War Surgery

From: bhatmanjim.weebly.com

The U.S. Army had more doctors than it needed prior to the Civil War.  Surgeons and their assistants found themselves working in remote outposts, spread throughout the country and on the Western Frontier.  Their patients were a small numbers of soldiers who saw little conflict.  Only diseases such as malaria and yellow fever were troublesome.  Surgeons were rarely involved with such diseases however.

As the Civil War approached the quality of medical training had decreased tremendously.  These inexperienced, unknowledgeable surgeons and doctors soon found hundreds of injured and dying men dependent on them.

The Union and Confederate armies shared similar medical practices.  Each regiment had one surgeon, and one assistant surgeon.  Their duties included daily examinations of soldiers’ ailments, and dealing with battlefield injuries.  The instruments and medications used for surgery were often the personal property of the particular surgeon.  Anaesthesia had not become familiarized on the battle field and opium was the primary drug used by patients to cope with severe pain.

Surgery in Civil War field stations and hospitals was quick and barbaric.  Oftentimes lines of soldiers would have to wait and endure the sight of their fellow soldiers being hacked, while they waited their turn.  As the war progressed anaesthesia was used on surgeries in medical hospitals.  Chloroform and ether were utilized in preparation to remove bullets or amputations.  This was done as quickly as possible, both because of the surgeon’s need to see other patients, and the continuation of the tradition of speedy surgery from the time before anesthetics.  Gangrene and maggots were common sights in Civil War hospitals as infection would overtake peoples’ wounds and as bodies would rot, quickly decomposing after death.  Needless to say, the survival rate of Civil War surgeries was not very high.  Many patients died from poor care or major infection.

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'Time Me, Gentlemen': The Fastest Surgeon of the 19th Century

By Matt Soniak, 10-24-12

Dr. Robert Liston was known both for his showmanship and his effectiveness.

Before anesthesia, speed was essential to minimizing pain and improving odds of survival.

Imagine lying on a table in a old-school operating room. Faces stare down at you from the viewing galleries above, and your leg throbs with pain from a broken bone -- infection is just starting to set in. The door opens and three men in blood-stiffened aprons walk in, carting a collection of knives and saws. Two of them grab your shoulders and arms and pin you to the table. The third picks out one of the knives from the cart.

"Time me, gentlemen," he calls out to the gathered spectators. "Time me."

The man grabs your leg and begins to cut just below the knee. He continues to hold onto your leg as one of his lackeys gets a tourniquet around it. To free his cutting hand, he clasps the bloody knife in his teeth and picks up a saw. He cuts back and forth through the bone, drops the severed leg into a bucket filled with sawdust, and sews you up, to the applause of the men sitting in the wings. As promised they've timed the whole procedure -- from first incision to clipping the loose threads on the sutures -- at just two and a half minutes.

In his most famous mishap, he was moving so fast that he took off a surgical assistant's fingers as he cut through a leg.

The man who just flew through your amputation with apparent reckless abandon was Dr. Robert Liston, one of the finest surgeons of the time.

Dr. Richard Gordon, a surgeon and medical historian, calls Liston the "fastest knife in the West End." His style may have seemed careless, but in the age before anesthesia, speed was essential to minimizing the patient's pain and improving their odds of surviving surgery. Slower surgeons sometimes had pain-wracked and panicked patients wrestle free from their assistants and flee from the operating room. Only about one of every 10 of Liston's patients died on his operating table at London's University College Hospital. The surgeons at nearby St. Bartholomew's, meanwhile, lost about one in every four.

Liston's quick hands were so sought after that patients sometimes had to camp out in his waiting room for days waiting for their turn to see him. Liston tried to see every last one of these patients, no matter their condition. He especially loved treating those cases that his fellow surgeons had dismissed as beyond help, which earned him a reputation among colleagues as being showy.

Occasionally, Liston's speed and showmanship actually were a hindrance to his operations. Once, he took a patient's testicles off along with the leg that was being amputated. His most famous (and possibly apocryphal) mishap was the operation where he was moving so fast that he took off a surgical assistant's fingers as he cut through a leg and, while switching instruments, slashed a spectator's coat. The patient and the assistant both died from infections of their wounds, and the spectator was so scared that he'd been stabbed that he died of shock. The fiasco is said to be the only known surgery in history with a 300 percent mortality rate.

Liston had more going for him than just a quick and (mostly) steady slice, though. He was a highly-regarded surgical instructor and prolific inventor. Some of his creations, like the "Liston splint" and "bulldog" locking forceps, are still around today. He also published two medical texts, The Elements of Surgery and Practical Surgery.

Towards the end of his career, Liston made medical history and performed a surgery that made his nimble hands obsolete in Britain. From that point on, pain would no longer be a hurdle to successful surgery, and speed wouldn't be the surgeon's greatest asset.

In 1846, Liston received a patient named Frederick Churchill, whose right knee had been causing him terrible problems for years. None of the treatments he'd been given before had worked, and now the only option was amputation. The day of the surgery, Liston walked into the operating room and, instead of grabbing a knife and asking his audience to time him, he pulled out a jar. Ether, American dentists and doctors had recently demonstrated, could be used as a surgical anesthetic. "We are going to try a Yankee dodge today, gentlemen," Liston told the crowd, "for making men insensible."

Liston's colleague, Dr. William Squire, administered the anesthesia. He held a rubber tube to Churchill's mouth so he could inhale the ether, and after a few minutes, he was out. Squire placed a handkerchief laced with more of the stuff over Churchill's face to keep him that way, and then Liston began the operation.

A mere 25 seconds later, the amputation was complete. Churchill roused a few minutes later and reportedly asked when the operation was going to begin, to the amusement of the audience.

Further use of ether in Europe's operating rooms revealed its drawbacks. It irritated surgeons' lungs, caused vomiting and other side effects in patients and, in some windowless rooms where surgery was performed by gaslight, ignited and caused fires. Anesthetics would continue to improve and become more common in medicine, but Liston wouldn't get to see much of their progress. He died in a sailing accident less than a year after Churchill's surgery, still the fastest knife London had ever known.

From: theatlantic.com

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Chisolm’s Manual of Military Surgery

From: waring.library.musc.edu

“In putting forth this Manual of Military Surgery for the use of Surgeons in the Confederate service, I have been led by the desire to mitigate, if possible, the horrors of war, as seen in its most frightful phase in military hospitals.”
Julian J. Chisolm
Preface to First Edition.

“When the war suddenly broke upon us, followed immediately by the blockading of our ports, all communication was cut off with Europe, which was the expected source of our surgical information. As there had been no previous demand for works on military surgery, there were none to be had in the country, and our physicians were compelled to follow the army to the battle without instruction. No work on military surgery could be purchased in the Confederate States. As military surgery, which is one of expediency, differs so much from civil practice, the want of proper information has already made itself seriously felt. In times of war, where invasion threatens, every citizen is expected to do his duty to his state. I saw no better means of showing my willingness to enlist in the cause than by preparing a manual of instruction for the use of the army, which might be the means of saving the lives and preventing the mutilation of many friends and countrymen.”
Julian J. Chisolm
Preface to First Edition.

From the outset of the war, Julian John Chisolm (1830-1903) realized that knowledge of military medicine was practically non-existent among doctors in the South. Using the knowledge gained during his time observing the treatment of soldiers wounded in the Second Italian War of Independence (1859) in Milan, Italy, Chisolm wrote and published his book, A Manual of Military Surgery: For the Use of the Surgeons in the Confederate Army With an Appendix of the Rules and Regulations of the Medical Department. First published in July 1861, the manual described how to treat specific types of wounds, construct field hospitals, and manage food, clothing, hygiene and non-surgical diseases. Later editions contained detailed illustrations showing how to perform specific procedures such as amputations. The manual became one of the most popular surgery books published by the Confederates States of America and resulted in the publication of three more editions. These later editions incorporated the knowledge gained from the battlefield to improve the treatments of gunshot wounds.

Four editions of the manual were produced during the course of the war and are now available for research use at the Waring Historical Library:
1861 edition
1862 edition
1864 edition
Or online:
1861 edition: http://www.archive.org/details/manualofmilitarychis
1862 edition: http://www.archive.org/details/manualofmilitar00chis
1863 edition: http://jdc.jefferson.edu/milsurgcsa/
1864 edition: http://www.archive.org/details/manualofmilita00chis

“After three years of incessant and bloody warfare I have been called upon to embody, in a new edition of “The Manual of Military Surgery,” the large experience of the medical staff of our army. It has been my aim to condense, in a concise, practical form, the improvements in the treatment of gunshot wounds which have been developed during our active campaigns, and repeatedly confirmed upon thousands of wounded.”
Preface to the Third Edition.

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History of Surgical Treatment of Appendicitis (Article in Serbian)

By Meljnikov I1, Radojcić B, Grebeldinger S, Radojcić N.

Abstract

Most of the history of appendicitis and appendectomy has been made during the past two centuries. Jacopo Berengario da Carpi gave the first description of this structure in 1522. Gabriele Fallopio, in 1561, appears to have been the first writer to compare the appendix to a worm. 

