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Tuesday, May 17, 2016

Part II - Human Medicine During the Civil War (Part 2 of 2)

By Dr. Robert Altman,  4-9-14


Dr. Altman practiced as a veterinary doctor for many years. He broke his talk into two sections:
HUMAN MEDICINE DURING THE CIVIL WAR
The Civil War is considered the deadliest war of all the wars in which the United States has participated (see table). Approximately 620,000 men (360,000 Northerners and 260,000 Southerners died in the four year conflict. Of these approximately 110,000 Union and 94,000 Confederate men died of wounds received in battle. The rest died of disease.

When the Civil War started in 1861, there were 85 medical schools distributed throughout 25 states, including the District of Columbia. All had small classes. Most of the surgeons in the war were trained during the 1840s and 1850s. This period was considered the end of the medical Middle Ages. Little was known about what caused disease, how to stop it from spreading, or how to cure it. Surgical techniques ranged from barbaric to barely competent. A Civil War soldier’s chance of NOT surviving the war was about one in five. The fallen men were cared for by an under qualified, understaffed, and undersupplied medical corps. However, working against incredible odds, the Medical Corps increased in size, improved its techniques and gained a greater understanding of medicine and disease every year the war was fought.

Prior to the Civil War a physician received minimal training. Nearly all the older doctors served as apprentices in lieu of a formal education. In Europe four year medical schools were common, lab training was widespread and a greater understanding of disease and infection existed. Just before the Civil War the average medical student in the US trained for only two years, had no clinical experience and no lab instruction. Harvard Medical School did not own a single stethoscope or microscope until after the war. In 1861, the Federal Army had a total of 98 Medical officers and the Confederacy just 24. By 1865 the Union had 13,000 doctors and the Confederacy about 4,000. In addition, more than 4,000 women served as nurses in Union hospitals. By the end of the war army doctors had treated more than 10 million wounded and sick men in just 48 months! When the war started, the US Army medical staff consisted of only the Surgeon General, 30 surgeons and 83 assistant surgeons. Of these, 24 resigned to go to the South and three were dropped for disloyalty. At the end of the war in 1865, more than 11,000 doctors served in varying capacities in the Union Army. Dr. Samuel Preston Moore was given the rank of Colonel. To improve the quality of medical practice, Moore insisted that every medical officer must pass an examination set by one of his examining boards. He disliked filthy camps and hospitals and believed in pavilion hospitals which were long wooden buildings, well ventilated, with space for 80 to 100 beds. An important reform was the establishment of the United States Sanitary Commission to clean up the hospitals, speed up sanitary supplies to field hospitals, general hospitals and hospital ships.

By far the most common procedure performed in the civil war was amputation. Almost any wound, no matter how minor, became infected. Without knowing the cause of infection and having no medications to combat it, any wound became infected -- mostly a Staph aureus or Strep pyogenes bacteria. Although infection was an important reason to amputate, the introduction of the Minié ball was the greatest cause. The Minié ball was invented by Claude-Étienne Minié, an officer in the French army in the 1840s. It differed from the standard round musket ball because of its conical shape and its hollow base at the back of the bullet. When the trigger was pulled and the gunpowder was ignited, the gasses formed would cause the hollow base of the lead .58 caliber bullet to expand. The bullet would then snugly fit into the rifled grooves of the gun barrel causing the bullet head to spin when exiting the gun barrel giving it much greater accuracy and increased range. This bullet caused devastating damage to both bone and soft tissue. On entering a limb the bullet would pulverize bone and muscle; ligaments and tendons were torn away. The wound was often 4 to 8 times larger than the base of the bullet and gangrene would inevitably follow. Extremity wounds shattered the bone and carried dirt and bacteria into the wound which invariably became infected. A little over 17% of extremity wounds led to amputations in both armies. Abdominal or head wounds were almost always fatal.

A common surgeon’s tent in the field had tables or wood planks or old doors placed on barrels where a surgeon and an assistant surgeon, often stripped to the waist and spattered with blood, used a saw and a knife to remove limbs very quickly, throwing the mangled limbs on a pile to be removed later. Most amputees were administered chloroform or ether and experienced little pain during the surgery. However, after surgery the patient suffered a great deal of pain with no medication to offer relief. Morphine was available but was used in limited doses.

