Wednesday, November 12, 2014

Post-Operative Care and Consequences during the American Civil War

By Adrienne Bruce

Surgical techniques became a priority for early medicine because there was such a high prevalence of limb and bodily destruction during the American Civil War. The regimental surgeon at the battlefield frontlines triaged more serious cases to be transported via ambulance to the field hospital in the rear of the battlefield, and here, a medical team would explore the wound and make the decision to resect or amputate, a decision often based on resources. While hemorrhage and loss of blood were common causes of death prior to surgery, infection control, pain management, and rehabilitation of veteran back into society determined post-surgical outcomes.

Of the 29,980 successful and reported amputations between 1861 and 1865, Union medical officials documented that 21,753 amputees survived (Jordan 2011). Despite the seemingly high amount of amputations during the Civil War, early nineteenth century physicians preached and practiced “conservative medicine." Based on this philosophy, they refrained from treating the patient when there was evidence that the disease or injury could have a favorable outcome without active interference (Figg and Farrell-Beck, 1993). While conservative medicine seems to contraindicate the necessity of amputations, surgeons believed that amputation was an end to a means, and that removal of the limb prior to infectious reaction would result in a more favorable outcome for the patient. Primary surgery, federally defined as surgical intervention within forty-eight hours of the injury, intervened prior to the onset of infection, but secondary surgery, intervention following the thirtieth day post-injury, was protocol for all injuries with expected inflammation (Figg and Farrell-Beck, 1993). Those that did not receive amputations by primary surgery were believed to be worse off in terms of morbidity and mortality, and the main source of these complications was infection as a result of operative inference.

Following surgery, soldiers and the medical staff were plagued with a road to recovery that involved pain management, infection control, and rehabilitation. Fortunately for Union troops, the United States Sanitary Commission, composed of laypeople and physicians, was established and approved on June 13, 1861 (Gilchrist 1998). Despite this safeguard to standardize medical treatment for military troops, two-thirds of amputees died during the first week following surgery (Watson 1985). While recurrent hemorrhage, gangrene, and erysipelas were of concerns, septicemia as a result of operative intervention was the worst fear of infections because it had a 100% mortality rate and did not manifest until after surgery (Watson 1985). Lint covering limb stumps was made by scraping woven linen and was then added to a wet compress of old muslin cloth and applied to the wound. However, water that was used to soak these compresses was often tainted with bacteria (Gilchrist 1998). Maggots were used to clean wounds because they ate dead tissue that provided a breeding ground for such bacteria. Additionally, potassium permanganate, sodium hypochlorite and nitric acid were used on wound treatment, particularly for gangrene (Gilchrist 1998). Staphylococcus aureus and Streptococcus pyogenes were the cause of the majority of post-surgical infections, and Streptococcus pyogenes was known to cause specifically hospital gangrene, an infection that was transmitted during the recuperation period following amputation (Gilchrist 1998). Furthermore, hospitals located in stable areas were ideal locations for the transmission of tetanus because Clostridium spores flourished in the manure-covered floors (Gilchrist 1998). Even with these treatment attempts, microbes killed more men during the Civil War than rifles and cannons because of poor sanitation.

Anesthesia use began during the 1840s and, thus, was poised to be a key factor in Civil War medicine. The major anesthetic agents were chloroform and ether administered with the help of a cloth formed into a cone-shape with a small sponge in the apex or with inhalers such as the Morton Ether Inhaler (Albin 2000). Additionally, chloroform and ether were often used in combination to attenuate the cardio-respiratory excitatory effects of chloroform, the decrease in flammability, and the stimulatory responses associated with ether, resulting in a mortality rate of 2.6 out of every 1000 patients (Albin 2000). Only about one-fourth of amputees received anesthesia during their surgery based on the records in the Medical and Surgical History of the War of the Rebellion. Both North and South experienced supply shortages that affected their ability to use anesthetics and distribute pain management. Northern troops had abundant supplies but their chaotic medical organization led to poor distribution of what was available. On the contrary, Southern troops experienced shortages due to Union naval blockages, resulting in less Confederate soldiers receiving anesthesia in comparison to Union soldiers. Additionally, the shortage of sponges in the South led them to use cotton rags and raw cotton as well as horse’s tail hair for surgical procedures. Southern surgeons were forced to boil cotton and the horse’s hair to remove dried blood from rags and make hair pliable for use in ligatures which inevitably reduced the spread of infection during surgery (Gilchrist 1998). Despite being at an increased disadvantage due to supplies shortage, Southern surgeons realized the potential of surgical sterilization prior to its full understanding.

