Wifi} Eonjpliipeijfs of Suffer. 
Removal of the Head of the Femur 
from the Lesser Sciatic Notch. 
-BY 
B. MERRILL RICKETTS, M. D., 
CINCINNATI, OHIO. 
REPRINTED FROM 
"THE TlflES AND REGISTER," 
December 15th, 1894. REMOVAL! OF THE HEAD OF THE 
FEMUR FROM THE LES- 
SER SCIATIC NOTCH. 
BY B. MERRILL RICKETTS, PH. B., M. 
D„ CINCINNATI. 
Joseph C., aet. 41, was injured about 
October 1, 1893. He was white, 
American, 6 feet 1 inch tall, weighing 
230 pounds. While making some exca- 
vation he was covered with dirt. It 
was found upon examination that the 
head of the femur was injured, frac- 
tured in some way or other, and that 
it was necessary to place him upon his 
back and treat it accordingly. The toe 
was everted, the heel elevated, the pain 
severe. At the end of several weeks the 
patient was pronounced well and left the 
hospital with an inch and a half shorten- 
ing and slight eversion. There was an- 
kylosis at the hip joint, the pain was se- 
vere; he several times attempted to re- 
turn to his duty, that of superintendent, 
and as many times was compelled to 2 
give it up on account of the severe pain 
and discomfort. He visited another city, 
and while there the ankylosis at tho 
knee joint, as the result of long-con- 
tinued confinement in bed, was broken 
up. On July 14, 1894, I was consulted 
with reference to a condition seldom 
met with, aside from the pain in the hip 
joint. 
Upon climbing stairs or walking very 
rapidly he would have a slight tickling 
sensation in the calf of the injured left 
leg, followed by an erection of the penis 
and the ejaculation of seminal fluid. 
This had become very annoying and hu- 
miliating. Upon examination I decided 
that there had not only been a fracture 
but a dislocation of the head, probably 
backward and downward, and that it 
was this dislocated head which was pro- 
ducing the unpleasant trouble. I there- 
fore advised an exploratory incision to 
determine the state of affairs existing 
in and about the hip joint, not how- 
ever, until I had made him thoroughly 
acquainted with all the risks attending 3 
such a procedure and the shortening 
that would ensue if the head of the 
femur was removed. However, I deemed 
it proper .and wise to have consultation, 
especially from a legal point of view, 
there being a suit for damages already 
pending in the courts. In consequence 
thereof, I asked Drs. J. L. Gillet and W. 
E. Lewis to assist me in a more thorough 
examination. Each of them believed 
that some abnormal condition existed, 
and agreed with me that an exploratory 
incision was necessary. The head could 
not be found, and it was in doubt on 
their part as to whether or not any- 
thing more than a fracture had taken 
place. 
As a result of our conference on Au- 
gust 2, in their presence, the patient 
being under the influence of chloro- 
form, I made a Langenbeck incision 
down upon the great trochanter, my 
object being to do whatever was found 
necessary. The bone upon being 
reached was divested of all the muscu- 
lar attachments. It was found that 4 
there was a great amount of bony tis- 
sue thrown out during the process of 
repair-a very large mass indeed-in 
and about the acetabulum. Upon reach- 
ing the lower border of this mass of 
new bony formation I found a most 
peculiar state of affairs. I found the 
bead of the femur resting on the lesser 
sciatic notch, and that it was small 
and somewhat absorbed. Its position, 
therefore, accounted for the irritation 
of the nerves supplying the genito- 
urinary organs. I soon found that it 
was impossible to remove this head 
without making a counter incision, 
which would have complicated mat- 
ters to a very serious degree, especial- 
ly as the hip was fleshy and enormous 
in size. I endeavored to prevent short- 
ening of the leg any more than al- 
ready existed, but it being impossible 
to dislodge the head in the lesser sci- 
atic notch, I found it necessary to saw 
off that portion of the bone above the 
remaining head, remove it and make a 
new acetabulum which would admit of 5 
the reduction of the head. After divid- 
ing the femur between the new mass of 
bone and the remaining head with the 
Wyeth saw I soon discovered what had 
taken place at the time of the original 
accident. 
The head had been dislocated back- 
ward and downward, leaving a portion 
in the acetabulum. After the remain- 
ing head, attached to the neck, had been 
dislocated backward and downward, the 
neck was fractured, the shaft run up 
one and one-half inches above its origi- 
nal point, leaving the disarticulated head 
in its new position to become attached, 
which it had done, to the shaft itself, 
the trochanter therefore being a little 
above its normal position. This allowed 
the inner portion of the shaft, from 
which tbo disarticulated head had been 
detached, to become adherent to that 
portion lying in the acetabulum. This 
therefore accounted for the great mass 
of new bony tissue, which was about 
three and one-half inches long and at 
least two to two and one-half inches 6 
wide. It also accounted for the pecu- 
liar position of the foot, the eversion of 
the toe and elevation of the heel; in 
fact, accounted for all the conditions 
found. A drainage tube was inserted, 
the wound closed with silkworm gut and 
dressed without even the ligation or tor- 
tion of an artery. However, slight hem- 
orrhage continued, in spite of the ex- 
ternal portion of the wound being pack- 
ed. The patient was placed in bed, the 
leg drawn down and kept in position. 
The pain was quite severe and the hem- 
orrhage continued for twenty-four hours, 
when I opened the wound to investigate 
its source. 
I found the oozing was from the bone, 
which had been chiseled away to the 
end of the femur. The amount of de- 
nuded bone surface was extensive, and 
therefore accounted for the continuous 
flow of blood. I packed the surfaces 
firmly, hoping it would prevent further 
hemorrhage. At the end of thirty-six 
hours another examination was made 
and it was found that the hemorrnage 7 
was somewhat less. At the end of forty- 
eight hours another examination was 
made and the hemorrhage was still 
diminished. It was not until Ihe end 
of seventy-two hours that blood erased 
to flow from the denunded bone surfaces, 
thus showing that I should have used 
the cautery at the time of the operation 
to prevent this outflow. I would here 
suggest and most earnestly advise the 
use of the cautery in all resections where 
new bone is involved or where the 
amount of denuded bone surface is ex- 
tensive, or even whether extensive or 
not if blood oozes from the surfaces at 
the time of the operation. The patient 
has made a good recovery, although 
tedious, and like all such cases has been 
a great care, he being a large, heavy man 
and having suffered considerably. 
At no time has he had any kind of 
support for his leg, other than pillows 
and blankets, There is about four and 
one-half inches shortening, with anky- 
losis at the hip joint. He has good knee 
motion, and will ere long be able to 8 
assume the responsibilities of his former 
occupation. I report this case to show 
how little is known what of takes place 
within a mass of muscular and adipose 
tissue. It has been said that all opera- 
tions upon the abdomen are explora- 
tory, and it might be well said that 
diagnoses cannot be made in cases of 
fracture or dislocation without an ex- 
ploration. I mean positive diagnoses. 
The question, therefore, arises, What is 
our duty to ourselves as well as to our 
patients in these complicated fractures 
and dislocations, where doubt exists as 
to their character? Especially may this 
question be asked where the results are 
not what might have been expected.