Civil War Medicine

Posed photo of patient, surgeons and nurses.

M*A*S*H*, Meatball Surgery and the Letterman Plan

by Alison Bruce

I grew up watching episodes of M*A*S*H*. Next to Star Trek, I'd say it was the most influential (and most intelligent) TV show I watched in my youth. Imagine my interest when I found out that the first mobile army surgical hospitals (not known as the famous acronym of course) emerged during the Civil War. With these Field Hospitals came the apparent butchery of speedy operations that M*A*S*H* viewers know as "meatball surgery."

Ambulance removing wounded.

The Army Corps Field Hospital, the Ambulance Corps and the Army Nursing Corps had their start in the Civil War. Triage was invented. New surgical techniques were developed. Spearheading these innovations was Jonathan Letterman, the medical director of the Army of the Potomac, aided by General George McClellan and Surgeon General William Hammond. All three men were forward thinkers willing and ready to reform the haphazard way the wounded were removed from the field and treated afterward. Letterman also instituted policies regarding camp and hospital hygiene which might have saved more lives than surgery.

The reality of field hospitals.

Disease killed more soldiers than combat wounds. Dysentery topped the list and it could by largely avoided - or at least contained - with proper hygiene. Although it wasn't until after the war that Pasteur's proof of the existence of germs was widely known, anecdotal evidence tied disease to human feces contaminating the water supply.

Many changes in battle field medicine came out of the trial and error of surgeons in the field. Of the physicians recruited by the Union Army, only a small percentage were qualified surgeons. Most had to learn as they went.

Amputation Kit from Civil War Museum at Wilson’s Creek National Battlefield

One of the first things they learned was they didn't have time to pick out bone, metal and cloth debris from a shattered limb. It was faster, and safer for the patient, if they amputated. Not only was there less chance of the wound becoming septic, but many more patients could be seen and saved.

This was often seen as butchery. It didn't help that field surgery was performed out in the open as much as possible. The light was better and the air fresher. Anesthesia, at the time, knocked the patient out, but it didn't immobilize him. Patients would twitch and groan during surgery, and needed to be held still, making it seem as if they were being tortured rather than saved.

Although he didn't invent the surgical techniques used, Dr Letterman heartily endorsed them and criticized the practice of "conservative surgery" where too often the limb was saved and the patient lost. He could see what needed to be done and he did it, with the object of saving as many lives as possible. This meant restructuring how everything was done from battlefield aid to hospital care. Called the Letterman Plan, he pretty well set army medical protocols that would be used up to the Korean War at the very least.

I often wondered whether, had I been confronted with the primitive system which Letterman fell heir to at the beginning of the Civil War, I could have developed as good an organization as he did. I doubt it. There was not a day during World War II that I did not thank God for Jonathan Letterman.
Major General Paul Hawley, Chief Surgeon of the European Theater in the Second World War

The Letterman Plan

Creation of an Organized Ambulance Corps

• Apportions ambulances evenly throughout the army, assigning them to individual units
• Gives full control of army ambulance to officers of the ambulance corps
• Makes ambulance officers directly answerable  to Medical Directors of the corps and army
• Staffs ambulances with trained and dedicated enlisted men to act as drivers and stretcher-bearers
• Forbids  the use of ambulances to carry personal baggage or other non-medical uses
• Forbids the removal and transportation of wounded and sick by anyone not belonging to the ambulance corps

Regulations for Organizing Surgical Field Hospitals

• Surgical field hospitals to be established for each division prior to anticipated engagements
• Sites for each division hospital to be selected by the Medical Director of each corps
• 1 surgeon to superintend each division hospital
• 1 assistant surgeon in each division hospital to manage supplies and physical needs
• 3 medical officers to conduct all surgical operations in each division hospital
• 3 medical officers to assist the operating surgeons in each division hospital
• Operating surgeons selected on the basis of skill and experience, regardless of military rank
  One of the assisting medical officers designated to perform all anesthesia
• Other medical officers detailed to assist in the division hospitals as available and necessary
• Surgeons admit and treat any soldier brought to their hospital regardless of his home unit

Advent of Forward First Aid

• At least one surgeon or assistant surgeon detailed to each regiment
• In battle, regimental surgeons establish temporary medical stations in the rear of action
• Medical personnel provide immediate care to wounded soldiers
• These stations serve as focal points of evacuation by ambulance

Introduction of Triage

Wounded are treated and evacuated in order of priority
Use of a 3 – tier system of priority:

• Most serious but survivable wounds are first priority
• Less serious wounds are second priority
• Likely fatal wounds (head, abdomen, etc.) are last priority

“Dressers” in field hospitals prioritize and prepare wounded for surgery

Long-Term Recovery Hospitals on the Battlefield

• Patients too severe to be transported to hospital centers are cared for near the battlefield
• Large tent hospitals are constructed to house patients for up to several months

Staged Evacuation and Treatment System

• Frontline medical officers gather and stabilize casualties, creating temporary stations
• Ambulances carry wounded from the battlefield
• Field hospitals treat wounded and deliver surgical operations
• Wounded are moved from field hospitals to long-term care

It's not hard to imagine a 19th Century Dr. Benjamin Franklin (Hawkeye) Pierce working in a Civil War field hospital. Even his name is perfect. No doubt he would berate any substandard surgeons and train up any talented surgical assistants. He'd work insanely long hours during and following battles, keeping up the spirits of his fellows with inappropriate black humor. When he had the chance, and could get away with it, he could even flirt (gallantly of course) with the beautiful nurses. At the time, the nurses were actually required to be "more than 30 years of age, healthy, and plain almost to repulsion in dress, and devoid of personal attraction." But in wartime, that might pass for gorgeous. In any case, a little dramatic license is always appreciated.

Bibliography

• Civil War Era Medicine, www.ozarkscivilwar.org/themes/medicine
• eHistory: Medicine: Civil War Battlefield Surgery, ehistory.osu.edu/uscw/features/medicine/cwsurgeon/amputations.cfm
• Letterman Plan, The, www.civilwarmed.org/letterman-dinner/the-letterman-plan
• National Museum of Health and Medicine: To Bind Up the Nation's Wounds, www.medicalmuseum.mil/index.cfm?p=exhibits.nationswounds.index