Myths of Civil War Medicine

[KG_SSpoom]

Myth 1: Alternatives to Amputation Were Ignored
Infection threatened the life of every wounded Civil War soldier, and the resulting pus produced the stench that characterized hospitals of the era. When the drainage was thick and creamy (probably due to staphylococci), the pus was called "laudable," because it was associated with a localized infection unlikely to spread far. Thin and bloody pus (probably due to streptococci), on the other hand, was called "malignant," because it was likely to spread and fatally poison the blood. Civil War medical data reveal that severe infections now recognized as streptococcal were common. One of the most devastating streptococcal infections during the war was known as "hospital gangrene."

When a broken bone was exposed outside the skin, as it was when a projectile caused the wound, the break was termed a "compound fracture." If the bone was broken into multiple pieces, it was termed a "comminuted fracture"; bullets and artillery shells almost always caused bone to fragment. Compound, comminuted fractures almost always resulted in infection of the bone and its marrow (osteomyelitis). The infection might spread to the blood stream and cause death, but even if it did not, it usually caused persistent severe pain, with fever, foul drainage, and muscle deterioration. Amputation might save the soldier's life, and a healed stump with a prosthetic limb was better than a painful, virtually useless limb, that chronically drained pus.

Antisepsis and asepsis were adopted in the decades following the war, and when penicillin became available late in World War II, the outlook for patients with osteomyelitis improved. In the mid-1800s, however, germs were still unknown. Civil War surgeons had to work without knowledge of the nature of infection and without drugs to treat it. To criticize them for this lack of knowledge is equivalent to criticizing Ulysses S. Grant and Robert E. Lee for not calling in air strikes.

Civil War surgeons constantly reevaluated their amputation policies and procedures. Both sides formed army medical societies, and the meetings focused primarily on amputation. The main surgical alternative to amputation involved removing the portion of the limb containing the shattered bone in the hope that new bone would bridge the defect. The procedure, called excision or resection, avoided amputation, but the end result was shortening of the extremity and often a gap or shortening of the bony support of the arm or leg. An arm might still have some function, but often soldiers could stand or walk better on an artificial leg than on one with part of a bone removed. Another problem with excision was that it was a longer operation than amputation, which increased the anaesthesia risk; the mortality rate after excision was usually higher than that following amputation at a similar site. As the war progressed, excisions were done less and less frequently.

[KG_SSpoom]

Myth 2: Surgery Was Done without Anaesthesia
Histories of the Civil War and Hollywood movies usually portray surgery being done without anaesthesia; the patient downs a shot of whiskey, then bites down on a bullet. That did happen in a few instances, particularly on September 17, 1862, at the Battle of Iuka, Mississippi, when 254 casualties were operated on without any anesthetic. This episode is recorded in the Medical and Surgical History of the War of the Rebellion and is the only known occurrence of any significant number of operations being performed without anaesthesia. On the other hand, more than 80,000 Federal operations with anaesthesia were recorded, and that figure is believed to be an underestimate. Confederate surgeons used anesthetics a comparable number of times. The use of anaesthesia by surgeons doing painful wound treatments in hospitals was well described but not tallied.

One explanation for the misconception about anaesthesia is that it was well into the 20th century before research led to more carefully designed applications. At the time of the Civil War, ether or chloroform or a mixture of the two was administered by an assistant, who placed a loose cloth over the patient's face and dripped some anesthetic onto it while the patient breathed deeply. When given this way, the initial effects are a loss of consciousness accompanied by a stage of excitement. For safety reasons, the application was usually stopped quickly, which is why surprisingly few deaths occurred. The Civil War surgeon went to work immediately, hoping to finish before the drug wore off. Although the excited patient was unaware of what was happening and felt no pain, he would be agitated, moaning or crying out, and thrashing about during the operation. He had to be held still by assistants so the surgeon could continue.

Surgery was performed in open air whenever possible, to take advantage of daylight, which was brighter than candles or kerosene lamps available in the field. So, while surgeons performed operations, healthy soldiers and other passers-by often had a view of the proceedings (as some newspaper illustrations of the time verify). These witnesses saw the clamor and heard the moaning and thought the patients were conscious, feeling the pain. These observations found their way into letters and other writings, and the false impression arose that Civil War surgeons did not typically use anaesthesia. That myth has persevered, but the evidence says otherwise.

