Gangrene

From: humanillnesses.com

Gangrene (gang-GREEN) is a condition that leads to the death of living tissue. It is caused by blocked blood flow or by bacterial infection.

KEYWORDS
for searching the Internet and other reference sources

Arteriosclerosis

Bacterial infections

Debridement

Frostbite

Hyperbaric chamber

What Is Gangrene?
Gangrene is a condition in which living tissue (skin, muscle, or bone) dies and decays. Gangrene most often affects the legs, feet, arms, and fingers, but it also can affect internal organs such as the intestine or gallbladder. Gangrene can occur when blood flow to an area of the body is blocked or when certain types of bacteria * invade a wound.

* bacteria are round, spiral, or rod-shaped single-celled microorganisms without a distinct nucleus that commonly multiply by cell division. Some types may cause disease in humans, animals, or plants.

Dry gangrene
Dry gangrene can occur when blood flow to a part of the body is blocked. When tissues in the body are deprived of the nutrients and oxygen carried by blood, they begin to die. Dry gangrene

Military Medicine
U.S. Civil War (1861-1865)
The biggest killer in the U.S. Civil War was not instant death by bullet or by cannonball: it was disease resulting from wounds. An estimated 388,500 men died from wounds and other illnesses, including gangrene. Doctors with dirty hands unknowingly infected wounds with gangrene-causing bacteria while trying to treat the injured soldiers.

During this war, doctors noticed that the wounds of some of the soldiers were infested with maggots, which are the larvae of houseflies or blowflies. Those maggot-infested wounds tended to heal faster than those without maggots, because the maggots were eating the dead or decaying tissue that resulted from gangrene infection. Thus, the maggots were cleaning out the dead and decaying tissue, allowing the remaining tissue to heal. They were doing the work that surgeons do today to treat gangrene through debridement of wounds.

World War I (1914-1918)
During World War I, 15,000 miles of trenches stretched along the western front in Europe. Troops who spent many weeks in these cold, wet trenches often developed swollen limbs, damaged sensory nerves, and inflammation, a condition that they called "trench foot."

Trench foot often resulted in gangrene, loss of tissue, and sometimes in loss of limbs to amputations. Physicians and military officers responded to the problem by instituting strict standards of hygiene that became part of the military's ongoing preventive health regimen.

can result from injury or frostbite * , but it most commonly is a complication of diabetes. Diabetes can lead to hardening of the arteries (arteriosclerosis), which restricts blood flow. This is especially common in the legs and feet.

Dry gangrene usually starts in the toes. A person might first feel numbness or tingling in the feet. As gangrene progresses and tissue starts to die, the person will experience severe pain in the affected area. Eventually, the tissue turns black, marking where tissue has died. This type of gangrene needs to be treated promptly, but it is usually not life threatening.

Wet gangrene
Wet gangrene occurs when certain types of bacteria invade an injured area of the body. It occurs most often after an injury in which a body part was crushed or when blood flow was obstructed by a blood clot or a tight bandage. The lack of blood flow causes some cells to die and leak fluid, which moistens the surrounding tissue. The moist environment allows bacteria, such as Streptococci (strepto-KOK-sy) and Staphylococci (staf-i-lo-KOK-sy), to invade the wound and multiply. Wet gangrene causes swollen and blistered skin, and it has a foul odor. Once wet gangrene sets in, it spreads quickly to surrounding tissue. If left untreated, it can kill a person in a few days.

Gas gangrene
Gas gangrene is a type of wet gangrene that usually is caused by the bacterium called Clostridium (klo-STRID-e-um). This type of bacteria requires very little oxygen to live, and it releases gases and toxins as waste products. Gas gangrene causes a high fever, brown pus * , and gas bubbles on the skin.

How Is Gangrene Treated?
When a person has diabetes, frostbite, or an injury, preventing gangrene is a high priority. Taking medications, maintaining good blood circulation, avoiding foot injuries, and not smoking are essential for preventing dry gangrene in people with diabetes. Prompt cleaning of wounds to avoid bacterial infection can prevent wet gangrene.

* frostbite is damage to tissues as the result of exposure to low environmental temperatures. It is also called congelation (kon-je-LAY-shun).

* pus is a thick, creamy fluid, usually yellow or greenish in color, that forms at the site of an infection.

* amputation (am-pu-TAY-shun) is the removal of a limb or other appendage or outgrowth of the body.

* antibiotics (an-ti-bi-OT-iks) are drugs that kill or slow the growth of bacteria.

See also
Bacterial Infections
Cold-related Injuries
Diabetes

If a person develops gangrene, dead tissue needs to be surgically removed before healing can begin (a process called debridement). Doctors try to improve circulation to the affected part of the body and surgeons remove dead tissue. Because bacterial forms of gangrene can spread quickly, part or all of the affected limb might require amputation. * People with wet gangrene also are treated with antibiotics. * Sometimes, people with gangrene are treated in a hyperbaric chamber. This procedure exposes the body to oxygen at high pressure, which promotes healing of the gangrenous tissue.

