Introduction
Of all the conflicts fought by the United States, none were as horrific for the surgeon as the Civil War. 19th-century United States was new and fast-growing. The rail and steel industries were booming, immigration was up, and the United States was on track to become a significant power in the western hemisphere. From a medical standpoint, however, the country was barely in its adolescence.
Licensing Surgeons in the United States
The “American doctor” generally lacked formal training or certification. Most of their knowledge came from experience and hearsay. The accreditation process consisted of buying a white coat and reading a few medical books. Amputation, the surgical removal of a limb or body part, had been successfully practiced in Germany for years. However, it wasn’t until 1827 that Doctor Valentine Mott performed the first successful amputation on American soil. Yet there was no distinct difference between a surgeon and a physician, as the surgical specialty did not yet exist.
With the advent and incorporation of anesthesia into American medicine in the 1820’s, medical schools began to appear. Yale University was established in 1813, Jefferson medical college opened in Philadelphia in 1826, and New York’s Bellevue Hospital Medical College was created in 1841. Medicine was concentrated on the east coast because the east coast had more infrastructure and resources (like libraries and developed cities). American medicine tended to develop and consolidate in densely populated urban areas like Philidelphia, Boston, Richmond, and New York[1].
Yet with the rise of formal medical institutions, the quality of care among doctors decreased due to the state giving medical schools the power to license their physicians. As more states were added to the union and more schools popped up, it became profitable to certify as many new students each year as possible to maximize tuition profits. To solve the decline in quality, medical societies were also given their own power to license surgeons and physicians. The hope was that these groups would hold themselves to higher standards and ensure that their representatives were worthy of membership[2].
In 1847, the American Medical Association was founded to combat this problem. Due to the existence of membership fees and the prerequisite of being a licensed doctor, however, it was more profitable to bestow licensing and collect the dues than to insist on a higher quality of care.
This is not to say that no quality science took place during this time. Samual Gross was a physician who used animal models to help him understand surgical procedures and diseases. He authored the first extensive systemic study of pathology in English and published Elements of Pathological Anatomy in 1839, which contained information about each organs weight, healthy color, size, and consistency.[3] He also authored An Experimental and Critical Inquiry Into the Nature of Wounds of the Intestines, which explored the pathology and progression of wounds in the intestines.[4] Both works were based on original research.[5]
A Portrait of Dr. Samuel D. Gross (The Gross Clinic). [6].
Courtesy of Thomas Eakins. Public Domain.
Anesthesia and Infection
Anesthesia redefined every aspect of surgery in the United States. Before its use, much of surgery focused on speed and minimizing pain. Yet with the advent of the unconscious patient, surgeons could take their time and ensure that the procedure was performed correctly, with minimum risk to life or limb.
For example, amputations could be done in as little as sixty seconds, but the result was a frenzied operation that produced a sloppy product, sometimes destroying critical structures and leading to permanent damage or even death. If the patient was anesthetized, then the surgeon could slow down and ensure that as much of the limb was preserved as possible. This resulted in cleaner procedures and better outcomes for patients. In wartime, chloroform was the agent of choice because it acted quickly and wasn’t flammable.
Infection was a surgeon's worst nightmare. In 19th century surgery, the only response to severe infection was amputation; there was no way to treat it and, if left unchecked, it guaranteed the patient’s death. Infection occurs when a virus or bacteria enters your body and begins to multiply. In response, your body induces a fever to attempt to denature invading cells. Additionally, the immune system mobilizes defenses which target specific structures of a bacteria and attach to them to neutralize the pathogen’s effectiveness; white blood cells can then clean up the inactive virus or bacteria. Viruses wreck havoc by disrupting normal cell functions or hijacking host cells to reproduce. Bacteria can also disrupt cell functions, but they can also multiply so fast that they crowd out host cells; they can also kill cells outright or secrete toxins that paralyze the cells around them.[7]
The modern answer is antibiotics: drugs that target specific aspects of a bacteria, like their RNA or specific proteins found in the nucleus or membrane. Because these traits are unique to bacteria, human cells are unaffected. If the body’s immune system fails to fight off the infection, then the pathogens continue to multiply until the host dies.
