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Tuesday, January 3, 2017

Commentary on Medicine, Army of the Confederate States of America

By Dr. Jack E. Butterworth, 3-25-2014.


In September of 1864 General Sherman entered Atlanta pushing all civilians out of the city. He burned all buildings not suitable for military use. General Jubal Early, in the Shenandoah Valley, was outnumbered by General Sheridan’s forces causing a retreating action by the Confederates. General Lee in the Richmond area was short on food and supplies with an approaching Northern Army. General Hood in the western arena had a deficiency of troops and both he and President Davis, after appraisal of the situation, were at a loss for optimism. The outlook for the Confederate Army was indeed grim.

Nevertheless, the September 1864 issue of the Confederate Medical and Surgical Journal was published. The Journal (C.S.M.S.J.) was edited by Dr. Samuel Preston Moore (1813-1889), the Surgeon General of the Confederate States of America.1 Moore had been trained as a military surgeon in the US Army in 1835 and he continued to serve as a Surgeon until 1861. During the Mexican–American War, Moore became friends with Col. Jefferson Davis, the future Confederate President. Moore resigned his commission as a U.S. Army surgeon on February 25, 1861 and returned to his medical practice in Little Rock, Arkansas. Davis appointed Moore to the position of Surgeon-General of the Confederate States Army Medical Department on March 16, 1861.

Dr. William D. Sharpe wrote in the Bulletin of the New York Academy of Medicine that, “The level of material in the (Confederate Medical and Surgical) Journal is high, at least as high as that of any of its American contemporaries, although pressures on space are evident in a sometimes excessively terse style.”

Doctors Peter N. Purcell and Robert P. Hummel Jr. writing about Moore in the American Journal of Surgery described his (Moore’s) career as CSA Surgeon General:

 “He reformed the mediocre medical corps by raising recruiting standards and improving treatment protocols and by placing the most capable surgeons in positions of authority. He improved the ambulance corps and directed the construction of many new hospitals for Confederate casualties. He was directly responsible for the barracks hospital design, which is still used today. He established the Confederate States Medical and Surgical Journal and directed a successful effort to develop substitutes for scarce pharmaceuticals from the indigenous flora of the South. He founded the Association of Army and Navy Surgeons of the Confederate States of America. With skill and dedication, Dr. Moore transformed the medical corps into one of the most effective departments of the Confederate military and was responsible for saving thousands of lives on the battlefield.”
The average Confederate surgeon had received approximately two years of formal training at the time of the War. They were mostly volunteers from the civilian sector of medicine and not primarily military men. Such a Journal was therefore of great value to such surgeons in advancing their ability to manage the magnitude of war wounds they received.  The 1864 issue of the Journal contains medical and surgical conditions pertinent to the War and the times. Detailed articles on tetanus, manufacturing of artificial limbs, treatment of gangrene, and the case presentation and management of an aneurysm of the femoral artery caused by buckshot wounding of a deserter shot by a militiaman were features of the 1864 edition.

 The details of the health of the patients describing the incident of their illness or wounding are most revealing in their descriptions of the personal nature of the War. From them we learn first-hand of the extent of war wounds and illness as well as the degree of treatment available at that time in history.

  One example of such detailed description is that of a 37 yr old male who was engaged in the battle of Secessionville at James Island SC, on 16 June 1862.

 “While standing in a small house and in the act of taking a cartridge from a box, a Minie ball passed through a 3 inch pine wall board and struck him in the ‘fleshy part of the forearm between the ulna and radius splintering them but not causing complete fracture’.” This wound led to suppuration (drainage of pus) and infection. Subsequently the man developed symptoms of Tetanus with the severe generalized symptoms of that complication.1

Tetanus was described by Hippocrates as early as 400 BC and was found to result from ‘wounds’ at that early date. It was predicted in Colonial American times that if a patient survived the fourth day, which was unusual, he was most likely to live. The condition presented dramatic signs of ‘locked jaw’ or spasm of the Masseter(jaw) muscles and ‘opisthotonus’  which is extreme spasm of the muscles of the back causing the patient to rest with only his head and heels touching the floor while he exhibited the spasms.

