseph Minott, Co. A, 4th Vermont Volunteers, was woim<h-(l early on June 2'i, 1804. He was on 
 duty on the advanced picket line hefore our fortitications in front of Petersburg, when an assault was made on the works, and a 
 large number of the skirmishers were killed, wounded, captured, or driven from the ground, which was not re-occupied for several 
 days. Minott had his right femur fractured in the upper portion of the shaft by a conoidal musket ball at the outset of the 
 attack, and he lay where he fell, beyond the reach of succor, the ground being commanded by the sliarpshooters of the enemy. 
 On the morning of the third day, June 25th, having been without food or drink for forty-eight hours, he crawled into our lines, 
 a distance of over half a mile. He was carried to the Field Hospital of the Second Division of the Sixth Corps, greatly 
 exhausted, of course, by the priv.ition, exposure, and sufl'ering to which he had been subjected. After he had received nourish- 
 ment and cordials, las injuries were examined, and it was found that besides the extensive comminution of the femur, rapidly 
 spreading gangrene had supervened. In front, mortification already extended to within a few inches of Poupart's ligament. A 
 consultation of the senior surgeons of the division decided that coxo-femoral amputation ottered the only chance of recovery, and 
 that the operation could not be delayed. On the afternoon of June 25th, therefore, the patient was rendered insensible by 
 chloroform, and the amputation was performed by Surgeon Goodwin. A short anterior flap was made by transfixion, and the 
 femoral artery was then tied. The edge of the knife was then directed downwards, and made to divide the capsular ligament; 
 the head of the femur was then disarticulated, and a long posterior flap was formed, gangrene not having ])rogressed so liigh up 
 on the posterior portion of the thigh. But little blood was lost. The patient rallied pnjmptly from the ett'ects of the chloroform 
 and from the shock of tlie operation. But this reaction was of brief duration. He soon began to sink, and expired in the 
 evening of June 25th, two hours after the completion of the operation. 
 
 The history of the next case is taken from the reports of the Third 
 Division Hospital at Alexandria, by Surgeon Edwin Eenlley, U. S. A^olun- 
 teers : * 
 
 Fig. XI. — IVmiir 
 witli lnii(ritu<liiiiil 
 and ot)li({iic fis- 
 sures. [»r<«lupe(i 
 1>V a niu.Hket l)all. 
 .<im. lll'Jd, .\. M. 
 .M. 
 
 Case XXXVI. — Sergeant Lewis Carroll, Co. H, 1st Delaware Volunteers, aged tvventy-thi'ee years, was 
 wounded on October 22, 1804, in one of the engagements attending iltijor (ieneral Warren's movement upon the 
 Weldon Railroad. A conoidal musket ball entered the right thigh in front, and, striking the femur at the 
 junction of the upper thirds, produced a remarkable longitudinal splintering of the boiu-, extending from an inch 
 below the lesser trochanter downwards for ten inches, together with several oblique fissures. The wounded man 
 was conveyed in an ambulance to one of the field hospitals of the Fifth Corps, where the ball was extracted, and 
 the sharp extremity of the upper fr,agment of the fenmr was sawn off. The fractured limb was then dressed, 
 and the patient was sent to City Point, and thence on an hospital steamer to Alexandria, where he was admitted 
 to the Third Division Hospital on November 2d. The thigh was swollen to three times the size of its fellow. An 
 incision six inches long on the outer side presented inflamed everted edges, between which fasciculi of muscles 
 {jrotruded. There was much febrile irritation, but the patient's strength was maintained to a remarkable 
 degree. On November lltli. there was quite free haemorrhage from a small artery, and the patient was 
 etherized and the vessel secured, and afterwards a thorough exploration of the wound was made. The very 
 extensive longilu<linal sidintering was recognized; the bone was found denuded in sever.il jilaces ; the soft 
 tissues of the thigh were infiltrated with jms of a very ofl'eusive character. In view of this condition of things, 
 it was determined to remove the liud) at the hi))-joint. The patient was placed under the influence of 
 chlorcjform, and the operation was ])erfonned by Surgeon E<iwin Bentley, U. S. Volunteers. An e.xternal Haj) 
 was n]ade by cutting from without inwards ; then the head of the fenmr was disarticulated, and an internal 
 flap was cut i'rom \vithin outwards. The loss of blood was slight, and the patient reacted promptly. The 
 progi'ess of the case for two or three days after the operation was very favorable. Then a chill occurred, 
 followed by a cold clammy sweat. The wound looked badly, and the discharge was unhealthy ; the stump 
 was kept covered with yeast jioultices. Beef essence, stiunilants, and anoflynes were administered. Six days 
 after the operation there was yellowness of the surface and of the conjunctival membranes; then delirium and 
 coma, and death oi. November 19th, eight days from the date of the operation. At tlie autopsy, pus was found 
 in the external iliac vein, metastatic foci in the lungs, and a gangrenous abscess in the eidarged spleen. The 
 prepai'ation of the fenuu- was sent to the Army Medical Museum. It is muubered Specimen 1020, and is 
 figured in the adjiieent wood-cut. 
 
 * See Ch-ndar Nu. (">, .S'. (i. ()., IHfif,. p. ;',(), Case IS.
 
 IN THE WAR OF THE REBELLIOIC. 
 
 39 
 
 T]ie registers of Judiciary Square Hospital, and a report of a board of 
 medical officers appointed to investigate the case, furnish the data Irom 
 which the following abstract is prepared:"'' 
 
 Case XXXVII. — Private George M. Spencer, Co. B, 2(1 New York Mounted Rifles, seventeen j-eai-s 
 of iiL'e.t was wounded on March 31, 186."), at Dinwiddle Court House, Virginia, by a conoidal musket ball, 
 which entered the right gluteal region, and striking the great trochanter, produced a fracture through the 
 trochantei'S, with very remarkable longitudinal splintering, extending nine inches down the shaft. (See 
 Fiijure XII.) The projectile then lodged. The wounded man was sent to City Point, and tlience by steamer 
 to Washington, and entered Judiciary Square Hospital on April 4th. There was already a good deal of 
 inflanunatory swelling and suppuration, but the constitutional condition was encouraging. Upon e.^amina- 
 tion of the wound, it was tliought tliat the fracture did not extend below the trochanter and tliat the joint 
 was ])robaljly involved, and it was determined to excise the head of the femur. The patient having stated 
 that he was anxious to avail of the benefit of any operation that w'as deemed necessary, he was placed 
 under the influence of chloroform on April l"2tli, and Surgeon ElishaGriswold, U. S. Volunteers, proceeded 
 to disarticulate the head of the femur tlirough a long vertical incision on the outside of the thigh, and to 
 remove the head with an obliquely fractured fragment of the shaft attached to it. The splintering of the 
 shaft was now discovered, and alter a hastj- consultation with the surgical staff, it was decided tliat ampu- 
 tation at tlie hip-joint was tlie only procedure whicli afforded the patient any prospect of recovery. This 
 operation was rapidly executed by Surgeon Griswold, aideil by Acting Assistant Surgeons Hill, McCalla, 
 C'olton, and Ahem, by the double-flap method. There was but little haemorrhage; but the shock of the 
 operation was too great. The usual means to promote reaction were diligently employed, but the patient 
 never rallied, and survived the operation less than an hour. 
 
 Fig. .Ml. LoiiK 
 fissnrinff of i 
 mur. Spec. 
 M. M. 
 
 SECONDARY AMPUTATIONS. 
 
 (Jf the nine cases included in this series two recovered and seven died, a percentage 
 uf mortality of 77.78. Three patients sank from the shock of the operation. One with 
 a shattered constitution, -with phthisis and lithiasis, died seventeen weeks after the opera- 
 tion, his stump nearly healed. One had secondary hemorrhage and phlebitis subsequently, 
 and succumbed in twenty-three days. One died on the tenth day from the giving way of 
 the femoral at the point of ligation. One died on the third day with surgical fever and 
 erysipelatous inflammation of the stump. Excluding the case in whicli death resulted from 
 profuse secondary haemorrhage, those patients survived longest in whom the operation was 
 longest deferred. The average period the patients survived the operation in the seven fatal 
 cases was twenty-two days. The shortest interval between the injury and operation was 
 forty-three days; the longest was two years, nine months and twenty-one days. The 
 average interval in the nine cases was four hundred and tw^enty-nine days. 
 
 The details of the first case are taken from a careful report from the openitor, 
 Surgeon Edw'iu Bentley, U. S. Volunteers : 
 
 Case XXXVIII. — Private Michael O'Neil, Co. E, 58th Massachusetts Volunteers, aged nineteen years, was wounded at the 
 battle of Cold Harbor, .Tune 3, 1864, by a conoidal musket ball, which entered the upper anterior part of the riglit tliigli and 
 passed backwards and slightly upwards through tlie limb, comminuting the upper extremity of tlie femur. Tlie fissures 
 e.Ktended about three inches down the shaft, and through the trochanters half-way up the neck. Tlie wounded man was sent in 
 
 * See Circular No. 6, S. G. O., 1865, p. 50, Case 21. 
 
 tThe preparation of the fr.ictured fenmr would imiiialc th;il the luiiieiil was umcli oliler. Ossification is conipli-tr, mid the 
 epiphyses are jierfectly united to tlie sliaft.
 
 40 
 
 AMPUTATIONS AT THK HIP-JOINT 
 
 an anibnlaiifc to tlir Wliite Hoiisi'. on the York river, anfi tlienoo liy an liospital steamer to Alexanilria. where lie was reeeived 
 at tlie Tliinl Division Hospital on June 7th. On admission, his limb was much swollen, j-et there was but little pain, and this 
 was not inei'eased by moving the limb. His general condition was satisfactory, though he reported that he was subject to attacks 
 of intermittent fever. His limb was arranged in a straight position, supported by cushions and pillows ; evaporating lotions were 
 aj)i>lii'd to the wound, and a nutritious diet was ordered. On June luth, several fragments of bone were extracted. On June 
 Idtli the pitient liacl -i chill ind was ordered to take four grains of siUphate of quinia every four hours. The injured limb was now 
 suspi udul \n means of >mith s anterior splint. On June 24tb tliere was another chill. The wound was now suppurating freely, 
 
 and the linib was very sensitive when handled. On June 31st, there was a slight chill. 
 From this d.ite to August 1st there was little change in the symptoms. It was now decided 
 that tliere was little hope of consolidation of the fracture. The suppuration was profuse, 
 and it was believed that the patient would inevitably succumb ultimately to the constitutional 
 irritation and the drain upon the system. It was determined, therefore, that amputation 
 shoidd be performed, and the character of the fracture admitted only of amputation at the 
 liip-joiut. On August 10th, the patient was anaesthetised by sulphuric ether, and amputation 
 at the hip-joint was perfoi-med by the lateral flap method by Surgeon Edwin Bentley, U, 
 S. Volunteers. There was but little lijemorrhage, and the operation was borne well. The 
 ]iatient had an anodyne, and was freely stimulated. For forty-eight hours after the 
 f>peratiou there was some febrile excitement, with complete anorexia. The fever then 
 subsided, and the appetite retui-ned. The wound looked well, and the amount of suppuration 
 was triHhig. The case progi-essed very favorably until August 'JOth, when secondary 
 lia'morrhage supervened, from ulceration of the femoral near the ligature. About six ounces 
 of blood were lost. A ligature was promptly placed upon the externa! iliac, just above 
 Pouparfs ligament. After the operation the p.atient was very weak and faint, and stimulants 
 were freely administered. On August '22d, there was an excess of febrile excitement, but 
 this abated on the following day, and the appetite again became moderately good. On 
 August Sf^th, there was nausea and vomiting, which persisted for forty-eight hours. The 
 wound at this time had assumed a very unhealthy appearance, and the patient had become 
 much emaciated. On the night of Se])tember 1st, there was delirium. Tlie case terminated 
 fatally on the morning of .September od. twenty-three days after the operation. At the 
 autdiisy, the viscera were found to be health}-, e.xceiit tliat there was an old cicatrix with 
 cretaceous deposit at the apex of the left lung. The lips of the wound were united in nearly their entire extent. There was a 
 large accumulation of pus within the flap, bathing the acetabulum and the gaping mouth of the femoral artery. The wound let^ 
 bv the incision above Pouparfs ligament, through which the external iliac was tied, communicated with an abscess between the 
 iliacus externus muscle and the iliac fascia, filleil with foetid pus. The ligature on the extenial iliac was found to be placed 
 .about half an inch below the origin of the epigastric ; the circumflex iliac was given off a little below the epigastric. There was a 
 fii-m conical plug in the external iliac, ending at the origin of the epigastric. Through this jilug ran a canal communicating 
 with the mouth of the circumflexa ilii; this canal was closed by a clot colored by included red corpuscles, and of more recent 
 formation than the plugging clot. Ulceration of the external iliac ju.st above the ligature had coiiinienced. The femoral vein 
 was collapsed and contracted ; tlie external iliac vein was distended by a dirty fluid, which, when placed uuder the microscope, 
 was found to abound in pus globules. Higher up, the contents of the vein consisted of a granidar detritus. The branches of the 
 external iliac vein was blocked up by dense coagula. The deep-seated abdominal lymjihatic glands were enlarged and deeply 
 injected. An examination of tlie fractured femur showed that it was shattered, with much loss of substance, just below the 
 trochanters; the Assures ran up witliiii the capsule, and the fractured extremities of the bone were carious, and had lost tissue 
 by absolution. • 
 
 Flo. XIII. CJunsliot fracture of the upper 
 cvtreniity of the riirht feiuur. Spec. 
 No. 3U!'8, A. M. M. 
 
 Tlie quarterly surgical report from Lincoln Hospital, a medical descriptive list from 
 Acting Assistant Surgeon John Morris, and a record of the autopsy 'by Acting Assistant 
 Surgeon li. M. Dean, have furnished the data for the history of the following case.''' The 
 fractured bone is deposited in the Army Medical Museum, and is numbered /Specimen No. 
 2288, The ends of the fragments are carious, and there is no trace of any rejiarative 
 action. f 
 
 * See Circular iVo. 6, S. G. O., 1865. p. 50, Case 15. 
 
 t Sec Catnloijuc of the Surgical Section of the United States Army Medical Museum, Washington, 186G, p. "247.
 
 IN THK WAi: OK TllK JtKBKLIJOX. 
 
 -U 
 
 Cask XXXIX.— Private Daniel II. Bowman, Co. C. lUltli Pennsylvania Voluiitocrs, 
 twenty-four years of age, was wounded on July 27, 1864, at Deep Bottom, on the left bank 
 of James Kiver. A conoidal musket ball entered at the upper posterior part of the right 
 thigh, comminuted the femur from the troclianters downward for several inches and lodged. 
 The wounded man was transported to Washington on an hospital steamer, and was received 
 at Lincoln Hospital on July ;!Otli. The injured limb was shortened two and a half inches; 
 the soft parts were badly lacerated. On August 7th, the position of the ball at the anterior 
 l>art of the thigh was detected. An incision was made and the ball and several detached 
 fra"ments of bone were removed. On August 17th, the wound looked badly, and there was 
 sliHit sloughing. For the next few weeks the patient lost ground steadily. There was 
 profuse suppuration, with great constitutional irritation. There appeared to be no attempt at 
 union at the seat of the fracture. The patient had become much emaciated, and his powers 
 of resistance were failing daily. After due consultation it was determined to amputate at 
 the hip-joint. On September 15th, the operation was performed by Assistant Surgeon J. C. 
 McKee, U. S. Army. The patient was rendered insensible by suliihurie etiier. The metliod 
 by antero-posterior flaps formed by transfixion was adopted. The amputation was rapidly 
 comjileted and very little blood was lost. The patient did not rally, but died one hour after 
 the operation, September 15, 1864. At the autopsy, the limgs were found to be attached to 
 the thoracic walls by firm fibrinous adhesions. In the upper lobe of the right lung there 
 were two small isolated abscesses. Otherwise the lungs were normal. The right weighed 
 l:i and the left 11 ounces. The abdominal viscera were normal, save that the liver and 
 kidneys were unusuallj- small, the former weighing 44i and the latter 9+ ounces. At the 
 seat of the ii-acture of the femur there was no attempt at repair; the fragments were carious : 
 a large one. consisting of nearly half of the cylinder of the shaft, was four inches long and 
 was (juite detached. Fissures penetrated the trochanters, and extended posteriorly half-way uji the neck of the hoi 
 
 The facts relating to the next case are taken from the casualty 
 lists of the Ninth Army Corps, and from the reports of the Beverly 
 Hospital :* 
 
 Case XL. — Private John Williams, Co. F, loth Ohio Cavalry, forty-four years of age, was 
 wounded at Peebles' Farm, near Petersburg, September 30, 1864, by a conoidal musket ball, which 
 jiassed through the left thigh and contused or partially fractured the femur. He was conveyi'd in an 
 amlndance to the Field Hospital of the First Division of the Ninth Corps, and his wounds were dressed, 
 and he was then sent by rail to City Point, and thence to the North in an hospital transport steamer. On 
 October 7th, he was received at the General Hospital at Beverly, New Jersey. For over three moutlis 
 the case progressed very favorably under the simplest treatment; but early in February, abscesses 
 formed in the thigh ; and, when they were incised, they discharged copiously an offensive pus. About 
 the same time the patient was attacked by an obstinate diarrhoea. On February 17, 1865, an exploratory 
 incision was made, and a careful examination with the finger and the probe indicated that the femur w.-is 
 necrosed as high as the trochanters. It was then considered that amputation at the hip-joint presented 
 the only chance for preserving life. The operation was performed by Assistant Surgeon Clinton Wagner, 
 IJ. S. A. The patient inhaled chloroform ; anterior and posterior semilunar flaps were made by trans- 
 fixion; the femoral artery was tied as soon as divided; disarticulation was then efl'ected, and the opera- 
 tion completed by securing the minor vessels. Very little blood was lost. The patient reacted satisfac- 
 torily, but sank and died, apparently fi-om shock, twenty-nine hours after the operation. An autopsy 
 revealed a healthy condition of the viscera and no lesion worthy of special mention. The fennn- 
 displayed an interesting example of necrosis of the entire diapliysis. It is numbered Sprrimrn 81 in 
 the collection of the Anuy Medical Museum. 
 
 The abstract of the next case is compiled from the registers of the 
 various military hospitals in which the patient was treated, and from a 
 letter from Dr. R. F. AVeir, surgeon of tlie civil hospital at which the 
 operation was performed :f 
 
 Case XLI.— Corporal Frederick Kelb, Co. O, 7th New York Volunteers, was wouuded at the 
 battle of Fredericksburg, December 14, 1862, by a conoidal musket ball, which fractured the right femur 
 
 (iuiishut fracture nf tlie 
 f:pec. -2288, A. M. JI. 
 
 Plo. XV. Necr...si> .4' 
 the femur followinEr 
 gunshot injurj'. Spec. 
 84, A. M. M. 
 
 * See Circular Xo. 6, S. G. O., 1865, yi. 50, Case 20, and .1 Report of Interesting Surijiml Operations performed at the 
 r. *'. J. General Hospital, Bevcrhj. New Jirsfi/, by C. WacnkI!, Assistant Surgeon, U. S. A. 8vo, pp. 16. [Printed but not 
 published.] 
 
 t See Circular \o. 6, .S. C. <)., 18(i.'>, p. .-.2. 
 
 6
 
 42 
 
 AMPCTATIOKf; AT TIIK IlIP-JOIiNT 
 
 at tlic juiiitiiiM (if till' ii]i]iiT mill iiikldle tliirds. After rcmaming for a fortiiiglit in tlif Field Hospital of tlie I'irst l>i vision of I lie 
 Second Corps lie ivtis e<iiive_ved to Washington and placed, ou December '2!ith, m the Patent Office Hospital, where the injured 
 limb was jd:i<-ed in a fracture box !iiid the wound was dressed with oakum. The ease progressed favorably, and on April 2, 
 1863, the patient was transferred to ,)iidiciary Square Hospital. He continued to improve, and, on May 9tli, was sent to Ue 
 Camp Hospit.al, at David's Island, New York. On July lUth, he w as removed to JIcDougall Hospital, at Fort Schuyler ; and 
 on January 19, ISBJ, he was I'cadmitted to De Camp Hospital. On June 8, 18f)4, he was discharged from the service of the 
 United States. The fracture had consolidated, but there was evidence of disease of the femur. On June 7, 1865, Kelb was 
 admitted to St. Luke's Hospital, in New York city. There had been a series of recurring abscesses in the thigh, and it was 
 believed that nearly the entire femur was necrosed. It was determined to anipiitate at the hip-joint, and, on June 7th, the 
 patient being ana'sthetiscd by suijihtiric etiier. ana the aorta being compressed by Signoroni's clamp tourniquet, the anipiitati(jn 
 was perfonned by the attending surgeon. Dr. E. F. Weir, by the method rcconiniended by Dr. Van iiuren,* an anterior H;ip 
 being formed by transfixion and a posterior one by^ section from without inwards. t The luemorrliage was sliglit and the shock 
 was moderate. The case at first pi-ogressed very favorably. Three weeks after the ojieration the healing of the stump was 
 far advanced and the patient was able to leave his bed. After this be began to lose groiuid very gradually, lie died on 
 October 4, 18(!5, nearly four months afler the operation. At the autopsy, the pelvis of the right kidney was found to be 
 blocked up with numerous calculi; there was an abscess in the lefl kidney, and there was tuberculosis of hotli lungs at an 
 advanced stage. The stiunp was still open and the horizontal portion of the os pubis was necrosed. A section of the 
 exarticulated fenuu' ])resented the characteristic lesions of chronic osteomyelitis. 
 
 Tlie liistorv of tlic following successful case of ainputatidii at tlie hip is (]erivc(l fnim 
 the regisfcrs of tlu- Thinl Hi vision Hospital at Alcxamlria., and of the Harewood Plospital, 
 and fviiiii letters from the operator and the patient. | 
 
 Cask XLII. — Private George W. Lemon, Co. C, fitli Maryland Volunteers, aged thirty years, 
 had his ]fi\ femur fractured, at the junction of the middle and upper thirds, by a conoidal musket 
 liall, at the battle of the Wildi^nicss, May f), 1864. He was left in a shelter tent on field, and fell 
 into the hands of the enemy. On May loth be was reeaptiu'ed, and was sent to Fredericksburg, and 
 llience to Alexandria, where he was received at the Third Division Hospital, ou June 14th. When 
 admitted he had diarrhcea, and was greatly emaciated. There was a bed-sore, fuur inches in 
 diameter, over the sacrum, and smaller sores over the prominences on the spine and scapula;. The 
 lowi-r end of the upper fragment of the femur protruded from the wound, from w-hich there was a 
 profuse ott'eiisive asli-colored discharge. To check the diarrhcea, to administer suit.'ible nourish- 
 ment, and to take pressure from the bed-sores by suiiporting the body ou air cushions, were the 
 first matters attended to. Then moderate extension was applied to the injured limb, and a tolerably 
 good jinsitioii was maintained by means of pillows and cushions. In three weeks the bed-sores 
 were heiileil. and there was a slight improvement in the general constitutional condition. Extension 
 of the limb causing pain, it was discimtinued. For the next ten or twelve months the patient 
 clung to life by the slenderest thread. Detaclied frugTnents of bone frequently gave rise to 
 inflammatory swelling, abscesses in the tliigli. and profuse suppuration. Yet the appetite and 
 digestion continued to be good, and the great drain upon the system was supported unusually 
 well. In May, 186.'), it was found that the fracture was quite firmly consolidated. The patient imw 
 occasionally sat up in a chair, but every attempt of the sort was followed by acute infiannnation of 
 the thigh, with increased suppuration. It was now decided that the patient must ultimately sink 
 under tlie profuse suppuration, and that an operation should be peifonued as soon as it was 
 oi>iiortune, and that every eft'ort should be made to put the patient in a condition to support this 
 shock. On October 12. 1865, Surgeon Edwin Bentley, II. S. Volunteers, proceeded to amputate at 
 the hip-joint. Chloroform was admini.stered ; the external iliac artery was compressed at the 
 pubis; anterior and posterior semilunar flaps were formed by transfixion, and the femur was 
 disarticulated. The humiorrhage was inconsiderable, and the )iatient reacted soon and satisfactorily. 
 From the day of the operation he steadily improved, with scarcely an untoward symptom. On 
 November l.")th, Dr. Bentley reported that the ligatures had all come aw^ay, and that tlie wouml 
 was grauulatiug kindly. In December, the stump was healed, and the patient began to g(^t about 
 on crutches. The fr'acture of the exarticulated fennir was found to be imperfectly but quite firmly 
 united, with great antero-posterior angul.ar defonnity .and Bhortening. The bone was sent to the 
 
 FIG. XVI. 
 
 C:..nj 
 
 «,li.l; 
 
 ii.-.i 
 
 t-' 
 
 nil' 
 
 sfiot fracture 
 
 i.r 
 
 till- 
 
 ii 
 
 ■ft 
 
 fi-iiiur. 
 
 Spi:r, 
 
 ■liij'ii 
 
 , A. 
 
 iM. 
 
 M, 
 
 * Transactions of Xem i'ork Amdrmy of Mftliclne. \dl. I. and Contributions to Prartical Surijertj. by W. H. Van BuKEN, 
 Svo. Phila., 1865, p. 9. 
 
 t M. A. (iu6rin hiu" suggested the same )ilan, Midennc Operatoirr. Tome I, p. ','7:t. 
 
 } S.-e Cirnilor Xo. 6, .S. (I. ()., 1865. p. .52.
 
 IN TIIF. WAT; ok TIIK RRDELLION. 43 
 
 Anm' Medical Musciini. wIutc it is jiri'servcd as Spcrlmen 4381!. A piislcrior view of it is oivcii liv llic wmnl-i-iil. and a lati'val 
 view ill Plate III. On Jaimarv 'M, 18C(>, a plidtograpli of tlie man was talven, I'l'oin wliirli tliu acconi]iaiiving plate is copied. 
 Lemon was tlien transferred to tlie Hurewood Hosijital, at Wasliington. He was tlieii ([iiite well, and able to go wliere he cliose 
 on erutclies. The cicatrix was firm and liealtliy. On February '.i, IHGti, lie was diseliarged from the hospital, and from the 
 service of the United States, at his own recjiiest. He went to his home at Bird Hill, Carroll county, Maryland, and resumed his 
 trade of slioemakiiig. He was granted a pension of fifteen dollars a month. On .\pril '2li, 1837, a letter was received from him, 
 in which he stated that his health was excellent; tliat he weighed ninety-nine and a half pounds, an increase of twelve and a 
 half pounds from the date at which lie left the hospital ; and that he had been able to walk to the village of Westminster, a 
 distance of seven miles, without fatigue. 
 
