(Talk delivered to OHS, April 2013)
This talk focuses upon the actions and record of the medical services of the Union army during the American Civil War of 1861-65. There are three reasons for this focus. The first is the practicality of concentrating only upon one side in a relatively short talk; the second is that the experiences and statistics of the Northern side were recorded more comprehensively and their records survived the conflict almost intact (many Southern records were destroyed in the burning of Richmond in 1865). The third is that the Confederacy was always struggling with a lack of resources and could barely keep its head above water – its medical innovations and improvisations were often remarkable under the circumstances, but their overall performance and their contribution to lasting developments was almost always less than that of their Union counterparts.
In his highly respected history of the American Civil War, Battle Cry of Freedom, James McPherson stated that “The Civil War was fought at the end of the medical Middle Ages”, echoing Peter Parish’s comment that “the medical services represent one of the Civil War’s most dismal failures.” 18% of wounded Confederate soldiers and 14% of the Union wounded died of their injuries. That latter figure (effectively one in seven) compares poorly with the Second World War where the proportion was one in thirty-three, and with the war in Vietnam where it was one in four hundred. Similarly, twice as many soldiers died of disease during the Civil War as were killed in combat – compared to the First World War, this was ten times the incidence of disease mortality. Even at the time of the conflict, public opinion, newspapers, official reports and the views of soldiers themselves appeared to agree that medical provision and competence were woeful. One enlisted man from Illinois wrote, “Our doctor knows about as much as a ten-year-old boy,” while an officer from Massachusetts declared his regimental surgeon a “jackass”.
Disease had been a greater killer of soldiers than enemy actions in almost every war in history up to this point. During the Napoleonic War, the ratio of men killed by disease compared to combat casualties in the British army had been ten to one. The Crimean War had produced a ratio of four to one. Despite the improvement in the mortality rate in the Civil War, disease was endemic within the Union forces. It has often been referred to as an ever-present “third army”. Between 10% and 50% of the soldiers in every theatre of operations could be ill and incapacitated at any one time, the numbers being highest among newly-raised regiments where the unfamiliar environment and cross-contagion of thousands of men from different backgrounds all crammed together made diseases particularly rampant. With an annual mortality rate of 5% among soldiers who fell ill, this was five times that among men of military age who remained at home. And since the illness rate was also five times that of equivalent civilians, expectation of death without ever stepping on to a battlefield was increased 25-fold.
So great was the incidence of illness, that it affected several major campaigns. The first siege of Vicksburg in 1862 had to be abandoned because more than half the Union soldiers and sailors fell ill in the swampy humidity of Mississippi in July. George McClellan’s Peninsular Campaign in Virginia was also aborted in July 1862 on the orders of Washington when 35% of the unwounded army, including McClellan himself, succumbed to dysentery, typhoid or malaria even before the traditionally worst months of August and September had been reached. However, the most dramatic incidence of this phenomenon occurred in Arkansas where no major fighting occurred at all between 1863 and 1865 because two thirds of each side’s substantial armies were permanently unfit for combat.
To understand the monumental nature of the task facing those responsible for managing medical care and provision during the Civil War, four factors have to be borne in mind. Firstly, the United States’ standing army in 1861 numbered a mere 16,000 men. The medical facilities required for such a small force were equally modest. In January 1861 there were just 90 medical officers in the entire United States Army (by 1865 this had grown to 11,000). By the end of the war, 2,100,000 men had fought in the Union army. Of these, 360,000 died, 250,000 of those succumbing to illness or disease. It has been estimated that on average every soldier was ill two or three times per year, and the number of patients dealt with over the course of the war was 6,500,000, of whom six million were there because of disease rather than battlefield wounding.
A second factor creating difficulties was that a sizeable proportion of the 1861 army medical staff were Southerners who joined the Confederacy’s war effort. Thirdly, there was no way of knowing that this would be such a long war – most commentators of the time thought it would be over within a few months, hence initial plans for medical provision were based upon that assumption. Fourthly, the technology of killing was going through a period of major change and improved effectiveness, but the tactics of warfare remained rooted in an older age of less efficient delivery of destruction and carnage.