Undoubtedly in this case at James Island, the ‘Minie ball’ carried bacteria from the pine wood to enter the wound. Additionally there was loss of circulation associated with necrosis(death) of tissue. Laudanum(tincture of opium) was used copiously for treatment when available for symptom relief and relaxation of the tetanic spasms.

 In “Doctors in Gray”, H.H. Cunningham describes the differences in wound trauma as small weapon munitions progressed from the round ball to the Minie ball and higher velocity shells. The ‘round ball’ small arms wound was most prominent early in the War. Cunningham notes that “ .. in 1863 the Army of Northern Virginia alone reported 27,206 cases that were hospitalized as a result of wounds”. This projectile caused significant bone fracture as well as soft tissue destruction.  Unfortunately because an injured soldier was considered to be a greater cost to the opposing army than one killed, it became more common for the armies to include a large number of ‘buckshot’ in their cartridges. On the Olive Drab website it is noted that, “ In the American Revolution, Gen. George Washington encouraged his troops to load their muskets with “buck and ball,” a load consisting of one standard musket ball and three to six buckshot, to increase the probability of a hit.”  This cartridge load caused multiple wounds and “ of 110 Confederate wounded treated in a Union hospital during the fighting around Atlanta, for example, many had from three to five wounds and the soldier with a single wound was the exception”. General Patrick R. Cleburne “ …was hit with 49 bullets at Franklin ..”.This use of buckshot greatly increased the wounded who required care by their units.

The introduction of the “Minnie Ball”, conical in shape, heavier than the old round ball, and of increased velocity fired from a rifled barrel, created even greater wounding than the round ball. Deering J. Roberts, a Surgeon in the Army of Tennessee stated. “ The shattering, splintering, and splitting of a long bone by the impact of the minie or Enfield ball were, in many instances both remarkable and frightful, and early experience taught surgeons that amputation [to avoid infection] was the only means of saving life”. 2

The ‘frightful findings” of all wounds increased the presence of infection which was not understood until later in the century. Tetanus, the streptococcal infection called erysipelas, and gangrene were the scourge of wounds. Undoubtedly what we now call ‘sepsis’ (generalized circulatory involvement) was the final complement to the pathogenesis of the war wound. It is difficult for many of us to realize that until the 20th cn bacteria and viruses as the causative agents of infection was not accepted. In the mid 19th cn Ignaz Semmelweis found that ‘hand washing’ reduced puerperal sepsis in his clinic in Hungary. He did not know why it did so but he understood that a process existed that reduced morbidity.  He was not only ignored for his success in reducing mortality his obstetrical clinics but was actually censored for differing with the medical opinions of his day.
 Antibiotics only came into use in WWII. During the War Between the States there was no understanding of the process by which ‘infections’ developed or were transferred from one patient to another. Even little use of antiseptic solutions was offered. Dr Middleton Goldsmith was a surgeon in the Union army stationed at Jeffersonville army hospital who focused on the treatment of gas gangrene. He wrote a classic book titled: A Report on Hospital Gangrene 1863.3 He believed it (gangrene) was caused by a miasm (a vaporous exhalation formerly believed to cause disease, Merriam –Webster) or poisonous substances that occurred on putrefied flesh.4  This actually was most often due to the anaerobic bacteria, Clostridium species, it was later proved. This complication remains a most dangerous condition in wounds today.

[2002 report] Clostridium perfringens gas gangrene is, without a doubt, the most fulminant necrotizing infection that affects humans. In victims of traumatic injury, the infection can become well established in as little as 6-8 h, and the destruction of adjacent healthy muscle can progress several inches per hour despite appropriate antibiotic coverage. Shock and organ failure are present in 50% of patients and, among these, 40% die. Despite modern medical advances and intensive-care regimens, radical amputation remains the single best life-saving treatment. Clinics of Infect Dis. 2002 Sep 1;35 (Suppl 1):S93-S100.

