Dr. Mudd's Diagnosis

[Rick Smith]

I have wondered if it was possible that Dr. Mudd made a misdiagnosis after examining Booth's leg.

Dr. Mudd stated that Booth had sustained a direct fracture to his fibula and that he found crepitation present. I suppose that the crepitation could have been from the broken ends of the bone moving against each other during the exam.

Mortimer Ruggles', one of Mosby's men who crossed the Rappahannock with Booth & Herold, and had a close look at Booth's injured limb, which Ruggles described as being greatly swollen and dark with bruising, said that with his experience of wounds, to save Booth's life would have necessitated the removal of the injured leg, and that even that may not have prevented a speedy death.

Not to be too hard on Dr. Mudd, as he had no modern scientific advantages to aid him, but it seems that Booth's injury was even more severe than Dr. Mudd's diagnosis suggested.

[Leon Greene]

Venturing with trepidation into a specialty not my own (that is, orthopedics instead of cardiology)....

Fractures are classified as simple (or closed, bone not protruding through the skin) or compound (or open, bone protruding through the skin). A comminuted fracture is one where the bone has broken into more than one piece. Other classifications of fractures can include complete or incomplete, meaning that the bone is separated into two parts (complete), or just cracked (incomplete). There are many other types of fractures, but those are the basics and the ones that Dr. Mudd should have been able to recognize.

Crepitus in a fracture can occur from the ends of the bones rubbing together (ouch!), or from air within the soft tissues if the bone has protruded through the skin (or if gas gangrene has appeared). Even a physician in the 1860s should have been able to tell the difference. Darkness and bruising can occur with either simple or compound fractures and doesn't help much with the diagnosis.

Amputation today is virtually never needed for the fracture of a fibula. However, in Dr. Mudd's time, amputations for compound fractures were common. A simple (non-compound) fracture of the fibula would not have needed an amputation, and Dr. Mudd should have been able to tell if the bone was protruding through the skin. Only in third world countries today are extremities removed for simple fractures, almost always inappropriately. It's therefore unlikely that Dr. Mudd missed the diagnosis, in my opinion. He had plenty of time to look for any bone fragments coming through the skin.

Amputations during the Civil War were very common, and a good surgeon could perform one in about 10 minutes. The quicker, the better, since anesthesia wasn't always the greatest. Anesthesia was given in over 80,000 surgeries performed on the troops in the Civil War. A sampling of over 8,900 cases revealed that chloroform was used in 76.2%, ether in 14.7%, and a combination of both in 9.1%. Administration was relatively simple, and often a minimally trained assistant performed the anesthesia. Toxic reactions were rare, and many of the deaths attributed to the anesthetic were, in fact, the result of the severity of the wound or the operation. As today, the risk of the operation (and of the anesthesia) was related to the duration of the surgery; most patients survived the immediate operation itself. Subsequent deaths were often the result of infectious complications. Death ascribed to the anesthetic itself occurred in 0.54% of cases using chloroform; in 0.30% of cases with ether, and in 0.24% with the combination of chloroform and ether. Since pre-operative evaluation for heart and lung disease wasn’t performed, many patients who died may have had pre-existing conditions that might have led to the anesthetic catastrophe.

Amputations were more lethal the closer the incision was to the soldier’s trunk. That is to say, amputation of a foot was less likely to cause death than amputation at the knee. A hand amputation was safer than the removal at the elbow. Overall, about 25% of amputees died at the operation. Hip amputations were fatal 83% of the time; removal of an entire upper arm, 24% fatal. 8 About 75% of all war wounds were to the arms or legs. The Union alone saw 30,000 amputations. 9 Abdominal, head, and chest wounds were almost always fatal. Doctors often triaged these patients to wait until other soldiers with more salvageable wounds were attended, worsening the self-fulfilling prophecy that head, abdominal, and chest wounds would be fatal.

Unfortunately for the victim of a bullet, doctors expected the wound to become infected. It was a normal part of the process; if pus didn’t appear, something was wrong with the “normal” healing of the wound. This situation reigned because doctors didn’t understand anything about the need for cleanliness. Instruments – if cleaned at all – were simply rinsed and passed from one amputation to another. Sponges were used from one patient to the next after only a quick rinse. Doctors proudly wore their bloodstained and pus-besmirched clothes from patient to patient. Clean dressings were almost non-existent, and surgery sites were covered with clothing or strips of torn cloth from the battlefield. (Joseph Lister began the era of antiseptic surgery only in 1865, at the close of the War.) When infection spread to the bloodstream (“blood poisoning” or “pyemia”), fully 90% of its victims died. Tetanus was another accompanying disease of war wounds; its mortality was 87%. 11 Bone infection (osteomyelitis) after an amputation was common. Overall, the mortality from an immediate amputation, regardless of location, was 28%; amputations performed later, after the wound was infected, had a death rate of 52%.

