LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE JKS\ S7U/VI \? NATIONAL LIBRARY OF MEDICINE NATIONAL I n jo Aavaan tvnouvn 3noiq3w jo Aavaan tvnouvn 3nidio3w jo Aavaan tvnouvn 3noio3w LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE •6 3NIDI03W JO AdVHSn 1VN0UVN \/ D EETTTTSO WIN IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIUIIIIIIIIIIIIIIIIIIIIIIIIIIIII s\ \ t^l> *^S X NLM051111330 NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE C 3N.D.Q3W jo Aavaan tvnouvn snoiojw jo Aavaan tvnouvn snid.qjw jo Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE • NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 4' sNo.aaw jo Aavaan tvnouvn 3NO.Q3W jo Aavaan tvnouvn ^ 3NOiajw jo Aavaan TVNOUVN 3 a LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 3NOIQ3W jo Aavaan tvnouvn 3nidio3w jo Aavaan tvnouvn 3noio3w jo Aavaan tvnouvn a. NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE i Wx o / y$ ■n 3NOIQ3W jo Aavaan tvnouvn 3noio3w jo Aavaan tvnouvn 3nidiq3w jo Aavaan tvnouvn / J y ■• rCiL&i. ANALYSIS OF FOUR HUNDRED AND THIRTY-NINE RECOVERED AMPUTATIONS IN THE CONTINUITY OF THE LOWER EXTREMITY. STEPHEN SMITH, M. D t» * rtT \&(t $Ss K X EXPLANATION OF THE PLATES. PLATE I. Gangrenous Uker of Finger of Confederate Soldier. Case VII- W. J. Black, pp. 248-250. At the time of the appearance of the gangrene, the patient was act- ing as a nurse in the Gangrene Hospital, at Vineville, near Macon, Georgia. A small blister appeared upon the third finger of the right hand, which gave much pain, assumed a dark gray and greenish color, and was surrounded by a purplish and blue border in the skin. Con- centrated nitric acid did not arrest the progress of the gangrene ; and this failure of the local treatment appeared to be due to the gradual poisoning of the system during the continued residence of this nurse in the infected atmosphere of the gangrene hospital. The drawing was executed on the thirteenth day after the appearance of the gangrene. The gangrene spread progressively along the borders, under the blue discolored skin. Notwithstanding the comparatively small surface in- volved, the constitutional symptoms in this case were well marked. PLATE II. General Appearance and Extent of Gangrenous Wound of Thigh of Confederate Soldier. Case VIII. Thomas Paine, pp. 250-256. This patient was wounded on the 17th of August, 1864, at Atlanta, Georgia. A fragment of lead weighing about one pound projected from a rifle shell, struck the middle of the left thigh, upon the external sur- face, and lacerated the parts, but did not fracture the bone. Gangrene attacked the wound on the tenth day. The drawing was executed on the thirty-first day after the appearance of the gangrene, and at this time the wound in the thigh was about eight inches in diameter, nearly circular, deeply and irregularly excavated, and coated with dark greenish gray and bluish and brown matter. No healthy pus was discernible • but in its stead the wound discharged a foetid sanious fluid. The large muscles of the thigh were exposed, and could frequently be observed quivering, especially after the application of nitric acid, which caused intense pain. Patient restless and nervous, with trembling hands and quivering distressed eyes. l EXPLANATION OF THE PLATES. PLATE III. General Appearance of Wound of Thigh of Thomas Paine, after the Disappearance of Hospital Gangrene. Case VIII. pp. 250-256. This drawing was executed twenty days after Plate No. 2. At this time the wound was improving, presenting a bright red granulating sur- face, and discharging healthy pus. By a comparison with the drawing of the wound during the state of gangrene (Plate No. 2), it will be seen that the parts surrounding the wound have greatly diminished in size, and that with the disappearance of the gangrene, and the improvement of the wound, the swelling and effusion have also disappeared. PLATE IV. Appearance of Internal Surface of Portion of Femoral Vein in Case of Pyaemia. Case XL VI.1 Ira Parker, Confederate Soldier, pp. 415-439. The femoral vein was distended with thick yellow pus. Many of the venous branches were in like manner filled with yellow pus. The pop- liteal vein and its branches, the anterior and posterior tibial veins, were traced to the disorganized tissues, and were in like manner distended with thick, cream-like yellow pus. At various intervals, but chiefly at the junction of the large vessels with the main trunk, and also in the region of the semi-lunar valves, clots of blood were found mingled with the pus, and firmly attached to the sides of the veins. At such points the walls of the veins appeared to be discolored by the coloring matter of the blood, and to be more softened than in those positions where no clots had been formed. The veins were traced directly to the disorgan- ized tissues of the calf and leg; and in the diseased, broken-down dif- fluent tissues and pus, the walls of the veins were rotten, and gave way upon the slightest touch. The femoral vein, near where it is continuous with the popliteal, and where several branches were received, and where there were semi-lunar valves, was much distended, and presented upon its exterior a dark blue gangrenous appearance. This portion of the femoral vein is represented in the Plate by 1, 2. The remnants of the coagula at the mouths of several vessels, and also attached to the semi- lunar valves, were here visible. The internal surface of this portion of the vein was covered with a tenacious fibrinous exudation, of a greenish yellow and bluish gray color, as represented in the Plate (1, 2), which adhered with tenacity. When this was scraped off, the walls of the vein presented a grayish-blue and black color, and evidently appeared to be gangrenous. The odor of the pus as well as of this portion of the vein was similar to that of tissues affected with hospital gangrene. i The Plate is incorrectly numbsred Case XLIV, EXPLANATION OF THE PLATES. PLATE V. Microscopical Appearance of Dark Gray, Green and Black Portions of the Exudation upon Surface of Femoral Vein in Case of Pyaemia. Cass XL VI. Ira Parker, p. 425. Exhibiting granular masses, with dark masses of the altered haematin of the blood, together with pus globules and masses of fibrous tissue, broken capillaries and fragments of muscular tissue: many of the par- ticles of coloring matter presenting a smooth angular fracture, as if they were crystallized. ANALYSIS OF RECOVERED AMPUTATIONS. GENERAL REMARKS. Amputations have been the subject of more discussion than any other branch of military surgery. At one period Former n J i iip opinions aa we find them regarded as the true method of treatment to the value « , of arnputa- of every considerable wound of the extremities, and at *><"« in mii- another period they have been rejected altogether, and e^y. the injured limbs have been left to the rude appliances of the time. Their value has generally been estimated by the mortality that has followed, and this has varied with nearly every campaign. Hence have arisen those remarkable fluctuations of opinion which are recorded in the earlier history of military surgery. It is but a century since that Bilguer, the Surgeon-General of the Prussian army, alarmed at the great fatality of amputations in the wars of that age, prohibited them altogether, preferring to leave the wounded to the then almost unaided eiforts of nature. The re- sults of this expectant plan of treatment, or non-operative inter- ference, as reported by him, were so favorable when compared with amputations, that professional opinion for a long period fa- vored an adoption of the expectant method. The fallacy of the reasoning of Bilguer, and of those who advo- cated his practice, is now very apparent. They made no Fallacy of ,. . . .. l'-ii • the reason- dlStmCtlOn as to the time at which the amputation was ing. performed after the receipt of the injury. Nor were the circum- stances relating to the patient and his subsequent surroundings duly considered. When at a later period the causes of the fatality of amputations began to be more thoroughly understood, and the time of the operation more judiciously selected, the mortality was much reduced, and the operation again became the popular method of treating severe wounds of the extremity. But the great advance in practical surgery within the last quarter of a century, has again modified the opinions of Effectorcon- . servative surgeons as to the necessity and value of amputations for measures. gunshot wounds. Compound fractures are now treated with a 8 NECESSITY OF AMPUTATIONS. success formerly unknown, and many limbs are saved that a cen- tury ago were incontinently sacrificed. The remarkable success "which has attended exsections for gunshot injuries of bone, both in saving life and in securing a useful limb, has rescued another large class of cases formerly condemned to amputation. Every campaign has enlarged the experience of military surgeons in the application of conservative measures, and thereby limited more and more the field of amputations. The Crimean and Schleswig- Holstein wars gave a powerful impulse to conservatism in military surgery, the former by its frightful mortality after amputations, and the latter by the great successes which attended conservative meas- ures, especially exsections. But notwithstanding these great improvements in the treatment Absolute ne- of gunshot wounds of the extremities, wherebv many ressity of . , ". amputations lives and limbs are saved that were formerly sacrificed, it in military . . ' surgery. cannot be denied that amputations must still occupy an important place in modern military surgery. The liability of the extremities to wounds and injuries is rather increased than dimin- ished by the improved methods of warfare, while their severity is greatly enhanced by the destructive nature of the missiles em- ployed. These facts may be illustrated by the records of the late war; of 87,822 wounds and injuries classified by the Surgeon- General from official returns, 55,245, or nearly two thirds, were located in the extremities, and from the same source it appears that of 17,125 operations of various kinds, 13,397, or about three fourths, were amputations. "While it may be true that many of these amputations might have been avoided by the judicious em- ployment of conservative means, it is nevertheless equally certain that in a vast majority of cases the wounds were amenable to no other form of treatment than amputation. We can scarcely be- lieve it possible that a campaign will ever again be inaugurated with an official order from the chief medical officer prohibiting all amputations. The position of the various questions relating to amputations at Position of the commencement of the late war can be stated only in quesSe- general terms. Many questions which had hitherto di- amputluons vided surgeons were now definitely settled. There was men°c?ment no longer any doubt as to the success of primary when of the war. compared with secondary amputations. A broad distinc- tion was very properly drawn between amputations in the upper and lower extremities, based upon the difference in their functions Every possible effort was advised to save the upper limb by con- COMPENSATIVE APPLIANCES. 9 servative measures. Exsection was well adapted to preserve the functions of the upper extremity, and was strongly recommended at any of its articulations involved in a gunshot injury in prefer- ence to amputation. Lesions of the shafts of the long bones were also treated conservatively to the utmost practicable limit. In the lower extremity far less importance was attached to conservative measures ; exsection here became a formidable operation, and not only imminently endangered life, but at best its results were doubt ful as regarded the serviceableness of the resulting limb. Gun- shot fractures of the long bones, especially when severe, were gen- erally condemned to amputation unless occurring under the most favorable circumstances for treatment. The propriety of amputation at the articulations of the upper extremity was well established ; but the same operation in the lower extremity was regarded with little favor. Amputation at the ankle- joint had attracted some attention, but in general surgeons pre- ferred amputation through the leg, and practiced the old routine. The point of amputation was still determined by the old rule of operating as far from the trunk as possible, or certain points of election were selected, originally fixed by circumstances or condi- tions long since become obsolete. The methods of operation were altogether unsettled, the preference being generally given to the circular and the flap. Formerly amputations were regarded as veritable mutilations. They were the dernier ressort, the only alternative of Amputatl0M which was death. The operation was repugnant alike to ^rila™' surgeon and patient, as by it the latter seemed reduced mutll*t">°»- to an almost helpless condition. No appliance could compensate for the loss of either an upper or lower extremity. For a hand nothing had yet been invented which even preserved the form, while the clumsy peg-leg was a substitute only in length. But in our time limb-making has been carried to such a state of perfection that both in form and function they so completely resemble the natural extremity that those who wear them pass unobserved and unrecognized in walks of business and of pleasure. The conservatism of artificial appliances has, therefore, become a most important department of both civil and military compen8a- surgery. Amputations are no longer to be regarded as ances. mutilations, especially in military surgery, as the government, in its munificent care of its soldiers, gratuitously furnishes every form of artificial substitutes for lost parts. In this respect amputations have become eminently a conservative measure. The surgeon has 10 SCOPE OF THIS ARTICLE. not only to consider the probabilities of saving life by his opera- tion, but also the possibilities of giving his patient a better limb with an artificial appliance than he would have if the injured limb were retained. From this statement it is apparent that there was ample room Direction for improvement in this field of operative surgery, and M toor we readily perceive in what direction we are to look for meSar-6" the results of the experience in the late war. In the first ingthewar. p1ace we gh^d expect to have all the circumstances and conditions which determine a resort to conservative measures, rather than to amputation, more accurately defined. When ampu- tation becomes the alternative, the period after the injury best adapted to secure successful results, as regards the mortality, would be thoroughly investigated and definitely fixed. The old land- marks which defined the boundary between primary and secondary amputations could scarcely fail of being removed, and others more discriminating established. Again, the much disputed question in regard to the propriety of amputation at the articulations would now* find a practical solution. Not only should we expect to have the general question as to the comparative dangers of these opera- tions settled, but equally should we have a fixed value placed upon amputation at each individual articulation. Another and not less important subject is the determination of the influence which the point of amputation and the methods of operation has upon the usefulness of the stump in the final adjustment of artificial appli- ances. This is a new question and of the greatest importance to the future happiness and comfort of the patient. How far the reasonable anticipations of the profession of the final settlement of the various questions relating to amputations have been realized by the vast experience of the late war, we are not in a position to decide. These final conclusions will be devel- oped only when the accumulated facts of the entire surgical ser- vice are reduced and systematized by the Central Official Bureau. The following paper is a contribution to our knowledge of the scop, of this results of amputation in the lower extremity. It is based ,rHcto- upon the careful study of the stumps of patients when prepared for the application of artificial limbs. Many of them came under our own observation at the U. S. General Hospital at Central Park, New York. This hospital was, for upwards of two years, the rendezvous of soldiers who had lost their limbs by ampu- tation, and, while inmates, large numbers were supplied with arti- ficial limbs by Dr. E. D. Hudson, of New York, who held a DR. HUDSON'S OBSERVATIONS. 11 government commission for the manufacture and adjustment of appliances to compensate for losses, deformities, etc., resulting from the service. In the practice of mechanical surgery, Dr. Hudson combines the learning and experience of an educated prac- tical surgeon, with a high degree of mechanical skill and ingenuity. In the adjustment of artificial limbs his observations have extended beyond the mere mechanics or art of his profession, and he has made careful studies of subjects relating to stumps, of great practi- cal interest to surgeons. The records from which the following tables are compiled, were made by Dr. Hudson upon blanks at the bedside of each patient preparatory to the adjustment of each limb. The measurements were all made with great care, and with that accuracy which only a mechanic after long experience can attain to, and they may be relied upon as nearly absolutely correct. While the view which we take of amputations must necessarily be quite limited, it nevertheless involves some points which are novel and of very great importance. Never before have we had an opportunity of studying on a large scale the final results of am- putation. These tables enable us to estimate with great precision the absolute and relative value of the various methods of operation, and of the stumps in different parts of the limb, and of the service- ableness of artificial limbs under every varying condition of stump. 12 ONE HUNDRED AND FIFTY-EIGHT CASES TABLE OF ONE HUNDRED AND FIFTY-EIGHT CASES T.D. B.8. C.H. S. J. C. Q. B. F. £. J. B. C. T. B.B. W. C. G. S. R. A. A. H. J. McG. H.E.F. T.P. J. F. E. C.J.O'B. A. G. I. T.P. N.A.U. J. D. G.D. A. T. T.W. D. Regiment. 9th U.S. C. T. IstN.Y.A. 11th Conn. 14th N. Y. Vols. lat U. S. A. 159th N. Y. Vola. 160th N. Y. VolB. 14th V. S. Infantry 1st U. S. Cavalry 1st U. 9. S. Shooters 6th Harris Cavalry 4th II. S. Cavalry 7th Verm't Vols. 20th Ind. 24th N. Y. Vole. 9thN.Y.M. 48th N. Y. Vols. U. S. Navy 69th N. Y. Vols. 61st N. Y. 9th N. Y. 82dN.Y. Occupa-tion. Limb. Sailor L. Farmtr R. Farmer R. Farmer L. Teamster R. Farmer L. Clerk L. Farmtr L. Farmtr L. Laborer L. Military R. Carpenter L. Laborer L. Machinist R. Cooper R. Clerk L. Tinman R. None R. Laborer R. Military R. Landsm'n L. Carpenter R. Laborer L. Joiner R. Clerk L. Tailor R. Point of Operation. Method. Middle third Anterior flap Lower third Lateral akin flapa and circular Middle third Circular Lower third Lateral flaps Lower third Circular Lower third Ant. poit. flaps Lower third Ant. post, flap Middle third Circular Lower third Circular Lower third Ant. poat. flap Lower third Ant. post, flap Lower third Circular Middle third Ant. post, flapa Lower third Ant. post, flap Lower third Ant. post, flap Middle third Ant. poat. flapa Middle third Circular Middle third Circular Middle third Ant. post, flap Lower third Bilateral flaps Middle third Ant. post, flap Middle third Ant. post, flap Lower third Ant. poat. flap Upper third Ant. post, flap Upper third Ant. post, flap Lower third Post flap Where per- formed. At Post Hos- pital On the field On the field On the field On the field On the field On the field On the field On the field On the field On the field On the field State Hospi- tal, Colum- bus, Ga. On the field Rebel camp On the field Field hospi- tal In Frederick Hospital, Md. On the field On the field U. S. gun- boat Frederick City Hosp'l Field hosD'l, St. Joseph's, Governor's Island Falmouth On the field On the field, 2d Staunton Hospital Length of Time after Injury. One hour Four hours Three houra Imme- diately One day One hour Twenty-fo'r houra Six houra One hour Five hours Nine houra Two weeka Thirty h'rs Twenty-fo'r hours Twenty h'rs Two hours Imme- diately One and a half hour Twenty-fo'r houra Irty-: n da Fragment of shell Fragment of shell Fragment of shell Fragment of shell Fragment of shell Minie-ball Minie-ball Musket-ball Minie-ball Piece of shell Solid shot Musket-ball Rifle-ball Musket-ball Solid shot Minie-ball en days | Twenty-fo'r Shell hours Twenty-fo'r hours Three days Eight days Grape-shot Shell Minie-ball 2d time, in sufnc'nt flap OF RECOVERED AMPUTATION OF THIGH. 13 OF RECOVERED AMPUTATION OF THIGH. Description of In- jury. Compound com- minuted fracture of knee-joint Destruction of foot and ankle-joint Comp'nd commi- nut. tract, of low- er third of thigh Comp'nd commi- nuted fracture of knee-joint and concivles of fem'r Comp'd fract. low- er third of thigh Destruction of knee and leg .... Comp'd com. fract, of middle leg, knee uninjured Nearly dissevering limb atknee-j'int Comp'd com. frac- ture ofknee-j'mt Comp'd com. frac- ture of knee-j'int Comp'd com. fract low. th'd of thigh Comp'd com. frac- ture of knee-j'int Muscular tis. oflej entirely denudec fr. ankle to knee Comp'd com. fract. low. th'd of fem'r Comp'd fracture of knee-joint. . Wound of knee Fort Wag- ner, S. C. Chapin's Bluff or Farm, Va. Comp'd fracture of Antietam, knee-joint. . . Md. Wound of knee- Antietam joint..... Md Sept. 29, 1864 Port Hud- son, La. Port Hud- son, La. Port Hud son, La. Peters- burs,Va. Deep Bot- tom, Va. Deep Bot- tom, Va. Bull Run, Va. Colum- bus, Ga. Spanish Fort, Md Fair Oaks Va. Fair Oaks, Va. Length of time from Amputa- tion to Exami- nation. Destruct. of knee-1 Port Hud- joint .....son, Miss, Comp'd com. frac- ture of knee-j'int Comp'd com. frac- ture of tibia, fibu- la, and femur . Wound of lower third of thigh . Destruc. low. third of leg occasioned by sloughing. . k com. fract. of the knee, thigh, &leg Comp'd com. frac. of upper third of legandknee-j'nt Comp'd fracture of knee-joint and head of tibia Wilming- ton, N. C. Wilming- ton, N. C. Antietam, Md. Freder'ks- burg,Va. FrederTcs- burg,Va. Freder'ks- burg.Va. Freder'ks- burg.Va. May 2, 1863 May 27, July 28, 1864 Aug. 15, 1864 Aug. 29, 1862 April 16, 1865 M'chffl. June 25, June, Sept 17 1862 Sept. 17 1862 May 29, Sept. 3, 1864 Sept. 17, 1862 Dec. 13, Dec. 13, 1862 Dec. 13, Dec. 13, 1862 Length of time from | Amputa- Length of tion to | Stump. Applica- tion. 4 mos. 6 mos. 9 mos. 13 mos. 9 mos. 7 mos. 6 mos. 9mos. 4 mos. 5 mos. 13 mos. 8 mos. 8 mos. 6 mos. 3mo!.& lyear 3 mos. lyear 5 mos. ) mos. I mos. 6 mos. 5 mos. 6 mos. 10 mos. 14 mos. 10 mos. 15 mos. 7 mos. 11 mos. 6 mos. 9 mos. 9 mos. 16 moa. 7 mos. 11 mos. 9 mos. 9 mos. 7 mos. Atrophy. Proximal Distal Portion. Portion. Remarks, Generally made at Time of Applica- tion of Artificial Limb. 7} inches 6 inches 10 inches 7 inches 9} inches 12} inch. 6i inches 10 inches 9} inches 9} inches 10} inch. 7} inches 11 inches 10 inches 9} inches 7 inches 6) inches 6 inches 9 inches 7J inches 7 inches 8$ inches 4} inches 3 inches 12J inch. None I 2 inches i inch 2 inches }inch I 1 inch I 1} inches ! None 1 inch i 2 inches 1 inch 3 inches 1 inch None 2} inches None Jinch 3 inches I inch 2 inches 3 inches If inches i inch None 3J inches J inch increase | inches {inch {inches None | inches 4inches J inch 2 inches None 2 inches 3 inches 2} inches 2 inches 3 inches {inches None None 1 inch Jinch J inches increase {inches Stump healed, very wellformed, effi- cient Very good, com- pact, well formed, healed by the first intention. Stump not healed, end of femur not well covered. Good, sm'th 6tump, well cicatrized. Well healed. Stump well covered by anterior flap, posterior flap re- dundant, flaccid. Stump diseased, ec- zema. Stump muscles retracted, femur protrudes, not en- tirely healed, or- dered bandaging from above down- ward. Considerably atro- phied, very good. Healed, very good. Healed, very good. Stump healed. Injured by necrosis, bone removed.not entirely healed. Not yet sound, ul- cer and fetid dis- charges. Diseased, herpes, enlarged. Stump unsound.re- traction muscles, bone exposed, ne- crosis, exfolia- tions in process. Healed in good or- der. Some thickening of the periosteum. Damaged by extr. sloughs along front and half the stump. Extensive cicatris- ation. Not healed. Stump very short and flexed upon the body. Cicatrization exten- sive, stump un- necess'ly long for thigh amputation. 14 ONE HUNDRED AND FIFTY-EIGHT CASES TABLE OF ONE HUNDRED AND FIFTY-EIGHT CASES Hams. J. K. W.M. R-H. C. H. G. A. C R.T. H. C. M a H. B. J. P. as. Regiment AH. V.T. O. L. E. J.G. R.L. J.B. B.B. J.W. J.B. E.T. G.W. A.K B. D. S. 76th N. Y. 14th W.Va. Vols. 153d Pa. Vol*. IstU. S. A UN. Y. Vols. 12th U.S. Infantry 11th Maine 148d N. Y. Vols. 7th N.Y. VoU. «th N. Y. Cavalry 9th N.Y. Cavalry Occupa- tion. 79th N. Y. 7th N. Y. H.Artill'ry VenezuTn Army 16th Conn. Vole. 24th N. Y. Vols. 176th N.Y. Vols. 6th Mo. Vola. 22dN. Y. Vola. 137th,or 139th N. Y. Vola. 3d N.Y. Vola. 4th Va. Vols. 34th Meat. Vola. 182d N. Y. Vols. 7th N. H Machinist Sil'rsmith Farmtr None Printer Laborer Farmer Captain Fanner Farmtr Butcher Farmtr Assistant Assessor arstone- utter Glazier Farmtr Surveyor Tailor None Boatman Carpenter Fanner Farmer Sash and blindmak. Fanner Point of Operation. Lower third Middle third Lower third Middle third Middle third Lower third Middle third Middle third Lower third Lower third Middle third Middle third Lower third Middle third Lower third Lower third Middle third Middle third Lower third Middle third Lower third Middle third Lower third Upper third Circular Circular Ant pott, flap Ant pttt flap Ant pott flap Anterior flap Ant pttt flap Circular Ant pott flap Ant pott flap Anterior flap Ant pott flap Circular Ant poet, flaps Circular Circular Ant poet flapa Ant pott flapa Aat post flaps Ant poat flap Circular Circular Rectangular flap Circular Whtre per- formed. On the field On the field Uth Corps hospital On the field Field hotpitl On the field On the field On the field On the field On the field On the field On the field On the field Field hospitl On the field Beaufort, Field hospit'l On the field On the field On the field On the field On the field Confederate hospital, c §. c! Length of Time after Injury. Two houra Six days Fourdayt Twtnty-fo'r houra One hour Five houra Two houra and a half Twenty-fo'r hours Two hours Three houra Imme- diately Two days Half aa ho'r Eight houra Twtnty-ont houra Forty-eight houra Five m'nths Two houra Forty-eight houra Five daya Twenty d'ya Three houra Eighteen houra Twenty-fo'r houra Thirty-aix houra Seventeen houra Twelve h'ra Forty houra OF RECOVERED AMPUTATION OF THIGH. OF RECOVERED AMPUTATION OF THIGH. — (Continusd.) 15 Description of In- jury. Destruction of leg Gettye- burg, Pa. Comp'd com. frac-! Shenan- ture of knee-j'int doah Val Comp'd com. frac- Gettya- ture of knee-j'int burg, Pa. Comp'd frac.of low. third of femur . Comp'd com. frac- ture of thigh above knee . . Comp'd com. frac- ture of upper half of leg and knee- joint ..... Comp'd fract.lower third of femur . Comp'd com. frac- ture of thigh. . Comp'd com. frac- ture of knee-j'int Comp'nd fracture of knee-joint. . Comp'd com. fract upper third of leg Comp'd com. frac- ture of the thigh at its lower third and knee-joint Destruction of leg Comp'd com. frac tureofknee . . Comp'nd commi- nuted fracture of femur .... Comp'd com. frac ture of low. third Comp'd com. frac ture of upper third of leg Comminuted frac- ture of knee-joint Comp'd com. frac- ture of kneej'int Comp'd com. fract 4inch.bel'wknee Simple oblique fracture of thigh Comp'd com. frac- ture of low. third of leg . . Com. tract of up- per third of leg Comp'd com. frac- ture of low. third of thigh. . Comp'nd fracture of knee-joint. . Comp'd com. frac- ture of low. third of thigh . . . Length of time from Amputa- tion to Exami- nation. Fair Oaks, Va. Bermuda Hundred Bayou Teche, La. Fair Oaks, Va. Wilder- ness, Va. Deep Bot- tom, Va. Benton- ville.N.C Newport News Poeotali- go, S. C. Winches- ter, Va. Stevene- burg.Va. Blue Springs, E. Tenn. Coal Har- bor, Va. Suffolk, Va. Antietam, Md. Fisher's Hill, Va. Beaufort, S. C. Lookout Valley, Tenn. Drury's Bluff Cedar Creek, Va. Winches- ter, Va. Comp'd com. frac- ture of knee-j'int Compound com- minuted fracture of thigh . . . Julyl, 1863 Aug. 22, 1864 July 1, 1863 June 18, 1862 June 29, 1884 April 12, June 25, 1862 May 5, 1864 July 21, 1864 Mch. 19, 1865 Oct. B, 1862 Oct. 11, Oct. 10, 1863 June 3, 1864 1861 April 24, 1863 Sept. 17, 1863 Sept. 22, 1864 Feb'y3, 1865 Sept. 17, 1862 Oct. 29, May 16, 1864 Oct. 19, 1864 Sept 19, 1864 Port Hud- son, La. Fort Wag- ner, S. C. 10 moa. 9 mos. 14 moa. 7 moa. 5 moa. 7 moa. 6 moa. 7 moa. 17 moa. 6 moa. 4 years 5 mos. lyear 10 mos. 10 mos. 4 moa. Smos. 7 mos. 3 mos. 4 moa. 3 mos. 7 moa. Length of time from Amputa- tion to Applica- tion. Length of Stump 13 moa. 10 mos. 15 mos. 11 mos. 6 mos. 10 mos. "mos. 7 mos. 19 mos. 7 mos. 4 years 6 mos. 15 mos. lyear 4 mos. Smos. 15 mos. 9 mos. 9J inches 8) inches 10) inch. 6} inches 8 inches 6J inches 7)inchea 10, inch. 9 inchea 9} inches Atrophy. Proximal Distal Portion. Portion. 3 inches 3i inches 3 inches 2 inchea increaae None None 1)inchea 1)inchea tinches 3 inches 11 inches J ineh 9 inchea 9} inches 3)inches 3 inches 3 inches 2 inches None 4J inches 1} inches Si inches 2 inchea 2} inches Generally made at Time of Applica- tion of Artificial Limb. 8 inchea 6} inchea IO) ineh. 10 inchea 5 inches 10J inch. U inches 9 inches 10 inchea 2J inchea J inch increase i inch 4 inch linch {inch increase None tinch ljinch linch linch 3 inches linch increase 1) inches 2 inches 2 inches linch 4 inches None 1J inch 3} inches Not healed, stump not well covered. Very good. Healed, extensive contrac. of flex- or muscles. Gangrene, conva- lescing. Healed in good con- dition. Stump good pro- portions, ant. flap well cicatrized, stump well cov- ered, smooth. Creditable though scanty covering. Very good. Not pr'perly heal'd, otherwise good. Stump well healed, finely covered, cicatrix well b'ck, clean front, a neat ■tump, full size. Very good, back of end damaged by sloughing. Healed, badly dam- aged by slough- ings, eczematous. St'mp healed, some angular pouting in front Healed, very good. Healed, insufficient in tegumental covering. Well healed and sound. Ordinary, healed. Lack of extension, became sh'rtened and limited. Stump not healed. Healed, very good. Healed, very good. Healed, very thin- ly covered by cic- atrix, caused by retraction. linch 1} inches Hemorrhage arreet- ed by a cord he had in his pocket, 24 hrs in a trench, at'mp ins'fflcient- ly covered owing to sloughing, ex- foliation, and re- traction. 16 ONE HUNDRED AND FIFTY-EIGHT CASES TABLE OF ONE HUNDRED AND FIFTY-EIGHT CASES J.B. W.H.H. J. M. H. W. P. S. P. D. E.J. D.W. B. J. C. J. McL. C. T. D. G.W.F. P.M. T.F. J.J. E.W. H.M.C. C. McD, W.A.K W. S. M. H. J.L. P.K. 3. H. D. H.D. T. McC. Regiment 100th N. Y. Vola. 17th Mich. Vola. 11th N. Y. Cavalry U.S. Navy 46th N. Y. Vols. 3d N. Y. Cavalry 150th N. Y. Vols. 14th Maine U. S. Inf y 20th Ind. Vols. 3d Maryl'd Vols. 1st V. H. Artillery UthVt Vol*. 3d N.Y. Vols. U. S. Navy U. S. Navy 10th Conn Vols. 2d U. S. Artillery 4th R. I. Vols. Freedm'n's Bureau 76th N. Y. Vols. 6th Conn. Vols. 37th N. Y. Vols. 79th N. Y Vols. 7th Mich. Farmer 37th N. Y. Brick- Vols. layer Seaman Landsm'n Shoe- maker. Stone-ma- son None Gilder Farmer None Farmer Farmer Ordinary seaman Coal pass'r Gardener Bar-tend'r Sailor Flagger Salesman Point of Operation. Lower third Middle third Middle third Middle third Upper third Upper third Lower third Lower third Lower third Lower third Upper third Middle third Lower third Lower third Lower third Middle third Middle third Middle third Middle third Lower third Lower third Middle third Middle third Lower third Middle third Middle third Anterior flap Circular Ant. poat. flap Circular Circular Circular Circular Circular Ant. post, flaps Ant. post, flap Circular Circular Ant post flaps Ant poat flaps Circular Circular Ant post flaps Circular Ant. post, flapa Ant. post, flap Circular Circular Ant. post flap Anterior flap Ant. post, flap Ant. post flap Morris Island On the field U. S. Hosp., Norfolk, Va. On the field On the field On the field On the field In hospital David's Isl- and Hospit'l, Cul- pepper C. H, Armory Sq. General Hos- pital Hospit'l ship, Ft Jackson Gunboat, Ft. Jackson On the field On the field On the field On the field Middletown Hospit'l. Md. Fortress Monroe In 3d Army Corps field hospital On the field On the field Steam'r Dan- iel Webster Length of Time after Injury. One hour Eighteen hours Twenty-fo'r hours Forty-eight days Six hours Two hours Seven hours One hour Seven hours Five months and a half Three days Thirteen days Twentr.fo'r hours Twenty-fo'l hours Twenty-fo'r hours Imme- diately Twenty-fo'r hours Four hours Two hours Four day6 2d time One year Forty-eight hours Fifteen d ivs Imme- diately Twenty-fo'r hours Three day6 Fragment of shell Minie-ball Fragment of shell Minie-ball Musket-ball Grape-shot Minie-ball Musket-ball Musket-ball Minie-ball Minie-ball Canister- shot Minie-ball Cannon-ball Musket-ball Minie-ball Piece of shell Gunshot Minie-ball Rifle-ball Minie-ball Musket-ball Rifle-ball OF RECOVERED AMPUTATION OF THIGH. OF RECOVERED AMPUTATION OF THIGH.— (Continued.) 