Dr. Mudd's Diagnosis

[Leon Greene]

Venturing with trepidation into a specialty not my own (that is, orthopedics instead of cardiology)....

Fractures are classified as simple (or closed, bone not protruding through the skin) or compound (or open, bone protruding through the skin). A comminuted fracture is one where the bone has broken into more than one piece. Other classifications of fractures can include complete or incomplete, meaning that the bone is separated into two parts (complete), or just cracked (incomplete). There are many other types of fractures, but those are the basics and the ones that Dr. Mudd should have been able to recognize.

Crepitus in a fracture can occur from the ends of the bones rubbing together (ouch!), or from air within the soft tissues if the bone has protruded through the skin (or if gas gangrene has appeared). Even a physician in the 1860s should have been able to tell the difference. Darkness and bruising can occur with either simple or compound fractures and doesn't help much with the diagnosis.

Amputation today is virtually never needed for the fracture of a fibula. However, in Dr. Mudd's time, amputations for compound fractures were common. A simple (non-compound) fracture of the fibula would not have needed an amputation, and Dr. Mudd should have been able to tell if the bone was protruding through the skin. Only in third world countries today are extremities removed for simple fractures, almost always inappropriately. It's therefore unlikely that Dr. Mudd missed the diagnosis, in my opinion. He had plenty of time to look for any bone fragments coming through the skin.

Amputations during the Civil War were very common, and a good surgeon could perform one in about 10 minutes. The quicker, the better, since anesthesia wasn't always the greatest. Anesthesia was given in over 80,000 surgeries performed on the troops in the Civil War. A sampling of over 8,900 cases revealed that chloroform was used in 76.2%, ether in 14.7%, and a combination of both in 9.1%. Administration was relatively simple, and often a minimally trained assistant performed the anesthesia. Toxic reactions were rare, and many of the deaths attributed to the anesthetic were, in fact, the result of the severity of the wound or the operation. As today, the risk of the operation (and of the anesthesia) was related to the duration of the surgery; most patients survived the immediate operation itself. Subsequent deaths were often the result of infectious complications. Death ascribed to the anesthetic itself occurred in 0.54% of cases using chloroform; in 0.30% of cases with ether, and in 0.24% with the combination of chloroform and ether. Since pre-operative evaluation for heart and lung disease wasn’t performed, many patients who died may have had pre-existing conditions that might have led to the anesthetic catastrophe.

Amputations were more lethal the closer the incision was to the soldier’s trunk. That is to say, amputation of a foot was less likely to cause death than amputation at the knee. A hand amputation was safer than the removal at the elbow. Overall, about 25% of amputees died at the operation. Hip amputations were fatal 83% of the time; removal of an entire upper arm, 24% fatal. 8 About 75% of all war wounds were to the arms or legs. The Union alone saw 30,000 amputations. 9 Abdominal, head, and chest wounds were almost always fatal. Doctors often triaged these patients to wait until other soldiers with more salvageable wounds were attended, worsening the self-fulfilling prophecy that head, abdominal, and chest wounds would be fatal.

Unfortunately for the victim of a bullet, doctors expected the wound to become infected. It was a normal part of the process; if pus didn’t appear, something was wrong with the “normal” healing of the wound. This situation reigned because doctors didn’t understand anything about the need for cleanliness. Instruments – if cleaned at all – were simply rinsed and passed from one amputation to another. Sponges were used from one patient to the next after only a quick rinse. Doctors proudly wore their bloodstained and pus-besmirched clothes from patient to patient. Clean dressings were almost non-existent, and surgery sites were covered with clothing or strips of torn cloth from the battlefield. (Joseph Lister began the era of antiseptic surgery only in 1865, at the close of the War.) When infection spread to the bloodstream (“blood poisoning” or “pyemia”), fully 90% of its victims died. Tetanus was another accompanying disease of war wounds; its mortality was 87%. 11 Bone infection (osteomyelitis) after an amputation was common. Overall, the mortality from an immediate amputation, regardless of location, was 28%; amputations performed later, after the wound was infected, had a death rate of 52%.

Of course, death of soldiers during the Civil War was more likely due to medical diseases - typhoid, yellow fever, malaria, dysentery, etc. But that's another story....

Now the REAL orthopedic surgeons can comment, and you can forget my amateurish ramblings above.