11 i

The Genuine

Southern Surgeon

JOHN OCHSNER, M.D.

M Y FELLOW MEMBERS of the Southern Surgical Association, to serve as your president is an honor I cherish. I know that in choosing me, it was not the intention of the council to praise an individual, but rather to reward a loyal member whose affection for the association is obvious and whose membership in the association is regarded as a privilege. I thank the council for this opportunity. A majority of the founding members of the Southern Surgical Association (originally the Southern Surgical and Gynecological Association) served as medical officers in the Confederate Army. However, with the exception of two generic papers presented by Bedford Brown (one on the treatment of gangrenous wounds and the other on stab wounds of the peritoneum), in which he inclusively mentioned some ofhis experiences during the Civil War, 1,2 surprisingly, no papers on surgery during the Civil War have been presented at meetings of this association. The exact reasons for this are unknown; however, maybe they wished to forget that holocaustic experience, or they had no reason to recall their surgical experiences because little was accomplished. It is likely that both factors were contributory. To be able to forget the War Between the States would have been a blessing. To quote Lincoln,3 "It was terrible to both the North and the South. It was terrible in its magnitude, in its persistence, in its ferocity, and in its cost of human life." More American lives were lost in the War Between the States than in all other conflicts in which our country has ever been engaged. If the population of our country at the time of the Civil War were compared with that of modern times, the loss would be even greater proportionally. An estimated 620,000 lives were lost: 360,000 Union soldiers and 258,000 ConfedPresented at the 103rd Annual Scientific Session of the Southern Surgical Association, Hot Springs, Virginia, December 1-4, 1991. Address reprint requests to John Ochsner, M.D., Ochsner Clinic, 1514 Jefferson Highway, New Orleans, LA 70121. Accepted for publication January 6, 1992.

From the Department of Surgery, Ochsner Clinic, and Alton Ochsner Medical Foundation, New Orleans, Louisiana

erate soldiers. The chance of a soldier returning home was less than one in four. Never has a period in American history aroused such interest, attested to by historians who have written more about the Civil War than about any other period. Americans have read more books about these 4 years than about all the rest of American history. More than 50,000 books have been published, and countless letters, diaries, novels, histories, memoirs, biographies, narratives, poems, scripts for stage and screen, and music have been written. Although most of the writings are devoted to heroism, sacrifice, and bravery, nearly an equal amount describe the anguish, squalor, and suffering. Having witnessed the horrors is ample reason for the early members of our association not to have desired recall for scientific publi-

cation. Family fought against family, friend against friend. Thousands of Southerners fought for the Union, and thousands of Northerners fought for the Confederacy. It was truly a war that divided not only states, but also families and friends. The tragedy of the war is probably best described by Allan Nevins in his book The War for the Union4: We have lost not only these men but their children and their children's children . . . we have lost the books they might have written, the scientific discoveries they might have made, the inventions they might have perfected. Such a loss defies measurement.

Conversely, medical advances are often spurred by wars. New concepts and improvement of surgical techniques and instrumentation have resulted; however, in the Civil War there were no discoveries and little was added to the existing medical knowledge. The state of the art and science of medicine was at a low ebb in 1860 at the beginning of the war. The discovery of Pasteur and associates and the techniques of Lister that completely

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revolutionized medical and surgical practice were unknown; hence, the live-saving management of wounds and the diagnosis and prevention of most diseases were denied the Civil War soldier. The problems and challenges of the doctors of the Confederate Army and Navy were astronomical. Only a few had experience in military medicine and surgery. Most had obtained training in the offices of old practitioners who served as preceptors. However, many ofthe younger doctors had attended medical schools that usually were connected with a college. Most of the established medical schools were in the North, and schools such as the University of Pennsylvania, Jefferson Medical College, Harvard School of Medicine, and University of New York attracted many Southern students. As the Southern population expanded, and as part of a move for Southern independence, medical schools were formed. The first such school was the Medical College of South Carolina located in Charleston in 1824, and by the time the first shot was fired on Fort Sumter, there were 21 medical schools in the Southern states. On February 26, 1861, a provisional congress of the confederate states at Montgomery, Alabama, authorized the establishment of a medical department of the army. It provided for one surgeon general, four surgeons, and six assistant surgeons. The surgeon general was to have the rank of colonel, surgeons the rank of major, and assistant surgeons the rank of captain. Medical officers were given authority to exercise command only in their own departments.5 President Jefferson Davis vetoed the bill, but as the war progressed, it became obvious that it was to be a long war, and he was empowered to appoint a provisional army of as many surgeons and assistant surgeons as deemed necessary. Not until April 1863 did he and the Congress realize the need for a medical department. He then appointed 10 medical inspectors charged with supervising hospital and camp sanitation and gave them full authority, allowing them to reorganize into a medical department. Eventually there were 18 surgeons serving as medical directors in the field and supervising the work of the medical officers. There were also eight medical directors of hospitals, six field medical inspectors, and seven medical inspectors of hospitals. Each command engaged in combat was to have one surgeon and two assistant surgeons. Ultimately, an estimated 3400 physicians served in the Confederate Medical Corps. The Union counterpart enrolled 11,700, or approximately one doctor for every 133 Northern soldiers, as compared with one doctor for every 324 Southern soldiers.6 The loyalty and fierce patriotism of the Southern doctors inspired most doctors to put aside their professional status and enroll as combat soldiers. Because the individual seceding Southern states and Confederacy did not have a medical department at the beginning of the war, more doctors saw combat duty in the South than in the North.

