Civil War Medicine
by Janet King, RN, BSN, CCRN.
Part III. The Surgical War
In 1918, a Federal surgeon, who had lived through the horrors of the Civil War, wrote:
"We operated in old blood-stained and often pus-stained coats, the veterans of a hundred fights...We used undisinfected instruments from undisinfected plush-lined cases, and still worse, used marine sponges which had been used in prior pus cases and had been only washed in tap water. If a sponge or an instrument fell on the floor it was washed and squeezed in a basin of tap water and used as if it were clean. Our silk to tie blood vessels was undisinfected....The silk with which we sewed up all wounds was undisinfected. If there was any difficulty in threading the needle we moistened it with bacteria laden saliva, and rolled it between bacteria-infected fingers. We dressed the wounds with clean but undisinfected sheets, shirts, tablecloths, or other old soft linen rescued from the family ragbag. We had no sterilized gauze dressing, no gauze sponges....We knew nothing about antiseptics and therefore used none.” So was written a description of the practice of surgery before the principles of asepsis and bacteriology came to be known.
This section will take a look at the more overt enemies of the soldier: bullet, shell, and sabre. We will see how each of these injured the soldiers and what the surgeons did to help them. Some of the common problems of the soldiers after their surgeries will be explored and then a young Vermont soldier will be followed - from the time of his wounding on through his discharge and resumption of his life.
Training of Surgeons
At the onset of the Civil War few civilian doctors could claim a specialty in surgery. Their surgical training was, for the most part, minimal and their surgical practice limited to mostly minor cases - i.e. sewing up a cut, or lancing a boil. These doctors served in the war as commissioned officers or in some cases as civilian "contract” surgeons. Some surgeons learned by experimentation, and some tried to treat gunshot wounds without having done so before. Some performed amputations without having any prior experience. In the early days of the war these surgeons were described as "butchers”. As George Adams, author of "Doctors in Blue”, has written - "The Medical Corps contained many men with little or no surgical experience, but with an eagerness to acquire it, which they did at bitter cost to many a wounded man.” Reforms were made where only the most experienced surgeons would actually do the operations. Medical Director Letterman devised a system that created division hospitals and brigade operating teams. Here the senior surgeons of each brigade performed the operations. Other medical officers were assigned duties with their regiments. Some were in charge of "advance depots” or "dressing stations”. Here they only stopped active bleeding and performed simple bandaging. In rare instances they might have to "tie off” an artery for major bleeding. They would then send the soldier on to the field hospital, after giving him a drink of whiskey as a "stimulant” and an opium pill for pain. At the field hospital, the more senior surgeons would assess the wounded man and fully treat his injuries. This reorganization removed many of the causes of complaint and by the latter part of the war the surgeons were described as "unprecedentedly good”. The surgeons would continue their education by lectures, observation of and assisting more experienced surgeons,and by distribution of knowledge via case studies and journal articles.
Effect of Bullet/Shell/Sabre
The three primary causes of wounds in the Civil War were:
- small arms ammunition: bullets, round balls, minie balls.
- artillery fire: solid shot, case shot, canister; and
- bayonet or sabre strokes.
It is said that the tactics of war always lag behind the weapons, and in the Civil War this was especially true. Soldiers were taught to fight as "massed” units and the range of the weapons and their destructive force was devastating on these masses.
