King Chloroform and Queen Gangrene: Medicine and Critical Care During the Civil War

"When passing a recruit the medical officer is to examine him stripped; to see that he has free use of all his limbs; that his chest is ample; that his hearing, vision, and speech are perfect; that he has no tumors, or ulcered or extensively cicatrized legs; no rupture or chronic cutaneous affection; that he has not received any contusion or wound of the head, that may impair his faculties; that he is not a drunkard; is not subject to convulsions; and has no infectious disorder; nor any other that may unfit him for military service." -US Army Regulation 1297

When most of us think of Civil War medicine and surgery, we picture woefully inadequate medical knowledge and piles of amputated limbs outside dirty field hospitals. In many respects, these assumptions are correct. However, many of these images are common misconceptions, and are only shallow representations of the time. Study of Civil War medicine reveals fascinating and often sobering information.

People often think that because men were recruited quickly, there was no system in place for vetting recruits prior to enlistment. In actuality, the Federal army had Army Regulation 1297, referenced at the beginning of this post. Unfortunately, although these regulations did exist, enforcement was often lax for two reasons: governors had recruitment quotas to fill, and medical examiners were paid per recruit. Generally, a prospective recruit passed if he could walk, carry a gun, and had two front teeth. The front teeth were necessary for tearing open the cartridge containing the bullet and gun powder.

To understand medical care during the Civil War, it is important to first understand the overall medical atmosphere of the time. Medical education consisted of two years of study. The first year entailed two 4-month long semesters of lecture. The second year was a repetition of the first. No clinical experience was required before graduation. In 1862, only six colleges of pharmacy existed in the United States.

Prior to the war, the United States had a standing peace time army of only 16,000 troops. The army had a total of 113 doctors. When the war broke out, twenty-four of these doctors went south and three were dismissed for disloyalty. There was a serious shortage of medical professionals in the Federal army, and there were essentially no facilities for them to work in. Before the conflict, the largest military hospital was at Fort Leavenworth, Kansas and it held only forty beds. The largest military treatment facility in Washington, D.C. was a two-story, six-room building previously used to quarantine smallpox patients. This "hospital system," if it can be called that, was nearly useless for large scale warfare.

The first major battle of the Civil War at Bull Run in Virginia on July 21, 1861 revealed just how horribly unprepared the army was in terms of medical care. There was no centralized ambulance corps to transport wounded men from the battlefield. What ambulances were available were driven by civilians, and these ambulances were abandoned when the first shots were fired. The abandoned ambulances were stolen by healthy soldiers fleeing back to Washington, D.C. Not a single wounded soldier from the battle was transported to Washington via ambulance. The Surgeon General didn't even order medical supplies until after the battle was over.

Fortunately for Union troops, by September of 1862 the hospital system had begun to improve. At the Battle of Antietam on September 17, there were 71 field hospitals. The ambulance corps had been formed in August, and these ambulances transferred patients from the field hospitals to larger battlefield hospitals established well behind the lines and out of artillery range. That same September saw the beginnings of large general hospitals. Overall, 2 million Union troops were admitted to military hospitals, with a mortality rate of 8%.

On the Confederate side, the largest general hospital was Chimborazo in the capital at Richmond, Virginia. The hospital complex consisted of five separate hospitals with thirty buildings each. There were 150 wards with forty to sixty patients per ward. Admissions totaled approximately 76,000 patients and the overall mortality rate was slightly higher than that of Union hospitals at 9%. [1] 


 
Model of the Chimborazo Hospital at Richmond. 

We cannot discuss Civil War hospitals without also discussing combat-related injuries. Most battlefield injuries were gunshot wounds caused by the recently invented Minie ball. Conical in shape and composed of soft lead, these 0.58 caliber projectiles flattened on impact and inflicted gruesome damage. As the ball cut deeper into the flesh, the wound grew larger. When bone was struck, the bone shattered above and below the impact site. Minie balls usually did not exit the body and may have required extraction with a bullet extractor similar to the one below. 