The first antibiotic drug was developed in 1935 by Gerhard Domagk.[8] Unfortunately, amputation was the only option available to injured Civil War soldiers. In the Union, 100,000 died in battle but 225,000 died of disease while 25,000 died of accidents and suicide.[9]
Other threats of early surgery included the often-lethal gangrene and gas gangrene. Gangrene is cell death due to infection or lack of blood flow. The skin turns black and, if not amputated promptly, will continue to spread as the infection worsens.[10]
An example of an amputated gangrenous arm of the confederate soldier Private Milton E. Wallen of Company C, 1st Kentucky Cavalry. [11].
Courtesy of Edward Stauch. Public Domain.
Gas gangrene is a complication when gas forms in gangrenous festering muscle tissue that forms raised blisters or pustules which release a foul gas when ruptured that can be contagious. Gas gangrene was terrifyingly contagious and could spread through a ward in as little as a few days, infecting any open wound.
Special wards were set up for gas gangrene patients; they would be taken to a separate room away from other patients and left to see if the infection resolved itself.[13] Patients reported dread when they realized they had been left to die and likely that the only way out of the room was in a body bag.
After a few days of working in the ward, nurses claimed that they couldn’t wash the smell of rot from their skin and hair.[14] The major post-surgical complication was hemorrhaging (the rupturing of a blood vessel), which could occur days after surgery and was fatal 60% of the time.[15]
Civil War Weapons and Injuries
90% of all Civil War injuries were caused by bullets.[16] There were two types of ammunition used.
Mine balls were hollow bullets that flattened and tumbled upon impact, causing them to do additional concussive damage. Used by infantry in their rifles, mine balls were the primary cause of injuries.
An illustration of various types of civil war bullets. [17].
Courtesy of The US Government. Public Domain.
Loaded into cannons, case or canister shot were solid lead or iron balls that acted as additional shrapnel to cause damage.
An example of a shot canister. [18].
Courtesy of Minnesota Historical Society. Creative Commons (BY).
Both artillery and gunfire resulted in horrific injuries. Exit wounds were almost always larger than entrance wounds and could sometimes be as large as a fist. If a bullet hit a bone, then it could shatter under the impact, sending bone and bullet shards into the surrounding tissue that had to be removed before the wound could be stitched shut. If a soldier survived being shot, then amputation was extremely likely.
A proximally fractured femur from a gunshot wound. [19].
Courtesy of The National Institutes of Health, Health & Human Services. Public Domain.
This is a typical example of what a surgeon might encounter on any given day. [20].
Courtesy of The U.S. Army Surgeon General's Office. Public Domain.
Treatment
The American Civil War produced serious injuries on such a scale that battlefield medicine had to be drastically altered. Before the invention of modern projectile weapons, injuries were limited to what could be inflicted by men, melee weapons, and arrows. Bullets made a significant change because explosions threw muddy fertile soil into gaping wounds, producing deep, messy wounds that were nearly impossible to treat without amputation.
Similarly, the time from injury-infliction to injury treatment could mean the difference between the patient living and dying, so a sophisticated horse-drawn ambulance system was developed. The ambulances would transport soldiers to field hospitals, temporary medical centers set up close to the battlefield. Once the patient wasn’t in imminent danger of dying, they would either be sent back to the battlefield or shipped to a general hospital in a fortified position.
Set up anywhere, field hospitals were basically four walls and a roof. Common choices included barns, homes, and churches—anywhere the soldiers could secure. Once the battle started, the wounded would start to trickle in and then flood into the field hospital, quickly overwhelming their capacity. Surgeons moved from man to man, working as quickly as possible while aids followed behind and performed diagnosis and bandaging. Surgeons worked with dirty tools and stuck filthy hands into open wounds, significantly increasing the rate of infections. Field hospitals were easy to identify due to the piles of limbs that accumulated around them as the battle progressed.[21]
An example of union surgeons performing one of many amputations in a field hospital at Gettysburg.[22].