17 Description of In- Jury. Destruct of knee- joint ..... Comp'd fracture of thigh at middle third..... Comp'd com. frac- ture of thigh. . Comp'd com. fract. of upper third of leg..... Comp'und fracture of middle third of thigh . . . Comp'und fracture of thigh . . . Destruct of knee- joint ..... Comp'und commi- nuted fracture of upper third of leg..... Comp'und commi- nuted fracture of knee-joint. . Comp'und tract of low. third of thigh Comp'und commi- nuted fracture of knee-joint, com- plicated with compound frac ture of left leg . Comp'und commi- nuted fracture of lower third of femur . . , Comp'und fracture (f lower third of thigh . . Comp'und commi nuted fracture of knee-joint. Comp'und comrai. fracture of lower third of thigh . Destruction of leg Wound of knee- joint ..... Comp'd com. frac- ture of knee-j'int Comp'd com. fract of leg and knee Comp'd com. fract. middle of leg, 2d necrosis of femur Wound of knee- joint ..... Fract're of the low- er part of the fe- mur ..... Fort Wag- ner, S. C. South Mountain, Va. West Louisiana Gunboat Mendota Peters- burg, Va. Rich mond, Va. Fort Fish- er, N. C. Culps F'rms, Ga, Baton Rouge, La. Coal Har- bor, Va. Coal Har- bor, Va. Manassas Gap, Va. Fort Fish- er, N. C. Fort Fish- er, N. C. Newhem, N. C. San Au- gubta. Me, Antietam Md. Chester Station Chancel- lorsville Length of time from Amputa- tion to Exami- nation. June 14, 1864 July 16, June 29 1864 June 1, 1864 Comp'und fracture of knee and leg Comp'und fracture of knee-joint. . Comp'und fracture of knee-joint Jan'y 15, 1865 March 14,1862 Sept 17, 1862 Feb'y2, 18G5 Sept. 18, 1862 May 10, Blue Springs, E. Tenn. MavSl, MaySl, 1&2 Length of time from Amputa- tion to Applica- tion. 9 moa. 5 moa. 5 moa. 7 moa. 9 moa. 13 mos. 10 moa. 4 mos. 5 moa. lyear 1 year 7 moa. 4 moa. 2 mos. 14 mos. 9 mos. 17 mos. 2d time 5 mos. 5 mos. 6 mos. 7 mos. 7 moa. 9 moa. 10 moa. 14 mos. 11 mos. 7 moa. It 24 daya 16 mos. 9 mos. 20 mos. 2d time 8 mos. 6 mos. 1 year 10 mos. 10 mos. Length of Stump 4J inches 7 inches 6i inchea 3J inchea 5 inchea 10} inch. 9 inches Atrophy. Proximal Distal Portion. Portion. {inch 2) inches Jinch i inch linch increase 3 inchea i inch 4) inches 7}inches 2} inchea 9} inchea 9J inches 7 inches 8 inches 51 inches 6 inches 9 inches 10 inches 8 inches 8^ inches 7 inches 2} inches 1Jinchea None linch 5f inchea 5 inchea 4) inches 2) inches 4} inches 1} inches None 2] inchea None 2 inches 3 inches 3 inches None J inch None Generally made at Time of Applica- tion of Artificial Limb. 3} inches 1J inch 2 inches 1J inch 10, inch. 8 inches 8 inchea 5 inches 2 inchea 5Jinches 3 inches 3Jinches i inch lj inches IS inches 2 inches Stump healed, ten- der, posterior flap atrophied, bone covered. Stump sound, smooth, efficient Healed, very good. End not well cov'd, retraction of mus- cles, leaving bone exposed. Healed, very short, imperfect Healed, poorly cov- ered. Very good, consid- erably injured by two other shots. Very good, nine inches of seques- tra. Scanty covering, extensive cica- tricea adhering to bone. Length excesaive, erysipelatous in- flammation, ab- scesses, ulcers,etc. Gangrene, not ready. Very fair, bone well covered,4J inchea of bone necrosed, removed whole shaft, periphery, new bone formed, leg bowed, from posterior slough. Very good, exten- sively cicatrized, long flaps. Stump ulcerated on posterior and up- per angle, indica- tions of exfoliat'n, will be efficient. Not healed, on furlough ten days. Excellent. Healthy. Stump sound and vigorous. Excellent St'mp healed near ly, not well cush- ioned. Healed. Stump pretty fairly covfd, not heiiled perfectly, will he good, habits not good, ulcers on other ankle, sore eyes. Walked with assist- ance half a mile, st'mp not healed, some granulated will be efficient 2 18 ONE HUNDRED AND FIFTY-EIGHT CASES TABLE OF ONE HUNDRED AND FIFTY-EIGHT CASES Kami. Regiment. Occupa-tion. Limb. Point of Operation. Method. Where per-formed. Length of Time after Injury. Cause. G. S.P. 24th Mass. Vols. Shoe-maker R. Upper third Circular On the field Eight hours Minie-ball W. s. 3d Artil- Farmer R. Lower third Ant. post flaps Hospital Three days Minie-ball F. O'B. J. H. D. J.S. lery 4th Regi-ment 3d N.Y. Artillery 4th N. Y. Vols. Cart-dri-ver Carpenter & joiner Brewer L. R. R. Middle third Upper third Middle third Lateral flaps Ant. post, flap Ant. post, flap Acad. G. H., Newb'n.N.C. On the field Four weeks Thirty-six hours Cut with an axe Musket-ball Minie-ball M. M. 69th N.Y. Vols. Carpenter R. Middle third Ant. post flap On the field Three days Rifle-ball D.C. G. S. 25th N. Y. Vols. 169th N. Y. Vols. C'ngsh're-man Teamster L. R. Upper third Middle third Circular Ant. post, flap On the field On the field One hour Two hours Solid shot Canister-shot G. S. 11th Conn. Vols. Hatter L. Middle third Ant. post flap On the field Two hours Minie-bal] F. S. 74th N. Y. Vols. 5th N. J. Vols. 5th Wis. Vols. 88th N. Y. Vols. Clerk L. Middle third Ant. post, flap Field Three days Rifle-ball J.H. - L. Upper third Circular On the field Six days Minie-ball J. C. T. D. Farmer Sailor L. R. Middle third Middle third Ant. post, flaps Ant. post flaps David's Isl-and Hospit'l Field Fifteen days Six hours Musket-ball Minie-ball I. B. B. 26th Iowa Vols. Farmer R. Lower third Ant. post flap Field Two hours Minie-bal] D.McC. 2d Mass. Vols. Shoe-maker R. Lower third Ant post, flap U. S. Gener'l Hosp. N. H. Thirteen months Fragment of shell F.I. R.W. G. 2d N. J. Vols. 84th N. Y. S. M. Black-smith Painter L. R. Middle third Lower third Anterior flap Ant. post, flap On the field in corps Hospital In field hos-pital Eighteen hours Thirty hours Canister-shot Minie-ball G. M. 40th N. Y. Vols. Varnisher R. Lower third Rectangular flap On the field Second day Shell J. T. 14th N. Y. Vols. Broker L. Lower third Circular On the field Twenty-fo'r hours Minie-ball T. H.W. 13th N. J. Vols. , Hatter L. Lower third Ant. post flap On the field Three hours Minie-ball J. A. i.C. 54th N. Y. Vols. 104th N. Y. Vols. Sailor None L. L. Middle third Upper third Ant. post, flap Circular At field hos-pital Eight days Four days Minie-ball necrosis Minie-bal] OF RECOVERED AMPUTATION OF THIGH. 19 OF RECOVERED AMPUTATION OF THIGH.—(Continued.) Length of] Length of Atrophy. Remarks, time from time from Description of In-jury. Amputa-tion to Amputa- Length of Stump. Generally made at Battle. Date. tion to Time of Applica- Exami- Applica- Proximal Distal tion of Artificial nation. tion. Portion. Portion. Limb. Comp'und commi- Seabrook April 11, 1863 4 mos. 8 mos. 4} inches J inch linch Stump not entirely healed, perioste- nuted fracture of Island, the middle of the S. C. um, some thick- thigh .... ened, short, and flexed. Wound of knee-Wound of knee . Washing-ton, N.C. Baltim're, Sept 9, — 11 mos. 8J inches 2 inches 3 inches Stump healed. March, 14 mos. 15 mos. 7 inches 2j inches 3 inches Inflammation and Md. 1862 gangrene ensued. Comp'd com. frac- Kinston, Dec. 14, 4 mos. 8 mos. 4} inches 2J inches 2 inches Stump not healed. ture of femur N.C. 1862 increase increase Comp'und fracture of knee.... Antietam, Sept 17, 9 mos. 11 mos. 8 inches linch 2 inches St'mp uneven, hav- Md. 1862 ing sloughed, cicatrices large, small ulcers re- maining. Comp'und commi-nuted fracture of Antietam. Sept. 17, 7 mos. lyear 8 inches None linch Secondary hemor- Md. 1862 rhage ensued, lower third of the femoral artery li- femur .... gated, st'mp near-ly healed, and pathological con-ditions fair, exc'pt cicatrix extensive on anterior part. Destruct. of knee- Antietam, Sept. 17, 7 mos. 9 mos. 3}inches None i inch — joint, etc. . . . Comp'und fracture Md. Coal Har- 1862 June 1, 5 mos. 6 mos. 6]inches 2J inches 2 inches Damaged by gan-grene, healed, bone covered by cicatrix only. lower third of bor, Va. 1864 Comp'und commi- Drury's Bluff.Va. May 16. 1864 1 year at 1 year * 6 inches 2} inches 24 inches Very good, some nuted fracture of 14 mos. 5 mos. damaged by gan- femur .... grene. Comp'und fract. of Williams- May8, 1862 8 mos. lyear 7J inches 1}inch 1 inch' Not ready. lower 3d of femur burg, Va. Williams- increase increase Comp'und fracture of Knee-joint. . May 11, 1862 8 mos. 8 mos. 4Jinches 1 inch None Ready. burg, Va. Williams- Comp'd fract. low-er third of femur June 20, 7 mos. lyear .55 inches 2 inches |inch — burg, Va. Antietam, Md. 1862 increase Comp'und fracture of thigh . . . Sept. 17, 1862 7 mos. 11 mos. 7 inches 2} inches 2} inches St'mp nearly ready. not healed, ball passing obliquely from the anterior later'l head of tib- ia, making its ex- it above the inter- nal condyles of femur, up the left leg, striking the right thigh mid- dle lower third of femur, causing comp'nd fractu.e. Comp'und commi-nuted fract. low- Lovejoy Sept 4, 11 mot. 13 mos. 8J inehes 3 inches 3}inches Damaged by gan- Station, 1864 grene, transpTted er third thigh. . Ga. one mile, then 4, then l.'iO, not dressed for 4 days, diet very poor. Destruction of ham Cedar Mountain, Sept. 15, 1863 8 mos. lyear 10 inches linch 3J inches Nearly healed, some eczema, angula- Comp'und fracture knee and leg . . Va. Gettys-burg, Pa. Julv 3, 1863 6 mos. 9 moa. 8] inches 2 inches 2 inches Stump irregularly covered, healed, efficient. Comp'und commi-nuted fracture of Comp'und commi- Gettys-burg, Pa. Gettys- July 1, 1863 July 2, 5 mos. 3 mos. 7 mos. 6 moa. 10 inches 10J inch. 3 inches None 2 inches 1 inch Stump udmirable, finely cov'red and proportioned. Stump favorable, clean in front, healed and ser-viceable. Stump healed, effi-cient. nuted fracture of upper third of leg and knee Comp'und commi- burg, Pa-Gettys- 1863 Julyl, 6 mos. 8 mos. 10J inch. 2}inches 2 inches nuted fracture of burg, Pa. 1863 knee-joint. . . Comp'und commi-nuted fracture of Gettys-burg, Pa. JnlyS, 1863 6 mos. 9 moa. 11inehes 2} inehes 2} inches Stump well healed, round, smooth, well covered, ex- knee-joint . . tensively cica-trized, stitches sloughed out. Comp'und commi-nuted fracture of Gettys-burg, Pa. Julyl, 1863 1 year. 2d time 14 mos. 2d time 8 inches None 1 j inches Damaged by sloughing, main-ly healed. Some hypertrophy, healed scanty, in-tegumentary cov-ering, some ul- lower third of leg Comp'und fracture of the middle of thigh .... Gettys-burg, Pa. Julyl, 1863 11 mos. ll moa. 13 mos. 1 year 2 inchea 1} inchea increase None ceration. 20 ONE HUNDRED AND FIFTY-EIGHT CASES TABLE OF ONE HUNDRED AND FIFTY-EIGHT CASES Name. Regiment Occupa-tion. Limb. Point of Operation. Method. Where per-formed. Length of Time after Injury. Cause. C.E. H. H.E. 20th N. Y. S. M. 16th N. Y. Farmer Farmer R. L. Upper third Lower third Circular Circular Hospital at Gettysburg, Hospital Seven days Ten days Minie-ball Gunshot C. McD. 117th N.Y. Vols. Clerk R. Lower third Ant. post, flap On the field Twenty minutes Musket-ball W. S. 15th Ind. Painter L. Lower third Ant. post, flap Field Twenty-fo'r Minie-ball G.W.S. Battery 14th Conn. Vols. Salesman R. Lower third Rectangular flap Field Tw'nty-one hours Minie-ball G. B. 2d N.Y. M. R. 7th Wis. 97th N. Y. Vols. Laborer R. Lower third Ant. post, flaps On the field One hour Musket-ball G. T. D. B. Fur-trap-per None R. R. Lower third Lower third Ant. post, flap Ant post flap On the field On the field Twenty-fo'r hours Tw'nty-one hours Fragment of shell Musket-ball R.H.P. 7th Wis. Carpenter R. Upper third Ant. post, flap On the field Twenty Minie-ball J.U. 107th N. Y. Vols. Farmer L. Middle third Rectangular flap On the field Forty-eight hours Grape-shot P. T. 24th Mich. Lumber-man R. Lower third Circular Hospital at Gettysburg, Three days Minie-bal] J. C. C. J. B. 7th Md. Vols. 4th R. I. Miller Carpenter L. L. Lower third Lower third Circular Anterior flap On the field On the field Four hours Seven hours Minie-ball Grape-shot M. S. 183d Penn. None R. Lower third Circular Douglas's Hospital On the field On the field Six days Minie-ball G. P. S. W.K.S. 21st Conn. Vols. 5th Conn. Vols. 49th N. Y. Vols. Farmer Merchant R. R. Middle third Lower third Ant. post flap Ant post, flaps Four hours Twelve h'rs Minie-bal] Shell T. K. Laborer L. Lower third Ant post flap - Tw'nty-one hours Rifle-ball J. H. V. 107th N. Y. Vols. Fanner L. Lower and middle third Ant post flap On the field Seven days 2d time Tw'nty-one days Rifle-ball, 2d time Extensive sloughinge and de-n'ded bone W.M.V. G.W.P. 26th N. Y. Vols. 21st N. J. Vols. Cigar-maker Book-keeper R. R. Lower third Middle third Circular Circular On the field On the field Five days Six days Minie-ball Musket-ball J. McW. 20th Conn. Vols. Student L. Lower third Circular Acquia Cr. Hospital Twenty-three days Minie-ball J. S.L. 5th N. J. Vols. - L. Lower third Ant. post flaps Potomac Hospital Armory Sq. H*spital,DC. At his home Four days Minie-ball J. H. J. E. C. 8th N. J. Vols. 16th Conn. Vols. Silver-plater Farmer R. L. Lower third Middle third Circular Circular Six weeks Four weeks Minie-ball Minie-ball H. S. 26th N. Y. Vols. Farmer R. Lower third Anterior flap On the field Thirty ho'rs Minie-ball J. G. 38th N. Y. Vols. B'nk-note printer L. Middle third Lateral flap On the field Five days Minie-ball M. R. 63d N.Y. Vols. Shoe-maker R. Upper third Circular On the field Forty-eight hours Rifle-ball J. P. 69th N. Y. Vols. 37th N. Y. Vols. Soldier R. Upper third Circular _ J. G. W. Salesman R. Lower third Lateral flap At home 107 days Gunshot J. C. 25th N. Y. Vols. Lather R. Upper third Ant. post, flaps In camp hos-pital On the field Five days Rifle-ball C.L. 1st Berdan S. Shooters " L. Lower third Ant. post, flaps Two hours Grape-shot OF RECOVERED AMPUTATION OF THIGH OF RECOVERED AMPUTATION OF THIGH. —(Continued.) 21 Description of In- jury. Comp'und fracture middle third of thigh..... Comp'd com. frac- ture of patella . Comp'und commi- nuted fracture of knee-joint . . Comp'd com. fract. low.third of thigh Comp'und commi. fracture of knee- joint ..... Comp'd com. frac- ture knee-joint. Comp'd com. fract. of leg near knee Comp^ind commi- nuted fracture of knee and leg . . Comp'd com. fract. middle of thigh Comp'd com. frac- ture of knee- joint ..... Comp'und fracture c'ndyle of femur, knee involved . Comp'd com. frac- ture knee-joint Compound com- minuted fracture knee-joint . . Comp'd com. frac- ture knee-joint Comp'd com. frac- ture knee-joint Destruc. upper p'rt of leg and knee Comp und commi- nuted fracture knee-joint. . . Compound com- minuted fracture knee-joint. . . Comp'd com. frac- ture knee-joint Compound com- minuted fracture knee-joint. . . Compound com- minuted fracture knee-joint. . . Fracture .... Comminuted frac- ture knee-joint. Comp'und fract're knee-joint . . Comp'd com. frac- ture of the upper third of leg . . Comp'und commi- nuted fracture of lower third of femur .... Comp'd com. fract. of lower and middle third of thigh .... Comp'd fracture of femur .... Comp'd fract. mid- dle third of leg . Comp'd fract. low- er third of femur Comp'd fr'ct. knee: destruction of leg Chancel- lorsville Chancel- lorsville Chancel- lorsville Chancel- lorsville Chancel- lorsville Antietam Md. Freder'ks- burg, Va. Freder'ks- burg, Va. Bull Run, Va. Bull Run, Va. Hanover C. H., Va. Hanover C. H., Va. Mav3, 18tS3 July 4, 1864 July 17, 1864 June 18, 1864 June, 1864 M'ch 81, 1865 May 25, 1864 M'ch 31, 1865 June 25, 1864 May 3, May 3, 1863 May 4, 1863 May 4, May 3, 1863 May 3, Dec. 13, Length of time from Amputa- tion to Exami- nation. Length of time from Amputa- tion to Applica- tion. 8 mos. 8 mos. 9 mos. 6 mos. 4 moa. Smos. Smos. 8 mos. 10 mos. 6 mos. 6 mos. 8 mos. 8 mos. 3 mos. 13 mos. 11 moa. 11 mos. 11 mos. 8 moa. 8 moa. 11 moa. 1 year 5 moa. 3 years 7 mos. 8 mos. 13 mos. 11 mos. 11 mos. 8 mos. 1 year 11 moa. 7 mos. 7 mos. 10 mos. 14 mos. 14 mos. 15 moa. 14 mos. 11 mos. 1 year & 20 days 14 mos. 7 mos. 3 years fi 2 mos. 10 mos. Length of Stump None 9£ inches 9 inches 12 inches 10 inches 11$ inch. 10 inches 5 inches 9$ inches 7} inches 9 inches 9 inches 9} inches 6$ inches 9 inches 10 inches 8] inches 10^ i°ch. 5} inches 9} inches 7} inches 9 inches 12} inch. 8 inches 3} inches 10 inches 3} inchea 8 inchea Atrophy. Proximal Portion. Distal Portion. 1}inches None None linch 2J inches 2$ inches 11 inches 1J inches 3 inches 3 inches 2 inches 2 inches 2$ inches 3 inches J inch None J inch 3Jinches 1 inch increase 61 inches None 1} inches 2 inches 4 inches 2 inches 3 inches 21 inches 2 inches 4 inches 2 inches 1 inch f inches 11 inches 4 inches 3 inches 3] inches 3} inches 11 inches linch 2j inchea 1 inch 31 inches 3 inches 4J inches 1 inch 3 inches 41 inches 4 inches linch 3 inchea linch }inch None 4 Inches None None 3 inchea 31 inches None 1 inch }inch 21 inches Generally made at Time of Applica- tion of Artificial Limb. Healed, very short, imperfectly cov- ered. Stump damaged by sloughing. Very good, some damaged by sloughing. Very good, not per- fectly healed. Very good. Healed very good. Nearly well. Healed, very well composed. Very good. Indications of mor- tification, stump ulcerated, will be well shaped. Healed very good. Heal'd, very good, except injury. Very good. Very good. Not healed. Nearly healed, some periostitis, necrosis. Stump mainly healed, ulcer on the inferior poa- terior part, badly cicatrized by sloughing ana exfoliations. Healed. Healed, periosteum some thickened, some tenderness, anterior and infe- rior part, cicatri- zation. Stump fair, scantly covered, tenderly healed, will prove efficient. Mortificati'n fourth day after injury. Stump healed, good condition. Bone protrudes, covered only with Bkin, muscles re- tracted, stump well, secondary. Stump imperfectly healed, excessive- ly long. Stump ulcerated over the end of bone, parts gran- ulating, has sloughed badly. Stump short, well healed, will prove vigorous. Gangrene. Good. Gangrene, conva- lescent. Stump poorly rounded. 22 ONE HUNDRED AND FIFTY-EIGHT CASES TABLE OF ONE HUNDRED AND FIFTY-BIGHT CASES T. G. R. C. P.R. L. D. P. A. S. F. M. T. B. G. C. J. F. W. B. G. M. R. E. K. 0. P. R. J.B. M. Q. P.H. J. M.B. J. M. T. M. S. M. M.J. C. J. H. J. H.C. C. W. C.H.M. Regiment. 36th N. Y. Vols. 23d Veter- an, III. 3d R. I. Artillery 5th N. Y. Vola. 4th N. n. Vola. 100th N. Y. Vols. 1st Vt Artillery 100th N. Y. Vols. 3d U. S. A. A. Sailor U. S. Navy 3d N. J. Vols. 10th Penn. Reserve 7th Ind. & 13th N. Y. 55th N. Y. Vols. 40th N. Y. Vola. 6th N. Y. Artillery With 111. Infantry 81st N. Y. Vols. 1st Texas Cavalry 4th N. Y. Vols. 17th N. Y. Vols. 69th N. Y. Vols. Occupa-tion. Limb. Laborer L. Builder R. Laborer R. Sailor R. Teamster L. Farmer R. Farmer L. Farmer R. Soldier R. Sailor L. Sailor R. Black-smith Moulder L. R. Carpenter R. Machinist R. Laborer L. Butcher R. Seaman R. Lieuten-ant Furnace-man L. L. None R. None L. Teamster R. Tinsmith L. Waiter R. Point of Operation. Middle third Lower third Lower third Middle third Middle third Middle third Middle third Middle third Middle third Middle third Middle third Lower third Middle third Lower third Lower third Middle third Lower third Lower third Middle third Middle third Lower third Middle third Middle third Ant. poet, flaps Ant. post flaps Bilateral flaps Rectangular flap Lateral flaps Circular Bilateral flapa Ant. post, flaps Ant. poat. flap Ant. post, flapa Ant. post, flap Circular Ant. post, flap Ant. post, flaps Bilateral skin- flaps and circular Anterior flap Anterior flaps Ant. post, flapa Ant. post, flap Ant. post, flaps Ant. post, flap Circular Circular Ant. post, flaps Length of Time after Injury. On the field On the field In field hos- pital, Morris Island, S. C. Rebel hospi- tal On the field On bo'rd reb- el transport, Charleston On the field Charleston, S. C. Bellevue Hospital On hosp. ship Louisiana Hampton Hospital On the field On the field Armory So. Hosp., D. C. On the field On the field Marine Hos- pital, N. O. On the field Ebenezer Church Frederick City Hoepit'l Three houra Three hours Two houra and a half Twenty-fo'r houra Twenty-fo'r hours Five days One yr. and nine months Six days One month Sixty-eight days Imme- diately Fifteen days Thirty ho'rs Three hours Half an hour Soon after injury Thirty-six hours Five ln'ntha Six months and a half Grape-shot Minie-ball Explosion of torpedo Fragment of shell Grape-ahot Fragment of sheU Grape-ahot Rifle-ball Gunshot Gunshot Pistol-shot Rifle-ball Rifle-ball Upsetting caisson Minie-ball With axe Gunshot Minie-ball Fragment of shell Shell Rifle-ball Musket-ball OF RECOVERED AMPUTATION OF THIGH. 23 OF RECOVERED AMPUTATION OF THIGH. — (Continued.) Length of j Length of Atrophy. Remarks, time from time from Description of In-jury. Battle. Date. Amputa-tion to Amputa-tion to Length of Stump. Jenerally made at Time of Applica- Exami- Applica- Proximal Distal tion of Artificial nation. tion. 8J inches Portion. Portion. Limb. Comp'd com. fract Malvern July 1, 1862 6 moa. 81 mos. 2 inches 1 inch Not healed. low. third femur Hill, Va. increase Compound com- Peters- April 2, 1865 3 mos. 4 mos. 12 inches 1 inch 11 inch Disc very good, should have oeen minuted fracture burg, Va. upper third of leg..... Destruction of leg at knee-joint. . disarticulation. Morris Island Sept. 11, 1863 Smos. 7 mos. 8J inches linch None Stump not healed, will be round and efficient. Compound com- Peters- AJ.^8, 5 moa. _ 8 inchea linch None Finely formed and minuted fracture burg, Va. increase covered, swelling on anterior mib> die of stump, of knee-joint white, painless, size indicative of some disease, 4x3. Comminuted frac- Morris Isl- Sept. 17, 4 moa. 7 mos. 8 inches 2 inches 1 inch Stump not healed, ture of knee . . and, S. C. 1863 will be efficient. Entire leg badly comminuted to Fort Wag-ner, S. C. July 19, 1863 10 mos. 1 year 61 inches 1J inches 3 inches Healed, poorly cov-ered, damaged by sloughing. Stump healed, well Destruct. of knee- Port Hud- May 27, 8 mos. 10 mos. 6 inches 21 inches 3 inches Compound com-minuted fracture 1863 increase covered. Fort Wag-ner, S. C. July 18, 1863 3 mos. 7 mos. 9 inches linch 1 inch Stump healed, pe-riosteum some of middle of leg thickened. Wound of knee- Utah Ter- June 4, 2 years & Smos. — 71 inches 1 inch 2 inches — ritory 1860 Ft. Donel. 1862 — — 7 inches None None — - & Philip Ft. Donel. 1862 - - 4 inches 2 inches 2 inches - - & Philip Hartford, Dec. 26, 1861 June 27, - - 91 inches 1 inch 1 inch - Comp'd com. frac- Conn. Gaines's 2 years 3 years & 4 mos. 81 inches 2f inches 3 inches Stump not healed, will De very good. ture knee-joint. Mill, Va. 1863 Comp'und fracture Gaines's June 27, 7 mos. 18 mos. 81 inches None None Not healed. lower third of Mill, Va. 1862 femur .... Comp'und fracture Yorkt'wn, April 30, 7 mos. 9 mos. 10 inches 1j inches linch Healed very good. of ankle-joint . Comp'und fracture of knee-joint . Va. WhiteOak 1864 June 27, 6 mos. _ 91 inchea 11 inch 21 inches Atrophy of muscle Swamp 1862 about union of the flaps, front and end smooth, tak- en prisoner to Richmond ; two months on board Sanitary Ship, then to City Hos-pital, N. Y. Not quite healed, some thickening Destruct. of knee N. Anna May 23, 1864 6 mos. 8 mos. 91 inches 2 inches 2 inches and exfoliation. Great toe, erysipe- _ May 27, 1864 May 26, 1864 May 9, 1864 6 mos. 7 mos. 91 inches 21 inchea 3 inches Nearly healed. las, gangrene . Comp d fracture of knee-joint. . . Compound com-minuted fracture of lower third of - 8 mos. 3 mos. 8 mos. 10 mos. 12 inches 8 inches linch 1 inch 11 inch 3 inches Healthy, united by first intention. Extensive necrosis, healed, extensive-ly cicatrized, ex- thigh..... cessive incisions. Comminuted frac- _ Oct. 14, 8 mos. lyear 7 inches 11 inch 11 inch Healthy. ture of knee- 1863 Wound of popliteal artery .... Hudson City, La. Sept. 1, 1863 7 mos. 10 mos. 8 inches 2 inches 3 inches Stump healed, some irregular, efficient. Comp'd com. fract. FrederTcs- Dec. 13, 9 mos. 1 year lOj inch. 21 inches 3 inches Stump healed. of entire leg . . Comp'und fracture of knee-joint . burg, Va. Bull Run, Va. 1862 Aug. 30, 1862 10 mos. 1 year & 28 days 8 inches 3 inches 1 inch Stump bruised, ul-cerated, good con-dition, habits in-temperate, leg badly cedematous Comp'd fract up-per third of leg Antietam, Md. Sept 17, 1862 11 mos. 1 year & 1 month 10 inches 11 inch 3 inches Stump not perfect-ly healed. and knee . . . 24 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES Name. L.H. W.R. S. O.K. P. D. P. S. S. B. D. H. P. T. L. J.M. W.R. R. G. F. F. E. D. N. R.A. N. D. P. S. G.W.M. P.B. J.L. B. M. J.F.M.R T.P. D.O'S M.M. Regiment. 10th U. S. Infantry 14th V. S. Infantry 140th N. Y, Vols. 15th N. Y. Vols. 59th N. Y. Vols. 56th Mass. Vols. 10th N. Y. Vols. 10th U. S. Infantry 2d N. Y. Vols. Occupa- tion. Farmer Soldier Brick- layer Farmer Farmer Ship-car- penter None 82d N. Y. Vols. 5th N. Y. Brick- H. Artill'ry layer 5th N. Y. Vols. 11th Conn. Vols. 14th U. S. Infantry 61st N. Y. Vols. 122d N. Y. Vols. 74th N. Y. Vols. 69th N. Y. Vols. 108th N. Y. Vols. 13th N. C. C. S. A. 2d N. Y. S. M. 8dU.S. Infantry 70th N. Y. Vols. None Tinman Teamster Farmer Mechanic Farmer French- man Laborer Farmer Student Military Hatter Point of Operation. Lower and middle third 1st, low. third 2d, middle & upper third Upper and middle Middle and upper third Lower third Lower third lst.lowerand middle third 2d, middle third Lower third Middle third Upper third Upper third Upper and middle third R. Lower third Upper and Middle third Upper and middle third Middle third Middle third Middle and upper third Lower and middle third Middle and upper third Lower third Middle and lower third Lower and middle third Upper third Upper and middle third Circular Ant. post, flap Posterior flap Ant. post, flap Posterior flap Ant. post, flaps Circular Bilateral skin flaps Circular Circular Ant. poat. flap Circular Ant. poat. flap Ant poat flapa lat, post, flap 21, bilateral flaps Posterior flap Circular Posterior flap Ant. poat. flap Ant. post, flap Circular Circular Posterior flap Circular Circular Circular On the field On the field Fredericks- burg hospital City Point Hospital Hampton Hospital On the field Brooklyn, N. Y. On the field On the field On the field On the field On the field Winchester Hospital On the field On the field On the field Newtown U, S. Hospital McDougal General Hos- pital On the field Length of Time after Injury. On the field Hospital 51st, New York On the field One hour 2d, forty- oue days Sixth day Five days Fourteen daya Seventy- seven days Twelve h'rs 2d,seven months One hour Two hours Seventeen hours Sixteen hours Fifteen hour. Thirty days 2d, in hos- pital Eighteen houra Seven daya Six hours Sixtee'i days Two m'ntha and twelve daya Forty-eight hours Three daya Twenty-fo'r hours Sixteen hours Thirty daya Four hours wIgSSS" TwW Mni-"aH °urg, Pa. OF RECOVERED AMPUTATION OF THE LEG. OF RECOVERED AMPUTATION OF THE LEG. 25 Length of Length of Atrophy. Remarks, time from time from Description of In- Battle. Date. Amputa- Amputa- Length of Generally made at Time of Applica-tion of Artificial jury. tion to tion to Stump. Exami- Applica- Proximal Distal nation. tion. Portion. Portion. 2} inches Limb. Comp'd com. fract. of lee, lower 3d Wilder-ness, v a. May 6, 1WJ4 Smos. - 101 inch. linch Not healed, will be good. Not healed, cetlem- Disr'pture of tarso- Wilder- May 3, 3 mos. — 51 inches | inch linch metatarsus, an- ness, Va. 1864 2d, 2 mos. increase kle joint, second June Hi, 1864 Comp'd com. frac- Wilder- May 8, 3 mos. 7 mos. 41 inches None 2 inches Healed badly, com- ture of low. third of leg .... Comp'und fracture ness, Va. Peters- 1N64 June 16, S mos. 6 mos. 7 inches 2J inches 21 inches posed, redundant flap. Healed, some dam- of tarsus . . . burg, Va. 1864 aged by exfolia- Comp'd com. frac-ture of leg above malleoli . . . Peters-burg, Va. July 13, 1864 4 mos. 5 mos. 8 inches linch 21 inches Healed, crest cica-trized, flap sepa-rated, pendulous, Comp'und fracture of ankle joint . Srottsyl-vania, Va. May 12, 1864 10 mos. 1 year llj inch. linch 3 inches limb very good. Long, damaged by gangrene. Comp'd com. fract. of tarso-metatar- Spoltsyl-vania, Va. Ma>- 17, 1864 9 mos. lyear Ill inch. None 21 inches Not entirely heal'd, very long, should sal bones, thro' the metatarsus have been Syme's. and tarsus. . . Flesh wound in Spottsyl-vania, Va. May, 9 mos. 10 mos. Ist.lOf inches |inch 3}inches First very bad, ul- front of ankle 1864 ceration, necrosis, joint by a spent ball, no fracture, 2d, 7| second, very fine. inches ball lodged in muscles, walked a mile .... Comp'und fract of Spottsyl-vania, Va. May 10, 1864 6 mos. 7 mos. 13 inches linch 21 inches Good, should have calcaneum, ball atr'phied been Syme's. lodged in it . . Comp'd com. frac- Spottsyl-vania, Va. May 9, 1864 5 mos. Smos. 71 inches 2 inches None Healed, enlarged, ture of leg, mid- increase damaged, poste- dle third . . . rior flap redun-dant. Comp'd com. frac- Spottsyl-vania, Va. Mar 11, 3 mos. 4 mos. 4J inchea 1 inch 11 inches Healed, some dam- ture middle and 1864 increase aged by ulcera- lower third . . tion, flexed. Middle third of leg Spottsyl-va 'ia, Va. May 11, 1864 3 mos. 5 mos. 31 inchea 1 inch 3 inches Healed, fair stump. External malleoli Snicker's July 18, 1864 11 moa. 14 mos. 2 inchea None None Walked four miles shattered . . . Gap, Va. after injury, healthy, thinly covered. dam-aged by sloughs. Excellent, model Comp'd com. fract. Snicker's July 18, 1864 11 mos. lyear 11inchea J inch 11 inches of oe calcis and G p, Va. stump. tarsus, necrosis . Comp'd com. frac- Peters- June 16, 6 mos. 11 mos. 4 inches If inches None Swollen, eczema- ture of upper burg Va. 1864 increase tous. middle of leg . Comp'und commi- Gettys- July 2, 1863 5 mos. 14 mos. 51 inches 1 inch 1 inch Flap sl'ughed,st'mp badly ulcerated, will be efficient. nuted fracture of burg, Pa. ankle joint . . Comp'd com. fract. Gettys- July 27, 1863 5 mos. 7 mos. 41 inches linch 3 inches Stump ulcerated, of middle of leg burg, Pa. redundant flap. Comp'd com. fract. Gettys- July 3, 10 mos. 8 inches linch 3 inches Good. of ankle joint . burg, Pa. 1863 Comp'd fracture of Gettys- July 2, 3 mos. 6 mos. 41 inches None 3 inches Stump damaged, fibula only, gan-grene, secondary hemorrhage . . burg, Pa. 1863 flexed, will be cic- atrized, efficient. Comp'd com. fract. Gettys- July 1, 1863 13 mos. 15 mos. 81 inches J inch 4 Inches Not healed, some of ankl joint . burg, Pa. exfoliation. Comp'und commi- Gettys- July 5, — 13 mos. 41 inches None 21 Inches Healed, much dam- nuted fracture of burg, Pa. 1863 aged by slough-ing, and cic'triza- tions on ant. part Disrupture of an-kle joint . . . Gettys-burg, Pa. Gettys- July 4, 1863 11 mos. 13 mos. 10 inchea 11 inches 4 inches Healed, damaged by sloughing. Disrupture of an- July 1, 1863 2yrs. & 2 yrs. & 71 inches } inch 31 inches Excellent. kle joint . . . burg, Pa. 4 mos. Smos. Comp'und commi- Gettys- ' July 2, 1863 2 years 2 years 9 inchea None 21 inches Healed very good nuted fracture of burg, Pa. tarsus .... Destruction at its Gettys- July 2, 1863 Smos. 7 mos. 11 inchea Knee support A good st'mp,flexed middle third . . burg, Pa. at nearly nghtan-gles, smooth and clean front for base of support, not perfectly healed, scabbed over. Compound com-minuted ftacture of middle third Gettys-burg, Pa. July], 1863 3 mos. 6 mos. 5 Inches i inch increase linch Stump not quite healed, will be smooth and effi- of leg .... cient. 26 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES G. M. J. S.R. R. S. T. A. S. T. M. J. F. C. C.H. P. McL. J. S. S. J. M. W.G. H. P. McH. w.s.w. C. P. T. B. 8. R. M. T. J. W. J. K. C.B. Regiment. 14th N. Y. S. M. 12th N. Y. Regulars Cavalry 8th In- fantry 28th N. Y. VoU. 7th Maine Vols. 65th N. Y. Vols. 9th H. A. 18th Penn. Cavalry 30th Mass. Vola. Confed'rate U. S. Navy 54th N. Y. Vols. 55th N. Y. Vola. 38th N. Y. Vols. 29th Conn. 56th N. Y. 12th Maas. 14th N. Y. Militia Occupa-tion. Limb. Stone-cut-ter R. Heating L. R.R. Tele-graph Su-perintend-ent L. None L. Mechanic R. Steam-boatman R. None L. Farmer R. Cotton spinner R. - R. Farmer L. Farmer R. None R. House-painter L. Carder of cotton L. Regular army Sailor L. R. Seaman R. None R. Carpenter L. Farmer L. Farmer R. Stone-cut-ter R. Clerk L. Point of Operation. Lower third Lower third Middle third Middle third Lower third Upper third Upper third Upper third Lower third Upper third Middle third Upper third Middle third Lower and middle third Upper third Junction up. & middle 3d Upper and middle third Middle and upper third Lower third Lower third Upper third Middle and lower third Middle and upper third Ant. post, flapa Posterior flap Ant. post, flap Ant. poat. flap Ant. poat. flap Ant. post, flap Circular Circular Posterior flap Circular Ant. post, flapa Posterior flap Circular Ant. post, flap Ant. post, flap Circular Lateral flapa Circular Posterior flap Posterior flap On the field U. 8. Hospi- tal, Newark Hospital, Culpepper Alexandria Gen'l Hosp. Culpepper C. HTHoapi- tal On the field On the field On the field On the field On the field On the field On the field Bermuda Hundred Brooklyn Hilton Head Hospital On board steamer Field hospi- tal On the field On the field On the field On the field Length of Time after Injury. Cause. One hour Shell Five days Railroad ac-cident Two hours Fragment of shell Twenty-six hours Grape-shot Two days Minie-ball Ten days Minie-ball Five days Piece of shell Three days Minie-ball Six houra Musket-ball Twenty-fo'r hours Minie-ball Thirty h'rs Minie-ball Thirty h'rs Minie-ball Fifty-five hours Eight hours Fragment of shell Musket-ball Two hours Fragment of shell - Gunshot Twenty-two days Eighty-five days Piece of shell Musket-ball Fifteen days Musket-ball Four hours Four hours By spring-ing back of falling tree Canister-shot Three days SheU One hour Railroad cars Five days Musket-ball OF RECOVERED AMPUTATION OF THE LEG. 27 OF RECOVERED AMPUTATION OF THE LEG. — (Continued.) Description of In- jury. Dissevering foot at ankle joint. Comminuted fract. of tibia, tarsal ar- ticulations . . . Disrupture of leg at lower third. . Comp'd com. fract. of ankle j'int and lower third of leg Comp'und fracture of lower third of leg above ankle joint ..... Comp'und fracture of lower third of leg..... Gettys- burg, Pa. South Bruns- wick, N.J. Haws' ShopB.Va. Cedar Mountain, Comp'd com. fract. of leg about the middle .... Comp'und fracture of tibia .... Comp'd com. frac- ture of ankle joint..... Comp'd com. frac- ture of middle third of leg . . Comp'd com. frac- ture of low. third of leg .... Comp'd com. fract. of middle third. Severe injury of calcaneum . . Comp'd com. frac ture of metatar bus and tarsus . Destruction of leg above joint Length of time from Amputa- tion to Exami- nation. Sept. 17, 1862 Aug. P, 1862 Cedar Mountain, 1S6J Va. Cedar Mountain, Cedar Mountain, Va. Cedar Creek.Va. Cedar Creek.Va. Cedar Creek.Va. Cedar Creek.Va. Cedar Creek.Va. Cedar Creek.Va. Cedar Creek.Va. Comp'd com. fract. lower third of leg Comp'd com. frac- ture junction of lower and middle third..... Comp'd fracture of ankle joint . . Comp'd fract. ab've ankle joint . . Lower back part of thigh and dis- rupture of ankle joint..... Below the knee . Comp'und commi- nuted fracture of leg and ankle joint . . • Comp'd fracture of lower third of leg James' Isl and, S. C Fair Oaks Va. Fair Oaks Fair Oaks, Va. Manassas, Va. Aug.9, Smos. 4 mos. 14 moa. 5 moa. Oct. 19, 1864 Oct. 19, 1864 May 20, 1864 Feb. 16, 1865 July 4, 1864 June 15, 1862 May 27, May 31, 1862 Aug. 14, 1863 Length of time from Amputa- tion to Applica- tion. Smos. 11 mos. 6 mos. 6 mos. Smos. 4 mos. 3 mos. 3 mos. 3 mos. 10 mos. 5 mos. 7 mos. 2 years 4 mos. 1" mos. 8 mos. 3 mos. lyear Smos. Length of Stump. 