Over the previous two centuries of warfare, infantry had stood in close-order formations, shoulder to shoulder, armed with smoothbore muzzle-loading muskets, firing in unison. The effective range of these muskets was about 60-80 metres, 250 metres being their maximum, if random, reach. In the 1850s Claude Minié produced a hollow-bodied conical bullet whose base expanded upon firing and gripped the inside of the barrel as it travelled down the musket. Barrels could therefore have a spiral groove carved into them imparting a spin to the projectile and making it much more accurate. It also increased the maximum range to 1,000 metres, and the effective one to 250. By late 1862, both sides were almost fully equipped with rifled weapons, and their effectiveness is demonstrated by the fact that 80% of all battlefield casualties were caused by bullets fired from rifled muskets. Bruce Catton, a well-known Civil War historian, said, “The hideous casualty lists of Civil War battles owed much of their size to the fact that soldiers were fighting with rifles but using tactics suited to smoothbores.”
Doctors (or surgeons as they were interchangeably called) didn’t have much status within the pre-Civil War armed forces, the highest rank they could reach being equivalent to major for the most highly qualified and long-serving. This reflected the equally low status which adhered to most doctors in American society at large, their prestige as a professional elite having declined since the 1820s. Although there were 40 institutions with 4,700 students which taught medicine and accredited doctors in 1860, the standard of education was extremely low. The awarding of a degree often had as much to do with paying fees on time as with any measure of knowledge or competence. To obtain a complete medical education, it was generally necessary to attend a European medical school. When war broke out in 1861 a handful of doctors who had been assistant surgeons, often in remote posts on the frontier with only a few dozen soldiers as their patient base, found themselves suddenly having to minister to thousands of sick and injured men, and in some cases thrust into the unaccustomed role of medical director of vast armies. However, the oversupply of doctors in civilian society at the start of the 1860s meant that there was a large reservoir of medical expertise available to be tapped, even if some of it was of an initially very low calibre.
This potential for creating an appropriate medical service for the rapidly growing Union military was not realised in the first year of the war. The image that has come down to us of incompetent butcher-surgeons treating their patients barbarously and carrying out amputations without anaesthesia arises from the events of 1861 and early 1862 (and also from popular portrayals such as the 1939 film of Gone With The Wind).
Examples of this image of quasi-medieval horror still persisted in the works of historians in the second half of the 20th century who largely accepted that the awful conditions experienced in the first twelve months or so pertained throughout the whole war. For example, in 1918 Union surgeon W.W. Keen recalled his experiences of operating during the Civil War, and he was quoted in 1962 by the writer Richard Shryock who accepted this general image:
We operated in old blood-stained and often pus-stained coats… with undisinfected hands… We used undisinfected instruments…and marine sponges which had been used in prior pus cases and only washed in tap water.
During this period, chaos and squalor did indeed prevail as the armies expanded rapidly and the first major engagements exposed the severe deficiencies of the existing system. Nothing illustrated these inadequacies more clearly, and nothing more negatively coloured future views of Civil War medical care, than the First Battle of Bull Run in July 1861.
This battle was especially redolent since it was fought only 25 miles from Washington. It was the first major engagement in the most important theatre of war (Northern Virginia), and it was witnessed by hundreds of civilians (including journalists) who had come out for the day in carriages to spectate at what they believed would be the swift crushing of the rebels. When the Union army was driven from the field in humiliating defeat, the ensuing rout saw many of the wounded abandoned and taken prisoner.
Ambulance drivers refused to listen to doctors because they were under the control of the Quartermaster Corps. Surgeons fled their injured charges, and ambulances were commandeered to transport officers and civilians back to the safety of the capital. It was reported that not a single wounded man arrived in Washington by ambulance wagon; those who did make it had walked there.
Bull Run exposed many glaring and major faults in the army’s medical provision. Not only were there inadequate ambulances and a conflict of jurisdiction over them and their drivers, but the wagons were of a poor design having only two wheels instead of four, making transport of injured men unsafe, unstable and uncomfortable. Although there should have been eight field hospitals for the size of the union army, there were none whatsoever to care for the wounded, so men who might have been saved instead perished. Because of this lack of field hospitals, the ambulance drivers, who had not been told where to take the wounded, improvised. They established a gathering point for a large number of the injured inside Sudley Church, its surrounding buildings and the graveyard. Graphic accounts of shocking scenes got back to Washington, and it quickly became public knowledge. The public learned of the communion table being used as the operating table, of the howls of the wounded and dying lying unattended, of the pools of blood on the steps of the church and of “blood trickl[ing] from the ambulance like water from an ice cart.” Bull Run provided some of the most powerful and indelible of those images emanating from the earliest days of the war, implanting the idea of medical mayhem and ineptitude upon the perceptions of the people of 1861, and transmitted down to subsequent generations as typical of the whole era.