Image: Amputation saws for treating gangrene infections were part of the military doctor's field equipment.

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Beware Gangrene! Treating This Deadly Disease

By Jake Hanson, 3-28-14

During the American Civil War, two-thirds of the 700,000 soldiers died, not from battlefield trauma, but from infections as a result of battlefield wounds. This means that though a man only took a bullet to his extremities—a hand or a foot—he had the potential to die from complications. The most dreaded of the diseases that could be caught was gangrene.

Confusion abounded about what it is and how to treat it. Indeed, in both the Union and Confederacy armies the mortality rate of soldiers who contracted gangrene was a dismal 45%. That is, if you got gangrene, you might as well flip a coin concerning your chances of survival.

We know today that gangrene is the result of microorganisms that dine on unhealthy flesh, and spread rapidly down the extremities and release poisonous gases as they go. They spread rapidly from person to person, and even from room to room.

Based on thousand year old treatment techniques for the condition from Classical times, Civil War medics treated infected soldiers by calming them with whiskey, giving them a balanced diet, debridement of dead flesh, and some form of topical treatments that had limited effectiveness and was often more harmful than helpful as in the case of the caustic nitric acid. And after treatment, medics would watch for ‘laudable pus’ which was erroneously believed to be a ‘sign of healing.’

In all, these treatments were ineffective and methods often unwittingly spread the disease throughout a hospital.

Dr. Middleton Goldsmith based in Louisville, Kentucky was Surgeon-in-Chief of all military hospitals in Kentucky as well as the Army of the Ohio. He was dissatisfied with conventional treatment and began to experiment with new ways to treat the condition. While he did not understand germ theory, which was currently being studied by Louis Pasteur, he understood the necessity of cleanliness in treatment which went a long way to the prevention of its spread.

The breakthrough for Goldsmith came when he began experimenting with bromine, a chemical element which he used aggressively to treat gangrene, first injecting it deep into infected tissue, then working his way out to a topical application. The result of his treatment was a drastic drop in the mortality rate from 45% to 2.6%. Goldsmith had found that the right medicine injected aggressively and rightly was the best way to treat this deadly disease.

The Apostle Paul writes in his second letter to his disciple Timothy that false teaching about Jesus spreads like gangrene—that is, it spreads aggressively. And without proper and aggressive treatment mortality rates increase. Just like Dr. Middleton Goldsmith found an effective way of treating gangrene, so also Dr. Paul gives us the way forward in treating the infectious disease of false teaching.

“Remind them of these things” writes Paul (2 Timothy 2:14). This is the medicine. What are ‘these things’? Paul just finished telling us the Gospel of Jesus Christ beginning in verse 8 that we are to remember Jesus Christ—Jesus Christ, the Son of God, who as John makes clear, “was God”(1:1) and this God “became flesh and dwelt among us” (1:14). Remember, Paul commands, Jesus who died for our sins, and rose up from the dead, and remember that He is the coming son of David whose reign will never end. And Paul continues to remind us that our salvation and life comes when we, by faith, die with Him, and we enter into eternal glory where we will reign with Him (can you imagine?) forever. This is all ours if we receive Him.

But, for those who reject Him (not those of us who have lapses in their faith), He also will reject us. An eternal and real rejection in hell.

Today, this teaching is being rejected, just as it was rejected in Paul’s day, and has been rejected ever since. We see it in the teaching that Jesus was just a good man, but not divine. We see it with those who reject the substitutionary atonement. We see it in those who teach that Jesus was not really resurrected from the dead. We see it in those who teach that we need not receive Jesus to be accepted by God. We see it when we hear that Jesus is but ONE way to God rather than THE way.

It does not take long to find these teachings. Open up a magazine article on Jesus this Easter season, watch a television show on the Bible, or enter into one of many churches around the country, and indeed the world, and you will find the epidemic of which Paul speaks—false teaching spreads like gangrene!

We tend to treat this disease in one of two ways. First, like the Civil War doctors treating gangrenous soldiers, some waited for “laudable pus.” “It’ll work itself out,” we say to ourselves. After all, false teaching has existed since the fall, but the Church still stands. But this lack of treatment fails to obey the commands of God: “Remind them of these things!”

The second way we tend to treat this condition is to, like some Civil War medics, throw caustic and abrasive acids on the wound, sometimes killing the gangrene, but taking out healthy flesh as well, bringing great pain and discomfort to those being treated. Often in our ‘prophetic’ voices we also pour acid on those infected by the gangrene of false teaching. Paul warns against this as well. “[Correct] those who are in opposition with gentleness” that “perhaps God may grant them repentance leading to the knowledge of the truth” (2 Timothy 2:24), knowing that those infected are not the real enemy, but the devil who holds them captive (vs 25).

