Rapp, D.a machine readable transcriptionSusan C. LawrenceKenneth M. PriceKenneth J. Winkle2011med.d2e2770Civil War WashingtonUniversity of Nebraska–LincolnCenter for Digital Research in the
Humanities319 Love LibraryUniversity of Nebraska–LincolnLincoln, NE 68588-4100cdrh@unlnotes.unl.edu2011
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Kenneth WinkleAJ HowellMatthew BosleyElizabeth LorangStacey BerryElisabeth TraceySarah SynovecThe Medical and Surgical History of the War of the Rebellion.
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2188344-46Medical and Surgical History of the War of the Rebellionwounds and injuries of the lower extremitiesflesh wounds of the lower extremitiescomplications of shot flesh wounds of the lower extremitieshæmorrhageligations of blood-vessels of the lower limbs after flesh woundsligation of the femoral arterybullet entered posterior aspect of thigh, below gluteal foldbullet divided both femoral artery and veinhæmorrhage at injury, immediate want of sensibility in leg and footgunshot wound of left thighfree communication between divided artery and vein permitted arterial blood to return by
vein, evinced by pulsation backward toward heartaneurismaneurysm developed at divided proximal vesselstraumatic aneurismaneurysmgeneral anesthesia, etherpost-mortem examination performedblessedadded figure encodingadditional proofing of transcription and encodingcase text extracted and transformed from larger fileEnrich Encoding, Edit and validateValidated FileSarah Synovec initial checking of OCR text; encoded P5
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CASE 98.—Private D. Rapp,
Co. K, 7th Indiana, aged 20 years, was wounded at
Robinson's Creek, November 30, 1863. He was admitted to the field hospital of the 1st division, First
Corps, where Surgeon G. W. Metcalf, 76th New York, noted: "Gunshot wound of left
thigh." On December 6th, the wounded man was
transferred to Douglas Hospital, Washington. Three days afterwards he was operated on by Assistant Surgeon W. Thomson, U. S. A., who furnished the following detailed report of the case: "He was
a well developed and very muscular man and had been apparently in good health. At the moment of
injury he was retreating, and was struck by a bullet on the posterior aspect of the left thigh a
short distance below the gluteal fold, which passed through the limb to the inside of the bone,
divided both femoral artery and vein, and made its exit three and a half inches below Poupart's
ligament, at the point of election in ligating the femoral in Scarpa's space. There was profuse
hæmorrhage at the time of injury, and an immediate want of sensibility in the leg and foot.
When examined on the 7th of December, the whole limb was found warm and the collateral
circulation had been established; but there was no pulsation in either of the tibial arteries.
At the superior margin of the wound of exit there was a small tense swelling, which pulsated
synchronously with the systole of the heart. An aneurismalaneurysmal thrill, resembling the loud purring of a cat, was distinctly felt, extending along the
course of the vessels into the pelvis, but not communicating laterally. The little finger was
introduced into the wound at the time of the operation, and the pulsation and thrill were found
to be closely localized and confined to the divided ends of the femoral vessels. There was no
extensive effusion of blood into the tissues of the thigh, and hence this was not in the strict
surgical sense of the word a traumatic aneurismaneurysm. It was concluded that the sac was composed only of the sheath, which had been united
by inflammation after the division and retraction of its vessels, and had then been some what
distended after the heart had regained its force. It was also suggested by Surgeon Lidell, who kindly saw the case with me, that there was a free
communication between the divided artery and vein in this sac which permitted the arterial blood
to return freely by the vein, as evinced by the pulsation communicating with such force backward
toward the heart in the line of the vessels. It was unmistakable that there existed a wound of
the femoral artery sufficient to cause its obliteration, that an aneurismaneurysm was being developed at the divided proximal extremity, and that the proper surgical
procedure would be to secure the ends of the vessel at the point of the injury. It was
determined to emulate the example of Mr. Syme, to lay open boldly the sac by a free incision and
search for and secure the bleeding orifices. It was hoped that the profunda had escaped injury
and every precaution was to be used to secure the femoral below its origin. A small
hæmorrhage on December 9th rendered
immediate interference necessary, and the following operation was then done with the assistance
of Surgeon Lidell and the medical officers of the hospital.
After the patient had been fully etherized and the femoral artery thoroughly compressed on the
pubes by the thumb of a reliable assistant, as evinced by the loss of pulsation in the tumor, an
incision four inches in length was made through the skin and fasciæ, immediately over the
tumor and including the gunshot wound, in a line parallel with the sartorius. A second incision
was now made into the tumor, which was dilated instantly by the finger to the size of the first.