 The facts from which the history of the following example of a successful secondary 
 amputation at the hip-joint was compiled, were contributed by the operator, Dr. George 
 C. Blackman, Professor of Sm-gery in the Medical College of Ohio. Dr. Blackman also 
 transmitted a sketch of the jjatient five months after his recovery, prepared in water-color, 
 carefully rendering the appearance of the stump at that period. The accompanying 
 chromolithograph is copied from this sketch :* 
 
 Case XLIII. — Private Woodford Longmore, a rebel soldier, twenty-five years of age, a robust, healtliy man, was wounded at 
 a skirmish at Cynthiana, Kentucky, on June 11, 1864. A ball from a Belgian rifle, at short range, passed through his right thigh, 
 shattering the shaft of the femur. There was profuse lucmorrhage and the shock was alai-ming. He remained almost inseiisilile 
 for three or four days, and for a fortnight there was extreme prostration. He was placed in a rebel field lio.sjjital, and tiie injured 
 limb was jmt in a fracture box, with which was connected a crutch piece extending to the a.xilla. On the evening of the 
 reception of the wound numerous detached bony splintere, a handful almost, wen^ e.vtracted. For six weeks, extension and 
 counter-extension were maintained, but so much suffering arose from this tri'.atmeut that it was discontinued, and the limb was 
 simply supported in a comfortable position. The patient was confined to his bed for eight and a half months. In the middle 
 of March, 1865, he was removed to Florence, Kentucky, seven miles from Cincinnati, and Dr. George C. Blackman, professor 
 of surgery in the Medical College of Ohio, was consulted in the case. There was a profuse discharge of otiensive pus, and the 
 patient's strength seemed to be failing under the protracted irritation and spoliation. There had been frequent recurrences of 
 abscesses in the thigh, attended with excessive pain and swelling, and followed by the elimination of fragments of necrosed 
 bone. Ever since the reception of his injury the patient had taken morphia very freely. Evidently there were still loose 
 sequestra and diseased bone with which sinuses communicated, and Dr. Blackman proposed to remove these sources of irritation. 
 On April 23d. tlie patient consented to an operation, and a number of necrosed fraginents were extracted with much relief to the 
 local irritation and benefit to the general health. During the ajitumn, however, evidences of extensive destructive iuHammation 
 of the shaft of the femur became unmistakable, and, in December, a second operation for the removal of fragments was 
 performed without advantage. The dischai-ge became more ofl'eiisive and sanious, and the strength of the patient rapidly gave 
 way. In January, 1866, his condition became almost hopeless, and the removal of the diseased limb was determined on. The 
 operation was performed on January IStli. Ether was administered and the lower e.'ctremities were kept elevated for a few 
 minutes before the incisions were made. Then the right femoral was conqiressed at tlie groin, and the disarticulation was rapidly 
 efi'eeted by Lacauchie's method. t A circular cut through the skin was made at the junction of the upper third of the thigh ; 
 then the integuments were retracted and the muscles were divided circularly down to the bone. A vertical incision was now 
 made on the outer side of the limb, commencing a little above the trochanter and joining the first incision. The head of the 
 bone was then exartieulated. There was but little haemorrhage, and the patient rallied from the operation remarkably well. 
 The following day he suffered greatly from nausea, wliich he ascribed to the use of the ether. This distressing complication 
 soon subsided, however, and thenceforward there was no unpleasant symptom, and the patient progressed rapidly towards 
 recovery. In February, 1867, Longmore reported himself to Dr. Blackman as in e.xcellent health, and as having recently 
 married. In the latter part of June, 1867, seventeen months after the operation. Dr. Blackman again saw him, and found that 
 his general health was good, and that his stump was sound, though subject to occasional attacks of neuralgia of extreme 
 severity. He was accustomed, in these attacks, to alleviate his suffering by taking large doses of morphia. An examination of 
 the limb after its removal showed that the entire shaft of the femur had been affected by osteomyelitis. The specimen, with its 
 delicately encased sequestra and fi-agile deposits of new bone, was destroyed by an unskilful preparer. 
 
 The history of the forty-fourth case is compiled from the registers of the Gettysburg 
 and Chambersburg hospitals, and from the careful report by Dr. William Pepper, resident 
 
 * The case is briefly referred to in the Cincinnati Journal of Medicine, A'ol. I, p. 101. February, 1866. 
 
 t M. A. E. Lacauchie, chirurgien principal, and chief medical officer of the French army of occupatimi in Rome, gives a 
 description, with illustratiuns, of his procedure for amputating at the hip-joint, in the diizcttc Medicate de Paris, Nos, 19, 20, 2.'>, 
 and 26, l.SoO.
 
 44 AMPUTATIONf; AT TTIF. ITTr-.TOTXT 
 
 sursi-con !(l the l't'nnsvlvaiii;i Hospital, containcil in 1 >i', TlKiinas G. ]\rort<->n's oxeellont 
 papii- on aiii|iiilali(ins at tin- liip-joint. '•' The patlioloo-ical preparation from this case is in 
 the collection of tlie Museum of the Pennsylvania Hospital; but, through the courtesy of 
 Dr. Morton, photographs of the preparation, from which tlie wood-cuts accompanying the 
 history are copied, have been sent to the Army Medical Museum. 
 
 Case XLI\'.— I'livate Janu'S McCiot-limi, Co. K. lUTtli IVimsvlvaiiia Vdluiitccrs, aged forty-eiglit years, was woiuulcd at 
 flii' battle of Gettysburg, Pennsylvania, on Jnly 1, 18G3, by a conoidal musket ball, wliicb entered at tbe inner aspect of tbe 
 nnddle of the right tliigli, and traversed the entire thickness of the limb, badly comminuting the shaft of the fenun- in its 
 |irogress. He lay upon the field for about five lioin-s, and lost a good deal of blood, although none of the larger vessels appeared 
 to liave been wounded. He was tlien conveyed to a temporary field hospital, and his wounds were dressed. On July (ith, he 
 was removed to th(> Seminary Hospital at Gettysburg, where lie remained until September' 4th, at which date there was profuse 
 suppuration and some sloughing at the wound <if entrance, and it was deemed expedient to put the patient under canvas in the 
 Camp Lettennan Hospital. On October Uth, lie was moved to the Town Hall Hospital at Chambersburg. Here he was able 
 to move about on cruti-hes, but the injured lirub was greatly enlarged and deformed, and numerous fistulous openings successively 
 fornu'd, tlu'ough which pus was freely discliai'ged, and bits of necrosed bone were occasiimally eliminated. On April 23, 1864, 
 by order of t!ie Medical Director at Harrisburg, he was discharged from tlie military service of tlie United States on account of 
 " pi'nnanent lameness resulting from gunshot fracture of tlie right femur." Nearly two years subsequently, April 9, ISBd, 
 Met ieehen entered tlie Peniisylvania Hospital, at riiiladelpliia. His general condition was satisfactory; his spirits were 
 excellent; a careful examination failed to detect organic di.sease of any visciis. His injured thigh remained greatly deformed 
 and enlarged ; the original wounds had long since closed, but there were numerous fistulous sinuses, discharging on an average 
 a gill of pus daily, and, at intei'vals, scales or nodules of necrosed bone ; three tracks seemed to ascend to within an inch and a hall 
 ol' tlie trodianter major. It was tliouglit probable that above this point the femur was healthy. After a careful consultation, it was 
 determined to remove the limb at tlie liip-joint. The patient was placed upmi tonic treatment, w-itli nourishing diet ; Ids bowels 
 were also carefully regulated. He com)dained of nothing excepting his cough, arising from a slight bronchitis, wliich, liowever, 
 gave him very little trouble. On April 21, ISfifi, Dr. D. H. Agnew, Sm-geon to the Pennsylvania Hospital, removed tlie liuib. 
 The abdominal tournitiuet was employed, and by this means the circulation of the abdominal aorta was completely controlled. 
 Tlie nn'tliod of operating was by antero-posterior skin flaps, with circular division of the muscles. The femoral artery was 
 ligated after tlie anterior fiaj) was dissected up. The femoral vein was not included in the ligature. Twenty-one of the smaller 
 arteries required deligiitiim. The disarticulation was accomplished in a minute and a half. Pressure was maintained by the 
 abdominal tourniquet for twenty-seven minutes while the minor vessels were secured. The liipm'orrhage during tlie entire 
 operation did not exceed three ounces, scarcely more than an ounce and ,n, half of which was arterial blood. Ether alone was 
 employed in inducing aua'Sthesia, and about three ounces sufficed, as he inhaled it without effort, and soon came under its 
 iiifiiience. The stumj) was p.acked with lint. The leg, when dr.atned entirely of blood, weighed twenty-two pounds, the entire 
 weight of the body at that time being about one hundred and forty-five pounds. Immediately after his removal to the ward, 
 an enema of half a dnu-lim of tincture of opium was administered, and this was repeated at eight in the evening, when the stump 
 was closed by lead sutiii-es, and dressed with cerate. On the following day the patient had entirely reacted from the slight 
 amount of shock Ibllowiug the ojieratiou. Pulse, which, under agitation from the approaching operation, had been averaging 
 front 100 to 11."), had had fallen to l)(i ; respiration 20 ; skin moist and pleas.-uitly warm. No stimulus; moderate diet, and a 
 drachm of laudanum by enema. On April 23d, he was more comfortable. Had passed a quiet night; had a good ai>petite. 
 A considerable part of the stump had united by first intention, aud tliore was only a little greasy, watery discharge from the 
 inner angle. Dry diessing contiuue'l. On April 2')tli, he was dohig well. Disch.'irge thin and small, and flaps were rapidly 
 uniting. He was ordered four ounces of whiskey daily, and half an ounce of Basliam's mi.xture. Dry dressing continued. 
 April 2.'Jth, no unpleasant symptom, save a rather frequent bronchitic congli. The flaps are united at the middle of the 
 stump; the discharge comes from the angles, and is evidently due to the breaking down of the subcutaneous fat. Laudanum 
 eiiemata were now given twice daily; warm-water dressiiig-s were substituted for the dry ai)plications. April 2(>th, he ate and 
 slejjt well, but was troubled by his cough, which was severe, accompanied by tenacious mucous sputa. The opiate enemata were 
 susjiended, and from I wo to four drachms of solution of sulphate of morphine were given every night ; during the day, a sedative 
 expectorant mixture every tliree hours. The stimulus was not increased. April 27th and 2Sth, steady improvement; cough 
 less troublesome, discharge more purulent, and increased in quantity; warm-water dressing still ap))lied. April 2'Jtli, discharge 
 purulent and (piite abundant, amounting, probably, to three or lour ounces daily. Ajnil :i(ltli. much the same, excepting that 
 the cough was again more troublesome. The union of the Haps was daily becoming more secure, and the discharge iu)W consisted 
 of laudable pus. Four ligatures came away. May 1st, seemed brighter and better than any day heretofore ; ate heartily, stump 
 looked perfectly healthy, discharge moderate; two more ligatures came away. May 2d, condition excellent; the stump was 
 rapidly healing; the skin remained as soft and healthy as on tlic day of operation. Most of the stitches had been cut away. 
 The pulsation of the exti^rual ili.ac artery, which for several days was very marked, had diminished greatly, and seemed as 
 though propagated througli a liiiii clot, lie had been troiilihd eousiihi ably with cough for two days. At midnight, in the 
 absence of llie watchman, lueuioiahage occurred, aud on the rctiiin of the latter the patient was found dead. Upon removing 
 
 ' The Amerirun .hurvil of thr Medknl Sriuico. Vol. 1,11. ]>. 17, .Inly. ISliii.
 
 IN TTTF, WAK OF TIIK RKBKLLTON. 
 
 45 
 
 tliH fli'pssing, it was sopii tliat ii sccomlan- lia-morrliage had taken place. Mos-t of tlie bidciil was rctaini'il eitlicr in tlii> stmn]) 
 of inside tlie dressing; tlie little that had escaped had Howed from the inner angle of the stiniip back nnder the body. Tlie 
 lia'inorrlMge was fonnd to have proceeded from the femoral artery. The most jiowerftd restorative measnres were employed 
 for a long time, bnt witliont prodncing the slightest effect. Upon dissecting the stump, the nnion was fonnd to be compli'te 
 over one-hall' of the entire surface of the ilaps, whilst the deeper portions of the stump were covered with healthy granulations. 
 The femoral vein, whicli was not ligated, was entirely occluded ; the femoral artery was patulous, its iinier coat projecting 
 somewhat beyond the other two ; the inner coat of the artery was deeply stained and roughened for at least one and a quarter 
 inches above the extremity ; higher up it appeared perfectly healthy ; the ligature which had secured the vessel was still attached 
 to a shred of the outer fibrous coat. It had evidently very recently cut its way through, and still retained in its loop the end of 
 the vessel which had sloughed off. Lying immediately in front of the femoral vessels, imbedded in a recent clot, was found the 
 plug which had been driven out of the artery. This was a firm, flesh-colored clot, of the calibre of the vessel, and long enough 
 to reach up to the origin of the deep epigastric niui circumflpx iliac arteries. No positive testimony could be obtained tliat tlie 
 patient had suffered from one of his violent spells of coughing immediately before the accident, as all in the ward were asleep 
 excepting the watchman ; bnt all the appearances render it highly probable that directly after the ligature of the femoral became 
 detached, the violent succnssiim of the diaphragm incident to a paroxysm 
 of coughing had expelled the clot from that vessel. All the other vessels 
 appeared completely obliterated. Only the thoracic and abdominal 
 cavities were examined. The lungs were large, and free from pleuritic 
 adhesions. They were somewhat emphysera,itous, and showed a large 
 amount of pigment over their surface. The anterior portions were 
 anffimic, but posteriorly there was marked congestion of the lower lobes. 
 The heai-t was quite flabby, and moderately dilated. There was no 
 valvular disease or apparent insufficiency, but microscopic examination 
 showed advanced fatty degeneration of the muscular fibres. Tlie liver 
 was also very soft and fatf.y. Kidneys anxniic and pale. Other viscera 
 healthy. The large vessels and heart contained very little blood. There 
 was a small collection of unhealthy purulent matter in the manubrium 
 of the sternum. The limb, upon dissection, showed very great disease 
 of all the soi\ parts between the trochanters of the femur and the knee- 
 joint. The muscles had undergone fatty degeneration ; their slieaths 
 were very much hypertroidiied, and of almost cartilaginous density. 
 Toward the bone there was a thick layer of tenacious colloid bone 
 cartilage, apparently resulting from periosteal disease. Through the 
 dense and morbid mass, fistvdons tracks radiated in every direction, many 
 of them containing small spicule of bone. The bone itself was diseased 
 from the condyles to witliin one and a half inches of the lesser trochanter. 
 The shaft had been fractured obli(iuely, with considerable comminution, 
 and union had taken place by formation of a very large amount of dense 
 bony structure, which projected in spurs and ridges in all directions. 
 The original track of the ball was marked by a deep groove, and one or 
 .two small fragments of lead were found imbedded in the bone. There 
 was a large anfractuous cavity bridged over in places by newly formed 
 bone, which still contained several quite large sequestra. There was 
 incipient periosteal disease along the linea aspera up to the trochanters. 
 A section of the bone showed that if osteomyelitis had existed, it had not 
 extended within several inches of the trochanters. 
 
 M 
 
 :/? 
 
 
 Fio. XVII. Coiistilidated punsliot ti.ujtiiic i 1 Ilu: reiiiui, 
 with secondary lesious. From a phototrniph by Wilhiiil. 
 
 Tlio particulars of the next case were obtained from tlie records of the different military 
 liospitals in which the patient was treated, and from a report obligingly furnished by the 
 operator, Dr William S. Forbes, Surgeon to the Episcopal Ido,spital of Philadelphia, 
 who also contributed to the Army Medical Museum photographs of the patient and of the 
 pathological specimen :''' 
 
 * The case is concisely referred to in Dr. Morton's )ia|» r, Aiiieritian Jouriuil of thr Medical Sck'iitTs. Vol. LII. p. oli
 
 46 
 
 AMPUTATIONS AT THK IIIP-.TOINT 
 
 Case XLV.— Scrtroant lliiaiu IT. Davis, Co. B, ir>fifh Niw York Vdl- 
 niitoei-s, aged twi'iitv-six years, was wounded at tlie battli- nl' ()]ir(|ii:ni. 
 Vir^'inia. on .Scpteiiiber U), 18()4, by a couoidal musket ball, wliii-h i)assi'(l 
 tlii'oiigb the Hesby l)art oi'tbe left thigh, and, entering the other thigh, fractured 
 the ujiper third ol' tlie right femur. He was sent by his regimental surgi'on, 
 Dr. (i. C. !?initb, to the Sheridan Field Hospital, near Wiuebester, where the 
 fracture was adjusted upon a double inclined plane. Tlience he was transferred, 
 on Jlarch fi, 1365, to tlie General Hospital at Frederick, Maryland, which 
 reports the Htsli wound in the left thigh healed, great deformity and shortening 
 of the fi-actnred limb, and eojiious suppuration from fistulous sinuses commu- 
 nieating with necrosed bone. On April 25lh, lie was transferri'd, in a somewhat 
 improved condition, to the Cuyler General Hospital, at Germantown, Penn- 
 svlvaiiia. wlieie no special alteration in his symptoms or treatment is noted. 
 On Mav K th 
 
 he was moved from Cuyler to Mower Hospital, and thence, on 
 October l^th, to the Post Hospital at Philadelphia. The register of the Post 
 
 Fig. X\'III. — Guusbnt friicture of the ri^rlit fennir witli 
 (^reiit shortening :md deformity, l-'roni a iiliotof:Tiii)li 
 1)V Newell. 
 
 ric. .\I.\.— Partial union of irunsliot fme- femur it was found to b( 
 ture of the fenuir. From a I'hotojrrapli 
 l>y Ithoiids. 
 
 Hosjiital states that the fracture of tin 
 fi'mur was consolidated at the date of his 
 admission, and that he was discharged 
 from service on November 8, 1865. In 
 the spring of 1868, Davis was received at 
 the Episcopal (civil) Hospital, in Phila- 
 delphia. The appearance of the injured 
 limb at the date of his admission is indi- 
 cated in the accompanying wood - cut. 
 The right lower extremity was shortened 
 six and a half inches ; there was false 
 ancliylosis of the knee and ankle joints 
 on this side ; extensive cicatrices on the 
 thigh indicated the location of former 
 sloughing ; there were five fistulous canals 
 communicating with diseased boin'; apparently the entire upper portion of tlie femur was 
 necro.sed. On May 5, 186G, Dr. William S. Forbes, Surgeon to the Ho.'*pital. .amputated the 
 limb at the hip-joint. Ether was employed as an aiutstbetic, but it did not act satisfac- 
 torily. The vessels were controlled by the abdominal aortic compressor. An anterior Hap 
 was made by cutting from without inwards, the integument being dissected U]i to form the 
 longer portion of the flap. Then the femoral artery xvas tied; and then the bone was dis- 
 articulated and the posterior flap was completed. The lia;morrhage was estimated at less 
 than eight ounces. The patient rallied bravely fi'om the shock of the operation. On the 
 folhnving. day his condition was promising, and the probabilities of his recovery were 
 regarded as verj' encouraging. Forty-eight hours after the operation the pulse fell, and 
 for about five hours there was great depression. This was followed by a febrile reaction, 
 acconipanied by an erysipelatous blush, which, commencing at tlie outer angle of the 
 wound, gradually involved its entire extent. jViter this the patient sank rapidly, and 
 expired sixty-four hours after the operation, May 8, 1866. On exauiiniiig the injured 
 imperfectly united by fragile masses of callus, which enclosed 
 large fragments of dead or diseased bone. 
 
 Tlio (l(>l:nls dl' tlic I'ullowmg caso Itiive l)oon cominuiiicatL'tl liy the optn-titoi', Brevet 
 Major Henry A. I'iiImus, Assistant Surgeon, U. S. Army. The pathological ])reparation 
 ill this case has been lorwiirded from New Mexico to the Army Medical J\[useiiiii. luit has 
 not yet been received : 
 
 Cask XLVI. — Antonio Mutieres, a Mexican, thirty years of .age, employed by tlie depot quartermaster at Fort Union, 
 New Mexico, was wounded in an altercation with another Mexican, on May 1(1, 1867, liy a couoidal jiistol ball, which entered 
 two inches below the anterior superior spinous process of the left ilium, and passed downwards and lodged in the neck of the 
 left femur at its junction with the head. He was admitted to the Post Hosjiital at Fort Union on May lltli, when As.sistant 
 Surgeon DuBois, Post Surgeon, enlarged the wound and extracted the ball and wadding with a pair of Tiemann's bullet 
 forceps. After the removal of the hall, the linger could be passed half an inch or more into the substance of the cervix, in wliidi 
 the ball had been imbedded. The patient suHered but little pain, but he grmlually lost Hesh and strength from the surgical 
 lever, suppuration, etc. On June 14tli, he began to have .severe pain, running up the side of the trunk and downwards to the
 
 IX TIIK WAR OF THK EEBKLLIOX. 1/ 
 
 knep, wliicli became more i-ontimious and distressing on the succeodiu<.' day. Surgeon J. C. McKee, U. S. Army, Cliicf Medical 
 Officer of the District of New Mexico, now saw the patient in consultation, and advised that amputation should he performed in 
 preference to an excision. At noon, on June 2ad, Assistant .Surgeon DuBois operated, assisted by Dr. Short, of Los Vegas, 
 and Dr. Simpson, of Moro. A rude clamp abdominal compressor had been made at the post under the direction of Dr. DuBois, 
 and this instnunent applied a little above and to the left of the umbilicus efficiently controUeii the aorta. A long anterior and 
 short posteiior flap were made. The disarticulation was completed in fifteen seconds. Eighteen arteries were Hgated. The 
 soft jiarts were much diseased, and there was a large amount of venous ha;nion'hage. A mixture of chloroform and ether was 
 used as an aiiiBsthetic. The patient breathed well notwithstanding the compression of the abdomen. The flaps were left open, 
 a cerate cloth being interposed. In the evening the patient was free from pain and had .slept a little; but he had not reacted 
 satisfactorily, and talked and laughed excitedly. His pulse was at IGO and feel)le. It was fuller and less frequent imnie- 
 <iiately after the operation. Milk punch had been given in small quantities every fifteen minutes. Hypodermic injections of 
 tincture of opium, in doses of fi-om ten to thirty drops, repeated every twenty nunutes or at longer intei-\-als, were now 
 administered. This remedy appeared to bring the jjulse up, and to act as a stimulant and not as a narcotic — a thirajieulic result 
 observed by Dr. DuBois in other cases of shock in using latidaniun by this method. The patient ilied at twentv mimiti's bi^fore 
 six, on the afternoon of Jiuje ;!'.!, 181)7, aliout thirty hours after the operation. At the autopsy the acetalmluni was found to lie 
 extensively diseased. 
 
 EEAMPUTATIONS. 
 
 This cntogory comprises seven cases, with the low mortahty rate of 42. 80 — four 
 patients having recovered. Of the three fatal cases, one died from pytemia, eight days 
 after the operation, and two, worn out by protracted suffering, were unable to support the 
 shock of the operation, and sank in a few hours. In six of the cases the antecedent 
 amputation was done on account of gunshot injuries; in one, for a bayonet stab of the knee. 
 Tlie' latter is placed in this section for convenience sake; yet not in its chronological 
 order, but at the elo.se of the entire series of histories of coso-femoral disarticulations. In 
 six of .the cases the previous amputations were done at the lower third of the thigh on 
 account of injuries of the knee-joint. In one the exarticulation was subsequent to an 
 amputation at the upper third for comminuted fracture of the shaft of the femur. In five 
 cases resections of the necrosed extremity of the femur, or extractions of cylindrical 
 sequestra, were practised in the intervals between the amputations in the continuity and 
 the disarticulations. The shortest interval between the original injury and the disarticu- 
 lation was nine weeks, and the longest three years and seven months ; the average was 
 nineteen months. In the four successful cases the average interval was fifteen months; 
 in the three fatal cases it was two years. In the fatal cases the prior amputations had 
 been primary in two instances; secondary, and at the upper third, in the remaining case. 
 The successful disarticulations followed primary armputation in the continuity in one 
 instance, intermediate amputations in two, and secondary in one. 
 
 The details of the first case are derived from reports from the Camden Street, Balti- 
 more, and Ladies' Home, New York, Hospitals, by Acting Assistant Surgeons John Nefl', 
 E. G. Waters, and J. W. Rolin, and from letters fi-om Dr. Gurdon Buck, and his house- 
 surgeon at St. Luke's, Dr. C. H. Packard:* 
 
 Case XL VII. — Charles H. Hawkins, a second lieutenant in Co. C. 4th New York Cavalry, aged twenty-three yeare, was 
 wounded in a reconnoissance ,i short distance beyond Strasburg, Virginia, on the night of .June 1, 1862. A conoidal ball, from 
 a Colt's cava! IT pistol, entered the posterior surface of the right thigh, and, passing downwards and forwards, fractured the 
 fenun* at the lower part of the middle third, and lodged under the skin about five inches above the knee. The wounded man 
 lay out all night in the rain and in the sun next day until three in tlie afternoon, when he was brought into cam]), and had the 
 ball removed bv his regimental surgeon. He wa.» then conveyed in an ambidance to an hospital in Strasburg. where his limb 
 was dressed witli a straight S])lint, moderate extension aiul counter-extension being maintained After ten d.iys he was carried 
 on a stretcher to a private house, where he remained seventeen days. Two fragments of boue were extracted during this 
 
 ' See rirmJnr No. fi. ."?. C. O.. ISnr,. p. .50, Ca.se 17, and .Imrrp-aii Mnlind Times, Vol. VI, p. la'i, and Vol. VIII. p. 1.
 
 48 
 
 AMPUTATIONS AT THK, IIIP-.TOINT 
 
 piTiocl. ][.• was iic-xt iransfcnvil to a tfiit hospital, five miles distant, near Midilletuwn. and after a sojouni of nine days, was 
 ai;aiii tfaiisferred to an liospital at Winchester, fourteen udles distant. Here the splints were removed, and the lind) was 
 bandao<'d. On July lOtli, he was put upon the cars and was conveyed to Baltimore, and admitted to tlie Camden Street 
 Hospital on July ^Oth. His general condition at this time was very unpromising ; there was mucli irritative fever, a copious 
 .snjipnration. and partial union of the fracture, with three inches shortening and much angular deformity. No apparatus was 
 applied; hut the limh was maintained in an easy position by pillows, and attention was mainly directed to improving the 
 "eneral condition by wliolesome diet and a supporting regimen. Two months subseiiui'ntly the patient had deeideiUy gained 
 ground, and it was determined to undertake an operation to remove the diseased bom? and to break up the faidty union of 
 the fra<nnents. On October 1st. the posterior orifice or wound of entrance was enlarged and a number of denuded fragments 
 of bone were removed by forceps, and tlie deformed callus was chiseled and gouged away. There was a temporary improve- 
 ment after this. The limb was put in a proper position and tlie wound was daily syringed out by iodine injections. After a 
 time, however, it became manifest tluit the broken extremities of the femur were still diseased. On April 5, 1863, the patient 
 was transferred to the Ladies' Home Hos]iital, in Fifty-first street. Now York city, where he was received on April 8th. He 
 was o-reatly reduced in strength ; the wounds discharged profusely, and he complained of mucli pain. On April a9th, Surgeon 
 A. B. Mott. IT. S. ^'ohmteers, amputated the limb at mid-thigh. The results of the operation were not satisfectory. Evidence 
 that the feunu' was disi'ased above the point at which it was sawn soon became apparent, and after a j)rotracted efl'ort to induce 
 healthv action, tlie flaps were freely laid open and the femur was resected, four inches of the sliaft being removed. After tliis, 
 tlie patient was put upon a full diet, with an allowance of brandy and of jiorter daily. The stump still failed to assume a 
 healthy action, but became much enlarged, undergoing apparently a fatty degeneration. On April 4, 1864, Lieut. Hawkins was 
 mustered out of tlic! military service, and was transferred to St. Luke's, a civil hospital, and came under tlio care of Dr. Gurdon 
 Buck. The patient was anoemic. liis appetite capricious; he was comjielled to keep his bed continually, on account of tlie pain 
 he sufl'ered when tlie stump was in a dependent position. For over five montlis every means were used to bring the patient up 
 to a condition in wliich an operation for the removal of the diseased fi'iuur stump, tlie great cause of irritation, might be safely 
 undertaken. At last it was decided that it could not reasonably be anticijiated that he should attain a better condition, and, on 
 September 21st, he was placed under the influence of sulphuric ether, and Dr. Buck proceeded to disarticulate. Tile tissues of 
 tlie stump were indurated and inelastic, and it was found necessary to bisect the stump, uncovering the neck of the bone ou the 
 Inner as well as the outer asjiect, by an incision which commenced above the great trochanter and ran around the extremity of 
 the bone to near the tuberosity of the ischium. During the operation the administration ol ether was suspended on account of 
 the extreme feebleness of the circulation, and brandy was freely given, mid warm applications were made to the trunk. The 
 loss of blood was not great, but every possil)!e means had to be called into requisition to bring about a partial reaction after the 
 operation, so great was the prostration and so feeble the recuperative powers. After twenty-four hours of great ajiparent 
 suft'ering, the patient died in a syncope, September 22, 1864. The portion of the femur removed consisted of the head, neck, 
 and trochanters, with four inches of tlie sluift. The head and neck were mucli softened and the shaft Wiis atroiiliied and fatly. 
 
