Civil War Washington

CASE 240.—Private Hugh Wright, Co. G, 87th New York, aged 28 years, a robust, healthy man, was wounded on May 5, 1864, at the battle of the Wilderness, by a conoidal musket ball, which entered the right thigh an inch within the track of the femoral vessels and two inches below Poupart's ligament, passed backward and outward, shattering the neck and trochanters of the femur, and, having been greatly flattened and distorted by the impact, it lodged amid the fragments of bone. The precise direction of the fracture is indicated in the accompanying wood-cut (FIG. 54).¹ He stated that after being wounded, he was carried to the rear by a number of his companions, and, in the evening, was taken to the field hospital of the 2d division of the Second Corps. Here he remained for three days. He was then sent in an ambulance wagon to Fredericksburg, and placed in a temporary hospital. He stated that his wound was repeatedly examined by different surgeons, but that no treatment was instituted beyond the application of a compress dipped in cold water to the wound. He was transferred, after a fortnight, on a hospital steamer, to Washington, and on May 25th he was admitted to Stanton Hospital, then under the charge of Surgeon B. B. Wilson, U. S. V. He was placed in Ward 6, under the care of Acting Assistant Surgeon J. B. Garland, who communicated a special report of the case. The injured limb was swollen, everted, and shortened. Pus had accumulated in the tissues about the hip. Notwithstanding the gravity of the injury, the patient's constitutional condition is said to have been hopeful. On exploring the wound with the finger, the patient being under the influence of chloroform, detached fragments of bone could be felt. On consultation with Acting Assistant Surgeon George A. Mursick,² an operation was decided upon, for the purpose of removing these loose fragments, and the missile, if it could be found. On May 27th, the patient was rendered insensible by sulphuric ether, and Dr. Mursick, assisted by Dr. Garland and others, made a straight incision, commencing above and behind the trochanter major and carried downward in the axis of the thigh. It was not in contemplation, at the beginning of the operation, Dr. Garland states, to exarticulate the head of the femur; but when the muscular attachments were divided, and the full extent of the fracture was revealed, and the joint was found distended with pus, it was at once determined to make a formal excision. The fragments of the neck were extracted piecemeal. The ball was found lying behind the neck, and was extracted. The capsular ligament being freely incised, a bistoury was inserted into the cotyloid cavity and the round ligament was severed, and the head of the femur was removed without difficulty. The jagged upper extremity of the shaft of the femur was then turned out of the wound by carrying the limb over the opposite knee, and was smoothed off by a chain saw. There was but trifling hæmorrhage, and no ligatures were required. The wound was carefully cleansed, dressed with dry lint, and left to heal by granulation. To keep the limb in position, long sand bags were laid on either side of it, and moderate extension was made by means of a weight attached to the leg and suspended from the foot of the bed. At night he took a grain of sulphate of morphia in a draught. The operation seemed to depress him very much, and reaction was slow. He passed a restless night, manifesting much nervous excitement. In the morning his pulse was feeble and frequent; his tongue dry and furred. He was ordered an ounce of brandy every three hours, a grain of opium every four hours, and as much beef tea and concentrated nourishment as he could take. On May 29th his general condition had much improved; the pulse was less frequent and stronger. There was free suppuration. The wound was dressed with a weak solution of permanganate of potassa. On June 1st he continued to improve, the wound looked well, and the character of the suppuration was good. The amount of brandy was reduced to four ounces daily. On August 1st he was still doing well. The wound was filled up with granulations from the bottom, with the exception of a sinus leading to the bone. It continued to suppurate quite freely, and some small pieces of dead bone had come away with the discharges. He had gained in flesh, and his health and spirits were good. On August 22d, he attempted, for the first time, to sit up in bed, but, owing to the rigidity of the parts and the agglutination of the muscles, the pain caused by the sitting posture was so severe that he was compelled to lie down again. Cold evaporating lotions were applied to the thigh. On August 23d the upper part of the thigh swelled and was painful, and the discharge was increased in quantity. On August 27th the swelling of the thigh had increased, the discharge from the wound was very free, thin, and flaky, and the surrounding surface was glazed and doughy to the touch. The wound of entrance had re-opened and discharged thin pus. An abscess formed on the inner side of the thigh, and about four ounces of thin flaky pus was discharged. The patient was restless. He was ordered twenty drops of the tincture of the sesquichloride of iron every six hours, with stimulants and nutritious diet. On September 1st the swelling and inflammation of the thigh continued. He complained of nausea and want of appetite. An abscess formed on the outer side of the thigh. On September 5th the abscess was incised, and a large quantity of thin, flaky, and offensive pus was evacuated. He had an irritable stomach, and Hoffman's anodyne was administered. On September 6th the edges of the incision in the abscess were beginning to slough, and nitric acid was freely applied. On September 9th he had diarrhœa; ten grains of subnitrate of bismuth and a grain of opium were given every six hours. On September 13th the diarrhœa had nearly ceased. The patient's general condition had improved, and the wound looked well, though the suppuration was still copious, and had improved in quality. On September 25th a large ring-shaped exfoliation from the upper end of the femur was removed through the wound of operation. On September 26th another exfoliation was removed. On October 6th, 1864, Private Wright was discharged from the military service on account of the expiration of his enlistment. On October 7th the swelling of the thigh had subsided; the discharge from the wounds had much diminished in quantity, and presented the appearance of laudable pus; the diarrhœa had ceased, and his general condition was much improved, he being able to sit up in bed. On October 30th, a sinus communicating with necrosed bone opened on the outside of the thigh. In the latter part of December, another abscess formed on the outer side of the thigh. When this was opened the swelling and inflammation