Thursday, November 3, 2016

Civil War Surgery

By Dawn Brezina, MD, 9-1-06

Thomas “Stonewall” Jackson and a small group of men rode at dusk along the still-steaming battlefield perimeter on May 2, 1863. During daylight the Confederates had won a stunning victory at Chancellorsville, Va. Despite marked manpower and hardware inferiority, the leadership of Generals Robert Lee and Stonewall Jackson sent Union General “Fighting” Joe Hooker literally running from the battlefield. Jackson’s evening patrol was to ensure stability and set his plan for the next day.

Encountering other Confederate soldiers on the path in the waning light, the Jackson patrol exchanged words with the men, but the North Carolina contingent of soldiers did not believe the approaching mounted men were Confederate, so they fired into their midst. General Jackson fell, having suffered two gunshot wounds. The large caliber (.58), soft-lead minie ball was heavy, and it expanded when it went through tissue, resulting in shattered bone and tearing of internal soft tissues. Minie ball injuries to an arm or a leg usually meant amputation, and torso or head wounds were most often fatal.

Friendly fire was the source of General Jackson’s mortal upper-arm wound. He was attended by the 27-year-old surgeon, Doctor Hunter McGuire, medical director of the left wing of the Army of Northern Virginia, under General Jackson’s command. Jackson had sustained a minor wound to his right hand and a severe, heavily bleeding wound to his left upper arm. Dr. McGuire amputated the left arm about two inches below the shoulder, administering chloroform anesthesia. Post-operatively, Dr. McGuire diagnosed his patient with pneumonia. Jackson remained ill and died a week later from, presumably, pneumonia. Interestingly, some historians wonder if he actually died of a pulmonary embolus because he had been in bed rest for a week and died of a respiratory event. Either way, he succumbed to complications of his initial injury.

Civil War-era surgery was a gruesome event; it is remarkable that so many of the soldiers actually survived the ordeal. Anesthesia was administered by placing a handkerchief over the nose and mouth and dropping chloroform on the cloth until the patient was unconscious. The surgeon then had about 10-15 minutes to accomplish the surgery with the patient asleep. The most common Civil War surgery was the amputation of an extremity and this was usually accomplished in about 10 minutes. First-person reports and photographic documentation confirm the mounds of discarded limbs outside Civil War field hospitals. It is interesting to note that the use of anesthesia without a protected airway—as in the case of Stonewall Jackson—was the likely etiology of his post-operative (aspiration) pneumonia.

Although the English surgeon Joseph Lister was on his way to setting the standard for antiseptic surgery, this concept did not make its way to the United States until after the 1860s. The Civil War ended in 1865. During the Civil War, surgical instruments were rinsed during and between cases in a tub of increasingly bloody cold water. The surgeon made his way from patient to patient in pus- and blood-splattered garments; it is little wonder that fever was a common and dreaded post-operative event. Surgical fever was often the result of pyemia, (literally pus in the blood), which presumably was the same diagnosis as sepsis. Other deadly complications included erysipelas, osteomyelitis, gangrene, tetanus, and pneumonia. Physicians had almost no way of treating penetrating torso injuries. Surgery was occasionally attempted, but usually fatal. Lacking any modality to localize the intra-abdominal or chest injury pre-operatively and realizing the need to complete the surgery in just minutes, torso surgery was usually not an option.

Those who survived their wounds—and their treatments—must have been a hardy lot. One wonders how many lives would have been saved with just a rudimentary understanding of aseptic technique. Today we face the same issues: amputation, post-operative pneumonia and pulmonary embolism, and wound infections. The problems of yesterday still remain the problems of today and tomorrow.



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