Tuesday, October 4, 2011

Surgery and tools during Civil War
excerpts from :ehistory.com, and the article of Alfred Jay Bollet, M.D.
The most common Civil War surgery was the amputation. A few words about why there were so many amputations may be appropriate here. Many people have construed the Civil War surgeon to be a heartless individual or someone who was somehow incompetent and that was the reason for the great number of amputations performed. This is false. The medical director of the Army of the Potomac, Dr. Jonathan Letterman, wrote in his report after the battle of Antietam:
The surgery of these battle-fields has been pronounced butchery. Gross misrepresentations of the conduct of medical officers have been made and scattered broadcast over the country, causing deep and heart-rending anxiety to those who had friends or relatives in the army, who might at any moment require the services of a surgeon. It is not to be supposed that there were no incompetent surgeons in the army. It is certainly true that there were; but these sweeping denunciations against a class of men who will favorably compare with the military surgeons of any country, because of the incompetency and short-comings of a few, are wrong, and do injustice to a body of men who have labored faithfully and well. It is easy to magnify an existing evil until it is beyond the bounds of truth. It is equally easy to pass by the good that has been done on the other side. Some medical officers lost their lives in their devotion to duty in the battle of Antietam, and others sickened from excessive labor which they conscientiously and skillfully performed. If any objection could be urged against the surgery of those fields, it would be the efforts on the part of surgeons to practice "conservative surgery" to too great an extent.
Still the Civil War surgeon suffers from being called a butcher or some other derisive term.
The slow-moving Minie bullet used during the American Civil War caused catastophic injuries. The two minie bullets, for example, that struck John Bell Hood's leg at Chickamauga destroyed 5 inches of his upper thigh bone. This left surgeons no choice but to amputate shattered limbs. Hood's leg was removed only 4 and 1/2 inches away from his body. Hip amputations, like Hood's, had mortality rates of around 83%. The closer to the body the amputation was done, the more the increase in the wound being mortal. An upper arm amputation, as was done on Stonewall Jackson or General Oliver O. Howard (who lost his arm at Fair Oaks in 1862) had a mortality rate of about 24%.
Following is a description of a common battlefield amputation. Missing arms and legs were permanent, very visible reminders of the War. Amputees ranged from the highest ranking officers, like John B. Hood, Stonewall Jackson, and Oliver O. Howard, all the way down to the enlisted men, such as Corproal C.N. Lapham of the 1st Vermont Cavalry who lost both of his legs to a cannon ball. Hood, Jackson, Howard, and Lapham were certainly not alone in their loss, as 3 out of 4 wounds were to the extremities...in the Federal Army this led to 30,000 amputations.
Surgery Before the Civil War
The introduction of anaesthesia in October 1846 allowed surgeons to operate more deliberately. But because infection almost always followed, very little surgery was done. Then came the Civil War and the need for an astounding number of operations to be performed by doctors without any prior surgical experience.
Statistics for the Massachusetts General Hospital, one of the premier hospitals of the era, illustrate the state of surgery in the first half of the 19th century. Between 1836 and 1846, a total of 39 surgical procedures were performed at that hospital annually. In the first 10 years after the introduction of anaesthesia, 1847 through 1857, the annual average was 189 procedures, about 60 percent of which were amputations. Opening the abdomen or chest was rare. About two decades after the Civil War, the volume of surgery in civilian hospitals increased enormously with the introduction of antiseptic and, later, aseptic techniques. Between 1894 and 1904, for example, an average of 2,427 procedures were done annually at the Massachusetts General Hospital and, by 1914, more than 4,000.
Many Civil War surgeons lived to see these developments and, reminiscing long after the war, lamented their own lack of preparation for the difficulties of treating large numbers of severely wounded men. "Many of our surgeons had never seen the inside of the abdomen in a living subject...," one physician wrote, adding, "Many of the surgeons of the Civil War had never witnessed a major amputation when they joined their regiments; very few of them had treated gunshot wounds."
Despite the lack of preparation, Union surgeons treated more than 400,000 wounded men--about 245,000 of them for gunshot or artillery wounds--and performed at least 40,000 operations. Less complete Confederate records show that fewer surgeons treated a similar number of patients. As would be expected, the numbers of surgeons grew exponentially as the war raged on. When the war began, there were 113 surgeons in the U.S. Army, of which 24 joined the Confederate army and 3 were dismissed for disloyalty. By war's end, more than 12,000 surgeons had served in the Union army and about 3,200 in the Confederate. During the course of the war, formal and informal surgical training programs were begun for newly enlisted surgeons, and special courses on treating gunshot wounds were given. Surgeons on both sides rapidly developed skills and knowledge that improved the treatment of wounds, and they devised many new surgical procedures in desperate attempts to save lives.