The minie ball was a fairly recent invention at the onset of the war. Some 94% of the total combat injuries were attributed to this missile. It was designed to be fired from a rifled musket; was made of soft lead; traveled at a high velocity (for that era) of 950 ft/sec; and was accurate at 200 to 300 yards. As it traveled, it would spin from the rifled barrel of the musket and would deform and tumble on impact. It’s effect on bone and tissue was incredibly devastating. It would smash, tear apart, and disintegrate what it hit. Most of the amputations that occurred were because of this great devastation. Often there would be 1 or 2 inches of bone entirely pulverized or missing altogether after the ball impacted, and the only recourse the surgeon had was to amputate. One surgeon, describing such damage, wrote, "The shattering, splintering, and splitting of a long bone by the impact of the minie ball is in many instances, both remarkable and frightening.” In addition to it’s destruction of bone and the mangling of skin and muscle, the ball would carry foreign material, i.e. pieces of uniform, bits of metal from belt plates, bone chips etc. into the surrounding wound and virtually guarantee an infected wound. The other common small arms ammunition - round balls - were slightly less dangerous. The soldier might get "lucky” and the ball glance off the bone instead of shattering it. Also, if luck was with him, he would be hit in an extremity. Some 71% of Union wounded were so "fortunate.” Why? Because, the lack of knowledge of bacteria and the difficulties of chest and abdominal surgeries in the Civil War era made the mortality very high for soldiers receiving wounds in those areas. For example - a soldier hit in the abdomen, where the ball struck the small intestine, and causing leaking of fecal material into the abdomen - had a 87% to 100% chance of his wound being a mortal one. Some surgeons advised that "When balls are lost in the capacity of the belly one need not amuse himself by hunting for them.” Still, there were surgeons who questioned this stance. Eventually the majority of doctors would try some type of repair, if for no other reason than to give the patient one last chance. Some treatments did succeed, and others were miserable failures. The trial of "hermetically sealing” certain chest wounds ended when the mortality was determined to be 100%. Sometime, the surgeons realized, it was best to "let nature run its course.”
The surgeons attended soldiers wounded in every body part including: damaged eyes; faces torn apart; jaws broken into bits; pelvic wounds that, because the bladder had been hit, leaked urine constantly onto the skin; intestines protruding from the abdomen and many others. Some surgeries had been done seldom if ever in their civilian practices and thus they had much to learn. Artillery fire accounted for some 5.5% of the Union wounded in the Civil War. This included artillery projectiles such as solid shot; canister, and spherical case shot; as well as torpedoes and grenades.
One surgeon stated the primary effect of artillery was the "demoralization of the troops under fire.” Here he noted the psychological effect of war injuries. In WW I this would come to be known as "shell shock” and today would be listed as "post traumatic stress disorder.” In the 1860’s these terms and syndromes were not understood, and often the soldier was simply considered to be "demoralized” or "unnerved.” In some cases the soldier was accused of cowardice. ( A mistake General Patton of WW II fame, would also make).One soldier described his feelings of being under fire as "...I feared that if I ever lost control of myself under shell fire my mind would be shattered...To be under heavy shell fire was to me by far the most terrifying of combat experiences...Fear is many faceted and has many subtle nuances but the terror and desperation endured under heavy shelling are by far the most unbearable.” That soldiers did suffer long term psychological wounds from shell fire is well documented. Drunkenness, severe depression or "melancholia,” desertion and other manifestations of mental health problems can be found throughout unit histories and in reviewing soldiers lives after the war ended.
Although the wounds from artillery fire were less numerous than small arms fire, they were more often deadly. A single round cannon ball - in one instance - killed the captain of one company outright, severed the orderly sergeant’s arm, a corporal’s leg and a private’s head before bouncing off into the woods!
Some artillery projectiles were designed to explode either in the air or on the ground, creating a shrapnel effect where hundreds of bits of heavy iron or lead would be thrown into or over a group of soldiers (who were in their massed formations), wreaking havoc.
One soldier described the bursting of a shell - "...Clouds of smoke shot out from the redoubt and out of these - large, black balls rose upward...passed, shrieking shrilly. Through the dust and uproar I saw men fall, saw others mangled by chunks of shell, and saw one, struck fairly by an exploding shell, vanish!”
The effect of this shelling upon the body was to tear off limbs, slice through tissue and scatter metal fragments throughout wounds. At times metal and other fragments the shell hit - i.e. nails, wood etc. would be carried into the wound as well. All in all, the wounds were often torn, lacerated and mangled.
Less than 0.4% of Union casualties were the result of sabre or bayonet wounds. This, however, did not make them less deadly. Approximately 50% of such wounds occurred to the scalp, skull, face or neck. Sometimes the victim had been involved in "fierce hand to hand combat”, but a large number of the cases were found to be due to "private quarrels, brawls, or inflicted by sentinels in the discharge of their duty.” The surgeons found these injuries tended to "excite inflammatory action in deep seated tissues and cavities, with the danger of formation and confinement of pus from the injury to blood vessels, nerves and viscera and the possibility of pyemia, gangrene, and tetatnus.”