The blame for this tragic fiasco fell firmly on the shoulders of the Army Medical Bureau’s head, Surgeon-General Clement A. Finley.
Only a month before Bull Run (but two months after the war had begun), Finley had proudly announced that the Medical Bureau had spent less than its actual allocation of money in the preceding financial year. This added fuel to the fire of a movement to replace this most conservative of men who was sceptical about any attempts to change the structure of medical provision, and actively hostile to the idea of any outside parties becoming involved.
The dead hand of Finley held back the required improvements until well into 1862. He ordered that any use of drugs not on his official approved list had to get his personal authorisation, he insisted that promotions should only be on the basis of seniority rather than merit, he quibbled over the need for medical equipment purchases, and on one astounding occasion he vetoed the funds for building a hospital on the islands off the coast of South Carolina, captured in the summer of 1861, declaring that the climate was too pleasant for hospital buildings to be needed. He also resisted allowing women to take a hands-on role as nurses, and doggedly opposed the role of the newly-founded United States Sanitary Commission, a civilian organisation which energetically channelled a tidal wave of voluntary action towards the aims of better health and hygiene in the Union military. It was the “Sanitary” whose influence and popularity with soldiers, civilian doctors, younger army surgeons, congressmen and Abraham Lincoln led to Finley’s dismissal and the appointment in April 1862 of a new Surgeon-General, 33-year-old William Hammond, a strong-willed reformist with eleven years of experience in the military.
This was a radical departure from the previous practice of appointing by seniority to the top position – Finley had been 63 when appointed, and his predecessor 81 when he finally left office.
With Hammond solidly in favour of co-operation between the Sanitary and the Army Medical Bureau, the US Sanitary Commission became even more influential.
Started up largely by women in the very first weeks of the war, it began as a charity to promote cleanliness and health in the army camps. It was modelled on the British private aid organisations of the Crimean War, adding the recruitment of nurses to its agenda at an early meeting in New York. Although Lincoln was originally sceptical about the idea of an auxiliary civilian organisation running in tandem with the Medical Bureau, referring to it as the “fifth wheel on the coach”, he was soon won over, creating the US Sanitary Commission by executive order in June 1861. By 1863 there were 7,000 local affiliates of the Sanitary, usually headed up by civilian doctors or other local leading citizens, while nation-wide the organisation had 500 paid employees (mostly men), and tens of thousands of volunteers (mostly women). These volunteers organised fairs and bazaars which raised enormous sums of money with which they bought clothing, blankets, food, medicines, bandages and even ambulance wagons to send to the army hospitals and camps.
The US Sanitary Commission furnished lodgings and meals for soldiers on leave and sent volunteer nurses to the theatres of war. It also played a major role in hospital design, camp layout, hygiene, drainage, latrine provision, water supply and even cooking practices. It sent inspectors, who were invariably doctors, to all the theatres of war to ensure that their recommendations were being carried out.
The US Sanitary Commission quickly emerged as a powerful political presence during the war years and became one of the leading voices for medical reform. Backed by congressmen, the president and Hammond, a vibrant and productive relationship between the army and this civilian body emerged – a remarkable event given the hostility to civilian “interferers” which armies of every nation have commonly shown throughout modern history. One of Hammond’s first acts was to order that at least one third of all nurses in army general hospitals were to be female. This meant that these women, numbering more than 3,000 by 1865, became employees in the pay of the Union army, an unexpected occurrence in an age of entrenched discrimination against women and in an arena of absolute male dominance. They were supplemented by thousands more volunteer nurses. The army also handed over several steamships to the Sanitary which turned them into floating hospitals.