 1 iVoiii the qUHrtei'ly surgical reports from 
 
 The eh'tiiils of the next case are derivec 
 University liospital, New Orleans :'•' 
 
 Casi-; XLVIII. — I'rivate Lewis Larry. Co. A. 1st New Orleans Volunteers, aged twenty- 
 tliree years, was shot through the left knee by a sentry. .July 17, 1864, while atteui))ting to avoid 
 arrest. He was carried to the Univer.sity Hospital. It was found that the condyles of the femur 
 were badly comminuted. Synovial Ihiid was dribbling from the wound, with hut little liamiorrliage. 
 Amputation at the middle ol the thigh w,is promptly perfin-med, under cliloroform, by double 
 flaps. Tlie patient did well for about tliree weeks, when he was attacked W'ith persistent diarrhcra, 
 to whicli he had been subject. Erysipelas now attacked the stump. Sloughing pbagedicna of tlie 
 Haps ensued, and purulent sinuses extended upwards along the femur, the necrosed extremity of 
 wliich protruded from the stump. It was decided that amputation at the hip-joint afl'orded the 
 only cliance of safety, and. on September 21, 1804, the operation was performed by Acting 
 Assistant .'burgeon F. Hassenburg. The patient being brouglit under the influence of chlorofonn, 
 and put in the usual ])osition for the operation, and the artery being controlled at the groin, un 
 antc^rior flaji was formed by transfixion, the capsule divided and disarticulation effected, and n 
 posterior flap cut from within outwards. The hannorrhage was incfuisiderable. and the patient 
 promptly rallied from the shock of tlie operation. For a few day.s afterwards Ids appetite and 
 general health improved ; then the wound assumed an unhealthy aspect, and finally sloughed. 
 Sym]itonis of ])va'mic infection set in, and death ensued on September iiO, 1864, a week subsecpiently 
 to the disarticulation. On dissecting the j>ortion of the tiiigli that was removed, it was found 
 riddled with abscesses. The periosteum was enormously thickened and contained flaky ossific 
 deposits. The shaft of the femur was necrosed quite up to the trochanters, the dead bone being 
 inchuh'd in a redundant friable involucrum. The preparation w.as forwarded to the Army Medical 
 Museum by Surgeon Samuel Kneeland. V. S. Vidunteers. in charge of University Hospital, and 
 is nnnibered Specimen 3738. 
 
 Fic. XX. — Diseased 
 femur from^ case 
 femcinil disartieiilalid 
 :!7;i»<.A. M. M. 
 
 ' See Circular M. 6, S. G. O., 186r,. p. .50. Case 16.
 
 IN THK UAi;, OK THK RKBKLLIO.V. 
 
 19 
 
 The following rcmurkable case of successful reamputatiou at the hip-joiut has already 
 been brought repeatedly to the notice of the profession.* Some additional details relative 
 to the ulterior history of the case are here given: 
 
 Case XLIX. — Private Ebcn E. Smith, Co. A, lltli Maine Volunteers, aged nineteen yeai-s, was wounded on August Iti, 
 18o4. in one of the engagements following Major General Hancock's movement upou Deep Bottom, on the left bank of .Jalnes 
 River. A musket ball passed tlu-ougli the right leg from within outwards, fracturing the head of the tibia. The wounded man 
 was conveyed to the Field Hospital of the First Division of the Tenth Corps, where it was determined that an attempt should 
 be made to preserve the liml). Constant cold applications were made to the wounds. After a f»nv days the patient was sent to the 
 North on an hospital steamer, and, on August 23d, he was received at the U. S. General Hospital at Beverly, New Jer.sey. On 
 admission, he suffered but little pain though the knee-joint was considerably swollen. On September 14th, secondary ha;inorrhage 
 occurred, and it was deemed advisable to remove the limb. The amputation was performed by Acting Assistant Surgeon 
 J. C Morton, at the lower third of the tliigh, by the circular methoil, the patient being anaesthetised by 
 chloroform. Ou e.Kamiuing the seat of the injury, it was found that a fissure ran through the external 
 
 tuberosity of the tibia and the external articular surface, and that the bone was carious in the vicinity of ' . i, 
 
 the fracture. The preparation was forwarded to the Army Medical Museum by Assistant Surgeon 
 C. Wagner, U. S. A., and is numbered Speciiacii 3709. Tlie case progressed favor.ably until October 17t]i. 
 ■when there was ha;morrha(je from the stnmp to tlie amount of twelve ounces. The stump was in 
 a sloughing condition, .and it was therefore determined to tie the femoral artery in Scarpa's space, wliich 
 was done by Dr. Morton. Tlie ligature came away on November 1st. The wound remained in nn 
 unhealthy condition, with a copious fuelid suppur.Ttion, and the necrosed extremity of the femur protruded 
 from the upper angle of the wound. On November 5th, the soft parts were retracted, and four inches of 
 the shaft of the femur were resected by the chain saw. After this the stump became nuich swollen, 
 frequent abscesses formed, and it was finally decided that necrosis involved the femur quite up to the 
 trochanters. This conclusion was verified hy an exploratory incision made on .January 19, 1865, when . 
 it was determined to proceed at once to amputate at the coxo-fenuiral articulation. The operation was 
 performed by Acting Assistant Surgeon John H. Packard. The patient being already under the influence 
 of chloroform, the fenu)ral artery w,is exposed and tied just below Poupart's ligament. Anterior and 
 posterior flaps were then formed and disarticulation eflected. Some difficulty was experienced in seciu'ing 
 an artery supposed to be the eomes ncrvi iscMadiei; but the quantity of lilood lost in the o])eration was 
 not considered large. There was extreme depression after the operation, and the patient was kejit on 
 the amputating table for two or three days, lest an attemjit at removal should prove fatal. Large quantities 
 of stimulants and concentrated food were administered, and artificial warmth was applied to the surface 
 of the body. Eight days after the operation, haemorrhage to the extent of six ounces occurred, and 
 a ligature was placed upon the external iliac artery by Dr. J. C. Morton. The ligature separated on 
 February 17th. On the 19th, there was profuse bleeding from the point of ligation, which was controlled by pressure. Direct 
 compression was maintained for fourteen days. After this the patient rapidly improved, and by the end of March he was quite 
 well. In April, Mr. Baumgras, one of the artists of the Army Medical Museum, was sent to Beverly, and made a sketch of the 
 patient. From his drawing, revised by Sir. Faber, the accompanying plate has been i)repared. On April 12th, Smith was 
 transferred to the White Hall Hos])ital, near Bi-istol, Pennsylv.-inia. On May 27, 183.'), Assistant Stn-geon W. H. Forwood. 
 U. S. Army, reported his discharge from service with a sound stump and robust health. After his discharge, Smith went to his 
 home at Kastbrook, in Mauie, and was granted a jiension of fifteen dollars a month. On February 27, 1837, and again on 
 March 9th, he wrote to this office that his general health was excellent, but that the cicatrix of his stimip was painful. In Jlay, 
 18G7, he was admitted to the eastern branch of the U. S. Military Asylum for disabled volunteer soldiers, at Togus Springs, near 
 Augusta, Maine. On May 12th, the sui-geon of the asylum, Dr. B. B. Breed, wrote that he " was apparently in pei-fect health, 
 and complained only of congestion of the stump after standing for some time." An attempt was proposed to adapt an artificial 
 limb to the stump. A preparation of the exarticnlated portion of the femur was forwarded to the Army Medical Museum by 
 Assistant Surgeon C. Wagner. It is numbered Specimen 81 of the Surgical Series, and is very well represented in the first 
 fiiiure of Plate VI. The remaining portion of the shaft has become necrosed quite up to the trochanters, and is included in a 
 fragile honeycombed deposit of new bone. 
 
 The abstract of the following successful case is abridged from the history published 
 by the opcrator,t Dr. A. M. Fauntleroy, who has courteously transmitted to this office 
 a photograph of the pathological preparation taken from the case, and also a photograph 
 taken in July, 1866, representing the appearance of the patient and of his stump sixteen 
 months after the operation, when the stump had completely healed. The accompanying- 
 plate is copied from this photograpli : 
 
 I.:. X.\I. Orifice of 
 (r.xit uf ;l inuskut tiail 
 Ihroiigrh the external 
 tul>orositv of the tibia. 
 Spec. 370i). A. M. M. 
 
 * See Circular No. 6, S. G. O., 1865, p. 49; Report of Interestiw/ Surgical Operations, by C. Wsvgner, p. 15; Morton, in 
 Amcriean Journal of the Medical Sciences, Vol. LII, p. 32; Packard, in A'cw York Medical Journal, Vol. 11. p. Uil. etc., etc. 
 t The Uichmond Mrdkul Journal. Vol. I, p. 7. .lanuarv, Irftili. 
 
 7
 
 50 
 
 AMPUTATIOKS AT THE HIP-JOINT 
 
 Case L. — Private K. A. Vick, Co. E, 43(1 North Carolina (Rebel) Infantry, aged tliirt_v-?eveii years, received a gun^i|l(>t 
 wound of tlie knee-joint at tlie battle of Cedar Creek, October 19, 1S64, and underwent primary amputation at the lower tliird 
 of the right thigh. On December 19th he was sent to the General Hospital at Staunton. On Jaiuiary 1, 18fi5, the stump had 
 almost cicatrized, but there were two small apertures through which fu'tid pus issued, amounting daily to four or five ounces. 
 On Feliniary 15, 1865. the daily discharge from the openings had considerably increased in quantify An exploration with a 
 silver jirobe revealed bone denuded of periosteum and much roughened. Another aperture led to a somewhat superficial 
 fistidous track of six or eight inches. It was evident that something must be done for the relief of the patient, and it was 
 deteruiined to open the face of the stump, with a view to the removal of the diseased bone. Tlie operation was performed on 
 Marcii 11, 1865. by the surgeon in charge of the hospital, Dr. A. M. Fauntleroy, assisted by Drs. T. W. Glocker and R. K. Carter. 
 The ])atient took a stimulant, and chloroform was administered. A transvei-se incision was then made over the face of the 
 Btumj). At the e.xposed extremity of the femur was a redundant mass of new bone, which was sawn off. It was then found 
 that the carious shaft of the bone w-as encircled by a soft porous os.seous deposit. About six inches of this formation was stripped 
 off by the gouge, yet the limits of morbid action had not been reached. The carious condition of the shaft was evidently 
 peripheral in origin, as the periosteum was in a state of fatty degeneration, whereas the medullary membrane was comparatively 
 healthy. It was determined to extend the exploration until sound bone was reached. With this view, an incision on the outer 
 side of the Ihigli, between the vastus extemus and biceps, was gradually extended upwards to a point between 
 the great tnichanter and the anterior iliac spine, and revealed the fact that the entire femur was diseased. It 
 was now decided to disarticidate at the hip-joint. The femoral artery was compressed upon the pubic bone, 
 and anterioi- and posterior flajis were fijrmed. the arteries being secured as they were cut. The loss of blood 
 was triHing. The cotyloid cavity was healthy. The flaps were brought together by silver sutures, and the 
 , stump was dressed with dry lint. As soon as consciousness was restored, the patient was fi-eely stimu- 
 lated by whiskey, and warm bricks were applied to the surface of the body ; the patient rallied completely in 
 a tew hours, and drank, during the day, nearly a pint of cream, and ate two soft-boiled eggs. The whiskey 
 was exhibited every half hour during the evening, and every hour during the night. At bed-time his 
 pulse numbered 120 beats. He stated that, normally, his pulse was very frequent and quick. On the following 
 moi-ning the patient was doing very well ; he ate three soft-boiled eggs for breakfast, and batter cakes, and 
 drank nearly half a pint of cream. Pulse still the same in quickness and frequency. He was ordered to take 
 H half an ounce of whiskey every hour during the day. On March 13th, in the evening, his condition was 
 
 l| satisfactory ; his appetite was remarkably good ; he ate during the day seven soft-boiled eggs, batter cakes, 
 
 and drank largely of rich milk. Suppuration having commenced, cold water waS directed to be constantly 
 apfdied to the stump to lessen the secretion of pus. Whiskey was continued in same amount, and at like 
 intervals as on the previous day, and he was ordered twenty drops of the tincture of the sesquichloride of iron 
 thrice daily, and ten grains of Dover's powder at bed-time. Whiskey was only to be given in the event of his 
 waking during the night. Sui)]iuration amounted to half a pint during the day. On Marcli 20, 1865, he was 
 still doing « ell. Suppuration was diminished in quantity and was laudable. Sutures were removed, and 
 adhesive sti-ips used to support the flaps and maintain them in apposition. The patient's bowels had been 
 regular since the operation. His tongue had at no time been furred. On March 26th, the patient had three 
 dejectiims, caused, probably, by imprudence in eating cabbage, for which he had a craving desire. This 
 diarrha'a was cheeked by a pill containing two grains of acetate of lead and half a grain of opium, given at 
 bed-tinu', and repeateil on the 27th. The stmnp was doing well. The discharge had abated to three or four 
 ounces. The patient was very cheerful. Marcli 28th, the progress of patient was highly favorable. In addition 
 Kio..\.\ II. Diseased to the iron, an ounce and alialf of cod liver oil, with an ounce of whiskey, was ordered to be taken an hour after 
 stomp of lemur, p^,.], ,m.;ii, March 29tli. the patient's condition was comfortable and favorable; the cod liver oil agreed with his 
 
 photo 
 prraph sent by Stomacl 
 I>r. Fauntleroy. 
 
 liis appetite contimu'd remarkal)ly good; he ate seven eggs dail}'. The stump along the lower 
 surface seemed to hiive united firmly ; on the side, granulations were healthy ; the pus discharged was laudable. 
 From this time forward the jiatient steadily inqirovcd. Not a single untoward symptom arose to retard recovery. On April 24th, 
 the face of the stump had entirely healed. Tliere w:is still a gr.anulathig sore at the outer angle. On .July IHih, 1865, the 
 patient started for his home, near Tarborough, in Jidgecomb, North Caroliru'i. He was in excelk'ut healtli. aiui h alked about on 
 cratches with facility. A year subsequently he was in Lynchburg, 'Virginia. Since that date no intelligence has been received 
 from him, and it is not known whether he still survives. 
 
 Tlieliistory of the next ease is comjulcd from tlie registers of the military hospitals in 
 wliii'h the patient was treated, from the pnblisiiecl report'-' of the o|)erator, Dr. Thomas G. 
 Morton, and from letters from the patient. Dr. Morton has kindly contributed to the 
 Army Medical Aiuseum a photograj^h of the preparation of the upper extremity of the 
 diseased femur, deposited in the pathological collection of the Pennsylvania Hospital ; and the 
 patient, Mr. Ulmer, has furnished a photograjih oi' himself, taken in September, 1866, seven 
 months subsequently to the operation, in which the condition of the stump is well exhibited: 
 
 • 'J'kc American Journal of the Medical Sciences. 'Vol. LII, p. 27, Jidy. 1866. 
 deseri|ilion of the patient, etc., in Dr. Mortim's report, are corrected in the text. 
 
 A few trilling errors relative to the militarv
 
 IN THE WAR OF THK REBELLION. 
 
 Flii. Will. Comminution 
 of the lower e.\trcniily of 
 the femur by :i musket ball. 
 Spec. 3734, A. M. M. 
 
 C.VSE lil. — First Sergeant Eihviii D. Ulmer, Co. G, loth New Jersey Volunteers, age<l twentr- 
 one years, was wounded at tlie battle of Cedar Creek, October 19, 1864, by a conoidal musket ball, 
 which entered the inner face of the left thigh, fractured the bone, and lodged under the skin on the 
 outer side of the limb. The femur was badly comminuted, fissures extending into the knee-joint 
 and upwards for seven inches. (See Figure XXIIL) There was but little luBmorrhagc at the time 
 of the injury. The ball was readily extracted at the Field Hospital of the First Division of the 
 Sixth Corps, and it was determined to attempt to save the limb. The wounded man was conveyed 
 to Baltimore, and received at Jarvis Hospital on October 24th. The train of s^\'mptoms consequent 
 upon gutishot injuries Implicatiug t!ie knee were soon developed. Intense arthritis supervened, with 
 dee]i dissecting abscesses in the thigh. On November 14th. twenty-six days after the injury, 
 haemorrhage to the extent of twenty-five ounces took place from both orifices, which were in a 
 sloughing condition. The patient was put under ether, and amputation at the middle of the thigh 
 ■was performed by Acting Assistant Surgeon Edward G. Waters, anterior and posterior tlaps of 
 integument being fonned, and the muscles being divided circularly. The patient was very weak and 
 nervous at tlie time, but he rallied promptly at\er the operation and convalesced rapidly, and in a 
 few weeks was able to get about on crutches. Yet the stump continued open and painful, and tlie 
 extremity of the femur was found to be necrosed. In March, 1865, it was found that a 
 cylindrical sequestrum was loose. This was removed on March 8th, by Acting Assistant 
 Surgeon B. B. Miles, with forceps. The patient's general condition rapidly improved 
 after this operation. On May 29, 1835, he was discharged from the service of the United 
 States, the stump still discharging slightly. On the following day, he started for Phila- 
 delphia, and, unfortunately, on the journey he fell with violence upon the stump. After 
 this, there was increased sup])uration, with deep-seated pain in the stump. On the 22d 
 of January, 1866, fifteen months after the original injury, while dressing the part as 
 usual, a hosuiorrhage occurred from one of the fistulous openings at the end of the stump, 
 C'vHnd'ricai !i"iounting, according to his statement, to at least a])int. On account of this hemorrhage, 
 sequestrum |ie was admitted into the Penn.sylvania Hospital. The usual local remedies were applied to guard against its 
 stump..5;)rc. return ; he was put upon a stimulating treatment, w-ith the best diet. The stump presented the following appear- 
 107,A.M.M. ances: The edges of the flaps were ulcerated, inverted, and covered with fungous granulations, which were red, 
 painful, and disposed to bleed on the slightest probing. No examination of the bone was made for fear of exciting 
 hfpmorrhage. On the outside of the stump, which was swollen, sinuses were fouud, the mouth of each being surrounded by 
 puffy, pale, gratmlating tissue. The femur seemed much thickened, could be felt through the integument, and was very ptiiuful 
 to pressure ; but no examination of the bone was made through the fistulous tracks. The head of the femur seemed also 
 involved on account of the pain about the region of the socket, and his inability to allow nmch motion in the joint. He was 
 greatly prostrated from the long continued drain, and lastly from the haemorrhage. The history of the ease, and the present 
 appearances of the stump, clearly indicated the existence of osteomyelitis, with necrosis of the neck, and probably ulceration 
 of the head of the bone. The risk of recurrence of dangerous haemorrhage, and the 
 extensive disease of the femur, obviously demanded operative treatment; the removal 
 of the stuni[) at the coxo-femoral articulation offered the only chance for recovery. 
 The patient's general health improved, and there w^as no further haemorrhage until about 
 the 1.5tli of February, when the discharge again became mixed with blood. On the 
 1' th, in the hospital amphitheatre, before the clinical class, the patient being etherised, 
 an exploratory operation was made. An incision upon the outer side of the thigh 
 revealed a diseased condition of the bone as high as the neck. Amputation was 
 decided upon in considtation with Drs. Hunt and Agnew. The abdominal tourniquet 
 having been applied, antero-posterior integumentary flaps were dissected up; the 
 femoral artery, which was exposed with some difficulty on accoimt of the hardemd 
 and altered condition of the tissues, consequent upon the previous inflammation of tlie 
 soft parts, was then tied. The muscles having then been cut, circularly, close to the 
 pelvis, the head of the bouc was readily disarticulated. The aorta was so conipletel\ 
 controlled by tlie tourniquet of Mr. Syme, that no arterial jet was observed during tl.i 
 operation ; the loss of blood being very trifling, hardly amounting to three ounce.-. 
 About sixteen ligatures were applied. The flaps were approximated with adhesive 
 plaster, no sutures beiug deemed necessary. The subsequent dresi-ings consisted of 
 lint soaked in pure laudanum, until the parts had almost healed, when simple cerate 
 dressing was substituted. The patient was much prostrated by the operation, but 
 reacted well. The discharge was very profuse ; and during the first week the edges of 
 the flaps appeared a little sloughy. Under vigorous stimulating treatment and the 
 local ajiplication of permanganate of potash in solution he rapidly recovered. No 
 other unfavorable symptoms having occurred, and the ligatures being idl away by the i^nd of the second week, two small 
 openings in the stump alone remaining, he loft the hospital March 27tli, tliirty-eight days aft^'r the operation, for bis home in 
 
 Fig. XXV. Mr. .Syme's Abdomiiuil Comprcs- 
 aor, as made by Kolbe.
 
 52 
 
 AMPUTATIONS AT TITK IIIP-JOINT 
 
 
 \ 
 
 w^- 
 
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 w'-' 
 
 A' 
 
 1 
 
 
 
 Ml 
 
 i 
 
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 Fin.XXVI. 
 
 Necrosi 
 
 
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 t'ciiitir 
 
 n.llouinff 
 
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 ■iteo- 
 
 invclit! 
 
 IS. 
 
 From ; 
 
 tl'l 
 
 H)tO- 
 
 irnil'h 
 
 '■y 
 
 \Vlll:ml. 
 
 
 ill,' iinillicni scitioii <>i' thf city. Tlio (.■xtirticiilnti'il portion ol tlir fi'iiinv |nv«'iit.il :i iliaracti'i-istic 
 ix:iiii]ilc oi' iH'i-rosis following osteoiiiyi'litis. A long, loosr s^ccjiu-striini was loiind I'ncasecl in a new 
 (li-posit of jiorous bone, and was not limited to the diapliyfis. l.iit ixfendid (juite into tlio necli, and then 
 projected tliroiigh the ulcerated capsular ligament. The head of the femur was ulcerated. The 
 acetaliuUnn was liealtliy. On Way ll'tli, the patient wiis aide to get about town on crutches. On the 
 tillth. he left for New Jersey to fill a sitnation as telegraph oiierator. On July a4th, he sent a letter to 
 this office from Jlilford. New Jersey, announcing that his health was excellent, and a few weeks 
 suhseiiuc-ntly he corroborated this statement by transmitting his pliofogi-apb. On October 27, 18B6, 
 he was supidied with an artificial limb by CTem<'r.t. of Philadelphia. On June 28, Ibfi", Mr. Ulmer 
 wrote to this ofiice that he had never had a day's illness since the hip-joint amputation was performed, 
 and had never been in better health than then. lie was stouter than ever before, weighing one hun- 
 dred and seventy-five pounds, or twenty-five more than his average weight when he had botli lower 
 extremities. His stump was firm and solid and gave him no pain or inconvenience. He considered Ins 
 artificial limb an excellent one, and coulil walk on it " right well," but found it inconvenient at his work, 
 which reipiired bini to sit all day on a high stool. 
 
 Tlie following history, commnnicat(-(l by the operator. Dr. James B. Whitcomb, of 
 Ijrooklyn. ('oiiiu'eticiit, formerly Surgeon 11th Connecticut Volunteers, relates to the case 
 ol' a cam)i lolltiwcr, a sutlers clerk: 
 
 Cask LII. — Henrv C'ani]iliell, .iged t-.vcnty- three years, received, in March, 18G3, at New Orleans, a ))istol shot in the left 
 knee. Primary amputation .at the junction of the middle and lower thirds of th(! thigh was performed by Acting Assistant 
 Surgeon Averv. The stump did not do well. Osteomyelitis sujiervemcl and resulted in necrosis. After a few months the 
 jiatient was removed to his home ii: ('onnecticut. In October, 18()4, eigl.tetn months sulisequent to the injury, lie was visited by 
 Dr. liauer, of New York, who laid open tlie cicatrix, crowded with fistulous opeiungs, and removed a cylindrical sequestrum five 
 inches in length. For a few months after the removal of this sequestrum the general health of the patient imjiroved, and hope 
 was entertained of his recovery without fu'ther operative interference; but persistent pain and constituti(mal disturbance then 
 recurred with augmented intensity. The lower part of the stmnp was riddled with siinises and the tissues w-ere nuich indurated. 
 The probe detected deail bone, or morbid bone forr.fttion, in every direction. This state of things became gi'adiuvUy woi'se, and, 
 after a ])rotraeti'd ridiance upon the reparative powers of nature, in October, 13(;G, the medical attendants resolved that an 
 oi>eration should be performed for the radical removal of the diseased bone. It was hoj)ed that it \vould be only lu'cessary to 
 remove a portion of the shaft of the femur. On October 2-M, the patient was placed uiuler the iutiuence of chloroform, and Dr. 
 Janie.s H. Whitcomb, assisted liy Dr. t'harles ISliss, of Willimantic, and others, proceeded with the o]ieration. An exploratory 
 incision was made on tlu' outside of the thigh, extending quite up to the frochantei'. On eximsing the new osseous formation at 
 the end of the stump, it was found to be more than twice the normal diameter of the shaft of the fenmr, rough, porous, and 
 fragile. The immensely thickene<l ]ieri<isteum was studded with plates and spines of ni'w boiu', and in many cases there were 
 foliaceous masses of callus unconnected w ith the shaft. Towards the upper extreuuty of the fennn- the periosteum appeared 
 less diseiised, but the bone was toiuid to be softened an<l disorganized quite uj) to the great troidianter. Taking the previous 
 history into consideration, it was thought unreasonable to anticipate recovery, or even temporary improvement, without the 
 removal of the diseased bone, and it was therefore decided to amimlate at the liiji-joint. The ],iatient had thus far inhaled 
 chloroform Ether was now substituted. Pressure with the thumb on the femoral artery served to control tlie h.X'morrhage. 
 A large antero-internal fla)) was formed and disarticulation eflcctcd. Tliere was very little loss of blood, liiit the patient was 
 greatly prostrated by the shock of the oiieration, which, from the beginning of the exjiloration to the completion of the 
 amputation, lasted fif^y minutes. The free adHiinistration of ammonia and brandy brought about reaction ; but it was temporary, 
 and the ca.sc terminated fatally, five hours after the operation, October 22, IHfifi. 
 
 Till' last case to be recorded is distinguished from all that litivc ])rec('ded. liy the fact 
 that it was not a case of gunshot injury. The first amputation was performed on account 
 of a bayonet wound of tht^ knee. The history of the case has alreatly been published 
 several times.''' 
 
 Cask LIU. — Private Lewis Francis. Co. I, 14th New York Militia, aged f(Uty-tW() years, was wounded .luly 'Jl. 1801. at 
 the first battle of Hull Knn, by a bayonet thrust, which ojjened the right knee-joint. He rt^ceived not less than fourteen other 
 stabs in different parts of the body, none of them imi>licating the great cavitiis. lie was taken prisoner, aiul conveyed to 
 
 * See Cirniliir A'n. (i. S. G. O., 1835, p. 49. and Hamilton's TrmlUe on MUitary Surt/ery, yi. 629.
 
 IN THE WAR OK THP: REBELLION. 53 
 
 Ricliniond and phiccd in hospital. Oni- of liis wounds involved the left te.stis. whicli was removed on July 24th. On October 
 28, 18(51. his right thigh was amputated at the middle, on account of disease of the knee with abscesses in the thigh. The 
 riouhle-tlap method was employed. The stump became inHamed, and the fenmr protruded. An inch of the hone was resected, 
 and the flaps were again brought together. In the spring of 18()2, the patient was exchanged and sent to Fort Monroe. Thence 
 he was transferred to a Washington hospital, and tlience, in March, 1802, to his liouie in Brooklyn. There was necro.sis of the 
 femur, and in May, 1862, its extremity was again resected by a civil surgeon. On October 28, 18fi3, Francis was admitted to 
 the Ladies' Home Hospital, New York. Necrosis had apparently involved the remaining portion of the femur. On May 21, 
 1664. Sunieon A. B. Mott, U. S. Volunteers, laid open the Haps and exarticulated the bone. The patient recovered rapidly and 
 liad a sound stump. He was discharged August 12, 1864. On October 1, 186.5, the photograpti from which the accompanying* 
 plate is copied was taken, and forwarded by Surgeon Mott to tlie Army Medical Museimi. Dr. Mott reported that the 
 |iathological specimen of the exarticulate<l femur was stolen from Ids hospital. For some months after his discharge Francis 
 enjoyed good liealth ; but then the cicatrix became unliealthy, pus was discharged through several sinuses, and there was 
 bleeding from the slightest irritation. In March, 1807, a messenger was sent to his residence, 54 Hamilton Street. Brooklyn, 
 and found him in very poor health. He had been unable to leave the house since November, 1860. On April 12, 1807, he was 
 visited liy Dr. E. D. Hudson, wlio reported him as then confined to his bed. There was a large ulcer at the upper outer angle 
 of the cicatrix, which comnnmicated witli extensive sinuses ; there was a fistula-in-ano also. The pus from the different 
 fistulous orifices was tliin, oily, and ichorous. There could be little doubt tliat there was disease of some portion, of the 
 innomiuatum. The patient was much emaciated, and had a cough \vith muco-purulent exjjectoi-ation. His pulse, however, was 
 not frequent, and he had a good appetite. In May, 1867, it was reported that his general condition had somewhat improved. 
 
 The seven foregoing cases, and Gutlirie's Ciucbid Rodrigo case,f are the onl}M-ecorded 
 examples, it is beUeved, in military snrgery, of amputations at tlie hip-joint succeeding 
 previous amputations in the continuity of the thigh. But in the records of the surgery 
 of civil life a number of similar cases are found, and it seems very proper to compare 
 these with the cases in military surgery. For amputation at the hip-joint, where the 
 thigh has been already amputated in the continuity for gunshot injury of the knee-joint 
 or lower portion of the femur, is required by such complications as osteomyelitis, or 
 necrosis, or uncontrollable haemorrhage, or gangrene; and these are precisely the causes 
 which demand disarticulation in civil practice, where the thigh has been already 
 amputated for disease or injury. It is probable that there is a greater liability to 
 osteomyelitis in amputations for gunshot fractures ; but this is balanced by the fact that 
 in civil practice the operation is sometimes necessitated by the recurrence of the malignant 
 disease for which the first operation was performed. 
 
