Wednesday, March 11, 2015

Thoracic Surgery in the Civil War

Excerpted from: U.S. Army Medical Department, Office of Medical History

Of a total of 253,142 wounds recorded in the Civil War, 20,607 (8.1 percent) involved the chest, and 8,715 of these (42.3 percent) were penetrating wounds (5). The overall case fatality rate for chest wounds was 27.8 percent and for penetrating chest wounds 62.6 percent. A number of cases were reported in which complete recovery followed gunshot wounds of both lungs. A number of recoveries were also reported after penetrating gunshot fractures of the sternum, apparently because the causative missiles were of low velocity.

In 1863, Assistant Surgeon Benjamin Howard recommended to Brig. Gen. William A. Hammond, The Surgeon General, that penetrating wounds of the chest in which suppuration had not occurred should be managed by removal of all foreign bodies; control of bleeding; paring of the edges of the wound; closure by metallic sutures; and the application of an airtight dressing, so that the wound would be hermetically sealed. In this recommendation, the implications of the physiology of chest wounds, their mechanics, and the principles of wound suppuration and wound healing were all overlooked. Because of failure to realize that sealing the wound hermetically was only part of the problem, infection was common, and a high case fatality rate was inevitably associated with this type of treatment.

Pneumothorax is mentioned in the Civil War history a number of times but apparently seldom reached an alarming stage. Tension pneumothorax is mentioned only a half dozen times.
Hemothorax, either alone or in combination with pneumothorax, was recognized as a dangerous complication, particularly because of the extreme dyspnea often associated with it. Early in the war, it was believed that the surest way to arrest bleeding was by bleeding the casualty further. In the Confederate Manual used during the war, however, venesection was described as a time-honored absurdity, and it is doubtful that it was ever practiced by any Confederate surgeon. The routine plan, when hemothorax was present, was to try to identify the bleeding point, control it, and then employ such general measures as cold acidulated drinks together with the administration of digitalis or opium. It was recognized that if the hemothorax was not absorbed, empyema would result.

Thoracentesis was used to relieve the effects of effusions resulting from acute and chronic pleurisy or from "traumatic pneumonia" (a term used to indicate infected hematoma, atelectasis, lung abscess, and other infectious sequelae). This method was not used, as in World War II, to evacuate hemothoraces and promote rapid expansion of the lung.

Operation was sometimes necessary to control bleeding from the great vessels. The usual procedure was to ligate only the proximal end of the vessel, and it is not surprising that there were no recoveries in wounds of the axillary artery, though there were 5 survivals in 25 casualties with wounds of the subclavian artery.

Four recoveries were recorded in gunshot wounds of the heart. Patients with wounds of the pericardium sometimes languished for several weeks with suppurative processes, but, in one series of 51 cases, there were 22 recoveries. It was noted that extreme dyspnea might accompany a wound of the heart because of intrapericardial pressure, which could be relieved by paracentesis.

Wounds of the esophagus are not specifically mentioned in the Civil War history, but a disproportionate amount of space is given to descriptions of hernia of the lung. Such hernias, it was stated, were extremely uncommon among British casualties at Waterloo as well as in the Crimean War. One case, described in detail, was managed by the technique first described by Tolandus of Parma in 1449 (1) and used successfully by Whittemore (6) in 1929 on nine patients. This technique, which amounts to a two-stage lobectomy, consists of creation of a hernia of the lung, followed by excision of the protrusion after adhesions have formed.



Dr Suresh Bhagia is a highly qualified, experienced, humble, Versatile, Cardiothoracic and Vascular surgeon based in Gujarat. After training in UK, USA and NZ, He came back to serve his motherland.

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