Did Army Surgeons Deserve So Much Criticism?
At the start of the war, and especially during both Battles of Manassas and the Peninsula Campaign in 1861 and 1862, care of the wounded was chaotic and criticism of surgeons was valid. Regular Army personnel in all departments expected a short war fought by professionals and tried to follow rules created for the 15,000-man prewar army scattered here and there at small frontier posts. But the Civil War involved large volunteer forces fighting huge battles and sustaining enormous numbers of casualties. The prewar system was overwhelmed. Hospitals were organized at the regimental level, and transportation of the wounded was improvised. Wounded men sometimes went days without any care. Surgeons operated in isolation, without help or supervision.
While newspaper articles and soldiers' letters described the poor state of affairs to anyone who could read, a new medical director of the Army of the Potomac, Dr. Jonathan Letterman, worked to improve medical care. He was remarkably successful, but the improvements went largely unreported. So public criticism continued to inhibit surgeons, keeping them from making the best decisions. And, as Keen observed, this may have cost lives.
One of many observers who agreed with Keen was William M. Caniff, professor of surgery at the University of Victoria College in Toronto. Visiting with the Union army after the Battle of Fredericksburg in the winter of 1862-1863, he wrote that American surgeons were too hesitant about performing amputations. In a long essay published in the British medical journal Lancet on February 28, 1863, Caniff observed, "Although a strong advocate of conservative surgery..., I became convinced that upon the field amputation was less frequently resorted to than it should be; that while in a few cases the operation was unnecessarily performed, in many cases it was omitted when it afforded the only chance of recovery."
While the criticism continued, medical conditions continued to improve. Evacuation and transportation of the wounded got better, as did the establishment and management of hospitals. And the percentage of the wounded that died after treatment dropped dramatically. After Antietam, for example, 22 percent of the 8,112 wounded treated in hospitals died; but after the Battle of Gettysburg one year later, only 9 percent of 10,569 died. Despite that, an editorial writer in the Cincinnati Lancet and Observer noted in September 1863 that "Our readers will not fail to have noticed that everybody connected with the army has been thanked, excepting the surgeons...."
Civil War Amputation Case
The wait for treatment could be a day, maybe two and that was not out of the ordinary. When treatment was finally done on the poor soldier, it was not done antiseptically. It would only be in 1865 that Joseph Lister embarked upon the era of antiseptic surgery. Surgeons did not even perform careful handwashing before operating. The doctors wore blood splattered clothes. When something was dropped, it was simply rinsed in cool, often bloody water. They used sponges that had been used in previous cases and simply dipped in cold water before using them again on the next person. A surgeon recalled: "We operated in old blood-stained and often pus-stained coats, we used undisinfected instruments from undisinfected plush lined cases. If a sponge (if they had sponges) or instrument fell on the floor it was washed and squeezed in a basin of water and used as if it was clean" The injuries to be dealt with were dreadful and the fault of the soft lead Minie Ball. With the capability to kill at over 1,000 yards, this soft lead bullet caused large, gaping holes, splintered bones, and destroyed muscles, arteries and tissues beyond any possible repair. Those shot with them through the body, or the head, would not be expected to live. Almost all wounds were caused by the bullet, with canister, cannonballs, shells, and edged weapons next on the list.
Amputation a choice
he weapons (particularly the rifle) of the 1860s were far ahead of the tactics; i.e. the generals still thought to take a position you needed to go at it with the bayonet. The cynlidrical lead bullet, the Minie ball, was rather large and heavy (.58 caliber usually). When it hit bone, it tended to expand. When it hit "guts" (i.e. the intestines) it tended to tear them in ways the old smoothbore musket ball did not. Since they crushed and smashed bone so badly, the doctors did not have much choice but to amputate a limb. Wounds to the stomach were almost always a death sentence.
Civil War doctors were woefully ill-prepared; of 11,000 Northern physicans, 500 had performed surgery. In the Confederacy, of 3,000, only 27. Many docs got their first introduction to surgery on the battlefield. Doctors usually did not specialize. Medical school, for many, was just 2 years (some less, few more). Surgeons reacted by adapting. They learned surgery on the job. And people died, of course, until they learned and became better... Many doctorss were political appointments; there were no licensing boards in the 1860s... Army exam boards often even let in quacks.
Of the wounds recorded in the Civil War, 70%+ were to the extremities. And so, the amputation was the common operation of the Civil War surgeon.