But aren’t I being a bit drastic here? Insisting that Jesus is the ONLY way, that Jesus really was and is God who took on flesh, died for our sins and really rose from the grave and that only if we believe in Him can we be saved? Isn’t this the caustic acid of which I warn?

Dr. Middleton Goldsmith faced similar questions. Wasn’t pure bromine too strong? Here are his own words:

"Many of the surgeons had no experience in the use of the remedy [of using bromine]. They were imbued with the idea, prevalent in the profession, that this agent is a highly corrosive and irritating one; and hence, they almost uniformly used it, in the beginning, largely diluted with alcohol, water, or ether [. . .] As the surgeons gained experience with the remedy, they gained confidence in its efficacy, and learned that it was not the corrosive and irritating agent which they had supposed it to be.

"Isn’t that what the Gospel is? Good News, the remedy of our sin-sick condition, and also the remedy of false teaching? But we often want to water it down because we hear that it is highly corrosive and irritating, when in reality, it is the false medicine that is caustic.

"The use of this medicine does not guarantee, however, approval. Paul himself was imprisoned for this Gospel. And he promises us that we too may be rejected for giving the life-saving medicine."

Though a hero, Dr. Middleton Goldsmith was not treated as one after the war. Residents of Louisville, sympathetic toward the Confederacy, turned against him, and so he moved to Vermont where he consulted for difficult medical cases and lectured but never served in active medical practice again.

But his task was complete. He had found an effective treatment regimen for gangrene and it would never be treated the same way again. To do so would be folly.

So use the medicine. Remind them of these things, and nip gangrene in the bud!

Sources: Since I know next to nothing about gangrene, here are some sources I used concerning Middleton Goldsmith:

“Gangrene Therapy and Antisepsis Before Lister: The Civil War Contributions of Middleton Goldsmith of Louisville”

“Hospital Gangrene During The Civil War - Civil War Medicine by Dr. Scott Watson”

From: thedecidedlife.com

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Middleton Goldsmith and Hospital Gangrene

From: library.uthscsa.edu

Middleton Goldsmith was a surgeon in the Union Army during the American Civil War working primarily in the Louisville, Kentucky area. He was born in Port Tobacco, Maryland in 1818, the son of surgeon Alban Goldsmith. His father was the professor of Surgery at Kentucky School of Medicine in Louisville in the mid-1830s, and Middleton served as his anatomy and surgical assistant. Middle enrolled in the New York College of Physicians and Surgeons in 1837 and graduated in 1840. He was a multi-talented and very popular young man who played guitar and banjo, knew Greek and Latin, and was an excellent storyteller. He cofounded the New York Pathologic Society and in 1844 became Chair of Surgery at Castleton Medical College in Vermont. After 12 years, he succeeded his father as Chair of Surgery at Kentucky School of Medicine, soon becoming the Dean of Faculty.
Army Career

Goldsmith joined the Union Army at the outbreak of the Civil War as a Brigade Surgeon and was quickly appointed Surgeon-in-Chief of all military hospitals in Kentucky and the Army of the Ohio, supervising the daily operations of multiple hospitals.

Over 700,000 combined Union and Confederate soldiers perished in the 4 years of that war – more than in all other United States conflicts up to the Vietnam War, combined. More than two thirds of those succumbed to disease and surgical infection, not to direct battlefield trauma. Surgeons faced the formidable problem of treating the infections of wounds sustained during battle, and hospital gangrene was the worst.

British surgeons with experience during the Crimean War a decade earlier recommended patients should have at least 1600 cubic feet to themselves to prevent the spread of gangrene between patients. In some Union hospitals, the space per patient was only about 175 cubic feet, less than a six-foot cube, nearly 10 times less than the British recommendation. Attempts to improve ventilation for gangrene soldiers in such crowded conditions prompted surgeons to cut holes in ceilings or walls to draw the air through. This often backfired, allowing the microbes causing the gangrene to spread to patients in other areas of the hospital.

Many gangrene treatments were tried, including hand washing between patients, whiskey, cathartics, balanced diets, and topical agents applied directly to the gangrenous wound along with debridement, which was often too late or spread the infection. Experiments with poultices of mud, flaxseed, slippery elm, or charcoal were tried. Chlorinated soda water, extremely strong sodium hypochlorite solutions, nitric acid, tinctures of iodine and iron, and turpentine were applied, often in combination and often overpowering and painful and difficult to tolerate and usually without the desired effect of curing the infection or curing it but causing even more damage to healthy tissue.