Sabre blows to the head often resulted in the brain itself being injured with problems of epilepsy (seizures), loss of hearing or vision, and "impairment of the mental faculties or insanity” sometimes resulting. These problems were sometimes short-lived, but often stayed with the soldier throughout his life.
If the sabre or bayonet cut into a vital organ or major blood vessel, the soldier often bled to death. Corpses of men killed in such fashion upon the battlefield were "rare and conspicuous by their peculiarly contorted look.”
Treatment of Wounds: Amputation vs. Conservative Approaches
At the beginning of the Civil War there were basically two schools of thought regarding proper treatment of severe injuries the extremities. One group believed that "conservative measures” should be given a chance, that a limb might be spared. The other felt that prompt amputation was a necessity in order to save life.
Conservatives could cite the European experience of the Crimean War, which showed amputations having a very high mortality rate. Unless the limb was essentially torn apart, these surgeons felt it best to attempt to save the wounded extremity.
Those who favored prompt amputation viewed conservative methods as impractical in a war where mass casualties were common. These surgeons believed that where the limb was badly lacerated or where the bone had penetrated the skin, or was much splintered, that amputation was a must and helped avoid septicemia (usually fatal blood infection). According to a military text of the time, published in 1863, "...the rule in military surgery is absolute - that the amputating knife should immediately follow the condemnation of the limb...When this golden opportunity before reaction (infection) is lost, it can never be compensated for.” It was also felt that, "[T]he soldier’s mood on the day of battle will help him withstand surgical shock.” These surgeons felt this was the soldier’s best hope of survival.
Still, some wounds were not treated by amputation, either because the doctor was of the conservative school, or because the situation did not warrant such, or in some cases where the soldiers did some "persuading” of the surgeon to be conservative. Records were made of soldiers who tried such persuasion, including going as far as to threaten the surgeon at the point of a gun to spare their limb. The term "sawbones” and the soldier’s and public’s perception of the surgeons as "heartless butchers” may have influenced some to try a conservative approach.
The soldier with a wound which caused a broken bone(s) could be treated as follows. After the surgeon probed the wound to remove any foreign material: bullet, pieces of bone, pieces of uniform etc., a dressing would be applied and the limb placed in some sort of splint or traction. A piece of board or fence, a bit of bark from a tree, or even a bundle of straw could be utilized, though there were splints made specifically for various injuries. The Hodgen splint had been invented by surgeon John Hodgen of St. Louis and was noted to provide better alignment of the extremity, thus preventing some common complications of broken bones: contracted, shortened extremities. It also allowed the wound to be dressed without disturbing its alignment and thus the healing of the bone. (These are still key elements in splints today). Forms of traction, such as Bucks traction, where force is applied in line with the leg, were developed. The use of plaster splints were also utilized. For upper extremities a variety of splints and slings could be constructed to keep the injured arm or hand in correct position and at rest.
Although amputation was the "accepted” mode of practice initially, as the war continued and the surgeons gained more experience other approaches and conservative methods were utilized whenever possible.
Amputations were classified as "primary” when performed within 24 hours of receipt of the wound. The reasons the surgeon would choose to amputate were to decrease the risk of infection; prevent septicemia; and as a rapid, efficient means of treating thousands of casualties. Amputation within this 24 hours held a 28% mortality rate.
"Secondary” amputations were those performed 24 or more hours after receipt of a injury requiring amputation. The surgeon may have wanted to try more conservative measures if he felt there was any possibility of saving the limb. But, due to such massive numbers of wounded men, all needing prompt attention, he may not have been able to tend the soldiers wound before it was "too late” and amputation had to be done. When done after 24 hours from receipt of injury amputation held a 52% mortality rate.