Distal hæmorrhage was anticipated, and it caused but little surprise when a most profuse
dark colored torrent poured out from the incision. The lower angle of the incision was rapidly
searched in vain for the source of the hæmorrhage, and it was feared that it might come
from the dark softened depth of the track of the ball. No pressure on the artery had the least
controlling effect upon it. The removal of the sponge was followed instantly by a boiling dark
torrent of venous blood, which so quickly filled the cavity as to prevent any examination. So
profuse and uncontrollable was the flow that visions of ligating the external iliac were vividly
presented to the mind. When the flow was found to arise from the superior angle of the incision
numerous and ineffectual efforts were made to secure the vessel, but the parts were so hardened
by local inflammation that the forceps glided over them as it would over a cartilaginous
surface. This point, from whence the dark blood seemed to flow, was finally compressed by the
point of the left index finger, and by means of the nail of the small finger of the right hand a
vessel was isolated, a ligature passed around it with an aneurismaneurysm needle, and this hæmorrhage, most embarrassing because uncontrolled by pressure,
was finally suppressed. The first ligature was applied at the superior angle of the incision to
the proximal extremity of the divided femoral vein, from which this unexpected and most annoying
artery and vein, hæmorrhage escaped by regurgitation from the saphenasaphenous. The blood found its way into the limb by means of arteries arising from the iliac
above the point compressed, was finding its way back by the saphenasaphenous, enlarged to compensate for the occlusion of the femoral, was poured into the femoral
a short distance above its divided proximal extremity, and then regurgitated through the stump
of the femoral into the superior angle of the incision. The proximal end of the femoral artery,
from which a crimson tide escaped on relieving the pressure slightly, was now easily found, and
this was ligated. The wound was now thoroughly cleansed of all clots of blood. The femoral
artery and vein, denuded of their sheath for a distance of two inches, were clearly seen at the
bottom of the wound, their divided extremities having become adherent to the neighboring tissues
during the inflammatory action of the previous ten days. As a precautionary measure a ligature
was cast around the femoral artery at the lower angle of the wound, and some little difficulty
was experienced in discriminating between the artery and vein, owing to the fact that from ten
days disuse the vein in becoming an impervious cord had become similar in size, color, and
consistency to the artery. A small orifice was observed in the vein near its distal extremity,
and from this occurred a free black flow on moving the limb. This was also included in a
ligature. The wound was now closed by one or two sutures and the patient placed in his bed. A
brief recapitulation may give clearness to the above account. The first vessel tied was,
therefore, the proximal extremity of the femoral vein near the entrance of the saphenasaphenous; the second, the femoral artery a short distance below the origin of the profunda,
both at the superior angle of the incision; the third, the femoral artery at the lower angle of
the incision and two inches from its distal extremity; the fourth, the femoral vein near its
distal extremity at the centre of the incision, and to control a flow from an incision through
its coats, which may have been made accidentally. The profunda had not been seen, and it was
hoped that it would suffice to keep up the circulation. No important arterial channels had been
interfered with by the operation, and a successful issue might be expected. The man was
stimulated, took morphia, and his leg was covered closely in bed with blankets to preserve the
animal warmth. This man had lost blood freely at the time of the injury; he had been subjected
to a very long and fatiguing transport in ambulances and cars before reaching the hospital, and
for seven days his food had not been as good or sufficient as might have been desired for one
about to undergo such an operation. He was pallid and haggard looking, and iron, nutrients, and
stimulants were freely ordered. There was great pain and restlessness during the ensuing night,
and large quantities of morphia were required to procure sleep. December 10th, no interference
with the circulation; leg and foot both warm. The whole limb is swollen, and bloody serum
escapes freely at the point of the injury. December 12th, the restlessness has been the most
marked symptom, caused seemingly by constant and severe but indescribable pain in the limb. The
pulse is 120, the countenance pale and haggard, the tongue dry and coated, and the general
symptoms indicate great nervous prostration. Large quantities of morphia have been found
requisite. The whole limb and foot are much swollen and œdematous. On the evening
unmistakable signs of sphacelus appeared, the foot became cold, and a hue of purple
discoloration was observed as high up as the ankle. The neuralgic pain and restlessness still
continued. On December 13th, all the symptoms were
worse. The discoloration, the dark purple hue of gangrene, extended rapidly upward, particularly
on the inside of the limb. The whole thigh became crepitant, the pulse more rapid and feeble. He
became more and more depressed, and finally died at 12 o'clock at night. These final scenes all
surgeons can imagine. The post-mortem revealed nothing interesting in the
great cavities. The whole thigh and leg were found gangrenous as far as the point of the injury.
The vessels were dissected, spread upon a board, and a most faithful picture was made of them by
the artist under Dr. Brinton's direction. Only the proximal
extremities of the vessels were found in the softened gangrenous mass; but they threw light upon
the history of the case. The artery was divided below the origin of the profunda, which was
uninjured, but not enlarged, as one would expect if the whole force of the circulation had been
directed toward it by the obliteration of the main artery. In ten days the profunda should here
have been as large as the femoral, if all the blood brought to the divided femoral had been
seeking a passage through its calibre. Its undilated condition gives color to the idea that most
of the blood brought to the divided femoral extremity found its way quickly back by the divided
femoral vein; that the pressure was thus relieved, and that the profunda received only its usual
supply of blood. That the limb was nourished by a collateral circulation, arising above the brim
of the pelvis, is clear from the fact that no pressure on the external iliac would restrain the
flow of blood from the saphenasaphenous through the femoral vein. The saphenasaphenous vein is normal, and its relation with the femoral indicates how easily the
regurgitating hæmorrhage was caused, as no valves are there to prevent it. For several
days—from the 9th to the 12th—there were no signs of an interference with the
circulation, but at that time gangrene appeared and spread with great rapidity. This may have
been due to the recent phlebitis of the profunda vein, which is now filled with a pink firm
coagulum. The irritation caused by the operation, or due to the passage of the ball, may have
induced the inflammation of this vein, now so vital to the support of the circulation. This
seems to have been a wound of an artery, resulting in an aneurismaneurysm the sac of which was composed of the re-united sheaths and enlarged probably by some
dissection upward, in which a free passage of blood took place from the artery to the vein. No
question as to the propriety of the operation now exists in my mind, since, as the sequel shows,
no digital compression over the femoral would have sufficed to prevent or control a secondary
hæmorrhage." The two specimens were contributed by the operator, Dr. William Thomson (see FIG. 19). The case is
cited by Dr. Lidell¹.
¹ LIDELL (J. A.). On the Wounds of Blood-Vessels, Traumatic Hæmorrhage,
Traumatic AneurismAneurysm, and Traumatic Gangrene, in Surgical Memoirs of the War of the Rebellion, collected
and published by the United States Sanitary Commission, 1870, Vol. I
(Surgical), p. 143.