 Samuel Cooper adverts to the successful amputation at the hip-joint by Sir Astley 
 Ooopei'l for disease of the higher part of the femur, with the remark that, as tliis patient 
 had formerly suffered amputation at the thigh, the operation was certainly unlike "the 
 sudden removal of nearly a quarter of him;" but he "cannot presume to say what 
 diflei'ence in the chances of success, and whether any, would be connected with this 
 circumstance." He adds that "the same remark ajjplies to a case lately under ^Ii-. ]\fayo 
 when the patient, a young woman, recovered. The proceeding was- adopted on account 
 of the agony experienced by the patient from a neuralgic affection of her stump." But 
 at the present day it is possible to say, without presumption, that the circumstance to 
 which S. Cooper alluded makes a very great diiference in the chances of success; and, 
 
 * Several of the cases illustrated by plates comi^ together so closely in the text that it has been decided to bind all the plates 
 at the end of the report. 
 
 t The patient. Trivate Mason, 23d British Infantry, or Welch Fusileers, had his thigh amputated at the iiu<ldle at the siege 
 of Ciudad Rodrigo, and was sent to the divisional lio.spital at Aldea del Obispo. Here the stump slougluul. and there was 
 imcontrollable secondary hicmorrhage. Guthrie amputated at the hip-joint, with the assistance of Dr. C'artan and Mr. Loane. 
 The patient survived the operation seven hours. A Treatise on (xnnshot Wounds, by G. J. GUTIIUIIC, F. M. i^. Thiid Lonilon 
 edition, p. 332. 
 
 t Dicttonari/ of PraHkal Surgery. 8th London edition. Vol. I, p. 117.
 
 54 AMIUTATIONS AT THK HIP-JOINT 
 
 latterly. Or. S. D. Gross/ Dr. W. H. Van Burcnr and Dr. J. H. FackarcF luive onipliaticall}- 
 insisted on the less danger of amputations at the hip-joint eiiected after tlie previous 
 removal of a portion of the limb lielow. Professor Gross enumerates eiglit cases, including 
 that of Guthrie. Dr. Packard recapitulates these cases, cites liis own operation, and 
 quotes Fayrer's successful, but not his unsuccessful case, and makes out a very favorable 
 exhibit for this class of operations.^ 
 
 Ten cases are on record of disarticulations at the hip-joint after previous amputation 
 of the thigh in its continuity for disease or for injuries received in the accidents of civil 
 life. The operators were Astley Cooper^^ Mayo,® Cajetan Textor,^ lh\ W. 8. Cox,^ Mr. 
 Syme,'' Dr. W. H. Van Buren,!" J. C. Bradbury," Dr. J. Fayrer.^" ^Ir. Hancock," Dr. 
 J. Fayrer." Eight of these patients recovered and two died, a mortality rate of 20. only. 
 Grouping these ten cases with the seven reamputations at the hip-joint of the war of the 
 rebellion and with Guthrie's Giudad Rodrigo case, a series of eighteen examples of 
 removal of thigh stumps by amputation at the hip-joint is obtained, with twelve recoveries 
 and six deaths. 
 
 For convenience in reference, I here insert a tabular statement of the fifty-three 
 amputations at the hip-joint described in this report, together with those of the one 
 hundred and eight previously recorded hip-joint amputations in military surgery of which 
 some details have been published. 
 
 ' A Si/stem of Surr/enj. 3fl edition. Philadelphi.T, 1.8(54. Vol. II. p. 1040. 
 
 - Contrlhutions to PraHkal Siiri/cri/. Pliiladelpliia, 1865, p. 10. 
 
 "Neio Tori- Medical Journal. Vol. II, p. 161. 
 
 ■•PaCKAKD, loc. cit. Dr. Packanl obsorviis that \iv kiiow.s of Guthrie's case only tliroiigli Professor Gross's tpiotation. 
 
 " In 1824. See Lancet. Vol. II, 1824, p. 98. 
 
 " In 1835, for neuroma. CosTELLO, Cyclopadia of I'ractical Suri/cri/, Vol. I, )). 182, and S. Cooi'Ei;, loc. cit., ]). 117; 
 anil DiitMTT'.s Surf/eon's Vade Mecum, 9th London ed., p. 777. 
 
 ' In 1841, for gangrene. Gazette Medicalc de Paris, Sept. 4, 1841. 
 
 ^ In 1844, in the case of a woman aged 23 years with carcinoma. Memoir on Amputations of the T]n>jli at the Hip-Joint. 
 liondon, 1845. 
 
 "In 1818. London and Edinhnriih Monthly Journal, ISM. and Medical Times, 1819, p. 2.''>2. This was the Hi'st siiccessfnl 
 amputation at the hip-joint in Scotland. 
 
 '"In 18.50. Contriliution.i to I'ractical Surf/ery. Pliiliulelpliia. 18115. p. 10. 
 
 " In 1851, on a sci-ofnlons hoy 10 years of age. Boston Medical and Surgical Journal, Vol. XLVI, 18,52, ]). 349. 
 
 '- In 1853. FAVliKit'.s Clinical Surf/ery in India, p. 0(59. London, 18ci!5. Case of Isliniael Hadji, aged 3(5 years. 
 
 1= In 1860. London Lancet, ISm. Vol. I, p. 319. 
 
 "In 1864. Fayuer, op. ««., p. 609. Case of Shaikh Asglmr, aged 16 years.
 
 IN MILITARY 8UEGERY. 
 
 PRIMARY AMPUTATIONS AT THE HIP-JOINT IN MILITARY SURGERY. 
 
 No. Date. 
 
 Operator. 
 
 D. J. Larrey... I A soldier of the 
 Freuch Army of 
 the Rhine. 
 
 D. J. Larrey. . 
 
 D. J. Larrey. . . 
 
 D. J. Larrey... 
 
 Bonhonime, oflicer 
 of the 18th Demi- 
 Brigade, Army of 
 Egypt. 
 
 DruDinier of Second 
 Light Demi-Brig- 
 ade, Army of 
 Egypt. Age 20 
 years. 
 
 A Russian soldier. 
 
 D. J. Larrey. . . 1 Lieutenant of Dra- 
 goons, of the 
 French Army of 
 inva^ijon of Rus.sia. 
 
 cs^diUot.- 
 
 A Swiss subaltern. 
 
 A Russian prisoner. 
 
 Gunshot fracture of 
 femur. 
 
 Fracture of the trochanter 
 of the right femur by a 
 fragment of a bomb-shell, 
 with, division of the fem- 
 oral artery and great lacer- 
 ation of the soft parts, at 
 St. Jean D'Acre, SjTia, 
 April or May, 1790. 
 
 Right thigh torn ofl' by a 
 shell. Femur fi-actured 
 quite into coxo-femoral 
 articulation. Great pros- 
 tration from haemorrhage. 
 May 19, 1799. St. Jean 
 D'Acre. 
 
 Left femur shattered by a 
 cannon ball. Two-thirds 
 of the thickness of the soft 
 parts of the thigh were 
 torn away. Witepsk, July 
 29, 1812. 
 
 A five-pound cannon ball 
 shattered the great tro- 
 chanter and neck of the 
 femur ; femoral artery un- 
 injured, muscles terribly 
 torn. Borodino, Septem- 
 7, 1812. 
 
 Gunshot wound of the thigh 
 with fracture of tlic tro- 
 chanter iniOor. July 29. 
 1830. 
 
 Gunshot fracture of the 
 neck of the right femur. 
 Poland, 1831. 
 
 Operation. 
 
 Larrey's method. 
 External and 
 internal flaps. 
 
 Larrey's method. 
 Preliminary li- 
 gation of the 
 femoral. 
 
 Larrey's method. 
 
 Larrey's method. 
 
 Larrey's method. 
 
 Died within a 
 week. 
 
 Liitenil flaps.. 
 
 Oval method of 
 Comuau. 
 
 Died of the 
 plague on the 
 eighth day. 
 
 Died in the re- 
 treat a few 
 days after the 
 operation. 
 
 Died on the 
 twenty-ninth 
 day from dys- 
 entery. 
 
 Remarks. 
 
 He did well for several hours, and 
 Larrey thought that a forced 
 march of twenty-four hours in 
 inclemi?nt weather induced the 
 fatal termination. Mcmoiresde 
 Chiriirgit Mih'taires ct Cam- 
 pagnes, par D. J. Lakhey. 
 Paris, 1812. Tome U, p. 180. 
 
 Union by first intention nearly 
 complete on the si.xth day. 
 Relation ChirurgicaU de 
 VATmce d'Orient, par D. J. 
 Larrey. Paris. 1803, p. 329. 
 
 Relation Chirnrgicale del' Armce 
 d'Orient, par D. J. Larrey. 
 Paris, 1803, p. 332. 
 
 Mcmoires de Ch irurgie Militaire 
 et Campagnes. Paris, 1817. 
 Tome ^\^ p. 26. 
 
 Never reached , Was moved to Kolloskoi and then 
 to Witepsk and Orcha, and said 
 to have been seen at Witepsk 
 by M. Bachelet three months 
 after the operation; also said to 
 have been seen at Orcha per- 
 fectly cured. Mem. de Chir. 
 Mil. et Camp. I'aris, 1817. 
 Tome rv, p. 50. 
 
 Died on the day 
 of the opera- 
 tion. 
 
 Gazette dcs HOpt'taux. 
 p. 392. 
 
 1831), 
 
 Died very soon i Annates de la Ckirurgie Fran- 
 
 after the oper- 
 ation. 
 
 f^aise et ^tranghre. Tome II, 
 1841. p. 279. Skdillot, Traitc 
 dc Mcdccine Opci-atoire, Tome 
 I, p. 455.
 
 56 AMPUTATIONS AT THE HIP-JOINT 
 
 PRIMARY AMPUTATIONS AT THE HIP-JOKT IN MILITARY SURGERY'— Continued. 
 
 No. Date, 
 
 12 
 
 1836 
 
 1853 
 
 l.\JLKY. 
 
 I 
 
 A French cunnonier Comminuted fracture, es- 
 
 of the lltli Uejrj- tending to within an inch 
 
 nient of Artillery. 
 
 F. Ilutin. 
 
 SU»»,»., a soldier of 
 the 1st Lipht Bat- 
 talion. 
 
 L.^,1*,, 2d Regfiment 
 of Enf!;ineers. 
 
 X.,j*Y, fi soldier of 
 the 18tli French 
 Light Infuiitry. 
 
 Dr. Lente John l);ilzell, aged 
 
 23 years. 
 
 J. Fayrer. 
 
 1854 
 
 ie54 
 
 18 1855 
 
 Thomas Alex- 
 ander. 
 
 Sloung Schw6-SIo, 
 a Burman, aged 
 3U years. 
 
 A Russian prisoner. 
 
 Thomas Alex- 1 A private of the 33d 
 andor. British Infantry. 
 
 Dr.UichardMc- 
 Konzie. 
 
 Asst. Surgeon 
 Wyatl. 
 
 Puulct Soldier, 
 
 Soldier. 
 
 An officer of the 
 Coldstream Guards. 
 
 19 ' 1855 Lustrcrnan. 
 
 UI'EUATION. 
 
 of the great trochanter of 
 the left femur, by a cannon 
 ball, accompanied by great 
 laceration of the integu- 
 ments and muscles ou the 
 outer aspect of the thigh. 
 Antwerp, Dec. 13, 1832. 
 
 Fracture of the uet-k of the 
 left femur by a musket 
 ball. Constantine, Africa, 
 December 3 1^36. 
 
 Fracture of the upper ex- 
 tremity of the left femur 
 by a musket ball. Con- 
 stantine, Dec. 4, 183(5. 
 
 Wound of the upper third of 
 the thigh by a musket ball 
 comminuting the great 
 trochanter and upper por- 
 tion of the femur. June 
 27, 1848. 
 
 Compound fracture of cer\'ix 
 femoris by a musket ball. 
 Astor Place Riot, N. Y. 
 Blay 10, 1R49. 
 
 Fracture of the left femur 
 through the neck and tro- 
 chanters, by a slug from a 
 musket. Rangoon, Ben- 
 gal, February 15, 1853. 
 
 Gunshot fracture of the 
 femur. Alma, September 
 20, 1854. 
 
 Gunshot fracture of the 
 femur. Alma, September 
 20, 1854. 
 
 Gunshot fracture of the 
 femur. Alma, September 
 20, 1854. 
 
 Gunshot fracture of the 
 thigh, together with Bev- 
 oral bayonet wounds. In- 
 kerman, Nov. 5, 1854. 
 
 Gunshot fracture of the 
 femur. 
 
 Gunshot fracture of the 
 fenmr, the patient in ex- 
 tremis. 
 
 Internal flap and 
 short posterior 
 flap. Prelim- 
 inary ligation 
 of the femoral. 
 
 Died Dec. 22, 
 1832. 
 
 Manec's method. Died Dec. 13, 
 1836. 
 
 Manec's method. 
 
 Single 
 flap. 
 
 Lateral flaps.. 
 
 Antero-posterior 
 flaps. 
 
 Died Dec. 
 1836. 
 
 Died June 28, 
 1848. 
 
 DiL'.l May 1:.', 
 1849. 
 
 REMAItKS 
 
 The patient did well till the 20th 
 of December, when he was 
 moved in au ambulance to 
 Boom. The next day the 
 wound looked badly and the 
 patient rajiidly sank. H. LaR- 
 RET, Hist. Chir. du Siege de 
 la Citade.lle d''AnvieTS. Paris 
 1833, p. 307. 
 
 liecueit de Mcm.de Med. d^ Chir. 
 et de Phar. Mil. le s6rie. 
 Tome XLIV, p. 219. 
 
 Recueil de Mem. de Med. de Chir. 
 et de Phar. Mil. Tome XLIV, 
 p. 220. 
 
 BaUDF.NS. Des Plaies d'Armes a 
 feu, dans Rtc. de Mcm.de Med, 
 de Chir. et de Phar. Mil, 2e 
 serie. Tome X, p. 130. 
 
 JVniisartions American Medical 
 Association. Vol. IV, 1848, 
 p. 316. 
 
 Died March 17, FAYKi-ut's Clinical Surgery in 
 1853. India. London, 1866, p. 630. 
 
 Died October 
 
 20, 1854. 
 
 Died October 
 
 11, 1854. 
 
 Died within 
 t wen ty -four 
 hours. 
 
 Died imme- 
 diately after 
 the4)j)eration. 
 
 Di(Hl in tine hour 
 after the oper- 
 ation. 
 
 Died five hours 
 after the oper- 
 ation. 
 
 IjONomoue, in Holmes's Sy.ttem 
 of Surgery, London, 1 861. 
 Vol. II, p. 82. 
 
 LONnsiOUE. Loco citato. 
 
 MACLEOD. Notes 0)1 the Surgery 
 of the ^far in the Crimea, 
 p. 369. 
 
 Military Med. Hist, of Cold- 
 stream Guards, in Med. and 
 Surg. Hist, of British Army 
 in the Crimea. Vol. I, p. 111. 
 
 ChenU. Rapport Med. Chir. 
 
 sur la Camp, d' Orient, p. 661. 
 
 CIIENU. Rapport Med. Chir. 
 sur la Cam]), d' Orient, p, 661.
 
 IN MILITARY SURGERY. 
 PRIMARY AMPUTATIONS AT THE HIP-JOINT IN MILITARY SURGERY— Conlliimd. 
 
 57 
 
 20 
 
 1855 
 
 1855 
 
 22 
 
 1855 
 
 23 
 
 1855 
 
 Operator. 
 
 Patient. 
 
 Franklyn . 
 
 Soldier . 
 
 Soldier . 
 
 A private of the 32d 
 French Infantry. 
 
 A private of the 77th 
 British Infantry. 
 
 Injury. 
 
 Gunshot 
 femur. 
 
 friirture of the 
 
 Gunshot fracture of 
 femur. 
 
 Comminuted fracture of the 
 left femur through the tro- 
 chanterB by a portion of 
 the percussion cap of a 
 shell, which was found 
 embedded in the bone. 
 Wound of left leg with 
 fracture of the fibula. 
 July 4, 1855. 
 
 Comminuted fracture of the 
 femur, extending nearly 
 the whole length of the 
 shaft and into the capsule 
 of the hip-joint. Sevasto- 
 pol, August, 1855. 
 
 Operation. 
 
 Remarks. 
 
 Died five hours Chenu. Rajyport Mid. Chir. 
 after the ope- stir In Camj). iVOrimt, p. (Jfil. 
 ration. 
 
 July 4, 1855, at 
 the Carenage 
 ambulance' sta- 
 tion. 
 
 24 
 
 25 1855 
 
 Dr. Dunlop --- 
 
 Surgeon Major 
 Trousdell. 
 
 Dr. McLean - 
 
 A soldier of (he 88th 
 Regiment, Con- 
 naught Rangers. 
 
 Private of 50th Brit- 
 ish Regiment. 
 
 18fi2 
 
 18(i2 
 
 Dr. Yandell.... 
 
 Dr. Gilmore. 
 
 1862 Dr. Gilmore. 
 
 Private of 99th New 
 York Volunteers. 
 
 Rebel soldier . 
 
 Fracture of the femur by Double-flap ope 
 
 Died eleven 
 hours after the 
 operation. 
 
 Died in ono or 
 two days. 
 
 Chenu. Rapport Mvd. Chir. 
 sur la Camp. d'Oricnt, p. *5(J1. 
 
 Cmenu. Rapport Mid. Chir. 
 sur la Camp, d' Orient, p. 660. 
 
 Private Williamson, 
 13th Mississippi 
 Regiment. 
 
 Private of 18th Mis- 
 sissippi Regiment. 
 
 a splinter of shell. 
 
 Coniminulion of the upper 
 third of the thigh to the 
 neck, with great lacera- 
 tion of soft partfl, by a 
 round cannon-shot. Se- 
 vastopol, 1855. 
 
 Comminution of neck and 
 trochanters of left femur 
 by a piece of shell. Naval 
 battle at Newport News, 
 March 9, 18(i2. 
 
 Gunshot fracture of the 
 upper extremity of the 
 left femur. Sbilob, April 
 7, 1862. 
 
 Guuahotfiucture of the right 
 femur by a conoiilal mus- 
 ket ball. Near Seven 
 Pines, June 4, 1662. 
 
 Gunshot fracture of the left 
 femiu". Malvern Hill, July 
 1, 1862. 
 
 ration. 
 
 Double-flap meth- 
 od. 
 
 Lateral double- Died in 
 tlap method. hours. 
 
 Died twenty- 
 two hours 
 after the ope- 
 ration from 
 exhaustion. 
 
 Died soon after 
 the operation. 
 
 Died the day of 
 thfojieriifion 
 
 Antero - postf rior 
 flaps. 
 
 Antero - posterior 
 flaps. 
 
 Died in seven 
 hours. 
 
 Was sent to Mis- 
 sissippi in six 
 weeks, his 
 stvuiip hfialod. 
 
 Died in one 
 
 hour 
 
 Military Medical Hist, of 77th 
 Regt., in Med. and Surg. Hist. 
 of the British Army in the 
 Crimea. Vol. I, p. 377. 
 
 Military Medical Hist, of BBth 
 Regt., in Med. and Surg. Hist. 
 of the British Army in the 
 Crimea. Vol. 1, p. 403. 
 
 The Surgeon's Vade Mecum : a 
 Manual of Modern Surgery. 
 By ROIJERT DRUirr. 9th 
 London ed., 1865, p. 160. 
 
 Circular No. 7, War Department, 
 Surg. General's Office, Wash- 
 ington, July 1, 18G7, p. 24. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 24. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 24. 
 
 Circular No. 7, AVar Department, 
 S. <;. O., Washington. July 1. 
 1867, p. 2.1.
 
 58 AMPUTATIONS AT THR HIP-JOINT 
 
 PRIMARY AMPUTATIONS AT THE HIP-JOINT IN MILITARY SURGERY— Continued. 
 
 No. Date. Operator. 
 
 Patiest. 
 
 INJL-RT. 
 
 Ol'EKATlON. 
 
 Result. 
 
 Remarks. 
 
 30 
 
 1862 Dr. Ciilniore 
 
 Priviile of 21st Mis- 
 
 Gunshot fracture of the tro- 
 
 Antero • posterior 
 
 Died in two 
 
 Circular No. 7, War Department, 
 
 
 1 
 
 sissippi Regiment. 
 
 chanters and neck of the 
 left femur by a conoidal 
 musket balL Malvern 
 Hill, July 1, 1862. 
 
 flaps. 
 
 daj's. 
 
 S. G. 0., Washington, July 1, 
 1867, p. 25. 
 
 31 
 
 1862 Dr. Couiptoii .. 
 
 A I,ientenant of an 
 
 A cannon ball struck the 
 
 Single flap 
 
 Died in eight 
 
 Circular No. 7, War Department, 
 
 
 
 
 Arkansas Regi- 
 
 right hip and shattered 
 
 
 days. 
 
 S. G. 0., Washington, July 1, 
 
 
 
 
 ment. 
 
 the upper extremity of the 
 femur. Corinth, October 
 3, 1862. 
 
 
 
 1867, p. 25. 
 
 :)2 
 
 1862 
 
 Dr. (;r;iiit 
 
 liebel soldier 
 
 Gunshot firacture of the 
 
 Lisfmnc's method. 
 
 Probably died.. 
 
 Circular No. 7, War Department, 
 
 
 
 
 femur by round ball and 
 
 
 
 S. G. O., Washington, July 1, 
 
 
 
 
 
 buckshot passing directly 
 
 
 
 1867, p. 25. 
 
 
 
 
 
 through the thigh. Octo- 
 
 
 
 
 
 
 
 
 ber 19, 1862. 
 
 
 
 
 33 
 
 1863 
 
 Dr. Coiiiiiton . . . 
 
 Private Robinson, 
 
 A fragment of a 34-poaDder 
 
 Antero - internal 
 
 Was in good 
 
 Circular No. 7, War Department, 
 
 
 
 
 Louisiana (Rebel) 
 
 shell buried itself in the 
 
 flap. 
 
 health six 
 
 S. G. 0., Washington, July 1, 
 
 
 
 
 Kegiment,age 35. 
 
 upper part of the left thigh, 
 smashing the trochanters 
 and neck of the femur. 
 Batterj' Pemberton, Mar. 
 13, 1863. 
 
 
 months after- 
 wards, and 
 probably ulti- 
 mately recov- 
 ered. 
 
 1867, p. 26. 
 
 34 
 
 1863 
 
 Dr. i'^hipiten . . . 
 
 Private Jas. Kelly, 
 
 Gimshot firacture of the up- 
 
 Single anterior 
 
 Recovered. 
 
 Circular No. 6, War Department, 
 
 
 
 
 56th PenDsylvania 
 
 per portion of left femur. 
 
 flap. 
 
 Still living, 
 
 S. G. O., Washington, Nov. 1, 
 
 
 
 
 Vols., age 28. 
 
 April 29, 1863. 
 
 
 July 1, 1867. 
 
 1865, p. 48. 
 
 S.i 
 
 1863 
 
 Dr. C'ompton. .. 
 
 Private Cooper, 
 
 A fragment of shell com- 
 
 Large anterior 
 
 Died in one 
 
 Circular No. 7, War Department, 
 
 
 1 
 
 Alabama (Rebel) 
 
 minuted the upper extrem- 
 
 flap. 
 
 hour. 
 
 S. G. O., Washington, July 1, 
 
 - 
 
 
 
 Regiment, age 20. 
 
 ity of the femur and frac- 
 tiired the tuberosity of the 
 
 
 
 1867, p. 27. 
 
 
 ••■• 
 
 
 
 ischium. Vicksburg. May 
 
 
 
 
 
 1 
 
 1 
 
 
 22, 1863. 
 
 
 
 
 36 
 
 18G3 
 
 Dr. Lay 
 
 Rebel soldier 
 
 Gunshot fracture of the up- 
 
 Single anterior 
 
 Died in one j Circular No. 7, War L>epartment, 
 
 
 
 
 
 per third of femur by a 
 
 flap. 
 
 hour. 
 
 S. G. C, Washington, July 1, 
 
 
 
 
 
 fragment of shell. Vicks- 
 
 
 
 1867, p. 28. 
 
 
 
 
 
 burg, Miss., June. 18C3. 
 
 
 
 
 37 
 
 18C3 Dr. llBwanl.... 
 
 Private James Mar 
 
 A conoidal musket ball com- 
 
 Antero posterior 
 
 Died in forty 
 
 Circular No. 7, War Depiirtment, 
 
 
 
 
 tin, Hfith New- 
 
 minuted the left femur, 
 
 *<jtisp9. 
 
 eight hours. , S. G. O., Washington, July 1, 
 
 
 
 
 York Volunteers, 
 
 the fracture extending into 
 
 - 
 
 ie(;7, p. 28. 
 
 
 
 
 age 20. 
 
 the coxo-femoral articula- 
 tion. July 13, 1^63. 
 
 
 
 38 
 
 1864 
 
 Dr. Oorgras 
 
 (ieorge Cook, a sea 
 
 Gunshot fracture of the up- 
 
 Antero - posterior 
 
 Died in two Circular No. 7, War Department, 
 
 
 
 man, sige 21. 
 
 per part of the left femur. 
 Smithfield, Va., February 
 
 flaps. 
 
 hours. S. 0. 0., Washington, July 1, 
 1867, p. 29. 
 
 
 
 
 1, 1864. 
 
 
 
 
 39 
 
 18C4 1 Dr. Brock 
 
 Private Wni. Wa- 
 
 A fragment of shell cttm- 
 
 
 Died in half an 
 
 Circular No. 7, War Department, 
 
 
 1 
 
 ters, 123d New 
 
 plctely carried away his 
 
 
 hour. 
 
 S. G. 0., Washington, July 1, 
 
 
 
 
 York Volunteers. 
 
 left thigh. Resaca, Ga., 
 May 15, I8G4. 
 
 
 
 18G7, p. 29.
 
 IN MILITARY SURfiKRY. 
 PRIMARY AMPUTATIONS AT THE HIP-JOINT IN MILITARY SURGERY— Continued. 
 
 59 
 
 No. 
 
 Date 
 
 Opebatob. 
 
 Patiest. 
 
 INJURY. 
 
 Operation. 
 
 Result. 
 
 REJtAEKS. 
 
 40 
 
 1864 
 
 Dr. CarDochan.. 
 
 Private Uich'd Gor- 
 
 The left thigh was complete- 
 
 Modification of 
 
 Died in ton 
 
 Circular No. 7, WarDepartment, 
 
 
 
 
 don, 7th Rhode 
 
 ly shattered by a fragmeot 
 
 Guthrie's meth- 
 
 hours. 
 
 S. G. O., Washington, July 1, 
 
 
 
 
 IslandVolunteers. 
 
 of shelL Spotts^vania, 
 
 od. 
 
 
 1867, p. 30. 
 
 
 
 
 age 88. 
 
 May 18, 1864. 
 
 
 
 
 41 
 
 1864 
 
 Dr. Jewett 
 
 Private Jacob Bar- 
 
 A fragment of shell shattered 
 
 Single antero-in- 
 
 Died in two 
 
 Circular No. 7, War Department, 
 
 
 
 
 ker, 26th Penna. 
 
 the trochanter minor and 
 
 temal flap. 
 
 hours. 
 
 S. G. 0., Washington, July 1, 
 
 
 
 
 Vols., age 22. 
 
 nine inches of the shaft 
 of femur. Spottsylvania, 
 May 18, 1864. 
 
 
 
 1867, p. 30. 
 
 42 
 
 1864 
 
 Dr. Shippen . . . 
 
 Private J.M.Brown, 
 
 A conoidal musket hall shat- 
 
 Single anterior 
 
 Died in one 
 
 Circular No. 6, War Department, 
 
 
 
 
 63d Indiana Vols. 
 
 tered the right femur, the 
 fissures extending through 
 the trochanter major. Lost 
 Mountain, Ga., June 16, 
 1864. 
 
 flap. 
 
 hour. 
 