91 inchea '1 inchea 'f inches f)} inches " effec- tive 51 inches 4 inches 31 inchea 131 inch. 31 inches Atrophy. Proximal Distal Portion. Portion. linch 2 inch } inch J inch None None 11 inches ' j inches None 1 inch linch None None 1 inch increase linch Smos. 7 mos. 51 inches 3 effective 8} inches 6 mos. 8J inches Smos. 3} inches _ 51 inches 4 mos. S inches 11 mos. 6 inches _ 12 inches - 10 inches - 11 inches 2yeara 41 inches 6 mos. 91 inches 8 mos. 41 inches Remarks, Generally made a. Time of Applica- tion of Artificial Limb. Jinch 1 inch 2 inchea linch linch 21 inches 4 inches None linch 1 inch linch 2 inches None 3 inches 11 inches 5 inches 21 inches None None None 21 inches 4 inches 4 inches 4j inches 1J inches 21 inches 2| inchea Stump mainly cica- trized, not entire- ly, will prove effi- cient, though re- dundant. Hypertrophy, near- ly healed, edem- atous. Some atr'phy, near- ly henled, crest protruded, cica- trized, otherwise well made. Stump ulcerated, dark red, some exfoliation. Posterior flap pen- dant, anterior denuded, nearly ready. Cicatrized, exfolia- tion, abscess in joint, anterior in- ferior part. Not healed, ulcera- tion exfoliation on inferior por- tion, jo nt in- flamed, e'entrized well, exfoliation of tibia. Scanty, well heal'd, posteri'r deficient in muscle, some enlargement in knee joint, effi- cient, serviceable for knee-bearing, six feet high and on the end. Very good for short stump. Very good. Not entirely healed. Mainly healed, very good. Small ulcer, some exfoliation, will be ve y fair. Enlarged, flap re- ceded, not good, healed, damaged by flap, etc. Excellent. Very good. Very good. Flaps, lateral, st'mp good. Gastrocnemii re- tracted, stump smooth. Excellent, hard and efficient. Stump not healed, flap pendulous, some damaged by exfoliation and extensive cica- trices. Bad posterior flap, pendulous, bad- ly amputated, sloughing. 28 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES M. C J. McC. J. W. D. H. J. M. A. D. W. 8. S. H. A. G. G.W. R J. L. C. H. 8. W.F.W. F.W.K J. 8. M. D. M. W. J. W. W.A.B G.W. G. G. Vf.D. i. DeF. (Indian) Regiment. 2d Conn. H. A. 155th N. Y, 39th Mass. 1st Regt. 8th Regt. Colored 9th N. Y. Vole. Confeder- ate 1st Md. Battery 1st V. H. Artillery 10th Vt. Vols. 14th N. H. Vola. 10th Vt. Vola. 2d Infantry Corps d'Afnque Ind. L. I. N.Y. 7th N. H. Vola. 67th Ohio Vola. 5th Artil- lery Chief of Occupa- tion. Shoe- maker Fanner Architect Seaman Seaman Cooper Farmer Farmer Farmer Carpenter Farmer Tailor Laborer Farmer Sailor Point of Operation. Upper and middle third Lower third Upper third Lower and middle third Upper third Lower third Lower third Upper third Lower and middle third Upper third Upper third Middle and upper third Lower third 1st, justab've ankle 2d,mid.ofleg Junction of lower and middle third Upper third 1st, amputa. lower third 2d, amputa. upper third Upper third Junction of middle and lower third Upper and middle third Upper third Upper and middle third Circular Bilateral flapa Poaterior flap Ant. poat. flaps Poaterior flap Ant. poat flapa Ant. post, flapa Circular Ant. post, flap Ant. poat. flap Ant. poat flap On the field On the field On the field On the field Brookly Coll'ge Hosp. On the field Harrisburg, Port Royal, S. C. On gunboat JohnP. Jack- Spring Hos- pital, Md. Ant post flaps On the field Ant. post, flap Circular Ant post, flap 2d, circular Circular Circular Ant. post, flap Posterior flap Posterior flap Bilateral flapa Poaterior flap Ant. post, flap Circular Bellevue Hospital On the field 2d, Central Park Winchester Church On the field On the field On the field 2d, Freder- ick City Ship Island, Miss. In post hos- pital Charleston Hosp., S. C. On the field Length of Time after Injury. Five houra Six hours Twenty-fo'r hours Seventeen daya Twenty-fo'r hours Thirty-five days Thirteen daya Seventeen hours 2d, 3 weeks Four daya Sev'nty-sev- en hours Three houra Six hours 2d, three months Half hour Sixty daya Five daya Half hour Muaket-bal] Minie-ball Minie-ball Solid shot Railroad cars Grape-shot Musket-ball Rifle-ball Shot Rifle-ball Rifle-ball Cannon-ball Gunshot Minie-ball 2d.exfol'tion and necrosis Musket-ball Grape-shot Conical-ball Musket-ball 2d, exfolia- tions Explosion of torpedo Piece of sheU Rusty nail OF RECOVERED AMPUTATION OF THE LEG. 29 OF RECOVERED AMPUTATION OF THE LEG. —(Continued.) Description of In- jury. Comp'd com. frac- ture of ankle j'int Comp'd com. frac- ture of ankle j'int Comp'd com. tract. of middle upper third of leg . . Disrupt, and carry- ing away entire foot..... Passing over ankle joint..... Comp'd fract. mid- dle third of leg. Comp'und fracture of ankle joint . Shattering ankle joint..... Taking off foot, at the same time wounding other foot..... Dissevering exter- nal malleolusmot injuring foot nor the tibia and as tragalus at artic ulation.so that he walked with the aid of a rifle. Comp'und fracture of ankle joint Comp'und fracture of the middle of leg .... . Wounding soft parts, lower parts Coal Har- bor, Va. Coal Har- bor, Va. Coal Har- bor, Va. Coal Har- bor, Va. Brooklyn, N.Y. Chantilly, Va. Cross Keys, Va. Port Roy- al, S. C. Vicksb'rg, Miss. Length of time from Amputa- tion to Exami- nation. of be'lly, gastroc- nemii .... Lower third of leg severed .... Ankle joint and foot ...... Comp und commi- nuted fracture of ankle joint . .. Comp'und commi- nuted fracture of ankle joint . .. Comp'und commi- nuted fracture of middle of leg .. Comp'und commi- nuted fracture of lower middle of leg ...... Comp und commi- nuted fracture of ankle joint, ab- scesses, etc. . • Comp'd com. fract. of lower third of leg • . • -,,* ' Destruction ot low- er third of leg, fastrocnemiiand iceps badly lac erated .... Comp'und commi nuted fracture of ankle joint Comp'und fracture of middle of leg Completely carp' ing away the leg at its middle. . Punctured wound, inflammation Malvern Hill, Va. Malvern Hill, Va. Malvem Hill, Va. Malvern Hill, Va. Malvern Hill, Va. Winches- ter, Va. Winches- ter, Va. Winches- ter, Va. Winches- ter, Va. East Pas- cagoula, Miss. Ft. Wag- ner, S. C. Ft. Wag ner, S. C Ft. Wag- ner, S.C. Sharps- burg, Md, June 1, 1864 June 3, 1864 June 3, 1864 Dec, 1862 Aug. 29, 1862 June 25 1862 June, 1862 June 28 1863 Length of time from Amputa- tion to Applica- tion. July 1, 1862 July 1, 1862 Sept. 19, 18T- Sept. 19, 1864 April 9, 1863 Sept. 19, July 21, 1863 Sept.19, 1862 7 mos. 6 mos. 1 year 11 mos. 4 mos. 5 mos. 7 mos. 1 year 4 mos. 4 mos. 9 mos. 8 mos. 7 mos. 7 mos. 7 mos. 10 mos. 11 mos. 8 mos. 4 years 8 mos. 7 mos. 13 mos. 13 mos. 6 mos. Length of Stump. 6 inches 14 inches 3 inches 101 inch. 81 inches 7 mos. ;4J inches 7 mos. j 101 inch. 9 inches lyear ft 5 mos. 6 mos. 10 mos. 9 mos. 8 mos. Smos. 14 mos. 11 mos. lyear 13 mos. 10 mos. 4 years Atrophy. 11 inch linch None 11 inch 1 inch None 1 inch None None 4 inches 31 inches 2 inehes 9 inches 7 inches 91 inches 21 inches 61 inches 5 inches 3J effect. 4j inches 3 efTctive 81 inches 4j inches 31 inches 61 inches 61 inches None linch None None j inch None None None 11 inch Increase 1 inch linch 1 inch 11 inches 2 inches None 2 inchea 41 inches None 41 inchea None None 2j inches Good, well healed. Healed, good. Indifferent, dam- aged by g'ngrene, knee support. Excellent. Remarks, Generally made at Time of Applica- tion of Artificial Limb. 1J inches 3 inches 4 inches None 31 inches 3 inches 11 inches 3 inches 2} inches 3{ inches 4 inches Clean, well formed stump, tibio-as- tragaloid articu- lation, artificial leg. End of stump ir- regular, flap ob- lique. Cicatriza. healthy, well, even, quite efficient, walked to Harrison's Landing, thence to Bellevue per transport, walked about till amputa- tion, secondary hemorrhage. Stump good, knee support Taken prisoner at Malvern Hill, Va. Very good, cover- ing angular. Very good, end ex- posed by slough- ing. Excellent for knee support, flexed. Very fair, stump d'maged by sl'gh- ing. Stump damaged by exfoliations and sloughings. St'mp some flexed, healed, will be ef- ficient. Healed mainly some exfoliation stump flexed hamstrings rigid. Some atrophied, healed, irregular, not well com- posed. Healed, flexed, rather short 30 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES J. D. T. R. T. C. M. P. H. B. P. B. C. W. S. L.H.M. E.LeG. J. R. C.W.R. H. A. G. A. C. H. G. F. M. J. W.T. C.L. J.L. M. G. A. A. Regiment. 23d Mass. Vols. 11th N. Y. Vols. 14th N. Y. Militia 1st Ells- worth Zouaves 22d N. Y. Vols. 20th Conn. Vols. 1st R. I. A. 11th Vt Vols. 1st U. S. Artillery 1st La. In- fantry 131st N. Y. Vols. 89th HI. Infantry 62d N. Y- Vols. U. 8. Navy 142d N. Y. Vols. 56th N. Y. Vola. 106th N. Y. Vols. Occupa-tion. Limb. None R. None L. Farmer R. Lieuten-ant L. Farmer L. Clerk L. Black-smith Butcher L. L. - L. Shoe-maker Farmer L. R. Carpenter L. Fireman L. farmer L. Shoe-maker L. STegro dri-ver R. Carpenter R. Railroad Conduct'r R. Railroad Manager Pianoforte maker R. L. Boat- R. swain's mate House-painter L. Carriage-maker R. None R. Fanner L. Point of Operation. Junction of middle and upper third Upper and middle third Middle and upper third Upper third Upper third Lower third Upper third Upper third Lower and middle third Lower and middle third Upper third Lower and middle third Junction of middle and upper third Upper third Upper and middle third 1st, extreme lower third 2d,junct. of low. mid. 3d June, of up- per and mid- dle of leg Middle and lower third Lower and middle third Circular Posterior flap Bilateral flaps Posterior flap Ant. post, flap Ant. post, flap Circular Posterior flap Ant. post, flap Ant post, flap Posterior flap Ant poat. flaps Circular Posterior flap Circular Anterior flap Ant. poat. flaps 1st, Circular 2d, Bilateral flap Bilateral and Circular Circular Ant. post, flap On the field In field hos- pital On the field Residence, New York Clifborne Hospital Rebel hosp., Richmond Bellevue Hospital On the field On the field Portsmouth Grove Hos- pital McDougal U. S. Gener'l Hospital On the field On the field On the field In the field hospital On the field On board ship On the field 2d, Central Park On the field On the field On the field Length of Time after Injury. Eight days Half hour Eight days Four days Eighteen hours Eleven months Forty-eight hours Three days Eighteen hours Half hour Half hour Five hours Seven weeks Twenty-fo'r hours Eighteen hours Seven months Seven and a half months Ten hours Three *< four hours Four hours Grape-shot Shell from Union gun while m rifle-pits Rifle-ball Rifle com- bustible ball Minie-ball Rifle-ball Shot Minie-ball Fragment of shell Fragment of shell Grape-shot Minie-ball Canister- shot Erysipelas from cut Grape-shot Caught in turret Piece of shell Canister- shot Musket-ball Fragment of shell OF RECOVERED AMPUTATION OF THE LEG. OF RECOVERED AMPUTATION OF THE LEG. — (Continued.) 31 Description of In- jury. Comp'und commi- nuted fract. low- er third of leg Comp'und fracture of lower part of leg and ankle . Comp'd com. fract lower third of leg, and flesh wound of calf of the other leg . . . Comp'undfract. of fibula, tibia split, etc. Comp'und commi nuted fracture of middle of leg Comp'und commi- nuted fracture of middle third. . Comp'd fract. low- er part of leg . Compound frac- ture ..... Length of time from Amputa- tion to Exami- nation. March 14.1862 March 14,1862 Comp'd com. fract. of middle third . Destruction of leg at lower third . Boring a hole in the tibia antero- posterior without fracture . . . . Comp'und commi- nuted fracture of 4th and 5th meta- tarsal bones, of internal and ex- ternal cuneiform and calcis . . . Comp'd com. fract of lower third . Severing leg at its middle and lower third ...... Comp'und commi- nuted fracture of middle third of leg .... 2d Bull Run, Va. Bull Run, Va. Bull Run, Va. Bull Run, Va. Chancel- lorsville Chancel- lorsville Fred'icks- burg, Va. Fred'icks- burg, Va. Coal Har- bor, Va. Port Hud- son, La. Port Hud- son, La. Lodged in foot, en- tering back ex- ternal malleolus making a circuit of foot . . . Middle of leg Tarsus metatarsus sundered . • • Comp'd com. fract. of foot, ankle joint, and lower third of tibia . . Comp'd com. frac ture of foot, heel, and ankle joint uninjured . . Entire destruction of ankle joint, subsequent dis- ease of bone . Comp'und fracture of upper middle of leg . - - • Compound com minuted fracture ankle joint . . Comp'd com. frac ture of ankle . July, 1861 July 29, 1862 July 21, 1861 July 21, 1861 April 29 Port Hud- son, La. James River, Va. Dilbyt'wn Dingle's Mill, S. C. Winches- ter, Va. June 1, 1864 May 27, 1863 Jan'y 16, 1864 May 8 Nov. 28, 1864 April 9, M'ch 16, 1865 Sept. 19, lyear 6 weeks 7 mos. 7 mos. 16 mos. 8 mos. 9 mos. 8 mos. 6 mos. 10 mos. 6 mos. Smos. 6 mos. 4 mos. Length of time from Amputa- tion to Applica- tion. 13 mos. 9 mos. 4 mos. 9 mos. 11 mos. 13 mos. 9 mos. 10 mos. Length of Stump 6 mos. 7mos. 7 mos. 61 inches 51 inches 4J inches 51 inches 4j inches Atrophy. 1 ineh 41 inches 11 inches 3.J inches None 9 inches 1 inch 51 inches 8 inches 31 inches 81 inches 41 inches 10 inches 6 inches 113 inch. 9J inches 4 inches 93 inches 9 inches None 11 inches } inch 1.J inches None {inch linch Generally made at Time of Applica- tion of Artificial Limb. Has been wearing a leg with rotatory motion at ankle joint, unreliable and unsatisfac- tory. Healed. Stump in bad con- dition,exfoliation, flap not united, ulceration, etc. Healing. 2 inches Retracted, flexion more than angle of 45 degrees. 1 inch 3 inches None 2 inches 31 inches 2 inches 21 inches 2 inches linch linch increase None 2 inches None linch 11 inches 1 inch increase 1 inch 2} inches None 48 inches 21 inches Fine stump. Stump healed and efficient. St'mp healed, some damaged by sloughing. Stump healed, flap redundant, pend- ulous two inches. Stump smooth, neat, efficient, thoro'ly healed. Well healed, excel- lent. Stump well healed, will be vigorous, is well formed. Flap redundant cicatrices exten- sive, angles pout- ing, healed, scab- by, will do pretty good service. Stump bad, necro- sis of tibia, sev- eral ulcers, livid, hypertrophied. Medium size, swol- len, partially healed. Good. Stump not healed, subsequent in- jury, delay. Very fine, healed primarily. Two and one half inches reampu- tated.not entirely healed, sluggish. Excellent Excellent. Healed good. 32 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES C. G. S. M.M. J. H. H. J. A. H. R. T. H. B. J. 8. O. C. J. Y. J. 8. B. C. C. P.P. B.W. B. F. H. B. T. McQ. J. G. N. F. G.F. Regiment U. S. Navy 4th U. S. Infantry 5th N. H. Vols. 38th U. S. Artillery 11th Maine 100th N. Y. Vols. 63d N. Y. Vols. 53d Fenn. Vols. 93d Penn. Vols. 67th N. Y. Vols. 45th N. Y. Vols. U. S.L. Artillery 48th N. Y. Vols. 69th N. Y. Vols. Powder boy 13d N.Y. Vols. Occupa-tion. Limb. Seaman R. Stone-cutter L. Farmer L. Farmer R. Farmer R. Sailor L. Farmer R. Black-smith L. Cabinet-maker Laborer R. R. Farmer L. None R. Farmer L. Cabinet-maker L. Farmer L. Fireman ongunbo't Diana Farmer R. R. Farmer R. Soldier L. Warrior R - L. Lock-smith L. Uphol-sterer R. Point of Operation. Lower third Lower third Upper third Junction of lower and middle third Lower third Lower and middle third Lower and middle third Lower and middle third Upper third Middle and upper third Upper third Junction of lower and middle third Middle third Lower and middle third Bilateral flaps Circular Circular Anterior flap Circular Ant. post, flaps Circular Circular Circular Circular Posterior flap Circular Ant. post flap Posterior flap Ant. post, flap Ant post, flaps Circular Circular Circular Ant. post flap Lateral flaps On gunboat 2d, at Mem- phis On the field On the field On the field On the field In the field hospital Beaufort General Hos- pital Hosp., Mor- ris Island Frederick City On the field On the field Annapolis Hospital In a farm- house, Woodstock, Va. General Hos- pital, Newbern, N.C. Patterson- ville, La. Portsmouth Hospital On the field U. S. Hospi- tal, Baltim're In field hos- pital Field hospi- tal Length of Time after Injury. Ten min'tes 2d, Twenty- two days One hour Five hours Three hours Five houra One hour Three days One hour One month Five days Four hours Six weeks Two hours Nine hours Two days Three mos. Twelve hours Two hours Four hours Six hours Three hours Musket-ball Grape-shot Minie-ball Musket-ball Minie-ball Fragment of shell Fragment ot shell Shell Musket-ball Musket-ball Minie-ball Minie-ball Shell Minie-ball Musket-ball Railroad cars Gunshot Shell Solid shot OF RECOVERED AMPUTATION OF THE LEG. 33 OF RECOVERED AMPUTATION OF THE LEG. — (Continued.) Description of In- jury. Comp'd com. fract. of tarso-metatar- sus..... Compound com- minuted fracture ankle joint aud Destruction of an- kle joint . . . Comp'd com. fract of ankle joint . Comp'd com. fract. middle third leg Comp'und fracture of ankle joint . Comminuted frac- ture lower third of leg .... Comminuted an- kle joint and foot Severing leg at an kle..... Striking leg p at unction of lower third, shattering the bone, exit at the heel Comp'und fracture lower third of leg..... Comp'd fracture of ankle and lower third of leg . Comp'd com. fract. of ankle joint, ball entering back of internal malleoli, and ex- it at anterior lat- eral portion for- ward of external malleoli. . , Comp'd com. frac- ture middle of leg by accidental discharge of mu ket. ... Comp'd com. frac- ture of tarsus, en trance tarso-me tatarsus, exit posterior exter- nal malleolus. Entirely severing leg at its middle third. .... Compound com- minuted fracture of ankle joint . Compound frac- ture of ankle joint .... Comp'd com. fract. of foot and lower part of leg . . . Comminuted frac ture of lower third of leg . . At ankle joint, low- er third of leg, severing the foot from the leg save a few shreds of tissues .... Severing the foot from the leg at the lower third, save by some shreds of muscle Poplar Grove,Va. Antietam, Md. Deep Bot- tom, Va. Deep Bot- tom, Va. Deep Bot- tom, Va. Morris Isl- and, S. C. Morris Isl- and, S. C. Antietam, Md. Wood- stock,Va. Sandy Ridge Berwick Bay en- gagement Drury's Bluff, Va. Drury's Bluff, Va. Gen. Por- ter's staff Fort St. Philip & Jackson Frederiks- burg, Va. Freder'ks- burg, Va. Sept. 17, 1862 July 27, 1864 Sept. 29, 1864 Aug. 31, 1863 Sept. 17, 1862 M'ch 28, 1863 May 16, 1864 May 16, 1864 June, 1861 April 24, 1862 Length of time from Amputa- tion to Exami- nation. 11 mos 10 mos 11 mos 5 mos 6 mos 5 mos, 4 mos 9 mos 14 mos. 14 mos. 11 mos. 8 mos. 8 mos. 7 mos. 10 mos. 4 mos. Length of time from Amputa-tion to Applica-tion. Length of Stump lyear 9 inches lyear 8 inches 1 year & 2 mos. 11 mos. 9 inches 101 inch. - 3} inches 7 mos. 10 inches 8 mos. 11 inches 13 mos. 121 inch. 1 year 12 inches 11 mos. 83 inches 1 year & 9 inches j mos. Lyear & W mos. 9} inches 1 year & 8 inches o mos. 19 mos. 4 inches Smos. 13 inches _ _ 9 mos. 61 inches 8 mos. 9 inches 3 years "J inches - 9 inches 10 mos. S inches 8 mos. 7 inches - 81 inches Atrophy. Proximal Portion. Distal Portion. 3 inch 11 inches None None 11 inches 4 inches 1 inch 21 inches } inch 2 inches linch 21 inches None 3 inches 1 inch 2 inches 1 inch 21 inches 2[ inches 3 inches None 3 inches 1 inch 41 inches 1J inches '2\ inches 1 inch increase 1\ inches 1 inch .31 inches _ _ None 2 inches 3 inch 3 inches linch 1 inch 1 inch 1 inch 1 inch None 1 inch 3i inches \ inch 11 inches Generally made at Time of Applica- tion of Artificial Limb. Nearly ordinary very good, hardy. Not healed, three quarters of an inch of necrosiB, hone removed. Stump healed. Excellent. Good, well excepi slight ulcer. Stump healed. Stump long, redun- dant, some in- flamed, ulcerated. will be efficient. Stump not healed, will be efficient. A model stump, healed by first in- tention, cicatrix hardly percepti- ble, silver liga- atures, stump right proportions. Stump healed, some damaged by sloughing. Not healed. Ulcer on end. Stump healed. Stump smooth, well healed, re- dundant: query, could parts have been secured from Syme's at ankle, vastly su- perior. Healed, excellent, compact, firm. Healed, some dam- aged by exfol.a- tions. 34 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES Name. Regiment. D.M. M. 35th N. Y. Vols. J. H. G.W. P. F. A. G. 9th N. Y. Vols. 30th N. Y. Militia 75th N. Y. Vols. M. W. 114th N. Y. Vols. W. B. 9th N. J. Vols. W.G.B. U. S. Navy B. J. B. 137th N. Y. Vols. H. R. 16th 111. Vols. E. S. 10th Ohio Cavalry J. R. U. S. Navy H. W. U. S. Navy J.B. U. S. Navy A. D. D. B. 15th N. Y. Heavy Ar-tillery 97th N. Y. Vols. J. C. 33d N.Y. Vols. Ista Ma Ga. Omaha Indian I. O. 11th N. H. Vols. J.B. 9th N. Y. Vols. E. E.W. J. McC. I. L. S. 144th N. Y. Vols. 1st D. C. Vols. 4th Mich. D. B. 1st Pcnn. V. K. S. S. J. c. 1st Penn. Reserve 142J N. Y. Vols. 55th N. Y. Vols. W.H.H. 1st Md. Vols. J.N. U. S. Navy Occupa-tion. Limb. Clerk R. R. Cabinet-maker Farmer L. L. Artist R. Foundry L. Boat- R. swain Farmer R. Brick-layer L. Farmer R. 3rdinary Seaman R. Ordinary seaman L. Sailor R. Clerk L. Miller R. Cooper L. - - Farmer & currier L. Farmer L. Carpenter L. Farmer L. None L. Farmer R. None R. Farmer L. Farmer L. Farmer L. Seaman L. . Point of Operation. Upper third Lower and middle third Upper third Junction of middle and lower third Lower third Upper third 1st, middle third 2d, extreme upper third Middle third Middle third Upper third Middle third Lower third Upper third Upper and middle third Lower third Upper third Upper third Middle third Lower third Extreme of upper third Middle and upper third Upper third Ant post, flap Circular Posterior flap Ant. post, flaps Bilateral flaps Circular Circular Ant. post, flap Circular Posterior flap Bifateral skin- flaps and circular Ant. post, flap Lateral flaps Bilateral skin flaps and circular Bilateral flaps Ant. post flap Ant. post flaps Circular Flap Circular Ant. post, flap Flap Flap Circular Circular Circular Bilateral skin flaps and circular Field hospi- tal On the field On the field General Hos- pital, Baton Rouge Hospital On the field Naval Hos- pital, Pen- sacola, Fla. On the field 2d, in general hospital On the field U. S. gun- boat General Jackson Norfolk U. S. Hospital On the field On the field On the field In Falmouth Hospital Union Chap- el Hospital On the field At Savage's Station On the field In field hos- pital De Camp Hospital On the field On Montauk, U.S. gunboat Length of Time after Injury. Five hours 2d operation eleven days Two hours Three hours Thirty days Half hour Two hours 2d, twenty- three days Twenty-one hours Sixteen days 1st, one hour 2d, caused by slo'ghing One day Fifteen hours Six days Half hour Three days Three hours Thirty-six hours Twenty-fo'r hours Three days j Fifteen days Threehours Twenty hours Cannon-ball Extensive sloughings simultane- ous with 1st dressing Minie-ball Fragment of shell Minie-ball Musket-ball Solid shot Extplosinn of torpedo Musket-ball Minie-ball Shell Minie-ball Grape-shot Grape-shot Canister- shot Fragment of shell Grape-shot Rifle-ball Minie-ball Rifle-ball ft buck-shot Minie-ball Solid shot OF RECOVERED AMPUTATION OF THE LEG. 35 OF RECOVERED AMPUTATION OF THE LEG. — (Continued.) Description of In- jury. Comp'd com. frac- ture lower half of leg, 2d, expos- ure of tibia, some exfoliations . . Comp'und commi. fract. lower third Severing leg at low- er third.... Comp'und fracture of tibia, astrag- alus, etc. . . . Near ankle joint Comp'd com. frac- ture of ankle joint and foot , Comp'd com. fract. of lower third . Comp'und commi- nuted fracture of lower third of leg Comp'd com. fract. of leg and ankle Wi ound of posterior tibial artery, no fracture . . . Compound com- minuted fracture of ankle joint . Comp'und fracture of lower third of leg .... Comp'und commi- nuted fracture of ankle joint . . Comp'und commi nuted fracture of anklejoint . . Comp'und commi- nuted fracture of tarsus .... Suppuration, in- filtration, and mortification . . Comminuted frac- ture of lower third of leg . . Carrying away the leg, except a few fibres from upper middle third . . Comp'd com. frac- ture of tibia . . Entirely destroy ing the tarsus . Comp'd com. fract. of middle of leg Comp'und fracture of anklejoint . Comp'und fracture lower third of leg Comp'd com. fract, of ankle joint . Comp'und commi- nuted fracture of middle of leg Comp'd com. f_ — ture of low. third of leg . . . . Destroying leg at middle third Freder'ks- burg, Va. Freder'ks- burg, Va. Fieder'ks- burg, Va. Baton Rouge Cleaning gun Mobile Bay, Ala. Fort Fish- er, N. C. Fort Fish- er, N. C. Hatcher's Run, Va. Hatcher's Run, Va. Rappa- hannock Roanoke Island, N. C. Falls Ch., Va. Rich- mond, Va. Gaines's Mills, Va. WhiteOak Swamp, Va. WhiteOak Swamp City Point, Va Meridian, Miss. Stono, S. C. Dec. 13, 1863 Dec. 13, 1862 July 7, 1863 1S64 Dec. 13, 1864 Oct. 11, 1862 Nov. 6, Nov. 29, 1862 Sept. 29, 1864 June 28, 1862 June 30, 1SU2 June 30, 1862 May 26. 1864 Feb. 15, 1S64 July 9, 1864 Length of I Length of time from | time iron iputa- | Amputa- ii to jtion to ami- Appla- nation, tion. Length of Stump. 4 mos. 5 mos. 7 mos. 7 mos. 9 mos. 3 mos. 4 mos. 2 mos. 6 mos. 5 mos. 4 mos. 5 mos. 4 mos. 7 mos. 8 mos. 5 mos. 9 mos. Smos. 1 month 7 mos. 11 mos. Smos. Smos. 4 mos. 7 mos. 9 mos. 13 mos. 1 year 5 mos. 5 mos 9 mos, 5 mos 4 mos. 6 mos, 5 mos 8 mos, 16 mos. 17 mos. 10 mos. 6 mos. 10 mos. 5 mos. 9 mos. lyear 6 mos. 6 mos. 3J inches 9 inches 3 inches 9 inches 3 inch 9 inches 9 inches 2J inches 7 inches 7 inches 3 inches 8 inches 61 inches 8 inches 8| inches 10 inches 8 inches 31 inches 6 inches 101 inch. 43 inches 3J effect. 31 inches 7 inches 10 inches linch 33 inches 3J incheB Atrophy. 1 inch None 11 inches 2 inches None 1 inches ncrease None None None None None 3 inches 1 inch increase Jinch linch 1 inch None None 1 inch 1 inch 3 inch None 3 inch None linch 13 inches 21 inches None 3 inches 3 inches 2J inches None None 1jinches None None I inch 3 inches 21 inches 2J inches 11 inches 21 inches 3 inches 33 inches 21 inches 4 inches None 3 inches Remarks, Generally made at Time of Applica- tion of Artificial Limb. Stump spread, ad- hesion. Stump mainly healed, pretty good covering and shape, crest cicatrized, ab- scesses, etc., will prove very good, some oedema. Healed by first in- tention, finely composed. Stump healed, sound. Very cedematous, healed, system debilitated. Very fair, stump flexed for knee Bupport Very good, scanty covering. Not healed, doing well, flexed for knee support. Bad, poorly cov- ered, damaged by sloughs. Very good, erest exfol'd, sloughed. Very long, com- pact, tapering good, healed. Healed, very good. Stump flexed, right angles, par- tially anchylosed. Stump fair, i defective, pi er at Kichni Stump slou exfoliation. Very good, formed. Very good, good knee port. Healed. i\"o!] inches 21 effect. Knee -upport 73 inches Atrophy. Proximal Portion. Distal Portion. None 21 inches 1 inch 5 inches None None |inch 3J inches 1 inch 2} inches 1 inch 2 inches 1 inch 21 inches 1 inch 2 inches None None None 3 inches 1 inch 3 inches 1 inch - 11 inch 3Jinches None None None 2A inches J inch 11 inches None None 1 inch increase None 1 inch 3 inches 3 inch 2| inches None 13 inches None None linch 1 inch None 2 inches 1 inch increase None Remarks, Generally made al Time ot Applica- tion of Artificial Limb. Considerably atro- phied, excellent. Very good. Some atrophy, four inches of seques- tra removed, 3 shaft ot bone cased, new bone, very good. Very good, poste- rior some re- tracted. Very good. Some atrophy, very good. Some atrophy, ex- cellent. Very good. Exfoliation, epi- demic. flap post, redun- dant, adhesions now broken up. Normal, very good. A prisoner three months in Peters- burg, one month in Richmond, st'mp firm, heal'd. Bad by sloughings, gangrene, ecze- ma. Knee flexed for knee support, very good. Stump not healed, ulcerated. Stump healed, flap pendulous, exfo- liations, extensive cicatrization. Stump damaged by sloughing. Stump not yet healed, will result favorably. Stump healed, effi- cient. Stump ill condi- tioned, flap pen- dulous, extensive cicatrization, mainly healed. Stump healthy, condition flexed, clean, good kuec support. Stump healed and well prop'rtioned. Stump contracted, caused by flesh wound of hip. in- volving the flexor muscles of leg, healed. Parts nearly healed, badly damaged by abscesses and sloughings below and above knee, stump pretty vig- orous. 40 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES Name. Regiment. Occupa-tion. Limb. Point of Operation. Method. Where per-formed. Length of Time after Injury. Cause. G. A. F. 14th Conn. Vols. Farmer L. Lower and middle third Circular On the field Four days Minie-ball J.B. 36th N. Y. Vols. Laborer R. Upper and middle third Circular On the field Half hour Piece of shell G. Z. 7th N. Y. Vols. Joiner L. Upper third Circular On the field Five days Musket-ball W.W.M. 20th N. Y. Vols, 2d Vt. Vols. - R. Lower third Circular On the field Three days Minie-ball J. H. M. Farmer L. Upper third Ant. post, flap' In hospital, Frederick City Infirm'rv H., Wash., D. C. In field hos-pital On the field Two hours Minie-ball L. R. S. T. J. W. 29th N. Y. Vols. 22d N. Y. Vols. 104th N. Y. Vols. None Sawyer underman Farmer R. L. R. Middle third Upper and middle third Lower third Ant. post, flaps Posterior flap Ant. post, flaps Twenty-fo'r hours Three hours Seven hours Fall Canister-shot Fragment of shell H. C. B. W. M. 8th Conn. 8th Conn. Baggage-master Hartford Railroad Operative R. L. Lower and middle third Lower third Ant. post, flaps Circular Willow Springs Hos-pital In the field hospital Six weeks Three weeks Minie-ball F.B. 59th N. Y. Vols. Painter R. Upper third Ant. post flap On the field Eighteen hours Rifle-ball F. H. M. 9th N. Y. Vols. Clerk L. Upper third Circular In field hos-pital. Fal-mouth, Va. Eighteen hours Musket-ball R. W. S. H. G. 9th N. Y. Vols. 18th Cjnn. Printer Laborer R. L. Middle and lower third Upper third Circular 2d,Bilateral flaps Posterior flap Stone Hos-pital 2d, NewYork On the field Nine weeks 2d,sev'nteen months Five hours Minie-ball Minie-ball W.H.M. 31st Miss. Vols. Farmer L. Lower third Ant. post, flaps On the' field Three hours Minie-ball B. B. F. W. 75th N. Y. Vols. 49th Regt. Farmer Sailor L. L. Middle third Lower and middle third Ant. post, flaps Ant. post, flaps General Hos-pital, New Orleans Lee's Mills Hospital Eighty-one days Minie-ball Rifle-ball H. K. D. 114th N. Y. Vols. Farmer L. Upper third Bilateral skin flaps and circular Campbell Hospital Fourteen days Minie-ball J. M. II. F. D. 7th Conn. Vols. 12th N. H. Brick layer Shoe-maker L. R. 1st, middle third, 2d, up-per third Upper third 2d, ant. post. flaps Ant. post, flap U. S. Hos-pital At Jarvis Hospital, Baltimore E'ghteen hours Ten months Twenty-seven days Grape-shot Minie-ball k. B. 20th Regt - R. Lower third Ant. post, flaps On the field Three hours Minie-ball E. R. Corps 12th U. S. Infantry Laborer L. Upper third Circular On the field Twelve hours Canister-shot C. W. 45th N. Y. Vols. Printer L. Lower and middle third Circular Gettysburg Hospital Tw'nty-two hours Fragment of shell V. i. M 1st R. I. L. Artill'ry Hatter R. Middle third Posterior flap On the field Twelve hours Musket-ball OF RECOVERED AMPUTATION OF THE LEG. OF RECOVERED AMPUTATION OF THE LEG. — (Continued.) 41 Description of In- jury. Comp'd com. fract. of lower third of leg..... Comp'und commi nuted fracture of lower third of leg Comp'd com. fract. of ankle joint . Comp'd com. frac- ture of middle of leg . . . . '. Comp'und fracture lower third of leg Comp'd com. fract. of lower third . Entire destruction of the foot at tibia astragalus articulation Through joint . Comp'und commi nuted fracture of middle and low- er third of leg . Comp'und commi- nuted fracture of middle of leg Comp'und commi nuted fracture of ankle and tibia . Comp'd com.fract. of lower third of leg..... Comp'und commi- nuted fracture of tarsus anterior to medio-tarsal line Comp'und fracture of ankle joint . Comp'd fract. mid- dle of leg, parts ab'venot injured Comp'und commi- nuted fracture of middle of leg Comp'd com. fract. of lower third of leg..... Comp'd com. fract. of external ankle and tarsus exclu- sive of calcane'm Comp'und commi- nuted fracture of ankle joint . . Comp'und commi, nuted fracture of middle of leg Comminuted fract of lower third of leg ... ■ Comp'und fracture of lower third of leg ... . Fred'icks- burg, y\. Fred'icks- burg, Va. Fred'icks- burg, Va. FredMcks- burg, Va. Mason's Hill South Mountain Antietam, Md. Fred'icks- burg, Va Fred'icks- burg, Va. Fred'icks- burg, Va. McDon- ald, Ga. Peters- burg, Va. Peters- burg, Va. Gettys- burg, Pa. Gettys- burg, Pa. Gettys- burg, Pa. Gettys- burg, Pa. Chancel- May 3, lorsville, 1863 Va. Dec. 13 1862 May 3, 1863 Oct. 2, 1861 Sept. 14 1862 Sept. 17 1862 Julyl, Length of time from Amputa- tion to Exami- nation. 