Ann. Surg. * May 1992

It is estimated that the number of physicians who served combat soldiers equalled the number who served in the medical department. Six physicians rose to the rank of general in the Confederate Army, all six serving as combat officers.7 No physician attained the rank of general through the Confederate Medical Department. Although the Confederate Surgeon General, Samuel E. Moore, carried out his duties with the relative rank of a brigadier general, there is no report of his being conferred this rank by the Confederate legislature.8 The great task before the Confederate Medical Corps is illustrated by the fact that nearly 4,000,000 cases of disease or wounds were treated, which translates to every Confederate soldier having fallen victim to disease or wounds an average of six times during the war.9 The doctor-to-soldier ratio was less than one halfthat of a modern army.'0 The Confederate Army was handicapped not only from the standpoint of manpower but also from the lack of drugs, pharmaceuticals, surgical instruments, supplies, food, and even books. In antebellum years, drugs, instruments, and texts were all supplied by Northern cities. The overall medical responsibility for a brigade or division was assumed by the surgeon. Once he learned from the commanding officer where the troops were to engage in batfle, he chose the site for the field hospital, usually behind a natural obstacle for shielding from hostile fire. The assistant surgeon would be placed between the regiment and the field hospital. At the front, the assistant surgeon provided first aid, which consisted chiefly of controlling hemorrhage, splinting fractured limbs, and administering pain killers, which sometimes was morphine or opium, but more often was only brandy or whiskey. He would send the wounded from the front on stretchers or by ambulance to the field hospital. The rude ambulances were usually springless farm wagons that severely jolted the wounded as they were drawn by mules through uneven or wooded terrain or on roads badly rutted by artillery and supply trains. If able to undertake the journey, the wounded Southern soldier often preferred to walk to the field or regimental hospital than to go by ambulance, were any available. Nearly 200,000 Confederate soldiers were wounded, of which 94,000 died in battle. The minie ball was responsible for 94% of the injuries; shells and canisters caused only 6%. The minie ball (Fig. 1), a cylindro-conical rifle bullet named for its inventor, Captain Claude Etienne Minie of France, produced a vicious wound. Unlike the bullets of today, which are made of steel and travel at such high speeds that they pierce through the body with a nice neat hole, the minie ball with its relatively low velocity would tumble in its course through the body, dragging with it pieces of clothing and debris. Wounds of the extremities accounted for almost 65% of all wounds; one half involved the upper extremity and as

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FIG. 1. Minie ball. one half involved the lower. Confederate soldiers suffered 25,000 amputations from these wounds. Reports of deaths from amputations varied between 20% and 87%, with an average of 30%.8,12 The mortality rate from delayed or secondary operation was double that of primary operation. Gunshot wounds ofthe abdomen, particularly those penetrating the viscera, were regarded as certainly fatal. Except when necessary to return viscera, no operation was attempted; all the surgeon could do was to administer opium and whiskey. Penetrating wounds of the chest were fatal in 62% of cases. Empyema was the primary complication and was treated by open drainage or insertion of drain tubes.'3 Whether the gaping chest wound should be hermetically sealed or left open was controversial. Operations were performed on any available flat surface, usually a door laid across barrels or boxes. The anesthetic agent used by the Confederate medical officer was almost exclusively chloroform, which had an advantage over ether because of its small bulk, because it was noninflammable, and because of its speedy action. It was dropped on a sponge, handkerchief, or cotton cloth and given sparingly to preserve the supply. The patient was

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awake by completion of the operation. Because speed was the most important factor in survival, the patient obviously received very little anesthetic; hence the operative death rate was inordinately low (only one per 2000 operations). At a national medical meeting some years after the war, Dr. Hunter McGuire reported that chloroform had been administered in hospitals over 40,000 times under his supervision without a single death.'4 The supply of this important agent to the Confederate Medical Corps was greatly enhanced when, during the Winchester Battle in May of 1862, Stonewall Jackson's men captured Union supplies and made off with 15,000 cases of chloroform. The ideal placement of the operating tables was in open air wherever the light was best, whether from the blazing sun or a silvery moon. During the vicious battles, the constant stream of amputations would proceed through the night, the surgeons operating by moonlight or lantern. The surgeon would stand with his sleeves rolled up, his apron smeared with blood, cleaning his knife on the sole of his boot or holding the knife in his teeth while his hands were otherwise occupied. Stories have recounted surgeons who would work hour after hour, and when unable to endure any longer, would break down and cry. Experience from the Crimean War dictated that early amputation could lower the mortality rate from severe wounds of the extremity.'5 Chisholm, in his 1861 "Manual of Military Surgery for the Use of Surgeons in the Confederate States Army",16 asserted that "All needful operations must be performed within 24 hours or the wounded would suffer from neglect." Many young doctors, anxious to become proficient in amputation, were overzealous in performing the operation; hence, it was not uncommon to see wounded men hide from the operating surgeons to save limbs condemned to amputation. This great propensity for chopping off limbs stimulated the Surgeon General in August 1863 to form a consultation board that had the power to approve every major operation if time allowed. Surgeons were taught that extraction of the bullet foreign body was vital to the care of wounds. Simple and elegant bullet probes and extractors were developed. Porcelain probes were believed to distinguish lead bullets from tissue and other foreign bodies. Surgeons also were taught that the finger was the best probe; however, the searching finger with its contamination was often the cause of the patient's death. Once the bullet was removed, steps were taken to control bleeding. The use of ligatures and the skill in their application was an advance in surgical technique learned by the Confederate surgeon. The ends of the ligature were customarily allowed to protrude from the open stump of the amputation. On the third or fourth postoperative day, when the ligated vessel necrosed, secondary hemorrhage frequently occurred. Three quarters of those who died in

