Between Flesh and Steel (31 page)

Table 10. Amputations in the Union Army (29,980 Reported Cases)

The improved kinetic power of the rifle bullet made amputation the most common battlefield operation during the Civil War. Of the 174,200 gunshot wounds to the arms and legs suffered by Union soldiers, 29,980 required amputation.
¹¹⁷
Confederate soldiers suffered 25,000 primary amputations (meaning as soon as possible after wounding) and the Union Army 20,993.
¹¹⁸
More limbs were lost in this war than in any other conflict fought by the United States, including World Wars I and II, Korea, Vietnam, Iraq, and Afghanistan. The old debate about primary versus secondary amputation reappeared. Within two years, experience had shown that the soldier's chances of survival increased with primary amputation. The mortality rate for primary amputation was 26 percent compared to 52 percent for secondary amputation.
¹¹⁹
Interestingly, however, 26,467 wounds of the extremities complicated by injury to the bone were treated “by expectation” (leaving the wound alone to heal itself) with a mortality rate of only 18 percent, which was much lower than the rate for either primary or secondary amputation.
¹²⁰

In the first year of the war, hemostasis was achieved mostly through the tourniquet and cautery, but both methods were dangerous to the patient. As the minimally trained surgeons gained more experience, however, they more commonly used ligature and pressure dressings to control bleeding. One of the war's beneficial medical effects was that it gave thousands of surgeons experience in ligature, a training they could practice in civilian life. The common practice, however, was to leave the ends of the ligature long and extending outside the body. These loose ends proved to be excellent avenues for infection, producing septic conditions that led to secondary hemorrhage. The mortality rate for such secondary infections was 62 percent.
¹²¹
The usual array of infections—tetanus, hospital gangrene, and various streptococcus infections—were ever present. In the early days, the mortality rate in some hospitals was as high as 60 percent. As surgeons gradually began using debridement and bromine solution applications, the mortality rate from wound infection fell to 3 percent near the end of the war.
¹²²

The Union blockade caused shortages of medical supplies that forced Confederate surgeons to develop alternatives that proved beneficial in fighting wound infection. Both sides cleansed wounds with sea sponges kept in buckets of water near the operating table. Used repeatedly after being squeezed in the dirty water, these sponges were major sources of disease transmission. A shortage of sponges in the South forced Confederate surgeons to use cotton rags instead. Since the rags were recycled, cleaned, boiled, and ironed, they served as relatively sterile wound dressings. The same was true of the bandages. With bandages in short supply, practitioners used raw cotton, but to manufacture the product, it was necessary to oven bake the cotton, producing a sterile bandage. While Northern surgeons used unsterile harness-maker's silk for ligatures and sutures, silk was not available to the Southern surgeons, who used horsehair for the same purposes. To make the horsehair sufficiently pliable for surgical use, they had to boil it. By happy accident, the boiling process produced sterile sutures.
¹²³
Nonetheless, wound infection, especially in the general hospitals, remained a major problem. William W. Keen (1827–1932), who served as a surgeon in the Army of the Potomac, noted, “It was seven times safer to fight all through the three days of Gettysburg than to have an arm or leg cut off . . . and be treated in a city hospital.”
¹²⁴

Military surgeons of the Civil War used chloroform and ether anesthesia on an unprecedented scale. Military physicians used no fewer than eighty thousand applications of anesthesia. Official records show that anesthesia was used in 8,900 operations
within general hospitals, of which 6,784 involved chloroform and 811 involved ether alone. In 1,305 cases, they used a combination of ether and chloroform. Remarkably, only thirty-seven deaths were attributed to anesthesia.
¹²⁵
They also made advances in immobilizing limbs, with plaster of Paris widely used for this purpose. Having studied in Europe, Dr. Gordon Buck (1807–1877) brought the technique to America, and the first application to immobilize a limb was accomplished in 1855. Dr. Nathan Little is generally credited with introducing the technique to the military medical community during the Civil War.
¹²⁶
In 1863, Union surgeon John Hodgen (1826–1882) introduced the famous Hodgen splint, which is still used today in fractures of the lower femur.

Drug application during the war was quite primitive because physicians of the period knew little about the specific effects of drugs. Except for calomel (mercurous chloride), which was so heavily prescribed that Surgeon General William Hammond (1828–1900) forbade its use as dangerous, most drugs did little harm if little good. The most indispensable and well-known drugs included morphine, opium, and quinine. Morphine was usually dusted directly on the wound and occasionally injected hypodermically. The hypodermic syringe appeared in the 1850s, but only 2,093 syringes were issued to the Union Army during the war. That their use had any medical significance is unlikely. Yet, Silas Weir Mitchell (1829–1914) noted that at the army hospital for nervous diseases, Turner's Lane Hospital in Philadelphia, more than forty thousand doses of morphine were given hypodermically to patients in a single year.
¹²⁷
A significant addiction problem resulted from the Union Army's wide use of opium pills and other addictive opium-based prescriptions. Records show that
ten million
opium pills were administered to patients during the war, along with 2,841,000 ounces of other opium-based preparations, such as laudanum, opium with ipecac, and paregoric. By contrast, only 29,828 ounces of morphine sulfate were administered.
¹²⁸
While not all addicts in the country were former soldiers, the United States had 200,000 drug addicts by 1900.
¹²⁹

A number of antiseptics were widely used, including potassium permanganate, sodium hypochlorite, bromine, iodine, turpentine, and creosote. Lister had not yet made his important discovery regarding antisepsis, and none of these preparations were used in wound treatment. They were, however, commonly used as deodorants in hospitals and did have the unintended effect of providing better sanitary conditions in the hospital wards.

