The Truth About Civil War Surgery

Compared to the many men who died because limbs should have been removed but weren't, Reynolds was lucky: he survived. "I have no hesitation in saying that far more lives were lost in refusal to amputate than by amputation," wrote William Williams Keen, a medical student with the military status of a West Point cadet. Like many Civil War medical workers, Keen learned his trade on the job, under extreme duress, as Civil War battles churned out thousands of wounded men.

After treating casualties of the September 1862 Battle of Antietam, Maryland, Keen went to work in Philadelphia at the Turner's Lane Hospital, a facility famous for making discoveries about nerve injuries. Later he became professor of surgery at the city's Jefferson Medical College and a leader in American surgery. In his Reminiscences (1905), he commented on the persistent practice of blaming Civil War surgeons for performing unnecessary amputations. Many other Civil War surgeons made the same point: amputations saved lives and failure to perform necessary ones sometimes resulted in fatal infections.

The image that surgery during the Civil War consisted of amputations, amputations, and more amputations, many done unnecessarily, developed early in the war. Soldiers' letters and hometown newspapers were filled with such accusations, and the notion stuck. True, more than 30,000 amputations were done on Union soldiers, and probably a similar number on Confederates, but most were necessary. British and American civilian surgeons who visited battlefield hospitals as observers and committed their opinions to paper agreed with Keen that Civil War surgeons were often too hesitant about amputating. Those experts felt that too few amputations were done, and that the accusations that surgeons were too quick too amputate led them to second-guess themselves, often incorrectly.

Surgery Before the Civil War
The introduction of anesthesia in October 1846 allowed surgeons to operate more deliberately. But because infection almost always followed, very little surgery was done. Then came the Civil War and the need for an astounding number of operations to be performed by doctors without any prior surgical experience.

Statistics for the Massachusetts General Hospital, one of the premier hospitals of the era, illustrate the state of surgery in the first half of the 19th century. Between 1836 and 1846, a total of 39 surgical procedures were performed at that hospital annually. In the first 10 years after the introduction of anaesthesia, 1847 through 1857, the annual average was 189 procedures, about 60 percent of which were amputations. Opening the abdomen or chest was rare. About two decades after the Civil War, the volume of surgery in civilian hospitals increased enormously with the introduction of antiseptic and, later, aseptic techniques. Between 1894 and 1904, for example, an average of 2,427 procedures were done annually at the Massachusetts General Hospital and, by 1914, more than 4,000.

Many Civil War surgeons lived to see these developments and, reminiscing long after the war, lamented their own lack of preparation for the difficulties of treating large numbers of severely wounded men. "Many of our surgeons had never seen the inside of the abdomen in a living subject...," one physician wrote, adding, "Many of the surgeons of the Civil War had never witnessed a major amputation when they joined their regiments; very few of them had treated gunshot wounds."

Despite the lack of preparation, Union surgeons treated more than 400,000 wounded men--about 245,000 of them for gunshot or artillery wounds--and performed at least 40,000 operations. Less complete Confederate records show that fewer surgeons treated a similar number of patients. As would be expected, the numbers of surgeons grew exponentially as the war raged on. When the war began, there were 113 surgeons in the U.S. Army, of which 24 joined the Confederate army and 3 were dismissed for disloyalty. By war's end, more than 12,000 surgeons had served in the Union army and about 3,200 in the Confederate. During the course of the war, formal and informal surgical training programs were begun for newly enlisted surgeons, and special courses on treating gunshot wounds were given. Surgeons on both sides rapidly developed skills and knowledge that improved the treatment of wounds, and they devised many new surgical procedures in desperate attempts to save lives.