7 mos. 18 mos. 9 mos. 3 mos. lyear 7 mos. 14 mos. 9 mos. 8 mos. 7 mos. Length of time from Amputa-tion to Applica-tion. Length of Stump. 14 mos. 8 inches 8 mos. 51 inches 13 mos. 21 inches 1 year 7J inches 7 mos. 31 inches _ 9 inches 9 mos. 41 inches 21 mos. 9 inches 21 mos. 9 inches 19 mos. - 7 mos. 31 inches 1 year & 5 mos. 3J inches 20 mos. 83 inches 10 mos. 21 inches 4 mos. 12 inches 14 mos. 71 inches 7 mos. 9 inches 9 mos. 3 inches < 15 mos. lyear 4 inches 3 avail-able 33 inches - 111 inch. 11 mos. 31 inches 10 mos. 8J inches 14 mos. 6)inches Atrophy. Proximal Portion. Distal Portion. 1 inch 2 inches None 1 inch None 3 inches 2 inches 2| inches None 23 inches 1 inch 1J inches None 13 inches 13 inches 4J inches 11 inches 21 inches 1 inch increase 1 inch None None linch | inch None None None 2 inches 1 inch 3 Inches 23 inches 2f inches None None 1 inch 23 inches None None 11 inches 3 inches None 21 inches 1 inch 3 inches 11 inches 33 inches Remarks, Generally made at Time of Applica- tion of Artificial Limb. Stump smooth, well modeled, neural- gia, anterior tibial nerve morbidly sensitive. Stump some dam- aged by exfolia- tion, will be effi- cient. Stump all available though short, ul- cers on the end. Healthy. Stump not healed, will prove effi- cient. Stump healed, scarcely sufficient cicatrix. Stump nearly well, circulation slug- gish, cold, bluish. Stump entirely healed, but look- ing very blue and tender, general health good. Stump tumefied, partially flexed, rigid at an angle of 45°, cicatriza- tion extensive. Stump ulcerated, diathesis scrofu- lous, abscesses, general system impaired, not dis- eased. Stump good, tume- fied, hard, three ulcers on end. Not good, very an- gular and redun- dant. Well cicatrized, very good, ex- cessively long. Stump healed, to come latter part of May. Healed, flexed, ham-strings rigid, otherwise good, wishes knee sup- port. Excellent. St'mp healed, dam- aged by abscesses, sloughings, exfo- liations. Stump neatly formed, healed by first intention. Stump healed, spread by infil- tration, and long angles of cicatri zation. Stump healed, in pretty good order, damaged by ab- scesses and exfo- liations along line of tibia. Healed, badly com- posed, efficient. 42 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES Regiment. Occupa- tion. i N. Y. Laborer in Vols. sugar- house H. D. D. K. J. W. C, J. C. T. C. L. W. S. W. B. O. S. A. B. B. McD. W.H. R. P. O'R. G.W. R. R. A. B. G. F. T. A.H. 66th N. Y. Vols. J.U. P. E. L. S. A. W. R.W. J. G. E. P. S. 42d 111. Infan try 40th Mass. Vols. 58th Penn. Vols. 6th N. Y. II. A. 146th N. Y, Vols. 11th Penn. Infantry 5th Vt. Vols. 10th N. Y. Vols. 49th N. Y. Vols. U. S. Navy 15th Mass. Vols. 72d N. Y. Vols. 20th N. Y. Vols. Cabinet- maker Moulder Laborer Carpenter and joiner Farmer Mechanic Hotel laborer Farmer Clothes- cutter Shoe- maker Farmer Captain Farmer Spinner Cigar- maker Jewel coses Farmer Laborer Printer Point of Operation. Upper third Middle and upper third 2d, middle third Middle of leg Lower and middle third Lower third Lower third Lower third Middle and upper third Upper third Upper third Upper third Upper third Lower third Upper third Upper third Upper third Upper third Lower and middle third Upper third Upper third Middle third Posterior flap Circular Circular Circular Bilateral flaps Circular Circular Ant. post, flaps Anterior flap Posterior flap Circular Ant post flap Circular Circular Posterior flap Circular Circular Bilateral flaps Ant. post flap Ant. post, flap Ant. post flap Middle third Middle third Ant. post, flap Upper and Lateral flaps middle third 1st, hospital, Gettysburg, 2d,Prof. Post, New York On the field On the field On the field Hospital, D.C. Field hospi- tal Portsmouth Hospital, Va. Field hospi- tal On the field On the field On the field Douglass Hospital On the field Field On the field On the field On board Boney On the field On Knick- erbocker On the field Field hospi- tal Navy Hospi- tal, Baltimore Length of Time after Injury. Six days Thirty-four days 2d, Four months Forty-eight hours Three hours Five hours One hour and a half One hour Two hours One hour Fragment of shell Rifle-ball 2d. seques- trum from dead bone Minie-bal] Grape-shot Musket-ball Minie-ball Musket-ball Fragment of shell Fragment of shell Twenty-fo'r Minie-ball hours Six hours Two hours Twenty-fo'r hours Six days Twenty-fo'r hours Seven days Seven hours Two hours Twenty-fo'r hours Twenty-fo'r hours Twenty-five Twenty- eight hours Piece of shell Minie-ball Minie-ball Rifle-ball Minie-ball Minie-ball Fragment of shell Musket-ball Musket-ball Rifle-ball Cannon- ball Round mus- ket-ball OF RECOVERED AMPUTATION OF THE LEG. OF RECOVERED AMPUTATION OF THE LEG. —(Continued.) 43 Description of In- jury. Comminuted fract. of ankle joint and lower tibia ; ex- tensive extrava- sation, lnortifica tion..... Comminuted fract. of ankle joint and lower part of tibia .... Comminuted low- er leg . . . . Disrupture of leg at ankle joint . Compound com, minuted fracture of ankle joint . Comp'd com. fract of foot and ankle Comp'und fracture of ankle joint . Metatarsus only . Comminuted fract. of ankle joint . Comminuted frac- ture of lower part of leg . Comp'und fracture of upper middle of leg .... Comp'und commi- nuted fracture of middle of leg . Disrupture of low- er half of leg . Comp'd com. fract. of ankle joint . Comp'und commi- nuted fracture of middle of leg . Comp'und commi- nuted fracture of middle of leg . Comp'und commi- nuted fracture . Comp'und commi- nuted fracture of middle of leg . Comp'd com. frac- ture of ankle, lower third . . Comp'und commi- nuted fracture of ankle joint . . Comp'und fracture lower third both legs..... Comp'und fract. of the middle of leg Comp'und fracture of ankle joint . Entering under in- ternal malleoli, exit at low. mid- dle of leg . . . Comminuted fract. through knee . Comp'd fracture of lower third of leg Fracture of ankle joint..... Gettys- burg, Pa. Gettys- burg, Pa. Coal Har- bor, Va. Coal Har bor, Va. Coal Har- bor, Va. Rapidan Murfrees- boro'.Ten Morris Isl- and, S. C Chapin's Farm, Va, Chapin's Farm, Va, Chapin's Farm, Va. Wilder- ness Va. Wilder- ness, Va. Wilder- ness, Va. Wilder- ness, Va. Wilder- ness, Va. Maudm're River, Va. Antietam, Md. Malvern Hill, Va. Antietam, Md. So. Moun- tain, Va. Antietam, Md. Gaines's Mills, Va June 3, 1864 June ], 1864 June 3, 1864 Feb. 6, 1861 Sept. 29, 1864 Oct. 7, 1864 May 5, 1864 May 5, 1864 May 5, 1864 Sept. 17, 1862 July 1, 1862 Sent. 17, 1862 Sept. 14, 1862 Sept. 17, 1862 July 28, 1862 Length of time from Amputa-tion to Exami-nation. Length of time from Amputa-tion to Applica-tion. 7 mos. 11 mos. 5 mos. 2d time 9 mos. 2d time 2 mos. 6 mos. 6 mos. 9 mos. 3 mos. 4 mos 2 mos. 4 mos 3 mos. Smos 2 mos. 5 mos - 18 mos 20 mos. 22 mos 10 mos. 13 mos 7 mos. & 24 days 10 mos 10 mos. lyear 6 mos. 9 mos. 4 mos. 6 mos. 6 mos. 7 mos. 13 mos. 14 mos. lyear 14 mos. 11 mos. 13 mos. 10 mos. 1 year 8 mos. 9 mos. 1 year & 3 mos. lyear & 10 mos. 4 mos. 7 mos. 7 mos. 8 mos. 9 mos. 1 year 9 mos. 1 year 7 mos. 10 mos. 4 mos. 4 mos Length of Stump 41 inches 61 inches 8 inches 101 inch. 12 inches 12 inches 15 inches inordi- nate 5 inches 3 inches 21 inches 2 inches 4J inches Hi inch. 21 inches 3 inches 31 inches 6 inches 3 avail- able 8] inches 73 inches 3 inches 7 inches 7J inches 61 inches 7 inches 71 inches Atrophy. 1 inch None 1 inch 11 inches None 1 inch 1 inch None 1 inch increase 1 inch 3 inch None linch 2 inches 31 inches 21 inches None None linch 23 inches None None None None None 123 inches 1 inch None 3 inch increase 1 inch 3 inch 3 inch } inch 3 inch 23 inches 2 inches None 3 inches 41 inches 11 inches 21 inches 3| inches Generally made at Time of Applica- tion of Artificial Stump flexed at an- gle 35", not en- tirely healed,crest angular by ulcer- ation, cicatriza- tion will afford knee base of sup- port. Flap very good, healed, stump flexed. 45°. Stump insufficient- ly covered from sloughing, heal'd, tender, will be effective. Healthy, well com- posed. Beautiful stump, very best, healed by first intention. Some atrophy, nearly healed. Some atrophied, healed, well formed, etc. Swollen, ulcerated parts inflamed, some exfoliation. Healed, well com- posed. Some ulcerated, eczematous. Very fair. Much atrophied, excellent. Healed, short, ir- regular. Very good, dam- aged some, fibula spread, knee sup- port. Good, not straight. Damaged by neg- lect. by sloughing. Very good and effi- cient, has psoas abscess of. right femoral region. Left leg fractured, not healed, right healed, sloughed, partial use.wo'nd- ed leg not flexi- ble at knee more than 45 degrees. Good st'mp, sound, some cicatrices by abscesses, exfolia- tions. Not healed. Artificial leg ap- plied, semitenni- nosus and semi- membranosus bi- ceps contracted, improving. 4-i TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES Regiment. Occupa- tion. C. L. W.F. B L. W.V A. L. A. L. 18th N. Y. Vols. 105th N. Y. Vols. 1st Penn. Artillery E. F. B. W.N. E. R. W.H. S. L. H. G. J. L. B. J. P. J. H. P. C. 48th N. Y. Vols. 76th Penn Vols. 6th Kansas Vols. 9th Penn. Cavalry 6th Vt Vols. 7th R. I. Vols. 101st N. Y. Vols. 20th N. Y. Militia 5th N. Y. Vols. 41st N. Y. Vols. 69th N. Y. Vols. 69th N. Y. Vols. Butcher Laborer Carpenter Ship-car- penter Ship- joiner Hack- driver Tinsmith Farmer Farmer Farmer Clerk Farmer Point of Operation. Upper third Lower and middle third Upper third Middle and upper third Upper and middle third Upper and middle third Lower third Upper third Upper third Lower and middle third Lower and middle third Upper and middle third Upper third Upper and middle third Upper third Upper third Lower and middle third Ant. post, flap Ant. post, flap Circular Ant. post, flap Circular Ant. post, flap Ant post, flap Ant. post, flap Where per- formed. Ant. post flap Circular Ant. post, flap Bilateral flaps Bilateral flaps Posterior flap Circular Circular Ant. post, flap Posterior flap Circular Circular Ant. post, flap Circular N. Y. City Hospital On the field In field hos- pital In Pa tent Of- fice Hospital On the field On the field Camden Hospital, D.C. Lincoln Hos pital, D. C. Charleston Hospital, S. C. General Hos- pital, Port Royal, S. C. Hospital at Beaufort, S. C. In Charles- ton Hospital Camp Taylor U. S. Hospi- tal, Troy U. S. Hospi tal,Pensacolt On the field Harwood Hospital On the field Cliffbume Hospital, D.C. On the field Hospital, Georgetown On the field On the field Length of Time after Injury. Twenty-fo'r hours Eight days Two hours and a half Forty-eight hours Seventeen days Fourteen days Three days Three days Twenty hours Three days Five months Four days Ten hours Six days Thirty days Six hours Four dayR Twelve days Four hours Fourteen days Six hours Two davs Railroad cars Minie-ball Piece of shell Minie-ball SheU Minie-bal] Rifle-ball Rifle-ball Grape-shot Grape-shot Musket-bail Minie-ball Explosion of torpedo Minie-ball Minie-ball Minie-ball Rifle-ball Musket-ball Minie-ball Fragment of shell Rifle-ball Shell Minie-bali OF RECOVERED AMPUTATION OF THE LEG. OF RECOVERED AMPUTATION OF THE LEG. — (Continued.) 45 Description of In- jury. Comp'und commi- nuted fracture . Comp'd com. fract. of lower third of leg..... Severing the tibia and 'fibula and entire front part of the leg at its lower third . . Comp'd com. fract. of ankle j'int.and low. third of tibia. Destruction of foot at ankle joint, etc. Comp'd com. fract. of lower third of leg..... Compound frac- ture of ankle joint and tarsus Comp'd com. fract. of ankle joint . Comminuted frac- ture of lower half of leg .... Comminuted frac- ture of middle of leg .... Comp'd com. fract of tarsus and cal- caneus, ankle joint not injured Compound frac- ture of tarsus . Comp'd com. fract. of lower third of leg Foot while feet in- sensible and in an almost mori- bund state by fever, gangrene ensuing. Destruction of foot at ankle joint . Comp'd com. frac ture of upper middle of leg . Comp'd com. frac- ture middle third of leg .... Comp'und commi nuted fracture of ankle joint . . Compound com minuted fracture of anklejoint Comp'd fracture of leg, lower middle Com p'und fracture lower middle of leg .... Comp'd com. frac- ture of the entire lower half of the leg ... Comp'und fract. of Jower third of leg Comp'und commi. fract. lower and middle of thigh Comp'und fracture knee jloint and patella . . Gaines's Mills, Va. Freder'ks- burg, Va. Freder'ks- burg, Va. Freder'ks- burg, Va. Freder'ks- burg, Va. Freder'ks- burg, Va. Freder'ks- burg, Va. Freder'ks- burg, Va. Ft. Wag- ner, S. C. Ft. Wag- ner, S. C. Ft. Wag- ner, S. C. Ft. Wag- ner, S. C. Ft. Smith, Arkansas Hospital Point Bocks Averys- boro.N.C. Freder'ks- burg, Va. Freder'ks- burg, Va. Freder'ks- burg, Va. Bull Run, Va. Bull Run, Va. 2d Bull Run, Va. Bull Run, Va. Antietam. Md. July 18, July II, 1863 Aug. 28 1864 May 3, Sept. 1, 1862 Aug. 31 1862 Aug. 30, 1862 9ept. 17 1862 Length of time from Amputa- tion to Exami- nation. 4 mos. 4 mos. 4 mos. 8 mos. 7 mos. 1 year 3 mos. 4 mos. 7 mos. 11 mos. 1 year 11 mos. 19 mos. 8 mos. 11 mos. Length of time from Amputa-tion to Applica-tion. Length of Stump. _ 31 inches 6 mos. 10 inches 6 mos. 5 inches 10 mos. 8f inches 1 year & 11 mos. 101 inch. 5 mos. 83 inches 1 year ft 2 mos. 101 >nch. 1 year & f mos. 91 inehes 18 mos. - 7 mos. Knee 10 mos. 111 inch. 1 year 81 inches lyear 4 inches 9 mos. 5J inches 5 mos. 111 inch. - 21 inches 9 mos. 4 inches 14 mos. 91 inches 15 mos. 101 ineh- 1 year & 3 mos. 6 inches 21 mos. — » 18 mos. 41 inches 10 mos. 21 inches 14 mos. 5 inches 22 mos. 10 inches Atrophy. None linch linch None linch increase 3 inch 1 inch linch 3 inch None 1 inch 1 inch None | inch None None 21 inches None 3 inches 13 inches 31 inches 43 inches 23 inches 41 inches 41 inches 3 inches 3 inchea 31 inches 1 inch 11 inches 2 inches 5 inches 2 inches 4 inches None None Remarks, Generally made at Time of Applica- tion of Artificial Limb. Extravasation, etc. Soleus and gastroc- nemius muscles entire. Stump in pretty good condition. Stump unsound, Borne ulceration and exfoliation, secondary. Some necrosis, small ulcers and thickening of per- iosteum, improv- ing. Stump flexed on thigh, badly ul- cerated, will re- quire knee sup- port. Stump not healed, flexed at nearly right angles, par- tial anchylosis, very tender near crest. Stump mainly healed, well formed. Stump healed. Slight atr'phy, very good. Very good, not quite healed. Much infiltrated", not healthy,much enlarged. Bad posterior flap, pendulous, dam- aged by exfolia- tion. A prisoner 9 days, stump healed and vigorous. Stump not entirely healed, prognosis favorable. Model stump, gen- eral health good. Stump flexed, not perfectly healed. Stump healed, flexed right angle, tendons rigid; good, clean knee support. Stump healthy. Stump ulcerated, not ready. 31 inches Stump well, cica- trices healthy. Necrosis of end of bone to be re- moved, stump | s'und and smooth. linch 33 inches 46 TWO HUNDRED AND EIGHTY-SEVEN CASES TABLE OF TWO HUNDRED AND EIGHTY-SEVEN CASES M. H. M. L. J. B. G. P.H. J. P. C. J. M. Regiment 9th N. Y. Vols. 63d N.Y. Vols. Battery E, N. Y. A. 46th N. Y. Vols. 115th N. Y. Vols. 52d Penn. 8th N. Y. Cavalry Occupa-tion. Limb. Printer L. Laborer L. Clerk R. Farmer R. Captain L. Boiler-maker L. Mason L. Farmer L. Farmer R. Shoe-maker L. None L. ' Point of Operation. Lower third 1st amputa- tion Lower and middle third Lower and middle third Middle and upper third Upper third Middle third Lateral flaps Syme's mode Posterior flap Circular Lateral flaps Circular Posterior flap Posterior flap Ant. post, flap Ant. post, flap Ant post, flap On the field On the field In field hos- pital On the field Stone Hospi- tal, Washing ton, D. C. In hospital In field hos- pital In Lincoln Hosp., D. C. Length of Time after Injury. 1st. 24 houra 2d,seven months Six days Six hours Twenty-fo'r hours Twenty-fo'r hours Twelve hours Two hours Eight days Solid shot sloughing A want of care Piece of shell Piece of shell Minie-ball Minie-bal] Fragment of shell Rifle-ball Fragment of shell Explosion of torpedo OF RECOVERED AMPUTATION OF THE LEG. OF RECOVERED AMPUTATION OF THE LEG. — (Continued.) 47 Length of Length of Atrophy. Remarks, time from time from Description of In- Battle. Date. Amputa- Amputa- Length of Generally made at jury. tion to tion to Stump. Time of Applica-tion of Artificial Exami- Applica- Proximal Distal nation. tion. Portion. Portion. Limb. Shattering the Antietam, Sept. 17, 9 mos. 1 year 121 inch. 1 inch 3 inches Stump nearly healed. phalanges and Md. 1862 2d, 3 mos. 2d, 5 mos. metatarsal bones of foot .... Comp'd com. fract. Antietam, Sept. 17, 9 mos. _ 73 inches 31 inches 31 inches Stump well cica- of ankle joint . Md. 1862 trized, neuralgia. Injury of foot through tarsus Jarnes Oct. 22, 7 mos. 8 mos. 81 inches None 3 inches Not entirely henl'd, River 1864 four inches of ne- crosed fibula re- moved, March 12, 1865, June 14, healed. Comp'd com. frac- Jackson- March 5 mos. 7 mos. 10} inch linch 3 inches Some necrosis, ul- ture of the tarsus ville, Fla. 26, 1863 cers will recover and end of tibia soon, stump well healed, model shape, excess of length. Comp'und commi. — Sept. 10, 5 mos. 7 mos. 51 inches 1 inch 21 inches Some atrophied, fract. lower third 1864 very good. of leg .... Comp'd com. frac- — Aug. 1, 5 mos. 7 mos. 4 inches None 3}inches Good stump, ture of low. third 1864 flexed. of leg .... Comp'd com. fract. — July 30, 6 mos. 9 mos. 71 inches None Jinch Very good. of foot and ankle 1,*4 Comp'und commi- Williams- Mnv S, 22 mos. 2 years & 5Jinches i inch 2 inches Stump healed, cic- nuted fracture of burg, Va. lMi2 1 mouth atrices extensive, lower third of leg owing to ulcera-tion, fibula long-est. Destruction of leg On picket Oet. 1, 4 mos. 6 mos. 5 inches 1 inch 3 inches Stump healed, pos- at lower third . duty 1S63 terior part pend-ulous. Comp'd com. frac- On picket Sept. 8, 5 mos. 8 mos. 10 inches 11 inches 4 inches Stump healed, vig- ture of tibia, as- duty ].n;.-: orous. tragalus, articu- lation .... Comp'und fracture Beverly of tarsus ... Ford, \ a. June 9, 8 mos. 11 mos. 83 inches 1 inch 3 inches St'mp healed, good. 1863 1 ' 48 LIMB AMPUTATED. I. LIMB AMPUTATED. comparative The following table gives the frequency of amputa- of ampX tion of the limb, whether right or left, in an aggregate of tion of right ,„ , . - , , ,• and left leg. 445 cases of thigh and leg amputations : — Limb. Right. Left. Total. 92 134 66 153 158 287 226 219 445 From this table it would appear that there is a difference in the liability of the two lower extremities to those accidents or injuries which necessitate amputation of the thigh or leg in military prac- tice. In a gross number, comprising both thigh and leg amputa- tions, this difference, though not very great, is in favor of the right limb. When, however, we separate the thigh from the leg ampu- tations, we find this discrepancy becomes very marked in regard to both classes of cases. In the thigh amputations the right limb required removal in more than half of the total number of cases ; while in the leg the left limb amputations considerably exceed the right. Nor is this peculiarity in the relation of thigh and leg amputa- Frequency ^ons to tne right and left side accidental; for, on re- taftiSta£-d ferrmg to other collections of cases, the same difference the'French11 is traceable. For example, in an aggregate of 484 ampu- army- tations in the thigh and leg, collated by Chenu1 from the records of French surgery in the Crimea, the following com- parative results are deducible : — Thigh . . Leg . . . Totals Right. Left. 73 169 61 181 242 242 134 350 484 In this table we have results strikingly similar to those which were obtained from the records of American military surgery. Of I Rapport au Conseil de Sante des Armies. COMPARATIVE FREQUENCY IN THIGH AND LEG. 49 the aggregate amputations in the lower extremity, the operation falls about equally on both limbs. But this result is found not to be due to an equality of amputations throughout the entire limbs, but to the fact that an excess of right thigh amputations is counter- balanced by an excess of left leg amputations in a given number of all amputations impartially collated. This result is not vitiated by the statement that the total number of leg amputations greatly exceeds that of the thigh amputations, for the same ratio holds true whether we diminish or increase the number of each. II. FKEQUENCY OF AMPUTATION IN THE SEVERAL REGIONS OF THE THIGH AND LEG IN 439 RECOVERED CASES. The comparative frequency of amputation in the various FreqKy™ regions of the thigh and leg in a given number of re- t^nvari covered cases, is illustrated by the following table : — of sthigh°and leg. Region. Thigh. Leg. 15 66 74 103 75 106 Totals............. 155 284 In regard to thigh amputations, we should infer from this table either that a much less number of amputations are performed in the upper than in the middle third, and in the middle than in the lower third, or that the same number being performed in each division, the proportion of recoveries are largely increased as we pass from above downwards. Both of these inferences are true, as will appear from the following statistical table : — British Army, in Crimea. Confederate Army. Sherman's Campaign. (Andrews.) Region. Rec'd. Died. Rec'd. Died. Rec'd. Died. Upper third .... Middle third.... Lower third .... 5 26 26 34 39 34 50 87 143 61 87 126 5 13 61 15 16 36 57 107 280 274 79 67 Grand totals • . . 164 554 146 4 50 COMPARATIVE MORTALITY. This table sustains the inferences drawn from the preceding table, that while amputations in the upper third of the thigh are much less frequent than in either of the other divisions of the thigh, they are also largely more fatal. In the British army in the Crimea, the amputations in the upper third of the thigh were but 23.8 per cent, of the total thigh amputations, while the fatal cases of amputation in this region equal nearly one third of the total mortality of thigh amputations. In the Confederate service, the amputations in the upper third of the thigh were 20 per cent, of the total thigh amputations, and the mortality was 22.2 per cent. of the total mortality. In Sherman's campaign,1 the amputations in the upper third were but 13.7 per cent of the thigh amputa- tions, but the mortality was in nearly the same ratio to the total mortality as in the British and Confederate service, being 22.2 per cent. Passing from the upper to the middle third, we find these statis- tics establish the fact that there is not only a larger gross number of amputations than in the upper third, but that there is a dimin- ished rate of mortality. The fatal cases in the middle third do not greatly exceed the cases of recovery, being 46 per cent., while in the upper third the fatal cases are very largely in excess. In regard to amputations in the lower third, these tables show that the number in general equals the total number in both of the other regions, with a still further reduction of the proportionate mortality, the successful considerably exceeding the fatal cases, except in the records of the British army. Applying these facts to the first table, which consists of only re- covered cases, and we may safely conclude that the 15 cases of recovery after amputation in the upper third represent a much larger number of fatal cases, and that the 66 amputations in the middle third represent about an equal number of fatal cases, while the 74 amputations in the lower third represent a less number of fatal cases, in the same regions respectively. In regard to amputation of the leg, the above table gives the largest proportion of recoveries in the lower third, and the least in the middle third; the upper and lower third being nearly equal in numbers, while the middle third furnishes but a little more than one fourth the total number of cases. It is stated in the Surgeon- General's Report,2 that the majority of cases of amputation of the l Statistics of Sherman's Campaigns, by E. Andrews, M. D., p. 64. a Circular No. 6. NATURE OF MISSILES. 51 leg was in the upper and middle third. In that case this collection shows a partial selection, and most favorable to amputation in the lower third. If, however, we compare it with the following other group of cases in which both the fatal and successful cases are recorded, we shall find a confirmation of the above conclusions: — FRENCH ARMY.i Region. Recovered. Died. 259 14 21 84 3 26 III. NATURE OF MISSILES. The following table comprises the various missiles with which the wounds were inflicted in 429 cases of amputation of the lower extremity : — Missiles. Missile. Minie-ball........ Musket-ball....... Rifle-ball........ Shell......... Grape-shot....... Canister-shot....... Solid shot....... Gunshot........ Torpedo ........ Pistol-shot....... Cut with an axe..... Fall of a tree ...... Injury by overturning of caisson Cannon-ball....... Railroad injury...... Injured in a turret..... Explosive ball...... Burn......... Fall ......... Rusty nail thrust into foot . . Totals....... Grand total..... Thigh. 429 Leg. 58 84 22 52 18 29 26 56 10 20 3 9 7 _ 6 5 1 4 1 - 1 1 1 1 1 - - 3 - 5 - 1 - 1 - 1 - 1 - 1 155 274 Nearly two thirds of the injuries which required amputation of the lower extremities, in a total of 429 recovered cases, were Legouest. 52: NATURE OF MISSILES. inflicted by the missiles of the infantry, namely, the mime, musket, and rifle balls. Of these, the minie-ball was used much more frequently than both the musket and rifle balls, or was much more destructive, the proportion being, minie-balls 142, musket and rifle balls 121. The difference between the recovered cases of amputa- tion after injuries inflicted upon the thigh and leg by these various missiles is considerable. In the thigh the amputations for injuries inflicted by the minie-ball are 58, and by the musket and rifle balls 40 ; while in the leg the minie-ball injuries are 84, and by the mus- ket and rifle balls 81. Recovery from amputations after injuries inflicted by shell are more frequent in the leg than in the thigh, in the following propor- tion : recovered thigh amputations about one sixth, and recovered leg amputations more than one fifth, of the total number of thigh amputations. It is noticeable that the solid shot gives a number of recovered amputations of the thigh and none of the leg, while the torpedo furnishes more recovered cases of leg amputation than of the thigh. We may compare the nature of the missiles with which severe wounds of the lower extremities were inflicted, as appears in the above table and in the records of the Crimean War : — NATURE OF THE MISSILES WITH WHICH THE WOUNDS WERE INFLICTED IN 466 RECOVERED AMPUTATIONS OF THE LOWER EXTREMITY, IN THE FRENCH ARMY IN THE CRIMEA. Limb. Thigh . . Leg . . . Totals 26 109 135 18 35 53 Eclats de Projectiles Biscaien. 86 192 278 Missiles which in- flicted wounds re- quiring am- putation of thigh and leg in French army in Crimea. It is apparent from this table that in the Crimean campaign, which partook of the nature of a siege, the most destructive wounds were inflicted by artillery. Both tables show a preponderance of recovered leg amputations in about the same proportion. NATURE AND LOCATION OF INJURIES. 53 IV. NATURE AND LOCATION OF THE INJURIES BY VARIOUS MISSILES IN 423 RECOVERED CASES OF AMPUTATION OF THE LOWER EXTREMITY. Thigh. Leg. Fractures. Wounds. Fractures. Wounds. 3 24 23 si 5 ■a '£ H i a 2 * 49 ■a •< 25 ■g o 9 tag a Hi 2 6 < o o Minie-ball . . Musket-ball . . 9 7 1 1 2 i 25 17 7 1 i _ Rifle-ball . . . 7 7 _ _ 2 i 18 7 3 1 _ _ Shell .... 1 14 6 1 _ 4 34 15 7 _ _ _ Grape-shot . . Canister-shot 3 2 6 1 2 - - - 11 8 7 1 2 - - - Solid-shot . . 1 3 1 _ _ _ 6 1 3 _ _ _ Gunshot . . . - 3 1 - _ - 4 1 - _ _ _ Torpedo . . . Railroad injury Cannon-ball . . 1 2 3 2 2 1 1 - - : Cut by axe . . 1 Fall of tree . . - - - - - - - 1 - - ~ - Injured in turret Explosive ball . 1 1 Burn .... 1 Fall .... - - - - - - 1 - - - - - Nail, wound by 1 Totals . . . 47 65 16 2 6 6 164 78 33 6 i 1 Thigh amputation for fractures . Leg amputation for fractures . . 128 275 Thigh amputation for wounds . Leg amputation for wounds 14 8 403 Tot al . 22 From the preceding table it appears that amputations for fractures are more frequent, in a given number of re- Proportion ,. i • i • r -t o °f ftmputa- covered cases, than for wounds, m the proportion ot lo tations for -. . . i #> wounds and to 1. And this difference is found, on inquiry, to be far fractures. the greatest in the leg. In the thigh the amputations for fractures are to amputations for wounds in the ratio of about 8 to 1, while in the leg amputations the ratio of fractures to wounds is as 34 to 1. The location of fractures is found in the amputations of the thigh, in largest number involving the knee, and in am- Locationof putations of the leg, involving the bones of the leg. The fracturM- 54 NATURE AND LOCATION OF INJURIES. largest number of fractures into the knee were produced by the minie-ball, and the next largest by shell. The fractures of the leg necessitating amputation were produced in largest numbers by the minie-ball, and next in frequency is the shell. Injury to the ankle joint was not as frequently the cause of amputation of the leg, in proportion to the total amputations of the leg, as injury to the knee the cause of thigh amputations in proportion to the entire number of amputations in that part. Fractures of the leg were followed by comparatively few amputations of the thigh, being in the ratio of eight amputations for fractures in the knee and thigh to one of the leg. Nearly the same ratio obtains between amputations of the leg for fractures involving the foot, and amputations for fractures of the ankle and leg. The following table, compiled from Chenu,1 affords a comparison comparative between the above collection and the French statistics of Frencnr°ste- tne army m tne Crimea, as to the frequency of amputa- tistics. t-on 0f t]ie thigh an(j ]eg for fractures in certain regions in recovered cases: — Region. AMPUTATION OF Thigh. 1 Leg. 48 13 24 43 1 - 196 57 29 129 282 This table presents a striking contrast with the preceding, so far as relates to thigh amputations. In the former, compound frac- ture of the knee was the form of injury necessitating amputation in nearly half the recovered cases, while in the latter this injury occurred in but about one fifth of the total cases. We are not able to determine to what this discrepancy is to be attributed, as we are not able to give the mortality in the Federal army ; but it is probable that there was a much greater mortality amono- the French, as the percentage of fatal cases in amputations for this injury was thirty-seven. l Rapport au Conseil de Sante des Armies. DISTRIBUTION OF INJURIES. 55 V. DISTRIBUTION OF INJURIES REQUIRING AMPUTATION OF THE LOWER EXTREMITY IN RECOVERED CASES. (a) One hundred and forty-one Amputations of Thigh Compound fracture of femur..... Compound fracture of middle third Compound fracture of lower third Simple fracture of femur..... Compound fracture of knee .... Compound fracture of knee and upper third of leg Destruction of leg ....•• Compound fracture of leg — upper third Compound fracture of leg — middle third . Compound fracture of leg — lower third Destruction of ankle ...••• Fracture........ Wound of thigh...... Wound of knee....... Wound of leg....... Wound of popliteal artery . . . ' • Gangrene of toe ...••• Total 10 7 27 1 59 12 6 3 5 9 2 1 2 5 1 1 1 141 (b) Two hundred and eighty-seven Amputations of Leg Comminuted fracture of the upper third Comminuted fracture of the middle third Comminuted fracture of the lower third Comminuted fracture of the ankle joint Fracture involving the ankle joint Destruction of leg Destruction of ankle joint Destruction of foot .... Destruction of calcaneum Compound fracture of calcaneum Wound of posterior tibial artery . Wound of soft parts of leg Gangrene following a burn Injury of tibia without fracture . Injury of knee and patella Injury of knee (?) . 3 67 75 57 2 20 14 8 1 1 11 11 1 1 1 11 Total 287 56 INJURIES REQUIRING AMPUTATION OF THE THIGH. Injuries requiring Amputation of the Thigh. — Of the injuries of the thigh requiring amputation, in a given number of recovered cases, compound fracture of the lower third is by far the most fre- quent; comprising nearly two thirds of all the cases. We have already alluded to the proof that a less number of amputations are performed in the middle and upper third of the thigh, and that they are more fatal in these regions. This fact will account in part for the great discrepancy which this table shows between the total recovered amputations in these different regions. The injury which necessitates the largest number of amputa- tions of the thigh is seen to be compound fracture of the knee. The total number of these injuries, including those which involve also the upper third of the leg, comprises about one half of all the causes of amputation of the thigh. This subject is deserving of a more critical examination. At the period of making his Report,1 the Surgeon-General states that 1,183 cases of gunshot wounds of the knee joint, with or without fracture of the patella, or of the epiphyses of the femur or tibia, had been recorded. Of these, 770 had terminated, and the results were known. The following statement of the treatment and its results, so far as ascertained, is given in the 1,183 cases of knee-joint injury reported : — Treatment. No. of Cases. Recovered. Died. Undetermined. Amputation .... Conservative measures 718 11 454 121 1 50 331 9 258 266 1 146 Totals . . . 