As in all past wars, disease was the most common killer of Union and Confederate soldiers. Both armies were armies of volunteers, and in the early years of the war
the armies performed little more than perfunctory medical examinations of their recruits. A normal day's load for physicians examining recruits was between forty and fifty examinations a day. The quality of recruits, often motivated by patriotic fervor and the enlistment bounty, was less than desirable. In 1861, a Union Sanitary Commission report noted that three-quarters of the soldiers who had been discharged from the Union Army were so physically unfit that they should never have been allowed to enlist in the first place.
¹³⁰

Most recruits came from largely rural populations. Their isolated locations had prevented them from developing immunities to a wide range of childhood diseases. Once they were brought together in the close quarters required of military life, many fell ill.
¹³¹
Their poor physical conditions and few immunities were compounded by generally poor nutrition from military rations and the general stress of military life. Scurvy was endemic, and outbreaks of cholera, typhus, typhoid, and dysentery took a generally heavy toll.
¹³²
Although tetanus mortality was high—89–95 percent— relatively few cases of tetanus arose because most battles did not occur in the richly manured soil of overworked farmland. Most cases of tetanus were contracted in field hospitals, when barns and stalls served as temporary surgical hospitals and aid stations.
¹³³
Disease killed approximately 225,000 men in the Union Army and 164,000 in the Confederate ranks. It is estimated that disease killed five times as many men as were slain by weapon fire.
¹³⁴

The Union Medical Department was totally unprepared for war. Its head, Surgeon General Thomas Lawson (1789–1861), was a sick and dying man who economized on expenditures by refusing to purchase medical books for the military. The small 26,000-man army was scattered along the frontier and had no military medical service to speak of. The regular army in 1860 had only thirty surgeons and eighty-three assistant surgeons, and twenty-four of them resigned to serve with the Confederacy.
¹³⁵
Medical supplies consisted of a few incomplete surgical kits and clinical thermometers. The country had no general hospitals, and the largest post hospital, located at Fort Leavenworth, Kansas, had only forty-one beds.
¹³⁶

There was no ambulance service. In the 1850s, Secretary of War Jefferson Davis (1808–1889) had ordered two military officers, one of whom was Capt. George B. McClellan (1826–1885), to prepare a study of the lessons to be learned from the Crimean War. McClellan's report included a section on ambulance trains and medical supplies and recommended creating an army ambulance corps. A committee was appointed to accept designs for medical transport vehicles, but by 1860, the army
had rejected all the designs and had not created an ambulance corps.
¹³⁷
For the war's first two years, neither side had a systematic way to evacuate the wounded. After the disaster at the First Battle of Bull Run (July 1861), where vehicles had to be commandeered from the streets of Washington to move the wounded, individual field commanders improvised what little medical transport they could. Toward the end of the Peninsula campaign, an army corps of thirty thousand men had an ambulance transport system sufficient for only a hundred casualties. At the Battle of Wilson's Creek (August 1861), the wounded could not be moved for six days owing to the lack of ambulances. In November 1861, Gen. Ulysses S. Grant (1822–1885) and his forces at Belmont, Missouri, had to abandon their wounded because they did not have ambulances.
¹³⁸
Ambulance transport in the Confederacy was even worse. In 1863, Confederate medical officers reportedly had only thirty-eight ambulances in the entire Army of the Mississippi. As the war continued, the situation worsened. In 1865, not a single ambulance could be found in the combat brigades of the armies of West Virginia and East Tennessee.
¹³⁹

Meanwhile, the appalling medical conditions of the Union Army provoked a public outcry, much as similar conditions had provoked public outrage among the British during the Crimean War. In 1861, Dr. Henry Bellows (1814–1882), a Unitarian minister from New York, led a committee that created the U.S. Sanitary Commission, which made recommendations to improve medical treatment. Its first suggestion was to fire Surgeon General Lawson and replace him with Dr. William Hammond. Upon assuming his position, Hammond appointed Dr. Jonathan Letterman (1824–1872) as surgeon general of the Army of the Potomac. Making several contributions to the Union's medical service, Letterman quickly set about reorganizing the system and creating an ambulance corps.

Letterman's ambulance corps was built around the Larrey model, and each army corps had its own dedicated medical transport assets. Each division, brigade, and regiment had its own medical officer responsible in a direct chain of command to the corps medical officer, who was responsible for coordination at all levels. The chief surgeon within each division controlled the ambulance corps, and he assigned all details regarding parking, roll call, stable call, veterinary services, and police duty to a line officer of the division. Each regiment received three ambulances and a complement of drivers and litter bearers, and each division had its own ambulance train of thirty vehicles. The ratio of ambulances to men averaged 1 to 150.
¹⁴⁰

Letterman established a trained corps of ambulance drivers and litter bearers and gave them a distinctive uniform and insignia. He specified that only medical
personnel could remove the wounded from the battlefield, a regulation designed to reduce the manpower loss that normally resulted when soldiers left the line to transport their wounded comrades to the aid station. Ambulance wagons were removed from the quartermaster's control and were to be used only for medical transport. Ambulances traveled in the front of the column to ensure they would be easily reached once the battle commenced. The first test of Letterman's ambulance system came at the Battle of Antietam Creek (September 1862). Union forces suffered ten thousand wounded scattered over a six-mile area, but the system reached and evacuated most of them within thirty-six hours. Three months later at Fredericksburg (December 1862), the system worked so well that the wounded piled up at the aid stations faster than they could treated.
¹⁴¹
Within twelve hours, all of the nearly ten thousand Union wounded had been located and cleared through the aid stations.