Did Army Surgeons Deserve So Much Criticism?
At the start of the war, and especially during both Battles of Manassas and the Peninsula Campaign in 1861 and 1862, care of the wounded was chaotic and criticism of surgeons was valid. Regular Army personnel in all departments expected a short war fought by professionals and tried to follow rules created for the 15,000-man prewar army scattered here and there at small frontier posts. But the Civil War involved large volunteer forces fighting huge battles and sustaining enormous numbers of casualties. The prewar system was overwhelmed. Hospitals were organized at the regimental level, and transportation of the wounded was improvised. Wounded men sometimes went days without any care. Surgeons operated in isolation, without help or supervision.

While newspaper articles and soldiers' letters described the poor state of affairs to anyone who could read, a new medical director of the Army of the Potomac, Dr. Jonathan Letterman, worked to improve medical care. He was remarkably successful, but the improvements went largely unreported. So public criticism continued to inhibit surgeons, keeping them from making the best decisions. And, as Keen observed, this may have cost lives.

One of many observers who agreed with Keen was William M. Caniff, professor of surgery at the University of Victoria College in Toronto. Visiting with the Union army after the Battle of Fredericksburg in the winter of 1862-1863, he wrote that American surgeons were too hesitant about performing amputations. In a long essay published in the British medical journal Lancet on February 28, 1863, Caniff observed, "Although a strong advocate of conservative surgery..., I became convinced that upon the field amputation was less frequently resorted to than it should be; that while in a few cases the operation was unnecessarily performed, in many cases it was omitted when it afforded the only chance of recovery."

While the criticism continued, medical conditions continued to improve. Evacuation and transportation of the wounded got better, as did the establishment and management of hospitals. And the percentage of the wounded that died after treatment dropped dramatically. After Antietam, for example, 22 percent of the 8,112 wounded treated in hospitals died; but after the Battle of Gettysburg one year later, only 9 percent of 10,569 died. Despite that, an editorial writer in the Cincinnati Lancet and Observer noted in September 1863 that "Our readers will not fail to have noticed that everybody connected with the army has been thanked, excepting the surgeons...."

Myth 1: Alternatives to Amputation Were Ignored
Infection threatened the life of every wounded Civil War soldier, and the resulting pus produced the stench that characterized hospitals of the era. When the drainage was thick and creamy (probably due to staphylococci), the pus was called "laudable," because it was associated with a localized infection unlikely to spread far. Thin and bloody pus (probably due to streptococci), on the other hand, was called "malignant," because it was likely to spread and fatally poison the blood. Civil War medical data reveal that severe infections now recognized as streptococcal were common. One of the most devastating streptococcal infections during the war was known as "hospital gangrene."

When a broken bone was exposed outside the skin, as it was when a projectile caused the wound, the break was termed a "compound fracture." If the bone was broken into multiple pieces, it was termed a "comminuted fracture"; bullets and artillery shells almost always caused bone to fragment. Compound, comminuted fractures almost always resulted in infection of the bone and its marrow (osteomyelitis). The infection might spread to the blood stream and cause death, but even if it did not, it usually caused persistent severe pain, with fever, foul drainage, and muscle deterioration. Amputation might save the soldier's life, and a healed stump with a prosthetic limb was better than a painful, virtually useless limb, that chronically drained pus.

Antisepsis and asepsis were adopted in the decades following the war, and when penicillin became available late in World War II, the outlook for patients with osteomyelitis improved. In the mid-1800s, however, germs were still unknown. Civil War surgeons had to work without knowledge of the nature of infection and without drugs to treat it. To criticize them for this lack of knowledge is equivalent to criticizing Ulysses S. Grant and Robert E. Lee for not calling in air strikes.

Civil War surgeons constantly reevaluated their amputation policies and procedures. Both sides formed army medical societies, and the meetings focused primarily on amputation. The main surgical alternative to amputation involved removing the portion of the limb containing the shattered bone in the hope that new bone would bridge the defect. The procedure, called excision or resection, avoided amputation, but the end result was shortening of the extremity and often a gap or shortening of the bony support of the arm or leg. An arm might still have some function, but often soldiers could stand or walk better on an artificial leg than on one with part of a bone removed. Another problem with excision was that it was a longer operation than amputation, which increased the anaesthesia risk; the mortality rate after excision was usually higher than that following amputation at a similar site. As the war progressed, excisions were done less and less frequently.