Most surgeons were aware of the relationship between cleanliness and low infection rates, but did not know how to sterilize their instruments. Because of frequent water shortages, surgeons often went without washing their hands or instruments thereby spreading bacteria from one patient to another. Most infections were caused by staph aureus and strep pyogenes. These organisms generate pus, destroy tissue, and release toxins into the blood stream. Gangrene commonly followed. Despite these fearful odds, 75% of the amputees survived. The typical treatment protocol for wounds not treated by amputation was to probe the wound for a bullet or shell or bone fragments. This was generally done by the the surgeons unwashed hands. Bleeding blood vessels were ligated and the wound was packed with lint. If the wound could be closed it was sutured closed, and if not sutured the edges of the wound were painted with iodine or other disinfectants such as carbolic acid, bichloride of mercury or sodium hypochlorite.

Every effort was made to treat the wounded within 48 hours. Men were evacuated from the field, often several days after they were injured because the battle was still on. They were usually carried by litter bearers. Most primary care was administered at field hospitals located behind the front lines. Those who survived were then transported by unreliable and overcrowded ambulances–two wheeled carts and four wheeled wagons and then put in two-wheeled carts and sometimes in four-wheeled wagons, riding over rough ground without springs, making the trip agonizing for a badly wounded patient to Army hospitals located in nearby cities and towns.

In time for the Battle of Antietam (September 17, 1862), the Army of the Potomac’s medical director, Dr. Jonathan Letterman, developed the Letterman Ambulance Plan. In this system, the ambulances of a division moved together, each ambulance under a mounted line Sergeant with two stretcher-bearers and one driver, to collect the wounded from the field, bring them to a field dressing station and then to the field hospital. There were many ambulance designs though the Letterman Ambulance proved to be the best. Most of the newer wagons had springs offering a much smoother ride. Ambulance wagons carried both sitting and recumbent patients. Where possible, railroads were used to evacuate wounded to hospitals in major cities. Sadly, ward attendants and orderlies were frequently recuperating patients, often barley able to care for themselves.

Disease caused 60% of all deaths – half from intestinal disorders (typhoid fever, diarrhea and dysentery), the remainder from pneumonia and tuberculosis. Measles, chicken pox, mumps and whooping cough were also prevalent. In the Southern areas, malaria and yellow fever regularly swept through army camps and naval fleets. It is estimated that 995 out of every 1,000 men contracted diarrhea. One quarter of noncombat deaths in the Confederate Army was from typhoid fever. A common cold often developed into pneumonia, the third leading killer after typhoid fever and dysentery. The brilliant results from cleaning up the Crimean War hospitals by Florence Nightingale inspired the North to add nurses to the Army under the supervision of Dorothea Dix. Sadly, she was disorganized, unyielding in controversy and deeply imbued with Victorian principles, and the doctors hated her. By contrast, Clara Barton, the founder of the American Red Cross, did an admirable job with the wounded and sick soldiers, winning over the doctors.

Contrary to common belief, anesthesia was used in most amputations and other surgeries. Chloroform, ether, or a combination of the two were used. Chloroform was preferred by far because of ether’s explosive properties, particularly in a field hospital where bullets or exploding cannon balls could trigger an explosion. The most common method of administering chloroform and ether was through a cloth or paper folded into a cone with a sponge or cloth soaked in the anesthetic fluid in the apex. The cone was held at some distance over the nose and mouth of the patient to allow the first few inhalations to become diluted with air and then allow the cone to be lowered to the nose until anesthesia was effected. The breathing of the patient had to be monitored very carefully because there was very little margin of error between anesthesia and death, particularly with chloroform. Anesthetic deaths were surprisingly low considering the crude means of administration. With chloroform anesthetic deaths occurred in 5.4 per thousand cases, and with ether 3.0 deaths per thousand, but chloroform was preferred because of ether’s tendency to explode.

In the Southern army, where chloroform was scarce, Surgeon J. J. Chisolm devised a cylinder 2½ inches long and one inch wide with a perforated plate on one of its surfaces and a cover with nose pieces. Chloroform could then be poured thru the perforated plate onto a sponge or cotton and inhaled by the patient thru the nose pieces. Both chloroform and ether evaporated in the air quickly. This method was a vast improvement over the open drip technique where much of the anesthetic liquids would evaporate and be lost, particularly when the surgery was done in the field.

Dr. Altman closed his talk by saying, "It amazes me how in those chaotic times record keeping was as efficient and complete as it was."

After a question and answer session, Dr. Altman received a well-deserved round of applause for his efforts.

Image: Army wagon fitted up as ambulance wagon

From: civilwarroundtablepalmbeach.org

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