PUNCTURED WOUNDS OF THE FEET. 
A Report oe Two Hundred and Three Cases Treated at the 
Medical Bureau, World's Columbian Exposition, dur- 
ing the "Construction Period," June 1st, 
1891, to May 1st, 1893. 
BY 
S. C. PLUMMER, A. M., M. D., 
ATTENDING PHYSICIAN, WORLD'S COLUMBIAN EXPOSITION, AND PROFESSOR OF ANATOMY, 
NORTHWESTERN UNIVERSITY MEDICAL SCHOOL. 
Reprinted from The Chicago Medical Recorder, June, 1893. 
PRESS OF 
The McCluer Printing Company, 
53 DEARBORN ST., CHICAGO. PUNCTURED WOUNDS OF THE FEET. 
A Report of Two Hundred and Three Cases Treated at the 
Medical Bureau, World's Columbian Exposition, dur- 
ing the "Construction Period," June 1st, 
1891, to May 1st, 1893. 
By S. C. PLUMMER, A. M., M. D., 
ATTENDING PHYSICIAN, WORLD'S COLUMBIAN EXPOSITION, AND PROFESSOR OF ANATOMY, 
NORTHWESTERN UNIVERSITY MEDICAL SCHOOL. 
Of 3,356 surgical cases, of all grades of severity, treated at 
the Medical Bureau of the World's Columbian Exposition, from 
its organization for the treatment of patients, June 1st, 1891, to 
the opening of the Exposition, May 1st, 1893, 203 come under 
the head of "punctured wounds of the feet," the implement in- 
flicting the injury being, almost invariably, a nail, and in a vast 
majority of cases, a rusty nail, an injury which, to the lay mind, 
calls up at once visions of lockjaw and other dire results, a dread 
not without foundation when viewed in the light of scientific 
knowledge; for we now know that the bacillus of tetanus is found 
in the dust of the street and is thus likely to be introduced into 
a wound of the foot, and that, moreover, the bacillus being an- 
aerobic, punctured wounds are of all kinds the most favorable to 
its growth. Perhaps, then, the greatest va-lue of this report will 
be its lesson as to the value of the prophylactic treatment of 
tetanus by the thorough disinfection of all suspicious wounds; for 
in no case, so far as known, has tetanus followed. 
The cases from which this report is made include all the cases 
of punctured wounds of the feet which came to the Medical Bureau 
during the Construction Period of the Exposition, and were treated 
by Drs. Allport, Yeager, Plummer, Marquis, Edgerly, Gentles and 
Hillmantel, of the medical staff. By the order of Dr. John E. 
Owens, the medical director, as complete records as possible have 
been kept of all cases treated at the Medical Bureau, but as the 
hospital keeps no patient over night, being essentially an emer- 
gency hospital, many cases have passed from under our notice 
after the first treatment. Of the cases included in this report 
86 were kept under observation during the entire period of dis- 
ability, that is, until the patient was able to return to work; 15 
other cases were seen for the last time at from 1 to 12 days after 2 
the injury. Many of the latter doubtless returned to work a day 
or two after last coming under observation, but being more in- 
terested in the practical than in the scientific aspect of their 
cases, did not report again at the hospital. The remaining 102 
cases were not seen after the first treatment. 
The occupations of the patients were as follows : Laborers 
64, carpenters 40, Columbian Guards 13, bridgemen 11, foremen 
5, painters 7, carpenters' helpers 5, electric wiremen 5, tinners 5, 
plasterers 4, staffworkers 4, janitors 4, moulders 3, roofers 3, iron- 
workers, steam fitters, plumbers, superintendents, cornice makers, 
inspectors and glaziers, each 2; and clerks, machinists, machinists' 
helpers, upholsterers, tallymen, engineers, draughtsmen, waiters, 
gasfitters, boilermakers, sculptors, teamsters, gardeners, and "not 
stated," each 1. You will thus see that 35 occupations are repre- 
sented, including all classes of society, and consequently all grades 
of cleanliness, or the contrary. 
In 202 cases, where the date of injury and date of first treat- 
ment are given, 173 are found to have been treated on the same 
day that the injury occurred, and 29 from 1 to 6 days after the 
injury; one case being treated 6 days after; one 4 days; one 3; 
seven 2, and nineteen 1 day after the injury. 
The cause of the injury was, in every case but one, a nail. 
