Thursday, September 2, 2010

Here's Your Manual, Doctor

Yesterday at the State Fair I had the chance to visit with one of the Revolutionary War re-enactors, who was portraying a regimental physician. In 30-40 minutes, I learned an awful lot about medicine of that era, some of which will no doubt find its way into my novels.

I learned that there were really only two medical colleges in the colonies - one in New York (which was captured by the British when New York fell) that would one day become Columbia, and one in Philadelphia that had only managed to graduate about fifty students before the war began. And none of those physicians had any training in treating combat wounds. Gunshot wounds were evidently a great rarity in the peacetime colonies (as you can imagine - a criminal is hardly going to take a five-foot-long musket with him when he robs somebody, and a single-shot pistol wasn't a great deal more useful), so the only ones who knew how to treat them would have been members of the British Army.

Thus, the Continental Congress authorized a Dr. Jones (presumably no relation to the guy who found the Lost Ark) to write a manual on treating combat injuries. That manual was then distributed to Colonial Army physicians, who were given two weeks to learn its contents before being expected to operate according to its guidance. Worse, in units where there was no physician, any man who could read was likely to be handed the same manual and ordered to act as the doctor.

Not that having a doctor was a great salvation. For wounds to the torso, knowledge of the internal physiology was so limited that there was simply nothing that could be done. Scholars of the era still thought that the role of the heart was to warm the blood, while circulation was simply the result of bodily movement. If you took a wound to one of your extremities (arms and legs, obviously - if you got shot in the head there likely wasn't much to do except bury you), they either extracted the bullet (if it didn't shatter a large bone), left it inside you (if it was in too deeply to get to), or amputated the limb (if the bullet's ricochets and shattered bone caused too much damage to repair). Without the amputation, by the way, you were all but certainly going to die of infection within just a few days. Even with the amputation, you had only a 55% chance of survival, but most reckoned that better than no chance at all.

A Bullet Extractor
The tools of the physician were remarkable. Laudanum could serve as a strong sedative, but it was rare in the colonies, particularly after the British blockade prevented imports from the poppy fields of Asia. In place of anesthesia, you got to bite on a stick while the doctor probed your wound with his finger. If he found it easily, he might remove it with a special set of forceps that had a rounded impression in the end that was meant to fit the round musket-ball (assuming the soft lead hadn't deformed into an odd shape on impact with the soldier's body or some hard, nearby object). Failing that, the doctor might probe with a long metal rod. The vibration he'd feel upon striking metal was different enough from flesh or bone to be a good indicator of where the bullet could be found. Perhaps he'd find the dime-sized lead ball stuck snugly in the soldier's flesh. In that case, he might apply a special bullet extractor - a long, thin, hollow tube with a handle on one end. Twisting the handle would deploy a screw from the bottom of the tube that could be driven into the lead ball. Once fastened tightly, the ball could be pulled out at last. One final technique was to insert a bit of cloth or some other irritant into the wound and hold the wound open with a retractor or some other tool for a few days. The swelling, puss and other healing processes within the wound would sometimes force the foreign object out (or far enough out that it could be removed manually). As long as all of this activity was accompanied by bright white pus, all was well. If the wound was too severe or the pus turned sickly, or if the flesh began to mortify and couldn't be cut away, then amputation was in order.

An Amputation Knife
Amputation was a quick, brutal, last-ditch effort to save a wounded man's life. After tightening a tourniquet made of quilted cloth straps and a large metal screw, the doctor would begin with a large, heavy knife with an edge on one side and an inward-curve in the same direction as the edge. The curve made it quick and easy to slice through the skin and muscle of the limb. Two cuts were made, until the doctor had a slice completely around the circumference of the appendage. Next, a smaller, very sharp knife would be used to cut any remaining tendons. Then an assistant would apply a leather or cloth harness to pull the flesh above the wound away from the cut. This would cause it to bunch up and come away from the site of the amputation, and allowed for extra flesh to be pulled back down afterward and be sewed over the end of the wound. The doctor would quickly saw through the bone and discard the amputated limb. A piece of waxed string - called shoemaker's cord because, well, because that's what it was - would be looped around a long metal probe with a pointed hook on the end. That point would be used to pierce the artery, pull it forward, and then the cord would be tightened around it to close off the blood vessel.

The wound was then padded with bread flour, wool lint, or a compress made of both together. It might also be treated with alum to help the blood clot. It would be loosely stitched, to allow for massive swelling, and then the soldier was sent off to recuperate. They had a little better than even odds to live.

Now consider battlefield medicine as one more massive challenge that faced the Colonies. They were fighting the most proficient military the world had ever seen to date, victors of campaigns across Europe and around the globe. They had very few well-trained officers, very little money for men and supplies, and they were completely blockaded at sea (lacking even a rudimentary navy). Yet through clever strategy, raw perseverance, and a little help from their friends (various Indian tribes, German General Von Steuben and the French navy, among others), the colonies, against all odds, managed to win their independence.

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