Statistics would show that the farther away from the trunk of the body, the greater the patient’s chance of survival. For example, injury to the forearm requiring amputation carried a 14% mortality rate, whereas injury to the hip joint requiring removal of the entire leg and thigh, carried a 88% mortality rate.
The soldier requiring an amputation would be placed on the operating table. This might actually be a table designed for surgery, but often anything suitable was utilized, including wood planks set up on barrels or saw horses, a standard table, or a church pew. Most often these procedures were done outside where the patient could be supplied with a "due supply of natural air.” Sometimes the surgeries would be performed in the overhang of a barn or in a tent. An anesthetic, usually chloroform or ether, was administered. (These agents were liquid, and were dropped onto a cloth or thru a funnel and the patient rendered "asleep” by breathing their vapors) Next, blood to the site would be stopped by a tourniquet, or as most surgeons preferred - by the hands of an assistant. This was done by applying firm pressure to the blood vessels supplying the extremity. The assistant would also retract the skin and underlying tissue above and away from the area the surgeon would cut. At this point the surgeon would cut into the skin and muscle down to the bone. The bone would be exposed and cut with a saw. Major blood vessels would be "tied off” with silk or other type of thread. The stump of the bone would then be made smooth with a file. The skin and muscle tissue held by the assistant would then be released and fall down over the bone, thus forming a "stump”. The surgeon would loosely sew the edges together, allowing the silk thread to protrude from the stump. The area would then be dressed.
From start to finish the average amputation took about 15 minutes. The severed extremity was allowed to fall into a bucket placed by an attendant. These buckets after a while would overflow, so brisk was the surgeons work. Soon great piles of amputated limbs would accumulate. Soldiers would write of seeing "gruesome sights” and "great piles of amputated limbs” as they were marched into battle. General Carl Schurz gave a detailed view of surgery done at Gettysburg: "Most of the operating tables were placed in the open where the light was best, some of them partially protected against the rain by tarpaulins or blankets stretched upon poles. There stood the surgeons, their sleeves rolled up to their elbows, their bare arms as well as their linen aprons smeared with blood, their knives not seldom held between their teeth, while they were helping a patient on or off the table or had their hands otherwise occupied...As a wounded man was lifted on the table, often shrieking with pain as the attendants handled him, the surgeon quickly examined the wound, resolved upon cutting off the injured limb. Some ether was administered and the body put in position in a moment. The surgeon snatched his knife from between his teeth, wiped it rapidly once or twice across his bloodstained apron, and the cutting began. The operation accomplished, the surgeon would look around with a deep sigh, and then say - "Next.”
After the operation the patient was aroused from the anesthetic rapidly, and removed from the table. He was then taken to an area to "recover,” sometimes as crude as a bit of hay under a tree.
Pain killing substances such as opium and it’s derivatives were used extensively to help decrease the soldier’s pain. Various routes of administering opium or morphine were utilized. Opium was given by mouth in the form of pills or mixed with water or liquor to be drunk. Another method was for the surgeon to wet his finger, place the opium powder on it, and place it in the wound. Some chose to sprinkle the powder into the wound, but this method was not found to be as effective as opium pills or liquid. Still, another route and for that era a revolutionary one, was to take 1/2 grain of morphine, mix 3 to 4 drops of water and by use of the Wood’s Endermic Syringe, inject the medicine beneath the skin. This, the soldiers felt, was the greatest method for relief of pain.
Repair of Other Wounds
If the soldier received a bayonet or sabre wound the surgeon would clean the affected part and attempt to sew it together if possible. The advanced and specialized techniques of the 1990s were unheard of in the 1860’s but surgeons of that era tried their best to repair extremely disfiguring injuries. These included lacerated and disfigured faces and heads. Along with this was the injury to underlying muscle, nerve and subcutaneous (fatty) tissue. These soldiers often survived their injuries only to spend a lifetime of pain and severe disfigurement. For those torn or mangled by artillery fire, the surgeons would assess their injuries, as they did for any wound. They would then repair what they could, clean and debride the affected areas, and if needed perform amputations.
After the wounds had been assessed by the surgeon, cleaned and surgery performed if needed, some type of dressing was applied. These dressings were meant to protect the wound against "contamination” but in reality, probably hurt more than helped.