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battle died as the result of hemorrhage, whether primary or secondary. Many battles were fought far from a metropolitan area. Because the number of casualties was so great, available surgeons were few, and hospitals were nonexistent, the result was disastrous. For example, at Shiloh, a Confederate army of 44,699 suffered 8012 wounded, and there were no hospital facilities within 100 miles. After the battle, the first order of business was to sort out those who could be saved from those who could not; for instance, a man shot in the head or spine was beyond help. Such wounded were merely placed in orderly rows and left to the resources of nature (Fig. 2). After many great battles, the battlefield as well as the roads to and from the battle site were lined with wounded in all stages of misery, groaning and crying and begging for water, whiskey, or food, and pleading for surgeons to come to their attention. Many were delirious, shouting out battle cries or calling for friends; some would even beg to be shot to escape their miserable condition." The horror was compounded by the inadequacy of resources available to help them. The Civil War surgeon lamentably knew nothing of the doctrine of sepsis and the proper use of antiseptics. Although antiseptic agents had been recognized in advance

FIG. 2. Surgeon and triage of the wounded.

Ann. Surg. * May 1992

of the war, Lister's first article on antisepsis was not published until 1867, a couple of years after the war ended. The importance of sterilization or even rudimentary cleaning of instruments and wounds had not been estab-

lished.'7 Physicians of that time theorized that healing from lost tissue was based on inflammatory reaction; therefore, the surgeon's aim was to promote suppuration in the form of a creamy pus, referred to as laudable pus, that appeared in wounds healing by secondary intention. The appearance of laudable pus on the third or fourth day was viewed with satisfaction, and in some locations after battle, the air was heavy and nauseating with its odor." The Confederate surgeon did use disinfectants, such as the chlorides, carbolic acid, permanganate of potash, turpentine, and powdered charcoal, not for their antiseptic effect, but as deodorants to control the offensive odors. Dressings for the wounds were obtained by diverse means. Cotton factories were the major source, and the women of the South furnished sheets, bedspreads, skirts, and other worn goods. When sponges became scarce, cotton rags were used, sometimes over and over again. The dressings and bandages that were passed from one patient to another were cleaned by boiling, which serendipitously produced a sterile dressing. Silks for ligatures were unavailable, but the Southern surgeons improvised, employing cotton or flax threads, and even horse-hair, which was boiled to render it soft and pliant, producing another accidental aseptic product. Gangrene, tetanus, erysipelas, and pyemia, the so-called surgical fevers, were primarily responsible for the delayed deaths among the wounded. As mentioned, surgeons of the day believed in "a laudable pus" and were astonished when an occasional wound healed without it.'8 Hospital gangrene usually occurred in the lower extremities. The patients were in acute pain with cold sweats and had nauseous, putrefying wounds. Little was known of gangrene before the war. Hospital gangrene, as it was called, included a wide range of infections, a combination of aerobes and anaerobes, such as Streptococcus combined with anaerobe gram-negative bacteria. First appearing in June of 1862 and progressively increasing throughout the war," hospital gangrene usually occurred in crowded camps and hospitals facilitated by extreme fatigue, depression, exposure to the elements, or insufficient food. The prevalence of the disorder is understandable, considering the lack of knowledge of antisepsis and the unsanitary conditions of the camps and hospitals. It is ironic that during the course of numerous detailed microscopic examinations of pus from gangrenous wounds, Dr. Joseph Jones saw the bacillus responsible for gangrene but dismissed any connection between the bacillus and the infection. 19 "Animalcules of simple origin and endowed with active rotary action abound in hospital gangrene." "The

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THE GENUINE SOUTHERN SURGEON

gangrenous matter," he postulated, "appeared to afford a nidus in which the simple forms of animal and even vegetable life are rapidly generated and multiplied." Jones' failure to connect the bacteria he observed with gangrene is easily understood considering that the miasmatic theory of disease, defined as "nocuous effluvium that emanated from the cold dark ground," was still firmly entrenched in America during the Civil War. The Confederate medical officer did his best to control the various surgical infections, and eventually a great premium was placed on cleanliness, proper ventilation, and a nutritious diet. The outbreak of gangrene caused some hospitals to be completely closed until they were thoroughly cleansed with disinfectants and whitewashed. An inefficient induction system failed to reject the unfit and disease-prone from active service. Recruits were lucky to have received any semblance of a physical examination. Tales of women successfully enlisting as men testify to the inadequacy of initial screening. Recruits from rural districts, unlike those from cities, had not experienced communicable infantile diseases, and failure to include the available smallpox vaccine as a standard part of the induction procedure resulted in alarming outbreaks during campaigns. Nearly 200,000 Confederate soldiers died from illness, three times more than from battle casualty. Armies were literally rendered inefficient or were destroyed, not so much by the actual fighting as by the steadfast action of disease. Because there was no knowledge of bacteriology and the relationship of bacteria to disease, there was an absence of preventive medicine. Most of the afflictions were attributed to the miasma. Thus, in the early portion of the war, hospital windows were left closed, pus was expected to collect in devitalized tissue, and contaminated dressings were passed from one patient to another when the previous owner either recovered or died. The major diseases that affected the Civil War soldier were infectious. Typhoid or camp fever accounted for 28% of the deaths. The camp was more hazardous than the battlefield, and because more time was spent in camp than in combat, more deaths occurred from disease than from battle. Most camps were an accumulation of filth, the odor of which could be detected from great distances. It was not uncommon for two thirds of a field regiment to be on sick call.20 Poor sanitation was the rule. Latrines were in close proximity to cooking areas. The importance of sewerage, garbage, animal offal, manure, and dead horse and mule disposal; of insect and rodent control; and of food and water protection and purification was largely unknown. Shoes were scarce, and as tents became less available with the progression of the war, soldiers were exposed to adverse weather conditions. Food was inadequate, particularly in view of the extra physical demand of exhaust-

