U.S Army Medical Department
By QMSgt Seamus "Shameless" O'Cooney & Whispering Dan Baldwin, 1st Btn 9th Reg't US Invalid Corps with research assistance from Monty Sidenstricker
Battle casualties far outstripped the abilities of both the Federal and Confederate Armies to provide for the wounded after battles. Since all believed that the War would be brief, with little blood spilled, little thought was given to the organization and funding of an extensive Medical Corps.
Men died by the thousands as gangrene and sepsis claimed lives. Medical knowledge was still evolving. Training was inconsistent and all too brief. There was no medical licensing board and one could become a doctor with one year's medical study. At the outbreak of the Civil War, the US Army had a Medical Corps consisting of only 98 surgeons and assistant surgeons.
Standard practice called for removal of the bullet or shell fragments. The amount of debris that was carried by these large, leaden, subsonic projectiles was great and fragments of uniforms or gear often corrupted wounds, introducing infection. Sabers and bayonets caused frightful looking wounds, but statistics showed that these implements of war inflicted barely 2 percent of the wounds. These wounds were cleansed, sutured and healed with few complications.
The surgeon, stating implements lacked sensitivity and dexterity, used his fingers to probe the wound and view the damage as an assistant would douse the opening liberally with carbolic acid, vinegar, whiskey, or water to wash away the blood. If the wound was too small to allow proper access, the surgeons would use a scalpel or scissors to enlarge the wound and to debride, or cut away, torn and shredded flesh. Metal probes and forceps were used to extract any foreign material detected. After extraction and debriding, the wound would be further doused then packed with a wad of moist lint scraped from linen or raw cotton to keep the wound open, thus allowing proper drainage during the healing process. Bandages were kept wet, and the patient was kept as still and quiet as possible, given small but frequent doses of whiskey or quinine as a supportive regime.
The urgency of operating during the "primary period" (the first 24 hours) was thought urgent in order to avoid the "irritative period" when infection showed itself. Believing the formation of "laudable pus" a sign of healing, surgeons were relieved by this "positive turn". The surgeon seldom had to wait more than three or four days for "laudable pus" to appear. This was believed to be the lining of the wound being expelled, thus clean tissue could replace it and the wound would heal. In fact, it was a sign that Staphylococcus aureus had invaded the wound, and was actively destroying tissue and over time would usually kill the soldier. In the rare cases when no pus appeared, medical practitioners described, "healing by first intention", and admitted that they knew not why.
Surgical fevers were disheartening for Field Hospital and General Hospital surgeons. Four or five days after a wound operation, the patient would be recovering well, producing copious pus. Then suddenly the pus stopped, the wound dried, and the patient ran a terrific fever. Despite drugs, the patient would very likely be dead in three or four days. The diagnosis was blood poisoning.
Erysipelas affected both armies. With a forty percent case mortality, it received serious attention. Recognized by a characteristic rash, it was thought by some to be airborne with the result that both Unionists and Confederates took steps to isolate erysipelas patients in separated tents or wards. The surgeons were in the dark as to how to treat this affliction, but it was noted that if iodine was painted on the edges of a wound, its further extension was stopped.
Civil War surgeons had not only iodine but carbolic acid as well, and a long list of "disinfectants" such as bichloride of mercury, sodium hypochlorite, and other agents. The trouble was that the wounds were too often allowed to become a raging inferno of infection before disinfectants were tried. One of the more positive features of Civil War surgery was that anesthetics were almost always used in operations or the dressing of painful wounds. Anesthetics were commonly employed in the Union armies, and despite mythology, anesthetics were very seldom unavailable in the Confederacy. The anesthetic of choice was chloroform, probably because ether's explosive quality made it dangerous at a field hospital operating table, where there was always the possibility of enemy gunfire, or other sources that could cause fire & explosions.
Surgeons in both armies experimented with the many different kinds of wounds they saw. For example, surgeons often attempted sealing sucking chest wounds. They would plug the wound with collodion or other materials, relieving the dreadful breathlessness of the patient, but sealing in the bacteria and debris that entered with the bullet. These cases often proved mortal, but the surgeons continued to experiment, though they also seldom knew the outcome of their experiments, because their patients were soon evacuated to a General Hospital.