 S. G. O., Wa.shingtou, Nov. 1, 
 1866, p. no. 
 
 43 
 
 1864 
 
 Dr. Buist 
 
 A private of 27th 
 
 A cannon ball shattered 
 
 Antero -^losterior 
 
 Died in thirty- 
 
 Circular No. 7, WarDepartment, 
 ^. G. O.. Washington, July 1, 
 
 
 
 
 Tenncsaee (Rebel) 
 
 the femiu- quite to the 
 
 flap method. 
 
 six hours. 
 
 
 
 
 Regiment. 
 
 neck of the bone. Jones- 
 boro', Ga., Aug. 31, 1864. 
 
 
 
 1867, p. 31. 
 
 44 
 
 1865 
 
 Dr. Gill 
 
 Private James A.. 
 
 Gunshot fracture of the left 
 
 Double-flap meth- 
 
 Died in seven 
 
 Circular No. 7, War Department, 
 
 
 
 
 Ailing, 3d Wis- 
 
 femur through the tro- 
 
 od. 
 
 hours. 
 
 S. G. 0., Washington, July 1, 
 
 
 
 
 consin Vols. 
 
 ■ 1 
 
 chanters. Averysboro', 
 N. C, March 16, 1865. 
 
 
 
 1867, p. 31. 
 
 INTERMEDIATE AMPUTATIONS AT THE HIP-JOINT IN MILITARY SURGERY. 
 
 No. 
 
 Date. 
 
 Operator. 
 
 Patient. 
 
 Injury. 
 
 Operation. 
 
 Result. 
 
 Remarks. 
 
 1 
 
 1809 
 
 D. J, Larrey. .. 
 
 A French soldier at 
 
 Thigh frightfully shattered 
 
 Larrey's method. 
 
 Died in three 
 
 In this and the following case the 
 
 
 
 
 Wagram. 
 
 by a cannon ball. Wa- 
 gram, July 6, 1809. 
 
 
 hours. 
 
 injuries were so appalling and 
 the prostration so great that 
 Larrey operated with Uttlo or 
 no hope of saving the patients, 
 and mainly to mitigate their 
 sufferings. Mcmoires de Chi- 
 rurgie MUitaircs et Campag- 
 nes, par D. J. Larrev. Paris, 
 1812. Tome lU, p. 350. 
 
 ,2 
 
 1809 
 
 D. J. Larrey... 
 
 A French soldier at 
 
 Thigh frightfully shattered 
 
 Larrey's method. 
 
 Died within 
 
 Afem. de Chir. Mil. et Camp. 
 
 
 
 
 Wagram. 
 
 by a cannon ball. Wa- 
 gram, July 6, 180it. 
 
 
 twenty - four 
 hours. 
 
 Tome m, p. 351. Larrey 
 ascribes the fatal event in this 
 and the preceding case to the 
 delay in operating. 
 
 3 
 
 1814 
 
 Samuel Cooper. 
 
 A British soldier ... 
 
 Fracture of the upper part 
 
 Circular operation. 
 
 Died in a few 
 
 The exarticulation was not com- 
 
 
 
 
 
 of the femur by a grape- ; Abernethy's 
 
 minutes. 
 
 pleted. S. Cooper. Diet. 
 
 
 
 
 
 shot. Profuse suppuration. method. "A 
 
 
 Pract. Surg. 8th London ed., 
 
 
 ) 
 
 
 
 Bergen-op-Zoom,March8, ■ few days" after 
 
 
 p. 116. 
 
 
 
 
 
 1814. 
 
 the injury. 
 

 
 60 
 
 AMPUTATIONS AT TITK HTP-JOINT 
 
 INTERMEDIATE AMPUTATIONS AT THE HIP-JOINT IN MILITARY SURGERY— Continued. 
 
 No. Date. Ofekatok. 
 
 4 1815 I G. J. Guthrie . 
 
 1848 
 
 Aug. Vidal, (de 
 Cassis.) 
 
 Dr. Beatson.. 
 
 L. Legouesl... 
 
 1854 
 
 Patient. 
 
 Fran9ois Duguet, 
 45th French Reg- 
 iment; age 25 yrs; 
 a prisoner after 
 Waterloo. 
 
 The upper extremity of the 
 right femur was shattered 
 and the soft parts on thfe 
 external aspect of the 
 thigh were extensively 
 torn l>y a cannon liall. 
 Waterloo, June 18, 1815. 
 
 Cv»*¥**f ii soldier 
 in the Battalion 
 d'Afrique, 24 y'rs 
 uia. 
 
 A French student 
 of medicine. 
 
 Thomas Lisbey. age 
 61. Conductor in 
 the Ordnance de- 
 partment. 
 
 Garassimoff. a Rus- 
 sian prisoner. 
 
 Ignatius Wdloken- 
 ski,oftho.5th Rus- 
 sian Infantry, 30 
 years of age. 
 
 Chiffttzoff, a Rus- 
 sian prisoner. 
 
 Result. 
 
 Guthrie's oblique Recovered., 
 method. July 
 7, 1815, 
 
 Comminuted fracture of the 
 lower third of the shaft of 
 the femur by a musket 
 ball, followed by purulent 
 sinuses extending around 
 the trochanter major. Bat- 
 tle of the Atlas, Algiers, 
 April 1, 1836. 
 
 Fracture of the upper ex- 
 tremity of the right femur 
 by a musket ball. Profuse 
 suppuration and great 
 constitutional irritation. 
 Paris, 1848. 
 
 Comminution of the neck of 
 the left femur by a uiusket 
 ball. Donnabew, March 
 
 19, 1853. 
 
 Comminuted gunshot frac- 
 ture of the upper extremity 
 of the femur. Alma, Sept. 
 
 20, 1854. 
 
 The upper part of the left 
 femur was completely 
 smashed by a conoidal 
 musket ball. Alma, Sept. 
 20, 1854. 
 
 interior flap. 
 April 14, 1836. 
 
 Entirely recov- 
 ered in six 
 weeks after 
 the operation. 
 
 Single 
 flap. 
 
 anterior I Died . 
 
 Antero - posterior 
 flaps. March 
 25, 1853. 
 
 At Dolma-Batg- Died September 
 tche Hospititl, 29, 1854, two 
 Consta:Ltinople. i days after the 
 operation. 
 
 Died March 25, 
 1853. 
 
 Single antero-in- 
 ternal flap. 
 
 October 5, 1854. 
 
 Died February 
 9, 1855. 
 
 Fracture of the femur 
 through the trochanters 
 by a musket ball. Inker- 
 mann, Nov. 5, 1854. 
 
 At Dolma-Batg- , Died December 
 
 tche nospital, 
 Constantinople, 
 Nov. 25, 1854. 
 
 2, 1854, one 
 week after the 
 operation. 
 
 This soldier was exhibited to 
 surgeons in London in 181G, 
 and in 1830 was living at the 
 Hotel des Invalides in Paris. 
 He was able to walk with the 
 aid of a very ingenious arti- 
 ficial limb. LakeeY: Clin. 
 Ckir., TomeV, p. 248. GUTH- 
 RCE: Treatise on Gunshot 
 Wounds, 3d London ed., p. 
 342. G u T H III E : Commen- 
 taries, 6th American ed., p. 77. 
 Guthrie calls him Francis De 
 Gay. 
 
 Lanceile FraiK^ise, July, 1836, 
 and Clinique des Plaies 
 d'Armes a Feu, par M. L. 
 Baudens, 8vo., Paris, 1836, 
 p. 517. 
 
 Velpeau and Guersant assisted. 
 Less than two ounces of blood 
 lost, ViDAL : Tra ite de Path- 
 ologte Externe et dt Midecine 
 Opcratoire. 3d ed. Tome V, 
 p. 700. 
 
 UaNKING'S Abstract, No. 21, 
 1855, p. 158. 
 
 Chenu. Rapport Med. Chir. 
 sur la Camp. d^Orient, p. fi60. 
 The ligature on the femoral 
 gave way. 
 
 The flaps had adhered to a point 
 by the middle of December, 
 at which date the patient was 
 able to walk about on crutches. 
 Shortly after he fell and hurt 
 his stump so that it bled. In- 
 flammation was sot up.renewed 
 haemorrhage followed, and, on 
 January 30, an uncontrollable 
 diarrhoea. Legouest : De Ip. 
 Desarticulation coxo-femorale 
 au Point du Vue de la Chirur- 
 gied'AmUe. ClIEXU : Op.cit. 
 MACLEOD : Surgeryofthe War 
 in the Crimea. Ist Lond. cd., 
 p. 369. 
 
 Profuse secondary haemorrhage. 
 CJIENII: Rapport Med. Chir. 
 sur la Camp d^Orient., p. GtJO.
 
 IN MILITARY rtXJRGERY. 
 INTERMEDIATE AMPUTATIONS AT THE HIP-JOINT IN MILITARY SURGERY— Continued. 
 
 r.i 
 
 . Date. 
 
 11 1855 
 
 12 
 
 13 
 
 15 
 
 1855 
 
 1855 
 
 1855 
 
 iy55 
 
 Ifi 1859 
 
 17 
 
 18 
 
 Mounier... 
 
 Pietrow, a Russian 
 prisoner. 
 
 Kerigla, a Russian 
 ' prisoner. 
 
 Mauger A Russian prisoner. 
 
 Salleron Soldier. 
 
 Salleron . , 
 
 Soldier. 
 
 A. Betherand. . 
 
 1861 
 
 19 
 
 20 
 
 21 
 
 1862 
 
 1862 
 
 Dr. Peachy. . . 
 
 Dr. Warren.. 
 
 An Austrian soldier, 
 a prisoner after 
 the battle of Pa- 
 lestro. 
 
 U. S. Soldier. 
 
 Gunshot fracture of the fe- 
 mur. Iiikermann, Novem- 
 ber 5. 1854. 
 
 Gunshot fracture of the fe- 
 mur. TraktirBridge,Aug. 
 16, 1855. 
 
 Gunshot fracture of the fe- 
 mur. Traktir Bridge, Aug. 
 
 Gunshot fractlue of the fe- 
 mur. Sevastopol, 1655. 
 
 Gunshot fractiu-e of the fe- 
 mur. Sevastopol, 1855. 
 
 Comminuted fracture of the 
 upper fourth of the left 
 femur by a. fragment of 
 shell, laceration of the 
 muscles on the posterior 
 aspect of the thigh. Pa- 
 lestro, June 4, 1859. 
 
 A musket ball fractft-ed the 
 right femur in the lower 
 third, followed by gan- 
 grene. Bull Run, July 
 21, 1861. 
 
 Operation. 
 
 Dr. Potts. . 
 
 Dr. D. P. Smith, 
 
 Dr. Blackman.. 
 
 1862 Dr. De Bruler. 
 
 Private J. H. Wolf, 
 4th Virginia (Reb- 
 el) Regiment. 
 
 Private Jackson, a 
 Rebel soldier. 
 
 Private Henry H. 
 Hale,14th Elinois 
 Vols., age 21. 
 
 A soldier of an Ohio 
 Regiment. 
 
 Private Peter Paus- 
 beck, 43d Illinois 
 Volunteers. 
 
 At Dolma-Batg- 
 tch6, December 
 19, 1854. 
 
 At Gulhane 
 
 Result. 
 
 Died December 
 29, 1854. 
 
 Remarks. 
 
 Purulent absorption audcholeri- 
 fonn diarrha'a. CmcNlJ : Itap- 
 port Mid. Chir. sur la Camp, 
 d' Orient., p. 660. 
 
 I Died Aug. 23, CUESU. Rapport Med. Chir. 
 sur la Camp, d' Orient., p. 660. 
 
 On the Jean Bart, 
 war steamer, 
 Aug. 18, 1855. 
 
 Oval method.. 
 
 Oval method.. 
 
 Single 
 flap. 
 
 Larrey's method. 
 July 29, 1861. 
 
 1865, during 
 the operation. 
 
 Died soon after 
 the operation. 
 
 Died twenty 
 hours after the 
 operation. 
 
 Died sixtyhours 
 after the ope- 
 ration. 
 
 Died three hours 
 after the ope- 
 ration. June 
 6, 1859. 
 
 Died two days 
 after. 
 
 CUENU. Rapport Mid. Chir. 
 sur la Camp, d' Orient., p. 601. 
 
 Salleron. Compie-rendu des 
 amput. prim, et des ampitt. con- 
 secutives, d-c, in Mem. de Chir. 
 Mil. Tome 21, p. 317, 2e serie. 
 
 Idem. 
 
 Bertuerand. Camp.d'Italiede 
 1859. Paris, 1860, p. 37. 
 
 A musket ball sliattered the Double -flap me th- Died in thirty 
 femiu- quite into the neck. od. August 21, ] hours. 
 Bull Run, July 21, 1861. 1861. 
 
 A badly comminuted frac- 
 ture of the upper extrem- 
 ity of the femur. Belmoni, 
 Missouri, Nov. 7, 1861. 
 
 Fracture of the upper por- 
 tion of the left femur by a 
 fragment of shell. Shiloh, 
 April 6, 1863. 
 
 A fragment of shell commi- 
 nuted the shaft, trochan- 
 ters, and neck of the right 
 femur. Shiloh, April 6, 
 1862, 
 
 Antero-posterior 
 flaps. Novem- 
 ber 15, 1861. 
 
 Long anterior flap. 
 April 12, 1862. 
 
 Antero-posterior 
 flaps. April 16, 
 1862. 
 
 The upper portion of the Lisfranc's method, 
 femur was crushed and April 21, 1862. 
 almost powdered by a 
 eonoidal musket ball. 
 Shiloh, April 6, 1862. 
 
 Died in ten 
 
 hours. 
 
 Died ii 
 days. 
 
 eight 
 
 Died in six days, 
 
 Died i 
 hour. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 33. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 33. 
 
 Circular No. 7, AVar Department, 
 S. G, O., Washington, Julyl, 
 1867, p. 33. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington. July 1, 
 1867, p. 34. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 34. 
 
 one Circular No. 7, War Department, 
 S. G. O.. Washington, July 1, 
 1867, p. 34.
 
 G2 AMPX'TATTOXS AT THE Hir-JOINT 
 
 INTERMEDIATE AMPUTATIONS AT THE HIP-JOINT IN MILITARY SURGERY— Continued. 
 
 26 
 
 27 
 
 Date. Opbbator, 
 
 1862 ; Br. Felton . 
 
 1862 
 
 30 
 
 31 
 
 34 
 
 1663 
 
 1863 
 
 1863 
 
 1864 
 
 1864 
 
 Dr. Pineo - 
 
 Dr. Crymes. .. 
 
 Dr. Bateman. 
 
 Dr. Bateman. 
 
 Dr. Shippeu.. 
 
 Dr. Ingram . 
 
 Private of Docke- 
 ray's Arkansas 
 (Rebel) regiment. 
 
 Private P. Johnson, 
 2d Delaware Vol- 
 unteers. 
 
 A private of Bragg's 
 (Rebel) Army. 
 Aged 26 years. 
 
 A i»rivate of 54th 
 Massachusetts 
 Volunteers (col- 
 ored). 
 
 John Chamberlain, 
 a U. S. soldier. 
 
 James Carden, a U. 
 tS. soldier. 
 
 Private Sullivan 
 Gaines, 2d Michi- 
 gan Cavalry. 
 
 Private Charles 
 Lackey, 7th Wis- 
 coDsin Vols. 
 
 Dr. Roberts. . . .' PrivateLeviEckley, 
 
 67th Ohio Vols. 
 
 Dr. Goodwin - 
 
 Private Joseph Mi- 
 nott, 4th Vermont 
 Volunteers. 
 
 A oonoidal musket ball shat- Novembers, 1862 
 tered the neck of the right 
 femur. Corinth, Octuber 
 3, 1862. 
 
 A conoidal musiet ball 
 perforated the great tro- 
 chanter of the right femur. 
 Fredericksburg, Decem- 
 ber 14, 1862. 
 
 Gunshot fracture of the tro- 
 chanter major and neck of 
 the femur. Dec. 28, 1862. 
 
 A fragment of shell fractured 
 the head and neck of the 
 femur. Fort Wagner, July 
 
 11, 1863. 
 
 Gunshot fiaciure of the up- 
 perextremity of the femur. 
 Chickamauga, September 
 20, 1853. 
 
 Comminuted fracture of the 
 femur by a piece of shell. 
 Chickamaug-a, Septemb^ 
 20, 1863. 
 
 Gunshot fracture of the neck 
 and head of the right femur. 
 Knoxville, Tenn., Jan. 
 31, 1864. 
 
 Gunshot fracture through the 
 trochanters of the right 
 femur. Spottsylvania.May 
 
 12, 1864. 
 
 Gunshot fracture of llie up- 
 per e.i£tremity of the left 
 femur. Bermuda Hundred, 
 May 20, 1867. 
 
 O unshot fracture of the right 
 femur in the upper third. 
 Petersburg, June23, 1864. 
 
 1664 
 
 1865 
 
 Dr. Bentley 1 Sergeant Lewis Car- Gunshot fracture of the right 
 
 roll, Ist Delaware femur; great longitudinal 
 Volunteers. splintering. Weldon Rail- 
 
 road, October 22, 1864. 
 
 Dr. Griswold.. 
 
 Privjiic tienrge M. 
 Spencer. 2d N. Y. 
 Mounted Rifles. 
 
 i unshot fracture through the 
 trochanters of the right 
 fomur. Dinwiddle C. H., 
 Vu., March 31, 1865. 
 
 Dec. 27, 1862. 
 
 Antero-posterior 
 flap method. 
 Jan. 5, 1863. 
 
 Manec's method. 
 July 13, 1863. 
 
 Sept. 21, 1863 . 
 
 Sept. 21, 1863.... 
 
 Single antero-in- 
 ternal flap. 
 
 Feh. 3. 1864. 
 
 Antero-posterior 
 flaps. May 21, 
 1864. 
 
 Result. 
 
 Died i 
 
 hour. 
 
 Died in three 
 hours. 
 
 Died in three 
 days. 
 
 Died in twenty- 
 four hours. 
 
 Died in thirty- 
 six hoiu's. 
 
 Died in six days, 
 
 Died ii 
 hour. 
 
 Died in twenty- 
 four hours. 
 
 Antero-posterior I Died in four 
 
 flaps. May 24, 
 1864. 
 
 A nt ero-post erior 
 flaps, thoi)Oste- 
 riormadc long. 
 June 25, 1864. 
 
 External and in- 
 ternal flops. 
 Nov. 11, 180-1. 
 
 Double-flap meth- 
 od. April 12, 
 1865. 
 
 days 
 
 Died in 
 hours. 
 
 Remarks. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 35. 
 
 Circular No. 7, War Department, 
 S. G. O.. Washington, July 1, 
 1867, p. 35. 
 
 Circular No. 7. War Department, 
 S. G. O., W^ashington, July 1, 
 1867, p. 35. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 36. 
 
 Circular No. 7. War Department, 
 S. G. O., WashingtiHi, July 1, 
 1867, p. 36. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 36. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 37. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 37. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 37. 
 
 two Circular No. 7, War Department, 
 S. G. O., Wnsliington, July 1, 
 1867, p. 38. 
 
 Died in eight 
 days. 
 
 Died i 
 
 hour. 
 
 CircularNo. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867. p. 38. 
 
 Circular No. 7, War Department, 
 S. G. O., W^ishiugton, July 1, 
 1867. p. 3I>.
 
 IN MILITARY SURGEEY. 63 
 
 SECONDARY AMPUTATIONS AT THE HIP-JOINT IN MILITARY SURGERY. 
 
 No. 
 
 Date. 
 
 Opeuator. 
 
 Patiext. 
 
 Injury. 
 
 OrERATION. 
 
 Result. 
 
 Reiuhks. 
 
 1 
 
 1811 
 
 Brownrigg' 
 
 Soldier 
 
 Gunshot fracture of the 
 
 Antero - posterior 
 
 Died in eight 
 
 Guthrie. Commentaries. 6th 
 
 
 
 
 femur. Elvas, 1811. 
 
 ' flaps. 
 
 days. 
 
 Am. ed., p, 77. 
 
 2 
 
 1812 
 
 Brownrigg 
 
 A private of the 13th 
 
 Gunshot fracture of the up- 
 
 Antero - posterior 
 
 Recovered 
 
 This man was living many years 
 
 
 
 
 Light Dragoons, 
 
 per part of the femur. 
 
 tlaps. At Ply- 
 
 
 afterward at Spalding, in Lin- 
 
 
 
 
 British Army. 
 
 Merida, Spain, December 
 29, 1811. 
 
 mouth, Eng- 
 land, December 
 12. 1812. 
 
 
 colnshire, in perfect health. 
 S. COOPER: Diet, rract. Surg., 
 8th Loud, ed., p. 117. Wm. 
 Sasds CoX: Mem. on Amput. 
 of the Thigh at the Hip-Joint, 
 Lend., quarto, 1845, p. 10. 
 A\'ERIL,L's Operative Surgery, 
 London, 1825, 2d ed., p. 217. 
 
 
 1814 
 
 
 
 Gunshot fracture of the up- 
 per extremity of the femur. 
 
 
 
 S. Cooper assisted in this ope- 
 ration. S. COOPER: Diet. 
 
 
 
 
 
 tion. Aber- 
 
 hours. 
 
 
 
 
 
 Bergen-op-Zoom. March 8, 
 
 uothy's method. 
 
 
 Pract. Surg., 8th Lond. ed., 
 
 
 
 
 
 1814. 
 
 
 
 p.ll7. GuTURiE: Trcatiseon 
 Gunshot Wounds, 3d Lond. 
 ed., p. 351. 
 
 4 
 
 1814 
 
 Dr. Emery 
 
 Sebastian de L' Am- 
 our, Corporal 
 Chasseurs Brit^ 
 taniques. 
 
 Fracture of the middle of 
 the left femur by a mus- 
 ket ball. Caries of the 
 femur. Profuse suppura- 
 tion. Near St. Sebastian, 
 Spain, August, 1813. 
 
 Lateral flaps. 
 Larrey's meth- 
 od. July 21, 
 1814. 
 
 Died Aug. 20, 
 1814. 
 
 Preliminary ligation of femoral. 
 GUTHRIE: Treatise on Gun- 
 shot Wounds. 3d Lond. ed., 
 p. 334. 
 
 5 
 
 1815 
 
 Mr. Blicko 
 
 A British soldier . . . 
 
 Contusion of the femur by 
 a musket ball, producing 
 
 
 Died in eight 
 days. 
 
 Guthrie : Treatise on Gunshot 
 Wounds, 3d Lond. ed., p. 351. 
 
 
 
 
 
 
 inflammation of the mar- 
 
 
 
 Dr. John Thomson's Report 
 
 
 
 
 
 row and abscesses along 
 
 
 
 of Observatiotis after the Bat- 
 
 
 
 
 
 thethigb. Waterloo, June 
 
 
 
 tle of Waterloo, octavo, Edin- 
 
 
 
 
 
 18, 1815. 
 
 
 
 burgh, 1816, J.. 270. 
 
 6 
 
 1830 
 
 Clot Bey 
 
 AliHomer.anArab, 
 
 Gunshot fracture of the 
 
 Single internal 
 
 Died November 
 
 Legouest. Chirurgie d'Armce, 
 
 
 
 
 aged 26 years. 
 
 femur. 
 
 • 
 
 flap. 
 
 17, 1830. 
 
 p. 700. Gazette desffopitaux, 
 Tome IV. p. 96. 
 
 7 
 
 1859 
 
 Arlaud 
 
 Louis Legalau, Pua- 
 i]eer,84th French 
 
 Fracture of the middle of 
 the shaft of the right 
 
 
 Recovered 
 
 Jules ROUX. De V Ostcomy elite 
 et des Amputations Second- 
 
 
 
 
 
 Regiment, age 25 
 
 femur by a musket ball. 
 
 
 
 aires. Paris, 1860, p. 99. 
 
 
 
 
 years. 
 
 Montebello, May 29, 1859. 
 
 
 
 
 8 
 
 1859 
 
 Isnard 
 
 A French captain . . - 
 
 Gunshot fracture of the 
 femur, involving the tro- 
 
 
 Recovered 
 
 Demme. Allgemeine Chirurgie 
 der Schusswunden inder Nor- 
 
 
 
 
 
 
 
 chanters, with extensive 
 
 
 
 ditalienischen Hospittelern, 
 
 
 
 
 
 injury to the soft parts. 
 
 
 
 von 1659. WUizbiu-g, 1861, 
 
 
 
 
 
 Solferino, June 24, 1859. 
 
 
 
 p. 254. 
 
 9 
 
 1859 
 
 Jules Rous, (de 
 
 Lt. Joseph Vitarel. 
 
 Comminuted fracture of the 
 
 Antero - posterior 
 
 Recovered ; re- 
 
 This oflScer was exhibited by 
 
 
 
 Toulon.) 
 
 65th French In- 
 
 upper third of the left 
 
 flap operation. 
 
 joined his 
 
 Baron H. Larrey to the French 
 
 
 
 
 fantry, age 24 
 
 femur by a musket ball, 
 
 Nov. 26, 1859. 
 
 regiment in 
 
 Academy of Medecine at the 
 
 
 
 
 years. 
 
 at Magenta, June 4, 1859. 
 Consen-ative treatment at 
 the hospital Maggioro at 
 Milan. At the end of four 
 months there was incom- 
 plete union with evidence 
 of the presence of necrosed 
 fragments and secondary 
 ecquc.strai. At this date 
 the patient was transferred 
 to Toulon. 
 
 
 June, 1860. 
 
 meeting of April 24, 1866. 
 His general health was good, 
 and the cicatrix firm and solid, 
 Jules Rous, De V Osteomy elite 
 etdes Amput: Sec., Paris, 1860, 
 p, 98. Bulletin de VAcademie 
 Impcriate de Medecine, T. 31, 
 p. 582.
 
 64 AMPUTATIONS AT TllK HIP-J0I:NT 
 
 SECONDARY AMPUTATIONS AT THE HIP-JOINT IN iULITARY SURGERY— Continued. 
 
 12 
 
 1864 
 
 1864 
 
 13 
 
 1864 
 
 1864 
 
 Soldier . 
 
 Dr. Bentley ' Private Michael 
 
 ; O'Neil, 58th Mas- 
 sachusetts Vols. 
 
 Private Daniel H. 
 BowmaD, 110th 
 Penna. Vols. 
 
 Dr. Wa^er j Private Williams, 
 
 13tli Ohio Cav- 
 alry. 
 
 I Corporal Frederick 
 I Kelb, 7th New 
 I Volunteers. 
 
 Operation. 
 
 17 
 
 19 
 
 Dr. Bentley. 
 
 1866 Dr. Bluckinan. 
 
 1866 ' Dr. Agnew 
 
 1866 
 
 Dr. Forbes. 
 
 Private George Le- 
 mon, f.th Maryland 
 Volunteers. 
 
 I'rivate Woodford 
 Lon^more. 
 
 Private James Mc- 
 (leeheii, 107th 
 Pf nna. Vols. 
 
 Sorfreant Hiram H. 
 J>avis, 15t;thNew 
 York Volunteers. 
 
 Gunshot fracture of the 
 femur. 
 
 Gunshot fracture of the up- 
 perestremity of the femur. 
 Cold Harbor, June 3, 1864. 
 
 The right femur was com- 
 minuted from the trochan- 
 ters downward by a conoi- 
 dal musket ball. Deep 
 Bottom, July 27, 1864. 
 
 Partial fracture of the femur 
 bj- a conoidal musket ball. 
 Peeble's Farm, September 
 30, 1864. 
 
 Gunshot fracture of the right 
 femur at the junction of 
 the upper and middle 
 thirds. FredericksburpT, 
 December 14, 1862. 
 
 Gunshot fracture of the left 
 femur. Wilderness, May 
 5, 1864. 
 
 Gunshot fracture of the shaft 
 of the right femur. Cyn- 
 thiana.'Kv., June 11, lf64. 
 
 Gunshot fracture of the shaft 
 of the right femur. Get- 
 tysburg. Jnly 1, 1863. 
 
 Gunshot fracture of the up- 
 per third of the right 
 femur. Cedar Creek, Sep- 
 tember 19, 1864. 
 
 Recovered . 
 
 Lateral flaps. 
 August 10, 1864. 
 
 Antero - posterior 
 flaps. Septem- 
 ber 15, 1864. 
 
 Antero - posterior 
 flaps. February 
 17, 1865. 
 
 Antero • posterior 
 flaps. June 7, 
 1865. 
 
 Antero ■ posterior 
 semi-lunar flaps. 
 October 12,1865. 
 
 Lacauchie's meth- 
 od. January 
 18, 1866. 
 
 Antero - posterior 
 skin flaps, with 
 circular di^^ si on 
 of the muscles. 
 April 21, 1866. 
 
 Antero - posterior 
 skin flaps. May 
 5, 1866. 
 
