PART 2. May 28, 2019. “BATTLEFIELD” MEDICINE: THE CIVIL WAR. “Many of America’s modern medical accomplishments have their roots in the legacy of America’s defining war.”

ASSIGNMENT: Profile medical advances made during World War I, World WAR II, the Korean War, Vietnam, Afghanistan and Iraq.

Memorial Day 2019

From 1967 to 1970, during the Vietnam War, I served first as a 2nd Lieutenant and  Administrative Officer of the 4th Casualty Staging Flight attached to Wilford Hall USAF Medical Center, Lackland AFB in San Antonio, Texas. We received combat casualties still in battlefield bandages, often within 24 hours of injury, and either admitted them to Wilford Hall or further transported them to hospitals near home.

New PART 2 after PART 1

Part 1. July 3, 2018. “BATTLEFIELD MEDICINE: THE REVOLUTIONARY WAR

“When the Revolutionary War began its actual skirmishes in 1776, early attempts to prepare for the medical needs related to War were made in the City of New York. During the spring and summer of 1776, Samuel Loudon was publishing his newspaper the New York Packet, in which he included numerous articles and announcements regarding the Continental Army. On July 29, for example, came the following announcement written by Thomas Carnes, Stewart and Quartermaster to the General Hospital of King’s College, New York. Anticipating an increase demand for medically trained staff, he filed the following request for volunteers:

“GENERAL HOSPITAL New-York, July 29, 1776 Wanted immediately in the General Hospital, a number of women who can be recommended for their honesty, to act in the capacity of nurses: and a number of faithful men for the same purpose…King’s College, New York” (A)

“One of the most famous surgeons, and the first, was Cornelius Osborn. He was recruited in the Spring of 1776 and had little training even as a physician. The Continental Congress was even concerned about the well-being of the troops and the militia. They passed several ordinances and helped establish the order for the several field Hospitals during the War. The hospitals served about 20,000 men in the fight. Each hospital was required for each surgery to have at least one physician or surgeon, and one assistant, which was usually and apprentice of some sort. Each hospitals staff numbers varied on how many wounded it served and the severity of the wounds….

Most of the deaths in the Revolutionary War were from infection and illness rather than actual combat. The common practice if a limb was badly infected of fractured was amputate it. Where most amputees died of gangrene a result of not properly cleaning instruments after surgeries. Only 35% of amputees actually survived surgery. There was no pain killers quite developed back then. So at most the patient were given alcohol and a stick to bite down on while the surgeon worked. Two assistant would hold him down, a good surgeon could perform the entire process in a mere 45 seconds, after which the patient usually went into shock and fainted. This allowed the surgeon to stich up the wound, and prepare for the next amputation. Another way they decided to clean wounds, disease, or infection was by applying mercury directly to the cut of injured space, and letting it run through the blood stream which usually resulted in death.” (B)

“To seek treatment for any serious ailment, a soldier would have had to go to a hospital of sorts. Military regiments had a surgeon on staff to care for the men, so the soldier’s first stop would be with the surgeon. During battles, the surgeon could be found in a makeshift or “flying” hospital that consisted of a tent, an operating table, and some medical equipment. If the surgeon could not treat the soldier, he might be sent to a hospital. Many regimental hospitals were in nearby houses, while general hospitals for more in-depth treatment were sometimes set up in barns, churches, or other public buildings. The conditions were often cramped, which resulted in the rapid spread of contagious illnesses and infections….

Woe to the soldier who required surgery after being wounded on the battlefield! The conditions in “flying” hospitals were deplorable. Not only was the operating room simply a table in a tent, but there was little thought given to keeping the table and tools clean. In fact, wounds were sometimes cleaned using plain water from a bucket, and the used water would be saved to clean out the next soldier’s wounds as well. (C)

Hospitalization was a serious problem during the American Revolutionary War. Plans were made quite early to care for the wounded and sick, but at the best they were meager and inadequate. However on April 11, 1777 Dr. William Shippen Jr., of Philadelphia was chosen Director General of all the military hospitals for the army. Consequently the reorganization of hospital conditions took place.

Four hospital districts were created: Easter, Northern, Southern and Middle. The wage scale was as follows: Director General’s pay $6.00 a day and 9 rations; District Deputy Director $5.00 a day and 6 rations; Senior Surgeon $4.00 a day and 6 rations; Junior Surgeon $2.00 and 4 rations; Surgeon mate $1.00 and 2 rations.

