CASE 386.—Private J. Friederick, Co. F, 127th New York, aged 19 years, was wounded in the right thigh at Honey Hill, November 30, 1864. Assistant Surgeon J. F. Huber, U. S. V., reported his admission to hospital at Hilton Head, on the day following the injury, with "compound fracture of femur, treated with splints," and his transfer to Washington, May 7, 1865, but gave no account of the progress of the case. The following notes were furnished by Acting Assistant Surgeon G. K. Smith, from Armory Square Hospital, and by Assistant Surgeon W. Webster, U. S. A., in charge of DeCamp Hospital, David's Island, New York. The wound was caused by a round ball, which entered the inner side of the thigh at its middle third, passing obliquely outward and forward, fracturing the femur and lodging. An attempt to stand on the limb after receiving the injury caused the thigh to bend to an obtuse angle at the seat of the fracture. The wounded man was placed on a shelter tent and conveyed to a steamboat, about eight miles distant, no examination of the wound having been made and no local support having been applied to the broken bone. During the night following the injury the ball was removed through an incision on the external aspect of the thigh. Cold-water applications were used, and a partial support was given by an arrangement of blankets around the parts. On arriving at the Hilton Head Hospital a surgical examination was made under chloroform, but with no operative result, the limb being exceedingly tumefied. Smith's anterior suspensory apparatus was then applied, and the topical applications of cold water were continued. This treatment was kept up until January 7th, when side splints, extending below the foot, were substituted, and the limb was maintained in a straight position. This apparatus was continued for nearly two months, and during this stage of the treatment the swelling greatly subsided, and about a half dozen pieces of bone were removed by the attending surgeon at various intervals. The largest of these is represented to have been about three inches long, one-half inch wide, and one-eighth inch thick. An abscess also opened, spontaneously, about two inches below Poupart's ligament. In the latter part of March the side splints gave way to a fracture-box, the cold-water dressings being still persevered in. On May 1st all local supports by means of splints were cast aside, bandages and pillows being sufficient from that period in consequence of the advanced stage of bony consolidation. On May 10th, when the patient was admitted to Armory Square Hospital, the fractured femur had firmly united, with seven inches shortening, a marked deformity by an outward curvature of the thigh, and very limited motion of the knee joint. There was still a slight discharge, and the extremity of the upper fragment lapping by the lower fragment presented itself on the outer aspect of the limb, close to the external condyle, at which point the skin was ulcerated through, exposing the end of the bone. By June 1st the patient's recovery was so far advanced as to enable him to walk about the ward with the aid of crutches. About the last of June, however, he was compelled to resume his bed in consequence of the appearance of an abscess on the outer side of the thigh, which was opened and gave exit to about eight ounces of sanious and offensive pus. Up to this time the purulent discharges from the wound had been moderate in quantity and healthy in character. On July 5th, however, the several openings were attacked by gangrene, which rapidly extended up the thigh and destroyed the skin and superficial and deep fascia nearly the whole length of its external surface. This disease was, at length, arrested by the application of bromine, and by August 15th the wound had become filled with granulations, and cicatrization was progressive. On August 17th the patient was transferred to Douglas Hospital, where a subsequent exploration of the limb resulted in the removal of six small sequestra from the external wound. Simple dressings were now used, and no further operative interference was required in the case until after the arrival of the patient at DeCamp Hospital, where he was transferred on October 23d. At this date he was strong enough to walk from the steamboat landing to his ward on crutches, and his general health was excellent. There were three apertures, two on the external and one on the posterior surface of the thigh, from which pus of a healthy appearance found exit in small quantities. An examination of the wound by means of a probe revealed secondary splinters, but not sufficiently approachable to warrant an attempt at their removal. The amount of new osseous deposit was considerable, but unfortunately the sequestra were found so intimately embedded in it as to cause their removal to be attended with great difficulty and even impossibility, and involving the sacrifice of so much new growth as to endanger the limb. On February 25, 1866, however, the further removal of necrotic pieces was induced by constitutional symptoms, which manifested themselves and indicated local irritation. Portions of the involucrum were removed by the trephine and chisel, where necessary for the purpose, and small masses of dead bone were extracted from each of the orifices. One of the pieces, deeply situated, measured about two inches in length. As a seeming consequence of the operation the unfavorable constitutional symptoms entirely disappeared, and the condition of the patient and his wounds became highly satisfactory." In June following he was supplied with an apparatus for the injured limb by E. D. Hudson, of New York City, and four months later he left for his home, having been discharged from service November 25, 1865, but re-admitted to the hospital one month afterwards. The Examining Board of Augusta, Maine, certified, in May, 1873, and in December, 1876: "The leg is withered and badly deformed, and there are discharging ulcers all the time. He can perform no manual labor of any kind, and is confined to his bed a large part of the time. The leg, from knee to foot, is nothing but skin and bone." The pensioner was paid June 4, 1879. The wood-cut (FIG. 151) represents a photograph of the patient, taken August 15, 1865. (Photo's of Surgical Cases, Vol. 9, p. 16, and Surg. Phot. Series, No. 90.) Card photographs, taken at a subsequent date at the DeCamp Hospital, were contributed by Assistant Surgeon Webster. (Card Photo's, Vol. 2, p. 22, A. M. M.)

FIG. 151.—Shot fracture of middle third of right femur. [From a photograph.]