Lint was a common dressing material. It was obtained from supposedly clean cloth. The lint was often applied wet, then covered with a piece of gauze muslin and held in place by an adhesive plaster. The dressing would then be kept wet as some felt it essential to keep the wound "clean and sweet.” Neither the lint nor the water nor the caregiver’s hands were sterile and many infections no doubt resulted from this. The "cool” water and ice that was often used in conjunction with these dressings no doubt had some soothing effect and would have decreased swelling to some extent - at least initially.
Poultices were sometimes used, especially when the surgeon felt there would be a value in "encouraging suppuration.” Wounds were expected to produce pus. The doctors termed this "laudable pus.”
Dressings were reused in some cases, greatly increasing the spread of infections. Doctors, nurses and other attendants, i.e. laundry workers, were sometimes infected as well by coming into contact with infected dressings and linens.
Changing dressings frequently in hospitals crowded with wounded soldiers proved impossible and this sad fact also greatly increased the infection rates of surgical cases, as well as leading to worsening of infections.
The state of health of the soldier prior to wounding (usually compromised by poor nutrition, exhaustion, and exposure of army life), poor sanitation of equipment and facilities, and the lack of effective treatments made wound infections the leading cause of death after wounding.
Surgeons of the time felt that pus was to be expected in wounds, but other symptoms of infection were "undesirable” and had some "external” cause. There was no consensus on just what that cause was. No specialists existed in infectious disease as there are today. "Noxious effluvia” (unpleasant smells of all kinds) were suspected of being the source of infection and that "absolutely pure air or an approximation thereof” was felt to be essential in keeping wound infections, termed "surgical diseases,” down. In 1864 the American Medical Association stated "The air is full of pus-corpuscles floating about as dust.” They stressed the importance of ventilation, hospital cleanliness and the disinfection of air, floors and chamber pots in helping prevent the spread of these diseases.
The most common infections encountered were "common suppuration”; tetanus; gangrene; pyemia; erysipelas; and osteomyelitis.
This was not a single disease per se, but was so prevalent among the injured soldiers the surgeons considered it a sign of normal healing!
We can imagine, owing to the conditions of wounding: by bullet etc., and by the treatment: from a dirty handkerchief hastily pressed upon the wound to the unsterilized instruments the surgeons used, why this was so.
Wounds would become red, inflamed and discharge great amounts of pus. If the soldier had a fairly strong resistance, was not exposed to other infections i.e. measles or dysentery; and if he suffered no other complications i.e. gangrene or blood infection - he had a 7 to 1 chance of surviving.
The most likely cause of many of these "common” wound infections is a bacteria - Staphylococcus. Today’s doctors do not consider any post operative infection as "normal” and go to great lengths to prevent and treat such infections. The advent of bacteriology, use of antiseptics and antibiotics and increased understanding of the spread of infection have helped win this microbial war. Sadly, none of this was understood during the Civil War.
Tetanus [ Lock Jaw ]: Some 89% of the soldiers who were infected with tetanus during the Civil War died. The surgeons felt that tetanus was due to "exposure to cold, damp, excessive heat or pressure on nerves by bandages, bullets etc.”
Symptoms:Stiffness of the jaw and neck; difficulty swallowing; restless, irritable - later: spasms of the abdomen, back, neck and face. Convulsions, and spasms of the windpipe (trachea) eventually shutting off air and resulting in death.
1860’s Treatment:Tincture of valerian; potassium bromide; yellow jasmine; belladonna; tartrate of antimony; chloroform; castor oil; turpentine; stimulants and opiates. Blisters, poultices and warm fomentations (See Section 2), were also used.