1,183 172 598 413 It would appear from these facts that in a little less than two thirds of the wounds of the knee joint amputation was resorted to, and a mortality of 73.23 per cent, occurred in the determined cases'. In the 11 cases submitted to exsection the mortality was 90 per cent. In a little more than one third of the total cases, conserva- tive measures were adopted, with a mortality in the terminated cases of 83.76 per cent. We may safely conclude that in this collection of cases amputa- tion was resorted to in the severest form of injuries, as when the joint was freely opened, with or without fractures of the extremi- ties of bones entering into the joint; while conservative measures were adopted in slighter forms of injury, and when there was 1 Circular No. 6. AMPUTATION FOR WOUNDS OF KNEE JOINT. 57 doubt whether the cavity of the joint was involved. And this opinion is confirmed by the Surgeon-General, who states that, " with six or eight exceptions, the fifty recoveries without amputa- tion, classified with gunshot wounds of the knee joint, were exam- ples of fracture of the patella, in which the evidence that the joint was opened was not unequivocal." It is evident, therefore, that amputation was the acknowledged method of treatment in severe gunshot injuries of the knee joint, during the war. And the comparative results of this treatment justify the rule now so firmly established in military surgery. The mortality was ten per cent, less than when conservative measures were employed, and nearly twenty per cent, more favorable than excision. If we take into consideration the remark of the Sur- geon-General that all the successful cases treated conservatively, except six or eight, were so slight as to be of a doubtful character, the comparative results of amputation in grave injuries of the knee joint are far more favorable. Professor Chisholm, of the Medical College of South Carolina, a surgeon to the insurgent forces, gives statistics1 of the con- servative treatment of gunshot wounds of the knee joint which are altogether more favorable than those compiled by the Sur- geon-General. Of 103 cases treated, 50 recovered, and 53 died; the mortality per cent, being but 52. In answer to the objection that many of these cases must have been of a trivial character, and could not have implicated the cavity of the articulation, he refers to the duration of treatment in the successful cases, which gives an average of 166 days, in proof of the severity of the wounds. The shortest period of treatment was 96 days. He concludes, therefore, that they were cases of the perforation of the joint by balls without the crushing of bones being detected. This comparison does not invalidate the general conclusion that amputation of the thigh should be the rule of practice in severe gunshot injuries of the knee. The following tables are instructive, as they illustrate the condi- tion of stump in an amputation at different points of the thigh after gunshot wounds of the knee joint. i Medical Times and Gazette. London, December 29,1866. 58 AMPUTATION FOR INJURIES OF KNEE JOINT. THIRTY-THREE CASES OF RECOVERED AMPUTATIONS OF THE THIGH IN THE LOWER THIRD, FOR GUNSHOT INJURIES OF THE KNEE JOINT. No. 25 8 Method. No. 19 6 7 1 Result. Good. Imperfect. Unknown. Minie, rifle, and musket ball . . Cannon-ball, shell, grape, torpedo ( Flap j Circular j Flap ( Circular 16 6 5 1 1 1 2 1 In these 33 cases it will be observed that amputation was suc- cessfully performed in the lower third of the thigh in 8 cases of wound of the knee joint by shells, by cannon-ball, by grape- shot, and by torpedo. These were doubtless very grave forms of injury, and attended with more or less destruction of the soft parts. In some instances it is noticed that the limb was nearly severed at the knee. The fact that they still admitted of success- ful amputation at a point so near the seat of injury is instructive, as it proves that in the severest gunshot wounds of the knee we may still select the most favorable point in the thigh for amputa- tion with a fair prospect of success. Another fact is noticed, namely, that in all of these cases of am- putation for wounds of the knee by shell and solid shot but one, the flap method was preferred. This is the more remarkable as the circular method is generally considered especially adapted to the lower third of the thigh, and to wounds attended with great destruction of the soft parts. Of these 33 cases, 26 were performed by the flap, and 7 by the circular methods. The results of these cases are more favorable to the circular method, all of which gave good stumps. TWENTY-NINE CASES OF RECOVERED AMPUTATIONS AT THE JUNCTION OF THE MID DLE AND LOWER THIRD OF THIGH. No. 20 9 Method. No. 9 11 8 1 Result. Good. Imperrect. 2 6 3 Very poor. Unknown. Musket, minie, and rifle ball Shell, solid, and grape shot (Flap J Circular j Flap | Circular 5 5 4 1 1 1 1 In this table we have a larger proportion of cases of wounds AMPUTATION AT MIDDLE THIRD OF THIGH. 59 by shells, solid, and grape shot. The ratio of these missiles to the musket, rifle, and minie balls is nearly that of one third. From this it appears that as a rule surgeons amputate higher than the lower third in wounds of the knee joint by these destructive missiles. But the most interesting feature of this table is the compara- tively large proportion of circular operations, and the comparatively unfavorable results of this method, when practiced at the junction of the middle and lower third of thigh after knee-joint injuries. Of the 12 circular amputations, 6, or one half, gave imperfect stumps, while of the flap operations 9, or more than one half, gave good results. The difference between the results in this and the preceding table is striking : in the former the final results of all the amputations were ver}*- favorable, and especially of the circular method ; in the present table both methods failed of giving gen- erally good results, the circular being the most unsuccessful. NINETEEN CASES OF RECOVERED AMPUTATIONS AT THE MIDDLE THIRD OF THIGH. Missus. No. 10 9 Method. No. 6 4 8 Result. Good. Imperfect. Very-poor. Unknown. Minie, musket, and rifle ball Shell, grape, canister, can-non, and solid shot . . ( Flap ) Circular Flap 3 3 7 1 1 1 2 In this table we find a still greater proportion of injuries of the knee joint by the larger form of missiles; 9 of the 19 cases being injuries by shells and solid shots. We have here still further evidence of the destructive character of the wounds of the knee which called for amputation, and the necessity which frequently existed of amputating at a distance from the wounds. We have noticed in the preceding tables that amputations in the lower third of the thigh gave good results, while those performed at the junction of the middle and lower third gave much more un- favorable results. In the middle third we find the table reversed, and both forms of amputation are again highly successful as regards the final results. The proportion of circular to flap amputations is about the same as in the first table. 60 AMPUTATION FOR INJURIES OF KNEE JOINT. FIVE CASES OF AMPUTATION AT THE JUNCTION OF THE UPPER AND MIDDLE THIRD OF THE THIGH. No. Method. No. 3 2 Result. Missile. Good. Imperfect. Very poor. 3 2 (Flap j Circular JFlap | Circular 2 1 1 1 FOUR CASES OF AMPUTATION IN THE UPPER THIRD OF THIGH. Missile. No. 3 1 Method. No. 2 1 1 Result. Good. Imperfect. Very poor. Solid and grape shot, and shell (Flap I Circular (Flap ( Circular 1 1 1 1 In amputation at the junction of the middle and upper third of the thigh the larger number of wounds were inflicted with solid shot. It is remarkable that in every case the circular operation was performed in preference to the flap method. The result, how- ever, was not favorable in the majority of cases. Of the four amputations in the upper third, but one was per- formed for wound by a minie-ball. From this fact we infer that, in general, wounds of the knee joint by a rifle-ball admit of ampu- tation in the lower part of the thigh, and rarely necessitate the removal of the limb high up. It is also apparent that in a given number of cases of amputation in the upper third of the thigh for gunshot wound of the knee, a large majority will be necessitated by the larger and more destructive missiles. The results of the two methods prove the value of the circular method. From these tables it would appear that in a total number of cases of recovery after amputation of the thigh, for gunshot injury of the knee joint, the operation was performed in the lower third in more than one third of the cases ; at the junction of the middle and lower third in a little less than one third of the cases ; in the mid- dle third in about one fifth of the cases; and above this point in PERIOD OF AMPUTATION. 61 a little less than one thirteenth of the cases. The total amputa- tions at and below the junction of the middle and the lower third of the thigh comprise more than two thirds ©f all the cases. It is evident, then, that in gunshot injuries of the knee joint suc- cessful amputation is far more frequently performed below than above the middle of the thigh. The comparative mortality of this operation, according to the Surgeon-General, was very small. Of 243 amputations in the lower third of the thigh for wounds of the knee, 112 died, being a mortality of 46 per cent.1 The Confed- erate army reports give the following statistics of this operation : total number of amputations in the lower third of the thigh for wounds of the knee, 269, of which 126 died, being a mortality of 46 per cent.2 We have here a striking coincidence in the success of a given operation for the same cause. It would be interesting to note also the comparative mortality of amputation at other points in the thigh for these wounds, but we have not the data. The period at which the operation was performed after the injury, in the majority of cases, proves not only the se- Period of verity of the wound, but the importance of early ampu- amPutatl0D- tation to insure a successful result. In more than one third of the cases the operation was performed within six hours of the injury, and in nearly one fourth of the cases it occurred between the 6th and 24th hour. In other words, within twenty-four hours of the injury about two thirds of the operations were performed. It should also be noticed that 67 or more than two thirds of the operations were performed on the field. These facts prove both the severity of the original injury, and the necessity of an early operation ; for it must be remembered that this is a record of successful cases. If there were any doubt as to the severity of the wounds which led to amputation in these cases, it would be dispelled Nature of by a reference to the record of the nature of the inju- the injury' ries. In all but 13 cases there existed a fracture, generally com- minuted ; in the remaining cases the joint was freely opened, and the leg nearly dissevered at this point. Of the missiles with which the wounds were inflicted, in 59 cases the minie, rifle, or musket ball was employed; in M.gsiles 17 it was a fragment of a shell; in 13 it was a solid shot. It follows that the wound must, in one third of the cases, have been of the severest character. i Report of the Surgeon-General (Circular No. 6.) 2 Chisholm, London Medical Times and Gazette, December 29,1865. 62 OPINIONS OF SURGEONS. The following opinions of surgeons sustain the conclusions drawn from the preceding statistics, and are worthy of record in this connection. Professor A. C. Post gives the result of his observations in regard to gunshot wounds of the knee joint as follows: — " Gunshot wounds penetrating the knee joint are generally fatal, unless the limb be amputated. This is especially the case when, in addition to the wound of the joint, there is extensive fracture of the articular extremity of the femur or tibia. "The practical rule which I would recommend in gunshot wounds of the knee is this, to amputate in all cases where the ball has passed through the centre of the joint, or where the inferior articular ex- tremity of the femur or the superior articular extremity of the tibia has been fractured, but to make an attempt to save the limb where the ball has not penetrated deeply into the joint, and when the patella only has been fractured. In the class of cases in which I have recommended an attempt to save the limb, the attempt will always be attended with some danger to the life of the patient." Surgeon George A. Collamore, 100th Ohio Vols., speaks of the causes of thigh amputation as follows : — " In gunshot fractures of the femur, amputation will depend on the location of the injury. If the fracture occur in the upper third, I should prefer to trust the case to nature, with such aid from position, splints, etc., as could be obtained. In fractures affecting the lower two thirds of the limb, I should amputate so as to remove the fractured por- tion. Gunshot wounds involving the knee joint invariably demand amputation, if possible, just above the condyles and below the medul- lary canal. Gunshot fractures of the tibia, involving much comminu- tion and laceration of the muscles, usually require amputation. It would be a very unusual case that I would attempt to preserve. In my opinion conservative surgery should not be carried too far in gunshot fractures of the lower extremities, admitting amputation. Extensive fractures of the tarsal bones, involving the malleoli or articulation, re- quire amputation at the ankle. Fractures of the fibula do not usually require amputation, as this bone is but slightly instrumental in the sup- port of the body." Professor Paul F. Eve, of the Confederate service, makes the following communication in regard to the success of amputation of the thigh during the war, as compared with the same operation in former wars: — " Ribes examined four thousand veteran soldiers in the Hotel des Invalides in Paris, and found not one who had undergone amputation of the thigh, or who had sustained an injury of the femur by a shot. Pro- PROFESSOR EVE'S REMARKS ON AMPUTATIONS. 63 fessor Malgaigne of Paris, with whom I was associated in the war, makes the same report of all similarly wounded during the Polish campaigns of 1831. At the close of the Mexican "War in 1847, Dr. McSherry of the United States navy, on detached duty, was permitted to accompany General Scott's army, and declared that, although he remained in the city of Mexico eight months after the battles, and walked the hospitals, he did not see one soldier restored to health after a gunshot wound of the thigh, involving its fracture. Of an almost similar import were my communications to the Nashville Journal of Med. and Surg., after the late Italian campaign. Writing from Turin, July, 1859, it was stated that while the results were good after injuries in the upper ex- tremities, the reverse was true of those involving the inferior, with or without amputation, whenever a compound fracture existed. Dr. Sal- leron, chief surgeon of the military hospital ef that city, assures me that the nearest he came to saving a patient thus wounded, was a Zouave shot in the Crimea, who remained seven months in a hospital at Constantinople before attempting to return to France, and when he did so, finally died of pyaemia. In Milan I took notes of five cases of compound fractured thighs, which were all I saw there, fifty-six days after being wounded: in three there was little or no hope of recovery ; another had had the limb amputated above the knee, and was doing well; while the fifth was the only one expected to recover with the limb. " In amputations of the thigh in the Crimean War, sixty-four in every one hundred died; in the Paris hospitals seventy-five per cent., and in the Polish and Mexican wars one hundred per cent, or every one op- erated on, died. Of twenty-one disarticulations at the hip-joint, every one was fatal, and eighty-six per cent., according to McLeod, of ampu- tations in the upper third of the thigh died. As late as 1861, Mr. Thomas Bryant, surgeon to Guy's Hospital, one of the best ap- pointed and managed of these institutions in London, reported seven- teen cases of thighs requiring treatment. Ten were amputated, seven of them died; seven were attempted to be saved, four died; thus, of the seventeen cases eleven died. The most favorable return ever made, is that of Jules Roux, naval surgeon at Toulon, who saved four of six he amputated at the hip-joint; being by far the best success ever ob- tained by any one, though the circumstances were very propitious under which he operated. He mentions having seen twelve of these dreadful disarticulations; seven died. He also states that there were twenty-one cases of consolidated fractures of the thigh passing through his hospital from Italy. As Toulon was the only door through which the maimed could reach home (for Marseilles is a commercial and not a military port), it is highly probable that of all the two hundred and fifty thou- sand men who went to aid the Sardinians, these twenty-one constituted the whole number of all those wounded through the thigh bone who once more returned to la belle France with two legs. 64 INJURIES REQUIRING AMPUTATION OF LEG. " In the late terrible civil war our profession has nobly performed her duty, and America has reason to honor her surgeons. With pride and gratulation we point to the hundreds and thousands saved by their skill, even in compound fractures of the femur. Lieutenant-General Ewell survives an amputation through the upper third of the thigh ; and so does Lieutenant-General Hood, performed by Professor Richardson of New Orleans, on the battle-field of Chicamauga. They so fully re- covered, as is well known, that subsequently each commanded army corps in person on the field. I have seen as many as three soldiers con- versing together in the streets of Augusta, Ga., each having lost a limb above the knee. I think I had two successful amputations of the thigh in Atlanta, and about the same number left under treatment in Co- lumbus, Miss. I regret not having access to my official reports, but there must have passed under my supervision over one hundred of these amputations during two years and a half of hospital service. It is right, however, to say here that the majority of these were fatal. " Primary amputations did decidedly best, and, if not before, this question ought now to be considered definitely settled. The majority of those who recovered after injury of the femur were operated on in the field, or before inflammation and its results had ensued. To this rule we have the single exception in those requiring disarticulation at the hip-joint. In these cases it is now ascertained that few constitutions can bear in quick succession such shocks as, first, the injury requiring this operation, and then, secondly, that produced by its performance. The statistics of McLeod in the Crimean War already referred to, giv- ing twenty-one primary operations, followed by twenty-one deaths, con- trasted with Roux's four successful out of six consecutive, or secondary amputations is determinate on this point." Injuries requiring Amputation of the Leg. — The largest per- centage of recoveries after amputation of the leg, occur from inju- ries in the lower third, and in this respect resemble the recoveries after amputation of the thigh. It is interesting to notice three recoveries after amputation of the leg for compound fractures in the upper third, the amputation being in the immediate vicinity of the injury. Amputation for compound fracture of the middle third gives also a large percentage of recovered cases. Injuries of the ankle joint led to amputation of the leg in about one fourth of the total cases. Injuries of the foot would seem to have been very rarely followed by amputation of the leg, but in the French army in the Crimea it was a frequent operation, there being fifty- seven amputations of the leg for wounds of the foot in a total of two hundred and twenty-five amputations of the leg, or about one fourth. METHOD AND FREQUENCY IN THIGH AND LEG. 65 VI. METHODS OF OPERATION, AND THE FREQUENCY WITH WHICH THEY WERE PERFORMED IN THE THIGH AND LEG. The following (able comprises the various methods of amputa- tion in the thigh and leg, and shows how frequently they Methods of were performed in each division of the extremity: — amputation. Circular ......... Antero-posterior flaps .... Posterior flap....... Anterior flap....... Lateral flaps....... Rectangular flap...... Skin flaps and circular of muscles Thigh. 155 Leg. 54 115 78 93 - 45 10 2 6 21 5 - 2 8 284 It is apparent that the amputations of the thigh and leg were performed either by the circular method or by some modification of the flap. Of the flap operations that which was generally pre- ferred was the antero-posterior flap ; the anterior, posterior, and lateral flaps being but seldom performed, with the exception per- haps of the posterior flap in the leg. Of the two principal methods, the circular and antero-posterior flap, we notice that the antero-posterior flap was preferred Antero-pos n i • i i • i 11 -l-ii terior flaps more frequently in the thigh, and the circular in the leg. mostfre- ... • n li • qnent in the In the thioh the antero-posterior flap method comprises thigh, and ° • imi -i ii.lti circular in half the operations, while the circular exceed but little the leg. one third. In the leg these methods are nearly reversed, the circular amputations amounting to nearly three sevenths, and the antero- posterior amputations to but about one third. Of the remaining methods the anterior, posterior, and lateral flaps have long been occasionally practiced, but without other meth any definite results. The rectangular flap of Teale ods- seems to have been performed in a few instances in the thigh. The method by flaps of skin and circular of muscles was per- formed in ten cases, two in the thigh and eight in the naps of skin ° and circular leg. This method seems to have become very popu- of muscles. lar with many military surgeons, especially with those who were compelled to transport their patients long distances. The surgeons in General Sherman's army came to prefer this operation to all 5 66 VALUE OF DIFFERENT METHODS. others. Their method of operating was to make lateral flaps of the skin and a circular incision of the muscles ; the lateral flaps brought in apposition gave a cicatrix running vertically on the face of the stump. In dressing the stump the ligatures were all brought out at the lower angle of the wound, and the drainage was perfect, leaving the upper portions of the wound dry. Accord- ing to the testimony of many surgeons who had great experience in the transportation of the recently amputated, these stumps required dressing much less frequently than other forms, and union by first intention throughout three fourths of the wound was an almost constant result. In some cases it is stated that the stumps would remain so dry that the dressings would not require renewal in four or five days. TESTIMONY OF SURGEONS AS TO THE VALUE OF DIFFERENT METH- ODS OF AMPUTATION. Testimony of The various opinions of surgeons in regard to the spe- to value of cial merits of the different methods may be gathered from different . „ ,, methods. the following extracts. Assistant-Surgeon Powers, U. S. Army, says : — " If the patient is obliged to be removed soon after amputation, I pre- Assistant- fer the circular operation, as the parts are steadier, and keep Powers. their place better; otherwise I generally use the flap opera- tion." Assistant-Surgeon N. A. Meacher says: — " I saw a great deal of trouble with stumps, on account of the flesh Assistant- sloughing and leaving the end of the bone protruding, and I Surgeon . , , . . ° Meacher. think the circular operation more liable to that trouble than the ' Liston flap,' which I prefer, unless it is in operating near the wrist or ankle." Surgeon C. E. Deming, 28th Ohio Vols., prefers the flap only in certain locations, as follows : — " In amputations of the arm, angle, and upper two thirds of the leg, surgeon 1 Prefer the flaP operation to the circular. The preference I Deming. have for the flap over the other is on several accounts; a more perfect covering is secured for the bone ; the integument is only disturbed in the line of the incision, while in the circular the muscles are rarely ever cut close up to the retracted integument; the flap has less cutting and is speedier done, and the size of the flap can always be proportionably estimated to the size of the limb ; in the circular it is TESTIMONY OF SURGEONS. 67 more or less guess-work. In the circular again the second cut is never exactly close up to the retracted skin; the third cut more or less haggles or cuts off the ends of the divided muscles of the second cut; the skin when brought over the end of the bone more or less gaps, and the cut ends of the muscles double in over the sawed end of the bone. It suppurates more and is usually longer in healing than the flap. '; At the lower third of the leg the circular is the best." Surgeon P. H. Bailhache, 14th Illinois Cav., says : — " In amputations I prefer the double flap (posterior and anterior) for the arm and thigh, and the ' combination ' or ' semi-lunar and gur_eon flap' for the leg and fore-arm. I am of opinion that the Bailhache. 'circular' amputation injures the integuments by frequent lesion of its nutritious vessels, which is done while dissecting it back upon itself — hence the flabby, waxy appearance of the parts in many instances. Some hold that there is less discharge of pus from a circular than from a flap operation; this may or may not be so; but even were such the case there is no advantage gained, as the drain upon the system is no greater, and the union of the flap is as speedy and as perfect. It is also said there is danger of transfixing or splitting the blood-vessels or nerves; this is mere theory, not substantiated by facts or experience, besides which ordinary care and a knowledge of the parts obviates the risk of doing so. Again, in the circular operation it is almost always necessary to split the integuments on one or both sides before they can be turned back and dissected sufficiently high to prevent the bone from protruding; so it is eventually ' two flaps' without the advantage of 'time' and at the expense of more or less injury to the integuments ; if the muscles are not required as a cushion for the bone they can be readily cut out afterward without destroying the areolar structure," etc. Surgeon George A. Collamore, 100th Ohio Vols., expresses nearly the same opinion. Although he formerly em- SuT.geon ployed the circular method, he now prefers the flap, CoUamore- believing that it " allows more perfect approximation of the sur- faces, and union by the first intention sometimes will take place, but never, so far as I have known, in the circular operation." Surgeon E. Batwell, 14th Michigan Vols., draws the following distinctions between the flap and circular: — " From close observation, I am unable to give preference to either as far as regards healing, both depending on the constitution of Su B your patient, and both healing with equal facility. Hemor- Batweii. rhage took place more frequently in circular operations, owing doubt- less to vessels of large size retracting more readily when divided straight across, than those cut slanting, as in flap amputation. As soon 68 VALUE OF DIFFERENT METHODS. as full reaction set in, these vessels poured out blood, and very fre- quently necessitated the opening of the stump to secure the bleeding artery. Anterior and posterior flaps healed more kindly than lateral ones, notwithstanding the latter possessed less tendency to accumula- tion of pus, and the sutures held the lips of the flaps together better; but the nervous twitchings of the stump made the bone protrude through the edges of lateral flaps more readily, and tore the newly organized plastic lymph. Any modifications of the above operations, or a combination of both, healed slowly and unsatisfactorily, invariably leaving painful stumps. Short anterior, with long posterior flaps made the process of healing very tedious, always leaving so painful a stump that a secondary amputation became necessary; I have thought that the nerve got under the bone, and was thus pressed on. The above observations were made from a similar number of flap and circular operations, with a view of deciding in my own mind the relative merits of each. I have measured the exposed surface, and was much aston- ished to find a larger extent on a circular than on a flap. In making the second sweep with the Catlin, I found that by inclining the edge of the knife towards the patient's body, so as to have the bottom of the incision an inch and a half or two inches higher up than the external, forming a hollow cone, a far nicer looking stump was formed, and one far better adapted for an artificial limb." Surgeon W. Manfred, 22d Kentucky Vols., is of opinion that the flap method is more successful than the circular : — " I generally prefer the flap to the circular operation ; it makes a Surgeon better stump, and there is less waste of muscle in making Manfred. the flaps, except in certain exceptional cases, when the cir- cular operation is probably the best, as when the muscle is very thick, or when it is injured by the ball so as to make the flap operation inadmissible. Moreover, my flap cases have been uniformly more suc- cessful than the circular." Surgeon B. T. Kneeland, — New York Cav., says: — " I prefer flap amputations always, which have the advantage of Surgeon saving time both in the operation and in the recovery, and as Kneeland. giving better results in every respect." Surgeon H. C. Robbins, 101st Illinois Inf., says : — " I prefer flap operations in the arm and thighs as more likely to surgeon cover the bones and afford a soft cushion for an artificial Robbins. iimb. In the fore-arm and leg I would use the circular operation for similar reasons." Surgeon N. Field, 66th Maryland Vols., says :__ TESTIMONY OF SURGEONS. 69 "I prefer the flap method, because, as I believe, it makes a better covering for the end of the bone. The circular requires care Surgeon to prevent trouble afterwards." Field- Surgeon J. C. Walton, 21st Kentucky Vols., prefers the flap, but believes that if the patient is transported any considerable dis- tance there is danger that the flaps will separate : — "I have generally performed the 'flap' operation, except in cases where there was much loss of the soft parts, or much contu- gurgeon sion. It is most conveniently performed, and in healthy sub- Walton' jects frequently heals more rapidly. It makes a better covering for the stump, and a softer cushion for an artificial limb. The only objection to this method is that it gives more suppurating surface, — provided the patients are kept quiet, and are not required to be moved from place to place; but should the case require transportation several miles over rough roads the flaps are apt to gap open." Surgeon Chaddock, 7th Michigan Vols., says : — " I prefer the flap; it gives greater mechanical neatness, less exposure of wound to air, and the chances of healing by first inten- gurgeon tion. I am also satisfied that the cut surface is less with the Chaddock. flap mode of operating, if well made, than it is in the circular." Surgeon-----,----------, says : — " In the arm and thigh I invariably performed the flap operation; making in all cases where practicable antero-posterior flaps. Surgeon__ My reasons for this method are several: 1st. The operation is more easily and quickly performed. 2d. The flaps are not so liable to slough as when they are made by the circular method. In the latter the skin and areolar tissue are dissected up to the extent of from two to four inches, cutting off, to a certain degree, their supply of blood ; hence lowering their vitality, and making them more liable to slough. In the former, the skin and cellular tissue retain their connections with the more deep-seated tissues, and their vascular supply is not interfered with. 3d. In the flap operation the stump heals more quickly and with less suppuration, because the parts are brought more perfectly in ap- position than they can be when the circular method is used. 4th. Because (and this follows as a corollary from the two preceding reasons) the flap method is less liable to be followed by pyaemia, erysipelas, or gangrene. 5th. Because this method gives stumps better adapted to artificial limbs than the other method : the end of the bone is more thickly covered. " These reasons, which I think will be found to be good ones, cer- tainly show the immeasurable superiority of the flap over the circular method. Even in the fore-arm and leg, I consider the flap the better operation." 70 VALUE OF DIFFERENT METHODS. Surgeon ----,--------, writes: — " I prefer the flap in large thighs, because I can judge more nearly Sur eon__ the exact amount of covering I will have on the end of the bone, and that there will be less likelihood of sloughing and of protrusion of the bone. There will usually be a better covering for the bone than after circular operations, and the skin will not be so ex- tensively detached from its normal relations to the muscular tissues, and it will not become so pale and so liable to ulcerate and slough where the ed nized. tation, namely, the period which intervenes between thjf receipt of the injury and the shock. This period would not ord* narily extend beyond an hour. 9 It may be stated here that these divisions of time cannot Jbe fixed in any given case. They depend upon physical conditions that change with individuals and with surrounding circumstances. Inflammation may occur within twelve hours of the injury, o| by treatment it may be delayed three or four or more days. /The Periods periods that have been fixed, and the terms that iiave natethecon- been employed to designate changes, are arbitrary and patient. are to be taken in the most general and liberal sense. In the redivision of these periods terms ought to be adopted that clearly define the meaning of those who use them ini every individual case. The old terms primary and secondary, jfchough i Notes on the Surgery of Crimean War. i i AMPUTATIONS IN DIFFERENT PERIODS. 