In1579 Caspar Bauhin proposed the ingenious theory that the appendix served in intrauterine life as a receptacle for the faexes. Many of anatomists added more or less insignificant ideas concerning the structure of the appendix and entered upon useless controversy concerning the name, function, position of the appendix vermiformis. The first successful appendectomy was performed in 1735 by Claudius Amyand. 

Geillaume Dupuytren considered that acute inflammation of the right side of the abdomen arose from disease of the caecum and not the appendix. As surgeons were wary of opening the abdomen for examination, early stages of appendicitis remained unknown. John Parkinson was able to give a good description of fatal appendicitis in 1812. Surgeons began draining localised abscesses which had already formed. 

In 1880 Robert Lawson Tait made the first diagnosis of appendicitis and surgically removed the appendix. In 1886 Reginald Heber Fitz published a study on appendicitis and named the procedure an appendectomy. In 1889, Tait split open and drained an inflamed appendix without removing it. Charles McBurney proposed his original muscle splitting operation in 1893 and this was modified by Robert Fulton Weir in 1900. Today we have a multiplicity of signs and symptoms, helping to diagnose appendicitis, and there are a lot of techniques for operation with little essential difference throughout. Kurt Semm performed the first laparoscopic appendectomy in 1981 which became a new gold standard in surgical treatment of acute and chronic appendicitis.

From: ncbi.nlm.nih.gov

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Under the Knife

By Terry L. Jones, 11-17-12

On Aug. 28, 1862, Maj. Gen. Richard S. Ewell’s Confederate division was fighting desperately in the fields and pine thickets near Groveton, Va., during the Second Bull Run campaign. Heavy fire was coming from unidentified soldiers in a thicket 100 yards in front. To get a better look, Ewell knelt on his left knee to peer under the limbs. Suddenly a 500-grain (about 1.1 ounces) lead Minié ball skimmed the ground and struck him on the left kneecap. Some nearby Alabama soldiers lay down their muskets and hurried over to carry him from the field, but the fiery Ewell barked: “Put me down, and give them hell! I’m no better than any other wounded soldier, to stay on the field.”

The general lay on a pile of rocks while two badly wounded soldiers nearby cried out for help until stretcher bearers finally arrived on the scene. Despite their own painful wounds, the two men insisted Ewell be carried off first, but he instructed the litter bearers to take them away. Hours after being wounded, Ewell was finally placed on a stretcher and taken to the rear. Dr. Hunter McGuire, Gen. Thomas J. “Stonewall” Jackson’s medical director, amputated Ewell’s leg the next day.

Campbell Brown, Ewell’s aide and future stepson, witnessed the operation. McGuire and his assistants sedated Ewell with chloroform and used a scalpel to cut around his leg just above the knee. In his drug-induced fog, Ewell feverishly issued orders to troops, but he did not appear to feel any pain until McGuire applied the bone saw. According to Brown, the general then “stretched both arms upward & said: ‘Oh! My God!’”

McGuire opened up the amputated limb to show the officers in the room that the operation had been necessary. The bullet had “pierced the joint & followed the leg down for some inches,” Brown later wrote. “When the leg was opened, we found the knee-cap split half in two — the head of the tibia knocked into several pieces — & that the ball had followed the marrow of the bone for six inches breaking the bone itself into small splinters & finally had split into two pieces on a sharp edge of bone.” Brown and a slave wrapped the bloody limb in an oilcloth, and the slave “decently buried” it in the garden. Brown kept the two pieces of bullet as souvenirs for his mother, who was engaged to Ewell, although he never told the general he had done so.

Rank was no protection from such brutal operations, and General Ewell was just one of many high-ranking officers to face the surgeon’s knife. In fact, statistically speaking, a Confederate general was more likely to require medical treatment than a private. Almost one out of four died in the war, compared with 1 out of 10 Union generals. Of the 250 Confederate generals who were wounded, 24 underwent amputations. General Ewell was one of the lucky ones who survived and returned to duty many months later with an artificial leg.

Approximately two out of every three Civil War wounds treated by surgeons were to the extremities because few soldiers hit in the head, chest or stomach lived long enough to make it back to a field hospital. From a technical point of view, damaged limb bones presented the greatest challenge to surgeons. The war’s most common projectile, the large, oblong Minié ball, often tumbled when it hit the body and caused much more damage to bone than smoothbore musket balls. One Confederate surgeon observed, “The shattering, splintering, and splitting of a long bone by the impact of a minié or Enfield ball were, in many instances, both remarkable and frightful.” When bone was damaged, surgeons had to decide quickly on one of three possible treatments. If it was a simple fracture, a wooden or plaster splint was applied, but if the bone was shattered the surgeon performed either a resection or an amputation.

Resection involved cutting open the limb, sawing out the damaged bone, and then closing the incision. It was a time-consuming procedure and required considerable surgical skill, but some surgeons became quite proficient at it. After the Battle of Savage’s Station in 1862, one Union surgeon completed 26 resections of the shoulder and elbow in a single day. He was said to be able to eat and drink coffee at the operating table while pieces of bone, muscle and ligaments piled up around him.

Besides being a difficult procedure, resection also carried a high risk of profuse bleeding, infection and postoperative necrosis of the flesh. Successful resections, however, allowed the patient to keep his limb, although it was limp, useful merely to “fill a sleeve.” Because of the time required, resections were not always practical when there were large numbers of patients to treat, but they were used more frequently after surgeons learned that amputations had a much higher mortality rate.

The amputation process was fairly simple. After a circular cut was made completely around the limb, the bone was sawed through, and the blood vessels and arteries sewn shut. To prevent future pain, nerves were then pulled out as far as possible with forceps, cut and released to retract away from the end of the stump. Finally, clippers and a rasp were used to smooth the end of the exposed bone. Sometimes the raw and bloody stump was left untreated to heal gradually, and sometimes excess skin was pulled down and sewn over the wound. Speed was essential in all amputations to lessen blood loss and prevent shock. An amputation at the knee was expected to take just three minutes.

Civil War surgeons almost always had chloroform to anesthetize patients before an amputation. The chloroform was dripped onto a piece of cloth held over the patient’s face until he was unconscious. Although not an exact science, the procedure worked well, and few patients died from overdose. Opium pills, opium dust and injections were also available to control postoperative pain.

The mistaken belief that amputations were routinely performed without anesthetics can be partially attributed to the fact that chloroform did not put patients into a deep unconscious state. Bystanders who saw moaning, writhing patients being held down on the table assumed no anesthetic was being used. As in the case of General Ewell, patients often reacted to the scalpel and bone saw as if in pain, but they did not remember it afterward. After his left arm was amputated (Dr. McGuire also performed that operation), Stonewall Jackson mentioned that he had heard the most beautiful music while under the chloroform. Upon reflection, he said, “I believe it was the sawing of the bone.”

Because surgeons preferred to operate outdoors where lighting and ventilation were better, thousands of soldiers witnessed amputations firsthand. Passers-by and even wounded men waiting their turn watched as surgeons sawed off arms and legs and tossed them onto ever growing piles. The poet Walt Whitman witnessed such a scene when he visited Fredericksburg in search of his wounded brother. “One of the first things that met my eyes in camp,” he wrote, “was a heap of feet, arms, legs, etc., under a tree in front of a hospital.” Indeed, after the December 1862 Battle of Fredericksburg, Union surgeons performed almost 500 amputations.

Early in the war surgeons earned the nickname “Saw-bones” because they seemed eager to amputate. This eagerness stemmed not from overzealousness but from the knowledge that infections developed quickly in mangled flesh, and amputation was the most effective way to prevent it. Those limbs removed within 48 hours of injury were called primary amputations, and those removed after 48 hours were called secondary amputations. The mortality rate for primary amputations was about 25 percent; that for secondary amputations was twice as high, thanks to the fact that most secondary amputations were performed after gangrene or blood poisoning developed in the wound. Surgeons learned that amputating the limb after it became infected actually caused the infection to spread, and patients frequently died. Thus, the patient was much more likely to survive if a primary amputation was performed before infection set in.

Primary amputations were also preferred because it was easier and less painful to transport an amputee than a soldier whose broken bones and inflamed tissue made the slightest jostle sheer torture. One surgeon admitted that an excessive number of amputations may have been performed during the war, but he added, “I have no hesitation in saying that far more lives were lost from refusal to amputate than by amputation.”

Where the amputation was made on the limb was as vital to survival as when it was done. Generally, the higher up the amputation was made, the higher the mortality rate. This was especially true for thigh wounds. More than half of all soldiers who suffered a femur wound died, and amputations at or near the hip joint had a 66 percent mortality rate in the Confederate Army.

