CASE 690.—Lieutenant C. G. Martyn, Co. A, 2d New York Heavy Artillery, aged 29 years, was wounded at Deep Bottom, August 14, 1864, and entered Armory Square Hospital, Washington, three days afterwards. Assistant Surgeon C. A. Leale, U. S. V., contributed the pathological specimen (FIG. 267), and the following history of the case: He was wounded by a minié ball, which entered the right leg between the tibialis anticus and extensor longus digitorum muscles, opposite the centre of the middle third of the tibia, passed through the leg transversely, fracturing the tibia and fibula, and made its exit at the anterior lateral aspect of the soleus muscle. Immediately after the reception of the injury the patient was removed to a field hospital, and on the following day he was placed under the influence of chloroform, when several spiculæ of bone were removed. Splints were then applied, and he was transferred to Washington, where the wound was dressed and the limb placed in a fracture-box. The general condition of the patient at that time was good. On account of great pain the fracture-box was removed on October 7th, and Smith's anterior splint was adjusted, which allowed the patient to rest more comfortably. On November 1st the splints were removed, and the limb was laid on a pillow and dressed twice a day with simple dressings. The wound had now nearly closed, but several sinuses existed and communicated with the bone, and the fracture had not yet united. By March 16, 1865, the patient was able to leave his bed and walk on crutches. He first came under my charge on April 1st, when, on an examination with the probe, I found the sinuses to communicate with dead bone; the discharge of pus was about three ounces per diem; appetite and general condition good. The discharge continuing to increase and the patient gradually growing weaker, he was placed under the influence of ether on April 25th, and an incision was made nine inches in length over the anterior portion of the tibia, when it was found that necrosis extended to within two inches of the ankle joint and nearly to the head of the tibia. A sequestrum nine and a half inches long was then removed, also several small pieces, and in the operation a longitudinal piece of newly formed bone had to be withdrawn. After the removal of the necrosed portion, new bone was found of sufficient thickness to hold the foot in its proper position. The loss of blood during the operation amounted to about ten ounces. The wound was dressed with charpie and cold water, and the patient took stimulants and an anodyne every four hours. On the next day he was very weak and had continued nausea, no appetite, and vomited all food as soon as swallowed, not being able to retain brandy even, which increased the nausea. Two ounces of beef tea was then given every four hours, but it also was nearly all thrown off. On April 27th, he was still weaker and the nausea continued, when two ounces of champagne with ice was administered every four hours, and four ounces of beef tea, per enema, was given three times a day. This was continued for two days, when the patient had a well-marked chill and was sinking fast, his nausea having increased to such an extent that the sight of other patient's food caused him to vomit. On April 30th, he was worse in every respect, when doses of five grains of oxalate of cerium was ordered to be given whenever the patient felt as though he would immediately vomit. By 9 o'clock P. M. he had used six powders, not having vomited once since taking the first, and having retained food eaten at noon. The champagne and beef tea were continued. By May 6th great improvement was noticed, and, there being no nausea or vomiting, the powders were discontinued. The wound was now granulating finely, and the discharge consisted of perfectly healthy pus. About June 25th, the patient could leave his bed and sit in a chair, the cavity having nearly filled and the wound being healthy and reduced to about half the size of the incision. He had perfect use of the ankle joint and the tibialis anticus muscle, and there was all probability of a very useful limb. By July 15th, he could bear considerable weight on the injured leg. The patient was subsequently transferred to Douglas Hospital, where he was discharged from service by special order of the War Department, October 13, 1865. In his publication¹ of the case Dr. Leale mentioned Surgeon D. W. Bliss, U. S. V., as the operator, and added that he saw the patient again just before he left Douglas Hospital, at which time the limb was in a healthy condition and the wound had nearly closed, leaving three small openings, which were prevented from closing by the great tension on the newly formed integuments. There was also slight contraction of the tendo-achillis, which could be easily overcome, although every possible care had been taken to guard against that result. The patient's name was subsequently admitted on the Pension Rolls, and afterwards he obtained employment in the New York City Custom House. Dr. G. K. Smith, of Brooklyn, May 11, 1874, certified that the patient, after receiving his discharge from service, entered Bellevue Hospital, New York City, where "Professor J. K. Wood performed an operation on his leg, cutting the tendo-achillis, and, I think, he also removed a large portion of the fractured bone. The wound healed in 1866, but soon broke open again, and continued to discharge until the month of June, 1873, when it finally healed. After leaving Bellevue Hospital he came under my care, and though his health was feeble, he performed his duties at the Custom House, with occasional loss of time, until the wound healed, in June, 1873. From that date his health failed rapidly. His liver began to increase in size, the heart became irregular in its action, respiration difficult and circulation very feeble. At length dropsy set in, and he died December 1, 1873. An external examination showed the liver to be nearly twice its normal size, and I have no doubt that death was caused by a waxy degeneration of the liver, the result of the shot fracture."

¹ LEALE (C. A.), Extensive Necrosis of the Shaft of the Tibia following Gunshot Fracture of the Bone, in United States Sanitary Commission Memoirs, Surgical Volume I, New York, 1870, p. 492.

FIG. 267.—A sequestrum, 9½ ins. long, from the right tibia. Spec. 1489.