Civil War Washington

CASE 832.—Private W. Lazier, Co. M, 5th Artillery, aged 25 years, was wounded in the right ankle joint, at Brandy Station, August 1, 1863, by a bullet, which entered close to the anterior edge of the internal malleolus, slightly comminuting it. On the following day he was conveyed to Douglas Hospital at Washington. The missile was supposed to have lodged, there being no external wound of exit and the patient not being aware of it having been removed. On the next day Assistant Surgeon W. Thomson, U. S. A., in charge of the hospital, etherized the patient and explored for the missile, but it could not be found. The comminution was so slight that it was deemed possible to save the foot with the aid of free incisions should they become necessary. A prescription consisting of two drachms of fluid extract of rhubarb, one scruple of quinine, and three ounces of whiskey was ordered, on August 5th, to be given in teaspoonful doses every four hours. Dead bone having been felt with the probe, and the inflammation becoming so extensive and severe as to render operative interference necessary, two large incisions were made at the sides of the internal malleolus on August 8th, by Acting Assistant Surgeon C. Carvallo, and several loose fragments of bone were extracted. On this day the patient also had a chill of ten minutes duration, and one-half drachm of quinine dissolved in four ounces of whiskey was prescribed to be taken in tablespoonful doses. On August 11th the inflammation became erysipelatous, involving the leg below the knee, and there was another chill. The quinine and whiskey mixture was then repeated and tincture of iodine was used to the limb, after which a wash consisting of one-half ounce of muriate of ammonia, ten grains of acetate of morphia, two ounces of sulphuric ether, and one pint of water, was applied over it. On August 13th there was still pain, swelling, and redness, and another chill of fifteen minutes duration took place. Fluctuation was well marked, and incisions were made to give free exit to pus. In addition to the quinine, tablespoonful doses of a mixture of two drachms of muriated tincture of iron, two ounces each of spirit of Mindererus and water, and half an ounce of simple syrup, were administered three times a day. On August 15th, incisions were again required over both malleoli and another on the on the calf of the leg to allow accumulated pus to discharge. The patient's condition was now too much depressed to allow an amputation. Two days later pleurisy developed, which was treated by counter-irritation of turpentine and alcohol fomentations to the breast, and mustard poultices. On August 18th the limb had grown very red, swollen, and painful as high as the knee, and, fluctuation being felt, another incision was made by Dr. Carvallo, after which the leg was placed in a bran-box, and the wash, with one-half drachm of fluid extract of hyosciamus superadded, was re-applied. Hæmorrhage from one of the incisions in the calf of the leg, and supposed to proceed from one of the muscular branches, came on one-half hour afterwards, when cold water, alum, and compression was applied, and Hoffman's anodyne mixed with brandy and water was given every half hour. Hæmorrhages recurred in the afternoon and evening, being decidedly arterial, and were checked by persulphate of iron applied with charpie. Though active interference was demanded, the undoubted disease of the lungs caused by metastatic abscesses from pyæmia, together with the very rapid and difficult respiration and the collapse of the patient from the loss of six or eight ounces of blood, made amputation impossible. The only other resort being ligation of the femoral, ether was carefully administered and that operation was performed at 9 P. M., at the point of election, by Assistant Surgeon Thomson, the leg being so distended with clotted blood as to make any effort to secure the divided vessels abortive. The clots of blood were removed from the leg by compression, and after the operation the case was treated with the largest doses of stimulants, including aromatic spirits of ammonia and fluid extract of senega. Though he reacted from the low state he was in before the operation, the patient gradually sank during the night and died at 8 A. M. on August 19, 1863. At the autopsy both lungs were found to be filled with metastatic abscesses; there was also effusion of serum in both thoracic cavities. No injured artery could be detected, nor could the missile be found. The detailed notes of the case were furnished by the operators. Dr. Thomson also contributed the bones of the injured ankle (Spec. 1682), showing the articular surfaces to be eroded by suppuration and the internal malleolus to be slightly fractured.