401

ing marches and combat action. Historians describe the soldiers as being cadaverously thin. As the war progressed, the diet of the Southern soldiers worsened. By the middle of the conffict, they made do with ant-infested corn meal and horse meat, but by the final days of the war, the troops were reduced to eating fried dog, boiled cat, and roasted wharf rats." Typhoid fever progressively diminished during the war, and chronic diarrhea and dysentery progressively increased. If typhoid was the great killer, dysentery and diarrhea was the great nuisance, affecting 78% of the soldiers annually. This bothersome and potentially lifethreatening malady was called dysentery when tenesmus was accompanied by blood in the stool, or diarrhea if blood was not present.2' Deaths from disease were fewer when the troops were campaigning or in battle than when they were in stationary encampments. Likewise, diarrhea and dysentery was less of a problem when the troops were on the move, because then the water supply was new almost every day and was less likely to have been contaminated by the men themselves. Privies in the camps were often established over water, thus polluting the water supply, a practice that was partially responsible for the morbidity and mortality rates from diarrhea and dysentery. Regulations eventually dictated that latrines were to be established at a distance, and men were compelled to use them under penalty. Because of the inconvenience of traveling to distant latrines, however, the soldiers, and in particular the "country boys," used the camp site. Also, penalties were rarely imposed. The treatment of diarrhea and dysentery was varied and nonspecific and in many instances harmful. Some physicians popularized cauterization of the lower 6 inches of the rectal mucosa. Malaria ranked second to diarrhea in producing disability. Although more prevalent among Southern troops, it was more fatal to the enemy, probably because of Southerners' previous experience with the disease.'8 The Confederate medical service used quinine as a prophylactic measure against malaria, but scarcity of the drug soon prohibited its use. Not infrequently, entire army departments were completely incapacitated. For example, in the Department of South Carolina, Georgia and Florida, with a strength of approximately 75,000 men, 41,000 cases of malaria were reported between July 1862 and July 1863. In other areas,22as many as 80% of personnel were afflicted at one time. A myriad of contagious and noncontagious diseases were encountered, such as streptococcal infections (especially a wound infection), typhus, pneumonia, diphtheria, smallpox, tuberculosis, and "rheumatism," a term used for any joint or extremity pain. One of the tragic aspects of Confederate medicine was that most of the deaths would have been entirely pre-

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ventable or curable by present-day knowledge and facilities. Soldiers died of conditions over which the Confederate medical officer had no control. They died because of exposure; because of inadequate food; because of lack of clothing, tents, blankets, medicine, and drugs; but mostly they died because of the lack of knowledge of the cause of illness and the proper management of wounds. Only in the North were drugs produced, and the blockade effectively prevented all drugs from getting to the South. The "Trading with the Enemy Act" of 1865, enacted by the Union, essentially prevented the South from obtaining drugs and equipment. Some of the doctors in the North suggested that medicinal agents be removed from the contraband list; however, when the proposal was presented to groups such as the American Medical Association, most ofthe doctors heckled and hissed. At the onset, the South had no pharmaceutical plants, and as a result, the Surgeon General ordered the establishment of facilities in Mobile, Charleston, Columbia, and Augusta. Although some drugs were manufactured, such as alcohol, silver nitrate, potassium, iodine, and ether, supplies were limited and many other kinds were needed. Opium, morphine, and quinine had to be smuggled in. Indigenous substitutes became the hallmark of Confederate medicine. Surgeon General Moore commissioned Dr. Francis P. Porcher to publish a book entitled Resources of the Southern Fields and Forest as a help for obtaining local drugs unable to be secured because of the blockade.23 Cucumbers were used for burns, pokeweed for camp itch, geraniums for diarrhea, persimmons for dysentery, and charcoal for diphtheria. A tincture of a compound of willow, dogwood, and yellow bark, appropriately called "old indigenous," was used as a substitute for quinine. Efforts were made to cultivate the poppy in Florida and North Carolina, whose unique seed capsules yield a gum with an effect not unlike Turkish opium.24 Union hospitals were able to get all the drugs they wanted. Private firms, which have remained as giants in the pharmaceutical world today, included Edward E. Squibb, John Wyeth, McKesson & Robbins, and Charles Pfizer and Company. Added to the problems encountered by the Confederate surgeon in practicing medicine was the low status of the doctor compared with field officers. The legal position of medical officers was poorly defined, and regimental surgeons were directly subordinate to field colonels. Moreover, when medical supplies, personnel, and transportation services were inadequate, which was the usual, surgeons had no control over procurement. Battlefield promotions and other rewards were won by the fighting men; however, regardless of their risks and work, the field surgeons would receive no more than a passing notice. The death rate among Confederate doctors, both from enemy action and from disease, was higher

