Civil War Washington

CASE 851.—Private J. Davis, Co. L, 1st Michigan Cavalry, aged 18 years, was wounded at Salem Church, May 28,1864. Surgeon W. H. Rulison, 9th New York Cavalry, reported his admission to the field hospital of the 1st division, Cavalry Corps, "with shot wound of left foot and hip." Surgeon J. A. Lidell, U. S. V., who operated in the case, made the following report: "The patient was admitted to Stanton Hospital, Washington, June 4th, with a gunshot wound of the left tarsus, inflicted by a minié ball, which struck the foot a little below the external malleolus and passed through the tarsus horizontally inward and somewhat backward, escaping a little below and behind the internal malleolus. It occasioned compound comminuted fracture of the calcaneum​, astragalus​, and posterior edge of the external malleolus. At the time of the operation, June 10th, the ankle and foot were much swollen, inflamed, and very painful; the leg was also swollen. The edges of the orifices of both entrance and exit were pouting and exhibited no tendency to close; discharge thin and scanty. Since the patient came to Stanton Hospital the wound had been treated with ice dressings, but was manifestly growing worse. He now had a good deal of constitutional disturbance; pulse quick and ranging from 110 to 120; skin dry and too warm; countenance pinched and anxious; tongue coated, and appetite poor. He was also restless, got but little sleep, and his general condition was daily getting worse. Wishing to avoid secondary amputation of the leg if possible on account of the great fatality which had lately attended it, resection was performed of the anterior extremity and part of the external side of the calcaneum​. Some fragments of the astragalus​ were also extracted, and a splinter from the posterior edge of the external malleolus. The incisions were made on the external side of the foot, from the orifice of entrance, first, to the base of the metatarsal bone of the little toe; second, to the base of the external malleolus; third, to the point of the heel; and fourth, to the dorsum of the foot, two and a half inches. Sulphuric ether constituted the anæsthetic. There was no shock. Ice-water dressings were continued. On June 11th the patient was cheerful and free from pain and the swelling and irritative fever had abated. He died of pyæmia on June 20, 1864. Autopsy: The ankle joint contained pus; the bones were partially denuded of their cartilage; muscles of leg infiltrated with pus. The left pleural cavity contained a large quantity of dark-colored effusion, and the left lung was compressed against the vertebral column; the inferior lobe contained an abscess about the size of an egg, which was filled with dark-colored and offensive pus. The right lung contained several superficial abscesses and some patches of lobular pneumonia. Thrombi existed in the femoral vein." In his publication¹ of the operation the operator furnished the following supplementary details of the patient's progress, as well as of the autopsy, in addition to his comments on the case: After the operation "the limb was placed upon a wire splint (Smith's) bent to a right angle, which was well padded and applied to the posterior part of the leg and sole of the foot, where it was properly secured by roller bandages for the purpose of keeping the ankle joint in a fixed position. The wound was plugged with lint and a full opiate was given. The constitutional treatment consisted in the administration of nutrients, tonics, and stimulants. On June 12th the patient had a severe pyæmic chill and sweat, and quinine in full doses was added to the treatment. On the next day he was much worse; wound discharging a thin dark-colored pus; chills and sweats increasing in frequency and severity; complexion assumed a bronzed hue; breath bovine; body exhaling a sweet mawkish smell; anorexia; debility; diarrhœa set in. Pneumonic symptoms also appeared, and a large proportion of blood was mingled with the sputa. He sank rapidly. At the autopsy the calcaneum​ was found to be fractured entirely through and its cancellous structure was gangrenous. The astragalo-scaphoid​ articulation contained pus and the articulating surface of its bones was entirely denuded of its cartilage. The connective tissue on the front of the leg was infiltrated with pus from the ankle joint upward to the extent of three inches, and the tibia and fibula were denuded of periosteum to the extent of two inches. The liver and spleen were both enlarged and softened, but the kidneys presented a normal appearance. There were clots in both ventricles of the heart. Comments: In this case also osteomyelitis supervened, which was conclusively shown by the gangrenous condition of the cancellous tissue belonging to the calcaneum​, or, rather, the gangrenous condition of the medullary tissue which filled the cancelli of that bone. Besides, it is probable that if the interior of the tibia and fibula had been examined the marrow would have been found inflamed at and above the place where those bones were seen to be denuded of periosteum at the post-mortem examination. It is also probable that the medullary tissue of the denuded portion of the tibia contained collections of purulent matter which were produced by the suppurative character of the inflammatory process involving that tissue. Furthermore, it is probable that the inflammatory process had extended to the medullary tissue of the tibia prior to the performance of the resection of the tarsus, and if its presence there had then been recognized, it would have contra-indicated that operation and called for amputation far up the limb. The thrombosis of the femoral vein was of recent occurrence. The coagulated blood which filled that vein presented a fresh appearance and had not yet undergone the puriform transformation, nor even become at all softened. It was therefore obvious that the thrombosis had not occasioned the visceral abscesses nor the inflammation of the lungs, since the morbid process in those organs was considerably older than the thrombus of the femoral vein. The thrombosis was a more recent event than the pyæmia. This circumstance is important, because it shows that the pyæmic process in this case could not have had its origin in the thrombosis, and that if any relationship or necessary connection existed between them, the pyæmic process induced the formation of the thrombi. The symptoms of irritative fever (or, speaking properly, the surgical fever of an irritative type), which where so strikingly relieved by the operation, had been produced entirely by local causes, namely, the inflammation of the various structures bordering upon and connected with the gunshot wound, such as the connective, the fibrous, the osseous, and the medullary tissues. The symptoms of the purulent infection did not make their appearance till two days after the operation. They presented a marked contrast to those of the surgical fever which preceded the operation. They denoted the occurrence of a poisoned condition of the blood and the whole system, under which the patient sank rapidly, and died on the eighth day after its advent."

¹ LIDELL (JOHN A.), in U. S. Sanitary Commission Memoirs, Surgical Volume I, pp. 524-6, and CULBERTSON (H.), Excision of the Larger Joints of the Extremities, in Transactions of the American Med. Association, Philadelphia, 1876, Supplement to Vol. XXVII, p. 314.