Of course, death of soldiers during the Civil War was more likely due to medical diseases - typhoid, yellow fever, malaria, dysentery, etc. But that's another story....

Now the REAL orthopedic surgeons can comment, and you can forget my amateurish ramblings above.

[L Verge]

Wow! Nothing amateurish in those ramblings for us novices! Thank you, Dr. Greene.

We know that Dr. Mudd was examining the leg (and probably setting it) under nothing but a flickering lantern or lamp, so there was certainly room for error. We don't know how much he manipulated or felt the leg to see how close the bone was to the skin, do we? Once he placed the makeshift splint on the leg, did he ever exam it again in the twelve-plus hours that Booth remained at his home?

There was certainly no x-ray taken to determine if the fracture left jagged edges on both sides or a clean break (the latter of which happened to my shoulder and actually made it harder to heal because the bones kept separating). In my case, keeping the bones immobile became quite a chore that kept this 10-year-old in three different types of casts, traction, and finally something called an airplane splint for nearly four months. Booth was certainly anything but immobile.

My assumption has always been that the constant movement from running, mounting horses, getting off horses, being supported upstairs, etc. caused damage to the interior layers of his leg that resulted in infection by the time Ruggles would have seen him. However, I don't recall any mention of the Garretts noticing a smell of gangrene or even a serious limp. I once had a student with gangrene forming on a cut to his knee. As soon as he pulled up his pant's leg, you could smell the wound.

Finally, someone refresh my memory: was there any mention of a badly damaged leg in Booth's meager autopsy report? Why do I think that the doctors concentrated on the death wound and nothing else?

[Leon Greene]

Yes, I guess that a flickering lantern would have made observation more difficult, but still I'd surmise that Dr. Mudd would have been able to see a compound fracture had it been present.

Here's the brief sentence regarding the leg injury from the autopsy:

"The left leg and foot were encased in an appliance of splints and bandages, upon the removal of which, a fracture of the fibula (small bone of the leg) 3 inches above the ankle joint, accompanied by considerable ecchymosis, was discovered."

No mention of bone protruding through the skin, but as you rightfully note, the major attention was directed toward the neck wound.

[L Verge]

Sorry that I wasn't clearer - I have never thought that Booth had a compound fracture either at the time it happened or even later when his activity might have caused the bone to come through the skin. I was thinking more of damage that was occurring inside his leg to flesh, muscles, etc. that would only worsen day by day.

I have a museum volunteer right now that has been out of commission since the end of May due to a severe bruising (no break) of his shinbone only. That bruise has ended up encompassing a large portion of his lower leg and a "crater" where the infection ended up breaking through the skin days after what should have been a simple accident. He is now facing a series of skin grafts once they get the wound to heal from the inside out (which it is reluctant to do). That is the same sort of scenario that I envision occurring inside Booth's broken leg -- if Ruggles's description can be believed.

[Rick Smith]

Thanks, Laurie and Leon. Lots of good information. Really appreciated the good insight into wounds & amputations from Leon.

I have always thought that there was something more going on with Booth's injured leg. As you say, Laurie, the injury / wound symptoms may have been worsened by so much movement. Booth sure was not using rest, ice, compression and elevation. by the time Ruggles saw Booth's leg, things had changed dramatically since Mudd's exam.

[Leon Greene]

Even though the official autopsy didn't report a compound fracture, this interesting report appeared in the New York Tribune on April 29, 1865:
"The surgeons who held the autopsy upon Booth assert that he must have endured untold anguish of body, as well as of mind, from the nature of the fracture of his leg, the small bone having cut its way through the flesh and protruded."

If true, this report adds additional information beyond the briefly-worded autopsy. The bone could have worked its way through the skin after the original injury, or could have occurred at the time of the fracture. Either way, it could have resulted in infection requiring an amputation in those days.

And, yes, severe tissue injury alone can worsen with time and additional trauma to the point of gangrene. Add a bit of infection, and things become worse more rapidly.

It seems that the more we think we know, the less we can really be certain. But all of you on this Forum are already aware of this phenomenon.

[John Fazio]

Rick, et al.:

Do I not recall that Dr. Mudd initially diagnosed the injury as a fracture of the tibia? We know absolutely that it was of the fibula, so doesn't his diagnosis say something about his competence, at least as it relates to fractures and the anatomy of the leg? Or did he just mis-speak because he was under a great deal of pressure when he was giving his statements?