Civil War bullet extractor. Credit: Des Moines University 

The majority of Minie ball wounds occurred in the arms and legs, but these wounds had a low mortality rate. Only 18% of gunshot wounds were abdominal, but these wounds were almost universally fatal due to intestinal injuries and lack of antibiotics. 

High fatality rates in combat can also be attributed to Revolutionary War era battle tactics used in the face of newer military technology. Recent innovations had resulted in more accurate rifles that could be fired repeatedly without reloading. A popular saying of the day was, "You could load it on Sunday and shoot it all week long." 

Most gunshot wounds necessitated surgical intervention. Contrary to the popular image of the reckless and saw-happy surgeon, only the most qualified surgeons were allowed to perform amputations. Only about 1 of every 15 Union surgeons could amputate. 

Amputations accounted for 3 of every 4 surgical procedures. The average amputation took 2-10 minutes to complete. If the procedure was performed within 24 hours, survivability was greater than surgery performed after 48 hours. In total, approximately 30,000 amputations were performed in the Union army with a mortality rate of 26.3%.[2] 

Civil War Amputation Kit. Credit: National Library of Medicine

The Hollywood image of primitive surgeries performed without anesthesia is largely inaccurate. The anesthetic properties of ether were known as early as 1846 and chloroform had been in use since 1847. In fact, according to the Medical and Surgical History of the War of Rebellion, chloroform was administered at least 80,000 times.[3] During the war, chloroform was the preferred anesthetic. Chloroform only required small amounts to be effective, it was fast-acting, and unlike ether, chloroform is non-flammable. Chloroform provided only light sedation, but it rendered the patient completely insensible to pain.[4]

Perhaps the most famous account of surgery performed with anesthesia is the case of the amputation of General Thomas J. "Stonewall" Jackson's arm. On the evening of May 2, 1863, Jackson was accidentally shot by Confederates of the 18th North Carolina at Chancellorsville. One ball entered his right palm, fracturing the bones of his hand and coming to rest just under the skin. The left arm received a ball in its upper half. The projectile severed Jackson's brachial artery and fractured the bone. A third ball entered outside the left forearm an inch below the elbow, exiting the opposite side just above the wrist. Compounding his injuries, Jackson's horse was spooked by the shots and bolted, causing Jackson to hit his head on a low-hanging tree branch. 

When the general was placed on a litter, one of the litter-bearers was killed by an exploding artillery shell. After being placed on another stretcher, one of the men carrying him stumbled, causing Jackson to fall to the ground. Finally, he was placed in an ambulance and transported approximately thirty miles to a field hospital where he would be attended by Dr. Hunter Holmes McGuire. 

McGuire informed Jackson that his arm would have to be amputated. Jackson agreed and around 2:00am on May 3rd, Chloroform was dripped onto a cloth and the general slipped into twilight. A circular amputation technique was employed and the operation concluded around 3:00am. Jackson awoke around 3:10am, and although he recovered well from the surgery, the fall he suffered during transport proved to be fatal. He developed pneumonia in his bruised lung and passed away. 



Though chloroform use was common, at times it was unavailable due to interruptions in supply lines. For some unfortunate soldiers, this meant they were forced to endure operations without pain relief. An account of this horrific experience comes to us from the writings of Private James Winchell of Company D, Berdan's First United States Sharpshooters. Winchell suffered a gunshot wound to his left arm between the elbow and shoulder at the Battle of Gaines Mill. He was subsequently captured by the Confederates. 

Concerning his capture and treatment, Winchell wrote that a Confederate surgeon came to examine him, pushed a thumb through the wound, and ordered Winchell carried out the basement of the hospital. Winchell writes: 

"[I was carried] into the yard to a scrub oak tree, 
where picking up some scattering straw and stone
for a pillow, I lay hours among vermin, fleas, mos-
quitoes, maggots, and flies, and oh! The last mentioned
was the worst. I can feel my arm ache yet, so tired was 
I keeping them away." 