81 applied to two very well understood divisions of time which em- braced certain conditions of the local injury, were rarely so em- ployed as to convey a definite meaning. The science of our day demands more positiveness in the nomenclature of diseases. It would be far better, therefore, in making a new classification of periods, to select terms which explain the existing condition of the patient or wound, and which are not arbitrary. We propose for the purposes of discussion in this paper to so divide the periods as to include all hitherto described, and under such titles New names as more nearly explain the condition of the patient or ofPenods- part. We name five periods, as follows : before shock (one hour or less) ; during shock (one to six hours) ; during reaction (sixth to forty-eighth hour) ; primary inflammation (forty-eighth hour to seventh day) ; secondary inflammation (after seventh day). The first two periods relate to the condition of the patient, and the last two to the condition of the wound. Much difference of opinion exists among writers as to the pro- priety of amputations in these different periods. This proprietyof question can be correctly settled only on the basis of the SS^" comparative mortality in each. The preceding collection riod' | of cases furnishes us the materials for forming correct conclusions \ upon this much debated subject. We are able to fix the time of \ operation in each case with so much exactness that we are enabled \ to determine the proportion of recoveries, in the different periods, to Ithe total recoveries, and thus determine the most favorable period *|br the operation. We will first present an analysis according to the divisions of Hamilton. NUMBER OF CASES IN FOUR HUNDRED AND TniRTY-ONE RECOVERED AMPUTATIONS IN THE IMMKDIATE, PRIMARY, INTERMEDIATE, AND SECONDARY PERIODS, AND HIE PER CENT. IN EACH PERIOD OF TOTAL AMPUTATIONS IN THE TIIIOH AND LEG. Immediate. Primary. Intermediate. Secondary. Thigh, 52, or 33.5 per ct. 49, or 31.6 per ct. 18, or 11.6 per ct. 36, or 23.2 per ct. Lcg/i 104, or 37.6 per ct. 82, or 29.7 per ct. 35, or 12.6 per ct. 55, or 19.9 per ct. | 156 131 53 91 i l SUMMARY. Immediate, 156, or 36.2 per ct. of total. I Intermediate, 53, or 12.3 per ct. of total. Primary, 131, or 30.4 per ct. of total. | Secondary, 91, or 21.1 per ct. of total. If we divide the cases included in the immediate period into those occurring within one hour, and those occurring between the 6 82 PROPRIETY OF IMMEDIATE AMPUTATION. first and the sixth hour, we should separate those operated upon before, from those operated upon during the shock, or nearly so, as follows: — Before shock. During shock. Thigh.....18, or 11.6 per cent. 34, or 21.6 per cent. Leg......24, or 8.6 per cent. 80, or 28.7 per cent. 42, or 9.7 per cent, of total. 114, or 26.5 per cent, of total. In regard to the propriety of amputation immediately after the Propriety of occurrence of the v injury, or before the shock is of any amputation, considerable intensity, as within one hour from the gun- shot, various opinions are held. Pare" and Wiseman evidently approved of immediate amputation in the sense in which we speak of it, namely, before the shock. Larrey advocated with great ear- nestness immediate amputation, and affirms that he lost a great number of patients by delay. He speaks of being most success- ful in cases where the operation was peu d'instans apres le coup. McLeod, speaking of the period which intervenes between the wound and the shock, says: "If this precious moment could be seized at all times, and that operation performed under chloroform, which assists so much in warding off the ebranlement we fear, how much more successful would our results prove than under any other circumstances they ever can be ! " Hutchinson says : " The operation ought not to be deferred one moment !" Guthrie says: " There can be no doubt that if the knife of the surgeon could in all cases follow the ball of the enemy, or the wheel of a railway carriage, and make a clean, good stump, instead of leaving a contused and ragged wound, it would be greatly to the advantage of the sufferer." He approves, in general, of imme- diate amputation in the arm or below the knee, remarking: " These operations may be done at any time from the moment of infliction until after the expiration of twelve or twenty-four hours, without any detriment being sustained by the sufferer with regard to his recovery." In those cases where the injury renders ampu- tation in the upper third of the thigh or at the hip joint necessary, he is in doubt as to the propriety of immediate amputation, and thinks the subject demands further investigation. Hamilton1 believes that the occurrence of delayed shock is rare, and would approve of immediate amputation only in extreme cases, "as, for example, when a limb is nearly torn off, and a dangerous hemorrhage, which cannot be arrested, is occurring; or when spicula of bone, such as neither the forceps nor fingers can i Med. Record, September 15,1866. AMPUTATION DURING SHOCK. 83 extricate, are causing intense suffering." He would also favor immediate amputation " in a considerable number of cases of injuries to larger limbs, when it is clearly seen that the patient is not faint, or depressed, or suffering under great nervous agitation." The above table shows that amputation was successfully per- formed during the late war within a period after the Results of injury which implies either that shock had not super- amputation vened, or that it was as yet but slight. In many cases the opera- tion is reported to* have been performed immediately, and some of these we know were immediately, in the true sense of the word, but a few minutes having elapsed between the receipt of the injury and the operation. It may be stated in regard to the compara- tively few cases reported, that they prove that a large mortality must have occurred, or that but few operations were performed. We incline to believe the latter is the true explanation. The opportunity to perform an amputation within an hour after the injury, occurs but infrequently compared with the cases which offer for amputation at subsequent periods. Various opinions are advanced by military authorities in regard to amputation during the existence of shock. Larrey Amputation went so far as to contend that the nervous "commo- shock. tion " was rather an indication of the propriety of the operation, because its effects "far from being aggravated, diminish and disap- pear insensibly after the operation.'' McLeod, quoting this state- ment of Larrey, says : " But even although that constitutional disturbance which is the result of injury is present, is it always necessary to wait its subsidence before operating ? If it be very decidedly marked, and the patient thus much prostrated, such delay may certainly be called for; but it is an opinion often stated by those who must be well informed on the subject, that such delay is not always advantageous, but manifestly the reverse." Hamilton decidedly condemns amputations during the stage of shock. He remarks that his experience has been, " after at least twenty years of observation in hospital practice, and after a pretty large experience upon the field, that amputations of large limbs, made after severe injuries and before reaction has fairly been established, have in most cases resulted speedily in the death of the patients." The cases to which Larrey refers, in which the nervous commotion is diminished by an operation, he explains to be those in which the broken bones, fragments of shell, splinters, clothing, or some other foreign substance lying in the track of the wound, are causing pain, and perpetuating the irritation. 84 AMPUTATION DURING PERIOD OF REACTION. The preceding table would seem to definitely settle the question Success of of the advantages of amputation within six hours of the within six injury. And this period includes the limits set by Ham- jur"" ° '" ilton to the stage of shock. Thirty-six per cent, in a total of four hundred and thirty recovered amputations, embracing all periods after the injury, were performed within six hours of the receipt of the wound. These statistics prove that immediate (Hamilton) amputations of the thigh and leg, that is, those per- formed before and during shock, are six per cent, more successful than those performed after reaction comes on and before inflamma- tory symptoms appear ; three times as successful as those performed in the intermediate period, or in the stage of primary inflammation ; and, finally, nearly twice as successful as the secondary operations. Comparing the thigh and leg amputations, it will be seen that the largest percentage of recovered cases in the immediate period occur in the leg. If we analyze the immediate amputations by dividing this period into two, the first of one hour, and the second from one to six hours, or into the amputations before the shock, and during the shock, we find that 9.7 per cent. Avere performed in the first period, and 26.5 per cent, in the second period. It is to be noted also that amputations before the shock were three per cent, more favor- able in the thigh than in the leg. The period of reaction extends from the sixth to the forty-eighth Period of re- hour. During this time the wound remains in a com- acti0Q' paratively quiescent state. The patient rallies and re- covers his normal general condition, and seems to be in a proper state for an operation. 'But these tables prove that the success of amputations in this period is not as great as before, or during the shock, or rather that in a given number of recovered cases the largest percentage occurs in the earlier periods. From this fact we learn that primary amputations are successful in proportion to the number that are performed before the stage of reaction com- mences. Heretofore the period of primary amputations has in- cluded the three periods above designated, namely, that before, and during the shock, and the stage of reaction ; and the general opin- ion of surgeons was that the successful amputations mostly fell in the third period, or were performed in the stage of reaction. By this discrimination of time, and the more careful designation of the periods within which operations were performed, we learn that the real value of primary amputations depends upon whether they were performed before the stage of reaction. GENERAL CONCLUSIONS IN REGARD TO SUCCESS. 85 The great fatality of amputations performed in the " interme- diary " period, or during the excitement which precedes intermediary suppuration, is strikingly illustrated in these tables. By period- far the smallest percentage of recoveries are reported for this period. This unfavorable result is not so much due to the condi- tion of the wounded parts, as to the general condition of the patient. The system is now suffering from the first onset of inflammatory fever, and there is necessarily a high degree of vas- cular and nervous excitement. The temperature of all the tissues of the body is raised by the blood surcharged with heat from the inflamed parts, and there is consequently an exalted tissue sensi- bility. The shock which follows an operation under these circum- stances is always most profound, and reaction correspondingly difficult and uncertain. The inflammation which supervenes is also more destructive of tissue, and exhaustive of the patient. These circumstances combine to render the intermediary period more dangerous than any preceding. The secondary period, which includes all operations performed after the seventh day, is seen to give a larger percentage secondary of recoveries than the intermediary period, but the results tions. are not as favorable as in either of the two earliest periods, namely, before, and during the shock. We have in this result only the general conclusions of military surgeons, long since established, that the secondary amputations are more fatal than the primary ; but we had not before so discriminated the divisions of the stages through which the patient passes, included in the primary period, as to determine at what precise time the least and greatest mor- tality occurred. We now discover that secondary amputations are not as successful as primary amputations at any period within the first forty-eight hours. We may conclude in regard to the success of amputa- General con- J • 1 p n elusions in tions at the different periods as follows : — regard to • i /» J i j: success of 1. Immediate amputations, or those performed before amputation 1 * at different the shock, give good results in military surgery. periods. 2. Amputations performed between the first and sixth hour after the injury, or during the shock, are more successful than when performed at a later period, but are not probably more successful than when performed immediately. 3. Amputations performed between the sixth and forty-eighth hour, or in the period of reaction, are more successful than at any subsequent period, but are not nearly as successful as amputations performed previously to the sixth hour. 86 OPINIONS OF SURGEONS 4. Amputations performed between the forty-eighth hour and seventh day, or in the intermediary period, are more fatal than at any time prior or subsequent to that period. 5. Amputations performed after the seventh day, or in the secondary period, are more fatal than amputations performed at any time prior to the forty-eighth hour after the receipt of the injury. TESTIMONY OF SURGEONS AS TO THE PERIOD AT WHICH AMPUTA- TIONS SHOULD BE PERFORMED. Surgeon D. F. Leavitt, 3d Massachusetts Cav., says : — " Amputation immediately after injury I think affords the best chance of recovery. If the patient is suffering from shock, I think sulphuric ether should be administered whether operation is required or not, it being, so far as I have observed, the best treatment for that condition. If time for primary operation has passed, and there are no urgent rea- sons for early secondary operation, such operation need not be per- formed until sufficient reasons aside from the ultimate usefulness of the limb exist. In capital operations such a course affords most chances of recovery. Other things being equal, a late secondary operation fur- nishes better chances of recovery than an early one performed while inflammation is acute, and the system has not had time to adapt itself to the burden it already has to bear." Surgeon C. J. Walton, 21st Kentucky Vols., says: — " The earlier an amputation is performed after the injury is received, the more successful will it be, unless the ' shock' is too great to justify operating immediately; then, of course, we should wait for reaction." Surgeon P. H. Bailhache, 14th Illinois Cav., says: — " Primary amputations are almost always successful, while interme- diary and secondary are generally fatal, particularly in general hospital practice. Of some thirty-five primary operations only two deaths occurred, one of these from malarial poison; while of ten cases of secondary amputation eight died." Surgeon B. W. Avent writes : — " I have for many years advocated the immediate procedure in un- complicated shock. The experience afforded during the last few years has greatly strengthened my former convictions. The principle which controls me in this selection is not alluded to by yourself or those to whom you refer; nor have I been able to find it elsewhere. Larrey INFLUENCE OF PLACE UPON ATROPHY OF STUMP. 87 may mean something of the kind, when he speaks of loss of patients, because his operations were, in some instances, too long deferred ; but his language is not explicit. In the limits of a letter I can merely mention the grounds upon which I act. The premises may be untrue, but the results have been more satisfactory, as a general rule, than in either the primary or secondary selection. I give it as follows: — " 1. Shock, following gunshot wounds, or other injuries of a kindred character, is purely nervous. 2. The impression is both local and con- stitutional. 3. Susceptibility to further impression is suspended pro- portionally to the recognized manifestation upon the subject. 4. Loss of blood is not essential to the production of nervous shock, but to a limited extent may be regarded as remedial in its effects. 5. Anaes- thesia may be employed with entire safety during any period of shock, though in many instances where the operation is near the wound, owing to the absence of sensation, this agent might be dispensed with. " I never adopt the immediate procedure when there has been serious loss of blood. Many of the failures incident to it, in my judgment, are referable to a want of discrimination at this point. The respective conditions from shock and loss of blood are so entirely dissimilar that but little experience is required to detect them. They are, however, often overlooked. " I remarked just now that loss of blood when limited is remedial in shock. I think there is no principle in surgery more conclusive." VIII. INFLUENCE OF THE PLACE OF AMPUTATION UPON THE AMOUNT OF ATROPHY OF THE STUMP. Among the final results of amputations, atrophy of the stump must be regarded as of the first consideration. Next in Atl.ophyof value to a firm and durable covering to the stump is stumP- a well nourished extremity. If the stump undergo progressive atrophy, the artificial limb requires much more care to maintain its adaptation. The constant shrinkage of the extremity renders the appliance loose, and hence it requires readjustment by continuous padding of the socket. This padding of the socket is not required when the limb maintains its full dimensions. The accompanying tables enable us to determine how far the method of operating, and the point of the limb at which the ampu- tation is performed, influence the subsequent nourishment of the stump. The measurements were made when the stump was healed, and prepared for the final adjustment of the artificial limb. The first or proximal measurement was made, in the thigh, at the high- 88 COMPARATIVE ATROPHY. est point where the circumference could be taken, and in the leg, immediately below the knee. The second, or distal measurement, was made directly around the extremity of the stump, at a point where the margins of the flap begin to incline towards the cicatrix. The figures entered in the tables under the head " atrophy," ex- press the difference in inches and fractions of an inch between the measurement at the points above indicated of the mutilated and uninjured limb. COMPARATIVE AMOUNT OF ATROPHY OF STUMPS IN THE UPPER, MIDDLE, AND LOWER THIRDS OF THE THIGH AND LEG, IN AN AGGREGATE OF 430 CASES. (In inches and fractions of inches.) Upper Third. Middle Third. Lower Third. Lata. Proximal. Distal. Proximal. Distal. Proximal. Distal. Thigh...... Leg....... 0.45 0.97 1.05 1.70 1 56 0.71 1.70 1.42 1.34 0.57 2.08 2.26 It must be borne in mind that the proximal measurements in the thigh are all made at the same point; and the same is true of the leg. It would appear from this table that the point of amputation exercises a very marked influence upon the degree of atrophy of the stump, both in the thigh and leg. In general, the amount of atrophy progressively increases as we recede from the trunk, an exception, however, being noticed in the middle third of both the leg and thigh, which we shall presently notice. In the thigh the proximal atrophy is least in amputation in the upper third, and greatest in amputations in the middle third. In amputations in the lower third of the thigh, the proximal atrophy is slightly less than in those performed in the middle third, but still it is three times as great as after those in the upper third. This fact proves a progres- sive proximal atrophy as the point of amputations in the thigh re- cedes from the trunk. In the leg this rule is reversed, and the proximal atrophy diminishes as the point of amputation recedes. And this atrophy diminishes in regular order, being least in ampu- tations in the lower third of the leg. It must not be supposed that the proximal atrophy is influenced Proximal by the amount of inflammatory thickening subsequent to atrophy not . „ . . , , ^ * increased by the operation, tor in that case the degree of atrophv would lnflamnia- . . , . ,° I J tion. in general depend upon the proximity of the amputation to the point of measurement. But this is by no means the case. INFLUENCE OF METHOD UPON ATROPHY. 89 Amputations in the middle third of the thigh, near the point of measurement, are followed by a greater amount of atrophy than those in the lower third, remote from that point; while in the le the anterior part of the limb, while the tissues are completely divided to the bone in a perpendicular direction on the posterior aspect of the limb. By these methods the principal covering of the stump is poorly supplied with nourishment, and hence atrophy would be more likely to occur. This is seen to be the case especially in the anterior flap method in the middle third, and the rectangular flap in the lower third. The methods which give the least atrophy of the stump, both in its proximal and distal portions, are the skin flaps and skin flap circular of the muscles, and the posterior flap. It is not ofmusci"ar difficult to understand why the posterior flap method gives results so favorable ; it leaves quite intact the full vascular supply to the entire covering of the stump. In this respect it might well be regarded as the best method of operation in the thigh, but these advantages are so counterbalanced by the tendency of the flap to retain pus, its heavy and unsuitable position for transportation, etc., that it has but few advocates. The method by skin flaps and cir- cular of the muscles gives results nearly as favorable as the poste- rior flap, and much more favorable than any other of the preceding methods. It is greatly preferable to the posterior flap method, both on account of the facility of drainage, and the neat apposition and lightness of the flaps, thus adapting it to transportation. The influence of the various methods of operation upon the nourishment of the stump is not so well marked in the leg Effect of as in the thigh. This is unquestionably due to the pecul- ^e'thods in iarity of the arterial distribution. The larger trunks are thele»- numerous, and are deeply situated in immediate relations with the bones. They are not, therefore, liable to division until the opera- tion is about to be completed. There would therefore be but little difference among these operations as regards the vascular supply of the flaps, except so far as the extent of the flap should modify the ultimate distribution of arteries. A.long flap would necessarily have less supply than a short flap, and would be more liable to immediate death and future atrophy. Of the different methods it will be noticed that the skin flaps and circular of the muscles gives the least atrophy in the leg as well as in the thigh. Many of the disastrous results of amputation in the lower extrem- ities have been attributed to immediate transportation. Effect of To this cause have been referred sloughing of flaps, gaping tion. 92 EFFECTS OF TRANSPORTATION. of wounds, protrusion of bone, etc. There is, undoubtedly, some truth in this very prevalent opinion, and yet the statement must undergo certain modifications. There were innumerable instances in which men suffering from recent amputations of the lower ex- tremity, had their wounds so imperfectly dressed and supported, wei-e so crowded and confined, and were so rudely transported, that the most unfortunate consequences ensued. But unfavorable results under such circumstances are not justly due to simple transportation, but rather to that want of care in the preparation of the patient, and the conditions surrounding him, which military exigencies necessitate or which are the result of negligence. There are abundant facts to prove that the transportation of recent amputations, when judiciously managed, is attended with the most happy results. During the long marches of Sherman's army from Atlanta to Savannah, and from the latter place north- ward, an opportunity was offered of determining the effects of transportation upon recent amputations. As soon as the amputa- tion was performed, and the wound properly dressed, the patient was placed in the ambulance or army wagon, and there remained until the army reached its destination. It is the testimony of sur- geons who had the care of these men, that their wounds healed with but little suppuration, sloughing did not occur, and scarcely a case proved fatal. Most of the amputations, made on the first, second, or third day's march, were entirely healed when the army reached Savannah. It should be stated that the army marched through a pleasant country, and with good roads ; the men were in good physical and mental condition, and the supply of fresh food of every description was abundant. The following testimony of surgeons upon the question of the dangers of transportation to the recently amputated is impor- tant : — Surgeon J. C. Walton, 21st Kentucky Vols., says : — " My observation proves that soldiers laboring under wounds not Surgeon involving fracture of the long bones, or who have undergone Walton. amputation, bear transportation remarkably well, and often express themselves as feeling improved, after being moved several miles over rough roads." Surgeon P. H. Bailhache, 14th Illinois Cav., writes: — "It is surprising with what ease recent cases of amputation bear Burgeon transportation. I have witnessed little or no bad effects there- Bauhache. from m some twenty-five or thirty cases." EFFECTS OF TRANSPORTATION. 93 Surgeon Charles E. Deming, 28th Ohio Vols., says: — " In nothing have I been more astonished than the very inconsidera- ble injurious effects of transportation upon recent amputa- surgeon tions of the inferior extremities. I have seen men with am- Demins- putated thighs, legs, and arms, transported sixty or seventy miles over the roughest of roads, in wagons, without producing any very serious consequences. Care should be taken to keep the stump constantly wet with cold water by an attendant, whose duty it should be to steady the limb when passing over very uneven places. " Wagons filled with hay afford the best means of transportation over roads ; ambulances jolt and rock too much." Surgeon E. Batwell, 14th Michigan Vols., says: — " No point of practice was so difficult to decide as the treatment of gunshot fractures. On one side we had what seemed to be a gurgeon simple compound fracture, with no great apparent comminu- BatweU- tion or laceration of the soft tissues, whilst on the other, we had statis- tical evidence of the fatality arising from endeavoring to save the limb. Out of six cases of compound fracture arising from gunshot wounds, after the battle of Jonesboro', but one recovered, and that too under the most favorable circumstances. The transportation to Atlanta was over a level sand road, and the dressing of the wounds was performed by skillful and efficient surgeons, regularly every day. Every requisite was furnished to mitigate suffering or to afford comfort, by the Sanitary Commission; but the result proved that if the limbs had been removed, a very different state of things would have followed ; for out of thirty- five cases of amputation but four proved fatal, and two of these were secondary operations. Such success in operation we consider unprece- dented, and we feel some just pride at the results gained. " I look on immediate transportation as not productive of half the danger to a patient as if necessity required us to remove them at a later period. The request I would myself make, if 1 had received a compound fracture from a gunshot wound, would be to have immediate amputation performed. " When Sherman swung his army to the south of Atlanta, a man was brought to hospital, and his left leg taken off at the upper third of the thigh, and before he was well out from the influence of chloroform, he was put into an ambulance, and continued to move with the army daily for seven days. He improved rapidly, and his wound was almost united on arriving at Atlanta, and in sixteen days he was sitting up, and in twenty was on crutches. " When obliged to move cases of amputation of the lower extremi- ties, I placed the stumps in slings suspended from the top of the ambu- lance ; by this all jolting was lessened, and the patients could save themselves much agony by holding and raising themselves ; besides, they 94 INFLUENCE OF METHOD ON RAPIDITY OF HEALING. could move and change position with far greater facility, and turn on their side without hurting or knocking the stump. I found that in our stationary hospitals this same plan, carried out by a simple frame across the cot, afforded the very greatest ease to our patients, both as regards facility of movement and dressing; besides, the wounds were very easily protected from flies, and the subsequent effects of maggots were thus obviated. You also had a better chance of applying cold water without drenching the bed, or any other application deemed necessary." Surgeon B. T. Kneeland,-----New York Cav., says : — " My experience in transportation of those who have suffered ampu- s tations is limited to army wagons, and I was frequently sur- Kneeiand. prised to witness the improvement of patients when thus removed, often exceeding that of patients confined to hospitals." X. THE INFLUENCE OF DIFFERENT METHODS OF AMPUTATION IN THE SEVERAL REGIONS OF THE THIGH AND LEG, ON THE RAPIDITY OF THE HEALING PROCESS. There is an opinion very prevalent among surgeons, both in influence of civil and military practice, that there is a marked differ- different , . -. . . , . . methods of ence in the rapidity with which amputation-wounds heal, amputation ,. _. ..,.., . on healing, depending upon, 1st, the region in which the operation is performed ; and, 2d, the method employed. It is necessary, of course, in estimating this difference, to discriminate carefully the cases selected, and place them upon precisely the same basis as regards their condition. If two operations are compared in this particular, the patients must be equal quantities in every respect, otherwise our conclusion will be vitiated by a preponderance of favorable or unfavorable conditions. Nothing would be more difficult than to select two patients thus equally balanced. It is quite impossible to determine whether any, and what, differ- sources of ences exist in the healing of these wounds, except as we error- take the averages of large numbers situated under nearly the same circumstances ; and even then our deductions can only approximate the truth. In this collection we are able to group together a large experience in amputations of the lower extremitv, and determine in a somewhat definite manner the period of healing of the amputation-wounds. It is true that there are many circum- stances incident to the healing of wounds in military surgery, which tend to vitiate our conclusions, such as injurious transporta- tion, insufficient food, sloughing of flaps from gangrene, necrosis, etc., etc. But in grouping together a large number of cases, all WHEN A PATIENT IS CURED. 95 having been subjected to the same untoward influences in a greater or less degree, the average results are rendered in a cer- tain degree truthful. Amputations are frequently pronounced cured when the wound is not completely closed, the surgeon having reference when a Pa- rather to the safety of the patient and his ability to leave cured. his bed than to the actual condition of the stump. But in the sense in which we are to regard the patient as cured, the condition of the stump alone is to be considered. No stump can, in this connection, be pronounced cured when the wound is not healed, and the cicatrix is not so far perfected as to admit the adaptation of an artificial limb. In the preceding tables a note is made of two examinations of the stump, the first, when the patient first came under observation, and the second, when the stump was ready for the adjustment of the artificial leg. In regard to the first examination, it should be stated that in general it was made when the surgeon discharged the case as cured, and when the stump was thought to be suffi- ciently healed for the proper measurements for the artificial limb. In many instances the wound was already completely cicatrized when the patient first presented himself for examination. In such cases the date of the completion of the cure is not stated. This column gives, therefore, merely approximate results. We can learn from it only that within given periods a certain number of stumps were completely cicatrized, and that a certain other number were not healed. The condition of the stump is generally noted, and the causes which led to its non-cicatrization are briefly speci- fied. In the second column the date of the application of the artificial limb is given. At this period the stump was healed and in a con- dition suitable for use. This period did not always mark the exact date of the perfection of the cure, as in some instances the stump had been healed for a considerable time. But in general it may be assumed that the date of the adjustment of the artificial limb marks the period of the completion of the cure, and the final dis- charge of the patient. The following table contains the results of a computation of the average periods of the healing and non-healing of stumps in various parts of the thigh and leg, and by different methods. Although the deductions are necessarily imperfect and want that scientific accuracy that is desirable, still, considering the large number of cases, they are worthy of record. 