Nonetheless, it is estimated that approximately three out of four soldiers survived amputations. Amazingly, some, like Confederate Brig. Gen. Francis T. Nicholls, endured more than one. His lower left arm was amputated after he was shot at the First Battle of Winchester and his left foot was taken off when he was wounded at Chancellorsville. After the war, Nicholls was a popular Louisiana governor who was said to ask people to vote for “all that’s left of General Nicholls” and to support him for governor because he was “too one sided to be a judge.”

Often, surviving an amputation seemed to be completely random. While some, like Ewell and Nicholls, seemed unhindered by the surgery, others died from what appeared to be rather minor wounds. Two members of Company B, 19th Michigan Infantry, were shot in the index finger in the same battle during the Atlanta campaign. One man treated himself by cutting off the mangled finger with his pocket knife. He wrapped the stub in a handkerchief and waited until the battle was over to have the wound dressed at the field hospital. The other soldier went immediately to the surgeon for a proper amputation. Gangrene set in within days, and the surgeon was later forced to amputate his arm at the shoulder. The soldier died soon afterward. The man who treated himself made a full recovery and lived to a ripe old age.

Taking care of amputees put a significant strain on both wartime governments. The Union provided its disabled soldiers with prosthetic limbs made from cork wood, metal or rubber and gave amputees $8 a month as a pension. The Confederacy was unable to be so generous and by 1864 was providing just 10 percent of the needed prostheses. Incredibly, Mississippi’s single greatest state expenditure a year after the war ended was the purchase of artificial limbs for its veterans, which consumed 20 percent of the state’s budget. Some amputee veterans were forced to look after themselves and paired up to form “shoe exchanges” where they chipped in to buy a pair of shoes and each man took the one he needed.

Amputation was the most common Civil War surgical procedure. Union surgeons performed approximately 30,000 compared to just over 16,000 by American surgeons in World War II. One postwar British traveler noted that amputees were “everywhere in town and farm communities through the South.” The men who had survived the surgeon’s knife were a visible reminder of the Civil War for decades.

Sources: Terry L. Jones, “The American Civil War”; Terry L. Jones, ed., “Campbell Brown’s Civil War”; Donald C. Pfanz, “Richard S. Ewell”; Ira M. Rutkow, “Bleeding Blue and Gray”; Robert E. Denny, “Civil War Medicine”; Frank Vandiver, “Mighty Stonewall.”

Terry L. Jones is a professor of history at the University of Louisiana, Monroe and the author of six books on the Civil War.

Image: Unidentified soldier with both arms amputated.

From: opinionator.blogs.nytimes.com

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Civil War Surgeries: The Truth Behind the Myth

By Karen, 3-3-14

You may have seen it in a film or read it in a book: a bloody Civil War surgery consisting of an incompetent surgeon, overeager to amputate, chopping off limbs unnecessarily and without anesthesia in a chaotic hospital tent. However, despite its prevalence, this traditional view of Civil War surgeries is mostly myth.

Myth 1: Surgeons amputated unnecessarily and too often.

The Civil War occurred before x-rays and antibiotics—and basic antiseptics, while used, were not used uniformly due to a lack of understanding of germs. As a result, infection was a deadly problem for the wounded, more deadly in fact than amputation. So when a man came in with a bone shattered by a bullet or artillery shell—especially if the bone was protruding through the skin—amputation was often the surest way to save the man’s life, as it would actually reduce the risk of fatal infection. If the surgeon didn’t amputate right away but waited instead, often until infection set in, the mortality rate rose from around 25 percent to twice that. In the Northern hospitals, after late 1862, if there was any doubt about whether a limb should be amputated, three surgeons were consulted; if the majority decided amputation was the right course, a fourth doctor would do the surgery. While there were certainly individual surgeons, especially early in the war, who amputated unnecessarily, surgeons in general were more likely to be criticized by other medical professionals for actually not amputating often enough.

Myth 2: Surgery was performed without anesthesia.

In reality, around 95 percent of operations, at least in the North, were done with anesthesia, often ether or chloroform. The rumor that the surgeries were done without anesthesia, a misconception widespread even at the time, was probably a result of the fact that the anesthesia didn’t always render the patient fully unconscious. Some patients under anesthesia were awake but numbed to the pain; others weren’t conscious of what was going on around them, but their bodies still reacted. Since many surgeries were performed outside—and even when they were done inside there were still bystanders—many soldiers saw the anesthetized patient thrashing around and yelling and assumed that meant he hadn’t been given anesthesia.

Myth 3: Military hospitals and their systems for operating were unorganized.

At the beginning of the war, this was generally true. The Northern military medical system wasn’t prepared for an extended war or for the number of casualties. But after 1862, when Jonathan Letterman was appointed medical director for the Army of the Potomac, things rapidly improved, at least in the North. Among the many changes he made, Letterman required the use of triage, reorganized how surgeons obtained their supplies, developed and unified the ambulance system, and hired hospital administrators.

Because of these and other misconceptions, Civil War surgeons were underappreciated then as well as today. While there were of course exceptions, as a whole the surgeons did the best they could with the knowledge and supplies they had. Walt Whitman—who spent countless hours visiting Civil War hospitals—perhaps summed it up best when he wrote, “I must bear my most emphatic testimony to the zeal, manliness, and professional spirit and capacity, generally prevailing among the surgeons, many of them young men, in the hospitals and the army. […] I never ceas’d to find the best men, and the hardest and most disinterested workers, among the surgeons in the hospitals. They are full of genius, too. I have seen many hundreds of them and this is my testimony.”

Image: Wounded soldiers in Armory Square Hospital, Washington DC; man with amputated arm at left and man with amputated leg at center

From: spotlights.fold3.com

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Civil War Amputation: How Lives Were Saved

From: gettysburgfoundation.org

“I noticed a heap of amputated feet, legs, arms, hands, etc. –about a full load for a one-horse cart. Several dead bodies lie near, each covered with its brown woolen blanket”
-Walt Whitman
Poet and Civil War nurse,   Falmouth, VA   1862

In the winter of 1862 the poet Walt Whitman traveled to Falmouth, Virginia in hopes of finding his wounded brother. The recently fought battle of Fredericksburg had left in its wakes thousands of freezing, bloody, casualties for Union medical staff to attend to. Unprepared for the sight of a field hospital with its attendant blood and gore,Whitman described it by conjuring scenes associated with a butcher shop or slaughter house - a sight and smell which many 19th century Americans would have been familiar with. Often described as butchery, Civil War surgery, especially amputations, deserve a second look. The exact number will never be known but approximately 60,000 surgeries, or 75% of all the operations done during the Civil War were amputations. From our modern perspective this seems drastic. However, the frequency of this invasive and disfiguring procedure was one of the few ways to combat deadly infections such as sepsis, pyemia and gangrene.

The weaponry and tactics used during the American Civil War caused damage beyond the capabilities of known medical procedures. The soft lead minie ball (bullet) used in the Civil War was very heavy and rather large close to the size of a present day .58 caliber bullet. When a fired minie ball struck a soldier’s bone it smashed or shattered it.

A broken bone protruding through the skin was termed a compound fracture, while a bone shattered by a bullet or a piece of shrapnel, it was called a comminuted fracture. Compound and comminuted fractures almost always resulted in an infection to the bone, a condition known as osteomyelitis. The bone marrow, along with the bone itself, usually became infected. If the infection spread through the bloodstream, death would eventually result. The best way to prevent this was the removal of the shattered limb within 48 hours of being shot. Doctors usually had no choice but to amputate the limb because of the extensive bone damage and the subsequent infection risk.

The process of amputation was not quite as crude as common imagery has us believe. Blood loss was always a major concern when performing an amputation. Often, especially in the middle ages, soldiers were left to try to survive infection rather than risk the probable death from blood loss. In 1674, French surgeon Etienne Morel invented a light and simple tourniquet that could easily be used on battlefields and in hospitals to stop blood flow. Thus, the practice of surgical amputations became a more common means of dealing with wounds of this nature.

The use of surgical anesthetics including chloroform and ether, had been established in the late 1840’s. Anesthetics were in use at almost all Civil War field hospitals and Union army records show 80,000 surgeries being performed using anesthesia over the course of the war. Confederate numbers, though not available, were probably comparable. The phrase “bite the bullet” – or the practice of having a bullet placed between the teeth of a surgery patient who didn’t have the benefits of anesthesia - is often linked to the Civil War. In fact, the phrase doesn’t appear until 1891 when Rudyard Kipling uses it in his novel entitled The Light that Failed, and virtually no surgeons or nurses comment on the practice during the American Civil War.

The medical theory of the time stated that the further from the heart, or body trunk, the amputation could be performed, the better the chances of survival of the patient. Approximately 75% of Civil War amputees survived and recovered from the procedure. Union Surgeon Dr. Jonathan Letterman (the namesake of Camp Letterman at Gettysburg) created a battlefield evacuation system which included the formation of a new ambulance corps. This decreased the time between wounding and arrival at a field hospital. Letterman was keenly aware that speed improved patient outcomes.