Finally, on July 1, 1862, four days after his injury, Winchell was to receive his much needed operation. He asked his surgeon for "Chloroform, quinine, or whiskey," but was told there was none to be had. He would have his arm amputated with no anesthesia. 

Winchell was placed on a table vacated by another amputee just minutes before. His shirt sleeve, filled with maggots, was cut away while the surgeons examined his wound. It was decided to sit him upright for the surgery. 

Winchell relates that he "set [his] teeth together and clenched [his] hand into his hair" as the amputation began. The top part of the arm was cut and the bone was removed. At this point, the surgeon wanted him to rest an hour, but he refused. After the operation, driven mad by the pain, Winchell wandered aimlessly before coming to rest once again under the scrub oak tree. He wailed and lamented that he had allowed the amputation, but he was eventually sent back to Union lines where he recovered and was discharged with a pension.[5] 

Illustration of arm amputation technique. Credit: CivilWarMedicalBooks.com. 

Patients like Winchell who managed to survive surgery were not out of the woods. Postoperative infections were a serious problem. "Laudable" pus, thick and creamy exudate now thought to be caused by staphylococcal bacteria, had a more favorable prognosis than "malignant" pus. Malignant pus was thin and bloody pus thought to result from streptococcal infection. The most dangerous wound infection was hospital gangrene. 

Hospital gangrene was first seen in large general hospitals. 45% of patients who developed this infection died. Gangrene was treated by first placing the patient under anesthesia. Dead tissue surrounding the wound was then cut away and the wound was packed with dressings soaked in bromine. These patients were then isolated and had their bandages changed last as nurses made their rounds. 

Illustration of hospital gangrene. Credit: The Lancet. 


More troops were killed by infection and illness than died in combat. Many factors contributed to non-combat related deaths, including overcrowded camps, improper use or lack of latrines, and poor food supply. The most common ailment among the troops was compounded by all three. Gastrointestinal distress was the most common reason for hospital admission during the war. 

711 cases of diarrhea per 1000 soldiers were reported every year. The mortality rate for acute diarrhea and dysentery was 2-17 per 1000 soldiers per year. Chronic diarrhea and dysentery killed 126-162 per 1000 soldiers every year. These numbers are startling, but diarrhea was not the only deadly camp disease. 


Amoebic dysentery in colon biopsy. Credit: Health Site. 


Malaria was also a serious concern, particularly for troops stationed in the south. Spread by infected mosquitoes, malaria flourished in the swampy ground and stagnant water of southern regions. 224 of every 1000 Union soldiers sought treatment for the disease. Although quinine could both treat and prevent malaria, the Confederates did not have enough supply to use it as a prophylactic and could only treat soldiers once they took ill.[6]  

Malaria. Credit: Centers for Disease Control and Prevention.


Mosquitoes also carried Yellow Fever. "Yellow Jack" or "stranger's illness" as it was sometimes dubbed, killed more than 10,000 people in the south. However, those fortunate enough to survive infection were immune for life. 




Not spread by mosquitoes but just as deadly, typhoid fever ravaged the Union army. Caused by exposure to food, flies, and drinking water contaminated by fecal matter, over 75,000 cases were reported. In 1861, typhoid killed 17% of those infected. By 1865, that number had risen to 56%. The disease was especially virulent in Washington D.C., where it took the life of Abraham Lincoln's son Willie. 

Salmonella Typhi bacteria. Credit: Hawaii State Department of Health. 