In the one exceptional case the cause was a piece of metal which 
fell upon the foot. In 39 cases, where the kind of nail is specified, 
24 were the ordinary blunt pointed steel nails, while 15 were the 
sharp pointed round wire nails. In 16 cases the nails were new 
and clean; in 23 cases rusty. 
In 5 cases the puncture extended clear through the foot; in 1 
case the punctured wound was complicated by a contusion, and 
in 1 case there were two punctured wounds. In 4 cases, where 
the patients tried domestic treatment before coming to the hospital, 
the foot was found swollen and painful. In 1 case the domestic 
treatment consisted of a mixture of sugar and soap; in another of 
a cow manure poultice. 
In 9 cases foreign bodies were found in the wound, this num- 
ber representing over 4 per cent of all the cases. In 3 cases 
pieces of rubber boot were found; in 2, pieces of leather; in 2, 
pieces of sock; in 1, a piece of a nail; and in 1, sand. 
In 119 cases in which the injured foot was designated, the 
right foot was found to be injured 70 times, the left 49 times. In 
79 cases in which the portion of the foot injured was designated, 
the location was as follows: Sole 46, dorsum 5, sides 6, toes 7, 3 
web of toes 3, and heel 2. The wounds of the dorsum were, in 
most instances, caused by pieces of falling timber having nails pro- 
jecting from them. In wounds in other localities the nail was often 
driven into the foot with great force owing to the fact that the man 
was weighted down with a burden at the time of receiving the in- 
jury. 
The treatment of punctured wounds of the feet may be 
summed up in one word, thoroughness, which implies primarily in 
the surgical treatment of any wound, the obtaining and maintain- 
ing of asepsis. In most cases the wound is apparently trivial; and 
the surgeon may share with the patient a feeling that active inter- 
ference is unnecessary; he will trust to good fortune for a favorable 
result, and if complications arise, treat them when they appear. 
This can be done only at great risk to the patient. When it is 
called to mind that, in over four per cent of cases, foreign bodies are 
present in the wound; and that there is a probability in every case 
that pyogenic microbes have been introduced, and a possibility that 
those of tetanus may also be present, and that under the very con- 
dition favorable to their growth, namely, an anaerobic condition, it 
will be seen how irrational this "let well enough alone" treatment 
is. One case in this series will illustrate the danger of this course. 
The injury was so trivial that no treatment was thought necessary; 
cellulitis followed and the man was disabled from duty for twenty 
days, a longer period than that of any other case where the dura- 
tion of disability is recorded. 
The domestic treatment by various kinds of poultices in the 
four cases coming under our observation was followed by cellulitis. 
Although our treatment varied much in different cases, the 
routine treatment finally agreed upon as being applicable to most 
cases and followed by the best results, was as follows: 
1. Thorough cleansing of the foot with solution of bichloride 
of mercury 1-1,000. 
2. Trimming the edges of the wound. 
3. Swabing out the wound with a probe lightly covered with 
cotton and dipped in 95 per cent solution of carbolic acid. 
4. Drainage. 
5. Antiseptic dressing. 
6. Rest. 
In the sole of the foot, where the epidermis is very thick, the 
edges of the wound frequently came together with valve-like ac- 
curacy, effectually preventing the escape of anything from the 
wound, so that, in some cases, it was only after trimming away the edges that the presence of a foreign body was discovered. This 
procedure also favors drainage. 
The use of the probe in cleansing these wounds is preferable 
to syringing, for two reasons: First, it is easy to reach the bottom 
of the wound with a probe, while it is doubtful in many cases 
whether this could be done with a solution applied by a syringe; 
secondly, a small particle of foreign material will often adhere to 
the cotton and thus be removed. 
In some cases the use of peroxide of hydrogen by injection 
was substituted for the probe with carbolic acid. This would sug- 
gest itself as being a particularly appropriate agent as far as the 
bacillus of tetanus is concerned, on account of the anaerobic qual- 
ities of the bacillus and the oxidizing property of the agent. 
For drainage a strand of silk-worm gut doubled upon itself 
was most frequently used. This has the advantage of being easy 
to introduce, and by its elasticity tending to keep the edges of the 
wound apart. In some of the larger wounds a gauze tampon was 
substituted for the silkworm gut. 