After the battle of Brandywine, September 11, 1777, hospitals were established at Bethlehem, Allentown, Easton and Ephrata. After the battle of Germantown, October 4, 1777, emergency hospitals were organized at Evansburg, Trappe, Falkner Swamp and Skippack. Hospitals at Litiz and Reading were also continued. By December 1777, new hospitals were opened at Rheimstown, Warwick and Shaeferstown. Yellow Springs (now Chester Springs) an important hospital was organized under the direction of Dr. Samuel Kennedy. At Lionville, Uwchlan Quaker Meeting House was also made a hospital for a time. Apothecary General Craigie’s shop, Carlisle, was the source of hospital drugs….

It seems there was carelessness in making necessary health reports, consequently Washington ordered on January 2, 1778: “Every Monday morning regimental surgeons are to make returns to the Surgeon Gen’l. or in his absence to one of the senior surgeions, present in camp or otherwise under the immediate care of the regimental surgeons specifying the mens names Comps. Regts. and diseases.” [Weedon’s Valley Forge Orderly Book, p. 175]

January 13, 1778. “The Flying Hospitals are to be 15 feet wide and 25 feet long in the clear and the story at least 9 feet high to be covered with boards or shingles only without any dirt, windows made on each side and a chimney at one end. Two such hospitals are to be made for each brigade at or near the center and if the ground permits of it not more than 100 yards distance from the brigade.” [Weedon’s Valley Forge Orderly Book, p. 191] The Commander-in-Chief always solicitous about the comfort of his soldiers issued the following order January 15, 1778: “The Qr. Mr. Genl. is positively ordered to provide straw for the use of the troops and the surgeons to see that the sick when they are removed to huts assigned for the hospital are plentifully supplied with this article.” [Weedon’s Valley Forge Orderly Book, pp. 192-199-204-216] ” (D)

PART 2. May 28, 2019. “BATTLEFIELD” MEDICINE: THE CIVIL WAR. “Many of America’s modern medical accomplishments have their roots in the legacy of America’s defining war.”

 “During the 1860s, doctors had yet to develop bacteriology and were generally ignorant of the causes of disease. Generally, Civil War doctors underwent two years of medical school, though some pursued more education. Medicine in the United States was woefully behind Europe. Harvard Medical School did not even own a single stethoscope or microscope until after the war. Most Civil War surgeons had never treated a gunshot wound and many had never performed surgery. Medical boards admitted many “quacks,” with little to no qualification. Yet, for the most part, the Civil War doctor (as understaffed, underqualified, and under-supplied as he was) did the best he could, muddling through the so-called “medical middle ages.” Some 10,000 surgeons served in the Union army and about 4,000 served in the Confederate. Medicine made significant gains during the course of the war. However, it was the tragedy of the era that medical knowledge of the 1860s had not yet encompassed the use of sterile dressings, antiseptic surgery, and the recognition of the importance of sanitation and hygiene. As a result, thousands died from diseases such as typhoid or dysentery.

The deadliest thing that faced the Civil War soldier was disease. For every soldier who died in battle, two died of disease. In particular, intestinal complaints such as dysentery and diarrhea claimed many lives. In fact, diarrhea and dysentery alone claimed more men than did battle wounds. The Civil War soldier also faced outbreaks of measles, small pox, malaria, pneumonia, or camp itch. Soldiers were exposed to malaria when camping in damp areas which were conductive to breeding mosquitos, while camp itch was caused by insects or a skin disease. In brief, the high incidence of disease was caused by a) inadequate physical examination of recruits; b) ignorance; c) the rural origin of my soldiers; d) neglect of camp hygiene; e) insects and vermin; f) exposure; g) lack of clothing and shoes; h) poor food and water…

Battlefield surgery…was also at best archaic. Doctors often took over houses, churches, schools, even barns for hospitals. The field hospital was located near the front lines — sometimes only a mile behind the lines — and was marked with (in the Federal Army from 1862 on) with a yellow flag with a green “H”. Anesthesia’s first recorded use was in 1846 and was commonly in use during the Civil War. In fact, there are 800,000 recorded cases of its use. Chloroform was the most common anesthetic, used in 75% of operations. ..A capable surgeon could amputate a limb in 10 minutes. Surgeons worked all night, with piles of limbs reaching four or five feet. Lack of water and time meant they did not wash off hands or instruments

Bloody fingers often were used as probes. Bloody knives were used as scalpels. Doctors operated in pus stained coats. Everything about Civil War surgery was septic. The antiseptic era and Lister’s pioneering works in medicine were in the future. Blood poisoning, sepsis or Pyemia (Pyemia meaning literally pus in the blood) was common and often very deadly…”  (A)