Ann. Surg. * May 1992

than that of any other staff corps. Statues of generals are in every town, and every village has its statue to a private soldier, but no state or national monument is dedicated to the Confederate surgeon. At Gettysburg, every battery site is marked with a recording tablet; every general who died is remembered in bronze or marble; but not a single notice of the surgeons who died can be found.25 The only individual to be executed for alleged war crimes during the Civil War was a doctor. A doctor by preceptorship, employed on Marshall Plantation at Milliken Bend, Louisiana, immediately before the war, Henry Wirz was commander of the prison at Andersonville, Georgia. During the Civil War, prisons were factories for disease and death, both in the South and the North.26 Grant stopped the practice of exchanging wounded prisoners in 1864 to increase the burden on Lee's limited resources.27 After the war, the Adjutant General of the US Army reported that 19,600 Confederates died in Union prisons and 26,168 Federals died in Confederate prison." Undoubtedly, the conditions at Andersonville Prison were deplorable. The stockade was overcrowded. With a capacity for fewer than 10,000 prisoners, the number imprisoned grew to over 33,000, for an average space of only 36 square feet per prisoner.28 Thus, even basic sanitary conditions could not be obtained. The decision to prosecute Dr. Wirz for the horrors of Andersonville placed Dr. Joseph Jones in an uncomfortable position, for he feared that the research he had done among the Union soldiers at Andersonville would be construed as documented evidence of Confederate atrocities. He stated, "The report of the Federal prisoners at Andersonville should never see the light of day, because it was prepared solely for the eyes of the Surgeon General of the Confederate States Army; and the frank manner in which the subject had been discussed would only engender angry feelings and place weapons in the hands of the victors." His worst fears materialized. Without any warning, Dr. Jones was ordered to report to Washington to Colonel Norton P. Chipman, Judge Advocate and Prosecuting Attorney in Captain Wirz's case, as a witness in the trial and to take with him all papers, reports, and recordings pertaining to the Andersonville Prison. At the trial of Captain Wirz, when Jones was questioned, he was surprised and dismayed that his 600-page report had been reduced to a mere 20 pages and that the material containing explanation for the dreadful conditions at Andersonville had been left out.29 He considered the abstract to be a most unfair and garbled statement. Although in the opinion of Dr. Jones and many others Dr. Wirz did the best he could with what the Confederacy provided, the aroused postwar attitudes of many victorious Northerners demanded that the rebellious South be punished. Neither Jefferson Davis nor Robert E. Lee nor any other well-known Southerner, however, was formally charged

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with war crimes. Instead, in a true 19th century witch hunt, Captain Henry Wirz, the Commandant of Andersonville Prison, became the sacrifice. Dr. Wirz was hanged on November 10, 1865 (Fig. 3). After the war, the desperate economic environment in the South naturally affected the medical profession. In the immediate postwar period, Southern surgeons were not held in high esteem by surgeons of the North and abroad, and to arise from that position required great effort and fortitude. Many notable surgeons served the Confederacy honorably and excelled after the war as physicians, educators, scholars, or politicians. As proof that the Confederate Medical Corps included many able and promising members of the medical profession, almost 100 Confederate medical officers were included in the authoritative medical biographical work, American Medical Biographies. To pay tribute to these 100 is beyond the bounds of reason; however, I would like to highlight two of the founding members of our association who excelled as surgeons both during and after the war.

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FIG. 3. The hanging of Captain Henry Wirz.

FIG.

4. Robert Alexander Kinloch.

Robert Kinloch

Robert Alexander Kinloch (Fig. 4) was born in Charleston, South Carolina, on February 20, 1826. He graduated from the College ofCharleston with distinction. He received his medical degree from the University of Pennsylvania and spent 2 years in the hospitals of Paris, London, and Edinburgh. Returning home, he began to practice in his native city when the war began. He was among the very first surgeons to receive a commission and was on duty at the first battle of Manassas. His military career was exceptional in that he served at various times on the staffs of Generals Lee, Pemberton, and Beauregard. Also, he was a member of the Medical Examining Board at Norfolk, Richmond, and Charleston and subsequently held the position of Medical Inspector of Hospitals for South Carolina, Georgia, and Florida. He was known as an innovative surgeon, having saved lives of soldiers not expected to survive. After the war, he practiced in Charleston, South Carolina, and was soon elected Chief of Surgery at Roper Hospital. In 1866, he was elected to the Chair of Materia Medica in the Medical College of the State of South Carolina with the understanding that he would transfer to the Chair of Surgery when the position became vacant. This agreement was fulfilled, and in 1869 he was transferred to the Chair of the Principles and Practice of Surgery and subsequently to that of Clin-

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ical Surgery, which he occupied until the time ofhis death. In 1888, he was elected Dean ofthe faculty and continued to serve in this capacity also until he died. He was President of the Medical Society of South Carolina, President of the South Carolina Medical Association, and a founder of the American Surgical Association, serving as a member of its council. He was also active in the American Medical Association and was First Vice President in 1884. For a short time, he was editor of the Charleston Medical Journal. Dr. Kinloch was considered a very able surgeon, bold and determined, possessing a rare skill in execution and perfect poise in the face of unforeseen emergencies. He was the first surgeon in America to successfully resect a knee joint for chronic disease, the first to treat fractures of the lower jaw and other bones by wiring the fragments, and the first to perform an exploratory laparotomy for gunshot wounds of the abdomen.30 He was original in his thinking and demonstrated a modern viewpoint that was not universal. He defended Listerism when most of his colleagues were attacking its principle. As a professor and as Dean, he worked diligently to elevate the standards of medical education and was annoyed when restrictions beyond his control hindered action. He stated, "The standards of the college could and should be elevated. It is painful to me to say that I am powerless to improve the situation."3' He was a man of strong convictions, rejecting the impractical but always acting professionally. In controversy he wielded a caustic pen and did not spare his adversary. Kinloch was by far the most prominent surgeon in his section of the South.32 Dr. Kinloch suffered from heart disease for many years and died of pneumonia on December 23, 1891. Hunter Holmes McGuire Hunter Holmes McGuire (Fig. 5) was born on October 11, 1835, in Winchester, Virginia, a town that changed hands approximately 80 times during the Civil War. His father, Hugh Holmes McGuire, was a prominent physician and surgeon who founded Winchester Medical College, the first medical college in the state of Virginia, from which Hunter McGuire received the first of two medical degrees. Afterward, Dr. McGuire traveled to Philadelphia, where he attended courses at Jefferson Medical College and at the University of Pennsylvania. He joined Drs. Luckett and Pancoast as teachers of a highly successful quiz course. Dr. McGuire was a superb teacher, and many Southern students in Philadelphia accepted him as their spokesman. The hanging of John Brown for his actions at Harper's Ferry led to conflict between Northern sympathizers and Southern medical students residing in Philadelphia. Because of the tension, the Southern students wished to transfer to a Southern school of medicine. As