 Died in twenty- 
 three days. 
 
 Died in one horn- 
 
 Died intwenty- 
 nint' hours. 
 
 Died four 
 months after 
 the operation. 
 
 Recovered . 
 
 1867 I Dr. Dubois Antonio Mutieres. . , 
 
 A conoidal pistol ball lodged 
 in the neck of the left 
 femur. Fort Union, N. 
 M.. May 10. 1867. 
 
 Antero - posteri 
 flaps. June 22. 
 
 18(w. 
 
 DESniE. SpeciaU Chirurgie du 
 Schusswunden in den Nordi- 
 talicnischen Hospitxlem, 1859. 
 Wiirzbiu-g.lSOl, p. 351. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 39. 
 
 Circular No. 7, War Department, 
 S. G. O., Washiuglon, July 1, 
 1867, p. 41. 
 
 Circular No. 7, M'ar Department, 
 S. G. O., Washingtuu, July 1, 
 1867, p. 41. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 42. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 42. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1667. p. 43. 
 
 Died in ten 
 days. 
 
 Died in siity- 
 
 four hours. 
 
 Died in thirty 
 hours. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 44. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 46. 
 
 Circular No. 7, War Department, 
 S. G. O., Washington, July 1, 
 1867, p. 47.
 
 IN MILITAUY SUKGERY. 
 
 EEAMPUTATIONS AT THE HIP-JOINT IN MILITARY SURG-ERY. 
 
 65 
 
 No. 
 
 Date. 
 
 OrEKATOR. 
 
 Patient. I 
 
 1 
 
 LXJUKY. 
 
 Operation. 
 
 Result. 
 
 Remarks. 
 
 1 
 
 1812 
 
 O. J. Gathrie... 
 
 Private Mason, 23d 
 
 Sloug-hing stump, after am- 
 
 Oblique method.. 
 
 Died seven 
 
 GUTURIE. Treatise on Gimshot 
 
 
 
 
 Infantry, Welch 
 
 putation at mid-thigh for 
 
 
 hoiu^ after the 
 
 Woujids. 3d Loud, ed., p. 3:12. 
 
 
 
 
 Fusileers. 
 
 i 
 
 gunshot injury, with sec- 
 ondary haemorrhage. Ciu- 
 dad Rodrigo, 1812. 
 
 
 operation. 
 
 
 2 
 
 1864 
 
 Dr. Buck 
 
 Lieutenant Charles 
 
 Diseased stump after ampu- 
 
 Antero - posterior 
 
 Died in twenty- 
 
 Circular Xo. 7, War Department, 
 
 
 
 
 H. Hawkins, 4th 
 
 tation at mid-thigh for 
 
 flaps. Sept. 21, 
 
 four hours. 
 
 S. fi. O., Washington, July 1. 
 
 
 
 
 N. York Cavalry. 
 
 gunshot fracture of the fe- 
 mur. June 1, 1862. 
 
 1864. 
 
 
 1867, p. 47. 
 
 3 
 
 18fi4 
 
 Dr. Hassenburg. 
 
 Private Lewis Lar- 
 
 Diseased stump after ampu- 
 
 Antero • posterior 
 
 Died in seven 
 
 Circular No. 7, War Department, 
 
 
 
 
 rey, 1st New Or- 
 
 tation at mid-thigh for 
 
 flaps. Sept. 21, 
 
 days. 
 
 S. G. O., Washington, July 1, 
 
 
 
 
 leans Volunteers. 
 
 gunshot fracture of knee- 
 joint. New Orleans, July 
 17, 1864. 
 
 1864. 
 
 
 1867, p. 48. 
 
 4 
 
 1865 
 
 Dr. Packard 
 
 Private El>en E. 
 
 Necrosis of femur following 
 
 Antero - posterior 
 
 Recovered 
 
 Circular No. 7, War Department, 
 
 
 
 
 Smith, 11th Maine 
 
 amputation at lower third 
 
 flaps. January 
 
 
 S. G. 0., Washington, July 1, 
 
 
 
 
 Volunteers. 
 
 of the thigh for gunshot 
 fracture of the head of the 
 tibia. Deep Bottom, Aug. 
 16. 18G4. 
 
 19, 1865. 
 
 
 1867, p. 49. 
 
 5 
 
 1865 
 
 Dr.Fauiitleroy. 
 
 Private R. A. Vick, 
 
 Caries of the femur after 
 
 Antero -posterior 
 
 Recovered 
 
 Circular No. 7, War Department, 
 
 
 
 
 43d North Carolina 
 
 amputation at the lower 
 
 flaps. March 11, 
 
 
 S. G. 0„ Washington, July I. 
 
 
 
 
 (Kebel) Regiment. 
 
 third of the thigh for gun- 
 shot wound of knee-joint. 
 Cedar Creek,Oct. 19, 1864. 
 
 1665. 
 
 
 1867, p. 50. 
 
 fi 
 
 1866 
 
 Dr. Morton 
 
 Serffeant Edwin D. 
 
 Osteomyelitis, after ampu- 
 
 Antero -posterior 
 
 Recovered 
 
 Circular No. 7, War Department, 
 
 
 
 
 Ulmer, 15th New 
 
 tation at mid-thigh for gun- 
 
 flaps. February 
 
 
 S. G. 0., Washington, July 1, 
 
 
 
 
 Jersey Vols. 
 
 shot fracture of femur and 
 knee-joint. Cedar Creek, 
 October 19, 1864. 
 
 17, 1866. 
 
 
 1867, p. 51, 
 
 7 
 
 1866 
 
 Dr. Wliitcomb.. 
 
 Henry Campbell .-- 
 
 Disease of the femur after 
 
 Antero - internal 
 
 Died in five 
 
 Circular No. 7, War Department, 
 
 
 
 
 
 amputation of the thigh 
 
 flap. October 
 
 hours. 
 
 S. G. 0., Washington, July 1, 
 
 
 
 
 
 for gunshot wound of 
 
 22, 1866. 
 
 
 1867, p. 52. 
 
 
 
 
 
 knee-joint. New Orleans, 
 
 
 
 
 
 
 
 
 March, 1863. 
 
 
 
 
 8 
 
 1864 
 
 Dr. Mott 
 
 Private Lewis Fran- 
 
 Necrosis of femur, following 
 
 Antero - posterior 
 
 Recovered 
 
 Circular No. 7, War Department, 
 
 
 
 
 cis, 14th N. York 
 
 amputation of the thigh at 
 
 flaps. May 21, 
 
 
 S. G. O., Washington, July 1. 
 
 
 
 
 Militia. 
 
 the middle for a. bayonet 
 wound of the right knee- 
 joint. Bull Run, Jiay21, 
 1861. 
 
 1864. 
 
 
 1867, p. 52. 
 
 In the historical summary, 108 authenticated amputations at the hip-joint in military surgery were referred to, and, in the 
 next chapter, 53 additional cases were described. Tlie tables include these 53 cases and 52 of the first series — 105 cases 
 altogether. I have been unable to obtain sufficient details of tlie 5G remaining cases to placethem in the tables. The results of 
 the wliole number of 161 cases may be summed up as follows : 
 
 
 Died. 
 
 ■i 
 Kecovered. Doubtful. 
 
 
 88 
 24 
 18 
 
 12 
 
 14 ' 3 
 1 
 1 
 
 
 
 Cases of Brownrigg, Demme. Wedemyer, Brodie, Richet, Robert, Guersant, and French Naval 
 
 Total 
 
 M2 
 
 16 ' 3 
 
 1
 
 OPINIONS OF SURGEONS ON AMPUTATIOxNS AT THE TIIP-JOINT. 
 
 In estimatiug the value of amputation at the hip-joiut as a resource in military 
 surgery, an examination confined to the results of the operation is not altogether sufficient. 
 The results should be compared with those of the two other expedients to which the 
 surgeon may resort in severe gunshot injuries of the higher part of the thigh: the excision 
 of the head of the femur, and the attempt at conservation of the limb. An exact com- 
 parison is impracticable at the present time. In addition to the histories of thirty-two 
 excisions of the head of the femur for gunshot fracture, recorded in the surgical report in 
 Circular l^o. 6, S. G. 0., 1865, pp. 62-74, there have been transmitted to this office 
 memoranda of over thirty such operations, which are yet under investigation. The 
 compilation of the voluminous statistics of gunshot fracture of the upper part of the 
 femur in possession of the office is still incomplete. It is believed that a full cliscussiou 
 of the results of both classes of cases will be in readiness for publication before the 
 conclusion of the present year. Meanwhile, it is of interest to know what were the 
 matured opinions on this subject of surgeons who had the largest opportunities of observing 
 grave gunshot injuries of the higher jjortion of the thigh, treated by these three methods. 
 
 Surgeon E. Shippen, U. S. Volunteers, Surgeon E. Bentley, U. S. Volunteers, Surgeon 
 J. T. Gilmore, P. A. 0. S., and Surgeon W. M. Compton, 2d Texas (Rebel) Regiment, 
 each amputated at the hip-joint in three instances. Both Dr. Shippen and Dr. Bentley 
 have the satisfaction of knowing that one out of three of their patients recovered and is 
 still living. Both Dr. Gilmore and Dr. Compton may boast that, in three primary 
 amputations, each had one patient who survived for weeks, and, in all probability^ ultimately 
 recovered. Yet none of these surgeons are warm advocates of primary amputation at 
 the hip. Dr. Shippen declares that the operation "should never be attempted, except 
 when no other means present themselves of saving the patient's life. It should always 
 be considered a last resort."'^ Dr. Couiptou would apparently attach little value to the 
 operation, since he closes his report l)y the exclamation: "Thus ended my third, and I 
 trust my last amputation at the hip!" Dr. Bentley exjjresses his view as follows: 
 
 "My ot)inion of amputation at the hip-joint is, that it will scarcely if ever be 
 admissible as a primary operation in military surgery, for the accident requiring so 
 formidable an operation necessarily produces so severe a shock as to make the operation 
 unjustifiable, in my judgment, if performed before reaction conies on, for the result will 
 be almost certainly fatah If it is delayed until reaction comes on, it will be rare to find 
 a man with sufficient stamina to umlergo so extensive a mutilation with a reasonable 
 prospect of a second favorable reaction. But as a secondary operation, the system has 
 become educated to endurance and suftering, and the brain and nervous system have been 
 brought in sympathy with the general condition; comfortable quarters, favorable surround- 
 
 'LcftcT iVi.ni Dr. Shippen. .\piil 9, ISW.
 
 68 AMPUTATIONS AT TITK IHP-JOTXT 
 
 ings, and a mind composed and liupeful, liave been secnred. AVitli all tliese conditions, I 
 believe the operation to be perfectly justifiable, and when properly executed, it may be 
 placed in point of success with amputations in the upper third of the thigh, at the knee, 
 or the shoulder joint. I should consider the method of amputation important, and would 
 always advise, when practicable, a long anterior and short posterior Hap. Care should 
 be taken to remove completely the cotyloid ligament around the acetabulum. AVhen the 
 operation is completed, the anterior flap should be allowed to carefully drop over the 
 ]:)osterior one, and left without sutures or plasters, covered only by a light layer of muslin. 
 I believe secondary amputation at the hip-joint will continue to grow in the confidence of 
 all prudent and judicious operators until it shall receive, if it does not already, general 
 sanction.'^ 
 
 Dr. Gilmore regards his case in which the patient survived the operation and went 
 to his home as altogether exceptional, and attributes the result to the very favorable 
 conditions in which the patient was placed as regarded nursing and after-treatment. 
 xVfter noticing three unsuccessful excisions of the head of the femur of which he was 
 cognizant, he writes : 
 
 "I was in the field during the entire war, and my experience is mostly in the 
 operative part of surgery. .l)ut this teaches me that amputation at the hip-joint is not a 
 good operation in gunshot wounds. I recall six cases that would usually be thought to 
 require amputation at the hip, which ended in recovery without operation; one, a 
 Mississippian, wounded at Fredericksburg; two Georgians, wounded at Ghancellorsville; 
 and three men wounded at Gettysburg, belonging to North and South Carolinian and_ 
 Georgian regiments, respectively. I believe that one-third of the cases of gunshot fracture 
 of the femur, supposed to demand amputation at the hip, would recover if left entirely to 
 the efforts of nature; while a much smaller proportion will recover if subjected to either 
 amputation or resection. ''^ 
 
 Surgeon Samuel Kneeland, U. S. Volunteers, is almost alone in regarding primary 
 ampmtations at the hip as preferable to secondary ojierations: 
 
 "j\Iy opinion on the value of the operation is, that it is justifiable, and that it has a 
 fair prospett of success as a primary operation and in a properly arranged field hospital ; 
 but that as a secondary operation, and in a crowded general hospital, the chance of 
 recovery is very small. '^ 
 
 Surgeon George Derby, U. S. Volunteers, views the operation favoral)lv, and writes: 
 
 "I have no doubt of the propriety of doing the operation under certain contingencies 
 in military surgery, and regret that I did not do it myself in one case which was under 
 juy care.' ■* 
 
 Surgeon R. B. Bontecou, U. S. Volunteers, says of ampiulation at the hip: 
 
 "Although the statistics are discouraging, I sliould advise and practise it where 
 resection was inadmissible. I sliould, however, make the operation by circular incision 
 of the upper third, soft parts permitting, and enucleate the bone by incision carried up 
 the outside of the limb to tlie trochanters, believing that tlie luemorrhage and shock to 
 the system would be less than l>y the usual methods.''^ 
 
 ' Letter tVoni Ur. liciitley, May 20, 1837. 
 - Letter from Dr. (Jiliiioi-e, March 28, 18(57. 
 ■'Letter friim Dr. Kncelaml, March 18, 18i)7. 
 ' Letter frcnn Dr. Derl).v. Marcli 19, 18,17. 
 Letl.-r tV.iin Dr. lii.Mti'mii, Aiiril 1.8, 1867.
 
 IN THK WAR OK TTIK RKRELLTOX. (i!) 
 
 Burgeon II. E. Goodman, U. S. Voluutcei-s, ]\Icdical Director of the Tweulietli Army 
 Corps, has also a favorable opinion of this procedure : 
 
 "I believe the operation of disarticulation at the hip-joint in military surgery useful, 
 and often necessary to save life. The cases operated on were frequently unfavorable from 
 the great amount of injury, as uncomplicated compound fractures were generally, in my ex- 
 perience, left to nature. If I should have a case of compound fracture of upper third of 
 femur, with injury of artery or nerve, or both, I should not hesitate a moment in regard to 
 the operation of amputation at the joint, feeling assured that if I neglected such an operation, 
 I failed to perform my duty; provided, however, there was strength sufficient to carry 
 my patient through the operation. AVith a skilful surgeon to operate and look after the 
 after-treatment, good assistants, a first class nurse, and favorable circumstances, 1 cannot see 
 why a hip-joint operation should necessarily be so much more unfavorable than one through 
 the great trochanter or two inches below. "^ 
 
 Acting Staff Surgeon S. A. Green remarks of the operation, that: 
 
 "No surgeon would perform it with any sanguine hope of success. It would not be 
 undertaken except in extreme cases, where. there would be otherwise no chance of recovery. 
 Yet, in such cases, one case in seven during the late war recovered. This chance must 
 be given to the patient. Still, with this percentage of mortality, we should hardly 
 consider the operation as one of value. Under certain circumstances, clearly stated on 
 page 52 of Circular Ko. 6, S. G. 0., 186-3, it is admissible in military surgery."" 
 
 Surgeon A. N. Dougherty, Medic;d Director of the 2d Army Corps, sums up his 
 
 opinion as follows : 
 
 "My opinion of the oi^eration is, that it is justifiable but not desirable, and not 
 imperative. I should never undertake it except at the urgent request of the patient, 
 after he had had the perils and probable issue laid fully before him.^ ' 
 
 Surgeon T. H. Squire, 89th New York Volunteers, whose observation of field surgery 
 was particularly extensive and protracted, observes : 
 
 "I am not willing to say that I think the operation unjustifiable; but I do say that 
 the operation ought not to be performed, except in cases where death is positively certain 
 without it. I think we cannot make a general rule of action, which, on the battle-field, 
 will apply to all cases that might come under this head. In weighing the probabilities of 
 each case, we must put two weights into the scale against the probabilities of recovery. 
 One weight, which may be said to be nearly uniform in all cases, is the great violence of 
 the operation itself; and the other weight, which may be very different in different cases, 
 is the anterior violence of the gunshot injury."^ 
 
 Surgeon 0. A. Judson, U. S. Volunteers, remarks of primary coxo-femoral amputation ; 
 
 "I can only say that I have never seen a case in which it seemed to me indicated, 
 and that its performance should be discountenanced under ordinary circumstances. I can 
 readily imagine, however, circumstances where it might be proper to resort to it, but they 
 are very exceptional."^ 
 
 ' Letter from Dr. Goodman, .\pril ;iO, 1867. 
 ■-' Letter from Dr. Green, April 1(1, 181)7. 
 ■' Letter i'roni Dr. Donglierty. Marcli 18, 18i;7. 
 ^Letter from Dr. Scpiire, Marcli SiS, 1807. 
 ''Letter fr(mi Dr. Jmisoii, April 1, 18(57.
 
 70 AilPUTATIONS AT THE HIP-JOINT 
 
 Surgeon C. N. Chamberlain, U. S. Volunteers, dei'lares: 
 
 "T (111 imt liclievo ampufaliun al the liiii-iniiit slujuld evei' bo resorted to wlien 
 aiujiutaliiiii licldw lli(^ jonit, even tbroiiL;:li tlie trucliauters, or when resection, partial or 
 eoniplete, atlbrils a promise of success. I migbt also add, "wlien free incisions into tbe 
 joint, with or without the removal of spicula\ can liopefully be made, the operation is 
 inadmissiljle. The necessity of transportation of the patient should be allowed its due 
 weight in deciding the question. In my opinion, the operation should never be performed 
 where any other operation or treatment can be suljstituted. In fracture of the head and 
 neck of the femur, together with extensive comminution of the shaft of the bone, or with 
 destruction of the principal vessels or nerves of the limb, death is the only alternative 
 and the operation is justillaljle."^ 
 
 iSurgeon E. Andrews, IsL llliiiuis Battery, would also restrict the operation as a 
 ]>rimary prociMlm-o (o a very limited class of cases: 
 
 "I should not advise this operation except in the most desperate emergency, such as 
 the tearing away of the whole limb by a cannon shot, followed by such a reactian from the 
 shock as gave reasonable hope of being able to stand the operation. I tliink it is entirely 
 inadmissible for mere bullet or shell fractures involving the hip-joint. My present opinion 
 is this: that no fracture of this region, of itself, justifies amputation at the hip. The 
 operation should never be performed at that point unless there is sucli a destruction of 
 tissue as leaves no lower point of election, and then only when the patient shows reai-tive 
 power enough to give hope of escaping death from the shock."" 
 
 Surgeon J. F. Galloupe, 17th Massachusetts Volunteers, exjn-esses similar views: 
 
 " ^^^hen the greater portion of the diameter of the limb is destroyed. I wouM (Mjiriplete 
 the division of the soft parts, in the most favorable manner for covering the stump, with 
 the knife, and disarticulate the bone as best I could. By this procedure, nature would be 
 relieved of the task of separating the injured limli, and the shock to the system would be 
 but little coni})ared to that which follows complete amputation with the knife. Under 
 all otlier conditions, I would decline to do the primary operation, believing that the 
 undisturbed eflbrts of nature would give the patient a better prospect of recovery than 
 would tollow amputation. T cannot resist the conviction that some of the cases which 
 have tlied after the operation, would have recovered if no operation had been done. In 
 my opinion, flie secondary ojH.'ration is demanded under a variety of circumstances, and 
 the necessity lor it must be determined by grouping the svmptoms and circumstances in 
 each case. In my opinion, the operation sliould not be discarded, but the utmost care and 
 skill should he used in deciding wliat cases demand this terrible interference, ami in 
 what cases ihe milications ai'e to avoul ibe opei'alion.' '' 
 
 Surgeun A. 11. llofi', U. S. \'oliiiiteers, says of |ii'imai'\' amputaliun at the hip joint for 
 gunshot injury : 
 
 "Out ol more than a ]iun(h'ed tlujusand siek and wounded soldiers transferreil under my 
 direction while connected with the hospital transportation department, no case of the kind 
 came undei- my observation; and of the seventeen thousand transported on the hospital 
 steamer I). A. January, under my direct supervision, I saw no case of the kind. As regards 
 an opinion, 1 am somewhat embarrassed, but a comparison with tlie result of operations in 
 tiie vicinity of the hip-joint may lead to some fair conclusions in reference to the value of 
 
 ' 1,1-ttiT liorji Dr. CliuriiliiMhiin, Maicli 18, 1SG7. 
 • l.Mvr fVoni Dr. Andii'ws, M;ireli :il, 1S67. 
 ' Leitcr Iroiii Di-, (inllcmpo, Marcli 2(1, 18G7.
 
 IN THE WAR OK THE REBELLION. 71 
 
 tliis o{)eration. Circular No. 6, S. G. 0., 1865, gives us reliable data in reference to 
 primary and secondary excisions of the head of the bone, with a sufficient number of 
 cases to show the almost hopelessness of this operation. Upper third amputation of the 
 thigh, although a less formidable operation than amputation at the hip-joint, does not 
 offer much encouragement to the surgeon. The day after the battle of Shiloh I had 
 occasion to make several amputations at the upper third of the thigh, most of them just 
 below the trochanter. These cases were all transported to the general hospitals at Saint 
 Louis, and were apparently doing well four days after the operation, but I think they all 
 ultimately died. I received very few patients on board the hospital transports tliat had 
 undergone amputation very high up in the thigh, and among the large number of applicants 
 for artificial limbs that came under my observation while stationed in New York city, 
 upper third stumps were great rarities. I am inclined to think that not more than ten 
 in a hundred, if as many, survive amputation in the upper third. In this operation I 
 fear statistics will not afford us very reliable data, as the division of the thigh into lower, 
 middle, and upper third has not been sufficiently well defined in reporting cases. You 
 may feel inclined to dissent from my statement in reference to the mortality of upper 
 third amputations of the thigh, with the statistics you have in your possession. I am 
 speaking from observation, you have the figures. But I am inclined to think there has 
 been a large number of mistakes made in measurement. I have made quite a number of 
 these upper third operations, and, with one or two exceptions, all primary, and have not 
 yet had the pleasure of shaking the hand of a single survivor. Taking the result of these 
 two operations, one involving the joint and the other in close proximity, average the 
 chances for recovery, and what conclusions would you arrive at in reference to the value 
 of amputation at the hip-joint, a much more formidable operation than either? 
 
 "The enumeration of the necessities for an amputation at the liip-joint, in my estimation, 
 is a more troublesome question to settle, and the real value of the operation will hinge 
 almost entirely on it, viz: what parts must be involved to make a resort to this ojoeration 
 necessary? If the head of the bone is involved, then I should think its excision would 
 offer the best chance. If the neck of the bone was shattered outside of the capsular- 
 ligament, this would offer no reason for the removal of the limb. If the large blood 
 vessels were involved so high up, you would scarcely reach the case in time to be of any 
 service; and if the whole limb was carried away up to the joint and a surgeon saw the 
 case in time to arrest the hfemorrhage, his work as an operator would be accomplished. 
 It would seem, then, when you come carefully to canvass the matter, that the conditions 
 requiring an amputation at the hip-joint, if I am right in my premises, would depend 
 on the destruction of the vessels. If this be so, then the operation is of no value as a 
 primary operation in militaiy surgery, and as a secondary one, I am free to confess, I have 
 but little confidence, yet I should be very far from agreeing to be deprived of the right of 
 doing the operation should a case occur that demanded it."^ 
 
 Surgeon S. W. Gross, U. S. Volunteers, who has studied the subject with much 
 attention, expresses his conclusions as follows : 
 
 "I have never seen a case of gunshot injury in which I thought tluit the procedure 
 was at all necessary; nor would I operate immediately after the reception of the injury, 
 except in the following cases: comminution of the head and neck of the bone with injury 
 to the great vessels; and in those cases in which the limb had been entirely, or almost 
 entirely, carried away by a round shot so high up that flaps cannot be formed in the upper 
 part of the thigh. The latter class of injuries, however, would be very apt to terminate 
 i'ntally from the shock sustained by the system at the time of reception of the wound. In 
 
 ' Letter from Dr. Hoff, March 30, 1(567.
 
 72 AMPUTATIONS AT THE lUP-JOlKT 
 
 cases of gunshot tmotuix' of the head ami neck of the bone, I woiihl never amputate 
 immediatel)', but wait, at any rate, until suppurative action had declared itself. For 
 osteomyelitis of the shaft of the thigh bone, whether the bone be primarily affected on 
 account of fracture or other gunshot injury, or be attacked secondarily after previous 
 amputation at some part of the thigh, disarticulation at the hip-joint is the only remedy, 
 and I should not hesitate to resort to it. J. Eoux's operations at "the hip-joint and shoulder 
 joint for this aft'ection have been remarkably successful and are very favorable to the 
 (iperation. Such, in mv opinion, are the only conditions wliicli demand hip-joint amputa- 
 tion. I have taken some pains to collect all the cases of the operation for gunshot injury, 
 and have succeeded in tabulating one hundred and thirty cases, of which nineteen 
 recovered and one hundred and eleven ditd, the mortality of the operation being a little 
 over eighty-hve per cent. Fifty-four operations were primary, with but two recoveries; 
 thirty-seven were secondary, with eleven cures; and six were intermediate, with two 
 recoveries. Of the remaining thirty-three cases, the time of performance of the operation 
 is uncertain. From the above statistics, the great advantage of deferring the operation is 
 ol)vious, since secondary exarticulation gives one recovery in every three and one-third 
 cases, whereas primary operation shows l)ut one recovery in every twenty-seven cases. 
 The great mortality of the latter should not, however, deter us from operating when the 
 procedure offers the only chance for life; but it should at the same time caution us to 
 exercise the greatest judgment in our diagnosis. I have no idea that primary amputation 
 Avill prove as fatal at the present day as formerly. The great sources of danger are shock 
 and lia;:morrhage. In regard to shock, we must take into consideration that the majority 
 of the primary operations belong to campaigns antecedent to the use of anesthetics. 
 Tlie ratio of mortality in all hip-joint amputations has certainly diminished since the 
 introduction of chloroi'orm, and I think that we possess in it a powerful agent against 
 sliock, which, in former days, was so fruitful a source of mortality. These considerations 
 are entitled to great respect, since the only successful primary operations — i. e., those of onr 
 late war — were performed under chloroform. Haemorrhage- as a source of danger is now 
 robbed of its terrors by the employment of the abdominal tourniquet for compressing the 
 aorta. This instrument is usecl in Philadelphia, and by Mr. Lister, of London, with the 
 best results. I have thus seen a hip-joint amputation with a loss of not more than five or 
 six ounces of blood. The employment of the abdominal tourniquet and anaesthetic agents, 
 I therefore hold, should make the operation more successful; and I should not be surprised 
 if the mortality would hereafter exceed Ijut little, if any, that of amputation in the upper 
 third of the thigh. Of the consecutive dangers, as the formation of secondary abscesses, 
 exhaustion from profuse su})puration, and pyjemia, 1 have nothing to say, as each case will 
 have to be met according to its peculiar merits.''^ 
 
 A reference to six cases of recovery fi'om gunsliot fractures of the higher ]>ortion of 
 the femur, in which tlie propriety of ablation of the tliigh had been canvassed, has already 
 been cited from a letter from Dr. Gilmore. It would be easy to multiply such instances. 
 One of the earliest casualties of the war furnishes an interesting example;" A soldier 
 had the neck and troclianfers of the riglit fcmin- shattered by a musket ball at the affair 
 of Big Bethel. < )ii his removal to Fort Monroe, a consultation was lield, at wliich Burgeons 
 Cuyler, IToff, ]\Icl\ay, Gilbert, and Assistant Surgeons J. S. Smith and White assisted. 
 The majority of voices favored amputation at the hip-joint; but Dr. Cuyler, the medical 
 director, decided that an attempt at conservation of the limb should be made. Tins man 
 
 ' Letter from Dr. Gross, April 14. ISCiT. 
 
 - A notice of the ea.-ie was i:iil,v |iul)lisli((l 1i_v .\ssistiiiit Siirjreiui ('. I!. Wliit<', U. S. A., in tin- .Imcrican MitHrul Times, p. 
 if*, .Iiilr 27. 1>C1.
 