Treatment for tetanus, erysipelas and gangrene was largely symptomatic. While Joseph Lister had used phenol for antisepsis, the practice was not well established at the time of the War.  Wound cleansing, surgical drainage, dressing changes, and nutrition were widely employed. Amputation was the most prominent surgical procedure performed by confederate surgeons. The less experienced surgeons often left insufficient tissue to cover the stump of the extremity leaving the bone exposed. This encouraged the further danger of osteomyelitis.

 Soaks and washes were used as well as iodine, tannic acid solutions, and camphorated oil. “ … one Confederate surgeon, C.J. Clark of the Third Alabama Hospital in the capital, concluded that they(the solutions) were responsible for much of the erysipelas in the Richman hospitals during the second year of the war and (he) championed the use of warm water dressings”.2

Such was the status of diagnosis and treatment of war related conditions in the mid nineteenth century America. Understanding the medical knowledge of the era and the degree of the conditions presented allows us to better assimilate the truly outstanding magnitude of the concerns facing the medical men of the Confederacy. In addition to the horrendous degree of wounding, both in wound intensity and volume of cases, the general deficiencies of food, clothing, shoes, and sleep compounded the obstacles for the medical sections of each detachment. We can be proud of how our forefathers met these difficulties and served their patients in this time of war.

While the Confederate Army Medical Department was small in size compared to that of the United States army, it was composed of dedicated individuals at the headquarters and field unit level. Dr. Hunter McGuire is perhaps the best known physician of his era and served as medical director for “Stonewall” Jackson’s fabled 2nd Corps. He was the physician who treated Jackson following his wounding at Chancellorsville. As a surgeon, physician, educator, writer, and southern gentleman he excelled beyond comparison. Dr. McGuire himself expressed admiration for the Confederate surgeon in this address to the Southern Surgical and Gynaecological Association, at their Meeting held in Nashville, Tenn., November 13, 1889.

…”And now of the Confederate surgeon let me say a word. How can I express, in adequate terms, my admiration for him! He possessed virtues peculiarly his own. Coming from civil life, it was wonderful to see how rapidly he adapted himself to the discipline of the army and conformed to the requirements of military life. The hardships he endured and the privations to which he was subjected soon transformed him from a novice to a veteran, and I can say, with truth, that before the war ended some of the best military surgeons in the world could be found in the Confederate army.”5

Dr. McGuire went on to describe how the Confederate Surgeon was pressed to devise methods of treating the wounded without adequate supplies or instruments. They used pine sticks for probing gunshot wounds and eating forks were bent to be used as periosteal elevators in skull fractures. They frequently harvested herbs from the forests in which they had grown up to be used for medications. Their ingenuity was motivated by the absence of medical instruments and supplies but they prevailed despite the state of their profession in war. In addition to medical ability the Confederate medical personnel displayed bravery in the face of cannon, gunfire, and bayonet, often taking great personal risks to administer their craft.

While the written history of the War Between the States is focused naturally on military aspects such as the strategies of the generals, bravery of the soldiers, and instruments of war itself, the medical component also has a history worthy of recording. This article serves as an introduction to that aspect and lists only a small portion of the concerns of the Medical Department and the Surgeons of the Confederate States Army. Hopefully it will serve to create interest for further investigation by today’s Southerners interested in understanding the complete story of our ancestors who participated in this conflict.

Dr. Jack E. Butterworth

References
Paperless Archives.com; BACM Research; BAMC Research paperless archives.com.   (The September issue of the Journal is available through the BAMC Research on disc for a $ 10.00 fee.)
Doctors in Gray, The Confederate Medical Service,  H.H Cunningham, 1958.
A Report on Hospital Gangrene, 1863, Dr. Middleton Goldsmith, Bradley and Gilbert Louisville, 1863.
Hospital Gangrene During The Civil War – Civil War Medicine,  Dr. Scott Watson
Between the States: Tennessee/ Virginia During the Civil War.  (The Overmountain Press, 1997,  V.N. “Bud”  Phillips.)
Address in Southern Historical Society Papers. Vol. XVII., Richmond, Va., January-December. 1889. “Progress of Medicine in the South.” Dr. Hunter Holmes McGuire, MD.

From: southernhistorians.org

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