It additionally pioneered the use of hospital trains. It was Dr Elisha Harris of the Sanitary Commission who came up with the plan for railroad cars which had stretchers hung by stout rubber cords and a carriage furnished as an emergency operating theatre. His design won a prize at the Paris Exhibition of 1867, and was subsequently adopted by the Prussian military.
US Sanitary Commission members and volunteers began keeping comprehensive records and adding to the stock of medical literature and knowledge within the United States, which would prove to be a most important resource. Starting by recording the burials of those who died while under medical care, they moved on to the problem of keeping track of patients – who were constantly being moved from one hospital to another. In September 1862 they established a hospital directory which eventually recorded the details of over 600,000 men. Constantly updated, it was a masterpiece of organisation which cut down hugely the amount of effort required by relatives and the army itself to track down missing men. It additionally provided a valuable source of general medical statistics as well as a centralised medical history of every regiment.
Next they began taking observations in camps and hospitals, while the civilian doctors among them started writing medical monographs and researching the latest medical and surgical developments coming out of Europe. 50,000 of these tracts were distributed to surgeons in the field who also benefitted from the medical advice and knowledge which the Sanitary’s inspectors disseminated. In time, the writing of monographs spread to the army surgeons who, although swamped after major engagements and inundated with disease-related sickness in the months of July to October, occasionally found enough breathing space to study, advance their knowledge and record/report their own findings and theories. There emerged a wave of enthusiasm and interest in their field which had not been apparent in the locust years of medicine from the 1820s till the 1850s. The medical establishment of the United States thus became more proficient and knowledgeable, in both the military and civilian sectors.
The reports of the US Sanitary Commission inspectors into the hospitals proved to be very valuable. Sixty physicians visited every military general hospital and produced a 2,500-page report in 1863. As well as issues of hygiene, sanitation and medical practice, they concerned themselves with the practical management of these large institutions. The army was not known for its skill in managing these parts of its own organisation, so Surgeon-General Hammond accepted their report and its recommendations as a blueprint for running his hospitals more efficiently. 1,500 camp inspections over four years led to the production of a mass of statistics on hygiene, sanitation, diet, medicine and climate which proved useful not only to the medical world, but also to insurance companies, education institutions and government agencies.
Without knowledge there can be no advances in any field or discipline. Equally, without information and understanding, there can be no knowledge. The two factors of information and understanding are therefore critical in any analysis and assessment of the Civil War’s contribution to the development of medicine and medical practices – and I would argue that these were plentiful.
Of equal or greater importance than the reports compiled by the US Sanitary Commission, were the monumental tomes published by the Surgeon General’s Office with the backing of Congress, entitled The Medical and Surgical History of the War of the Rebellion. Issued in six volumes between 1870 and 1888, compilation and editing was under the direction of Army Surgeon-General, Joseph K Barnes. In 1868 Secretary of War, Edwin Stanton, secured a Congressional appropriation sufficient to cover the publication of 5,000 copies of the six-volume set and ensuring that it was widely circulated.
The Medical and Surgical History was partly based upon a similar British Army publication which was undertaken after the Crimean War had exposed the failings of British military medical provisions. The American one was, however, much larger, more comprehensive and better organised. It was proposed, planned and begun during the war rather than retrospectively. Within a month of taking up the office of Surgeon-General in the Spring of 1862, William Hammond had already begun the process of keeping better records of medical care by ordering that more detailed reports of the physical condition, diagnosis, treatment and prognosis of every patient who was wounded and passed through the hands of the Medical Bureau’s facilities must be produced and forwarded to Washington. Over the course of the war years, factors beyond statistics of injuries, illness and treatment were also gathered – for example sanitary and hygiene reports, analyses of hospital layouts, commentaries on diet in the field and in hospitals, surgical instruments, medical practices, the evacuation of the wounded, burial procedures and even commentary on self-wounding and “malingerers”.
Much of the six volumes was taken up with case histories, many tens of thousands of them. It is one of the great strengths of the work that it included observations not just by the editors, but also by the original doctors. The inclusion of the names of surgeons in every case was valuable, not just to historians, but to those later specialists who sought to find out why and how certain techniques and practices evolved over time.