Modern Knowledge:Tetanus is a highly fatal disease which can be prevented by a vaccine - "tetanus shot.” It is caused by the tetanus bacillus (clostridium tetani), which grows in the intestines of animals and man and is prevalent in rural areas. The organism enters the body through a break in the skin, i.e. metal fragments which lacerate the skin, bullet wound etc. If the wound is contaminated with soil, dust, or animal or human feces containing the tetanus bacillus the injured person may develop tetanus. Today a non-vaccinated person would immediately receive tetanus anti-toxin and a tetanus vaccine. The wound would be thoroughly cleaned using sterile technique. Specific antibiotics and techniques would be used if the patient developed tetanus, but this can, in most cases be prevented if prompt treatment is sought.
Gangrene [Hospital gangrene; Moist gangrene; Dry gangrene; Mortification]:Civil War surgeons were often indiscriminate in categorizing the patients who had gangrene. Some stuck with the term they were most familiar with, so determining how many cases of gangrene, and of what type, is difficult. Today’s doctors classify gangrene into 3 main types. The following examples are those which occurred during the Civil War, although the doctors of that era did not know the precise cause.
Moist Gangrene: This results from the loss of blood circulation due to a sudden stoppage of blood flow - i.e. accident that destroys tissue (cannon ball or bullet wound); blood clot; tourniquet that was left on too long. At first the wound tissue looks like a bad bruise, is swollen and perhaps blistered. Later as the disease progresses the tissue is destroyed and the gangrene spreads rapidly and toxins are formed and absorbed into the general circulation.
Dry Gangrene: This occurs more gradually as blood flow is slowly reduced through the arteries. The tissue of the affected part gradually shrinks, becomes cold and without a pulse.
Gas Gangrene: Although the surgeons of the 1860’s did not know the cause of this type of gangrene, they surely saw the results. Most likely they classified what they saw into the other types of gangrene. This condition occurs in wounds infected by a bacterium (clostridium) and is often attributed to dirty, lacerated wounds in which the deeper tissues of muscle and fat become filled with gas and a bloody-serous fluid fills the wound. The bacteria eat away the tissue and produce toxins. This type of wound would have been produced by such mechanisms as pieces of shell, deep sabre wounds or deep bullet wounds.
Hospital Gangrene: This form of gangrene is now considered "extinct.” There is no agreement to it’s nature, though some feel it was some type of bacterial infection, perhaps streptococcus. The effects, as seen by the surgeons and soldiers of the 1860’s were devastating and deadly. "The patient might see a black spot the size of a dime appear on a healing wound, and watch with horrified interest it’s rapid spread until his whole leg or arm was but a rotten, evil-smelling mass of dead flesh.”
1860’s Treatments:Some hospitals made efforts to isolate gangrene cases, as it had been noted to be "contagious and infectious.” Surgeons tried various drugs in a "conservative” approach at treatment. These included the use of bromine, considered one of the "miracle drugs.” The patient was given ether or chloroform as an anesthetic; the diseased and sloughing tissue would be clipped and cut out until the wound was as clean as possible. Then pure bromine (a very costive agent!) would be applied beneath the edges of the wound. Lint moistened with a weak solution of bromine would be used to fill up the entire cavity or ulcer. Sometime "miraculous” results occurred and the patient was saved from amputation or further treatment. Other drugs used included: nitric acid, creosote, poultices of cinchona, ginger and flaxseed and various nutrients and stimulants.
Modern Knowledge:Today the specific cause of gangrene would be determined. If the problem required surgical intervention to remove a clot or bypass the blocked blood vessels this would be done. Wounds would be tested to determine what bacteria was causing the infection and antibiotics would be given accordingly. Removal of dead tissue, and as a last resort - amputation, would be performed if needed.
Pyemia ["Pus in the Blood”; "Blood infection”]:
This disease affected some 2,818 men - killing all but 71 of them! Often the soldier would seem to be recovering well. Suddenly his fever would go up, he would exhibit symptoms of dehydration, his wound would draining a "watery, thin and foul smelling fluid,” and the sutured area would separate. Death generally followed in a few days. Doctors were beginning to regard this "disease” as a "contagion arising spontaneously in any putrefaction of wound products.” They were also beginning to believe that it could be spread by the surgeons hands and recommended greater cleanliness in surgery.
1860’s Treatments:Tonics, stimulants, dilute sulfuric acid, quinine, iron, opium and liquor.