As the Civil War progressed surgeons gained vast amounts of knowledge about how to make an amputation successful and became deft at performing them at times for hours in field hospitals situated close to heavy fighting. Such was the case at the George Spangler Farm. The Spangler’s farm was commandeered as the 11th Corps field hospital on the first day of the battle of Gettysburg. Dr. Daniel Brinton, engaged as division surgeon-in-chief at the Spangler Farm’s Eleventh Corps field hospital, wrote in his diary on July 5: “...Four operating tables were going night and day…We worked with little intermission, & with a minimum amount of sleep.” Division Commander General Carl Schurz toured the 11th Corps Hospital during heavy rains that followed on July 4, 1863 and noted that he: “saw long rows of men lying under the eaves of the buildings, the water pouring down upon their bodies in streams. Most of the operating tables were placed in the open…partially protected by the rain…There stood the surgeons, their sleeves rolled up…their bare arms as well as their linen aprons smeared with blood…around them pools of blood and amputated arms or legs in heaps…a surgeon, having been long at work…put down his knife, exclaiming that his hand had grown unsteady, and that this was too much for human endurance, hysterical tears running down his face.”

In April of 1863 the U.S. War Department issued General Order #105 which called for the organization of the Invalid Corps, also known as the Veteran Reserve Corps. This organization was formed to make suitable use in a military or semi military capacity of soldiers who had been rendered unfit for active field service on account of wounds or disease contracted in the line of duty.

In March of 1864, General Order No. 111 stated that the title of the Invalid Corps would be changed to The Veteran Reserve Corps. The Veteran Reserve Corps was divided into two battalions; the First Battalion was composed of men whose disabilities still allowed them to use a musket and do minimal marching. The Second Battalion was made up of soldiers whose disabilities were of a much more serious nature, such as amputees. These men were used as guards, nurses, orderlies and cooks. During the course of the war, over 60,000 soldiers served in the Invalid and Veteran Reserve Corps.

Image: Walt Whitman, circa 1863. Photo Credit: The Library of Congress

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Combat Medicine: Battlefield Surgery

By Becker Staff, 10-20-10

The demands of treating the many wounded and sick during military conflicts have put great pressure on caregivers, physicians, and surgeons in every age. The unique difficulties and situations of wartime medicine, however, have sometimes led to important medical advancements. Surgery, especially, has developed remarkably from work being done on combat wounds since the time when Galen advanced his knowledge of human anatomy by studying the gladiatorial injuries he treated. Paracelsus also found his time spent traveling with various armies across Europe to be essential for his education in surgical techniques. In the Rare Books Collection of the Bernard Becker Medical Library are numerous books in which surgeons describe how their work with wartime casualties helped lead to the development of better surgical care for everyone.

The library’s books on wartime surgery reveal tremendous advancements in surgical technique, often spurred on by the conditions of military conflict, but they also make it clear that modern war has continued to become more destructive.

In fact, the man who helped to make surgery a respected medical specialty in the 16th century worked out many of his most important techniques on injured soldiers. In his first book, which discussed treatments for gunshot wounds, the French surgeon Ambroise Paré described how he had discovered that the contemporary method of cauterization with boiling oil led to more pain, infection, and amputation than simply cleaning wounds with a turpentine-based solution. Paré would go on to develop arterial ligatures and many techniques for securing shattered limbs. His work and writings brought him great fame, so that he ended up serving the kings of France and his books on surgical techniques were published many times. The library has several early editions of his collected works.

Surgical techniques continued to improve over the next two centuries, but little was done to ensure the delivery of effective medical care during combat even as armies became larger and their weapons more horrific. Only when the French Republic put together a huge force of citizens did military administrators seek to improve surgical conditions on the battlefield. Dominique Jean Larrey stands out as the organizing genius of this period of war across much of Europe. He created a force of quick ambulance carriages for the French that delivered the wounded to military field hospitals as close to battles as possible, where a triage system determined who needed the most immediate care. Since surgeons still had to deal with the tremendous risk of infection from bullets and shrapnel, the most frequent surgery remained immediate amputation, a procedure that Larrey helped to perfect. The Becker Library holds several editions of these memoirs of his years spent improving medical care during the Napoleonic Wars.

Military medicine and surgery continued to improve over the course of the nineteenth century, especially after the international disasters of the Crimean War encouraged further development of medical institutions. Surgery still had to be quick and infection remained the major killer, but surgeons now had an effective infrastructure of field units and hospitals to care for the wounded. By the time of the American Civil War, surgeons often used chloroform as an anesthetic to allow them to perform precise surgeries on unconscious patients, while the use of morphine helped to ease the pain of injuries. Frank Hamilton wrote a short pamphlet on modern surgery at the beginning of the war to advise surgeons. After his experiences over the course of the conflict, he followed that up with a huge text in 1865, highlighting all the advances in medical practices for the battlefield including the transport of the wounded, specific surgical techniques, and methods of effective bandaging to ensure proper healing. Hamilton would go on to become a famous surgeon who attended presidents.

In 1861, the renowned Philadelphia surgeon, Samuel D. Gross also produced an important manual on military surgery for the army’s use in the coming conflict. His guide proved invaluable to surgeons in the field. Their work clearly had become an essential part of the war effort, for in 1862 the Confederate government in Richmond, Virginia ordered a pirated copy of the Gross book to be produced for their military doctors. And then they demanded another reprint a year later. Like the Hamilton book, this text discusses the use of chloroform for battlefield surgery and describes the best techniques for ligation and amputation to deal with the dreadful wounds of modern warfare that were likely to lead to infection and gangrene.

By the 1870s, a new understanding of what causes infection led to the development of aseptic surgery. Reducing the risk of infection through aseptic surgery and antiseptic wound cleaning revolutionized surgery by making it much safer. So, the development of anesthesia and aseptic operating rooms meant that surgeons could perfect difficult, detailed procedures for work on specific conditions. Soon afterwards, x-ray imagery offered a guide to the surgeons’ hands before any operation had even started. The Boer War witnessed the first applications of these new technologies which had dramatic results for battlefield medicine. Now wounded soldiers had much better chances of surviving and making it home in one piece. This book shows the new level of care being given with x-rays that showed every bullet fragment and surgeries that allowed perforated intestines and fractured skulls to be repaired.

During World War One, the force of the new artillery and the unsanitary conditions of trench warfare made the work of surgeons and other medical caregivers on the frontlines very difficult. And while advancements such as motorized ambulances and transfusions meant that more lives could be saved, surgeons also had to deal with new concerns such as trenchfoot, gas poisoning, and flamethrower burns. De Tarnowsky’s book was meant to be a field manual for all of the medical situations one would face at the front, so it includes discussions of complicated bladder surgery under anesthetic and the best methods to stitch up a wounded face for later plastic reconstruction, as well as gunshots and fractures.

* Please note: Becker Briefs pages may contain links, email addresses or information about resources which are no longer current.

Image 1: Frank Hastings Hamilton. A Treatise on Military Surgery and Hygiene. New York: Bailliere Brothers, 1865. xxWO 800 H217t 1865

Image 2: Confederate States of America. A Manual of Surgery: Prepared for the Use of the Confederate States Army, by Order of the Surgeon-General. Richmond: Ayres & Wade, 1863. xxWO 800 C748m 1863

From: becker.wustl.edu

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On Surgery's Cutting Edge In Civil War

By Mary Belferman, Washington Post Staff Writer 6-13-1996

The canvas on the wooden stretcher is ocher with age, soiled a deeper brown in places with the blood of Civil War soldiers. In the flowing script of the last century, a Union surgeon inked his name across it -- good supplies were hard to hold on to. Nearby are tidy leather kits with tools for field amputations, the foot-long saw and scalpels now shining with cleanliness.

More than 600,000 soldiers died in that war, from wounds and diseases and malnutrition and infection, despite the best efforts of doctors and nurses who knew nothing of germs. "The real war will never get in the books . . . the hospital part," wrote poet Walt Whitman, who nursed soldiers in Washington.

The National Museum of Civil War Medicine, opening Sunday in Frederick, will tell that part. "It's the story of care and healing, courage and devotion amidst the death and destruction . . . [and] major advances that changed medicine forever," museum director Burton Kummerow said.

The only museum in the country dedicated to the medical side of the conflict, it will house and exhibit more than 3,000 artifacts, including the only surviving surgeon's tent from the war. Doctors' saddlebags are packed with small bottles and packets that once held quinine and other potions. An ambulance that carried wounded men from the battlefield has the advantage of crude springs to ease the rough wagon ride; many didn't.

Much of the collection comes from museum Chairman Gordon Dammann, an Illinois dentist who has been amassing Civil War medical objects for more than 20 years. The museum was his idea. "There's never been anything like it done before," Dammann said, calling the 1861-65 war "a turning point in American medicine."

Anesthesia, introduced in the 1840s, had its first widespread use during the Civil War. War surgeons developed an inhaler for its use, an improvement over the soaked rag, to conserve supplies. Confederates developed the prototypes of mobile army surgical hospital (MASH) units as they fled before Gen. William Tecumseh Sherman's advance. Perhaps most importantly, ambulances and a system for evacuating the wounded from the battlefield and treating them were established for the first time. Nursing was elevated to a profession, with thousands of women working in hospitals for the first time.