Myth 2: Surgery Was Done without Anaesthesia
Histories of the Civil War and Hollywood movies usually portray surgery being done without anaesthesia; the patient downs a shot of whiskey, then bites down on a bullet. That did happen in a few instances, particularly on September 17, 1862, at the Battle of Iuka, Mississippi, when 254 casualties were operated on without any anesthetic. This episode is recorded in the Medical and Surgical History of the War of the Rebellion and is the only known occurrence of any significant number of operations being performed without anaesthesia. On the other hand, more than 80,000 Federal operations with anaesthesia were recorded, and that figure is believed to be an underestimate. Confederate surgeons used anesthetics a comparable number of times. The use of anaesthesia by surgeons doing painful wound treatments in hospitals was well described but not tallied.

One explanation for the misconception about anaesthesia is that it was well into the 20th century before research led to more carefully designed applications. At the time of the Civil War, ether or chloroform or a mixture of the two was administered by an assistant, who placed a loose cloth over the patient's face and dripped some anesthetic onto it while the patient breathed deeply. When given this way, the initial effects are a loss of consciousness accompanied by a stage of excitement. For safety reasons, the application was usually stopped quickly, which is why surprisingly few deaths occurred. The Civil War surgeon went to work immediately, hoping to finish before the drug wore off. Although the excited patient was unaware of what was happening and felt no pain, he would be agitated, moaning or crying out, and thrashing about during the operation. He had to be held still by assistants so the surgeon could continue.

Surgery was performed in open air whenever possible, to take advantage of daylight, which was brighter than candles or kerosene lamps available in the field. So, while surgeons performed operations, healthy soldiers and other passers-by often had a view of the proceedings (as some newspaper illustrations of the time verify). These witnesses saw the clamor and heard the moaning and thought the patients were conscious, feeling the pain. These observations found their way into letters and other writings, and the false impression arose that Civil War surgeons did not typically use anaesthesia. That myth has persevered, but the evidence says otherwise.

Myth 3: Most of the Wounds Were to Arms and Legs
Another misconception common in Civil War history is the concept that most wounds were to the arms and legs. At the root of this myth are statistics that state that about 36 percent of wounds were to the arms and another 35 percent to the legs. These numbers are based on the distribution of the wounds of soldiers evacuated and treated in hospitals, as shown in the records in the Medical and Surgical History of the War of the Rebellion. The trouble is, many soldiers with more serious wounds did not make it to hospitals and were therefore not counted. Wounds of the chest, abdomen, and head, for example, were often fatal on the battlefield. Soldiers with these more serious wounds were often given morphine and water and made as comfortable as possible as they awaited death, while men with treatable wounds, such as injured limbs, were given evacuation priority.

A similar statistics-based misjudgment arises in connection with artillery wounds. These were often devastating, fatal immediately or soon after; few soldiers hit by artillery missiles lived to be evacuated. For this reason, the recorded number of artillery wounds treated is low. That fact has led some authors to conclude erroneously that artillery was largely ineffective.

Myth 4: Every Surgeon Had Authority to Amputate
During the first year of the war, and especially during the Peninsula Campaign in 1862, army surgeons performed all operations. Soon the overwhelming numbers of battle wounded forced the army to contract civilian surgeons to perform operations in the field alongside their army counterparts. Their ability ranged from poor to excellent.

Accusations soon arose that surgeons were doing unnecessary amputations just to gain experience. This was undoubtedly true in some cases, but it was rare. After the Battle of Antietam in September 1862, Letterman was so disturbed by public criticism of the army surgeons that he reported:

The surgery of these battle-fields has been pronounced butchery. Gross misrepresentations of the conduct of medical officers have been made and scattered broadcast over the country, causing deep and heart-rending anxiety to those who had friends or relatives in the army, who might at any moment require the services of a surgeon. It is not to be supposed that there were no incompetent surgeons in the army. It is certainly true that there were; but these sweeping denunciations against a class of men who will favorably compare with the military surgeons of any country, because of the incompetency and short-comings of a few, are wrong, and do injustice to a body of men who have labored faithfully and well.