“Early on, stretcher bearers were members of the regimental band, and many fled when the battle started. Soldiers acting as stretcher bearers rarely returned to the front lines. As the war evolved, stretcher bearers became part of the medical corps. At the battle of Antietam, there were 71 Union field hospitals. As the war went on, these were consolidated. There were ambulances here that were used to bring the wounded to temporary battlefield hospitals, which were larger, often under tents, and out of artillery range. Later in the war, patients were transported to large general hospitals by train or ship in urban centers. These did not exist when the war began. There was no military ambulance corps in the Union Army until August of 1862. Until that time, civilians drove the ambulances. Initially the ambulance corps was under the Quartermaster corps, which meant that ambulances were often commandeered to deliver supplies and ammunition to the front…

Large general hospitals were established by September of 1862 (11). These were in large cities, and soldiers were transported there by train or ship. At the end of the war, there were about 400 hospitals with about 400,000 beds. There were 2 million admissions to these hospitals with an overall mortality of 8%. In the South, the largest general hospital, Chimborazo, was in Richmond, Virginia. It was built out of tobacco crates on 40 acres. It contained five separate hospitals, each made up of 30 buildings. There were 150 wards with 40 to 60 patients per ward. The census was as high as 4000. They treated about 76,000 patients with a 9% mortality (12)…

Three of every four surgical procedures performed during the war were amputations. Each amputation took about 2 to 10 minutes to complete. There were 175,000 extremity wounds to Union soldiers, and about 30,000 of these underwent amputation with a 26.3% mortality… Only about 1 in 15 Union physicians was allowed to amputate. Only the most senior and experienced surgeons performed amputations. These changes were put into effect because of the public perception that too many amputations were being performed. Amputations were not carried out using sterile technique, given that Lister’s classic paper on antisepsis did not appear until after the war in 1867…

Physicians at the time had an extraordinary workload. The following was excerpted from a letter Dr. Daniel Holt wrote to his wife, Euphrasia:

You cannot imagine the amount of labor I have to perform. As an instance of what almost daily occurs, I will give you an account of day-before-yesterday’s duty. At early dawn, while you, I hope, were quietly sleeping, I was up at Surgeon’s call and before breakfast prescribed for 86 patients at the door of my tent. After meal I visited the hospitals and a barn where our sick are lying, and dealt medicines and write prescriptions for one hundred more; in all visited and prescribed for, one hundred and eighty-six men. I had no dinner. At 4 o’clock this labor was completed and a cold bite was eaten. After this, in the rain, I started for Sharpsburg, four miles distant, for medical supplies (17). (B)

Most of the major medical advances of the Civil War were in organization and technique, rather than medical breakthroughs.  In August of 1862, Jonathan Letterman, the Medical Director of the Army of the Potomac, created a highly-organized system of ambulances and trained stretcher bearers designed to evacuate the wounded as quickly as possible.  A similar plan was adopted by the Confederate Army.  This system was a great improvement on previous methods.  He established a trained ambulance corps, consolidated all of the ambulances of a Brigade, and created a system of layered levels of care for the wounded on the battlefield.  The levels of care were small field dressing stations (usually directly on the battlefield), field hospitals (located in a safer place just beyond the battlefield), and a system of general hospitals in most large cities.  Transporting the wounded men from one hospital to another was also coordinated.  The Letterman plan remains the basis for present military evacuation systems.

A system of triage was established that is still used today.  The sheer number of wounded at some of the battles made triage necessary.  In general, the wounded soldiers were divided into three groups: the slightly wounded, those “beyond hope”, and surgical cases.  The surgical cases were dealt with first since they would be the most likely to benefit from immediate care.  These included many of the men wounded in the extremities and some with head wounds that were considered treatable.  The slightly wounded would be tended to next, their wounds were not considered life-threatening so they could wait until the first group was treated.  Those beyond hope included most wounds to the trunk of the body and serious head wounds.  The men would have been given morphine for pain and made as comfortable as possible… 

Hospitals became places of healing rather than places to go to die, as they were widely considered before the war.  The large-scale hospitals set up by the medical departments had an astounding average death rate of only 9%…  Women nurses were first truly accepted during the war, mainly out of necessity.  Although there was a great deal of prejudice against them, especially early on, surgeons came to see that their contributions went a long way in aiding the patients.  Once they had an established place in medical care they would not give it up.  Nursing as a profession was born.