 IN THK WAR OF THE P.EBELLION. /b 
 
 is now a stalwart, laborer, and suti'ers little or no inconvenience from his injury. The fol- 
 lowing history of his case, together with an .excellent photograph, was lately transmitted 
 by Surgeon R. B. Bontecou, U. S. Volunteers, who had charge of the case for a long time: 
 
 Private Pliilip Sweeney, Co. C, 3d New York VoUmteers, was wounded in tlie affair at Big Bethel, June 10, 1861, by a 
 conoidal musket ball, which shattered the neck and trodianters of the right femur. He was admitted to Hygeia Hospital, Foit 
 Monroe, on .June liith, and was treated by moderate extension and dilatation of the wound by sponge tent.s, in order to facilitate 
 the extraction of primary sequestra, of which many were removed. Suppur.ation and exfoliation persisted until March, 18S2. 
 In April, there were two severe attacks of erysipelas involving the entire limb. These greatly reduced the patient, but he 
 quicklv 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 Hospital in New York city, where a number of necrosed fragments were removed. On May 2r>, 18t)3, he was discharged 
 from service, being able to walk without a crutch, the limb being but slightly shortened. He soon afterwajds engaged himself as 
 a laborer at an iron foundry in Troy, New York, where lie has since worked without intermission. On July 20, 1866, he w'as 
 examined bv Dr. R. B. Bontecou, who found him in perfect health, the injured limb a trille shortened and the knee rather stiff, 
 owing to the destruction of connective tissue about the extensor muscles of the thigh diu-ing the suppuration following the 
 erysipelatous .attacks, and doubtless the formation of adhesions. The knee-joint was in good condition and had sufficient motion 
 to allow a fii-m, good gait. 
 
 Brevet Lieutenant Colonel Charles K. Winne, Assistant Surgeon, U. S. Army, has ' 
 transmitted the following history of a case of gunshot fracture of the cervix femoris, in 
 which he desired to perform excision, but refrained on account of the opposition of the 
 patient. Dr. Winne now believes that had the patient consented to the operation the 
 result would, perhaps, have been less favorable: 
 
 C. F. Beyland, a German, aged 26 years, a clerk in the Quartermaster department, was wounded by an Enfield rifle ball 
 late in the evening of December 8, 1861. The ball entered behind, ranging downward and forward, emerging in front, completely 
 fracturing the neck of the right femur, and producing a longitudinal fissure of the great troch.-mter. The wound was dressed 
 by Sm-geon Caphart, 1st West Virginia Cavalry, who transferred the case to Assistant Surgeon Winne, U. S. A., December 
 9tli. The shock having subsided, the soiled dressings were removed and the wound thoroughly examined, the patient being 
 under the influence of chloroform. As the neck of the fermur was extensively comminuted, Dr. Winne proposed excision, but 
 all operative interference being resolutely opposed, he was placed in Hagadorn's splint, no extension being used, the wound 
 constantly wet with evaporating lotions, and anodynes administered as often as necessary. On December 10th, the skin was hot 
 and dry ; pulse 107 in the morning, 130 in the evening. As he had not had a passage from the bowels for several days, a 
 draught of citrate of magnesia followed by an enema was ordered. On December lltli, the bowels were moved four times with 
 relief to the patient. There was excessive thirst, the tongue was dry, the pulse 130. There was no great pain in the limb, 
 tliough it was swelling rapidly. Hagadorn's splint was changed for a box extending frimi the foot to the axilla, and on the 
 inside to the middle of the thigh, the limb being kept motionless by pads. December 12th, rested well during the night, sweat- 
 ing considerably ; outer aspect of thigh and groin nmch swollen and dark color; no difference in temperature, no pain ; pulse 
 120 and feeble ; nourishing diet, with wine in addition. December 13th, slight chilliness followed by fever. On December 29th, 
 Dr. Winne returned from leave. During his absence the case had been treated by Dr. Caphart. Two large abscesses had 
 formed in the upper and outer part of the thigh, and discharged through opening made by entrance of ball. Appetite good, and 
 rests well at night, though he is much less cheerful and suffers constant pain. January 13, 1862, appetite and sleep natural, 
 pain lessened, as an abscess which had formed in the gluteal muscles, bun-owing along the outer and posterior surface of the 
 thigh, was now discharging pus mingled with blood. The exit wound has healed, pulse 100. The limb is kept perfectly 
 motionless as he lies on a stretcher placed above the mattress; the lower wound is dressed, and his bowels moved through an 
 opening cut in the stretcher, which is raised at these times. January 26th, has been doing well, has very little pain, and that 
 only occasionally; no swelling on anterior i>art of thigh ; discharge perfectly healthy in character; appetite excellent, and 
 sleeps marly all night ; complained to-day of inability to pass urine, which was relieved by fomentations ajjplied to the permeum 
 and over the bladder. January 29th, pain for the last two days severe and constant, discharge increasing in quantity ; greater 
 swelling on posterior part of thigh ; no change in other respects. March 1st, the discharge from the wound for the last week 
 has been profuse, exceedingly foetid and mingled witli hlood, another abscess having formed, which is the fifth since the injury 
 was received. The outer aspect of the thigh extending to the anterior superior spinous process of the ilium is nmch swollen, 
 skin discolored, and slight pressure in the groin or on the hip produces intense pain. I'atient's body is very nuich emaciated, 
 pulse 100 and feeble ; is taking wine or whiskey daily. March 16th, suppuration decreasing and more healthy than it had been ; 
 swelling in thigh diminishing; he also feels better. March 24tl), suppuration still decreasing, general condition favorable. 
 April ,5tli, he was removed from Clarksburg to Parkersburg, a distance of eighty miles. As the bed on which he lay was not 
 changed, he bore the trans|)ortation by rail very well. A few days afterwards another large abscess formed, which, on being 
 opened, discliargid a large (luantity of exceedingly foetid pus. May 8th, the lower gunshot opening has entirely closed, all pus 
 now issuing from opening made in abscess ; the discharge is still very fojtid. though decreasing in quantity. Removed the 
 fracture box and applied .Smith's .anterior splint. May 20th, the patient is doing admirably, not more than one drachm of pus is
 
 74 AMPUTATIONS AT THK HIF-JOINT 
 
 (l:nlv (liscliarged, and it is now assuming more of a serous t-liaracter. No pain exists even when pressure is made on tlie 
 fracture. He can raise tlie pelvis several inches from the bed, and can move the limb as much as the splint will permit ; has 
 been sittinir up in bed sevei-il days. May a.jth, the splint was removed; a few drops of serous discharge occasionally exudes 
 from tlie ojiening in the side. .Tune -jath, has been walking on crutches more or less every day since June 15th. The limb is 
 shortened two inches; can be adducted and abducted, but can be rotated to only a very slight degree; extension can be 
 performed and the limb can be semi-flexed. An extensive deposit of new bone, which can be distinctly felt through tlie 
 nmscular tissues, has taken jdace at the seat of fracture, and extending downward over and below the trochanter, confirming 
 Di'. 'Wiinie's diagnosis that the fracture implicated the trochanter, which wa.s considered probable, from the character of the 
 missile and the history of other cases. .July. IfJIJS. the patient was discharged from treatment and returned home. Dr. Winne 
 heard from liim dirictly a year afterwards, ami at that time he had dispensed with crutch. 'S and could walk perfectly well with 
 the aid of a cane. 
 
 T4ie two following cases are good examples of recoveries from gunshot fractures ot the 
 neck or trochifnters of the femur without operative interference. It i.s not known, 
 however, that anipiitalion at the hip-joint was proposal in either case: 
 
 Private .James McCabe. Co. A, I'Jth Massachusetts Volunteers, was wounded on September 17, 18G2, at the battle of 
 Antietam. by a musket ball which entered just below the riglit groin and made its exit at the buttock, fiacturing the neck of the 
 femur in its passage. He was conveyed to Hospital No. 5, at Frederick, Maryland, and was treated with the limb in an 
 extended position. On November Dth. he was transferred to Frederick Hospital No. 1. In December, a large metastatic abscess 
 formed about the right shoulder. Avliich was incised 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 nuiscles of the acromial and humeral regions, and the patient 
 could not raise his hand above his chin. On .Jime IGth. he was sent in good condition to the Jarvis Ho.spital. at Baltimore, and 
 thence to I'oint Lookout Hosjiital. wliere he remained until July 3, 1863, when, the wound being healed, he was discharged 
 from the service of the United States On June 10, 1867. he was examined at the ofKce of Surgeon General Dale, of Massa- 
 chusetts. The fracture was firndy consolidated. There was but a slight lini]) in walking. His general health was excellent. 
 He received a pension from the U. S. Government, and was emiiloyed in the "Soldiers' Messenger Corps." He experienced no 
 ])ain. 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 ot horse cars in Boston. 
 
 In the next case, the recovery was equally satisfttctoiy and perniiinent: 
 
 Private Andrew F. Dinsmore, Co. E, 3d Michigan Volunteers, aged nineteen years, was wounded at the battle of Fair 
 Oaks. May 31, IStW, by a nuisket ball which fractured the trochanters of the left femur and lodged. His wound was dressed 
 on the field l>y Surgeon D. W. Bliss. U. S. \'olunteers, and he was then removed to the Hygeia Hospital, at Fort Mcmroe. In 
 tlie middle of June he was transferred to the De Camp Hospital, at David's Island, and was there treated by moderate extension 
 and counter-extension, and bv the removal of numerous detached fragments of bone. By the end of ISiYi, firm union had taken 
 place, and on April 19, 18(i3. the wouml having healed, Dinsmore was discharged from the service of the United States, having 
 a strong and useful limb, with trivi.al shortening and deformity. On July 11, 1863. he enlisted in the 2d Battalion, Veteran 
 Keserve Corps, and served three years. From time to time a fistulous orifice would appear in the cicatrix and discharge a 
 small cmantitv of pus. <j|i December 21, 1866. Mr. Dinsmore was in good health, siifi'ering little or no inconvenience from his 
 injury, thouidi the ball remained in the limb. He was then emidoytul as a clerk in the Genend Land Office. At that date he 
 was photographed at the Army Medical Museum. The})icture is numbered 1.57 in the surgical series of the photographs of the 
 Museum. 
 
 Even when the hrad of the femur has l)een fractured by a musket hall, recoveries 
 have taken jilace iuid<T conservative treatment. The folhiwiiig case is an example: 
 
 Lieutenant Colonel James C. Strong. 38th New Y(uk Vnhuiteers. was wounded at the battle of Williamsburg. Virginia. 
 May 5. 186'i. bv a conoidal musket ball which entered over the right sartorius muscle about four ini'hes below its origin, and 
 made its exit near the right margin of the low'er pcution of the sacrum. Surgeon A. J. Berry, 38th New York Volunteers, 
 examined the wound .and found that the ball had deeply grooved the head of the femur, and hail fractured the niijier rim of the 
 acetabulum. A detached fragment of the rim nearly an incli and a half in length, a part of it covered with articular cartilage, 
 to"ether with portions of clothing, were extracted from the wound. On the 8tli of May the patient was transferred by a steamer 
 from Queen's Creek Landing to the Hygeia Hospital at Fort Monroe. Hen^ he remained until the l;!th, when he undertook a 
 jiainful journey of five days on a litter, and reached his home in Untl'alo, New York. The injured limb was semi-Hexed and 
 njtated inwards, the head of the femur being dislocated upon the ilorsum of the ilium. Any attempt to ]dace the limb in [losition 
 produced such acute sufl'ering that the effort was abandoned. For ten weeks there was profuse suiipuration with burrowing of 
 pus in the thigh and intense pain, with chills, profuse perspiration and great prostration, afier which a very gradual amendment 
 took jilace. On December Vi. 1862. the patient was removed to Philadelphia, and entered at the Officers' Hospital at Caminack's 
 Woods, where he was able to bear treatment by Buck's method of extension by weights. Here a number of spiculjc of bone 
 were extracted or washed from the wound. On January 0. 18''i3, the patient w.is discharged from the hospital. On .June 1st 
 tlie wounds wi-re nearly closed, and he rejoined his ri'ginient im crutches and was mustered out with the regiment on .Tune 22. 
 l"6:i. On Seiitember 2'Jth hv. wa.s appointed Colonel in the Veteran Reserve Corps. He was subsequently brevetted Brigadier
 
 IN THF WAR OF THK REBELLION. (O 
 
 Gem-ral. In .Tiily, 186. ■, he visiti'd tlie Army Mi'dical Museum and was exaniiui'd by Assis^tant Surgeon (i. A. Otis, U. S. 
 Army, anrl liis ])h()tograpli was taken. General Strong was then in good health. His limb was sliortened nearly five inches, 
 but, by the inclination of the pelvis and extension of the toes, lie was enabled to walk with surprising ease and activity, with or 
 witliout a cane. The head of the fenuir was firmlj' anchylosed on the dorsum of the ilium. The cicatrices appeared sound. 
 His picture is numbered 156 in the surgical series of the photographs of the Museum. . ■• 
 
 That the neck of the femur should be fractured by a musket ball without fissures 
 extending into the articulation, appears almost impossible. Yet it was thought that such 
 a condition existed in the following case: 
 
 Captain William A. Bugh, Company G, 5th Wisconsin Volunteers, aged thirty-five years, was wounded at tlie engagement 
 at Williamsburg, Virginia, on May 5, IS62, and after lying a few hours on the field, he was removed to a temporary hospital, 
 and thence to an hospital transport in the York river and sent to Baltimore, where he was received at the Camden Street IT. S. A. 
 General Hospital, on May 10, 1862. A conoidal musket ball had entered the right groin, passed slightly downward, ti-aversed 
 the line of union between the thigh and trunk, fractured the neck of the femur in its transit, and emerged posteriorly at the fold 
 of the buttock On tlexing 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 synjptom, 
 and in the middle of July, 1862, consolidation of the fracture was sufficiently firm to permit the patient's removal to the liouse 
 of a friend. The limb was shortened one and a half inches. In October, Captain Bugh was able to move about on crutclies 
 and the wounds were entirely healed. About this time he took a journey to Washington, and was promoted to a Lieutenant 
 Colonelcy in the 32d Wisconsin Volunteers and placed on recruiting service. He served until April 25, 1863. His recovery 
 was so rapid and uninterrupted that he reluctantly assented to the assurance of his surgeon. Dr. Edward G. Watere, that he 
 would be incapable of active duty in the field. A letter was received at this office 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 sufl^ered no inconvenience from the sliglit shortening of the femur. 
 
 Brevet Major W. M. N^otson, Assistant Surgeon, U. S. Army, made the autopsy in 
 
 the case of Captain J. !M. L , related in Circular 'No. 6, S. G. 0., 1865, p. 33, and he 
 
 is confident that the fracture was extra-capsular in that instance.^ It is barely possible 
 that the lesion may have been of a similar character in the following case : 
 
 Private James Vanderheck, Co. F, 145th New York Volunteers, 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 
 forwards and inwards, fractured the neck of the femur, and nutde 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 12th Corps Hospital at Aquia Creek. 
 The injured limb was simply placed in a cgmfortable position, without any attempt at extension. On June 14, the patient was 
 removed (ra an 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 sub- 
 sequently, he was transferred to Philadelphia, and thence, on October 12, to New York, where he was admitted at 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. At that date he walked with crutches. His limb was shortened two inches, with 
 eversion. He was allowed a pension of fifteen dollars a month. On August 2, 1866, Dr. E. Bradley, examining surgeon of 
 the Pension Bureau, reported that Vanderheck's general health was good, but that there ^vas much lameness. The fracture 
 was firmly consolidated. 
 
 The records of this office include numerous histories of patients who have recovered 
 with tolerably useful limbs after gunshot fractures of the upper third of the femur. In 
 several of these the trochanteric region was implicated. The surgical series of photographs 
 of the Army Medical Museum includes illustrations of fifteen such cases. 
 
 ' See Catalogue of the Surgical Section of the Army Medical Museum, p. 235.
 
 7(3 AMPUTATIOIvS AT THK HIP-JOINT. 
 
 CONCLUDING OBSERVATIONS. 
 
 In 1861, Stromeyer declared that it was "not yet proved that amputation at the hip- 
 joint was deserving of a place among the resources of military sui'gery," Loeffler denied 
 tliat we were yet assnreil llial an adult could hear this eperation, and Rochard formally 
 protested against it as a primaiy procedure.^ For some years previously M. Sedillot had 
 taught tliat j)rimary amputation at the hip was always fatal. Jubiot and Baudens had 
 insisted tliat hip-joint amputation was an exception to the general rule requiring all 
 amjiutations deemed indispensable to 1)0 performed immediately, and ]\I. Legouest had 
 sought to establish the rule that the operation sliould never be performed primarily unless 
 the thigh was almost entirely torn away from the trunk, which opinion, after a favorable 
 report from Baron H. Larrey, was formally adopted by the Surgical vSociety of Paris." 
 
 The experience accpiired in the war of the rebellion indicates that these maxims and 
 rules are too unqualified and absolute. A soldier who underwent primary amputation at 
 the hip for gunshot injury more than four years ago (see Dr. Shippen's case, ante, p. 26) 
 is still alive and well, so that the possibility of •such a result cannot in future be questioned. 
 In two other instances, (see Case III and Case VIII, of Drs. Gilmore and Compton, ante, 
 pp. 24 and 26,) patients suflieiently recovered from the operation to bear transportation to 
 their homes; and though tlieir sulisequent history has not been traced, because they lived 
 in very remote localities, it is cpiite probable that they recovered completely.^ I have 
 classified these (-ases in the tallies with that of the lieutenant of dragoons on whom Baron 
 Larrey operated in 1812 — wlio survived three months, but failed to return to France, 
 conceding that the ultimate results were doubtful. I have appealed to Larrey's report of 
 liis case'' to jirove that it was a primary one, and that the French surgeons could not 
 fairly claim it as a success and yet classify it among intermediate amputations. This 
 case must he admitted to give what weight it has, with those of Dr. Cilmore and Dr. 
 Compton, in favoi- of primary anqjutation at the hip for injury. Uu the other hand, the 
 list of failures is discouragingly long. Taking the forty-four primary operations enumerated 
 in the tables and a<lding to tlieru twenty-eight similar cases which are only reported 
 
 ' SriiOMEVKK, Maximen der Kriei/shcilkunst. LoErKLM!, GrundsiiUe und Iler/cbifiir die Behandluwj der Schtisswunden im 
 Krkye. Rocii.iHD, Du Urn-ice ChiruryicaU dc la Flotte, appended to Saurel's Traite dc Chiruryie Sarale. 
 
 ■^Sk.dim.ot, Traite dc Med. Oper. Jubiot, Theses dc Montpellier, 18i0. hwrn-iss, La G-uerre de Crimec. Lkgouest, 
 De la Desartindatlon Coxo-fimorale au Point dc Vme de la Chiruryie d'Armie. II. Lahrey, Mim. de la Society de Chirurgie, 
 Tome V. 
 
 ' Oiite misled b_v tlie erroneous report of au alleged sueee.«st'id ))nniarv amputation at tlie iiiji at Menijiliis in the early 
 part of the war. (see ante, p. 'il,) I am unwilling to cite any case as successful in which the permanency ot' the cure is not 
 incontrovertihly established, and 1 have not quoted au example of successful primary amputation at the hip for gunshot injury 
 published by Dr. W. A. East, of San Antonio, Texas, in the Southern Journal of the Medical Sciences, vol. 1, p. i'M, August, 
 1866. Dr. East states that in the latter part of the year 1861, in Lavacca County, Texas, he amputated at the liip-joint, ten 
 hours after the reception of the injnry, in the case of a negro refugee, aged twenty-five years, who had the head of the right 
 teniur shatti'i'ed by a ritU^ ball. He states that he employed Larrey's nu'tliod, and that "the man's recovery was rapid; indeed, 
 at the end of si.\ weeks he was hobbling about on criitclies." At>er a few weeks an abscess formed in the lumbar region, from 
 which a llattened ball was e.\li-acted. In the winter of 1885-00, Dr. East heard from Dr. Douglas, who ha<l assisted at the 
 operation, that the man continued well. 
 
 ' Mimoirea de chirurnif. inililaire el campagms, Paris, 1817, Tome iv, p. GO. See ante. p. l."), note 8.
 
 CONCLUDING OBSERVATIONS. // 
 
 immerically, we obtain a total of seventy-two primary amputations at the hip for gunshot 
 injury, of which sixty-eight were fatal and one was successful, while the issue in three 
 cases was involved in uncertainty. 
 
 Appalling as they are, these figures do not teach that the operation is to be abandoned. 
 Few will deny that when the thigh is torn away by a large projectile so high up that 
 amputation in the continuity is impracticable, it is incumbent upon the surgeon to regulate 
 the wound by suitable incisions, and to disarticulate the head of the femur. This is the 
 first condition under which primary coxo-femoral amputation is admissible in military 
 surgery. But one instance (Case XIV, ante, p. 29) was reported in the late war in which 
 the operation was practised under such circumstances. 
 
 In the nest place, it may be safely asserted that when the upper portion of the femur 
 is very extensively comminuted by solid shot or fragments of shell, and the soft parts are 
 greatly lacerated in such proximity to the trunk as to forbid amputation in the continuity, 
 the limb should be at once removed at the hip. There is no recorded instance of 
 recovery from such a condition under conservative treatment, or after excision of the upper 
 portion of the femur, while Dr. Compton's patient thus injured (Case VIII, p. 26) survived 
 immediate amputation at the hip for six mouths certainly, and perhaps recovered com- 
 pletely. Of the nineteen primary coxo-femoral amputations described in this report, two 
 were performed for injuries by solid shot (Cases VI and XVIII) and eight (Cases I, II, 
 VIII, X, XI, XIV, XV, XVI) for injuries inflicted by fragments of shells. Four 
 intermediate amputations (Cases XXIII, XXIV, XXIX, XXXI) were performed for 
 similar injuries and all resulted fatally. Thus, the delayed operations were less successful 
 than the j^rimary. It may be added, that in such injuries as are described in Dr. Carnochan's 
 case {ante, p. 30) and illustrated in Figure VII, delay is out of the question, for clearly 
 the patient would not survive it. The operation must be done immediately in such 
 instances or not at all. 
 
 The third condition under which primary coxo-femoral amputation appears .to be 
 admissible in military surgery, is when, with fracture of the upper extremity of the femur, 
 the femoral vessels are wounded. This condition existed in four of the cases described in 
 this report. (Cases VIII, XI, XIV, and XXVII.) It is erroneous, therefore, to allege, 
 as some surgeons have done, that all patients with such wounds will perish from haemorrhage 
 before surgical assistance can be afforded them. In Dr. Lay's case, [ante, p. 28,) the 
 femoral was immediately ligated, and the wounded man was then conveyed to the hospital 
 where the amputation was performed. In Dr. Compton's case, (Case VIII,) so often cited, 
 the femoral was compressed, and the amputation was done sur le champ, and the patient 
 went to his home with his stump healed. In Dr. Pineo's case, (Case XXVII,) in which 
 the operation was delayed for a fortnight, and until gangrene had supervened, there had 
 been little primary haemorrhage. The result was promptly fatal. The advantages are 
 again with the primary operations. 
 
 The observations of the late war affoi"d but little data for the determination of the 
 question propounded by M. Legouest :^ whether, in the event of the simultaneous division 
 
 ' De la Dharticulation Coxo-fimoraU a« Point de Vue dc la Chimnjie d'Ann(e. Dans Bcc. de Mem. de Med. dc Clnr. ct dc 
 Phar. Mil. Tome XV, p. 240, Deuxi&iiie S6ne.
 
 78 AMPUTATIONS AT THE HIP-JOINT. 
 
 of tlio feiiK)ral artery and vein near the cmu-al arch withont fracture of the femur, if the 
 surgeon has had the good fortune to master the haemorrhage, it woiUd be better to 
 immediately disarticulate at the hip, or to tern|)ori/.e and await the invasion of gangrene? 
 
 Another cjuestion admitting of argument is: whether in those cases of fracture of the 
 trochanters by conoidal musket balls accompanied by such extended longitudinal Assuring 
 as precludes excision, the surgeon should not advise immediate ablation of the thigh? 
 The experience acquired in the late war tends to determine this question affirmatively. 
 This form of injury is illustrated in Figure's XI and XIT, representing specimens taken 
 from patients who underwent intermediate amputations which resulted fatally. An 
 examination of the histories of ten or twelve similar specimens in the collection of the 
 Armv ]\Iedieal ]\Iuseum, taken from patients wlio were treated without operations, slfow 
 that they survived their injuries, on an average, about one month. It is probable that 
 tliese patients would have liad a better chance for their lives if they had been amputated 
 primarily. 
 
 In short, the observations detailed in this report do not sanction the conclusion that 
 ablation of the thigh is an exception to the general rule requiring amputations that are 
 indispensable to be done immediately, and that even a brief delay is desirable in hip-joint 
 amputations. On the contrary, they tend to show that unless the nature of the injury is 
 such that the operation can be delayed until the secondary period, it is better that it should 
 be done at once. 
 
 It must be admitted, however, that this view conflicts with very weighty evidence 
 heretofore accumulated. Though the eighteen intermediate amputations of the late war 
 resulted fatally, yet we find among the sixteen other intermediate cases recorded in the 
 tables two recoveries, and to these must be added the well attested successful operation of 
 Wedemeyer and probably that of Langenbeck, these being excluded from the tables 
 because they are not re.ported in detail. Since this report was sent to press a letter has 
 been .received from Dr. B. P. Lay, of Padticah, Kentucky, giving information of two 
 additional I'atal coxo-femoral amputations which he performed during the war, and Dr. J. 
 Hcyfelders rej)ort on tlie wounded after the battle of Sadowa,^ winch records tliree 
 unsuccessful amj^utations at the hip, has come to hand. It is believed that these five were 
 intermediate operations. Adding them to tlie thirty-four intermediate amputations 
 enumerated in the tables, and adding also Demnie's three cases and those of AVedemeyer, 
 Robert, (lucrsiuit, and Langenbeck, we make the statistics of intermediate amputations at 
 the hip-joint for gunshot injury forty-six cases, with four successes and forty-two deaths, a 
 more favorable exhihit than can yet be claimed lor the primary operation. 
 
 To the statistics of secondary hip-joint amputations, the surgery of the late war 
 brings its contribution of two successes, (Cases XLII and XLIII,) or, if the reamputations 
 are inchubjd, of six successes. Leaving the latter out of consideration for the present, 
 and adding only the successful secondary operations of Drs. Bentley and Blackman to 
 those of Brownrigg, Arlaud, Isnard, Roux, and Neudorfcr, we find that in nineteen 
 secondary amputations at the hip-joint thus far recorded in military surgery there were 
 
 ' Gitcdte MMieiUc dc Paris, Nos. '.i'2, 33, 35, 1807. Two opfi-.atioiis wcri' iloiic at the Cliutcau cit' Hnnli-ck ; liotli patients 
 siiccunilu'd witliiii r<»fty-cii;lit lumrH. One was pi_*i*foniM_'iI at \t'f,'<flisfli, witli a I'utal result.
 
 CONCLUDING OBSERVATIONS. 
 
 79 
 
 twelve deatlis, a mortality rate of 63.15, or less than the average mortality in amputations 
 in the continuity of the thigh. It must be remarked also of one of the seven unsuccessful 
 secondary operations (Case XLI) described in this report, that the patient succumbed four 
 months subsequent to the operation, which had in reality succeeded, from an internal 
 disease unconnected with the operation; and of another, (Case XLIV,) that the favorable 
 prospect of recovery which existed was lost through the negligence of the nurse, who was 
 absent when a fit of coughing detached the ligature from the femoral artery and led to a 
 fatal haemorrhage that might readily have been controlled. 
 
