Civil War Surgery
The War broke out during a transition period in medical knowledge. Anaesthesia had been used since the 1840's and thus allowed operations to be performed that hitherto would have been impossible. However there was no knowledge or understanding about the spread of infection until the 1870's. Thus, able to carry out major surgery, medical staff unwittingly caused serious problems with infection.
By far, the most common of wounds to be dealt with, were caused by gunshot. The Minié Ball made a hideous wound, often changing shape as it entered the body and dragging in dirty clothing; upon hitting bone it caused shattering which in turn increased the severity of the damage. Approximately 71 per cent of gunshot wounds were on arms, legs, hands or feet.
There was a difference of opinion amongst Union surgeons about the need to amputate damaged limbs or attempt to repair and try to save them, however, for the staff at the field hospitals time was short. If in doubt the limb was removed. Abdominal wounds were far more serious and the percentage of soldiers surviving them was far less than those losing a limb; bowel and stomach wounds being the most serious.
One of the problems for the wounded was that the transportation from the primary care station to a general hospital was crude and unsanitary; if the wound had not been infected on the battlefield it was almost certainly contaminated en route in ambulance, train or boat. The transportation personnel were more interested in speed of delivery than the comfort of the soldiers in their care.
The officers in charge of advance field hospitals confined the treatment of the wounded to stopping haemorrhage and to bandaging. Tourniquets or compresses were applied, liquor in the form of whiskey or brandy given to counteract shock, and the patient was usually given an opium pill or a dose of morphine. Bandaging of wounds became less common as the war progressed as it was found that they became soiled and contaminated and were causing problems as they were cut away. Splints to be used on fractured limbs were usually cobbled together using fence rails or board, ambulances were furnished with "Smith's Anterior" a suspended splint in ambulances but many staff did not know how to use it correctly. One contribution to medical science was the Hodgen Splint, invented in 1863 by Surgeon J Hodgen. This was a splint that provided room for examination, prevented contraction and allowed drainage of the wounds without disturbing the break. The basic design is still in use today.
The wounded were brought to the field hospital and laid out on straw; the less serious cases would be dealt with by a "dressing surgeon" who together with a medical orderly would operate a triage system passing over the mortally wounded and getting the most needy to the operating table. Pressure of the work load and the primitive conditions of the field units often meant that recommended procedures often were by-passed. It was thought that it was important to operate before infection could set in, but to avoid work whilst the patient was in deep shock. However, there was not the luxury of time available to the surgeons, the operating table had hardly been swilled down after one case before the next was brought in.
The management of the cases after surgery was relatively simple and consisted of rest, the relief of pain by opiates, doses of liquor or quinine to "support the system" and the application of cold compresses to keep down inflammation.
These quick operations broke all the rules of modern asepsis, cleanliness was almost impossible and the field stations soon became a gruesome spectacle as the surgeons worked through the hundreds of cases brought to them. From a Spotsylvania hospital a surgeon wrote home to his wife that he had been steadily operating for four days and that his feet were badly swollen. "It does not seem as though I could take a knife in my hand today. Yet there are a hundred more cases waiting for me. The poor fellows beg for the chance to have an arm or leg taken off. It is a scene of horror as I ever saw."
Pain relief came in the form of opiates; in the state of shock and under the influence of the anaesthetic the pain of the initial surgery was mitigated. It was as shock subsided and infections took hold that the misery of pain was suffered. The poor handling and rough transportation did not help in any way to ease the wounded soldiers plight. Opium was administered in tablet form and often morphine was rubbed into the wound. The hypodermic syringe became more common in the later years of the war and morphine was then injected.
The problem of infection was never really solved; surgeons had little understanding of the healing process and thought that the pus-producing infections were the normal process of tissue repair. When wounds healed without this action as it is now expected to do so, it was thought unusual. Thus large amounts of fatalities occurred due to Septicaemia, Pyaemia and the now unknown "hospital gangrene". The doctors at the time expected this as they were common in the civilian hospitals at the time.