96 AVERAGE PERIODS OF HEALING. AVERAGE PERIODS OP HEALING AND NON-HEALING OF AMPUTATION WOUNDS OP THIGH AND LEG. Thigh. Leo. Region and Method. Healed. Not healed. Healed. Not healed. So. 1 4 6 11 15 9 12 9 22 9 Av. No. months. No. 3 1 6 2 11 4 14 5 4 1 Av. No. months. No. 14 25 9 11 15 9 6 9 7 14 19 3 22 18 2 Av. No. months. No. 9 5 5 2 5 1 3 7 4 6 Av. No. months. Upper third. Antero-posterior flaps . . . Upper and middle third. Antero-posterior flaps . . . Posterior flap...... Middle third. Antero-posterior flaps . . . Posterior flap...... Middle and lower third. Antero-posterior flaps . . . Posterior flap...... Lower third. Antero-posterior flaps . . . Posterior flap...... 7 11 n H »A 9 H 9 H 8 10 8 "A H H m 13 "A 10$ "A 10 H n 10| 10^ isA 10§ 13 10 10 10§ 12f 10f In regard to retracted flaps, so frequently noticed, Surgeon Hodgen makes some practical observations. He states that he " has observed a great number of cases of sursenn retracted flaps, following almost every variety of amputa- Iloduen on. i-ii i • -i-., treatment of tion, and given the subject some study. Most ot them hav- flaps. ing been transported in ambulances, army wagons, rail- road cars, and steamboats, were so often disturbed that there was little chance for a speedy union, and every possible facility offered for retraction of the soft parts, and the protrusion of bones. Amputa- tions are performed during ansesthesia. The muscular tissue, which forms a larger part than any other element of the covering of the bones after amputation, is completely relaxed, and the dressing is ADAPTATION OF COMPENSATIVE APPLIANCES. 97 performed before the anaasthetic influence passes off; and when it does pass off, the muscles, resuming their original tonicity and irri- tability, contract, thus retracting the flaps, and either forcing the bone between the flaps or so firmly against them that ulceration rapidly follows, and the bone protrudes. Another cause is the manner of dressing stum-ps ; thus, strips of adhesive plaster are heated and applied, one end on one surface of the limb, and the flap is drawn by this strip, which is carried firmly over the end of the stump, and the remaining end fixed tightly to the highest pos- sible point upon the opposite surface of the limb, and so on, one after another, until a sufficient number of strips is applied to hold the lips of the wound together. It is apparent to any thinking man that these freshly cut surfaces are pressed tightly against the bone, and this is favorable to ulceration. Perhaps, the most fre- quent cause of protruding bones is careless handling in applying dressings after the first dressing. The surgeon observes a limb requires dressing, for the bandages are saturated with pus. The bandages are removed, and perhaps also the adhesive strips, without having the parts properly supported by a competent assistant, so that newly formed attachments are broken up and the flaps fall asunder, allowing the bones to protrude." He recommends a method of treatment which he has followed with success, namely, extension of the retracting flaps by adhesive strips with a weight. His rule is — when flaps are to unite by granulation, apply extension ; when the bones protrude, apply extension ; and when the cicatrix is tense and firm and slow to heal, apply extension. Never saw off protruding bones in these cases. XI. ADAPTATION OF COMPENSATIVE APPLIANCES. In the adaptation of an artificial limb to the stump we have the final results of amputation in the lower extremity. Sec- Artificial ond only in importance to the life of the individual is the value of the stump for compensative appliances. The great aim of the surgeon now is, when the first question is answered and the safety of the patient is duly considered, at what point and by what method shall amputation be performed to secure a stump most favorable to the application of the best form of artificial limb. ^ We have no longer the rich and poor man's stump ; these artificial aids are now brought within the means of every man ; the poorest soldier and sailor, through the wise munificence of government, 7 AMPUTATIONS AT THE ANKLE JOINT IN MILITARY SURGERY. BY STEPHEN SMITH, M. D. AMPUTATIONS AT THE ANKLE JOINT. Amputation at the ankle joint seems to have been a compara- tively infrequent operation during the late war. In a Frequency total of 9,705 amputations, but 67 ankle-joint amputa- tion.eopera tions have as yet been fully ascertained at the Surgeon-General's office. The record is, however, stated to be far from complete. Whatever may prove to be the total number of these operations, we are satisfied that ankle-joint amputations, by any of the recog- nized methods, were not regarded with favor by the surgeons of either the Federal or insurgent armies, at the close of the war. On a very extensive personal inquiry of army surgeons of large experience, there was found to be great unanimity of opinion in the total rejection of these operations from military surgery. At the commencement of the "war, amputation at the ankle joint was considered a legitimate procedure in civil practice, its estimate In some one of the several methods of operation it was practice. almost universally regarded not only as free from danger as any amputation in that vicinity, but as yielding admirable results as respects the future usefulness of the limb. So much importance was attached to this amputation at that time that one of the oldest and most experienced army surgeons, C. S. Tripler, instructed the surgeons of the division of the army of which he was then medical director (the Army of the Potomac),to amputate at the ankle joint by Pirogoff's method in preference to amputation through the leg, when practicable.1 The objections of army surgeons to ankle-joint amputations are various. In the experience of some, sloughing of the flap is the chief source of mischief; others allege that exten- objections to n ^n ' th'sopera- sive suppuration, or necrosis, generally follow, necessi- tion. tating reamputation ; while a few did not regard the stump as the most serviceable, and rejected it without trial. Considering the importance which civil surgeons generally attach to these opera- tions, both on account of their comparative safety and the value of the stump for future usefulness, it becomes a matter of considerable I Consult Tripler's order. 102 COMPARATIVE SUCCESS. importance to determine on what grounds the unfavorable opinion of army surgeons is based, and what should be the status of ankle- joint amputations in military surgery. It must be observed, in limine, that amputation at the ankle joint is always an alternative operation. It is selected in preference to An opera- an amputation at a point higher up in the limb. It should pediency* also be added that it is an operation of expediency. It is not a dernier ressort. If it fails of success the surgeon may still, with rare exceptions, perform the alternative amputation through the leg with the prospect of as favorable results as when the latter is the first operation. In determining the value of ankle-joint amputations, therefore, the following questions naturally arise for our consideration : — I. The comparative success of this amputation. (a.) As regards mortality. (5.) As regards the necessity of reamputation. (c.) As regards the comparative frequency of sloughing, ne- crosis, etc. II. The comparative serviceableness of the resulting stump. (#.) As regards the ability for unaided locomotion. (5.) As regards the adaptation of the stump for an artificial limb. I. COMPARATIVE SUCCESS OF ANKLE-JOINT AMPUTATIONS. (a.) Comparative Mortality. — From the Surgeon-General's Re- comparative Portl we learn that in a total of 67 amputations at the aSjoint ankle Joint> 9 proved fatal, and 58 recovered. This state- amputation. ment giveg a mortaiity m t^s operation of 13.43 per cent. From the same source it appears that in 2,348 amputa- tions of the leg, 611 proved fatal, and 1,737 recovered, being a mortality of 26.02 per cent. Again, the total amputations of the lower extremities, including the toes, partial amputations of the foot, etc., were 5,058, as reported to the Surgeon-General, and of this number 34.55 per cent, proved fatal. The results of amputation in the British army durino- the Crimean war do not differ materially from those given above. Amputation at the ankle joint proved fatal in about 18 per cent, of the cases operated upon, while amputations of the leg gave a mor- tality of 36 per cent.2 i Circular No. 6, Surgeon-General's office. 2 Medical and Surgical History of the British Army, etc. FREQUENCY OF REAMPUTATION. 103 The surgical records of the insurgent armies furnish some col- lateral evidence. A consolidated table of amputations from June 1, 1862, to February 1, 1864, is published,1 from which it appears that ankle-joint amputations were fatal in 20 per cent., and ampu- tations of the leg were fatal in 27 per cent, of the cases operated upon. From these statistics it appears that amputation at the ankle joint is 50 per cent, less fatal than the alternative amputation through the leg. Compared with the mortality after the total am- putations of the lower extremity, including the most trivial, it is but a little more than one third as fatal. If we were to decide the merits of this operation, then, by its comparative fatality, or by the dangers to life which it involves, we should give it the prefer- ence, unhesitatingly, over all other forms of amputation of the leg. But the absolute value of an amputation cannot be decided alone by its mortality. We have to consider, also, — (5.) The Comparative Frequency of Reamputation after Ampu- tations at the Ankle Joint. — It is difficult to determine comparative with any considerable degree of accuracy the frequency retmputa-0' of reamputation in any given class of cases. We are able, tl0n- however, to arrive at approximative results, which indicate very clearly how in general the question is to be decided. In 31 cases of ankle-joint amputation, 4 required reamputation, or about 12.9 per cent.; in 65 amputations of the lower third of the leg, reampu- tation was required 6 times, or in about 9.2 per cent, of the cases. It is evident from these facts that reamputation after ankle-joint amputations was more frequent than after amputations in the leg. In examining as to the causes which led to reamputation we find that in ankle-joint amputations it was performed once on account of retraction of the flaps, and three times on account of sloughing and necrosis. In amputations in the lower third of the leg ream- putation was practiced five times on account of sloughing and necrosis ; one case cause unknown. (c.) Comparative Frequency of Sloughing and Necrosis.—Slough- ing of the flap after Syme's amputation, and necrosis of Frequency the adapted portion of the calcaneum after Pirogoff's am- and10necro°s putation, are alleged to be the chief sources of failure S18, after ankle-joint amputations. The following collection of cases gives a total of 23 ankle-joint amputations by Syme's method, and 1 A Manual of Military Surgery, etc., by J. Julian Chisholm, M. D., third edition, Colum- bia, S. C, 1864. 104 SERVICEABLENESS OF STUMP. 10 by Pirogoff 's method. Of the 23 cases of Syme's amputation, 4 are reported to have been followed by sloughing of the flaps, and 3 by necrosis. In other words, 7 in 23 cases were followed by sloughing and necrosis, or 30.4 per cent. Of the 10 cases of Piro- goff's amputation, 2 are reported to have been followed by necrosis, in one case the os calcis necrosed, and in one the posterior part of the lower extremity of the tibia was involved. It is noticeable that in two cases of sloughing after Syme's operation the stumps healed and ultimately became serviceable. It cannot be alleged, however, that the comparative difference between these two operations is sufficient to decide the question as to the point of election. If ankle-joint amputations present any very considerable advantages in other respects over leg amputa- tions, no prudent surgeon would regard this slightly greater liability to sloughing and necrosis as a sufficient reason why he should be deterred from selecting the former. Before determining the question, we must consider the compar- ative value of the stumps resulting from these different opera- tions : — II. COMPARATIVE SERVICEABLENESS OF THE RESULTING STUMP. (a.) As regards Locomotion. — Ankle-joint amputations differ Serviceable- from amputations in the leg in this essential particular, stump. namely: in the former the support is taken directly upon the extremity of the stump, and in the latter upon the sides of the limb. In model stumps of each class it will be found that the one which takes direct support upon the extremity is not only capable of enduring a much larger degree of service, but the per- son suffers far less inconvenience. Direct pressure upon the heel flap may be endured as long in Syme's stump as similar pressure upon the natural heel. And the same is true of stumps following Pirogoff's method. Patients with these stumps have frequently been known to walk successive days twenty and thirty miles with only the simple covering or protection of the heel of a common shoe or boot. Mr. Syme stated in a clinical lecture that " Patients who had suffered the operation, were able to stand, walk, and even run, without any covering or protection of the stump ; and a gen- tleman present, having had his attention accidentally directed, a few days before, to some boys who were amusing themselves on a slide in the street, discovered that one of them had undergone am- putation at the ankle joint." Professor Van Buren, of New York, AMPUTATION FOR ARTIFICIAL LIMB. 105 recently met at his clinic the third person on whom Mr. Syme performed this operation, sixteen years before, who stated that he had walked thirty miles in a day without inconvenience from his stump. These are by no means exceptional cases. Surgeons who have been accustomed to meet with the results of this operation most frequently, uniformly testify to the ease with which patients betake themselves to the stump with only such covering as they can rudely adjust. Of the stumps left by Syme's and Pirogoff's operation, the latter has the greater length, and thus requires less compensation. Amputations through the leg, at whatever point, and however skillfully performed, never furnish stumps which take Amputation direct support. The limb is useless for locomotion by notefive°di- any simple means of compensation ; it is only when an rectsuPP°rt- artificial limb is accurately and skillfully adjusted that it serves the purpose of even simple progression. Again, in amputation at the ankle joint the patient retains power over the muscles of the calf which are essential to the act patienthaa of running. It is extremely rare that a patient who has mu^e'Tof suffered amputation of the leg can make even the pretense jomtlmput" of running upon his artificial limb. The muscles, espe- tatIons- cially of the calf, have shrunken from disuse, and progressive, per- manent atrophy of the parts below the knee ensues. In ankle- joint amputations, however, the tendons of all the muscles employed in locomotion retain their former, or acquire new attachments, and are immediately and constantly exercised in the movements of the limb. It is true this movement of the muscles is more limited than in the normal limb, but it is nevertheless sufficiently great to preserve much of their activity, and consequently their nutrition is but partially impaired. The importance of preserving the functions of the muscles of the leg is seen in the perfection of gait which persons with ankle-joint amputations soon acquire. They can not only run, often with great ease and facility, but they acquire the power of leaping, dancing, etc., to such perfection that their disability frequently passes unrecognized. (5.) As regards the Adaptation of the Stump for an Artificial Limb. — As previously stated, the stump after ankle-joint Adapt!ltion amputation takes direct support upon the extremity. Mr. anarutSdIir Quain thus speaks of the advantages of direct support, llmb- in referring to Syme's amputation: "It is free from any valid objection, and, what is more important, the result in practice has been found to be good. A person who has undergone this opera- 106 CONCLUSIONS. tion is enabled to bear his whole weight upon the end of the stump without inconvenience ; and on this account the facility of progres- sion is, with a proper apparatus, decidedly greater than when the amputation is performed at any higher part of the limb." The advantages of the ankle-joint stump over those of the leg Advantages for the adaptation of an artificial limb, are admitted by ankie.mpa the most competent mechanical surgeons to be of the most undoubted character. In Syme's amputation the patient walks upon the end of the stump with ease and grace, can run, leap, and dance, and is capable of enduring fatigue little short of that of the sound limb. We speak now of successful cases. No results at all comparable with this are attainable with any form of stump above the ankle. This review of the comparative merits of ankle-joint and leg amputations as exhibited by statistical evidence authorizes the following conclusions: — 1. Ankle-ioint amputations are fifty per cent, less fatal Conclusions. . than leg amputations. 2. Ankle-joint amputations are three per cent, more liable to be followed by reamputation than leg amputations. 3. The stumps left after ankle-joint amputations are far more serviceable than those resulting from leg amputation for unassisted locomotion. 4. An artificial limb can be far more usefully applied to an ankle-joint than to a leg stump. It may be stated in general terms that the experience of the Experience late war nas established the fact that ankle-joint amputa- oi late war. tjons are jess fataj tnan jeg ampUtations, but that slough- ing and necrosis are more likely to occur in the former than in the latter; that the resulting stump in ankle-joint amputations is much more favorable for unaided or aided progression than in leg ampu- tations. The correct inference from these conclusions is that ankle-joint amputations should be recognized as occupving an important place among the legitimate operations of military sur- gery. It remains to consider the causes of failure in ankle-joint ampu- causesof tations as illustrated in this collection of cases, the reme- feilure- dial measures adapted to prevent or mitigate such causes, and, finally, the comparative value of the methods of operation proposed by Syme and Pirogoff. CAUSES OF FAILURE. 107 CAUSES OF FAILURE IN ANKLE-JOINT AMPUTATIONS. The striking difference in the success of ankle-joint amputations in civil practice from that in military practice, depends upon causes not difficult to determine and appreciate. Surgeon David P. Smith, United States Vols., who has had a large experience, and is a warm advocate of the operation, says:— " When done in our army for gunshot wound, the results have not, by any means, been uniformly successful. It appears, however, Surgeon ,,/.., ,;. , . . , ., , , David p. that the failures can hardly with justice be attributed to the Smith on form of operation. From much conversation with army sur- failure. geons upon this topic, and from no inconsiderable personal experience, it is believed, first, that the operations have been generally too long delayed, and at last done when, from the undermining of tissues by the burrowing of pus, there could be no reasonable hope of success; and, secondly, that the manual performance was faulty in the ex- treme." He illustrates the failure of the operation from the first cause by his own experience: — " The four cases of ankle-joint amputation occurring at Fairfax Sem- inary General Hospital, were performed upon wounded removed at a late date from the disastrous field of the second Bull Run battle, where they had undergone much privation and hardship. The tissues were undermined with pus. Had I not witnessed Mr. Syme's own practice, and heard him detail his experience of constant success under the most adverse circumstances, I should have preferred amputation in the con- tinuity of the leg in these cases, so great was the suppuration about the ankle above the point of section. Mr. Syme's procedure was strictly followed in all four cases. " One recovered, and left the hospital with a good firm stump. " One, apparently the most suitable of all for this operative procedure, succumbed to pyaemia. In this case no section of bone was made, even the malleoli being suffered to remain. " Two, on account of sloughing of flap and protrusion of bone, were obliged to submit to amputation of the leg." The various causes of failure of this operation may be considered under the following heads: — I. Sloughing of the Flaps. — In the early history of ankle- joint amputations, especially by the method of Syme, Si0UgMng0, sloughing of the flaps was a frequent accident. Many ****• surgeons were led to discard the operation altogether after repeated failures from this complication. Experience proves, however, that 108 SLOUGHING OF FLAPS. sloughing cannot be regarded as a necessary or even a frequent result of this operation. It occurred but four times in twenty- three cases as we have already shown. There are apparently two principal causes of sloughing of the flaps, namely: (a.) Contusion of the soft parts entering into the flaps ; (J.) Destruction of the nutritious arteries of the flap in the operation. (a.) Contusion of the Soft Parts. — It not unfrequently happens contusion of that in the accident that caused the injury for which soft parts, amputationis performed, there is a much larger destruc- tion of the soft parts than at first appears. Especially is this true of railroad injuries, gunshot wounds, etc. The sudden and ter- rible violence of the impinging body not only destroys the vitality of the part which it encounters by direct contact, but the same destructive effects are manifested in contiguous tissues after several days over a surface often surprisingly extensive. And this decep- tion is rendered the more complete by the apparent accuracy with which we may at first limit the destroyed parts. The line of demarcation seems well defined by the discoloration which borders the upper limit of the lesion of tissues. But within a day or two the fallacy of this observation becomes unpleasantly apparent. Parts that at first were believed to be uninjured become cold, the purple discoloration of incipient gangrene extends, and the slough that forms proves that the skin and subjacent tissues were devital- ized by the shock far beyond the bounds that had been set. Hence, it not unfrequently happens that the surgeon called to Liability to perform an immediate amputation after railroad and gun- in?uredate in snot injuries, of the severe class, is deceived as to the parts- extent of the actual destruction of the vitality of the soft parts, and, in his anxiety to save as much of the limb as possible, makes the whole or considerable portions of the flaps of tissues which are already destroyed and must slough. This result is often seen in civil practice after severe railroad injuries, and the same is true of military practice, especially where the injury has been in- flicted by a missile of large size, as a cannon-ball, grape-shot, etc. In no part of the lower extremity are we as liable to meet with Heei most this accident as at the heel. The crushing of the foot bv exposed to , . # ° J injury. railroad cars, or by missiles used in war, not unfre- quently impairs the vitality of the soft parts about the heel and ankle to such a degree, that when they are subjected to the neces- sary bruising of an amputation, sloughing to a given extent en- sues. ILLUSTRATIVE CASE. 109 It is evidently no fault of the operation that in such a case sloughing of the flap occurs. Sloughing doubtless to the same extent would follow any form of amputation which involved tissues similarly injured. The error is in the judgment of the surgeon ; amputation should have been originally performed where it was subsequently. But this error is not always reprehensible, for the most experienced and judicious surgeon cannot foresee always the extent of the injury. Where there is a rational doubt, the facts embodied in this paper will, we think, authorize the operator to decide in favor of ankle-joint amputation, as in general preferable to leg amputation, and holding the latter in reserve. There is a practical point, illustrated by this collection of cases, bearing upon the question of amputation when the soft parts about the heel have suffered severe contusion and laceration, which deserves the most serious consideration. If the tissues of the heel have been destroyed, the surgeon should not at once pOBSibiutyof decide that this precludes amputation at the ankle joint, saYing flaps- as might be inferred from the preceding remarks. Important as are the tissues of the heel for the covering of the stump where it is to take direct pressure, it is nevertheless true that the tissues of the sides of the ankle and the dorsum of the foot will soon become sufficiently dense to bear readily the weight of the body. If therefore the operator is convinced that on general prin- ciples an ankle-joint amputation is preferable to a leg amputation, he should consider well before he rejects the former, if it is not possible to secure sufficient flap tissue around the ankle. The following case illustrates this point: — Case I. Wound of the Ankle by the Fragment of a Shell; Extensive Destruction of the Soft Parts ; Amputation by Lateral Flaps ; Slough- ing; Final Cicatrization and a Useful Stump. — C. D. was wounded June 24, 1864, by the fragment of a shell, which struck the Extensive sole of the foot just anterior to the heel, lacerating the soft ofeoftparte; parts extensively, and injuring the tarsal and metatarsal lateral flaps- bones. He was removed to the Mower U. S. General Hospital, where amputation was performed on the third day by Acting Assistant-Sur- geon W. P. Moon. Owing to the laceration of the soft parts, a com- plete posterior flap could not be made from the heel. Flaps were, therefore, dissected from the sides of the ankle and foot, and particu- larly from the sole on the external part. For a few days the case progressed favorably; sloughing then oc- curred to a small extent, and finally a small fragment of bone sepa- rated; abscesses also formed, one being of considerable size. The 110 LATERAL FLAPS. wound at length completely cicatrized, and the stump assumed a good shape, though it was somewhat tender. Case II. Wound of the Ankle Joint by a Spiral Case-shot; Destruc- tion of the Heel; Formation of Lateral Flaps; Recovery with a Useful Limb. — A. L. T., private, 20th Regiment Massachusetts Vols., was wounded at Fredericksburg, Va., May 2, 1863, by a spiral aps" case-shot which passed through the ankle joint, destroying the articulation and the soft parts about the heel. Amputation was performed about four hours after the receipt of the injury. Notwith- standing the destruction of the heel, it was decided to amputate at the ankle joint, and make the flaps from such uninjured tissues in the neighborhood as could be brought to cover the stump. A sufficient amount of-tissue was accordingly dissected from the lateral parts of the ankle to cover the stump, and disarticulation was performed. With the exception of several abscesses which formed from time to time, the wound progressed favorably, and at the end of three months cicatriza- tion was complete, and he could bear his weight upon the stump. The only unpleasant sensation experienced was a prickling. At the end of five months an artificial limb was applied by Hudson, of New York, which enabled him to walk " with ease and comfort." Case III. Extensive Laceration of the Tissues of Foot and Heel by Fragment of a Shell; Amputation at Ankle Joint with Lateral Flaps ; Recovery with a Useful Limb. — H. H. C, private, 100th Regiment New York Vols., was wounded at Drury's Bluff, Va., in May, Lateral flaps ,„_.■,,-, n . 1864, by the fragment of a shell striking the left foot. "The soft parts of the foot and heel were so extensively lacerated as to pre- clude the formation of a flap from the heel, if amputation were per- formed at the ankle joint. It was, therefore, determined to amputate at the ankle joint, with flaps formed from the sides of the ankle. The operation was performed by Surgeon Kettinger, United States Army, and flaps were made from the lateral aspects of the ankle. The case progressed favorably, although the patient suffered at the same time an amputation of the other foot by Chopart's method. The cica- trix became firm and healthy, and the patient could bear his weight upon it with comparative ease. An artificial limb was subsequently applied by Hudson, of New York, with the most satisfactory results. Equally good results may be obtained by taking the principal flap from the dorsum of the foot, as is seen in the following case: — Case IV. Amputation of the Ankle Joint for an Old Railroad In- jury; Principal Flap taken from the Dorsum of the Foot on Account of Ulceration of the Tissues of the Heel; Sloughing of the Extremity of the Flap ; Final Cicatrization of Wound; Useful Stump. — This case was FLAP FROM DORSUM OF FOOT. HI treated in Bellevue Hospital, and the history is taken from its records: " B. T. K.----Regiment New York Vols., was admitted to nap from Bellevue Hospital in March, 1864. About two years before, fo°otum his left foot was caught under a rail-car wheel and severely crushed. He had on the foot a very stout boot, with an unusually thick and firm sole, which saved it from being entirely destroyed. The wheel traversed the foot from the heel to the toes, passing diagonally along the dorsum from the external malleolus to the great toe, fracturing the tarsal, met- atarsal, and phalangeal bones in its course. An attempt was made to save the foot. Suppuration was established throughout the foot, with sloughing of the contused integument. Fragments of bone were removed, involving the tarsal and metatarsal bones, but the wound both on the dorsum and palmar surfaces finally completely cicatrized, and he was discharged. " On entering Bellevue Hospital, about two years from the time of the injury, the foot was so completely crippled that he was unable to walk except with crutches. It was so twisted upon itself by the cicatrix on the sole as to assume the position of a talipes varus. An ulcer existed upon the heel, and the tissues of this region were for the most part cicatricial. The cicatrix upon the dorsum was not very firm or adher- ent, except over the metacarpal bone of the great toe. " Amputation at the ankle joint by any of the ordinary methods was impossible; but it was determined to make the flap from the dorsum, and take the risk of sloughing in the line of the cicatrix. The opera- tion was performed by Dr. Stephen Smith. A sufficient flap was readily secured, which, turned backward, effectually covered the whole surface of the stump. As was feared, the extremity of the flap where the cicatrix was most dense, sloughed off, but the remainder rapidly united. The stump was moulded by adhesive strips, and assumed a very fine appearance. The patient left the hospital able to walk with comparative ease." The following case illustrates still more strikingly the value of an ankle-joint amputation : — Case V. Bony Anchylosis of Tarsal and Ankle Joints ; Extreme Thick- ening and Degeneration of Soft Parts ; Sloughing of a Portion of Anterior Flap ; Successful Moulding of the Stump by Adhesive Strips ; Recovery with a Well-formed and Useful Stump. — The following history Moulding of is taken from the records of Bellevue Hospital, where the case 3K,by was treated: Patrick Connelly, corporal, 70th Regiment New strips. York Vols., was wounded at Bristow's Station, Va., August 29th, 1862, by a minie-ball. The point of entrance was the posterior part of the left heel, and it was removed from beneath the integument on the dor- sal face of the tarsus, having completely traversed the tarsal bones. The limb was at first condemned to immediate amputation, but subse- 112 MOULDING BY ADHESIVE STRIPS. quently efforts were made to save it. Suppuration soon became estab- lished throughout the tarsus, the foot, and ankle ; sinuses formed in various directions, and portions of bones from time to time escaped from the various sinuses. At the end of a year the inflammation had so far subsided that he was able to walk about on crutches. He obtained his discharge from the army, and returned to his business of a mechanic. He was able at length to bear considerable weight upon the foot, but he was finally obliged to seek more permanent relief. On entering the hospital his foot was a large, shapeless mass, the swelling and puriform appearance extending from above the ankle to the toes. On the posterior part of the heel was the depressed cicatrix of entrance, and upon the centre of the tarsal region in front was the open extremity of a sinus which corresponded with the point of exit. There was no apparent motion at the ankle or tarsal joints. A probe passed into the sinus came in contact with uncovered bone. His gen- eral health was good. A consultation decided in favor of amputation of the leg. The question of amputation at the ankle joint was discussed, but the soft parts were so thickened and unhealthy, that it was believed that an operation which involved such tissues would necessarily prove a failure. Subsequently Dr. Stephen Smith amputated at the ankle joint. On incising the soft parts, they were found of the consistence and appear- ance of fat pork, and so thick and dense that it was impossible to turn the flaps back for the purposes of dissection. The ankle joint being fixed by bony anchylosis, it was sawn through. So thick and unyield- ing were the flaps, that it was found impossible to unite them, and they were left unadjusted. On the following day a slough began to form around the old sinus, which finally involved two square inches of surface. It was very soon noticeable that the infiltrated tissue began to soften and disappear, melt down apparently, and the flaps became more thin and pliable. Adhesive strips, cut very narrow, were now applied very accurately to the flaps, and the stump rapidly took a round and symmetrical form. Owing to the sloughing, a large cicatrix remained drawn somewhat across the face of the stump. This cicatrix was slow in healing, scabs forming of large size. He experienced con- siderable inconvenience for a time from this unhealed junction of flaps, but at length the cicatrix was perfectly formed, and he walked with ease with the heel of a boot for his support. Dr. E. D. Hudson, of New York, applied an artificial limb to the stump, which eventually served him perfectly. He continued under observation for several months, as gate keeper at the hospital, and always expressed himself as able to do his duties with little or no incon- venience from the stump. DESTRUCTION OF ARTERY. —NECROSIS. 