Ann. Surg. * May 1992

FIG. 5. Hunter Holmes McGuire.

their leader, Hunter McGuire was successful in transferring all the students to the Medical College of Virginia without a loss of credit. He apparently paid from his own pocket the train fare of the entire group (there were over 300 medical students). One hundred forty of these students attended the Medical College of Virginia, and the others transferred to other Southern schools. Along with the students from Philadelphia, Hunter McGuire matriculated in the Medical College of Virginia, where he received his second medical degree. When Virginia seceded from the Union, he volunteered and was mustered in as a private in the 2nd Virginia Regiment. He was soon commissioned a surgeon and appointed Medical Director ofthe Army of the Shenandoah under the command of General Stonewall Jackson. He continued to serve as Chief Surgeon of Jackson's command until the death of that great soldier. In May of 1862 at the battle of Winchester, Virginia, McGuire (who considered military surgeons to be noncombatants) persuaded General Jackson to release seven Union surgeons who had been captured. Under the agreement, these surgeons would do their best to influence the United States government to release Confederate medical officers as well. A few weeks later, all medical officers who had been confined by both parties as prisoners of war were released and returned to their respective commands. Although the plan of exchanging medical officers as noncombatants was eventually interrupted by some disagreement between the Commissioners for Exchange, Dr. McGuire continued to release surgeons whenever it was in his power. His practice of liberating medical prisoners worked to his advantage. When he was captured at Waynesboro by Sherman's army, Sherman, on learning of McGuire's identity and knowing of McGuire's release of medical officers, some

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THE GENUINE SOUTHERN SURGEON

of whom were from Sherman's own command, ordered McGuire's immediate release.33 When General Jackson was wounded in the left upper extremity and right hand after achieving his greatest victory at Chancellorville, McGuire inherited the sad duty of amputating his left arm. Although General Jackson did well for the first 5 postoperative days, with primary healing of his wound except for the bone, where healthy granulation appeared, Jackson developed pneumonia that proved fatal on the 8th postoperative day. After the war, McGuire returned to Richmond and was immediately successful. Some of his competitors thought he was capitalizing on his wartime fame and questioned the manner in which he had treated the South's most famous casualty. To exonerate himself of any charges of faulty judgment, Dr. McGuire published a report of Stonewall Jackson's injury and demise. His case was presented in such an interesting and authentic manner that never again was the treatment of General Jackson questioned.34 In 1866, Dr. McGuire was elected Professor of Surgery at the Medical College ofVirginia, a position he held until 1878, when he became Professor Emeritus. In 1883, he organized the St. Luke Home for the Sick with a nurses' training school. He had a huge medical practice, but he never turned away any old soldier who had worn the gray. Consequently, many did come to him with their illnesses and were treated without charge. Other patients would wait, business would wait, and even operations would wait, while no one dared interrupt his conversation with an old soldier as they reminisced.

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FIG. 6. University College of Medicine, circa 1895, founded by Hunter Holmes McGuire.

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Foreseeing the need for an extended and revised medical curriculum, Hunter McGuire founded the first 3-year medical school in the South, the University College of Medicine (Fig. 6), holding its presidency until the time of his death on September 19, 1890. After existing for 20 years, the University College of Medicine consolidated with Memorial Hospital and the Medical College of Virginia under the name of the latter. Dr. McGuire was a bold, rapid, and dexterous surgeon. He knew when to operate, and better still, when to stop operating. He was the first to perform a suprapubic cystostomy for the formation of an artificial urethra in prostatic obstruction, an operation that, as the preferred operation of the time, relieving a terrible human suffering, earned him worldwide fame. As a teacher, he was fluent, lucid, and impressive (Fig. 7). As an author, he contributed regionally and nationally to many aspects of the practice of surgery. Hunter McGuire had the rare distinction of having been elected president of every medical professional society in which he held membership, including the Medical Society of Virginia, the Association of Medical Colleges of the Army and Navy of the Confederate States, the American Medical Association, and the American Surgical Association, and he was the second president of our own Southern Surgical Association. He was granted honorary degrees from the University of North Carolina and from the Jefferson Medical College in Philadelphia. In his Presidential Address to the Southern Surgical Association, he ended the address with the following statement35: Gentlemen of the Southern Association, let our motto be lofty aim and united action. As southern men, let us show to the world

Ann. Surg. * May 1992

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FIG. 7. Hunter McGuire teaching students. The student to whom he is speaking is his son, Stuart McGuire.

.I that under changed conditions we have still the stamina of our forefathers. As members of our beloved profession, let us strive to be the first in scientific attainment, first in integrity, first in high purpose for the good of mankind.