The field hospital was hell on earth. The surgeon would stand over the operating table for hours without a let up. Men screamed in delirium, calling for loved ones, while others laid pale and quiet with the effect of shock. Only the division's best surgeons did the operating and they were called "operators". Already, they were performing a crude system of triage. The ones wounded through the head, belly, or chest were left to one side because they would most likely die. This may sound somewhat cruel or heartless, but it allowed the doctors to save precious time and to operate on those that could be saved with prompt attention.
The surgeon would wash out the wound with a cloth (in the Southern Army sponges were long exhausted) and probe the wound with his finger or a probe, looking for bits of cloth, bone, or the bullet. If the bone was broken or a major blood vessel torn, he would often decide on amputation. Later in the War, surgeons would sometimes experiment with resection, but amputation was far more common.
Deciding upon an amputation, the surgeon would adminster chloroform to the patient. Holloywood's portrayal of battlefield surgery is dramatized and largely false; anesthesia was in common and widespread use during the war.... it would make more complicated and longer operations possible as the era of antiseptic surgery began in 1865 (too late for the poor Civil War soldier). With the patient insensible, the surgeon would take his scapel and make an incision through the muscle and skin down to the bone. He would make incisions both above and below, leaving a flap of skin on one side.
Taking his bonesaw (hence Civil War slang for a doctor is a "Sawbones") he would saw through the bone until it was severed. He would then toss it into the growing pile of limbs. The operator would then tie off the arteries with either horsehair, silk, or cotton threads. The surgeon would scrape the end and edges of the bone smooth, so that they would not work back through the skin. The flap of skin left by the surgeon would be pulled across and sewed close, leaving a drainage hole. The stump would be covered perhaps with isinglass plaster, and bandaged, and the soldier set aside where he would wake up thirsty and in pain, the "Sawbones" already well onto his next case.
A good surgeon could amputate a limb in under 10 minutes. If the soldier was lucky, he would recover without one of the horrible so-called "Surgical Fevers", i.e. deadly pyemia or gangrene.
15 years after the War, surgeon George Otis cited the five principal advances of Civil War surgery: the surgeons had learned "something" about head injuries, how to deal with awful "ghastly wounds" without dismay, they had learned how to litigate arteries, information on injuries to spine and vertebrate had been "augumented," and "theory and practice" in chest wounds had been forwarded.
A little about the "Surgical Fevers". These were infections arising from the septic state of Civil War surgery. As you should have been able to see, the Civil War surgeon was interested not so much in cleanlieness, but speed. As such, and not knowing anything about antiseptic surgery, fevers arose. Of these, the most deadly was probably pyemia. Pyemia means, literally, pus in the blood. It is a form of blood poisioning. Nothing seemed to halt pyemia, and it had a mortality rate of over 90%. Other surgical diseases included tetanus (with a mortality rate of 87%), erysepilas, which struck John B. Gordon's arm after he was wounded at Antietam, and osteomyelitis which is an inflammation of the bone. Also, there was something called "Hospital Gangrene". A black spot, about the size of a dime or so, would appear on the wound. Before long, it would spread through, leaving the wound an evil smelling awful mess. The Hospital Gangrene of the Civil War is an extinct disease now.
Amputation manual by by Samuel D. Gross
Amputation manual by by Samuel D. Gross
Surgery tools during civil war
Surgery tools during civil war
How Did American Surgeons Compare to Europeans?
The efforts of Civil War surgeons should be compared with those of their contemporaries: doctors who treated the casualties of the Crimean War of 1854-1856 and the Franco-German War of 1870-1871. Fatality rates during the Civil War, especially those following amputations, compare favorably with those of the British and especially the French in the Crimean War and were much better than those of the Russians and Turks (although statistics for those armies were less thorough).
The data for the British in the Crimean War are the most comprehensive available, thanks in large part to the interest taken in statistics by the renowned nurse Florence Nightingale. The British performed a total of 1,027 amputations, with a fatality rate of 28 percent. Overall, Union surgeons had a fatality rate of 26 percent, performing more than 30,000 amputations. Fatality rates varied with the location of the amputation; the closer to the trunk, the higher the percentage. One place the Union surgeons stood out most over their British counterparts was in amputations at the hip. In every recorded attempt by British surgeons, the patient died. Union doctors, on the other hand, succeeded 17 percent of the time.
The medical data for the Union forces in the Civil War are the most complete of any war involving America. Careful consideration of these records and the state of medicine here and in Europe at the time reveals commendable efforts and results. Overall, American surgeons during the Civil War did a respectable and generally successful job of trying to save lives. They deserve a better reputation than the lowly one they have received.
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