Unfortunately, the war also occurred just a few years before Louis Pasteur discovered the role of germs in infection; doctors dug bullet fragments out with unwashed fingers and operated with bloody instruments for lack of clean water.

It was a time of change in war technology as well as medicine. Rifled gun barrels and pointed, conical bullets came into wide use by both sides early in the war, multiplying casualties. The old, round bullets fired from a smooth-bore musket bounced off bone and were accurate to less than a hundred yards. The new, pointed projectile spun through a rifled bore, the spin producing a bullet accurate to 300 yards.

The heavy, conical bullet tore into the skin, carrying dirt and clothing with it and smashing the bone, often not exiting because of its large caliber and low velocity. Amputation generally was the safest way to handle such a wound; those shot in the hip or wounded internally often didn't survive.

Civil War amputation brings to mind scenes of agonized soldiers slugging whiskey and biting bullets as their limbs were chopped off without anesthesia.

"Hollywood has done a great disservice with that image -- that's one of the myths we want to dispel with the museum," said museum Vice President F. Terry Hambrecht, a neurosurgeon who collects Civil War medical artifacts. "In the vast majority of cases, they had plenty of anesthesia. The tools are very similar to those used in medical field operations today. The capital saw is virtually identical; it's just stainless steel instead of nickel-plated steel, with different handles. And in most cases, their technique was good. They just didn't know about infection. They understood that with cleanliness you had fewer complications, but they didn't know why. Given the conditions and the knowledge they had, they did a good job."

Whiskey was given, but it was meant to help the soldier bear up.

"A wounded soldier was given alcohol as a stimulant, some morphine derivative as a painkiller and ether or chloroform as anesthesia," explained Adrian Wheat, a retired U.S. Army surgeon and a member of the museum board. "They weren't completely put to sleep -- they remembered surgery but didn't feel pain. Observers would have seen that they were awake -- that might be the origin of the rumor that people were operated on awake, without anesthesia."

Along with dispelling misconceptions, the museum hopes to tell the stories of medical heroes on both sides, including the women who became nurses against the disapproval of their families. Jonathan Letterman, medical director of the Union's Army of the Potomac, was "the father of battlefield medicine in the United States," Dammann said.

In the beginning of the war, wounded soldiers languished for days before they were retrieved. Sometimes their friends would stop fighting and carry them to the rear, knowing no one else would, recounts historian James M. McPherson in "Battle Cry of Freedom." Litter-bearers were musicians, other soldiers and anyone who could be spared. Letterman developed a system for evacuating the wounded, establishing ambulances and dedicated personnel for each regiment.

The wounded were treated in three stages: "There was a dressing station 60 to 70 yards from the front line," Dammann said, noting that 350 doctors on the Union side were killed in battle. "First aid was done here, tourniquets and splinting. From there, they went back into battle or to a field hospital, maybe in a barn or church three or four miles behind the lines. Here they had operating surgeons, where they did amputations. Wounds of head, chest and abdomen weren't treated; they were given painkillers and most died there. From here, they were evacuated, usually by train, to fixed hospitals." Letterman's system saved lives, but for every man killed in battle, two died of disease. Many perished from malnutrition, especially in the South.

The museum's official opening Sunday will mark its first phase, director Kummerow said. Tools, uniforms and other items will be on display, and several scenes will be set up using real artifacts and reproductions, including a camp scene and a field hospital. The museum already sponsors living history talks and walking tours.

However, much of the museum remains on hold. Dammann and others who intend to give or lend items are keeping the bulk of their collections until the museum's security and environmental and fire controls reach a higher standard. Recent thefts around the nation underscore the increasing value of Civil War artifacts.

For example, Dammann said, "an amputation kit I paid $600 for 25 years ago is now worth about $4,000." About $6 million is needed for the museum, some of it already raised. Kummerow hopes to redo the museum completely within a few years to bring it up to standard.

Then he also hopes to introduce other innovations, such as identity cards featuring real soldiers to help personalize the war for visitors. This is one idea he took from the Holocaust Museum, he said; another is "how to exhibit a subject that is, by nature, somewhat gruesome." Some of the more explicit exhibits, unsuitable for young audiences, will be separated and marked.

Kummerow has high hopes for the museum, which was several years in the planning. Former Maryland governor William Donald Schaefer, a hospital administrator in World War II, was an early supporter. "It's a great thing to support the past, and the Civil War is now a hot issue," Schaefer said. "I see it as a major tourist attraction, unique in the country, and tourism is a major economic boon for an area. Frederick is a good place for it."

Frederick was picked as the location for several reasons. During the war, Frederick witnessed three Confederate invasions, 38 skirmishes and two major battles. A hospital and supply center, the town opened its doors to 6,000 wounded after the battle of Antietam, and the building that houses the museum was used as an embalming station after the battle.

Frederick is also near other Civil War sites, including Gettysburg, Antietam and Washington; with the growing public interest in the war, founders hope the museum will draw 100,000 visitors annually. Frederick and Maryland chipped in with funds to launch the museum, and the city is leasing the building to the museum for $1 a year for the first five years. Entrance is free, with a donation suggested, but the city hopes the attraction will pull in tourist dollars for other businesses.

One of the stories the museum illustrates is that doctors treated all wounded, not just their own. "Give the wounded men every attention possible and make no distinction between Federals and Confederates," Gen. Ulysses S. Grant is quoted as saying.

At battle's end, "those in possession of the field left doctors behind, and they treated all the wounded," Kummerow said. A sculpture commissioned for the museum from a local artist illustrates this: a Union doctor bends over a fallen Confederate soldier.

As Letterman put it, "History teaches us that a wounded and prostrate foe is not then our enemy."

From: washingtonpost.com

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Was Civil War Surgery Effective? (Abstract)

By Matthew Baker

Economics Working Paper Archive at Hunter College from Hunter College Department of Economics

Abstract:
During the U. S. Civil War (1861-65) surgeons performed a vast number of surgical procedures such as amputations, resections, excisions, and bullet extractions. The efficacy of wartime surgery has been the subject of continuing debate since the start of the war. One reason debate continues is the dearth of empirical evidence on the (in)effectiveness of surgery. To shed light on the subject, I analyze a data set created by Dr. Edmund Andrews, a Civil war surgeon with the 1st Illinois Light Artillery. Dr. Andrews’s data can be rendered into an observational data set on surgical intervention and recovery, with controls for wound location and severity. The data also admits instruments for the surgical decision. My analysis suggests that Civil War surgery was effective, and increased the probability of survival of the typical wounded soldier, with average treatment effect of 0.25-0.28.

Downloads: (external link)
http://econ.hunter.cuny.edu/wp-content/uploads/sit ... /HunterEconWP444.pdf (application/pdf)

Related works:
This item may be available elsewhere in EconPapers: Search for items with the same title.

More papers in Economics Working Paper Archive at Hunter College from Hunter College Department of Economics 695 Park Avenue, New York, NY 10065. Contact information at EDIRC.
Series data maintained by Jonathan Conning (jconning@hunter.cuny.edu).

From: econpaprs.repec.org

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Writing on the Operating Table: Letters of James Langstaff Dunn, Civil War Surgeon

by Sarah Johnson, 2-8-13

Gerald Linderman’s Embattled Courage defines the pursuit of courage as the prime motivator for Civil War soldiers. For men going off to war, idealistic notions of courage and duty caused them to rise above their fears and fight for their cause. However, the last chapter of Embattled Courage, titled “Disillusionment”, argues that eventually Civil War soldiers developed a hardened and stoic indifference to the suffering around them. Linderman argues soldiers stopped feeling like a vital part of an important cause and more like a small, insignificant piece of a vain struggle. The letters of James Langstaff Dunn, volunteer surgeon of the 109th and later 111th Pennsylvania Volunteers, offer a different interpretation, one that copes with the death and destruction by a grisly determination to see the war to its end.