Hunter McGuire probably did more than any to elevate the perceived postwar substandard status of the Southern surgeon to its present-day place of honor. Dr. McGuire had a cerebrovascular accident, and after 6 months of a distressing illness, death came as a merciful relief on September 19, 1900. Historians have argued whether the real reason for the Civil War was economic rivalry between the North and the South rather than slavery. It stands to reason that both are accurate because slavery, although an unacceptable inhumane practice, placed the South at an economic advantage. It is of interest that Lincoln did nothing to abolish slavery until nearly 2 years after the war had begun. The Emancipation Proclamation on September 22, 1862 stated, "On the first day of 1863, anyone holding slaves will be in rebellion against the United States ofAmerica." If the Southern surgeon was handicapped after the war, a freed slave had an almost impossible task. Robert Fulton Boyd Robert Fulton Boyd (Fig. 8) was born of slave parents in Pulaski, Tennessee, in 1858. He was educated in public schools in Pulaski. To continue his education, he worked halfthe day for his board while attending school the other half of the day and at night. He attended Fisk University and received his undergraduate degree from Central Tennessee College, after which he received an M.D. from Me-

harry Medical College in 1882 and a D.D.S., also from Meharry, in 1887. While attending college, he taught in the public schools and became principal of the public school for blacks in Pulaski. Dr. Boyd was the first black man to venture into practice in Nashville. To further his education, he did postgraduate study at the University of Michigan and the Postgraduate Medical School of Chicago. He returned and became an assistant to Dr. Paul Eve. (Incidentally, Dr. Eve was the first to set up a medical board for the induction of physicians into the Confederate Army.) He joined the faculty ofMeharry, and during his career he chaired the Departments of Anatomy, Physiology, Hygiene, Chemistry, Medicine, Gynecology, and General Surgery.36 In 1900, he established the 33-bed Mercy Hospital. When the building was destroyed by fire, he opened the Boyd Infirmary (Fig. 9), which served as the primary site for clinical training of Meharry students and was a major factor in the approval of the curriculum by the Flexner Committee and in the ultimate survival of the institution. Other black medical schools, with the exception of Howard University, were unable to meet the criteria for approval. Dr. Boyd proposed the organization of a teaching hospital for Meharry and suggested that the hospital be named in honor of its first president, George W. Hubbard. In 1910, the Hubbard Hospital was opened and has grown to a modern 400-bed institution. Dr. Boyd was one of the founders ofthe National Medical Association and was its first president. He was a respected teacher, acknowledged by most black surgeons of the time as their national leader. He was always affable, farsighted, and a friend of younger men, and he bristled

THE GENUINE SOUTHERN SURGEON

Vol. 215 *No.5

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with energy. His life outside his profession was equally intensive. He served as president of the Peoples Savings Bank and Trust Company in Nashville, the first black trust company in the country. As a public-spirited citizen, he was always on the firing line of anything that would help his race and community. He even ran for mayor of Nashville. Unfortunately, the brilliant career ofDr. Robert Fulton Boyd ended prematurely at the age of 54, from what was thought to be acute indigestion, but was probably a myocardial infarction. As mentioned earlier, Confederate surgeons were not credited with many accomplishments; however, they toiled valiantly for the cause in which they believed. Through their efforts during the war, from certain lessons they learned, indispensable developments were stimulated: (1) Surgical dexterity: Their experience in handling the knife and the saw and the application of surgical ligatures led to the establishment of standard surgical maneuvers.

FIG. 8. Robert Fulton Boyd.

served FG. 9. Boyd Infirmary, whichMeharry

as a clinical institution for

Medical College.

(2) Surgical initiative: Surgeons became less squeamish about entering previously forbidden areas such as the abdomen, chest, and cranial vault. (3) Public health: Surgeons realized that cleanliness was associated with good results and that bad water, bad sanitation, and bad food led to misery and disease. (4) Anesthesia: Its general usefulness was demonstrated beyond doubt through hundreds of thousands of administrations of chloroform and ether. (5) Mobile hospitals: These hospitals were first used during the Civil War; they were the forerunner of

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the highly sophisticated mobile units used in

recent

wars.

(6) Dentistry: The Confederate army was the first to establish a dental service and to demonstrate the effectiveness of surgical exploration of the oral cavity, which eventually led to the formation of American dentistry. (7) Nursing: Good nursing was found to be as important as proper medical attention, and it appeared that some of the best nurses were women. (8) Orthopedics: Orthopedics was tremendously stimulated by the development of numerous innovative practical splints and workable artificial limbs. (9) Rehabilitation: The multitude of amputees necessitated the development of rehabilitation. (10) Medical Documentation: For the first time, medical and surgical successes and failures were systematically reported and analyzed. Never before had postmortem examinations been performed and recorded on

such a large scale.

The South's most proliferative collector of medical history and data was Dr. Joseph Jones, who was guilty of

romanticizing the conflict according to some sources, but who nevertheless described what I consider the genuine Southern surgeon37: The medical practitioners of the South gave their lives and fortunes

without any prospect of military or political fame preferment. They searched the fields and the forest for remedies; they improvised surgical implements from the common instruments of everyday life; they marched with the armies; and watched by day and night in the trenches. The Southern surgeon rescued the to the country, or

wounded

on

the battlefield, binding up the wounds,

and preserving

the shattered limbs of their countrymen: the Southern surgeons through four long years opposed their skill and untiring energies to the ravages of war and pestilence. At all times and under all circumstances, in the rain and sunshine, in the cold winter and burning heat of summer, and the roar of battle, the hissing of bullets and the shriek and crash of shell, the brave hearts, cool heads and strong arms of Southern surgeons were employed but for one purposethe preservation of the health and lives and the limbs of their countrymen. The Southern surgeons were the first to succor the wounded and the sick, and their ears recorded the last words of love and affection for country and kindred, and their hands closed the eyes of the dying Confederate soldiers. It is but just and right that a Roll of Honor should be formed of this band of medical heroes.

