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Tuesday, May 27, 2014

Treatment of Wounds: Amputation vs. Conservative Approaches

by Janet King, RN, BSN, CCRN


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.

From: vermontcivilwar.org

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