 A number of surgeons have expressed .the opinion that an amputation in the con- 
 tinuitv might have been substituted for the successful secondary disarticulation described 
 in Case XLII, since the upper portion of the femur, which is well depicted in -plate III, 
 presented externally a normal appearance. Dr. Bentley preferred to exarticulate in this 
 case because of his conviction that disease of the superior fragment of the bone was the 
 the principal source of irritation. The specimen (No. 4386 of the Surgical Series) was 
 sent to the Museum after maceration, and the opportunity of examining it in the recent 
 state was lost; but, upon subsequently making a longitudinal section of the superior 
 portion of the bone, I found the compact tissue diminished in thickness and very porous, 
 the spongy tissue obliterated up to the level of the lesser trochanter, and above that point 
 rarihed, presenting reticulations of extreme tenuity. There was a general discoloration of 
 the internal structure, which I have observed in all long bones that have been affected with 
 osteomyelitis when prepared according to the process employed at the Museum. A trans- 
 verse section of the upper fi-agment was prepared for the microscope by Mr. Schaeffer, 
 (Specimen 2121, Microscopical Section A. M. M.,) and was pronounced by Dr. Woodward 
 to present the characteristic microscopical alterations of osteomyelitis.^ Dr. Bentley's 
 
 ' Brevet Lieutenant Colonel J. J. W'oodwartl, Assistant Surgeon, U. S. Avniy, 
 lias kindly furnished me with the Ibliouing account of the striictui-al alterations 
 of bono in osteomyelitis, and I ani indebted to Brevet Major Edward Curtis, 
 -Assistant Surgeon, U. S. Army, for the photonn'crograph from whicli the illus- 
 trative wood-cut is copied: 
 
 ''Tlie first anatomical alterations in osteomyelitis beyond mere hyperemia of 
 tlic involved blood-vessels, appears to be cell nmltiplication aft'ecting the con- 
 nective tissue corpuscles of the marrow, and of the connective tissue surrounding 
 tlie blood-vessels in tlie canals of Havers. As a conserjuence. the true osseous 
 tissue is encroached upon, and the portions of it wliicli immediately adjoin the 
 nndtiplying connective tissue disappear. In sections of the macerated long bones, 
 therefore, the compact substance appears preternaiurally porous to tlie naked eye, 
 and in microscopical sections it is observed, as in Figure XXVII. that many of the 
 canals of Havers are somewhat larger than natural, while othei* have extended 
 into irregular channels often of considerable .'?izc. Similar changes render the 
 arcoliE of any involved cancellated structure larger tlian normal, while the narrow- 
 cavity ot the shaft is somewhat enlarged, tlie compact .substance appearing 
 unusually thin as well as porous. The precise steps by which the true osseous 
 ti.-siie tliu.s disappears .are not thoroughly made out, and observers dis|)ute ,as to 
 their details. It appears probable, however, that the bone cells which occupy the 
 lacuna; next to the multiplying connective tissue themselves enlarge and niulti|dy, 
 the matrix between them being absorbed, and that thus the bone cells themselves 
 contribute to the resulting gi-anulatiim tissue. The fat in the adijiose tissue cells 
 of tile marrow is also absorbed, and these cells appear to contribute by their 
 multiplication to the gi'anulatiou tissue formed, as is the case in inflammation of 
 the subcutaneous adipose tissue." 
 
 "Tile subsequent iilterations of suppuration or gangrene mid not be here 
 described."
 
 80 ' AMPUTATIONS AT THE HIP-JOINT. 
 
 dcc'ir^ioii is llierei'ore viudicated by the pathological conditiou as well as by the successful 
 issue of his case. 
 
 The large number of reamputations at the hip-joint constitutes an interesting and 
 novel feature in the surgery of the late war. Had these been included, as has commonly 
 been done, with the secondary amj^utations, the statistics of the latter would appear in a 
 still more favorable light. The successful reamputations augment to the number of seven 
 the total of recoveries during the war after amputation at the hip-joint, apart from the 
 probably successful cases of Drs. Gilmore and (Jompton (Cases III and VIII). The 
 appearances of the stumps of these seven survivors, long after their recovery, are presented 
 in th(^ plates appended to this report. Of tliese plates, it mav be remarked in passing, 
 that sev(U-al of them were unavoidably copieil i'rom very inferior photographs, and that the 
 prints of the first of the series are inferior to the proofs. 
 
 It is probable that anaesthetics were administered in each of the fifty-three operations 
 described in this rejDort, except in that of Dr. Lay (Case XI). But in the reports of six of 
 the cases this point is not mentioned. In thirty-two of the forty-six remaining cases 
 chloroform was used; in eleven, ether; and in three cases a mixture of the two was 
 employed. Although, in case XVI, the supposed effects of the chloroform excited some 
 anxietv, and in case XXVI, in which the patient died upon the operating table, the 
 surgeons thought that chloroform had been too freely administered, there is not sufficient 
 eviileni'e that aiuesthesia tended to promote the iVital result in any instance. On the 
 contrarv, there is reason to lielieve that ans-sthesia, in addition to its beneficent influence 
 mion the morale of the patients, diminishes the shock both of injuries and operations. 
 But it would be expecting too much of antestliesia to anticipate that it should remove this 
 great source of danger altogether, and it has been pointed out in the prefatory remarks to 
 the did'erent categories of cases, that m tlie primary operations more than one-half of the 
 patients succumbed to the direct shock of the mutilation, while less than one-third of those 
 o]ierat(^d on at a period remote from the injury perished from this cause. 
 
 In twenty-seven of the operations, the riglit thigh was extirpated; in twenty, the 
 left; in thi' reports of six cases, it is not specified which limb was removed. 
 
 It has been already mentioned that fourteen of the operations were done for injuries 
 produced l)y cannon shot. Thirty-eight operations were performed on account of Avounds 
 caused I>y small-arm projectiles, or for lesions consequent upon such injuries. In thirty 
 cases the missiles were conoidal musket l)alls; in four, musket balls of 
 undescribed shapes; in one case, the large round l>all with buckshot; in 
 three, conoidal pistol balls. Mstly, one operation was rendered neces- 
 sary by complications following a bayonet wound of the knee-joint. 
 Next to the shock to tlie sjrstem, hiT^morrhage during the opera- 
 tion has been esteemed the prinei])al immediate source of danger in 
 amputations at the hip-joint. Since the beginning of the war some 
 progress has been made in our means of averting this peril. In 1845, 
 Mr. W. S. Cox advised that the arterial compressor invented by 
 vSignoroiii, of Padua, should be emi)loved in amputations at the hip- 
 joint to control tlie arterial circulation at the groin without impeding 
 
 [■■li^.XXVIIl. Sigiinmni'a hi.rsc- ' , i- 1 1 I 1 i I • rri • i- tl ', 
 
 si„„Mdrn|.rfS6.,r. tile retum (il t)looi[ livthc N'euis. i I US suggestiou ap|iareiitly met
 
 CONCLUDING OBSERVATIONS. 
 
 81 
 
 with but little favor, and surgeons continued to rely in this operation upon digital com- 
 pression of the crural artery upon the ramus of the pubes, or else upon preliminary ligation 
 of the femoral artery. After all, the bleeding fi'om the branches of the internal iliac was 
 chiefly feared; for, in most of the methods of operating, the femoral could be readily 
 commanded, either by preliminary ligation, or by compression in the flap prior to its 
 division. But, by lengthening the blades of Signoroni's tourni- 
 quet, it may readily be made available for comjsression of the 
 abdominal aorta, and thus the bleeding from the gluteal, obtu- 
 rator, sciatic, pudie, and other arteries at the back of the thigh, 
 may be controlled as perfectly as that from the branches of the 
 femoral. When this is accomplished, amputation at the hip-joint 
 may be done with great security as regards haemorrhage, as has 
 now been demonstrated in many instances. Compression of the 
 aorta has been resorted to without any injurious effect upon the 
 general circulation or the respiration in most of the hip-joint 
 amputations recently done in England; and since 1860, when it 
 
 . T ■ I-,! -1 T 1 1 ■ 1 11 f T IT) i -i FICXXIX. Sigi.oroni's tourniquet mod- 
 
 was introduced m Philadelphia by rroiessor Josepti rancoast, it iAed for compiession ot the aorta. 
 
 has been employed in several such operations in that city. It was successfully adopted 
 in five of the fifty-three cases detailed in this report by Drs. Weir, Morton, Agnew, Forbes, 
 and DuBois. As Siguoroni's instrument is liable to slip, one of the circular arterial 
 compressors may be advantageously used. A modification suggested by Skey or Syme 
 and employed in Philadelphia is figured on page 51. Other forms have been recommemled 
 by Carte, Lister, and Pipilet. The circular tourniquet made 
 for the U. S. Army by Tiemann, of New York, is repre- 
 sented in Figure XXX. 
 
 In twenty-three of the fifty-three amputations at the hip 
 described in this report, the hasmorrhage, during the opera- 
 tion, is described as "slight," "inconsiderable," "trifling," 
 or "trivial;" in five, it is said to have been moderate; and 
 in three cases it is admitted that it was excessive. In 
 twenty-two cases this point is not alluded to. On an 
 average, fourteen or sixteen ligatures were required. In six 
 cases the femoral was ligated as a preliminary measure. 
 One or two surgeons preferred to include the femoral vein 
 in the ligature of the artery. Acupressure was not employed 
 in any of the cases. It was applied in an hip-joint ampu- 
 tation for disease, by Dr. A. Hewson, in 1865,-^ but there was much loss of blood before 
 all the needles were placed, and the patient died without reaction. 
 
 The hfemorrhage, at the time of injury, is described as profuse in one of the fitty- 
 three cases, and as copious in another. In a third, there was free bleeding from a small 
 vessel twenty days after the injury. 
 
 ' Amei-kan Jwirnal of the Medical Scicnec!:. Vol. LIT. ]i. :i2. July, ISfiG. 
 11 
 
 Fig. XXX. Aortic compressor made by 
 TieiiKiiin.
 
 82 AMPUTATIONS AT THE HIP-JOIXT. 
 
 There was secondary haemorrhage in five of the fifty-three operations. In one case 
 it \xafifou(ho)/ante and promptly fataL In two others it was copious, and necessitated the 
 ligation of the external iliac. In one of these cases, (Case XLIX,) the bleeding recurred 
 on the se2:)aration of the ligature and was controlled by digital compi'ession, persevered in 
 for a fortnight. 
 
 Of the forty-two cases in which the cause of death is stated, the patients succumbed 
 to the direct shock of the operation in twenty-one cases, three died of pyaemia, one from 
 sudden secondary luemorrhage, and eighteen from causes grouped under the general head 
 of exhaustion, in tlu'ee of whom there had been much haemorrhage during the operation, 
 in two of whom erysipelas involved the stumps, and in four, gangrene. In two of the 
 operations gangrene had invaded the limbs before the operation was performed. 
 
 Of the different modes of operating little need be said. Fourteen or more have 
 attained the distinction of being generally known by the names of the surgeons who 
 proposed them. Several of them have been practised only on the dead subject. In 
 military surgery, especially, there must be much variation in the mode of operating, 
 according to the location of the injury. I shall briefly recapitulate the diflferent methods 
 with which the jnedical officers of the army are familiar, in order to point out which were 
 employed in the operations done during the war. 
 
 CIRCULAR aiETHOD. 
 
 Aberncthy proposed this method for amputating at the hip-joint, and demonstrated 
 it at his lectures for many years. He made a circular division of the integuments, about 
 three inches below Poupart's ligament, retracted the skin as much as possible, divided the 
 muscles by a second circular incision, and then disarticulated. His precepts were followed 
 by Cole and S. Cooper.^ It would appear that Kerr had already employed this method 
 in his operation in 1774.^ (iraefe^ operated by this plan, using a knife of his invention, 
 enlarged and rounded off' at the end, to divide the muscles obliquely after the manner of 
 Alanson. The circular operation was practised also by Krimer* and Jaeger.^ Veitch ^ 
 advocated it and jiroposed a trivial modification. Larrey finally advised a modification of 
 the circular method, ' although liis own operations were done by forming double lateral 
 flaps. Lacauchie has lilvcwise recommended the circular method, modified by a vertical 
 incision over the trochanter major to facilitate disarticulation.® Surgeon R. B. Bontecou 
 approves of this plan, because it enables the operator, upon definitely ascertaining the 
 extent of the injury in the femur, to disarticulate or to saw tlic bone below the trochanters, 
 at his option {ante, p 68). Li llie operations performed during the late war, this inethod 
 was successfully adopted by Dr. Blackman, (see a7ite, p. 43, Case XLIII,) and was 
 employed also by Dr. Compton in the case of his patient who survived the operation for 
 six months or more (see ante. p. 26, Case VIII). 
 
 ' Coopkk'.s Dirtionary of Praclical Surgery, 8th London ed., p. 115. 
 
 - An Aeconnt of the Operation of Amputation of the Thigh at the Upper Articulation, lately performed , in Edinburgh Medical 
 and Philompldcal Commentaries, vol. vi, p. 3:}7. See also South's Chelius, Am. cd., vol. iii, p. 690. 
 
 ^ Xormen fiir die Ablosung griiaserer Gliedmassen, p. 117. 
 
 ■•Von Guakfe and Vox Wai.tiieu'.s Journal, vol. xii, p. l-.il. 
 
 ^'Hamburger Zritgrhrift, vol. iii, part i. 
 
 ''Edinburgh Medical Journal, vol. iii, p. i:U, 1807. 
 
 ''CliniqiK C'hirwrgirale. par le Baron D. J. Larhkv, Tome iii, p. fiV.l 'J'lie (>i)cia(iiiM is figured and di^.-icriLrd in 
 HiMirgerv's Plates, Tome vi, PI. 88, Fij,'. 3. 
 
 • tinzrtir Mcdicalr dc Paris. Ninneros ID, 20, 2.5, 26. 1850. And .!««. rf< la (Mr. Iranf. el Strang. 'I'. II. |.. 11.
 
 CONCLUDING OBSERVATIONS. 88 
 
 MIXED METHOD. 
 
 This method, wliifh was first recommended by Le Dran, * consists in making flaps 
 of integument and dixiding the soft parts by circular incisions. It was largely and 
 advantageously employed iu the war of the rebellion in amputations in the continuity. 
 It was described as the most suitable operation for the hip-joint by Skey," and was 
 adopted by Dr. J. Mason Warren in his successful hip-joint amputation in 1859.^ Professor 
 Joseph Pancoast operated successfully by this method in 1860, and again in 1865, and 
 Professor S. D. Gross employed it in his successful amputation at the hip in 1865.^ It 
 was employed by Drs. Agnew, Forbes, and Morton in three of the cases detailed in this 
 report; Case XLIV, Case XLV, and Case LI, the last being a successful operation. 
 
 OYAI. METHOD. 
 
 The V-shaped incision for disarticulating at the hip-joint was proposed by Belmas in 
 1824, and frequently demonstrated by him on the dead subject at the medical school at 
 Strasbourg. Entering the knife an inch above the great trochanter, he made an oblique 
 incision downwards, outwards, and backwards to a point four fingers' breadths below the 
 ischial tuberosity ; then placing the knife in the superior angle of this wound he made 
 another incision forwards, downwards, and inwards till it joined the first; then the muscles 
 on the outside were deeply divided; the knife reached the articulation externally and 
 opened it. An assistant introduced his fingers into the wound and compressed the 
 femoral, and the division of the soft parts was then completed and disarticulation effected. 
 In 1S27, Scoutetten^ published a minute description of this operation and of the surgical 
 anatomy of the region, illustrated by excellent plates. Sundry modifications, such as 
 dissecting up the skin before dividing the muscles, disarticulating the femur before 
 dividing the internal mass of soft parts, making a vertical cut over the trochanter and 
 letting the oblique incisions diverge lower down so as to preserve more integument, 
 putting the apex of the V-shaped incision near the superior iliac spine instead of above 
 the trochanter, making a preliminary ligation of the femoral artery, etc., constitute the 
 procedures of Sanson, ® Cornuau, '' Malgaigne, ^ and FouUioy." It is admitted that the 
 thigh may be removed at the hip by the oval method, in a brilliant, expeditious manner; 
 but M. Velpeau sneers at it as a dissecting room operation, and Mr. Cox, 8. Cooper, 
 Costello, and others, also object that it has not been tested on the living subject. These 
 objections are unfounded. . M. Sedillot operated by this method in the campaign in Poland 
 in 1831,^° and Sir Astley Cooper's operation in 1824 was certainly performed according 
 to this plan," though the epithet "oval" had not then come into use. Although Guthrie 
 
 ' Traits des Operations de Chtrurgk, Paris, 1742. 
 
 ' Operative Surrjery, by F. C. Skky, F. R. S., Am. ed., 1851, p. 336. 
 
 ■' Boston Medical and Surgical Journal, vol. 60, 1859, p. 3i9, and Surgical Observations, with Cases and Operations, by J. 
 Ma.sox Warren, 1867, p. 402. 
 
 ■■ The American Journal of the Medical Sciences, vol. lii, p. 58. , 
 
 '•La Methode Ovalaire, ou NouvelU Mithode pour amputer dans les Articulations, par II. Scoutktticn, (]uartii. Paris, 
 1827, p. 31. 
 
 '' Sahatier, Mdd. Opir. fidition de MM. Sanson et Begin, Paris, 1832. Toiiih iv. \\. G82. 
 
 'M. Velpeau, Koav. litem de Med. Oper. Tome 1, p. 525. 
 
 ' BouRiiEUY. Iconographif. d'Anat. Chir. et de Mid. Op. Tome vi, p. 274, et Planclie 83, Figs. 1, 2, I't 3. 
 
 'VlD.iL. Traits de Path. Ext. ct de Med. Oper. TroisiiSme 6d. Tom;- v, p. 701. 
 
 '" SfcDiLLOT. Traile dc Med. Oper. Troisifeme ed. Tome i, p. 465. 
 
 " S. Cooper's Surgical Dictionarg, 8th ed., p. llfi.
 
 84 AMPUTATIONS AT THE HIP-JOINT. 
 
 styled liis jilaii of auiputatino- at tlio hi]) a ilnulilc fla|i ojieration. it is essentially identical 
 witli the (ival niethud. and is so described by many anthors (Sanson, Chelius, Malgaigne, 
 etc.) Professor Heyfelder. of Erlangen, adopted this method some years since in five 
 successive amputations at the hip-joint, three of which resulted favorably, and he attributed 
 his success in a great measure to the advantages for the apposition and cicatrization of 
 the wound afforded by this plan of operating. In the cases detailed in this report, the 
 oval method was adopted once ordy, in Case XV, by Dr. Carnochau. 
 
 FLAP METHOD. 
 
 1 . Single Flap. — Puthod proposed this procedure, ^ recommending that a single 
 flap should be cut from within outwards, from the gluteal region and posterior part of the 
 thigh. Bryce [ante, p. 12) is said to have operated by this plan. It is commended by 
 Hunczorsky." It is perhaps the most objectionable of the modes of amputating by 
 single flap. 
 
 Lalouette originated the plan of amputating at the hip by a single antero-internal 
 tiap.'' Jle directed the operator to make a semi-circular cut from the trochanter to the 
 ischial tuberosity and to carry it at once down to the joint, to divide the capsular and 
 i-oiind ligaments, and then, grazing the neck of the bone, to cut downwards and inwards 
 a fiap (if adequate dimensions. Delpech modified this plan by first tying the crural 
 artery, forming the flap by transfixion and making it more internal, disarticulating, and 
 then dividing the soft parts posteriorly.'' Lenoir revived Lalouette's plan, in which the 
 prompt disarticulation of the head of the femur is easier than in Delpech's procedure. 
 
 Plantade was one of the first to propose, in 180(3, to put the single flap altogether in 
 front. He advised that it should be cut from without inwards, and rectangularly, after 
 tlio manner of Pavaton.^ In 1831, Dr. Ashmead, of Philadelphia, who was then in Paris, 
 demonstrated a modiiication of Plautade's procedure, ^ consisting in cutting an anterior 
 semi-lunar flap from without inwards, reflecting it and securing the arteries, disarticulating 
 and dix'iding the remaining soft parts by an horizontal incision. M. Velpeau commended 
 this plan and adopted it in his case of amputation at the hip. In 1831, also, Manec'' 
 demonstrated on the cadaver a modification closely resembling Ashmead's, excejDt that 
 the single anterior flap was made liy transfixion. The plan of amputating at the hip by 
 a single anterior ov antero-iuternal flap was preferred and practised by Langenbeck, 
 Baudens, Vidal, i\I. St'dillot, and M._ Velpeau. Surgeon E. Shippen, U. S. Volunteers, 
 gave it a decided preference, and employed it in three operations. It was also adopted 
 during the late war by Surgeons Jewett, D. P. Smith, Whitcomb, Lay, and Kiidoch. and 
 by Surgeon Comjitoii in two operations. 
 
 2. Two LatJ'Uial Flaps. — Larrey** proposed a plan of amputating at the hip by two 
 lateral flaps, which has been often practised. After the preliminary ligation of the crural 
 
 ' MoiSAND. Op. cit, p. 207. 
 
 - Anweisuii'j zu Chiriin/isriien Opcradoncn, p. 2.^6. 
 
 ■' M. Velpkau. Nouv. turn, dc Med. Op6r. Tonio i, p. 519. 
 
 ' Journal ii6n{ral de Medcdne. Tonic ciii. p. 429, 1823. 
 
 ■■' HocKOKliY. Operations r/c)wr(dts. 'I'niiK' vi. p. 272. 
 
 '■ M. Vkli'EAC. Op. cit., p. b2\. 
 
 ' I'rdcis Iconoi/raphitjuc dc Mid. Op6r. H d'Anat. Chir. par BunXAUn et Ilrirni:, p. 8(5. 
 
 " M(m. de Chir. Mil. 'I'lmii- ii. |). ISfi. Cl'mique Chir. Atl.-is, pi. 13.
 
 CONCLUDING OBSERVATIONS. 85 
 
 artery and vein, on wliicli lie always insisted, standing on the inner side of the limb, he 
 thrust a straight knife perpendicularly between the muscles attached to the little trochanter 
 and brought out the point diametrically opposite; then turning the edge obliquely inwards, 
 he cut a rather small inner flap. He tied all bleeding branches of the obturator and 
 pudic arteries, and then, taking a bistoury, laid open the capsular ligament, and, abducting 
 the thigh, divided the inter-articular ligament. He then resumed the amputating knife, 
 and formed an external flap. Lisfranc ^ is said to have amputated at the hip on the dead 
 subject in ten seconds by his modification of the lateral flap method. He entered a 
 narrow, long catling one inch below and half an inch to the inner side of the anterior 
 superior iliac spine and thrust it downwards until it struck the head of the femur, when 
 it was carried to the outer side of the bone and pushed on, the handle being carried 
 outwards so that the point should emerge just below the sciatic tuberosity. The knif« 
 was then carried around the great trochanter and an external flap three or four inches 
 long was cut. Then the knife was made to enter and emerge at the points at which the 
 limb was first transfixed, but the blade was this time carried to the inner side of the 
 femur and cut an internal flap. An assistant followed this incision with his fingers, and 
 compressed the femoral arter}^ in the flap before it was divided. Disarticulation was then 
 accomplished. Dupuytrcn~ operated in nearly the same manner, but he cut the flap 
 fi-om without inwards, which made the operation more tedious. Of the operations detailed 
 in this report, those by Surgeons McLean, Gill, De Bruler, Grant, Peachy, and Warren, 
 and one of the oj^erations bj^ Surgeon Bentley (Case XXXVI) were performed by the 
 lateral flap method. 
 
 3. Anteeo-posterior Flaps. — Amputation at the hip by forming anterior and 
 posterior flaps by transfixion, sometimes described as Beclard's ^ operation, is the plan 
 recommended by Liston, ^ and that most commonly selected at the present day. It was 
 employed in twenty-seven of the fift3'-three operations described in this report. Some 
 surgeons prefer, after forming and reflecting the anterior flap, to secure the arteries before 
 disarticulating. Others regard it as an improvement to cut the posterior flap from without 
 inwards. The majority advise that the posterior flap should be made very short. When 
 this is done the result of the operation differs very little from that of tlie single anterior 
 flap procedure. Dr. Bentley, whose experience in this operation entitles his opinion to 
 much weight, recommends that care should be taken to remove completely the round and 
 capsular ligaments and all the fibrous and fatty tissue about the cotyloid cavity. 
 
 In primary amputations, the procedure of a single anterior flap has been most 
 successful. In secondary amputations, the condition of the tissues is frequently such that 
 the mixed method of integumentary flaps with circular division of the muscles presents 
 many advantages. 
 
 Of the general condition of those who recover after amputations at the hip-joint, as 
 illustrated by the seven survivors of this operation during the war, it may be observed 
 that the progress of those who underwent secondary operations was similar to what is 
 
 ' Pricig de Midecine Opiratoire, par ,J. Lisi'RAN'C, Paris, 1846. 
 
 - Lei;cms Oralcs de Clin. Cldr. par 5L le Uaron Dui'liYTltl'.N, Tome iii. p. 3R9. 
 
 " BouiMiKltY, Opirations Ginirales. Tome vi, p. ii73, pi. 89, fig. 1. 
 
 ' Khmenls of Suri/eri/, liy RoUKliT IjISTon, p. 787.
 
 86 AMPUTATIONS AT THE HIP-JOINT. 
 
 observed in patients who recover after amputations for disease. The functions of nutrition 
 were promptly recuijerated. Such a subject has been compared to a tree in which one of 
 the principal branches has been lopped off, and it has been supposed that the rei^arative 
 material destined for the member that has been removed continues to be prepared by the 
 digestive organs and gives greater vigor to the remaining portions of the organism. On 
 those persons who have lost a lower limb a comparatively sedentary life is imposed, and 
 hence another cause of a tendency to obesity. It has been stated, at page 52, that Mr. 
 Ulmer, now employed in a publishing house in Philadelphia, weighs at this time twenty- 
 five pounds more than his average weight before he lost his limb. His photograph, sent 
 to this office within a few weeks, would hardly be recognized as the picture of the same 
 person represented in plate VIII, copied from a photograph taken ten months ago, except 
 from the identity in the appearance of the stumj). Lemon, Longmore, and Smith have 
 also largely gained in weight. 
 
 The rule is reversed in primary amputations for traumatic causes, after which patients 
 commonly became emaciated rapidly, and long remain in a state of feebleness, from which 
 they recover very gradually. Such has been the experience of Kelly. Though more than 
 four years have elapsed since his recovery from a primary coxo-femoral amputation, he still 
 writes that his health is delicate, and that he can do but little towards earuing a maintenance. 
 
 Of the condition of the stumps of the seven survivors, it is known that in the case 
 of Francis there are sinuses and other indications of disease of the innominatum. Lons- 
 more has neuralgia in the stump, and Smith suffc'rs from a sense of congestion of the stump 
 after being long in an erect posture. In the others the stumps are healthy. Ulmer alone 
 wears, with comfort, an artificial limb. 
 
 Of the changes that take place in the jjclvis after amputation at the hip, our 
 information is limited to the single case of the soldier whose thigh was exarticulated by M. 
 Sedillot, on account of disease of the femur after a fracture by a fall from a window, who 
 survived the operation twenty-two years. In this instance the acetabulum was obliterated, 
 and its location was covered by a fibro-fatty substance. The articulations of the sacrum 
 and coccyx were anchylosed and deviated to the right. The internal iliac fossa was 
 abnormally hollowed. The anterior superior spine of the ilium was nearer than is natural 
 to the sacro-vertebi'al angle, and the external wall of the os innominatum had become 
 almost' vertical. 
 
 The accessions to our means of estimating the \'alue of the operation of amputation at 
 tlio hip-joint as a resource in niihtary surgery afforded by the war of the rebellion, may bo 
 summed up as follows: 
 
 1. AVe have learned that tlie primary operation for traumatic causes is not uniformly 
 fatal, as has latterly been taught, and are enabled to define three conditions under which 
 it should be undertaken, while two other conditions in which it may be justifiable are left 
 sub judice. 
 
 2. j\[uch evidence has been brought to controvert the prevailing doctrine that 
 disarticulation at the hip is an exception to the general rule requiring all amputations 
 deemed indispensable to be performed immediately, the eighteen intermediate amputations 
 l)(M-formc<l durim!; the war havino; all resulted fatallv. 
 
 loo *'
 
 CONCLUDING OBSERVATIONS. 
 
 87 
 
 3. We have proved that secondary amputations at the hip for necrosis of the whole of 
 the femur or for chronic osteomyeHtis following gunshot injury, may be performed with as 
 successful results as hip-joint amputations for other pathological causes. 
 
 4. It has been shown that when, after amputations in the continuity of the thigh, the 
 stump has become diseased, reamputations at the hip may be done with comparative 
 safety. 
 
 I am, General, 
 
 Very respectfully. 
 
 Your obedient servant, 
 
 GEORGE A. OTIS, 
 Assistant Surgeon and Brevet Lieutenant Colonel, U. S. Army. 
 
 Curator of the Army Medical Museum.
 
 ERRATA ET CORRIGENDA. 
 
 On page 11, 28th line, for twenty-fifth, read twenty -nititfi. 
 
 On piipe 14, 7th line, for practiced, read jtractised. 
 
 On pogre 15, 11th line, for primary, read intermediate. 
 
 On page 18, last line but one in notes, for Varti'rnionde, read Vantcrmnndc. 
 
 On pacrc 29, 28th lino, omit the words and that after the word disbaiidmont. 
 
 On puffe 35, Case NXVII, 10th line, for ana'esthesia read anwsthesia. 
 
 On page 37. litJth Hui-, for McLellan, read McCleUan,
 
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