Dunn’s early letters reflect Linderman’s analysis of Victorian ideals about courage. He wrote his wife on May 2, 1861 assuring her that “the boys are healthy and in good spirits, ready to do their duty.”[i] The 109th PA received their baptism of fire on August 9, 1862 at the battle of Cedar Mountain. In the aftermath, Dunn spent twenty-four hours in surgery with no food and little water. He performed twenty-two amputations of the thigh alone, and “a great many” on arms.[ii] Dunn would go on to be involved in Second Bull Run, South Mountain, Antietam, Chancellorsville, and Gettysburg before being transferred to the west to Chattanooga, Lookout Mountain, Mission Ridge, and the Siege of Atlanta, in addition to other minor engagements.[iii]

Along the way, Dunn experienced, first-hand, the destruction the war brought. Stealing a moment to himself after Chancellorsville, he wrote to his wife assuring he was safe. The letter begins, “I have just one minute to write and I am writing it on the operating table.”[iv] Charged with putting broken men back together, Dunn was forced to evaluate the costs of the war and justify them to himself. The first patient Dunn lost haunted him. Lieut. Austin, a New Jersey cavalryman, was described by Dunn as “a handsome fellow, not over 21 or 22…I will remember his boyish looks and earnest appeals for help as long as I live.”[v]

A second incident that deeply affected Dunn was the loss of his hometown friend, J. W. Patton. Patton was hit by a shell at the top of the humerus, near where the arm articulates with the shoulder. The hit caused his humerus to fracture all the way down to his elbow. Dunn examined the wound and determined the arm could be saved, but after he passed on to treat another soldier, the arm was amputated by another surgeon.[vii] Amputation of the arm at the shoulder was a relatively simple procedure for an experienced surgeon, disarticulating the humerus at the joint with the shoulder was a natural place to separate and there was rarely a problem with controlling the bleeding. Three-fourths of shoulder amputees survived.[viii] Patton, however, did not. Dunn was profoundly hurt by what he deemed as an unnecessary loss of life; had not thought the arm needed amputation in the first place.

Dunn’s response to the trauma of war was not with disillusionment.  His war experiences reflect determination. Dunn’s letters reveal, instead of bitterness with the war, frustrations with the political wavering at home; he was a severe critic of Copperheads and Peace Democrats of the North. Dunn’s tirades against the Copperheads boiled down to a belief that the broken men on the field, bleeding and dying, deserved better than quasi-commitment at home.[ix]  Dunn’s 1864 New Year’s Resolution demonstrates his convictions and his justification for the costs of war:

"Still, my life is spared. Tomorrow is New Years Day. I hope…that its end may see the close of this fearful War, to be crowned with garlands of a glorious peace in and undivided country, and with every man, black or white, enjoying the rights that God has given him. I know that some call this abolitionism, but it must come as the fruits of the many fearful sacrifices that have been, and are now being made by the best blood of the nation."[x]

[i] Paul Kerr, Civil War Surgeon-Biography of James Langstaff Dunn, MD, AuthorHouse, 2005, Letter to wife, Temperance, May 5, 1862, 21.

[ii] Kerr, Civil War Surgeon, Letter to wife, August 15, 1862, 63.

[iii] Kerr, Civil War Surgeon, 333.

[iv] Kerr, Civil War Surgeon, Letter to wife, May 4, 1863, 92.

[v] Kerr, Civil War Surgeon, Letter to wife,  May 12, 1863, 89.

[vi] Kerr, Civil War Surgeon, L
etter to wife, May 12, 1863, 89.

[vii] Kerr, Civil War Surgeon, Letter to wife, May 17, 1863, 94-95.

[viii] Medical and Surgical History of the Civil War, Volume X, Wilmington: Broadfoot Publishing Co., 1991.

[ix] Kerr, Civil War Surgeon, Letter to wife, January 27, 1863, 82.

[x] Kerr, Civil War Surgeon, Letter to wife, December 31, 1863, 153.

Photos from the National Archives.

From: gettysburgcompiler.com

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Advancements in Surgery Through the Ages

by Lisa J. Fulghum, 6-5-15

Imagine yourself standing in a medical tent on September 17, 1862 not far from Sharpsburg, Maryland, as the bloody battle of Antietam rages on the other side of the bridge. With nearly 22,000 dead and many more wounded after just 12 hours of fighting, what is a good surgeon to do? Your shirt is stained with the blood of the many you have already treated, yet more men than you can count lay suffering nearby. With only 98 medical officers to serve the entire Union army and just 24 for the Confederates when the war began, trained medical professionals are still hard to find.1 It will be a very long night. Your options are as limited as the precious time you have.

Ether and chloroform (when they are available) are the only viable methods of anesthesia, besides a stiff shot of whiskey. The best surgeons, commonly called butchers by reporters and patients, are the ones who are quick and hopefully accurate. Amputation is the most common surgery of the day, and a good surgeon can amputate a limb in just 15 minutes.2

Standing amidst the grizzly scene, you call for another cup of coffee, wipe your surgical saw on your apron and look for the nearest patient who is likely to survive long enough to complete a surgery. Inwardly, you hope that one day you will have a better method for dealing with such carnage.

An estimated 60,000 amputations were performed during the Civil War. Nearly 75% of amputees survived the surgery, though that depended greatly on the limb that was amputated. A forearm amputation mortality rate was 14%, but legs amputated at the hip had an 88% mortality rate.3

History of Surgery
Since the beginning of time, man has developed and refined instruments for surgical procedures and for healing people. Throughout our history, humankind has had notable physicians who made monumental contributions to medical science.

As early as 600 B.C. Sushruta , India’s preeminent surgeon, pioneered rhinoplasty and other forms of plastic surgery. Since cutting off a person’s nose was a common punishment, Sushruta’s expertise was highly valued.4 Among other things, believe it or not, he even documented cataract surgery.5 Developing and documenting 120 surgical instruments (in bronze, silver, and iron) and employing many relatively modern techniques, Sushruta was revered as a master physician 150 years before Hippocrates.

Around 1000 A.D. Abu al-Qasim al-Zahrawi (a.k.a. Albucasis in Europe), the master Muslim physician of Spain, wrote a 30-volume medical encyclopedia called Al-Tasrif (The Method of Medicine). It was the medical reference text used for over 500 years. Albucasis invented and described over 200 new instruments. With hand sketches of what instruments looked like, how they were constructed and how they were to be used, he documented instruments like his obstetric forceps and an urethrascope. Not only was he the first author to describe an ectopic pregnancy and the hereditary nature of hemophilia, but he also pioneered sublimation and distillation for the preparation of medicines. Albucasis described ligatures 600 years before Paré adopted their use, even using catgut for internal stitches so the stitches would dissolve as the patient healed.6

Surgery was not always the prestigious profession that it is today. During the middle ages in Europe, surgery was considered a lesser profession, and physicians did not deal with such things. The local barber was frequently the town surgeon.

Stop the Bleeding
During the Middle Ages, one of the major hindrances of a successful surgery was excessive bleeding. Medical innovators like Guy de Chauliac emerged. He released (1363) his 7-volume library of surgical knowledge, the Chirurgia Magna, in which he described the use of a tourniquet for blood control during an amputation. In his work, he also described intubation, suturing, blood clotting, and the use of surgical instruments.7

By the mid-1500s Ambroise Paré, a barber-surgeon, introduced the lost art of ligatures to control blood flow in wounds or during surgeries like amputation. He favored ligatures over cauterization that was the preferred method of the day, because ligatures reduced the pain patients suffered. Paré invented the crow’s beak hemostat to stop blood flow during amputation.8

Kill the Pain
The pain of surgery was a limiting factor. A doctor could only operate for the length of time a patient could endure. The introduction of anesthesia opened the door for a host of new procedures.

Humphrey Davy, the scientist who discovered the elements potassium and sodium, was one of the first to identify the anesthetic properties of nitrous oxide and ether in 1799. Both were used as recreational drugs at the time. In 1842 Dr. Crawford W. Long, who had observed the effects of ether at some of their nitrous oxide parties, was likely the first to use it in surgery. He administered it to James Venable before removing a cyst from James’ neck.9

In Scotland a year later (1847) James Young Simpson was assisting a woman with a difficult childbirth and used ether to minimize her pain. Because of the side effects, he began experimenting with chloroform. Chloroform was soon accepted, and even Queen Victoria used it for childbirth.

Physicians then began looking for a local anesthetic. The birth of the hypodermic needle (1850s) allowed for intravenous anesthetics.10 Surgeons like William Stewart Halsted, who was one of the “Big Four” founding professors of Johns Hopkins, was one of the first to explore the use of cocaine as a local anesthetic. He would inject the anesthetic into a nerve trunk to numb an entire limb or the spinal cord.11

Incidentally, it was he who introduced the radical mastectomy for treatment of breast cancer. In addition, he also invented the Halsted Mosquito Forceps, a small pair of hemostatic forceps. One of the other “Big Four” was Howard Atwood Kelly, who developed the Kelly Forceps, one of the most popular and commonly used hemostatic forceps.