113 (5.) Destruction of the Nutritious Artery of the Flap during the Operation. — Mr. Syme remarks upon this cause of Destruction failure: " That the flap may and probably will still ^^^ occasionally slough, is unhappily too true; but that this °Peration- result is always owing to an error in the mode of performance, I think does not admit of any question. For as the integument, being detached from its subjacent connections, can derive nourish- ment only from the anastomosing vessels, it is evident that if scored crossways, instead of being separated by cutting parallel to the surface, the flap must lose its vitality." In his early practice of Syme's operation, Mr. Ferguson, of London, committed the error above alluded to, and so frequently did he meet with sloughing of the flaps that he rejected the operation altogether. Subsequently, however, he became one of its strongest advocates, stating: " In so far as I can judge, it is one of the greatest improvements in modern surgery as regards the subject of amputations." That there is great danger of wounding the posterior tibial artery in making the principal dissection from above downward, and from before backwards, is a demonstrable fact, and there is no doubt that it is one source of failure of this operation. While we are not able to determine how frequently this accident happens, we know that among army surgeons the erroneous method of operation alluded to by Mr. Syme was occasionally practiced. We feel authorized, therefore, to attribute to this cause a certain percentage of the failures of ankle-joint amputations from slough- ing of the flaps. II. Necrosis. — It cannot be seriously alleged against Syme's amputation that the small amount of necrosis which occa- Necrosis in sionally results to the extremity of the tibia or fibula is a putation. valid objection to its performance. It is stated to have occurred four times in twenty-three cases, and in three of these the necrosis does not seem to have interfered with the final success of the case ; one was still under observation. It is extremely rare that the necrosis is of any considerable extent, or so complicates the recovery as to necessitate reamputation. The opponents of Pirogoff's amputation urge the dangers of necrosis with great pertinacity, although experience de- Necrosisafter cidedly disproves the correctness of their logic. Theo- amputation. retically the argument is strong and almost conclusive against the operation. It is essentially a resection of bones with an attempt to obtain union by placing the fragments in simple contact. It 8 114 EXPERIENCE OF SURGEONS. cannot be denied that the section of the calcaneum does occasion- ally undergo necrosis, and finally separates from the flap, but it must now be considered a rare accident, and dependent rather upon the imprudence of the operator in his effort to excise the bone, than upon any intrinsic fault of the method itself. Pirogoff remarks: — " Notwithstanding the suppuration and considerable gravitation of pus Piro off r mto tne ^aP m the third case; notwithstanding the softness marks. an(j fatty degeneration of the os calcis, which could be cut with the knife, in the second case; and lastly, notwithstanding the bleeding fungous excrescences which formed on the bones, also in the second case ; still the remains of the os calcis united firmly with the tibia and fibula. Lastly, one of the cases, the third, proves that the exarticulation at the ankle joint after my method — at least in children and young people — may be undertaken even in cases of diseased ankle joint, provided disorganization has not extended too far over the soft parts about the articulation. In the boy in the second case, I found pus in the capsule during the operation, the cartilages softened and decayed, the ends of the bones also softened and in a state of fatty degeneration, yet the result was most successful." Mr. Busk, of London, says : — " Some have feared that the section left of the calcaneum would not Mr Busk's readily unite with the extremity of the tibia; but this fear is remarks. groundless. In the last operation performed by Mr. Tudor, union was found to be quite firm on the twelfth day.....In my first case the man could support his whole weight on the stump within a fortnight." Mr. Croft, of the Dreadnought hospital ship, London, gives the experience of the surgeons of that ship in six cases, as follows : — " Six times the operation has been performed, and in four instances Mr Croft's w^tn most perfect success; but in the two remaining death experience, removed the subjects of operation before cure was completed — in the first instance by granular disease of the kidneys, and in the second instance by secondary deposits of pus in various joints. In two of the six cases in which cure was completed, the operation was per- formed for the removal of scrofulous disease of the articulation between the tarsal bones, and in the two others the operation was for frost-bite of the anterior part of the foot. Progress towards health was marked by suppuration along the tendons of the tibialis anticus and posticus, and the peroneal tendons in each of the cases, but not by exfoliation of bone. The posterior part of the os calcis was united firmly with the DR. HEWSON'S COMMENTS. 115 tibia, generally in about three weeks ; but in one instance — the last in which the operation was performed — union was good at the end of twelve days." He thus expresses his confidence in the union of the bones under the most unfavorable conditions: — " Although the os calcis may be diseased at and about its articulation in instances of scrofulous disease of the joints of the tarsus, it is rarely that the posterior part is rendered too unhealthy to be made use of in the formation of a stump." Hewson, of Philadelphia,1 has operated five times, and makes the following comments, bearing upon the question of necrosis of the os calcis : — " In all a cure followed rapidly. In two especially, the result was least to be expected. These were the adults, one of whom Dr Hewson,8 was a seaman advanced in years, and who had been leading comments. an exceedingly intemperate life ; and the other a soldier, who had been wounded in a battle after long and tedious marching in pursuit of the enemy, and who was operated on four weeks after receiving his wound, in a military hospital where gangrene was prevailing to a very great extent at the time. How much the firm and speedy union of the bones in all these cases was the result of the expedient resorted to, namely, the strip of adhesive plaster and the weight, to prevent the contraction of the muscles attached to the tendo Achillis, is a question which we are not prepared to answer. The possibility of such a union not taking place, has been the only theoretical objection apparently of any impor- tance advanced against the operation. But how far such an objection has been realized in the experience of others we have not been able to ascertain. Our own experience certainly points to its being of little, if any, value. For surely there could not be found two more unpromising cases for any operation than those of the adults here reported, and it is against the operation in adults especially that this objection would seem to have greatest force. The very perfect character of the union which took place between the bones in Bowers' case, as is to be seen in the specimen which we had the good fortune to obtain after his death, fur- nishes as strong a refutation as a single instance could of this theoret- ical objection." Of the ten cases of amputation at the ankle joint by Pirogoffs method, reported in the following tables, but one was attended with necrosis of sufficient amount to necessitate reamputation. i The American Journal of Medical Sciences, July, 1864. 116 ILLUSTRATIVE CASES. The patient was a Confederate soldier, and the case is reported by James M. Holloway, M. D., Professor of Anatomy, Louisville, Ky.i Case VI. Pirogqff's Amputation at the Ankle Joint; Necrosis of the Section of the Os Calcis and of the Tibia ; Reamputation of Leg. — Reamputa- A. B., soldier, was wounded at Chattanooga, Tenn., in 1863. crosis0inne" Amputation at the ankle joint by Pirogoffs method was per- mutation, formed a few days after the injury. The reporter first saw the case in January, 1864. The flaps had united, but a number of sinuses communicated with the coaptated surfaces of the os calcis and tibia, at the bottom of which denuded bone could be felt upon the introduction of the probe. In addition to these, other sinuses situated on the lateral aspects of the lower third of the leg, communicated with the sheaths of the tendons. These latter, so far as could be learned from the patient, appeared subsequently to those leading to the carious bones. The integuments overlying and adjacent to the diseased bone and inflamed sheaths of tendons, presented a remarkably healthy appear- ance ; so much so that the true condition of the stump did not transpire until a more thorough examination was made, while the patient was under the influence of chloroform. Such was the complete disintegra- tion of the os calcis and the end of the tibia that amputation of the leg was found to be necessary. The following cases illustrate most forcibly the fact that the segment of the os calcis will become united to the tibia under the most unfavorable circumstances: — Case VII. Wound of the Ankle Joint; Pirogqff's Amputation; Feeble Condition of Patient; Attack of Erysipelas ; Symptoms of Pyaemia ; Convalescence ; Recovery with a Useful Limb? — Lieutenant W. C. W., Thebonewui Co. I, 5th Michigan Cav., was wounded April 1st, 1865, at the unite under ° r ' ' most un- battle of 1 lve Forks, by a conoidal musket-ball, which passed conditions, through his left ankle joint. He was immediately carried to the hospital at City Point, and amputation at the ankle was performed on the same day by Surgeon St. Clair, 5th Michigan Cavalry; the artic- ulating surfaces of the tibia and calcaneum were removed, and the cut surfaces were brought into apposition. On April 16th, 1865, the patient was transferred to Armory Square Hospital, at Washington. On admission he was in a feeble condition. An erysipelatous blush extended above the knee on the injured side, an abscess had formed in the lower part of the leg, and no union of the flap had taken place. With the employment of stimulants and nutritious diet, with emollient applica- l Am. Journal Medical Sciences, January, 1866. 2 Circular No. 6, Surgeon-General's office. GOOD RECOVERY IN UNFAVORABLE CASE. 117 tions to the limb, there was a gradual improvement, until April 28th, 1865, when symptoms of pyaemic infection supervened. Rapidly recur- ring chills, an icteroid coloration of the skin and conjunctiva, anorexia, and a frequent feeble pulse, suggested the gravest prognosis. Ener- getic treatment was adopted. An ounce of brandy was given every two hours, and quinia, sesquichloride of iron, and beef tea were freely administered. On May 6th, the grave symptoms began to subside, and, by the end of the month, the patient was fairly convalescent. On June 26th, he was pronounced well. The os calcis had firmly united to the tibia, and there was a good solid stump. Case VIII. Amputation at the Ankle Joint by Pirogoffs Method on the Battle-field at Malvern Hill; Patient taken Prisoner, and conveyed i?i an Army Wagon to Richmond ; neglected and exposed to Great Hard- ships for Several Days ; exchanged, and conveyed to City Point without Care or Support in extremely Hot Weather ; transported to Fortress Monroe before Proper Dressings were applied ; Perfect Union of Hard and Soft Parts without the Slightest Necrosis or Sloughing ; Useful Limb. — H. B., private, 5th New York Art., was wounded by a shell at the a second un- battle of Malvern Hill, July 1,1862. The injury was inflicted ?™ termi- principally in the metatarsal and tarsal regions, producing a n^m*e™r* compound comminuted fracture of the bones of the foot, with ery- the exception of the astragalus and calcaneum. Chloroform was admin- istered, and amputation by Pirogoffs method performed. He was imme- diately after taken prisoner, and placed in an army wagon and conveyed to Richmond. The weather was extremely hot, and he had no means of supporting or protecting the stump. He remained at Richmond several days, during which he was crowded together with other prisoners, with- out care, his limb remaining undressed. He was finally exchanged and conveyed to City Point, a distance of twenty-six miles, most of the dis- tance on the railroad, the remainder in an ambulance, but the entire distance he was compelled to take his chances with the crowd. From City Point he was conveyed to Fortress Monroe, where he had the first proper dressings applied. No sloughing or necrosis occurred ; the bone united promptly, and the flaps adhered as if union had taken place by first intention. He came under observation at Central Park Hospital several months after, when the stump was in the most perfect condition. It had the appearance of having healed by first intention, throughout. He bore his weight upon it, walked easily with a cane, but complained of slight tenderness. An artificial limb was applied by Hudson, of New York, and he was discharged in a condition to be able to follow almost any ordinary employment. The two following cases were reported by Adinell Hewson, M. D., surgeon to the Pennsylvania Hospital:* — l Am. Jour. Med. Sci., July, 1864. 118 HEWSON'S CASES. Case IX. Foot crushed by the Recoil of a Gun-carriage ; Attempt to save the Foot; Great Distortion of Foot; Amputation at the Ankle Joint by Pirogoff's Method; Prompt Union of Bone ; Recovery with a Useful Limb. — Tom Bowers, a tall, thin, but well-formed seaman, aged Hewson's * forty-eight years, applied for admission to the Pennsylvania case. Hospital, on the 3d of March, 1863, on account of distortion of his right foot, the result of an injury received on board of one of the Mississippi gunboats in the attack on Vicksburg, in the month of June previous. The foot had then been crushed by the recoil of a gun- carriage, and the bones of the metatarsus had evidently — according to the patient's account — been much comminuted, with great contusion of soft parts, but no great amount of laceration of integument. Attempts had, therefore, been made to save the foot. Extensive phlegmonous inflammation ensued, and extended up the leg, which bore the marks of the free incisions which had been made for the escape of the pus. The foot itself was distorted by the conglomeration of the bones, through the callus thrown out for their repair, and by a large mass of cicatricial tissue on the plantar surface, all of which combined to draw the toes down and prevent the patient walking on the sole. It was thus only by a very forced elevation of the forepart of the foot, and throwing the whole weight on the back of the heel, that he could get along on the limb. For this deformity he applied at the hospital, desir- ing to have the leg amputated. It was evident that a partial amputa- tion of the foot was the only remedy for him. The cicatricial mass on the sole would not allow of a Lisfranc tarso-metatarsal disarticulation, or of a Chopart inter-tarsal. It was, therefore, determined to make a Pirogoff amputation.....Some symptoms of delirium tremens manifested themselves on the following day, and these were soon devel- oped into a well-defined attack of that disease. The operation was consequently delayed until the 28th of the month (March), when it was performed.....Owing to the rigidity of all the tissues of the foot, considerable difficulty was experienced in effecting sufficient dislocation at the ankle to saw off the os calcis at the proper angle. Indeed, this was found impossible without injuring the soft parts. The bone had consequently to be broken after it was partly sawn through. No dressing was applied over the wound. The stump was put in a fracture-box, and the weight of a brick, about four and one half pounds, was applied by means of a long and broad strip of adhesive plaster on the back of the leg to overcome all tendency to displacement of the os calcis, by contractions of the muscles attached to the tendo Achillis. The healing took place very slowly. Still the patient was well enough to be discharged on the 25th of May, eleven weeks after the operation. The os calcis was noted to be firm to the tibia on the twenty-sixth day. Case X. Wound of the Ankle Joint; Suppuration in the Joint; SENSITIVENESS OF STUMP. 119 Amputation by Pirogqff's Method on the Twenty-eighth Day; Subsequent Necrosis of Fibula ; Rapid Union of Os Calcis and Tibia ; Recovery with a Useful Limb. — O. C, aged twenty, private, 7th "Wisconsin Regiment, was wounded on the first day of the battle of Gettysburg (July 1,1863)> by a bullet in the right foot. From the battle-field he was sent to the United States Military Hospital, Philadelphia, where he arrived on the 6th. The wound did not appear at first to be a serious one, and our attention was not called to it until some time after his admission, when the foot and ankle had become very much swollen and inflamed. On probing the wound it was found that the ball had passed through the astragalus, and must have consequently implicated the ankle joint. It was, therefore, determined to amputate the foot, and, as the tissues of the heel ap- peared sound, it was decided to attempt a Pirogoff, which was done on the 28th of the month (July). On opening the joint it was ascertained that the malleoli had both become considerably denuded by the suppu- ration which had been going on in the joint, so that it became necessary to remove the ends of both the tibia and fibula an inch above the joint. The denudation of the bones led us to form a rather unfavorable prog- nosis for the operation. The inflamed condition of the tissues, espe- cially of those composing the anterior flap, caused delay in the process of union, which took place, however, throughout by granulations, and the portion of os calcis was found to be firmly adherent to the tibia on the twenty-eighth day after the operation. When the cicatrization of a greater part of the flaps had been accomplished, it was discovered that two suppurating points, one quite on the front of the leg, and the other behind the line of the fibula, communicated by sinuses with a large piece of necrosed bone evidently belonging to the fibula, and which had pushed the os calcis somewhat to the inside before it had become firm to the tibia. These sinuses were dilated by sponge tent, and this portion of bone detached without even disturbing in the least the union between the tibia and os calcis. The patient is now just beginning to throw his weight on the stump, which has been entirely healed for about a month. He ran with ease on the end of the stump before the members of the college at the meeting at which this communication was made." III. Sensitiveness of Stump. — But it is frequently alleged that the stump after ankle joint amputations is very SensitiTenesg liable to be tender, and will not tolerate direct pressure. of stump- In this case we not only lose all the advantages claimed for direct support, but from the shape of the stump it is difficult to obtain sufficient lateral support of the limb to render the artificial appliance useful. This objection cannot, however, be founded on a very large experience. In the thirty-one cases in the accom- panying tables, tenderness of the stump of a degree sufficient to interfere with the application of an artificial limb is not once men- 120 TESTIMONY OF SURGEONS. tioned. Hewson, of Philadelphia, speaking of the ease with which patients walk who have PirogofFs stump, says: — " No such results as these have ever been obtained from the Syme Hewson's operation — for not more than one half of the cases which experience. naye appije(j to Mr# paimer for artificial limbs have been able to bear any pressure whatever on the end of the stump, and that a long time after they were entirely healed. The only case of a Syme ampu- tation of which we have had the opportunity of seeing the results was unable to bear his weight on it a year after it was made." This statement is in direct opposition to the experience of sur- geons of large experience. Fergusson, of London, who has re- peatedly operated by this method, says : — Fergusson's " In so far as I can judge, it is one of the greatest improve. opmion. ments in modern surgery as regards the subject of amputa- tion." Quain, of London, says it is — " Free from any valid objection, and what is more important, the Quain's result in practice has been found to be good. A person who opinion. nag un(jerg0ne this operation is enabled to bear his whole weight upon the end of the stump without inconvenience; and, on this account, the facility of progression is, with a proper apparatus, decidedly greater than when the amputation is performed at any higher part of the limb." Erichsen, of London, confirms the above estimate of Syme's am- putation. He says it — " Constitutes one of the greatest improvements of recent date in Erichsen's operative surgery, as by its performance amputation of the opinion. jeg may 0ften De avoided, and the patient being left with an exceedingly useful stump, the covering of which being ingeniously taken from the heel, constitutes an excellent basis of support." But the strongest and most important testimony as to the entire opinion of serviceableness of Syme's stump is given by Hudson, of ofNewVork. New York, who states that in fifty cases to which he has applied artificial limbs he has not met with a single instance where the stump did not, after proper preparatory treatment, take the direct pressure without inconvenience, and invariably give a most happy result. This treatment consisted in removing scabs from the cicatrix, healing superficial indolent ulcers, etc. We need only add that in a large collection of cases from civil practice DISPLACEMENT OF HEEL FLAP. 121 but one Syme's stump was found sensitive. It is very important that the surgeon should examine the cicatrix occasionally Bad effects after the cure seems to be complete, to insure a firm cicatrix.011 closure of the wound. If a small space is left over which scabs form, these incrustations become so thick before the patient re- moves them that they take the whole pressure when the stump is placed upon the floor, and the violence is expended upon the small ulcerated surface on which they rest. I have frequently seen stumps which have been pronounced tender, found capable of sustaining the weight of the body, and enduring great fatigue when these incrustations were removed. It is the duty of the surgeon not only to remove these constantly recurring scabs, but to heal by appropriate treatment the chronic, indolent ulcer from which they spring. Surgeons have mistaken the early sensitiveness of the wound for a permanent disability. A certain degree of tenderness SenSitiVeness must necessarily exist for a time as the result of so con- p^anlnt0' siderable a wound, but as cicatrization progresses the sen- disablllty- sitiveness generally gradually subsides, and ultimately ceases to give the patient any trouble IV. Tendency to Displacement of the Heel Flap back- ward by the Action of the Muscles of the Calf. — Dispiace- A final cause of failure is alleged to be due to the action ™™ ^^T1 of the muscles of the calf, which so act upon the heel, or ward' posterior flap, as to bring the cicatrix upon the most dependent part of the stump, and expose it to injury in walking. The ob- jection is based upon clinical experience, and this result has led to reamputation in some cases. We have reason to believe, however, that this posterior displace- ment of the flap is due to circumstances entirely within within the the control of the surgeon. The remedy is found in the the surgeon. after treatment. Displacement will never take place to an extent sufficient to interfere with complete usefulness of the stump, either in Syme's or Pirogoff's stump, when the posterior flap is well sup- ported and proper traction is made upon the calf. Surgeons too frequently leave the flap entirely unsupported, so that even its weight displaces it. The natural tonicity of the muscles of the calf under such circumstances leads to their abnormal contraction, and hence to the permanent displacement of the flap. The fol- lowing case illustrates this displacement from want of support: — 122 VALUE OF DRESSING. Case XL Amputation at Ankle Joint by Syme's Method; no Support Case where given to the Posterior Flap ; Great Displacement backward. — support48"0 I. M., 46th Georgia Vols., was wounded March 25,1865, by a rifle-ball which passed through the ankle joint. Amputation by Syme's method was performed twenty-four hours after the injury. When examined forty days after the operation the wound was healed, but two or three sinuses discharging gave indications of the presence of dead bone. The stump was placed on a pillow, with the extremity projecting over it, without the slightest support to the flaps. The large posterior flap hung pendulous from the end of the stump, its own weight being sufficient to displace it completely from the face of the tibia. No effort had been made to adjust and retain it with adhesive strips." This case had been pronounced a failure by those who had it in charge, and reamputation was recommended with great unanimity. But no one who has witnessed the benefits of the proper application of adhesive strips in moulding a stump can doubt that the displace- ment was entirely due to the lack of proper dressings. In Cases IV. and V., the flaps were of the most unpromising character, value of being large, thick, and infiltrated, but they were moulded to dressing. ^e stump with great ease, and formed a conical extremity of great perfection. In no form of amputation do we regard the kind of dressings and their method of application of so great importance as in amputation at the ankle joint. From the very first there should be proper support given to the posterior flap, and the best form of support is by means of narrow adhesive strips. In the later stages of the treatment, this dressing is of great value in giving proper shape to the stump. When early and thoroughly applied, the strips fix the posterior flap upon the extremity of the limb, and retain it there so firmly that the flexor tendons form attachments to its anterior part, and effectually counteract the contractions of the muscles of the calf. In a well-formed Syme's stump the patient has power to move the heel flap anteriorly as well as posteriorly, showing that the flexors of the foot have become attached to it. In regard to the displacement of the flap in Pirogoffs stump, it Displace- ls ^^ more evident that the fault is in the after treat- in^'rogoff1? ment. That serious results follow its displacement is stumps. proved by those cases in which reamputation was the only remedy by which the defect was overcome. But it is evident that in these cases little effort could have been made to counteract the contraction of the muscles of the calf, during the period of ossific union of the extremity of the os calcis and the tibia, for when that union was once complete, all farther tendency to dis- ADAPTATION TO TRANSPORTATION. 123 placement ceases. This fact is proved by Hewson's cases, IX., X., in which this contraction was immediately counteracted by proper dressings, and the bones united symmetrically, giving a very useful stump. We must attribute, therefore, the failure to secure a good apposi- tion of the heel flap in either Syme's or Pirogoffs am- Failure due putation at the ankle to the neglect of proper after treat- treatment. ment. V. Not adapted to Transportation. — It is very generally alleged against ankle-joint amputations, that owing to Not adapted the large size of the posterior flap and its imperfect nour- utk>nnspor" ishment, the stump will not endure transportation. We have not a sufficient amount of accurate and reliable information on this subject to determine how far this objection is worthy of serious consideration. The accompanying collection of cases contains several instances of patients who had undergone ankle-joint ampu- tations, and were subsequently subjected to transportation long distances without inconvenience. Case IX. proves that Pirogoffs stump, the most liable to be seriously affected by transportation of the two, may not only be transported, but even subjected to much rough handling, without interrupting the process of ossific union. This must undoubtedly be considered an exceptional, per- haps an extraordinary case, but still it must be accepted as proving that the character of the operation does not preclude transporta- tion, even under the most unfavorable circumstances. Without sufficient facts to decide this question as to the power of ankle-joint stumps to endure transportation, we would Necessity of suggest that much must depend upon the manner in ings"* which dressings are applied. If they are carefully adapted so as to thoroughly support the parts, we doubt if the inconvenience will be greater than in an ordinary flap stump. We may in this place notice a so-called modification of Syme's amputation, performed by Surgeon David Prince, United States Vols., who reports the following case : — Corporal W. P. Everett, Co. H., 9th Alabama Vols., received a musket-shot on the inner side of the tarsus, in the battle of prince's Williamsburg, May 5, 1862. There was no counter opening, modiflcati<>n- and it seemed probable that the ball had lodged among the tarsal bones. No ball, however, was found, from which it follows that it must have come out at the same opening at which it went in, or that the injury had been occasioned by some other substance. The operation was commenced by making an exploratory incision in 124 COMPARISON OF SYME'S AND PIROGOFF'S METHODS. the course of the tendon of the tibialis anticus, discovering numerous fragments which were successively removed, when it was found that all the bones of the tarsus were fractured; and on this account it was re- solved to amputate the metatarsus, and exsect the tarsus. A transverse incision was made over the scaphoid and cuboid bones. The separation of the bones was prosecuted by Liston's large cutting forceps, and the soft parts on the plantar surfaces cut in the manner of a flap. The exsection of the tarsus was prosecuted with Fergusson's large gouging forceps, removing the whole of the astragalus and nearly the whole of the calcaneum. As the fragments of bone were pulled away from their attachments, a considerable amount of periosteum and some shells of bone were left for the formation of new bone. The mal- leoli were cut off by the bites of the forceps, so as to present a tolerably smooth surface to receive subsequently the plantar integument. No other opening was made in the integument than that in front. The parts were kept somewhat in position by a roller bandage, without sutures or any close approximation. The wound must heal and contract by granulation. The theory of this operation is to preserve the circulation in the plantar integument, without cutting off its supply by dividing the tissues, as is necessary in the manner of cutting the lateral ligaments of the ankle joints. These ligaments are left in connection with the surround- ing parts, unless accidentally pulled away by the traction upon the bones to which they are attached. The bones should not be cut away from their attachments, but pulled away, in order to leave as much as possi- ble of the periosteum. The patient went from under my observation, and I have not since heard from him. AN APPRECIATION OF THE COMPARATIVE VALUE OF THE METHODS OF AMPUTATION AT THE ANKLE JOINT BY SYME AND PIROGOFF. Although an important feature of Syme's original operation was comparative the formation of the principal flap from tte heel, we shall, syme's and in this comparison, include as Syme's amputations all methods. cases in wThich the os calcis was completely removed with the other tarsal bones. Pirogoffs method is distinguished by an excision of the posterior portion of the os calcis, and the union of the retained fragment with the tibia. A comparison of these two methods involve for the most part a consideration of the same points as in the comparison of leg and ankle-joint amputa- tions. 1. Comparative Mortality. — It is difficult to determine with any comparative degree of certainty the mortality from these operations. mortality. « 0 3 S-a c 3 p.»£