Motivated at least in part by a desire to improve the public perception of the medical department, Letterman issued an order on October 30, 1862, requiring that "in all doubtful cases" involving Union soldiers, a board of three of the most experienced surgeons in the division or corps hospital would decide by majority vote whether an amputation was necessary. Then, a fourth surgeon, the available doctor with the most relevant skills, would perform the procedure. This system remained in effect for the rest of the war.

After the war, Surgeon George T. Stevens, historian of the the Army of the Potomac's VI Corps, described how the operating surgeon was chosen:

One or more surgeons of well known skill and experience were detailed from the medical force of the division, who were known as "operating surgeons"; to each of whom was assigned three assistants, also known to be skillful men.... The wounded men had the benefit of the very best talent and experience in the division, in the decision of the question whether he should be submitted to the use of the knife, and in the performance of the operation in case one was required. It was a mistaken impression among those at home, that each medical officer was the operating surgeon for his own men. Only about one in fifteen of the medical officers was entrusted with operations.

The Confederate army had a similar problem with excessively zealous surgeons, and it instituted a similar solution. In the 1863 edition of his Manual of Military Surgery, Professor J.J. Chisolm of Charleston, South Carolina, bluntly addressed the issue of unnecessary surgery:

Among a certain class of surgeons ...amputations have often been performed when limbs could have been saved, and the amputating knife has often been brandished, by inexperienced surgeons, over simple flesh wounds. In the beginning of the war the desire for operating was so great among the large number of medical officers recently from the schools, who were for the first time in a position to indulge this extravagant propensity, that the limbs of soldiers were in as much danger from the ardor of young surgeons as from the missiles of the enemy....

It was for this reason that, in the distribution of labor in the field infirmaries, it was recommended that the surgeon who had the greatest experience, and upon whose judgment the greatest reliance could be placed, should officiate as examiner, and his decision be carried out by those who may possess a greater facility or desire for the operative manual.

The new procedures helped the patients, but they hardly changed public opinion. In the end, despite advances in surgical practices and their results, Civil War physicians were unsuccessful in improving their public perception.

How Did American Surgeons Compare to Europeans?
The efforts of Civil War surgeons should be compared with those of their contemporaries: doctors who treated the casualties of the Crimean War of 1854-1856 and the Franco-German War of 1870-1871. Fatality rates during the Civil War, especially those following amputations, compare favorably with those of the British and especially the French in the Crimean War and were much better than those of the Russians and Turks (although statistics for those armies were less thorough).

The data for the British in the Crimean War are the most comprehensive available, thanks in large part to the interest taken in statistics by the renowned nurse Florence Nightingale. The British performed a total of 1,027 amputations, with a fatality rate of 28 percent. Overall, Union surgeons had a fatality rate of 26 percent, performing more than 30,000 amputations. Fatality rates varied with the location of the amputation; the closer to the trunk, the higher the percentage. One place the Union surgeons stood out most over their British counterparts was in amputations at the hip. In every recorded attempt by British surgeons, the patient died. Union doctors, on the other hand, succeeded 17 percent of the time.

The medical data for the Union forces in the Civil War are the most complete of any war involving America. Careful consideration of these records and the state of medicine here and in Europe at the time reveals commendable efforts and results. Overall, American surgeons during the Civil War did a respectable and generally successful job of trying to save lives. They deserve a better reputation than the lowly one they have received.

This article written by Dr. Bollet ,who is the author of the recent book Civil War Medicine, Challenges and Triumphs, published by Galen Press. This article originally appeared in the October 2004 issue of Civil War Times magazine. For more great articles, be sure to subscribe to Civil War Times magazine today!