Surgeons reports and letters tell a dreadfully gruesome account of the work that they had to do, the lack of water, the untrained orderlies and the work load are all mentioned time and time again.
I would be wrong to dismiss the efforts of the doctors and medical staff as being poor, throughout the whole of the war huge resources and improvements were made. The medical budget of 1864 exceeded the total amount of money spent on the pre-war army. Medical knowledge was on the verge of major breakthroughs and I consider the numbers of wounded that survived horrific injuries that would even now cause major concern, a testament to the efforts of the Medical Staff and the Sanitary Commission.
Main Sources: Doctors in Blue, by George Washington Adams; Official Records of the Union and Confederate Armies Medical and Surgical History of the War of Rebellion; History of the United States Sanitary Commission.
Pvt. Hugh R Martyr, 20th Maine
The above article first appeared in the ACWS Newsletter, February 2001
SURGERY IN THE FIELD
The wounded soldier who received medical attention in the field (and base hospital) had still to run the considerable risk of surgery. After ambulance facilities were available, field hospitals were sometimes overwhelmed by major battle casualties. The limited number of surgeons worked around the clock and haste and neglect were unavoidable under such circumstances. Anaesthetics, generally chloroform, were available, but there was no notion of aseptic procedure. As W W Keen recalled some years later:
"We operated in old blood-stained and often pus-stained coats with undisinfected hands we used undisinfected instruments and marine sponges which had been used in prior pus cases and only washed in tap water."
Nearly all wounds became infected. In the case of chest or abdominal wounds, surgeons probed with their fingers, prescribed morphine and tried to stop external bleeding. Otherwise there was little that could be done. Death within three days from haemorrhage and/or infection was the normal result. The average Union mortality from gunshot wounds of the chest was 62 percent of cases and from wounds of the abdomen, no less than 87 percent. By way of contrast, only about 3 percent of all American wounded failed to survive in World War II.
The chances for survival following an injury to the extremities were better though not good. Joints were resected and limbs amputated with alarming frequency, often in an attempt to prevent the spread of infection. It was usually the ensuing infection, which caused death. The so-called "surgical fevers" included tetanus, erysipelas, hospital gangrene, and septicaemia.
Medical supplies were transported to the battle areas as part of the general field train, and carried to the front lines in ambulances, or on pack mules, or on the shoulders of the regimental hospital stewards.
The major effective drugs in use were quinine and morphine. Whiskey was frequently administered to the wounded to induce "reaction", and as the solvent for quinine sometimes administered daily as a suppressant of malaria. Chloroform, sometimes mixed with small amounts of ether, served as an anaesthetic. Among other drugs used were opium, pepsin, various emetics and cathartics, iodine, and calomel.
Dysentery, one of the most important diseases from the viewpoint of both high morbidity and mortality, was treated with oil of turpentine, among many other substances, and ipecac was administered for enteritis; probably neither of these was very effective.
The paratyphoid fevers were not separately recognised and diagnosed; the term "typhomalarial fever" was used to describe debatable cases of prevalent remittent fever.
The lack of preventive measures and specific therapy for treatment of the various diseases became a major factor in the outcome of some battles, and at times, of entire campaigns.
The original organisation of the medical serve offered inadequate provision for the removal of the great numbers of casualties from collecting points to hospitals in rear echelon areas. On September 7, 1862, in a letter to Secretary of War Stanton, Surgeon General William A Hammond requested the formation of an ambulance corps. The corps, complete with animals, personnel, and supplies, was first established under the guidance of Dr Jonathan Letterman, Medical Director of the Army of the Potomac.
On the Confederate side, the task of transporting the wounded was complicated by the difficulty of running supplies and equipment through the northern blockade of southern Atlantic ports and the lower Mississippi River.
As in the North, the duties of Confederate surgeons included supervising the moving of the wounded from the battle lines to facilities in the rear. Toward the end of the war, the entire transportation system of the Confederacy, including their ambulance organisation, collapsed for want of the necessary equipment and supplies.
The above three articles first appeared in the ACWS Newsletter, June 1999