William Williams Keen, MD, ended up a famous brain surgeon. But the Philadelphia native admitted he “was as green as the grass around me as to my duties” when he first wielded a scalpel as a Civil War “sawbones.”
Keen performed his share of amputations, starting at the battle of First Bull Run in 1861.
“Those of us who went through the Civil War are the most anxious to avoid another war,” Keen wrote in “Surgical Reminiscences of the Civil War,” a paper he presented to the College of Physicians of Philadelphia in 1905. “Only a righteous and noble cause can justify such sacrifices and suffering.”
Keen survived America’s bloodiest conflict uninjured. He died in 1932 at age 94. An 1859 graduate of Brown University in Providence, Rhode Island, he studied medicine in Philadelphia, Paris and Berlin. Keen was a longtime professor of surgery at Philadelphia’s Jefferson Medical College, his alma mater, and founder of the Philadelphia School of Anatomy, where he also taught for a number of years.
Keen’s reputation as a surgeon did not go unnoticed. He was on the surgical team that secretly removed a cancerous tumor from President Grover Cleveland’s jaw in 1893. The operation was performed aboard the presidential yacht.
But he was more than an authority on operations. In 1921, he was summoned to examine a future president who had been stricken with paralysis in his legs. Keen’s diagnosis was polio. The patient was Franklin Delano Roosevelt.
Keen’s Civil War memoirs, which were published in a little pamphlet, are a grisly account of battlefield surgery.
Keen was still a student at Jefferson when he volunteered as assistant surgeon of the Fifth Massachusetts Infantry in Washington on July 4, 1861. He did not earn his diploma at Jefferson until 1862. Afterwards, he was an acting assistant Army surgeon who helped staff military hospitals, including Turner’s Lane Hospital in Philadelphia.
He conceded that Civil War surgeons – dubbed “sawbones” – were not always competent as healers. He recalled watching a brigade surgeon help another surgeon amputate a soldier’s arm at the shoulder joint. The operating physician asked the brigade surgeon to compress the subclavian artery, Keen recalled.
“This he proceeded to do by vigorous pressure applied below the clavicle,” Keen said. “With a good deal of hesitation, I at last timidly suggested to him that possibly compression above the clavicle would be more efficacious.”
The brigade surgeon scowled at the upstart.
“…With withering scorn, he informed me that he was pressing in the right place as was proved by the name of the artery, which was subclavian. I do not remember whether the operator took a hand in this little linguistic discussion or even overheard it,” Keen recalled. “I had my rather grim revenge, happily, not to the serious disadvantage of the patient. When the operator made the internal flap the axillary artery gave one enormous jet of blood, for the subclavian persisted in running where it could be compressed above the clavicle, in spite of its name. I caught the artery in the flap, as I had been taught to do by Dr. [John H.] Brinton [a well-known army surgeon] and instantly controlled the haemorrhage.”
But Keen also confessed that he, too, was “utterly deficient…in training for my position. People sometimes imagine that a practising physician can be transformed into an army surgeon merely by putting a uniform on him.”
He praised the Army Medical School in Washington, which he said “…so wisely provided for training medical officers…A similar medical school does the same good work for the Navy.”
Also in his remarks, Keen described common postoperative treatment of amputees.
“An amputation stump was always dressed with a Maltese cross of lint spread with cerate,” he remembered. “Hanging out of the two ends of the wound were from five to 20 or 30 silk ligatures, one, two, or three of them with one or more knots tied in them in order to identify those ligatures which belonged to the larger vessels.
He added, “From about the fourth or fifth day traction was made upon each string to see whether the tissues had rotted away sufficiently to allow it to become detached. The knotted ligatures on the large vessels were not touched for a week or 10 days, and not uncommonly when they came away, either spontaneously or from traction, a gush of blood would announce a secondary haemorrhage, requiring reopening of the wound or, in some cases of repeated haemorrhage, a ligation of the vessel higher up in the limb, or an amputation. Sometimes, as in [British Admiral] Lord [Horatio] Nelson’s case, these ligatures on large vessels did not come away for many years.”
Keen said Civil War surgeons were thankful they had anesthesia – ether and chloroform. But antiseptic surgery was in the future.
“…Hence erysipelas, pyaemia and hospital gangrene were rife. Many a time have I had the following experience — indeed, it was fully expected and looked upon as unavoidable: A poor fellow whose leg or arm I had amputated a few days before would be getting on as well as we then expected; that is to say, he had pain, high fever, was thirsty and restless, but was gradually improving, for he had what we looked on as a favorable symptom — an abundant discharge of pus from his wound,” he said. “Suddenly, overnight, I would find that his fever had become markedly greater, his tongue dry, his pain and restlessness increased, sleep had deserted his eyelids, his cheeks were flushed, and on removing the dressings I would find the secretions from the wound almost dried up and what there were watery, thin, and foul-smelling, and what union of the flaps had taken place had melted away. Pyaemia was the verdict and death the usual result within a few days. The total number of cases of pyaemia reported during the war was 2818, of whom 2747 died, a mortality of 97.4%.”
He recounted other grim death statistics.
“Of 852 amputations at the shoulder-joint, 236 died – a mortality of 28.5%. Of 66 cases of amputation of the hip-joint 55, or 83.3%, died. Of 155 cases of trephining, 60 recovered and 95 died, a mortality of over 61%. Of 374 ligations of the femoral artery, 93 recovered and 281 died, a mortality of over 75%,” he said. “These figures afford a striking evidence of the dreadful mortality of military surgery in the days before antisepsis and first-aid packages. Happily such death-rates can never again be seen, at least in civilized warfare.”