John

[L Verge]

(08-04-2015 07:08 PM)John Fazio Wrote:  Rick, et al.:

Do I not recall that Dr. Mudd initially diagnosed the injury as a fracture of the tibia? We know absolutely that it was of the fibula, so doesn't his diagnosis say something about his competence, at least as it relates to fractures and the anatomy of the leg? Or did he just mis-speak because he was under a great deal of pressure when he was giving his statements?

John

Good points, and the first one serves to reinforce my idea that Mudd did not thoroughly FEEL the leg or manipulate it to determine what was broken or damaged. He may have just assumed that yanking it into place and splinting it would cure the problem and let him get back to sleep (or figure out a way to get the assassin to the next agent).

[Leon Greene]

In medicine I always say that the answer to any question beginning with "Is it possible...?" is "Yes." But it would be extremely unlikely. All fractures can worsen due to excessive movements, but it would be exceedingly unusual for a stress fracture to progress to the extent noted by Dr. Mudd, by Mortimer Ruggles, by the autopsy findings, or by the reported injury in the New York Tribune. So, "possible"? Yes. But don't bet any money on it.

[STS Lincolnite]

In my 20+ years experience working with athletic injuries (many fibular fractures, sprained ankles, etc.), the description of Booth's leg would be expected following a fibular fracture given his circumstances. I would note that generally speaking, the amount swelling and ecchymosis (bruising) are not always representative of the severity of the initial injury. As Laurie and Dr. Greene stated, the amount of swelling and bruising could have been partially related to many secondary tissue injuries resulting from movement - but if Mudd's splint did it's job there shouldn't have been that much movement at the fracture site.

There is one other thing, however, that I think would be a major contributor to this type of local swelling and bruising. These post injury signs are very commonly seen after injury when people keep their leg in what we call a dependent position (leg lower than the level of the heart). As Rick alluded to, one of the first treatments we would typically implement after this type of injury would be elevation of the injured extremity above the level of the heart. This allows for the various chemical mediators and resultant swelling and bleeding to be evacuated from the immediate area - relieving pain and allowing greater function. When not elevated, all the post injury "junk" is just sort of trapped in the area while continuing to accumulate. This would certainly result in significant swelling, bruising, and often times a sort of rigidity (do to the swelling taking up any tissue slack). It is unlikely that Booth spent much time while on the run with his leg elevated above the level of his heart. Immediately after his injury, he spent long hours in the saddle with his legs obviously down. Even when he was hiding out for days he may have been laying down, but probably did not have his leg above the level of his heart. He then spent even more time in the saddle or otherwise seated. I have treated some sub-acute, relatively minor injuries (fibular fractures, sprains) that looked absolutely horrific, but when appropriate treatment (simple elevation along with ice and some simple range of motion exercises to activate sort of a "muscle pump") is applied they are vastly improved in appearance, pain levels, and function in as quickly as hours and certainly in a day or two.

I don't think it likely that Booth had an infection of any type if the skin was not broken (I tend to go with the autopsy report, not the newspaper account). In an infected limb you may see bruising (but not necessarily). If infected, you would see swelling along with the hallmark signs of infection which are redness and streaking. The descriptions do describe ecchymosis but I don't recall any mention of redness or streaking (though my memory may not serve me here). In an open wound, Laurie is absolutely correct, there would certainly be an odor associated with an infection, but I have seen a number of instances of infection (for example in a surgically closed incision) that do not have any odor.

As far as Mudd feeling or manipulating the leg to identify a fibular fracture, it doesn't typically take much for this type of injury. A simple compression of the lower leg will elicit pain, movement, and the described "crepitation". This is due to the creation of what we call a "false joint" at the fracture site. Such a test takes maybe 20 seconds if that. I have correctly identified several of these fracures in my career.

John, I think you are right when you stated that Mudd may have just misspoken if he said fractured tibia. Those two bones should be easy to distinguish for a physician. I suppose there is also the chance he was intentionally being deceptive and trying to put forward the idea that the man he treated had a broken tibia not fibula. So if Booth was caught he could say the man he treated had a broken tibia so it couldn't have been Booth. That probably would've worked better if he had gotten rid of Booth's boot.

Sorry, that post got kind of long - didn't intend it to be so.

[L Verge]

I wonder how long Booth kept Mudd's splint on? If Ruggles was able to see the injured leg, wouldn't that mean that the splint was off? I know that the variety of casts and splints that I wore for a summer thanks to a smashed shoulder were mighty uncomfortable (as well as unhandy to deal with). As highly strung as Booth was, it wouldn't surprise me to find out that he ditched his splint after a few days.