Due to the sheer number of wounded patients the surgeons had to care for, surgical techniques and the management of traumatic wounds improved dramatically.  Specialization became more commonplace during the war, and great strides were made in orthopedic medicine, plastic surgery, neurosurgery and prosthetics.  Specialized hospitals were established, the most famous of which was set up in Atlanta, Georgia, by Dr. James Baxter Bean for treating maxillofacial injuries.  General anesthesia was widely used in the war, helping it become acceptable to the public.  Embalming the dead also became commonplace.

Medical technology and scientific knowledge have changed dramatically since the Civil War, but the basic principles of military health care remain the same.  Location of medical personnel near the action, rapid evacuation of the wounded, and providing adequate supplies of medicines and equipment continue to be crucial in the goal of saving soldiers’ lives.”  (C)

“Many misconceptions exist regarding medicine during the Civil War era, and this period is commonly referred to as the Middle Ages of American medicine. Medical care was heavily criticized in the press throughout the war. It was stated that surgery was often done without anesthesia, many unnecessary amputations were done, and that care was not state of the art for the times. None of these assertions is true. Actually, during the Civil War, there were many medical advances and discoveries..

Medical                Use of quinine for the prevention of malaria

Use of quarantine, which virtually eliminated yellow fever

Successful treatment of hospital gangrene with bromine and isolation

Development of an ambulance system for evacuation of the wounded

Use of trains and boats to transport patients

Establishment of large general hospitals

Creation of specialty hospitals

Surgical Safe use of anesthetics

Performance of rudimentary neurosurgery

Development of techniques for arterial ligation

Performance of the first plastic surgery..” (B)

“However, while “advanced” or “hygienic” may not be terms attributed to medicine in the nineteenth century, modern hospital practices and treatment methods owe much to the legacy of Civil War medicine. Of the approximately 620,000 soldiers who died in the war, two-thirds of these deaths were not the result of enemy fire, but of a force stronger than any army of men: disease. Combating disease as well treating the legions of wounded soldiers pushed Americans to rethink their theories on health and develop efficient practices to care for the sick and wounded.

At the beginning of the Civil War, medical equipment and knowledge was hardly up to the challenges posed by the wounds, infections and diseases which plagued millions on both sides. Illnesses like dysentery, typhoid fever, pneumonia, mumps, measles and tuberculosis spread among the poorly sanitized camps, felling men already weakened by fierce fighting and meager diet. Additionally, armies initially struggled to efficiently tend to and transport their wounded, inadvertently sacrificing more lives to mere disorganization…

The wounded and sick suffered from the haphazard hospitalization systems that existed at the start of the Civil War. As battles ended, the wounded were rushed down railroad lines to nearby cities and towns, where doctors and nurses coped with the onslaught of dying men in makeshift hospitals. These hospitals saw a great influx of wounded from both sides and the wounded and dying filled the available facilities to the brim. The Fairfax Seminary, for example, opened its doors twenty years prior to the war with only fourteen students, but it housed an overwhelming 1,700 sick and wounded soldiers during the course of the war…

However, the heavy and constant demands of the sick and wounded sped up the technological progression of medicine, wrenching American medical practices into the light of modernity.  Field and pavilion hospitals replaced makeshift ones and efficient hospitalization systems encouraged the accumulation of medical records and reports, which slowed bad practices as accessible knowledge spread the use of beneficial treatments…

The sheer quantity of those who suffered from disease and severe wounds during the Civil War forced the army and medical practitioners to develop new therapies, technologies and practices to combat death. Thanks to Hammond’s design of clean, well ventilated and large pavilion-style hospitals, suffering soldiers received care that was efficient and sanitary. In the later years of the war, these hospitals had a previously unheard of 8% mortality rate for their patients…

In field hospitals and pavilion-style hospitals, thousands of physicians received experience and training.  As doctors and nurses became widely familiar with prevention and treatment of infectious diseases, anesthetics, and best surgical practices, medicine was catapulted into the modern era of quality care. Organized relief agencies like the 1861 United States Sanitary Commission dovetailed doctors’ efforts to save wounded and ill soldiers and set the pattern for future organizations like the American Red Cross, founded in 1881.

Death from wounds and disease was an additional burden of the war that took a toll on the hearts, minds, and bodies of all Americans, but it also sped up the progression of medicine and influenced practices the army and medical practitioners still use today. While the Union certainly had the advantage of better medical supplies and manpower, both Rebels and Federals attempted to combat illness and improve medical care for their soldiers during the war. Many of America’s modern medical accomplishments have their roots in the legacy of America’s defining war.” (D)

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