Courtesy of Attributed to Charles J. Tyson & Isaac G. Tyson. Public Domain.
If it was clear that a soldier was going to die, he would be carted off to the side, given as much alcohol as could be spared, assured that his turn would come soon, and left to die.[23]
Field hospitals were rife with infection and could very well aggravate an already serious case. If stables or barns were used, then the mortality rate due skyrocketed to 90% due to tetanus.[24] Often, the operating table was little more than an unclean bed or a plank balanced atop two barrels; lacking sanitation led to the perfect breeding ground for deadly contagious infections.[25]
If a soldier made it to a general hospital, then their chance of living increased by about 90%.[26] Hospitals had a dedicated staff, adequate room between beds, and separate rooms for nurses, laundry, patients, surgery, and recovery—all of which helped to keep the rate of infections down. On both sides of the war, surgeons successfully completed nearly eighty thousand surgeries without anesthesia[27].
An example of a civil war hospital on a steamship, the large open areas, and space between beds kept infection rates to a minimum. [28].
Courtesy of Harper's Weekly Illustration. Public Domain.
If a bullet was lodged in the body, then it had to be removed before the wound could be closed. Otherwise, it could move and cause more damage, or it became a constant source of stress for the immune system until it could be encased in scar tissue. If a bullet had to be removed, a surgeon would insert a probe into the wound until they felt the bullet, then they would slide forceps along the probe till they reached the bullet. Finally, they would grasp and remove it.[29]
An example of various types of probes and forceps designed to remove bullets. [30].
Courtesy of Wellcome Images. Creative Commons (BY-SA).
If amputation was required, then the surgeon first had to tie a tourniquet above the incision site to reduce blood loss. On a good day, the patient would be provided anesthesia or, on a bad day, a bite block to muffle any screaming and prevent them from biting hard enough to hurt their teeth or jaw. Once the patient had been secured and the site had been prepared, the surgeon would cut the surrounding muscle with a Liston knife. These were long thin blades specially designed to slice through thick muscle and down to the bone, clearing the way for the serrated saw[31].
A modern example of Listen knives of various sizes. The long thin blade was specially shaped to slice through muscle. [32].
Courtesy of Wellcome Images. Creative Commons (BY-SA).
Once the muscle was cleared from around the bone, several tools could be used, each tailored to the type of amputation necessary. A bone saw had a sturdy, serrated blade that was used to saw through bone.[33]
Large bone saws like this were designed to saw through thick bones. Smaller saws were better suited for smaller bones like fingers and toes. A pair of Liston-style knives are also included. [34].
Courtesy of Laika ac. Creative Commons (BY-SA).
If the bone was shattered and only held on by a few thin strands, or in the case of something delicate like a finger needed to be amputated, then bone-cutting forceps could be used. These were like wire cutters for bones.[35]
These clippers are best suited for cutting through small finger bones or rough shards of splintered bones; they provided the means for precision amputation. [36].
Courtesy of AfroBrazilian. Creative Commons (BY-SA).
If something like a femur or other large bone needed to be broken down, then a mallet and chisel could be used. These were designed to break up large bones or crack through bad comminuted fractures, when the bone splits into two or more pieces[37].
An example of a personal bone chisel. Notice that the chisel is blunt because they are used on bones; there is no advantage to having a sharp edge on the chisel. [38].
Courtesy of Author: Taylor, Robert Tunstall | Contributing Library: Francis A. Countway Library of Medicine | Digitizing Sponsor: Open Knowledge Commons and Harvard Medical School. Public Domain.
All these tools were usually bought at the surgeon’s own expense and carried in a basic wooden box, like a toolbox for bloodshed.
