Whether you are one to believe that the Civil War started with the brush ups between Kansas and Missouri, or South Carolina seceding from the union of states, something we do know that started are the practices what we regard today as triage and ambulatory services, aseptic surgery, and postoperative wound care.
The battle of Bull Run is recognized as the first official battle of the Civil War. Initially civilians or regiment members were assigned in getting the wounded off the field and to medical care. This did not go well. Ambulances were driven by civilians who fled when the first shots were fired. If they left the ambulances behind, healthy soldiers stole them to flee back to Washington, DC. Not a single wounded soldier returned to Washington, DC, in an ambulance (10). Tragically, wounded soldiers remained on the battlefield for days, the first two spent in the rain. Incredibly, Surgeon General Finley did not order medical supplies until after the battle was over. (Reilly, 2016)
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The following year in July, Medical Director of the Army of the Potomac, Major Jonathan Letterman in just six weeks, before the battle of Antietam, revolutionized the Army Medical Corp. The three-tiered system he began is still very similar to how we treat emergency patients today. First, surgeons near the front made the initial assessment and treatment, including tourniquets, morphine, and water or whiskey. Then, it was decided who could be saved, and who had fatal injuries; finally, ambulances at collection points transported the wounded to field hospitals in nearby buildings, and those with more severe injuries to general hospitals. (Liebig, Tremblay, Soballe, & Ignacio, 2016) There were 71 Union field hospitals at the time of Antietam, by the end of the war about 400. Standards of care were elevated, and training was becoming standardized. It was far from aseptic, but it was better than the Bull Run.
Before we get too far into surgery, it must be mentioned that hygiene in army camps was atrocious. Major Letterman had also implemented standards of hygiene and health that drastically cut sicknesses and disease throughout the Army. The use of chloroform as an anesthetic had been around since the 1840s, this gave a surgeon the time he needed to his work. Prewar there were 113 doctors in the army. At the start of the war, 24 went south and 3 had defected. At the end of the war, there were over 12,000 doctors in the Union Army and over 3000 in the Confederate Army. Before the war, the largest military hospital was at Fort Leavenworth, with 40 beds. The only hospital in Washington, DC, before the war was a two-story six-room building used to isolate smallpox patients. (Reilly, 2016) Three of four surgeries were amputations. Each amputation took around 5 minutes.
Chloroform was administered, the surgeon would take his scalpel and make an incision through the muscle and skin down to the bone. He would make incisions both above and below, leaving a flap of skin on one side. Taking his bone saw, he would saw through the bone until it was severed. He would then toss it into the growing pile of limbs. The operator would then tie off the arteries with either horsehair, silk, or cotton threads. The surgeon would scrape the end and edges of the bone smooth, so that they would not work back through the skin. The flap of skin left by the surgeon would be pulled across and sewed close, leaving a drainage hole. The stump would be covered perhaps with isinglass plaster and bandaged. Infections were rampant in dirty field hospital tents. ((Goellnitz)emphasis added)
During the war documentation was difficult and knowledge spread slowly. When word spread of Major Lettermans advancements in regimental health other practices were experimented and allowed. Prewar amputation mortality was above 60%, sometimes into the 70%s. By the end it was down to about 25%. Dirty tents, too close to the front lines, dirty doctors, dirty instruments and sponges were exchanged for field hospitals in homes or barns out of firing range with controlled traffic, tools were washed, new sponges/rags or used ones, at least, laundered clean, all pioneered at the time. Surgery done within 24 hours of injury proved better mortality than waiting days, from any doctor amputating to becoming a specialty where only 1 in 15 physicians were authorized to amputate. Experiments in bandage changing, soaking them in bromine, mixing plasters and poultices for infection control and patient isolation became normal practice after the lessons learned in battlefield medicine. Unfortunately, it wasnt until Listers paper on antiseptic principles in 1867 that many of these practices were standardized.
Each one of these subjects can be a paper unto its own. When tied together one can see a bigger picture, that even in the bedlam of war and misery, great things can be accomplished. Other notable advancements caused by Civil War surgery are; safe use of anesthetics, the beginnings of neurosurgery, development of arterial ligation, and plastic surgery. It was said War is the only proper school for the surgeon. Thankfully because of the horrors of the Civil War we ended up with thousands of trained doctors attending at hundreds of hospitals and surgical practices that often surpassed Europe in reduced mortality rates and postoperative infection. We stand upon the shoulders of men and women that gave their lives and bodies to the practice of medicine in those years. Let us honor them by continuing good surgical conscience and aseptic principles.
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