Post-operative pain was controlled with opioids, specifically morphine. Morphine effectively managed pain but also heightened pain sensitivity, aggravated already existing pain problems, particularly in soldiers with previous amputations, and immunosuppressed soldiers creating additional infection control issues (Albin 2000). Despite its effective use, morphine use led to addiction that was known as “Army Disease,” which often led to increased crime, drug addictions, violence and unemployment among veterans (Dean 1991). It is hypothesized that many soldiers masked possible psychiatric and stress conditions related to their amputations under the guise of excessive morphine misuse.

As a result of the rise in amputations during the Civil War, the manufacturing field for prosthetics, artificial limbs, and other supportive devices exploded during the nineteenth century. Between 1846 and 1861, thirty-four patents for new or improved artificial limbs, crutches, and invalid chairs were recorded, and between 1861 and 1873, this number grew to one hundred thirty-three (Figg and Farrell-Beck 1993). While there were one and a half times more men that survived the War with upper extremity amputations than lower extremity amputations, there were more limbs and devices patented for the lower extremities (Figg and Farrell-Beck, 1993). Manufacturers sought to make their products strong, light, and durable for ease of gait and comfort but also quiet, non-corrosive, and realistic to help veterans assimilate into society despite their deformities. Despite such a crude appearance, these devices allowed veterans to return to their normal lives following the War.

Overall, the federal government provided little social or occupational rehab for disabled veterans prior to the War. In 1862 Congress began a general law pension system that allowed pension for soldiers with permanent bodily injury as a direct result of military duty following March 4, 1861 (Figg and Farrell-Beck, 1993). Starting in 1864, invalid veterans received a monthly pension for each disability, and each year this system increased payments and provided additionally for disabilities. Veterans were also eligible for an additional allowance to cover artificial limbs, which ranged in average cost of fifty to seventy-five dollars between 1863 and 1864. The Congressional Acts of 1866 and 1867 provided free transportation to and from artificial limb fittings and guaranteed replacement of these limbs every five years (Figg and Farrell-Beck, 1993). Through these implementations, the federal government sought to help Civil War amputees to assimilate into daily life and demonstrate its appreciation for their service.

Following the Civil War, the sheer volume of Union veterans’ claims led to absorption of substantial amounts of national resources. In fact, the federal government spent more funds on veterans between 1865 and 1870 than it had in the preceding eighty years (Gilchrist 1998). Veterans had to submit evidence and photographs of their injuries from physicians and affidavits of witnesses to the Pension and Records Division. Reviewed evidence was submitted for a decision from the Congressional officials (Gilchrist 1998). By the end of the nineteenth century, veterans received benefits that included incidental medical and hospital treatment for all injuries and benefits that covered their widows and dependents (Figg and Farrell-Beck, 1993). While the federal government’s provisions were vast for Union soldiers, they did not provide for former Confederates. Confederate amputees did not receive artificial limb assistance until 1864 when the Association for Relief of Maimed Soldiers provided them with benefits.

Armed with artificial limbs and support from the government, most soldiers who returned home were praised by both nurses and civilians. Their injury served as a symbol of courage and their survival was perceived as a form of pride (Figg and Farrell-Beck, 1993). While many returned to duty even after amputation, many found it difficult to return to work. Former generals initially found it easier to find occupations outside of the War because of their prestige, but the majority of veterans returned to farmlands. Both North and South government provided land for veterans to encourage farming endeavors. Additionally, the federal government passed Section 1754 in 1865 to grant preference to disabled veterans for civil service jobs. For example, the Lincoln Institute, an early predecessor of the Veteran’s Affairs, trained the disabled in telegraphy, typewriting, and bookkeeping (Figg and Farrell-Beck, 1993). The severely wounded often were used during the War as the Union’s Invalid Corps, men who worked as clerks, watchmen, cooks, and attendants due to the shortage of nurses.

Despite the federal government’s help in returning veterans to society, many veterans struggled psychologically with amputations and surgery on the battlefield. Some surgeons pioneered the idea of “irritable heart” or “trotting heart,” which were conditions that essentially defined stress, such as paralysis, diarrhea, and headaches. Such symptoms were often attributed to overexertion or sunstroke (Dean 1991). In fact, the Union Army did not recognize insanity as grounds for discharge, and surgeons had to send soldiers to the Military Hospital for the Insane in Washington to diagnose them. Even so, symptoms of stress short of total breakdown were still viewed as cowardice in society, and most veterans suffered the stress of warfare and amputation quietly (Dean 1991). Despite having survived the war and the complications of amputation surgery, many veterans still suffered in post-Civil War life. Through the consequences of both Civil War medicine and postoperative care during the Civil War, history suggests that the road to amputation was one of both physical and mental strife.



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