Experiments in Treating Gangrene

When Goldsmith found himself surrounded by many hospital gangrene patients in Kentucky, he focused on the problem. He reviewed many of the documented outbreaks from early in the war and theorized that the three diseases of gangrene, erysipelas, and pyaemia were in some way connected, although his lack of knowledge of the “putrefactive agent” made his task very difficult. He reviewed the curative agents then in use and concluded that corrosive acids such as nitric acid stopped the gangrene but were also very destructive of living tissues and were impossible to administer safely. He also noted other topical remedies like poultices did not arrest the infection and the consumption of coffee and whiskey did nothing.

Goldsmith noticed that in hospital wards where bromine was used as an aerosolized deodorant, gangrene patients seemed to recover more than in other wards. He recommended the placement of volatile bromine in all patient wards. He developed a method of applying bromine deep into muscular layers after wound debridement then injecting bromine subcutaneously and applying it topically to exposed surfaces. A second application was only applied in cases where the gangrene odor returned.

In an independent report of Goldsmith’s method by another surgeon, G. R. Weeks, it was noted that of 104 patients receiving a bromine-based treatment, there were only 3 deaths, which were due not to gangrene but to pyaemia and cellulitis after the gangrene was improved. Weeks concluded the treatment was 100% successful in preventing death in hospital gangrene patients while other treatment regiments averaged around 25% mortality. Patients recovering with other treatments averaged 15 days convalesce, those with weak bromine 9 days, and pure bromine only 2 days. Similar results were reported by other observers such as John H. Brinton, another high-ranking Union surgeon.

Report to the Surgeon General

Goldsmith thoroughly documented his investigations in his report to the Surgeon General entitled A Report on Hospital Gangrene, Erysipelas and Pyaemia, as observed in the departments of the Ohio and the Cumberland, with cases appended. This 1863 report included colorfully detailed case reports and a foldout table containing all his research data, as well as his correspondence with other surgeons. The data collected included patient’s name, rank, company, regiment, when wounded, where and when gangrene began, tissues involved in the wound, region of wound, general treatment, local treatment, when infection arrested, duration of gangrene, and hospital. His precise data collection and reporting allowed him to claim near complete eradication of hospital gangrene from his wards.  Only 8 of his 304 patients receiving bromine-based therapy died, a mortality rate of 2.6 per cent. The overall mortality of hospital gangrene cases from the Civil War has been reported as 45.6 %. By the end of the war, surgeons applied variations of his bromine treatment throughout the country.

Goldsmith died in 1888.  He greatest achievement was his contribution to surgical antisepsis and his revolutionary bromine therapy. His work predated Joseph Lister’s 1867 paper linking microbes and surgical infection and preventive measures.

Image: American Civil War soldier lies in bed with a gangrenous amputated arm. The picture above is a sketch of Private Milton E. Wallen of Company C, 1st Kentucky Calvary, wounded by a Minié ball while in prison at Richmond, July 4, 1863.  He was being treated for gangrene in August 1863 when Edward Stauch traveled from Washington to make this sketch.   By USG [Public domain] via Wikimedia Commons.

Note: Most of the material in this article, other than illustrations, was summarized from John Trombold’s excellent article on Middleton Goldsmith’s research on gangrene therapy. (See sources below.)  Book illustrations were scanned from the Nixon Library’s copy of Goldsmith’s book.
Come view Goldsmith’s Report on Hospital Gangrene, Erysipelas and Pyaemia in the P. I. Nixon Medical Historical Library.

~Anne Comeaux

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Hospital Gangrene During The Civil War

By Dr. Scott Watson

Laudable Pus and Hospital Gangrene: This is a term first introduced to me by Dr Paul Stanton MD (then chairman of Surgery at East TN State Univ) during my surgery residency.It's an antiquated medical term that refers to a time in medicine when puralent suppuration(wound infection, pus) was considered a normal part of wound healing and a stage in healing most patients must pass thru to final healing of a wound or amputation incision. We now know and recognize four general stages of wound healing and puralent drainage/infection is definitely not one of them. Claudius Galen(circa A.D. 130-200) believed the formation of pus was a critical and essential part of wound healing. His fame as a prolific writer on the science of medicine and the proliferation of medical texts originating from the Golden Age of Greece would provide guidelines for medical practice for 2000 years.

That surgeons welcomed the sight of a purulent wound may be explained by the environment in which they were forced to practice. Wounds could be classified into two different categories: those with suppuration and those without. Wounds productive of a creamy, yellow ooze tended to run a chronic course, taking months to heal, but the patients were generally free of systemic symptoms. It was noted by Steven Smith as late as 1887 that "amputation wounds rarely, if ever, recovered at Bellevue, except after long-continued suppuration." Conversely, a thin, watery discharge was associated with a fatal outcome, with the patient dying of sepsis within days. With an infection rate of almost 100%, a purulent wound represented the lesser of the two evils. Therefore, it is of little wonder that even the most conscientious surgeons preferred and even encouraged the formation of pus.[1]