The antiseptic dressing most frequently used consisted of 
powdered boric acid next to the wound and a covering of dry bi- 
chloride gauze, held in place by a muslin roller. At first iodoform 
was extensively used instead of the boric acid, but comparative 
tests showed it to be in no way superior. 
Rest was directed to be as nearly absolute as possible for at 
least two days, at which time the patient was directed to return for 
redressing ; with elevation of the foot. In thirty-eight cases the 
wound was so slight that the patient was allowed to return to work 
at once; but in the other 165 cases rest was uniformly enjoined. 
Suppuration was as a rule prevented. In many cases the wound 
was found perfectly dry on the second day after the injury; but in 
the majority there was a slight discharge without, however, any evi- 
dence of inflammatory reaction around the wound. Drainage was 
usually removed the second day after the injury. The dressing 
was reapplied and the patient prohibited from walking on the in- 
jured foot until the wound was entirely healed. 
Of ninety-eight cases which were under observation at least two 
days after the injury; eighty-six recovered without appreciable sup- 
puration or any other sequelae. Of the twelve cases in which 
there were sequelae, in five there was suppuration; in five cellulitis, 
in one abscess, and in one, synovitis of one of the metatarso- 
phalangeal joints, which was probably punctured. In one case of 
suppuration the patient had removed the antiseptic dressing and 5 
applied a piece of meat in its stead; in another a foreign body had 
remained in the wound and was expelled during the suppurative 
process. In one of the cases of cellulitis rest had been prescribed, 
but patient returned to work at once, and, after four days' work 
was disabled for seven days. 
In cases where inflammation of any kind followed the injuiry, 
the wound was thoroughly cleansed, usually with peroxide of hy- 
drogen, and the wound dressed, in most cases, with a wet boric 
acid dressing. 
I wish again to call attention to the fact that tetanus was not 
a sequel in any of the cases, showing that its occurrence does not 
depend upon any particular kind of nail causing the injury, or upon 
its being clean or rusty; nor does it depend upon the portion of the 
foot injured. 
In eight-six cases the entire duration of disability is recorded. 
In thirty-eight of these cases the men return to work at once. In 
the remaining forty-eight the disability extended over periods 
varying from one to twenty days. The average for the eighty-six 
cases four days. As this, however, includes all the cases in which 
the disability was nothing and only part of those in which one or 
more days were lost, it is manifestly too low for a general average. 
In the forty-eight cases in which the patient did not return at once 
to work, and in which he was kept under observation until able to 
return to work, the duration of disability is seven days. Taking 
this as the average for the 165 men who did not immediately return 
to work, the estimated total number of days lost on account of 
punctured wounds of the feet is 1,155, an average of a little less 
than six days for each of the 203 cases. This represents almost a 
loss of four years' work for a single man. 
DISCUSSION. 
Dr. L. L. McArthur: I wish to congratulate the Doctor on 
the opportunity of a lifetime to present so valuable a paper to the 
society. Certainly no surgeon has before had an opportunity to 
see and care for so many cases of punctured wounds of the feet 
under modern aseptic methods. Dr. Plummer is to be congratulated 
on the methodical and scientific manner in which he has approached 
the subject and presented it. He is to be congratulated on the 
excellent results which have followed the application of our pres- 
ent scientific knowledge of the causation of inflammation, especially 
of tetanus, for it is well known and proven, that the microorganism 
of tetanus is always to be found in rich loam, and hence, in the dust 6 
which will be likely to adhere to the soles of the feet in Jackson 
Park. Our knowledge of tetanus teaches us, too, that symptoms 
rarely make their appearance before the ninth day, so that a wound 
which may appear to be healed on the third or fourth day and no 
attention paid to it, when suddenly the spinal and nervous phe- 
nomena, are apt to become apparent. Some years ago I looked up 
the subject of tetanus, and in looking over the literature of the war 
of rebellion as to cases of tetanus reported, if I recollect correctly 
there were 12,000 injuries of the hands and feet, and among these 
fifty-two cases of tetanus occurred in the feet, and some eight or 
ten in the hands. I believe the free drainage used in the doctor's 
cases has done much to prevent tetanus in them. I have no doubt 
that the specific organisms of tetanus were introduced into many 
of these wounds. Its poison or ptomaine has a definite chemical 
composition; has been extracted and undergoes chemical reactions 
as do the alkaloids; with the different precipitants it can be recog- 
nized, and moreover has a definite physiological effect upon the 
lower animals. If free provision is made for its escape from the 
wound no constitutional symptoms are manifested. This organ- 
ism is not one which lives readily in the human body; if its pto- 
maine be allowed to escape the blood soon inhibits its growth. 
