Civil War Washington

CASE 23.—Private W. Young, Co. K, 4th New York, aged 19 years, was wounded at Fredericksburg, December 13, 1862, and admitted to Campbell Hospital, Washington, four days afterwards. Surgeon J. H. Baxter, U. S. V., recorded: "Gunshot wound of leg; patient transferred to Baltimore January 8, 1863." Surgeon L. Quick, U. S. V., reported that the patient was discharged from McKim's Mansion Hospital, March 18, 1863, for "gunshot wound of left leg, ball entering near the head of the tibia and emerging through the internal belly of the gastrocnemius muscle, producing lameness." The Boston Examining Board certified, October 27, 1865: "Has had wound of leg below knee, * * ball emerging one inch below and behind the internal condyle of the femur, evidently passing across the internal saphenous vein. Cicatrices not adherent, but there is some loss of substance of muscle, and the veins of the leg are varicose, probably in consequence of the wound. Motions of joint good. He says he has pain in leg on walking or standing, and much pain in popliteal space while sitting." On August 25, 1876, this pensioner came under the care of Dr. J. Collins Warren, at the Massachusetts General Hospital, who reported the further progress of the case to the Boston Society for Medical Improvement, in the Boston Medical and Surgical Journal, Vol. XCV, No. 18, as follows: "Was wounded fourteen years ago, at the battle of Fredericksburg, by a musket ball, which entered the calf of the left leg a little to the inside, and came out opposite the inner aspect of the knee joint. There was no unusual amount of hæmorrhage at the time, and the wound healed well, but on recovery a small bunch remained in the popliteal space, growing larger at times, and again almost wholly disappearing. One year ago it grew larger than before and began to pulsate. It soon filled the hollow of the knee, and during the last two months has spread rapidly on the inside of the thigh. The skin over the popliteal space is made tense by an ill-defined pulsating mass, which spreads along the course of the femoral artery to within eleven inches of the anterior superior spinous process of the ilium. The left knee is nineteen inches in circumference, while the right knee measures but thirteen and one-fourth inches. The patient suffers severely from pain in the calf and foot, which is relieved only by frequent subcutaneous injections of morphine. A pound cannon-ball applied to the femoral diminishes but does not arrest pulsation in the vessel. Heavy pressure with the hand arrests pulsation entirely. August 30th: The patient was etherized and pulsation in the femoral was arrested by two hospital tourniquets applied, near the apex of Scarpa's triangle, alternately every fifteen minutes for twelve hours. During this period the patient was kept profoundly etherized, about a pound and a half of ether having been consumed for that purpose, with the exception of a few minutes during the afternoon, when some beef-tea and brandy were administered. The pulse during this time gradually rose from the normal rate to about 120, but subsided somewhat after nourishment had been taken. On removing the tourniquets pulsation had ceased, although on auscultation a slight murmur was heard beneath the tumor. At midnight there was no return of the pulsation, but the next morning a slight pulsation was observed, which gradually increased to its previous force. September 10th: Pressure was applied as before by tourniquet without ether, the patient preferring to bear the pain, and was continued for twenty hours, but had no effect upon the pulsations, which reappeared after it was removed. September 19th: The patient was etherized, the sac laid open, the clots, which were numerous, everted, and the artery tied at each end. It was found that the sac extended to the point of bifurcation of the popliteal artery. Two ligatures were therefore necessary at this point. The patient rallied well from the operation, and for the first week the wound healed rapidly. An attack of erysipelas arrested the healing process and reduced the patient greatly. On October 3d, hæmorrhage occurred from the upper end of the wound during the afternoon, and although digital pressure was immediately resorted to by an attendant, and in a few minutes the tourniquet was applied, the patient sank, and died the same evening. Dr. Fitz showed the specimen, which consisted of the aorta from its origin, the left femoral, and a portion of the aneurism​ in continuity. The fatal hæmorrhage had resulted from the sloughing of the walls of the artery at the upper end of the aneurismal​ sac, where the ligature had been applied. There was no alteration of the inner surface of the femoral artery, but the fibrous tissue was indurated around it, corresponding with the region where compression had been applied. The entire inner coat of the thoracic aorta was thickened, wrinkled, elevated in patches of an opaque grayish-white color, and the canal was dilated, especially that of the arch. Just above the cœliac axis these alterations ceased abruptly, the interior of the abdominal aorta being smooth and yellow, its walls evidently in a normal condition. The specimen was particularly interesting from the absence of changes at the point of compression and the presence of chronic inflammatory conditions of the thoracic aorta, such as are associated with the formation of aneurisms​ in a young man in whom a popliteal aneurism​ had arisen directly or indirectly from a traumatic cause."