CASE 485.—Private E. Green, Co. K, 119th Pennsylvania, aged 35 years, was wounded in the right thigh, at Rappahannock Station, November 7, 1863, and was admitted to Armory Square Hospital, Washington, two days afterwards. Surgeon D. W. Bliss, U. S. V., furnished the following description of the injury, and of the operation which he performed: "The missile, a conical ball, entered one and a half inches above and to the right of the patella, passing across the limb, fracturing the femur in the lower third, and lodging on the inner and posterior side, nearly opposite the point of entrance. The limb was treated in a skeleton fracture-box, and water dressings were used. On November 18th, the ball was extracted. Hæmorrhage occurred on the following day, and again three days afterwards. The discharge of pus became copious about December 1st, and dry gangrene of the toes and dorsum of foot appeared. The upper fragment of the femur protruded one and a half inches, and at every effort to extend the limb so as to retract the protruding bone violent hæmorrhage ensued. The patient's system was greatly reduced, and careful attention was paid to retain his digestive powers by a rotation of stimulants and nourishing diet. A slight change in the position of the limb, on December 28th, brought on a hæmorrhage to the amount of twenty ounces in three minutes time evidently from the femoral artery, which was then controlled by pressure. By January 20, 1864, sloughing of the heel and dorsum of foot had commenced, and the patient's system was still so much debilitated that a decision to operate, which had been retarded as calculated to prove fatal, was now arrived at as a last chance to preserve life. On the following day the thigh was amputated at the middle third by antero-posterior flaps, four arteries being tied and but little blood lost. Ether was used as the anæsthetic. At the operation an abscess was discovered in the anterior flap extending upward for three inches, and the femoral artery was found to be destroyed in the upper part of the popliteal space, evidently by the missile. Above the point of the amputation the vessel was healthy; but no clot was found. The vessels of the leg were much constricted. The lower fragment of the femur was flexed at an angle of thirty degrees with the leg, and, by contraction of the muscles of the thigh, was pressed firmly against the wounded extremity of the femoral artery, thereby preventing fatal hæmorrhage. The flaps of the stump presented an unhealthy appearance, being much indurated and infiltrated with serum. Tincture of chloride of iron was applied to the entire surface with a view of stimulating the parts and of obtaining its hæmostatic effect upon the capillary vessels which failed to contract from cold and exposure to the air. A large tent was placed through the fourchette of the stump so as to prevent the accumulation of pus, the flaps being gently brought together and tepid water dressing applied. The patient improved daily, and was in a fair way of recovery one week after the operation." The amputated portion of the femur was contributed to the Museum by the operator, and is shown in the wood-cut (FIG. 202). The specimen shows the parts about the fracture to be dead and stripped, and its upper half to be covered with an involucrum of foliaceous callus tolerably dense posteriorly, also some periosteal deposit above the condyles. The patient subsequently entered Judiciary Square Hospital, and was discharged July 7, 1864. He was furnished with an artificial leg by B. F. Palmer, August 26, 1865, and was paid as a pensioner until September 4, 1867, since when he has not been heard from.

FIG. 202.—Shot comminution of the lower third of right femur. Spec. 2033.