Modern Knowledge:Today doctors categorize pyemia more precisely based on where the infection is. If bacteria is found in the blood, the term septicemia is used. The first goal is to determine the causative organism i.e. streptococcus or staphylococcus and a host of other potential bacteria. The second goal is to find the best antibiotic for the job, both of which are done by culturing blood samples. Fluids and special drugs are given to combat the shock-like effects of this widespread bacterial infection. Comfort measures and cooling measures i.e. Tylenol for temperature would also be utilized. If caught quickly this infection can be eliminated, but in some cases the patient still succumbs.
Surgeons noted that when erysipelas struck a patient after receiving a wound, that patient had a 41% chance of it being a mortal one. At first the skin and underlying tissues of the wound would become inflamed and red. A rash that consistently included red, round or oval patches that promptly enlarged and spread hallmark this infection. Eventually the affected part would be swollen and tender, hot to the touch and at times, blistered. The patient often complained of headache, fever and vomiting.
1860’s Treatments:Isolation of cases and those articles which had touched the patient were attempted. The doctors reasoned that erysipelas was spread by "prevailing winds” and "airborne particles.” Some felt the disease was caused by "reabsorption of putrid substances of a wound.” They tried various medicines including: laxatives; diaphoretics; tincture of iron; and chlorate of potash. In addition, painting the inflamed area with silver nitrate or iodine was accepted treatment.
Modern Knowledge:Today we know this disease as Group A hemolytic streptococci - a bacterial infection causing the skin and surrounding tissues to become infected. Once determined that the patient has such a wound infection, the doctor is able to prescribe specific antibiotics to combat this bacteria. In addition principles of aseptic wound care would be utilized and the area kept clean. Care would be taken against spreading this disease via linens,instruments or other articles infected with the patients wound drainage.In the majority of cases the patient would recover without further problems.
Osteomyelitis (Bone infection)
This acute inflammation and infection of a bone or bones was usually the result of some type of surgical procedure. Without aseptic and sterile techniques, cutting into the bone almost assured such a disease. In some cases this infection would become chronic with the wound "spitting out” bits of diseased bone for decades, causing much pain and suffering for the soldier - long after the war ended. At first, the wounded soldier would complain of chills, high fever and severe pain, tenderness, swelling and redness of the skin over the affected bone(s). Eventually the condition would progress and if the patient survived he might be left with an extremely stiff joint or non-functional limb.
1860's Treatments:Quinine; liquor of potassium iodide; morphine; opium and some use of mercurial compounds. "Local treatments” such as rest of the infected part; application of cold compresses; cupping and leeches were also tried. Sometimes operations were performed to cut out the infected areas.
Modern Knowledge:Common bacteria found in cases of osteomyelitis are: streptococci and staphylococci. Today Orthopedic and Infectious Disease doctors would be very aggressive in treating such an infection. Great care is taken not to have this infection occur, as it tends to become chronic and can cause many problems and great destruction of the bone. The surgeon would first attempt to drain or "clean out” the infected area and then place the patient on long term antibiotic therapy (months to year) via the intravenous route. Careful monitoring for reoccurrence and progression of the disease would be done. Modern surgical techniques and the initial treatment of victims of trauma - i.e. gunshot wound victims - have prevented many cases of this disease.
Maggots: Friend or Foe?
Surgeon C.S. Wood of the 66th NY Volunteers wrote of the problems his amputation patients had with flies and the maggots they produced in the hospital wards - "In 12 hours the wound is literally covered with maggots and in 24 hours the stump looks as though a swarm of bees had settled into it.” Another surgeon recorded - "The maggot does damage in the wound, not by attacking living tissue, but by the annoyance created by the continued sensation of crawling.”
The Union doctors and care givers tried their best to eradicate the flies through the use of netting and injections of chloroform onto the stumps of amputees. The Confederate doctors, while tending gangrene cases in a prison stockade at Chattanooga and denied such "luxuries” made a startling discovery. They found that the Confederate wounds healed quickly, while those of the "well cared for” Union troops (without maggots) became gangrenous or otherwise infected, and the Union soldiers died in great numbers. After this discovery the Confederate surgeons welcomed their new found "friends” - though the Yankee doctors never seemed to learn such a valuable lesson.