Laudable pus referred to a thick yellow creamy wound discharge and was a localized infection(probably staphlococcus). It was treated with local wound care and various antiseptics. If the infection didn't spread, the wound slowly healed and the infection would ultimately resolve. Hospital Gangrene was an entirely different matter. It is caused by anaerobic bacteria (which thrive in low oxygen levels) classically Clostridium bacteria. The infection typically begins in open wounds which may have a component of dead tissue present. Poor sanitation can allow inoculation as the bacteria are common flora to our GI tract. The organisms produce gas as a byproduct hence the telltale findings of rapidly advancing erythema, watery thin wound discharge, crepitance to the tissues(gas under the skin can be felt and heard on palpation of the wound), fever, rapid pulse, rapid respiration, low blood pressure. The infection can spread with amazing speed. Modern treatment includes high dose penicillin, surgical debridement of all dead infected tissue(amputation if needed), and hyperbaric oxygen therapy.

Despite these measures, mortality is still high. My first exposure to gas gangrene came as an intern in the emergency room where a middle aged women presented with acute onset of severe back pain. With no history of trauma I first suspected kidney stones. After sending her for CT scan it was hard for me to believe the results. A large mass(colon cancer) had perforated allowing for direct sending of Clostridum bacteria from the colon into the muscles of her back and from there widespread infection throughout her body. Gas was seen in deep tissues of the upper and lower abdomen and back. Air was even seen in the spinal canal and around the brain. Antibiotics etc were given. The infection was too widespread for any surgical debridement and the patient passed away in a few hours. This condition was intensively studied and it's distinction from laudable pus was well recognized by civil war surgeons.

Dr Middleton Goldsmith was a surgeon in the Union army stationed at Jeffersonville army hospital who focused on the treatment of gas gangrene. He wrote a classic book titled: A Report on Hospital Gangrene 1863 Bradley and Gilbert Louisville. He believed it was caused by miasm or poisonous substances that occurred on putrefied flesh.In a later passage he did note there could be passage from one patient to another after an experience where a patient was admitted to the ward with hospital gangrene. Although he died quickly, in short order all four other patients on the same ward contracted gangrene and died. Patients on a different ward in adjacent building did not become infected. He attributed it to airborne transmission of poisons.

He studied many cases of Gangrene both his own and several case reports from other military surgeons. He was convinced that topical and locally injected bromine solutions on infected wounds would improved survival.He also recommends wound debridement and cleaning with the bromine applications. See below.

Copies of this book were issued to Union Surgeons encouraging the use of bromine on these wounds.

Louis Pasteur (1822-1895) vanquished the long-held myth of spontaneous generation and attributed fermentation and meat putrefaction to living microscopic organisms. It was the simplicity and rationality of his experiments that persuaded many of his contemporaries to adopt germ theory.[1]

Joseph Lister (1827-1912; Fig. 1), a professor of surgery at Glasgow, was the first to see the connection between Pasteur's discovery of the fermentation process and the suppuration of wounds. In April 1867 he published his ground-breaking paper on antisepsis, stating that "all the local inflammatory mischief and general febrile disturbance which follow severe injuries are due to the irritating and poisoning influence of decomposing blood or sloughs." Lister began applying carbolic acid to compound fracture wounds. The wound healed without suppuration, amputation was averted, and the mortality rate from amputation plummeted from 45 to 15%.[1]

(1)Miller, Jason T et al; History of Infection Control and its Contributions to the Development and Success of Brain Tumor Operations.Neurosurgical Focus 5/95

From: civilwarmedicalbooks.com

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Joseph Lister and the Story of Antiseptic Surgery

From: hektoeninternational.org

 In some respects the year 1860 represents a watershed in the history of surgery. It was the year when a young surgeon from the Edinburgh Royal Infirmary by the name of Joseph Lister came to the University of Glasgow to take up the position of  Regius Professor of  Surgery. It was also a time when surgery was emerging from its semi-barbarous  medieval state  owing to the introduction and widespread acceptance of general anesthesia. Yet on the wards of the average hospital the odds of a patient surviving a surgical operation were about the same as escaping  alive from fighting Napoleon on the battlefield of Waterloo almost fifty years earlier.

Indeed on these surgical wards wound infections spread from patient to patient like wildfire. No surgeon could ever be certain that his patient would survive his surgery.  Compound fractures were the surgeon's nightmare, often ending up in “hospital gangrene” and amputation. The death rate from major surgical operations or limb amputation was as high as 40%, rising to 60% in French hospitals.  Even simpler operations carried a high risk of death from infection. The hospitals were blamed for this, and there was much talk of closing them down and having the patients being taken care of at home. In Nuremberg, the city fathers seriously considered pulling down the Allgemeines Krankenhaus.