[KG_SSpoom]

Myth 3: Most of the Wounds Were to Arms and Legs
Another misconception common in Civil War history is the concept that most wounds were to the arms and legs. At the root of this myth are statistics that state that about 36 percent of wounds were to the arms and another 35 percent to the legs. These numbers are based on the distribution of the wounds of soldiers evacuated and treated in hospitals, as shown in the records in the Medical and Surgical History of the War of the Rebellion. The trouble is, many soldiers with more serious wounds did not make it to hospitals and were therefore not counted. Wounds of the chest, abdomen, and head, for example, were often fatal on the battlefield. Soldiers with these more serious wounds were often given morphine and water and made as comfortable as possible as they awaited death, while men with treatable wounds, such as injured limbs, were given evacuation priority.

A similar statistics-based misjudgment arises in connection with artillery wounds. These were often devastating, fatal immediately or soon after; few soldiers hit by artillery missiles lived to be evacuated. For this reason, the recorded number of artillery wounds treated is low. That fact has led some authors to conclude erroneously that artillery was largely ineffective.

[KG_SSpoom]

Myth 4: Every Surgeon Had Authority to Amputate
During the first year of the war, and especially during the Peninsula Campaign in 1862, army surgeons performed all operations. Soon the overwhelming numbers of battle wounded forced the army to contract civilian surgeons to perform operations in the field alongside their army counterparts. Their ability ranged from poor to excellent.

Accusations soon arose that surgeons were doing unnecessary amputations just to gain experience. This was undoubtedly true in some cases, but it was rare. After the Battle of Antietam in September 1862, Letterman was so disturbed by public criticism of the army surgeons that he reported:


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.

Motivated at least in part by a desire to improve the public perception of the medical department, Letterman issued an order on October 30, 1862, requiring that "in all doubtful cases" involving Union soldiers, a board of three of the most experienced surgeons in the division or corps hospital would decide by majority vote whether an amputation was necessary. Then, a fourth surgeon, the available doctor with the most relevant skills, would perform the procedure. This system remained in effect for the rest of the war.

After the war, Surgeon George T. Stevens, historian of the the Army of the Potomac's VI Corps, described how the operating surgeon was chosen:


One or more surgeons of well known skill and experience were detailed from the medical force of the division, who were known as "operating surgeons"; to each of whom was assigned three assistants, also known to be skillful men.... The wounded men had the benefit of the very best talent and experience in the division, in the decision of the question whether he should be submitted to the use of the knife, and in the performance of the operation in case one was required. It was a mistaken impression among those at home, that each medical officer was the operating surgeon for his own men. Only about one in fifteen of the medical officers was entrusted with operations.

The Confederate army had a similar problem with excessively zealous surgeons, and it instituted a similar solution. In the 1863 edition of his Manual of Military Surgery, Professor J.J. Chisolm of Charleston, South Carolina, bluntly addressed the issue of unnecessary surgery:


Among a certain class of surgeons ...amputations have often been performed when limbs could have been saved, and the amputating knife has often been brandished, by inexperienced surgeons, over simple flesh wounds. In the beginning of the war the desire for operating was so great among the large number of medical officers recently from the schools, who were for the first time in a position to indulge this extravagant propensity, that the limbs of soldiers were in as much danger from the ardor of young surgeons as from the missiles of the enemy....


It was for this reason that, in the distribution of labor in the field infirmaries, it was recommended that the surgeon who had the greatest experience, and upon whose judgment the greatest reliance could be placed, should officiate as examiner, and his decision be carried out by those who may possess a greater facility or desire for the operative manual.

The new procedures helped the patients, but they hardly changed public opinion. In the end, despite advances in surgical practices and their results, Civil War physicians were unsuccessful in improving their public perception.

[KG_Panzerschreck]

Great info Steve, I really enjoyed reading it.

[KG_RCT_Hasty]

Thanks for the read !