References Brown B. The general and local treatment of gangrenous wounds and diseases. Transactions of the Southern Surgical & Gynecological Association 1890; 3:139-162. 2. Brown B. Personal experience in stab wounds of the peritoneum and intestines and their treatment. Transactions of the Southern Surgical & Gynecological Association 1896; 8:39-62. 3. Ward GC, Burns R, Burns K. The Civil War. New York: Albert A. Knopf, 1990. 4. Nevins A. The War for the Union. New York: C. Scribner's Sons,

1971. 5. Cunningham HH. Doctors in Gray; The Confederate Medical Service. Baton Rouge: Louisiana State University Press, 1958. 6. Breeden JO. The forgotten man of the Civil War: The Southern experience. Bull NY Acad Med 1979; 55(7):652-659.

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Surg. * May 1992

7. Warner EJ. Generals in Gray. Baton Rouge: Louisiana State University Press, 1959. 8. Steiner PE. Physician-Generals in the Civil War: A Study in Nineteenth Mid-Century American Medicine. Springfield: Charles C.

Thomas, 1966. 9. Stark RB. Surgeons and surgical care of the Confederate States Army. Virginia Medical Monthly 1960; 87:230-241. 10. Blaton WB. Medicine in Virginia in the Nineteenth Century. Richmond: Garrett and Massie, 1933. 11. Brooks S. Civil War Medicine. Springfield, Illinois: Charles C. Thomas, 1966. 12. Barnes JK. Medical and surgical history of the war of the rebellion (1861-65). In The Medical and Surgical History of the Civil War. Wilmington, NC: Broadfoot Publishing Company, 1990. 13. Pryor EB: Clara Barton: Professional Angel. Philadelphia: University of Pennsylvania Press, 1987. 14. McGuire S. Hunter Holmes McGuire, MD, LLD. Annals of Medical History 1938; 10:1, 136. 15. Diffenbaugh WG. Military surgery in the Civil War. Milit Med 1965; 130:490-496. 16. Chisholm JJ. A Manual of Military Surgery for the Use of Surgeons in the Confederate States Army: With an Appendix of the Rules and Regulations of the Medical Department of the Confederate States Army. San Francisco: Norman Publishers, 1989. 17. Aldea PA, Aldea GS, Shaw WW. A historical perspective on the changing methods of management for major trauma of the lower extremity. Surg Gynecol Obstet 1987; 165:549-562. 18. Adams GW. Confederate medicine. Journal of Southern History 1940; VI:151.

19. Jones J. Observations upon the losses of the Confederate armies from battle wounds and diseases during the American Civil War of 1861-1865 with investigations upon the number and character of the disease supervening upon gun-shot wounds. Richmond & Louisville Medical Journal 1869; 8:339-358. 20. Zellem RT. Wounded by bayonet, ball, and bacteria: medicine and neurosurgery in the American Civil War. Neurosurgery 1985; 17:850-860. 21. Blaisdell FW. Medical advances during the Civil War. Arch Surg 1988; 123:1045-1050. 22. Hood RM. Medicine in the Civil War. Tex Med 1967; 63:53-55. 23. Porcher FP. Resources of the Southern Fields and Forests, Medical Economical, and Agricultural. Charleston: Evans & Cogswell, 1863. 24. Wilson R. Medicine in the days of the Confederacy. J S C Med Assoc 1970; 66:169-172. 25. Mitchell SW. The medical department in the Civil War. JAMA 1914; 66:1445-1450. 26. Riley HB Jr. Medicine in the Confederacy. Milit Med 1956; 118: 53-63, 114-153. 27. Bollet AJ. To care for him that has borne the battle: A medical history of the Civil War. Part I Introduction. Resident & Staff Physician 1989; 35:121-129. 28. Futch OL. History of Andersonville Prison. Gainesville: University of Florida Press, 1968. 29. Breeden JO. Joseph Jones, MD: Scientist of the Old South. Lexington: University Press of Kentucky, 1975. 30. Linder SC. Medicine in Marlboro County, 1736-1980. Baltimore: Gateway Press, Inc., 1980. 31. Waring JI. A history of medicine in South Carolina 1825-1900. J S C Med Assoc 1967; 63:253. 32. Ravitch M. A Century of Surgery: 1880-1980. Philadelphia: JB Lippincott, 1981. 33. Manson OF. Biographic sketch of Dr. Hunter Maguire. Va Med Monthly 1877; 4(7):481-484.

34. Maguire H. Account of the wounding and death of Stonewall Jackson. Richmond Medical Journal 1866; 1:406-412. 35. McGuire HH. Presidential address. Southern Surgical and Gynecological Transactions 1889;II: 1-12. 36. Organ CH Jr, Kosiba MM, eds. A Century of Black Surgeons: The U.S.A. Experience,1st Edition. Norman, Oklahoma: Transcript Press, 1987. 37. Jones J. The medical history of the Confederate States Army and Navy. Southern Historical Society Papers 1892; 20:113-114.

The genuine Southern surgeon.

11 i The Genuine Southern Surgeon JOHN OCHSNER, M.D. M Y FELLOW MEMBERS of the Southern Surgical Association, to serve as your president is an hon...
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