Hygiene in hospitals was deplorable.  A haunting mildly nauseating smell of putrefaction clung to the clothes of the surgeons, some of whom were not ashamed to speak of the “good old hospital stink.” Old rags were strewn about the operating room, also sponges and dirty instruments. Surgeons rarely washed their hands; wore street clothes while operating; and circulated freely between the living patients they treated and the dead ones they dissected or autopsied.  No attempt was made to isolate septic cases, and the nurses and dressers moved directly from patients with erysipelas to healthy ones. The water supply was often polluted, and toilets could be placed in close proximity to the patient area. A hospital was not expected to be more spotless than a carpenter’s shop.

According to the prevailing theory of the time, wound infections (“putrefaction”) were attributed to gases (chiefly oxygen) entering the wound and causing tissue breakdown. Opinions varied as to how the air became tainted, but the observations of Semmelweiss had made no impact on the conservative medical establishment of the time. No surgeon ever risked opening an abdomen or entering a joint. Abscesses were left unopened, rarely drained, or treated by making incisions with valvular openings  that would prevent the entrance of oxygen.

But in France a rising young chemist, Louis Pasteur, was about to unleash a great revolution. He had studied milk, wine, beer, silkworms, and yeasts. Between 1850 and 1860 he had performed a series of rigorous experiments that led him to conclude that the souring of milk by the production of lactic acid and the conversion of glucose to ethanol to make wine were initiated by living microscopic organic matter present in the air. None of these processes would take place when air was excluded from the media in which these experiments were conducted. Pasteur then demonstrated that putrefaction of organic matter such as dead meat would also not in occur  when air was excluded, indicating that this too was caused by the matter present in the air; and it was his genius to make the final leap that human diseases occurring during life would also be caused by aerially transmitted  germs.

So it was at a propitious time that young Joseph Lister came to Glasgow. Born in London in 1827 into a Quaker family, he had been exposed to science since boyhood. Trained by his father to use microscopes, he had studied microscopic fungi and other botanical specimens, dissected small animals, and articulated skeletons. He went to two private schools, and had learned French and German, chemistry, physiology, botany, and microscopy. He had trained under distinguished professors of medicine and physiology, graduating from the University of London in 1852 and later becoming a fellow of the Royal College of Surgeons. While at University College he had written papers on the muscle of the iris and the involuntary muscle fibers of the skin; and had witnessed there the first surgical operation done under ether anesthesia. After graduation he moved to Edinburgh (1853), secured a surgical appointment at the University and the Royal Infirmary, married his chief’s daughter, and spent the next seven years operating, lecturing, and engaging in research. In 1860 he was appointed Regius Professor at the University of Glasgow.

For years Lister had impressed on his students the marked difference in outcome between simple fractures, when the skin was intact, and compound fractures, in which the surface of the skin was broken and amputation was common. One afternoon in 1864, while walking home with a colleague, the professor of chemistry, the latter drew his attention to one of Pasteur’s papers. From that he learned that fermentation and putrefaction were caused not by the gases of the air but by living particles floating in it and settling down on surrounding objects.  If these primitive forms of life could be destroyed by boiling, then why not by chemicals ?  Indeed, “antiseptic” substances  had been used since time immemorial, even by the early Egyptians, and probably also before that. Alcohol had been used freely on the continent, also at times “oil and wine,”  glycerin, chlorine, iodine, and  coal tar. By 1851 carbolic acid had been used in England to preserve cadavers, and in 1860 Jules Lemaire in Paris had published on its use in the treatment of wounds but was largely ignored. All these agents, moreover, were used for treatment, not prevention.

After reading Pasteur’s paper Lister conceived the idea of preventing surgical infections by destroying the organisms that caused it. He settled on a substance called German creosote, used to clean up a sewage plant in nearby Carlisle and then available as a 5% carbolic acid solution. For his first patient, one with a compound fracture of the leg, he produced a small bottle of carbolic acid, poured some into the wound and made a paste of it by mixing it with the blood, then covered the wound and added some fresh carbolic acid every day. The patient recovered with no infection. Between 1865 and 1867 he treated eleven cases of compound fractures, of which nine healed without infection. Next he successfully removed a tumor from a man's arm by applying his antiseptic to the sutured wound; then used it for several amputations, also for a large ventral hernia that required removing  a great amount of fat. As carbolic acid was irritating in solution, Lister dissolved it in oil and later mixed it with powdered chalk to form a sort of a paste or putty that was applied to the wound. To prevent secondary hemorrhage he also used carbolic acid to sterilize the gut suturing material.

After 1870, not being wedded to carbolic acid, Lister used absorbent gauze impregnated with various other antiseptic substances. Between 1871 and 1887 he also used a carbolic acid spray to purify the air in the operating room. It was a pump with a long handle that came to be called the “donkey engine” and caused much mirth but was abandoned when Lister realized that pathogenic organisms were not plentiful in the air. In fact, at a meeting in Berlin in 1890, he said that “As regards the spray, I am ashamed that I should ever have recommended it for the purpose of destroying microbes in the air”.