The reason the maggots worked was the fact that they eat dead or diseased tissue. They may have been awful to see and feel crawling about in a wound, but they got rid of the infection locally and left the remainder of the wound clean and healthy. Today maggots have been bred for special uses and perhaps they may once again be seen as our "friends.”
OTHER POST-OPERATIVE COMPLICATIONS
Doctors classified major bleeding after the surgical procedure as "primary”, "secondary” or "intermediary.”
Primary hemorrhage was defined as a major escape of blood occurring from a ruptured blood vessel(s) within 24 hours of receipt of a wound. Intermediary hemorrhage was defined as occurring "from 24 hours until the establishment of suppuration on the fifth or sixth day” from receipt of wound. Secondary hemorrhage was described as occurring from the sixth day to even months after the injury or surgery.
Secondary hemorrhage was usually caused by an infection which had disintegrated the blood vessel’s wall, usually an artery, which then resulted in massive and irreversible blood loss and death.
As has been noted in the description of an amputation, the surgeon would "tie off” the bleeding blood vessels with a ligature (suture) of non-sterile silk, linen or cotton thread. One end would be left hanging out of the wound. On daily rounds, the surgeon would tug on this ligature to see if the loop on the blood vessel had rotted loose. When this suture came away, the surgeon hoped a blood clot had formed thus preventing the vessel from bleeding. If this was not the case, then a secondary and frequently fatal hemorrhage would occur. Unfortunately this happened with "dreadful frequency.” Sometimes the patient would be almost to the point of discharge from the hospital and ready to return home, when suddenly - due to the disintegration of the arterial wall - the vessel would bleed profusely. The surgeon would try to stop this, first by manual compression of the artery, and perhaps an attempt to re-tie the vessel. In most cases it was a lost battle, while the soldier bled to death in front of his doctors, nurses and comrades.
The surgeons tried various styptics (blood clotting agents) such as astringents i.e. alum, tannic acid and persulphate of iron, perchloride of iron and silver nitrate - but these did little good. This deadly post-operative complication held a 62% mortality rate.
WOUNDED VERMONTER UNDERGOES SURGERY
On July 8, 1863 23 year old Corporal C.N. Lapham, Co. K, 1rst VT Cavalry was in battle at Boonsboro, MD. He was struck by a cannon ball which essentially carried away the majority of both his legs.
He was taken to the field hospital at Boonsboro where his wounds were bandaged while he awaited the surgeons help. On July 10 Surgeon L.P. Woods of the 5th NY Cavalry performed amputations of both Corporal Lapham’s legs. The right leg had to be amputated above the knee, since the knee joint was shattered. The left leg, Surgeon Woods was able to preserve a bit more of, being amputated at the knee joint.
After a period of recuperation, Corporal Lapham was transferred to the General Hospital at Burlington,Vermont. Four months after receipt of his wounds he was discharged home. There he was depended on friends and family to nurse him, and provide for him. A year later, in May of 1864 he was taken to New York City where the government paid to have artificial limbs constructed for him. Dr. E.D. Hudson saw him that month and noted "The right stump is healed and in good condition, though the supporting cicatrix (scar) at the base is not good. Regarding the left stump - this forms the most useful, reliable and comfortable support [for him] and constitutes his chief dependence..”.
After being fitted for artificial limbs Lapham returned to Baxter Hospital and was eventually discharged and pensioned by the government on August 25, 1864.
The story of Corporal Lapham is a "happy one” in that it shows the man’s spirit and persistence. Five months after his discharge from Baxter Hospital he enrolled in the Collegiate Institute in Poughkeepsie, New York. While there he found time to write to doctor who helped him regain some "normalcy” in his life - Dr. Hudson - who had made his "new legs.” He wrote...”I can walk with ease on level ground, get up and down stairs readily and am getting along much better than I anticipated in so short a time.”
Lapham finished his schooling and became a clerk in the US Treasury Department in Washington, D.C.
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