Dr. A. Belcham Keyes : It seems to me that Dr. Plum- 
mer's estimate of the number of lacerations and contusions in 
punctured wounds is small. It is difficult to conceive that a nail 
would not lacerate and contuse to a certain extent. Foreign 
bodies are, of course, various and probably minute foreign bodies 
are carried into every wound, the chances of suppuration depend- 
ing on the number present, and power to produce sapremia or 
septicemia of the particular microorganisms introduced. 
We understand that the bacillus of tetanus has its natural 
habitat in moist earth. Most of the cases I have seen, some seven 
or eight have been from wounds of the hands, perhaps because 
in this climate the feet are all protected by shoes. One interest- 
ing case was of a man who was shot in the groin by a thirty-eight 
caliber revolver, and two weeks later when the wound was granu- 
lating nicely, developed tetanus. The granulating surface was 
excised but the man died, it being impossible to control the 
convulsions. The thyroid gland of this man was removed and 
inserted in the abdominal wall of two dogs; it was absorbed, but 
the dogs remained perfectly well. Dogs, according to Kitasato, 
are not as easily inoculated as other animals; tetanus does not 
seem to develop until the wound is granulating or perfectly healed, 7 
i. e., until the oxygen is cut off on account of the anaerobic dis- 
position of Rosenbach's bacillus. It should not be forgotten that 
wounds are too small sometimes to be seen; we know how a 
severe cellulitis may occur from a minute puncture that clears up 
by a wet antiseptic dressing. Microorganism requiring a very high 
power microscope to see can enter a very small puncture. 
In the County Hospital I found foot injuries showing a great 
deal of dirt and other foreign bodies, if carefully cleaned, heal rap- 
idly. The foot is a long distance from the circulation centers; we 
know how hard it is in old people to heal wounds of the feet com- 
pared to the scalp; also the feet are prone to infection even in the 
most cleanly person; and lastly, elevation of the limb plays an 
important part. While in this age, perhaps the proper surgical 
treatment would be to excise where practicable the parts exposed 
to infection at the primary dressing. 
Dr. Bayard Holmes: We can only hope that Dr. Plummer 
will be at the World's Fair when they are tearing it down. The 
nails will then be dirty and have the bacilli from all over the world 
upon them, and after those dirty nails are thrust into the feet it 
will be interesting to know whether he will have such luck as he 
exhibits in this report. 
Dr. S. C. Plummer, in closing the discussion, said : I wish to 
thank the gentlemen of the society for the kind manner in which 
the paper has been received. In regard to Dr. Keyes' suggestion 
as to classification of these punctures, I would state that a great 
many of these wounds were made by sharp-pointed wire nails 
which could not produce very much laceration. Where the wound 
was made by the larger square-ended nails, of course, we could 
call it strictly speaking a contused punctured wound. But as the 
essential feature of the cases was that the wounds were punctured, 
that is, the edges were closed so as to shut off the deeper portion 
of the wounds from the air; they had all the essential characteris- 
tics of a punctured wound, and I classified them accordingly. The 
fact that these wounds are as a rule followed in a certain percent- 
age of cases by tetanus, and that in all this large series of cases 
there was no case of tetanus is very suggestive. Of course the 
absence of tetanus might have been a coincidence, but it looks as 
though there was some relation between the prompt drainage and 
attention to the wound, and the fact that tetanus did not follow. 
As to the existence of the tetanus bacillus in the ground at the 
World's Fair we cannot say positively, it was not looked for. It 
seems to me the soil there is favorable for the development of the 8 
bacillus; it has been in use for two years and the surface soil of the 
roads has been mixed with soil brought from the city upon the 
wheels of vehicles. Consequently it seems to me the tetanus 
bacilli must certainly have been present in the park sometime dur- 
ing the construction period. And, moreover, if the association 
with horses has anything to do with the causation of tetanus, as 
Dr. Shakespeare, of Philadelphia, has suggested, there certainly 
was a good opportunity for the introduction of the bacillus through 
that medium, because horses were used there from the beginning, 
the first work done having been grading, in which horses and 
mules were largely employed.