The American History of Wartime Head Injuries and Helmets, Part 2

A ward in Washington D.C.’s Carver General Hospital during the Civil War. Image: The National Archives

New weapons and unchecked germs cause terrible casualties in the Civil War – and the helmet remains missing from combat

The Civil War was the deadliest conflict in US history. Roughly 620,000 soldiers died from combat, accident, starvation, and disease,” though an exhaustive study by one historian has estimated the total was likelier 750,000 (and possibly 850,000) out of just over 2.2 million combatants. This death toll means that somewhere between one and 13 to one in 10 “white men who were of military age in 1860 died as a result of the Civil War.”

Disease killed far more men than combat, and individuals who were wounded often died of infection due to unsanitary medical conditions:

Medical knowledge about the connection between sanitation and general health was sketchy … so camps and even hospitals were often unclean and correspondingly unhealthy. Neither the germ theory nor the nature and necessity of antisepsis were yet understood.

Soldiers dreaded hospitals and sometimes went to great lengths to conceal sickness in order to avoid them. …

[Surgeons] operated in old bloodstained and often pus-stained coats and often used infected medical instruments. Physicians performed amputations with implements washed in water bloody from previous operations, thereby routinely spreading infection.

A massive contributor to the death toll was the fact that the weapons of the Civil War had evolved faster than military tactics. Swords, sabers, and bayonets were still used, but artillery had greatly improved since the Revolutionary War, as had the firearms carried by the common soldier.

Rifle muskets had about four times the accuracy and range of the smoothbore muskets they replaced, and the mass-produced Minié ball, which “flattened and deformed upon impact” wreaked havoc on bodies:

The Minié ball didn’t just break bones, it shattered them. It didn’t just pierce tissue and internal organs, it shredded them. And if the ragged, tumbling bullet had enough force to cleave completely through the body, which it often did, it tore out an exit wound several times the size of the entrance wound. Civil War surgeons were quickly overwhelmed by the gaping wounds, mangled bodies and mutilated limbs they were asked to repair as the scope of the war broadened and casualties mounted.

These fearsome weapons, combined with the outdated Napoleonic battle tactics of slowly-moving, grouped men making frontal assaults on defensive positions, resulted in slaughter at numerous battles. The five bloodiest battles in the Civil War were: 

• Gettysburg: 48,049 casualties; 7,058 killed (estimated) 

• Battle of Spotsylvania Courthouse: 31,086 casualties; 4,240 killed

• Battle of Chickamauga: 34,624; 3,969 killed

• Battle of the Wilderness: 28,699; 3,723 killed

• The Battle of Antietam: 22,726 casualties; 3,675 killed

To put that in perspective, more men were killed at Gettysburg alone than the combined US deaths in the recent wars in Iraq (4,542) and Afghanistan (2,412); while the number killed in each of the nine bloodiest battles in the Civil War eclipsed US soldiers killed during the D-Day Invasion of Normandy in 1944 (2,499).

 

“This photo shows a 21-year-old corporal who was shot in the head at the Battle of Farmville in 1865, shortly before the South surrendered in the Civil War. Years after he was discharged, his physician noted, ‘He has many symptoms of disturbance to the brain.’” Source:Dr. Stanley B. Burns and CBS News

As in every war, head injuries played a role in casualties, and both Northern and Southern soldiers overwhelmingly wore caps, kepis, and other hats that offered little protection. Medical knowledge of head injuries had grown since the Revolutionary War; “a great deal was known about closed head injury and gunshot wounds to the head. Compression [pressure caused by bleeding or inflammation within the skull] was differentiated from concussion, but localization of lesions [wounds] was not precise.”

A 2012 article in the Journal of Neurosurgery summarized the treatment of head wounds in the Civil War (emphasis added):

Ether and especially chloroform were used to provide anesthesia. Failure to understand how to prevent infection discouraged physicians from aggressive surgery. …

The Union experiences in the treatment of head injury in the Civil War were discussed in the three surgical volumes of The Medical and Surgical History of the War of the Rebellion. Wounds were divided into incised and puncture wounds, blunt injuries, and gunshot wounds, which were analyzed separately. Because the patients were not stratified by severity of injury and because there was no neuroimaging, it is difficult to understand the clinical problems and the effectiveness of surgery. 

Civil War surgeons also used trephination to relieve pressure caused by a head wound:

Private Patrick H. Green, Co. H, 125th New York Volunteers, while on furlough, received a blow on the left side of the head from a shrug shot, on the night of May 23d, 1863. He was treated by a private physician until June 3d, when he was admitted into the Ladies' Home Hospital, New York City. Twenty-four hours after his admission he had a spasm of the right side of the body, and, upon examination, there was found to be a depressed fracture of the skull. 

The scalp was laid open by an incision, and trephining was performed, and the depressed portions of bone were removed. The scalp wound was united by sutures, and a compress of cloths wet with tepid water were applied. Rest and quiet were enjoined. The convulsions ceased after the operation, and the wound discharged freely. The patient progressed favorably, and was discharged from service on September 21st, 1863, for hemiplegia. Acting Assistant Surgeon John W. Robie reports the case.

Drilling was used as a last resort, however, given the high chance of infection – and the above Private Green and other gunshot victims who survived were fortunate. Basically, if a soldier was seriously wounded in the Civil War, there was a decent chance he would not make it out of a hospital, and even less of a chance he would leave with all of his limbs.

To Be Continued: The American History of Wartime Head Injuries and Helmets

In the next piece in this series, we cover the dawn of modern warfare and the debut of the US combat helmet as America enters the Great War. Much like the Civil War, World War I was a conflict in which tactics did not keep up with technology. And physicians struggled to understand a new form of an old injury: a mysterious combination of combat stress that overlapped with head injuries caused by explosions.

Previous installments: The American History of Wartime Head Injuries and Helmets, Part 1