An example of a surgeons toolkit
An Example of the amputation process from start to finish. Note that figure 5 depicts the skin left over past the end of the arm to effectively be able to seal the amputation. [40].
Courtesy of Bernard Claude | Digitized by the Historical Medical Library of The College of Physicians of Philadelphia. Creative Commons (BY-NC).
The Effects of the War
The American Civil War provided two things to developing surgeons in the United States: an unending stream of new patients on which to practice and an explosion in surgical literature. At the start of the war, most surgeons were incompetent and botched even the most simple of procedures. Yet when each battle produced thousands of injured patients, the learning curve was steep because the injuries and conditions only allowed for a handful of common procedures, which were quickly perfected[41].
The medical literature circulating during the Civil War consisted mostly of how-to manuals—surgeons writing a barebones field manual for the most common procedures and injuries, and rushing them off to be printed and distributed. Celebrated surgeon Samual Gross published A Manual of Military Surgery which detailed tips for the battlefield, including how to stay with your unit during engagement and construct litters to transport patients. He also included an extensive medical section where he explained how to recognize and treat different conditions and injuries.[42]
After the war, The medical and surgical history of the war of the rebellion (1861-65) was written and published by Joseph Barnes (et. all) and was recognized as the first major, original medical work produced in the United States.[43] This spawned several new licensing laws that returned the power to license surgeons back to the state, significantly raising the quality of practice. However, there was still no widely-held distinction between a surgeon and a physician, in spite of surgeons completing difficult procedures like abdominal surgeries and facial reconstructions[44].
By about the 1870's, surgery was comparable between the United States and Europe, with the only difference being that scientific research was concentrated in the older, more experienced institutions of Europe. Renowned English surgeon John Erichsen visited the United States in 1874 and was very impressed by what he saw, commenting on the high social status of doctors. He stated that neither law nor the church provided a place for the men of the highest intellectual caliber to enter and feel significantly challenged, so they turned to medicine[45]. Additionally, because higher education was so rare and highly regarded in the United States, doctors were seen as the most intelligent and educated that the country had to offer[46].
Germ theory was first proposed by Louis Pasteur in the 1860’s, but it was the work of Joseph Lister that applied that theory to the operating room.[47] Lister insisted that all his tools be washed in between patients, that the operating rooms be kept clean, and that antiseptics be applied to open surgical wounds[48]. The medical community was slow to accept his ideas about germ theory, but the combination of a decrease in infections where these methods were applied, and the near-miraculous results of his surgeries, began to influence influential surgeons.[49]
His ideas were grudgingly accepted in the 1880’s and infection rates began to decrease. Areas Gerster wrote The Rules of Aseptic and Antiseptic Surgery in 1888, which detailed how antiseptic surgery should be performed and the results of a clean operating room.[50] This was the final text that convinced the medical community of Lister’s ideas, and it started a golden age of surgery in Europe. This golden age came to the United States in the early 1900’s when waves of American medical students (who had been training in Europe) began to bring home Lister’s ideas.[51]
An example of a John Hopkins operating room dated 1943. Notice how the surgeons and nurses wear full gowns and gloves, use sterile tools, and keep the room clear of other personal and patients. Lister's ideas became the foundation of modern American Surgery. [51].
Courtesy of Author: Ann Rosener | The Library of Congress's Prints and Photographs division. Public Domain.
Two events were crucial in the professionalization of surgery in America: Samuel Gross founded the American Surgical Association in 1880, and The Annals of Surgery—a journal devoted exclusively to surgery—was edited by Lewis Pilcher. The final stage of American surgical development occurred in May 1889 when William Halsted started working at the new John Hopkins University. He set the tone of surgery from the dramatic operating theatre to the more subdued operating room, while also emphasizing independent, original research and innovation.[53] With a dedicated medical school of surgery, surgical society, and a specialized surgical journal, American surgery became a real science[54].
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