CASE 471.—Captain W. E. Davis, Co. B, 30th North Carolina, aged 25 years, was wounded in the skirmish at Kelly's Ford, Virginia, November 7, 1863. He was conveyed to the hospital of the Third Corps, and, November 10th, was transferred to Washington and admitted into Douglas Hospital. Acting Assistant Surgeon Carlos Carvallo reported that the ball entered the anterior external aspect of the right leg about two and a half inches below the inferior edge of the patella, one and a half inches external to the median line of the leg, and one and a quarter inches below the head of the fibula, where it fractured the bone, and descending downward, inward, and backward, emerged in the posterior internal aspect of the leg, midway between the inferior edge of the patella and the internal malleolus, internal to the bulk of the gastrocnemius muscle. The right foot was cold, of a purple hue, and entirely senseless; the leg, from knee to upper portion of lower third, was swollen and emphysematous, and the middle third was of a yellow and dark green, intermixed with a brown-purple hue. Diagnosis: Gangrene of the foot and leg from gunshot wound of leg, with, most probably, injury and obliteration of the main arteries. Amputation was the sole treatment indicated, the foot and lower portion of the leg being completely mortified. Assistant Surgeon W. Thomson amputated the thigh at the lower third by the circular method. The femoral was secured by digital compression and the tourniquet. Very little arterial blood was lost. A grain of morphia was administered in a half ounce of whiskey immediately after the operation, he having readily revived from the ether narcosis, and he stated that he had slept undisturbed during the operation, without dreaming, and was now entirely free of pain. The cut surface of the stump showed the tissues infiltrated and of an unhealthy appearance. Stimulants were administered. The stump was dressed with dry charpie. At night the pulse was 130, tongue moist, skin dry. The stump was boggy and crepitant to pressure, and a dark discoloration was visible on the external aspect extending to the tensor fascia lata. November 12th, towards evening a line of demarcation was visible of a large slough in external side of skin flap, no discharge from stump; tension of the skin caused by three sutures, which were removed, followed by gaping of the flap. About 9 P. M., the pulse became frequent (145), and there was great paleness of the conjunctiva and skin. The extensive sloughing, weak pulse, and anæmic appearance presented a hopeless prognosis. Late in the evening, a strong solution of bromine was directly applied to the surface of the stump by means of charpie. The application was at first painless, but, after penetrating the mortified tissues and coming in contact with sensitive parts, it caused such pain that the patient was fortified during the operation by a half ounce of sherry wine in powdered ice and one-half grain morphia. 13th, Dr. Holly touched the line of demarcation (which was very well marked, and extended to the whole circumference of the stump) with pure bromine, by means of a flattened stick, in order to facilitate and hasten the efforts of nature. He also applied Dr. Thomson's solution of bromine (composed of one drachm of pure bromine, three drachms of bromide of potassium, and three ounces of water), by means of a glass pipette to all the sinuses beneath the mortified integuments and the sinuses near the arteries; besides this application, after carefully washing the stump with "blue wash" (solution of permanganate of potassa), and protecting the integuments outside with castor oil and the surface of the stump with a thin muslin rag, the vapor of bromine was administered by pouring an ounce of solution of bromine on charpie; this was applied to the face of the stump and covered with simple cerate spread on sheet lint and inclosed by oil-cloth and a bandage. The application of bromine was repeated at 1 and 7 P. M., and the nourishing food and stimulants continued. An injection of soap and water caused the first passage since the date of the injury and gave great relief. 14th, the effects of the bromine yesterday had hermetically sealed the surface of the stump, covering it with a yellowish gray matter, which was removed as much as possible, a large amount of mortified integuments being cut away and three loose ligatures removed. Decubitus of gluteal region, somewhat to right of sacral bone; bedsore the size of the palm of the hand, with a yellow greenish slough, which was partly removed with the assistance of a scissors. India-rubber rings employed, and ointment of cinchona bark. Bromine was freely applied four times during the day. There was an abundant discharge of thin unhealthy pus, and the removal of a great quantity of slough discovered a red granulating surface. 15th, wound dressed with bromine at 9 A. M. and 4 P. M. Doing very well; slough removed in large pieces. 17th, large quantity of sphacelated integuments removed and vapor of bromine applied. The stump was exposed for an hour to a painter's view. 18th, the decubitus is becoming the most painful and prominent feature of his complaint. For the first time he had a free passage without adjuvants; slept on his belly. On the 19th, he was put on a water bed, on which he lay much easier. An extensive slough was removed from the inferior portion of the flap, as also from the decubitus, which discharges healthy pus in large quantity; could see an artery pulsating. Bromine applied to bedsore. Patient felt bright, and eat a hearty dinner. In the evening, he complained of a little pain in his throat resembling tonsilitis​. 20th, on examining the patient's throat, it was found that he could only open his jaws enough to show the tip of his tongue. Tetanus diagnosticated. Nutritious diet and stimulants were given as usual. At 4 P. M., a laxative was administered. The decubitus was dressed with pulverized cinchona. The stump, which had a beautiful red granulating surface, with one single ligature, was dressed at night with castor oil. He had had contractions and jerking of the stump once in the morning, but had not paid any attention to it until 6 P. M., at which time it became more frequent, recurring nearly every half hour; three ounces of brandy and a half grain of morphia were ordered at 10 and 12 P. M. and 2 and 4 A. M. 21st, trismus well confirmed. Contractions of glottis muscles and fits of suffocation after taking fluids, though administered in small quantities and through a pipette. There was rigidity of the masseters and sterno-cleido-mastoid​ muscles, and of the muscles of the back of the neck, which were quite hard. The head inclined backward and to the left side; diificulty of articulation. The difficulty of swallowing increased and only fluid nourishment could be taken. He gradually sank, and died November 22, 1863, of asthenia. A post-mortem examination of the stump was made November 24th. There was a natural clot of blood at the distal end of the femoral artery. The neurilemma of the sciatic nerve appeared thickened, and the fibres of the nerve more gross and coarse than usual. The ends of several nerves were strongly attached to the external surface of the stump. The body and spine were not opened. A drawing, by Hospital Steward E. Stauch, of the gangrenous stump, is copied in the chromo-lithograph​, PLATE XXI, opposite.

PLATE XXI. GANGRENE OF A THIGH STUMP. Case of Captain W. E. Davis, 30th North Carolina