With the introduction of anesthetics, medical science continued its forward advance. However, the discovery of effective anesthetics came with unintended consequences. While it made non-traumatic surgery possible and allowed for longer and more complicated surgeries, it also opened the patient to a greater chance of infection.12 By the mid-1800s when the use of anesthetics was the norm, it was not uncommon for a European hospital to have an 80% mortality rate for surgical patients.13

Wash Up
When physicians learned to combat infection, we cleared another medical hurdle. Honey, willow bark, balsam, wine, and vinegar were used historically as antiseptics to dressed wounds. However, before the mid-1800s, there was little concern for cleanliness among physicians. At that time, a bloody apron was considered a badge of honor. In 1795, Scottish physician Alexander Gordon suggested that doctors could transmit contagions, and he recommended that obstetricians wash their hands and clothes before treating patients. Opposing the standards of the day, American physician Oliver Wendell Holmes concluded in 1843 that the spread of puerperal fever (after childbirth) was connected with unwashed doctors. Independently, Hungarian doctor Ignāz Semmelweis made the same conclusion in 1847. Implementation of new cleanliness guidelines lead to a maternal mortality drop from a high of 18% to about 1%. Amazingly, these doctors understood what to do but not why.14

Louis Pasteur proved the existence of airborne microorganisms. By 1862, he completed his first tests indicating that bacteria cause wine, beer, and milk to sour. He then pioneered the process of pasteurization to kill the microorganism. Pasteur continued his extraordinary research in germ theory and went on to invent vaccinations for diseases like cholera, tuberculosis, and small pox.15

Following these discoveries, Joseph Lister put it all together. He determined that if airborne bacteria caused wine to spoil, then airborne microorganisms could also cause infection after surgery or childbirth. In 1865, he pioneered a method of using carbolic acid (phenol) as an antiseptic for treating wounds. He published his work in 1867 in The Lancet. It was not fully accepted until the 1890s when Heinrich Koch proved that germs cause disease.

Lister introduced sterile catgut for internal stitches. He also tied bones together with sterile, silver wire and left it inside of the patients. This was a revolutionary idea, because previously, the germs left behind by such a procedure would have caused gangrene and certain death.16 Lister also invented the Lister bandage scissors.

Hurdles to Modern Surgery
While the mechanics and instruments in a surgeon’s toolkit have changed dramatically through the ages, surgery still remains an intricate and delicate handicraft practiced and perfected by the gifted and skilled. As the science of surgery has evolved, three major hurdles had to be overcome: the control of bleeding, the control of pain, and the control of infection. In the last 150 years, these incredible medical advancements have completely revolutionized the surgical process and given humankind a much brighter future.

Now, as you stand in a modern operating theater, garbed in a sterile gown complete with surgical mask, binocular loupes and neoprene gloves, you can marvel at the array of gadgetry to monitor the patient’s heart rate, O2 levels, and blood pressure. The lead surgeon is assisted by a staff of anesthesiologists, nurses, and technicians. Complex surgeries of critical organs can take hours as skilled surgeons work miracles never before even imagined. The civil war surgeon would have marveled at the spectacle of a laser surgery, laparoscopy, MRI and CT technology, chemotherapy, and robotic surgery. Given the phenomenal advances of the last century, we have to wonder what revolutionary breakthroughs await us in the next 150 years. Will you be the Louis Pasteur, Ambroise Paré, Albucasis, or Joseph Lister of our modern age?

References

Civil War Medical Care, Battle Wounds, and Disease (Civil War Medical Care, Battle Wounds, and Disease) www.civilwarhome.com/civilwarmedicine.html 02/10/02
Clements, I.P. History of Surgical Amputation (HowStuffWorks) health.howstuffworks.com/medicine/modern-treatments/amputation2.htm
Billings, J. (2001). Hardtack and coffee, or the unwritten story of Army life. Scituate, Mass.: Digital Scanning. www.civilwar.org/education/pdfs/civil-was-curriculum-medicine.pdf
ISPUB.com (Internet Scientific Publications) Sushruta: The first Plastic Surgeon in 600 B.C. by S Saraf, R Parihar ispub.com/IJPS/4/2/8232
Roy, P., Mehra, K., & Deshpande, P. (1975). Cataract surgery performed before 800 B.C. British Journal of Ophthalmology, 59(171) bjo.bmj.com/content/59/3/171
Albucasis (Doctor - the Father of Modern Surgery) english.turismodecordoba.org/seccion/albucasis-doctor---the-father-of-modern-surgery
Guy de Chauliac www.thefamouspeople.com/profiles/guy-de-chauliac-447.php
Ambroise Paré www.apimsf.org/default.aspx?id=22
Dr. Long’s Discovery www.crawfordlong.org/id10.html
Blatner, A. (2009, February 16). Anesthesia / History of Medicine. The Discovery and Invention of Anesthesia. www.blatner.com/adam/consctransf/historyofmedicine/4-anesthesia/hxanesthes.html
The Four Founding Physicians http://www.hopkinsmedicine.org/about/history/history5.html
Antisepsis www.discoveriesinmedicine.com/A-An/Antisepsis.html
Lamont, A. (1992, March 1). Joseph Lister: Father of Modern Surgery. https://answersingenesis.org/creation-scientists/joseph-lister-father-of-modern-surgery/
Henderson, D.K., Lee, L., and Palmore, T (2014, June 1) The Contemporary Semmelweis Reflex: History as an Imperfect Educator www.infectioncontroltoday.com/Articles/2014/06/The-Contemporary-Semmelweis-Reflex-History-as-an-Imperfect-Educator.aspx
Louis Pasteur (2014) www.biography.com/people/louis-pasteur-9434402
Antisepsis

A Purdue University graduate, Lisa Fulghum is the Content Director at WPI. For nearly 50 years, WPI has been supplying laboratory equipment for life science researchers, including a variety of German and Swiss made surgical instruments.

Image: This toolkit is over 100 years old.

From: alnmag.com

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Lt. Col. Edward Bacon Witnesses Civil War Surgery

By Mark, 7-22-12

Although great advancements and improvements in the medical treatment of wounded soldiers were made during the Civil War, surgery in the field hospitals remained a frightening experience. In June of 1863, the 6th Michigan Infantry was engaged in the Port Hudson Campaign in Louisiana as part of the 1st Brigade of the 2nd Division of the Union Army’s Nineteenth Corps. On the 13th of the month, a line of 100 skirmishers from the 26th Connecticut and 15th New Hampshire Infantry regiments, also of the 1st Brigade and 2nd Division, advanced upon the Confederate works and were repulsed with casualties. In his memoir published shortly after the war in 1867, Lieutenant Colonel Edward Bacon of the 6th Michigan recalled seeing the army surgeons at work on one of the wounded from that engagement. Bacon did not think highly of army surgeons, but his description of the horrible scene in a field  hospital of a soldier suffering from a terrible wound is unforgettable.

"There is the dim flicker of lights in the midst of surgeons, with their young assistants, crowded around a rough bench, on which lies the subject, a nobly formed young volunteer of the Fifteenth New Hampshire. Chloroform has been used in vain. He is crying, in an agonized, despairing voice, “O kill me! kill me! do kill me!”  I see his large, manly breast, heaving with agony, as he lies on his back , held by some of the young doctors, who have their eyes set upon the hands of older doctors, at work now with probe, now with knife and saw, and now with other frightfully appearing instruments of torture. The young man has been shot in the shoulder, and the doctors are digging out his arm for experiment.  Some one of them says aloud, “There is not much chance for him”. The glimmer of candles flickering in the night breeze, dimly showing the naked  form of the writhing victim, and the hard faces of the surgeons, with their bloody hands and saws, the darkness hanging over us like a pall, the stars sparkling in the vault of heaven–the same stars beheld by our friends at home, far away, and by our enemies in the beleaguered fort before us–all together make a tableau not to be forgotten.  I am glad to find myself at last riding away from the horrid odors and sights of that hospital. The voices of myriads of insects of every kind and size, and the occasional boom of a connon, with straggling shots from the sharp-shooters, are not enough to drive from my ears the groans and cries of the poor New Hampshire soldier, dying in the hands of his tormenters as we left."
–Edward Bacon, Among the Cotton Thieves

In his History of the Fifteenth Regiment New Hampshire Volunteers 1862-1863, regimental historian and veteran Charles McGregor identified the wounded man in Bacon’s account  as 22 year old Private Elias H. Hadley. Hadley was shot in the shoulder during the advance, and refused an offer by the Confederates to be taken to their side for treatment of his wounds. Hadley remained on the field in the hot sun until nightfall, nearly bleeding to death in the process. He was taken to the hospital, where his arm was removed at the socket. Hadley died shortly after the amputation, as Bacon had predicted.

From: ironbrigader.com

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The History of Surgery at VCU

By James P. Neifeld, M.D., F.A.C.S.

The history of the Department of Surgery and the Medical College of Virginia go hand-in-hand.

In 1837, Dr. Augustus Warner, a graduate of the University of Maryland who was on the surgical faculty at the University of Virginia, became disillusioned with the clinical material available and felt that Richmond would provide a much broader patient base. He organized a petition to have Hampden-Sydney College put a medical college in Richmond.

Egyptian Building 1860sDr. Warner became the first Professor of Surgery, as well as Dean when the institution opened in 1838. He was known for being a superb surgeon, performing a partial mandibulectomy in nine minutes! The first permanent building was the Egyptian Building, which opened in 1845 and is still being used as a building for the Medical School. This was the first permanent hospital of the Medical College of Virginia and had well ventilated wards and private rooms.

Dr. Warner died in 1847 (probably of appendicitis) and was succeeded by Dr. Charles Bell Gibson. Dr. Gibson was also a well known surgeon and was one of the first surgeons to use anesthetics. He wrote on femoral artery ligation, treatment of femur dislocations, and resection of a maxillary sarcoma. In 1861 the Commonwealth of Virginia organized its military forces with a medical department under Dr. Gibson as Surgeon General. He died in 1865.