At first Lister’s antiseptic approach met a mixed reception. Acclaimed by his staff and by those who had studied the details of his technique, it was highly praised in Germany and most other countries, but not in London. In 1869 he left Glasgow to become professor of surgery in Edinburgh. Then in 1877 he accepted an invitation to become professor of surgery at King's College Hospital in London, largely because he felt it was his mission to promote his method.  But the London surgeons were neither impressed nor persuaded. One surgeon while operating sarcastically asked the nurses to close the door, so as not to allow Mr. Lister’s germs to come into the room. The nurses also grumbled and were difficult to work with, being accustomed to regard the wards as their private domain into which no man should come without their permission and interfere with any of their arrangements, such as ventilation or the ways they dressed the wounds.  But Lister prevailed. His reputation grew. The surgeons were converted.  By 1890 the whole world had accepted Lister’s great innovation, and by then the microbes causing sepsis had been identified and cultured.

Eventually most surgeons abandoned antisepsis and switched to the aseptic technique, which Lister pointed out was just a modification of his antiseptic methods and sometimes indeed needed antiseptic support. He made other improvements to surgery, useful surgical instruments, an aortic tourniquet, and was the first to use carbolic acid to treat varicose veins. He was also the first surgeon in Britain to use a rubber drainage tube, the patient in question being Queen Victoria.  Many honors were showered on him; he retired from active surgery in 1893, was elected President of the Royal College of Surgeons in 1895, and made a baronet in 1897. He died in 1912. He is remembered as the innovator who revolutionized the history of surgery, dividing it into the era that came before him and the era that came after him.

References
British Medical Journal. May 29, 1897; Dec 13, 1902; Sept 27, 1924; May 16, 1925; Apr 9, 1927; Apr 1, 1967.
Clark PF, Joseph Lister, his life and work. The Scientific Monthly 1920; 11:518.
Ford WW, The bacteriological work of Joseph Lister. The Scientific Monthly 1928; 26:70.
Harley, Williams, Masters of Medicine, PAN-Books Ltd,1954.

Image 1: Dr. Joseph Lister

Image 2: Surgery using Lister's carbolic acid sprayer

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The Dangers of Amputation Surgery

From: civilwarmonitor.com

This drawing of Union soldier Milton E. Wallen highlights the dangers of amputation surgery. After having his arm removed by Confederate doctors, Wallen headed toward Union lines for medical attention. While recuperating at the Navy School Hospital in Annapolis, Wallen’s stump became infected with gangrene. “Hospital gangrene” was a chronic problem during the war. A small black spot would appear in the wound and slowly expand, resulting in loosened skin, necrosis of body tissue, and corresponding putrid smells. The likelihood of gangrene increased the longer an amputation surgery was delayed—thereby increasing the likelihood of death post-surgery. However, by 1864, Union surgeons learned to control gangrene by pouring carbolic acid—a painful but effective antiseptic—over the infection. (Image Credit: National Museum of Health and Medicine.)

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Osteomyelitis (Bone Infection)

by Janet King, RN, BSN, CCRN

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.

From: vermontcivilwar.org

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Gangrene

by Janet King, RN, BSN, CCRN.

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 its 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.

From: vermontcivilwar.org

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Pyemia ("Pus in the Blood"); ("Blood infection")

by Janet King, RN, BSN, CCRN.

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.

From: vermontcivilwar.org

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Maggots: Friend or Foe?

by Janet King, RN, BSN, CCRN.

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."

From: vermontcivilwar.org

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Disease and Infection

From nps.gov

Nearly two thirds of deaths during the war resulted from various diseases that plagued the soldiers, and 39% of soldiers who died from wounds received in battle, actually died from infection that set in after treatment. In all, Union Physicians treated an estimated 600,000 cases of disease ranging from childhood illnesses, such as Mumps and Measles, to Venereal Disease.

Diarrhea and Dysentery were the most commonly treated of all the illnesses and also responsible for the most deaths. In fact, during the first 2 years of the war, 27% of all diseases treated by onfederate doctors were some form of the diarrheal illnesses. Considered to be a “miasmatic” (coming from bad air) illness, the original treatment was to purge the body of any “irritating food or secretions” dehydrating a patient even further before morphine was administered. If given early enough, the painkiller, which also has properties to induce constipation, could save a soldier’s life.

Hospital Gangrene was probably one of the most feared of any disease. The infection presented itself initially as a black spot on a slowly healing wound. As the infection progressed, the black spot spread slowly through the wound and then on to perfectly healthy tissue, turning the once pink tissue to a mass of rotting flesh. Amputation was usually the end result; but before that extreme measure was taken, doctors tried a number of things including cauterizing the infected flesh with silver nitrate and even packing the wound with lint soaked in turpentine.