subsided. He continued to do well until February 6, 1865, when another abscess formed in the lower third of the thigh, on the outer side. This was incised and the pus evacuated. Several pieces of dead bone came away with the discharges from the wound of operation. About the middle of March, 1865, he was able to get out of bed, and to walk about the ward on crutches. Soon after, in getting out of bed, "he let his leg fall and hurt it." This accident was followed by inflammation and swelling of the thigh, and an abscess in the lower third of it, on the inner side. This was incised, and a small quantity of pus was evacuated. He was now attacked with erysipelas, which extended from the knee to the hip. This was combated with tonics and stimulants, such as iron and quinine, and rapidly disappeared. From this time he did well, taking daily exercise about the hospital on crutches. On April 17th, he was transferred to the Ward Hospital, at Newark, New Jersey. His general health was tolerably good. He could not bear much weight on his limb, and inflammation and abscesses followed any unusual exertion. He remained at this hospital until May 6, 1865, when it was reported that he "eloped." As a discharged soldier, he was no longer under military authority, and was at liberty to go. For many months, though diligent inquiries were made, he could not be traced; but, in July, 1866, Surgeon General L. W. Oakley, of New Jersey, transmitted a letter from Dr. W. Pierson, of Orange, New Jersey, which stated that Wright had entered the almshouse at that place in June, 1865, and had remained there until the following spring, under Dr. Pierson's professional care. At first, the mutilated limb had been enormously swollen from œdema, and there was an ichorous discharge from a sinus near the hip joint. With careful bandaging, the œdema gradually disappeared. In the spring of 1866, Wright left the almshouse, and engaged himself as a laborer on a farm. He wore, Dr. Pierson reported, a cork-soled shoe of his own manufacture. The limb was shortened precisely five inches. The circumference of the injured thigh at the highest part was one inch less than that of its fellow. He walked well without crutch or cane, bearing his full weight on the mutilated limb. There was quite free motion at the hip, but little at the knee. There were no open fistules​, and no tenderness about any of the cicatrices. Dr. Stephen Wickes, of Orange, reported, in the summer of 1866, that Wright was in good health, though somewhat intemperate; that he worked daily at light tasks, and was even able to mow grass. He commonly walked with a cane. According to the measurement of Dr. Wickes, the limb was shortened four and three-quarter inches. About this period, Dr. Mursick, the operator in the case, discovered his former patient, and examined him. He found the resected end of the femur firmly attached to the pelvis by ligamentous tissue an inch and a half long. The agglutination of the muscular sheaths had nearly disappeared. The limb was quite under control. The man could flex and extend it slightly, and adduct to a limited extent; the power of rotating and abducting was lost. Motion at the knee was quite restricted, on account of the thickening and consolidation of the surrounding tissues resulting from inflammation. He stated that latterly the improvement in his limb had been very decided; that when he first commenced to walk, the limb felt like a weight attached to the body; this sensation had entirely disappeared. January 15, 1867, Hugh Wright was found duly established at his residence in North Orange, Essex, New Jersey, receiving a pension dating from October, 1864, the date of his injury. The Pension Examiner, Dr. A. W. Woodhull, of Newark, reported "that at that date there was about six inches shortening, with no power of flexion or extension at the hip and the power of rotation to a very limited degree. All motion of the injured limb for progression was imparted by lateral swing of the body itself. I may add that the knee joint of the injured limb is stiffened. " On October 19, 1867, Dr. Mursick again examined Wright, and took him to New York, and had his photograph taken. The negative is preserved at the Army Medical Museum, and is No. 188 of the Surgical Series of Photographs, a reduced copy of the lower limbs as shown, in the photograph, is presented in the wood-cut (FIG. 53). At this period, Wright reported that his limb had given him no trouble since the sinuses healed, in May, 1865, and that it sufficed for all purposes of locomotion. He stood on it very firmly, and could move it in any direction with an easy, swinging motion. He had been engaged for a year and a half as a farm hand, and was employed at that time as a wood-chopper. He had for a short time earned larger wages as a hod bearer, and had climbed high ladders with a heavy hod of bricks on his shoulders; but he found this avocation too fatiguing. His general health and physical condition were good. The knee joint continued quite stiff. It could be flexed to about quarter, perhaps, of the normal extent. When he walked, the rounded upper extremity of the femur played up and down on the dorsum of the ilium over a space of an inch and a half. In November, 1868, Dr. Mursick again examined Wright, and reported on his condition. The utility of his limb had augmented during the twelve months that had elapsed since the last examination. The attachment of the femur to the pelvis was strong; the cicatrices were firm and healthy. All the movements of the thigh were performed with almost as much facility as in the normal state; rotation, even, as well as flexion, extension, adduction, and abduction. His general health was good. On August 3, 1872, Wright's pension was increased to $18 per month on account of increasing disability and because additional legislation permitted larger payment to the more gravely mutilated. In September, 1873, Pension Examiner A. W. Woodhull reported the local disability unchanged, and, on October 26, 1874, the sudden death of the pensioner, Hugh Wright, from supposed cardiac disease was reported. Unfortunately no autopsy was made and the valuable opportunity of examining the relations of the resected joint was unimproved.

¹ An anterior view of this specimen is printed in the surgical report in Circular No. 6, S. G. O., 1865, p. 74, and in the Catalogue of the Surgica​ Section of the Army Med. Museum, 1866, p. 246.

² MURSICK (G. A.), A successful Case of Excision of the Head of the Femur for Gunshot Fracture, in New York Med. Jour., 1865, Vol. I, p. 424. See also Circular No. 6, S. G. O., 1865, p. 68, Circular No. 2, S. G. O., 1869, pp. 41, 135, Photographic Series, A. M. M., Vol. IV, p. 38.

FIG. 53.—Appearance of limb two years and five months after operation. [From a photograph.]

FIG. 54.—Shot comminution of neck and trochanters of right femur. Spec. 3375.