At the time of the secession of the South, there were many Southerners attending medical schools in the North. A large group was in Philadelphia. Hunter Holmes McGuire led a group of 150 medical students to Richmond, many of whom transferred to the Medical College of Virginia. Through the Civil War many of these people made major contributions to the Confederate cause.

faculty 1893Hunter McGuire was well known and thought to have been a major figure for the southern medical establishment during the Civil War, but he was actually quite junior. His wartime notoriety derives from the amputation of the arm of Stonewall Jackson and his subsequent demise (probably from pneumonia).

Dr. James McCaw, who served MCV for about 50 years, planned and organized the largest hospital that ever existed in the western world. Chimborazo Hospital was located just east of the Medical College of Virginia campus and was said to have had as many as 7000 beds. It had one of the lowest mortality rates of any hospital in the Civil War. The buildings were ventilated and accommodated 40 to 60 patients. There were also approximately 100 tents with eight to ten soldiers or convalescent patients per tent. Over 76,000 patients passed through this hospital and 7000 died, an exceptionally good record for the time.

MCV was the only southern medical school to remain open throughout the Civil War. The fire that burned much of Richmond at the end of the war did not affect MCV. Learn more about Civil War Hospitals in Richmond.

After the war, Dr. McGuire practiced in Richmond and became closely associated with MCV. He became the third Professor of Surgery in 1865. He was one of the first surgeons to practice Listerism, the first to perform a suprapubic cystostomy, and he reported ligation of the abdominal aorta. Despite a busy private practice he was always willing to treat charity cases and treated Confederate soldiers without charge. He is one of the very few to be President of the American Surgical Association, Southern Surgical Association, and American Medical Association. He was Professor of Surgery until 1881 but resigned following a fight with the Board of Trustees. After his resignation, he founded St. Luke’s Hospital and in 1892 his interest in teaching led him to help found a new medical school, the University College of Medicine. This medical school developed a faculty better than MCV’s and the curriculum was extended to three years.

The fourth Chairman of Surgery at MCV was appointed in 1881: Dr. John Dorsey Cullen. He had been assigned to General Robert E. Lee during the war. He was said to have been a skillful surgeon and an excellent teacher. He published on hepatic abscess, traumatic tetanus, and diseases of the bones. After his death in 1893, George Ben Johnston became the next Professor of Surgery. He was also an advocate of Listerism and published on nephrectomies, imperforate anus, renal and hepatic diseases, and biliary surgery. He became President of the Southern Surgical Association and the American Surgical Association. During his time as Chairman, MCV became the first medical school in Virginia to require a four-year term. Following the Flexner Report, Dr. Johnston and Dr. Stuart McGuire, then President of the University College of Medicine, merged the two medical schools in 1913 to form the new Medical College of Virginia.

Dr. Stuart McGuire, son of Dr. Hunter McGuire, was an eminent surgeon in his own right and was chosen Dean of the Faculty. Dr. Johnston died in 1916 and Dr. McGuire took over as Chair of Surgery. He became known for his publications on toxic goiter, cholecystitis, and appendicitis. He was said to be an outstanding organizer and teacher.

During this period of time World War I was raging in Europe and it was decided to organize a Red Cross Hospital in Richmond based on MCV. Dr. Stuart McGuire helped organize this unit. He was the first Director of this unit, was replaced on a temporary basis by Major Alexander Williams, but after the unit went to France, Dr. McGuire resumed his position as Director. US Army Base Hospital 45Base Hospital No. 45, as it was known, was supposed to be far behind the front lines but it actually was within a few miles of the front lines and served not just as a base hospital but as a triage and evacuation hospital. Within two weeks of a major United States offensive in September, 1918, 8000 casualties arrived. The mortality rate was one of the lowest of any of the military hospitals of that time; Dr. McGuire was awarded the French Medal of Honor as well as the Distinguished Service Cross from the United States Government.

Following the war, Dr. McGuire became President of MCV. In that position he had to give up being Professor of Surgery and Dr. Murat Willis succeeded him. Dr. Willis had a busy clinical practice, apparently was rarely at MCV, and most of the teaching was done by Dr. Paul LaRoque. Dr. LaRoque arrived in Richmond in 1905 to join the faculty of the University College of Medicine. He was a prolific writer on many subjects including pelvic surgery, vascular surgery, and intestinal obstruction, but his major contribution was in the field of hernia surgery. He died suddenly in 1934.

Surgical Ampitheater 1920sOne of the critical problems the Medical School faced was the lack of a full time faculty. Dr. Isaac A. Bigger was appointed as the first full-time Chair of Surgery in 1930. He was one of the most beloved men of his time. His primary contributions were in thoracic and cardiovascular surgery. He was the first to resect a pulmonary bleb, which is responsible for spontaneous pneumothorax. The repair of tracheo-esophageal fistulae was another major interest of his and he accomplished one of the first major series of successful heart wound repairs. He co-edited a very successful operative surgery textbook into a sixth edition with Dr. Guy Horsley. Dr. Bigger was President of the Southern Surgical and was instrumental in the formation of the Virginia Surgical Society. During Dr. Bigger’s 25 years as Chairman of the Department of Surgery, research laboratories, a better defined residency program, and excellence in clinical care all developed.

Surgical Ampitheater 1930s

Dr. Everett Evans was a brilliant faculty member recruited by Dr. Bigger to develop burn wound care. The Burn Unit was the first civilian intensive care unit in the United States and the first burn formula for fluid replacement was developed under Dr. Evans’ leadership.

When World War II was imminent, military hospitals were again based on individual university and large private hospitals. Dr. McGuire was asked to reorganize Base Hospital No. 45 as the 45th General Hospital but due to age and poor health he asked Dr. Carrington Williams to take over. The surgical services were organized into General Surgery and other services under the overall leadership of Dr. Guy Horsley. The Unit served with distinction in North Africa and Italy and a large number of MCV physicians and nurses made names for themselves. The Unit established the first blood bank in a military hospital in March, 1944, and soon averaged about 430 units transfused per month. Secondary wound closure (at day four to five) was pioneered in this unit, fibrin sealant was first used for brain surgery and hepatic hemorrhage, primary nerve repair was developed as was a method of rapid blood acquisition. These advances were soon used throughout all military hospitals.

David Hume & Staff 1960sAfter World War II, people returned home and the Department of Surgery continued to flourish under Dr. Bigger until his death in 1955. In 1956, a young surgeon from Boston, David Hume, was named Chairman of the Department of Surgery. Dr. Hume became the beneficiary of one of the largest NIH grants ever awarded to that time, over six million dollars, and developed a transplant program at MCV. His research included work in transplantation, endocrinology, vascular, and bariatric surgery. He mapped the hypothalamus and published seminal papers on pheochromocytomas and parathyroid disease. He helped describe the use of azothioprine, steroids, and total body irradiation for immunosuppression. Dr. Hume was a revered figure, superb teacher and developed an incredible faculty.

Dr. Jim Brooks, a pioneer in thoracic surgery, Dr. Arnold Salzberg, a pioneer in pediatric surgery, and Dr. Richard Lower, who developed the technique of heart transplantation in animals, were members of the faculty. 1980Dr. B. W. Haynes became Director of the Burn Unit and Dr. Walter Lawrence, Jr., an eminent surgical oncologist, founded the first Division of Surgical Oncology at any university hospital. Many leaders in transplantation and other leaders in American surgery were trained under Dr. Hume’s tutelage.

In 1973, Dr. Hume died in a plane crash in Southern California. Dr. Lawrence was the Interim Chairman until the arrival of Dr. Lazar Greenfield in 1974. Dr. Greenfield headed the Department for 12 and one-half years. He provided a great deal of stability, had a major interest in thrombo-embolic disease, and worked closely with Thoracic Surgery, Vascular Surgery, and Cardiac Surgery. Dr. Greenfield hired a large number of faculty and both research and clinical care continued to flourish. In 1986, Dr. Greenfield left to become Chair of Surgery at the University of Michigan in Ann Arbor.

Dr. Andrew Wechsler was recruited from Duke in 1988, and brought very much of a business atmosphere to the Department. Dr. Ronald Merrell was recruited from Yale in 1999, and during his brief tenure the Hume-Lee Transplant Unit and the Evans-Haynes Burn Unit became realities. In 2003, Dr. Merrell resigned as Chairman and Dr. James Neifeld became Chairman of the Department of Surgery. During the next three years, many faculty were hired in the Department both in clinical and research positions, teaching was revamped, and the administrative aspects of the Department were enhanced to meet current requirements. Then in August 2014, Dr. Neifeld retired and Dr. Vigneshwar Kasirajan, former Chair of the Division of Cardiothoracic Surgery, was appointed new Chair of Surgery.

The Department has jumped from 42nd to 27th nationally in NIH funding. The institution continues to develop the campus to expand clinical and research activities, and the future appears bright.

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