Amputation, the most common surgery performed during the Civil War, was often the treatment prescribed when an extremity was the site of the wound. An assistant applied chloroform or morphine to reduce the patient's pain. Far from sterile, surgeons often operated while wearing a bloody or pus stained coat and apron. He might hold the lancet or probe in his mouth while working with his hands. If he dropped an instrument or sponge, he would pick it up, rinse it in a pan of cold water and continue his work. With a tourniquet above the wound, the surgeon cut off the blood flow to the limb. He would direct assistants to firmly grip and restrain the patient so that he could quickly use a scalpel to slice through the outlying tissue and flesh around the limb. A flap of flesh was left intact to be folded over the stump and sewn in place with silk sutures to provide a cushion for the stump. A hacksaw like tool with replaceable blades, called a capital saw, was employed to quickly saw through the bone. During the overwhelming flow of wounded after battle, an amputation might take about fifteen minutes.
The amputated limb would then be dropped onto a nearby pile of other amputated limbs, hands and feet. At the end of the day, these parts would be buried if there was time or just thrown out into the woods behind the hospital after the day's labors. Time was of the essence, so immediately following the amputation, the soldier would be lifted off of the surgical platform and another soldier would be placed on the platform for the next amputation.
The surgeon knew to a certainty, that unless amputation was completed immediately, the soldier rarely survived. Similarly, if wounded anywhere in the torso, abdomen, chest, neck or head, the soldier also was generally seen as "hopeless", whether because there was often no time to probe & to extract bullets, or because surgeons knew that time spent doing so was ultimately a waste of time. Thus was born the concept of triage, though not by official policy or name.
In time for Antietam, the Army of the Potomac, under its medical director Jonathan Letterman, developed the Letterman Ambulance Plan. In this system the ambulances of a division moved together, under a mounted line sergeant, with two stretcher-bearers and one driver per ambulance, to collect the wounded from the field, bring them to the dressing stations and then take them to the field hospital.
In the event of a general engagement, the assistant surgeon laden with lint, bandages, opium pills and morphine, whiskey and brandy, would establish an "advance" or dressing station just beyond musket fire from the battle. The assistant surgeon would give the wounded man a stout draught of liquor, expecting it to counteract shock; then perhaps dusted or rubbed morphine into the wound or gave an opium pill.
By the mid war years the advantages of using a syringe to inject morphine became apparent. The assistant surgeon examined the wound, with special attention to staunching or diminishing bleeding. After removing foreign bodies, he would pack the wound with lint, bandage it and apply a splint if it seemed advisable. The wounded were then transferred to the Field Hospital, officially the regimental hospital tent.
From the second year of the War onward there was an increasing tendency to take over a farmhouse, school, or church, if such was available, to use as an enclosed hospital and surgery. Ambulances transported the recumbent with a rough ride to the Field Hospital, usually anywhere from three to five miles, well away from the effects of enemy artillery.
Once treated at the Field Hospital, wounded were next evacuated, usually by wagon train or railroad, to General Hospitals located near large cities for further recovery or for specialized treatment.
Dr. J.S.Billings, of the US Army Medical Corps wrote," During the first year of the war there was no good organization for collecting the wounded. In the second year they had acquired the idea that the doctor might be considered a general staff officer, and there was by then an ambulance corps. In the third year there was an order issued that the chief surgeon of the corps, and the division surgeon, should be at the division hospital, because there they could be more easily found. The brigade surgeons were often made the operating surgeons. The result of this was that all of the chief officers were gathered together at the division hospital; and there was plenty of work for them. The other surgeons and assistant surgeons were without directions, and were left to exercise their own will and pleasure, if they had any. In the case of Dr. Keen [a comrade of Dr. Billings] when he didn't get orders, he acted on his own good judgment, but a good many did not have that quality, and hence did little or nothing!" [Transactions of the College of Physicians of Philadelphia, 3rd Series, Volume 27, pp 115-121, 1905].