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Hospital Gangrene

By Glenna R. Schroeder-Lein
 

Hospital gangrene was a severe streptococcal wound infection that proved fatal to many soldiers, both North and South, during the Civil War. Because it was much more serious than other types of gangrene and developed only in large hospitals in major cities where many kinds of infections were treated, researchers suggest that it may have resulted from a combination of several types of bacteria.

Hospital gangrene was extremely contagious and fast moving. A soldier with a healthy wound could contract the disease and be dead in several days. The edges of the infected wound turned a grayish color and the surrounding tissue was destroyed rapidly, as much as an inch per hour in some severe cases. The gangrene caused blood clotting in the small arteries leading to the tissue, causing the tissue to die and drop off, leaving gaping wounds.

The first step in caring for a hospital gangrene patient was to move him to a tent or separate building to prevent the further spread of gangrene. Here he and fellow sufferers were provided with their own sponges, towels, and sheets, which were frequently washed. Dressings and bandages were often reused elsewhere but not in the gangrene ward.

In cases where gangrene affected a limb, doctors might amputate to prevent the spread of the disease. Where gangrene infected a previous amputation, doctors might amputate again further up the stump. Despite all medical efforts, about 46 percent of hospital gangrene patients died. Many of the survivors had permanent deformity in the affected area.

Excerpted from: The Encyclopedia of Civil War Medicine

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John Meck Cuyler, M.D.

A Confederate Surgeon's Sacrifice

John M. Cuyler was born in Savannah, Georgia on March 9, 1810. He entered the Regular Army as an Assistant surgeon in 1834, being among the first to pass the rigid examination instituted in 1833.

Dr. Cuyler was a graduate of the West Point Military Academy. He was actively engaged in the Creek War of 1838, and the Seminole War of 1840. He served with distinction through the Mexican War, receiving promotion as Major and Surgeon on February 16, 1847. From 1848 until 1855,he served at West Point.

When the secession crisis and Civil War ensued, he chose to remain with the U.S. Army. He was the senior medical officer at Fort Monroe during the first years of the war. He served as Medical Inspector and Acting medical Inspector General. He served on examining boards. Dr. Cuyler was promoted Lieutenant Colonel and Medical Inspector on June 11, 1862.

He served at the II Corps field hospital at Gettysburg. While operating upon a gangrenous wound, his scalpel slipped and cut into his finger. Realizing that the wound would becoming infected, and wishing to avoid spreading the infection to this other patients, Dr. Cuyler had his own finger amputated immediately. He took this action at a time when the germ theory of infection was only a suspicion and not an accepted medical fact.

He was breveted Colonel on November 29, 1864 and Brigadier General on March 13, 1865. He retired on June 30, 1882, and died on April 26, 1884, in Morristown, New Jersey.

Excerpted from: The Journal of Civil War Medicine, Vol. 10, No. 3

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Infections in the Civil War

If a soldier survived his wound and subsequent surgery, he wasn’t necessarily healed. He still faced the looming specter of infection.
Infection can develop when a great amount of tissue damage and necrosis, or, death of the tissue, exist. Civil War doctors didn’t know the causes of infections and weren’t able to treat them. Frequently, the infections reached a stage where amputation of the infected limb became the best option.

Although surgeons were aware of a correlation between cleanliness and a low infection rate, most battlefield conditions didn’t permit even a cursory attempt at cleanliness. Sterilization of wounds and surgical tools was unknown.

Almost every soldier who underwent surgery during the war suffered post-operative infections known as “surgical fevers”. Most of these were actually caused by Staphylococcus aureus and Streptococcus phyogenes, bacterial cells that generate pus, destroy tissue and release deadly toxins into the bloodstream.

Surgeons unwittingly passed these germs from one patient to another as they reused bloodied instruments with unwashed hands. Bullets were also responsible for carrying dirt and germs into the wounds.

Nothing about the surgeries was sterile or antiseptic. After probing a wound with unsterilized instruments or fingers to remove pieces of bullet, shell or bone, doctors sprinkled morphine powder into the wound, packed it with moist lint or unsterilized cotton and bandaged it with wet, unsterilized bandages.

Alcohol, bromine and iodine were in use, but not recognized for their antiseptic properties. Inflammation and quantities of pus—known as “laudable pus” were expected as part of the “healing” process.

Ironically, it was just at this time that Louis Pasteur of France was demonstrating his “germ theory”—the concept that invisible organisms caused the infection of surgical wounds. Joseph Lister of Scotland was basing his own work on that theory.

In 1865, Lister, who would become known as “the father of antiseptic surgery”, successfully used carbolic acid to prevent wound infection. If the work of Lister and Pasteur had been known and accepted during the Civil War, the use of even simple vinegar as an antiseptic would have dramatically reduced the number of deadly infections.

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