If a soldier avoided typhoid, he still had measles to contend with. At least 67,000 cases were reported, and more than 4,000 of those cases died. Of the 1,200 soldiers of the 12th North Carolina, 800 contracted measles over a span of just four months. One reason for the high death rate in measles cases was the rural lifestyle of most of the troops. These farmers had little or no immunity to childhood diseases. Among African Americans, the mortality rate was nearly twice that of whites: 11% versus 6%.[7]  

Measles Virus. Credit: Virology-Online.com


With so much disease and so many wound infections among the troops, competent hospital care was crucial. A letter written by Ward Master Lauramann Howe Russell to his daughter Ellen in 1862 offers a glimpse into critical care practices. Ward Masters were non-commissioned officers primarily responsible for the safekeeping of patient's belongings and maintenance of hospital furniture and equipment. Although in theory, Ward Masters were not involved in direct patient care, Russell describes observing dressing changes and surgeries and mentions taking responsibility for patients. 

Russell's letter also provides valuable information concerning the workings of a typical Civil War hospital. Generally, a Ward Master and two nurses could care for a 50-bed, non-acute care ward. When no physician was available on the ward, the Ward Master shouldered the responsibility for patient medication, food, and comfort. [8] 

The letter also offers insight into the work of nurses. Although most people think of women when picturing the Civil War nurse, the idea of women working in hospitals was controversial. Hospitals were considered a "male realm" in which female attendants were inappropriate. Some critics feared women would be unable to cope with hospital gore and they felt exposed male patients were improper for female eyes. However, some viewed hospitals as an extension of the domestic sphere and believed women were specially suited to comfort and treat the sick. 

The Lauramann Howe Russell letter. Credit: Journal of Anesthesia History. 

Because of this controversy, more men than women worked as nurses. In addition to nurses assigned by the army, convalescent soldiers well enough to work also performed nursing duties. Women were often underpaid and went unrecognized for their efforts. Despite all this, women played a vital role in hospital care. They were called nurses, but their duties often overlapped with cooks and laundresses. [9]

The Civil War brought unfathomable suffering and death. However, the conflict also galvanized the determination of courageous men and women. 19th century medical knowledge blossomed after the guns ceased. 

It is my belief that the primitive and often unprepared for medical care during the Civil War was not due to simple ineptitude and ignorance as our modern minds lead us to think. I believe it speaks to the overall expectations that most people held for the war. Most believed there would be a few black eyes, but ultimately the fighting would be brief before they could return home victorious. Very few individuals could foresee what was to come. 

Sources

1. Reilly, Robert F. "Medical and Surgical Care During the American Civil War, 1861-1865." Baylor University Medical Center Proceedings 29, no. 2 (April 2016): 138-142. CINAHL Complete, EBSCOhost (accessed December 27, 2017), 139. 

2. Ibid, 140.

3. Cutter, Laura, and Tim Clarke Jr. "Anesthesia Advances During the Civil War." Military Medicine 179, no. 12 (December 2014): 1503. MEDLINE, EBSCOhost (accessed December 27, 2017), 1503. 

4. Reilly, 140. 

5. Albin, Maurice S. "In Praise of Anesthesia: Two Case Studies of Pain and Suffering During Major Surgical Procedures With and Without Anesthesia in the United States Civil War- 1861-1865." Scandinavian Journal of Pain no. 4 (2013): 243-246. InfoTrac Health Reference Center Academic, EBSCOhost (accessed December 26, 2017), 245. 

6. Reilly, 141.

7. Ibid, 142. 

8. Gorbaty, Benjamin. "The Lauramann Howe Russell Papers: A Window into Critical Care Medicine During the American Civil War." Journal of Anesthesia History 3 (October 1, 2017): 117-121. ScienceDirect, EBSCOhost (accessed December 28, 2017), 117. 

9. Ibid, 119. 







Comments

  1. This is an excellent overview of Civil War medicine! There are some really interesting accounts of Jackson, who in his delirium, recalled hearing the sound of the saw on the bone as his arm was being amputated (eek!). Hunter McGuire certainly had a stellar career. I think one of the contributing factors to the rise of medical schools in postbellum America was due in large part to the high number of experienced surgeons on both sides. Samuel Hollingsworth Stout served as the chief surgeon of the Army of Tennessee and helped establish the now-stellar medical schools at Emory and Baylor.

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