The books covered a truly vast range of topics and offered many examples of, and insights into, areas where misunderstanding of causes, misdiagnoses, faulty or useless treatments, and poor medical practices were not shied away from. Tentative theories and constructive comment abounded in these volumes – the methodology didn’t just consist of dry statistical tables and purely empirical, value-free observations. These were books with a purpose – the advancement of learning, the enhancement of the United States’ military medical services, and the improvement of the health of the nation as a whole.
There was an extremely large appendix of 353 pages which contained reports written by 289 doctors in which they recounted their war experiences, highlighting particularly interesting cases, dramatic events in the field, descriptions of good and bad facilities, observations on camp hygiene, commentaries on the efficacies of different medicines and even offering up new theories of surgery, post-operative treatment, pharmacology and pathology. As well as the major diseases such as malaria, typhus, typhoid and yellow fever, the work also covered poisoning, alcoholism, drug addiction, venereal disease and an early stab at understanding and categorising psychological illnesses.
The books were remarkable for the number of illustrations which they used. Photographs, colour plates, etchings, engravings and lithographs illuminated the many thousands of pages of text of the series. Photographs in particular were very much cutting-edge technology.
Not only were wounds, injuries and disease symptoms in patients photographed, but so too were surgically-removed body parts. These grisly specimens themselves were often sent on to Washington as part of a further project instigated by Hammond. This was the creation of a pathological collection which then became the centrepiece of the subsequent Army Medical Museum, a learning aid almost as useful as The Medical and Surgical History volumes which allowed trainee physicians to see in three dimensions the real effects of injuries and disease.
In the 20th century the museum became the Armed Forces Institute of Pathology, one of the world’s leading research and consultation centres on pathology. It is now the National Museum of Health and Medicine. John Brinton, the museum’s first curator, personally visited several Eastern Theatre battlefields to collect specimens and solicit contributions from Union army surgeons, while Hammond sent a standard letter to all surgeons requesting their co-operation in forwarding specimens and photographs.
Hammond was determined to use the death and injury resulting from this awful war as a resource, as a source of improved medical provision to lessen the injurious and mortal effects of future combat. In previous wars few people would have dreamed of bringing back gangrenous stumps, pieces of shattered skulls or quantities of viscera of one’s own soldiers. This was a radical move which ran the risk of being condemned by self-righteous prigs. However he didn’t dwell on misfortune which could not be undone, nor did he surrender any ground to squeamishness. He sought rather to use the sacrifices of so many young men to help others avoid their tragic fate through the means of science and reason. This was part of that very progressive 19th-century rationalist outlook of the sort evident elsewhere in the works of, for example, Charles Darwin and Samuel Smiles.
There is also methodological genius at work in the specimen-gathering project. At what juncture other than during a major war would it have been possible to gather so much study material? Indeed, other than in a civil war fought in close proximity to the institution in which the specimens were to be kept and displayed, how practical would the project of shipping preserved body parts have been? Equally significantly, when would it be possible to get so many unpaid researchers to do most of the work for you in gathering and preparing specimens, and also writing up all the details and history of the artifacts? Hammond skilfully gave his willing field workers all the information and help which they needed, and added a clever piece of incentivisation by promising to display the names of the contributors on the exhibits in a prestigious museum in the nation’s capital.
As well as presenting a vast amount of information, The Medical and Surgical History also helped to shape a developing understanding of medical theory. The 1860s were not the end of the medical middle ages, since there had been continuous advances in almost all fields of practice over the preceding decades. Contrary to popular images, chloroform and ether had been in use as anaesthetics since the 1840s which had allowed surgery to take great strides forward. Very few major operations or amputations took place in the Civil War without the use of one of those – usually chloroform. Anatomical knowledge was highly advanced. Smallpox prevention through inoculation was a standard practice. Bleeding a patient to aid recovery had virtually disappeared by the 1850s, as had treatments such as purging, blistering and cupping.
However, despite such progress, there was a need for a sea-change in understanding the concepts of pathology, contagion, microbiology and germ theory. Until germ theory became accepted as the cause of disease, medical understanding still held to the very old idea of the four humours – blood, phlegm, yellow bile and black bile. Unable to see as deeply into human anatomy as would later be possible, it was believed that poisonous bodily substances constricted small blood vessels. This restricted blood flow and caused disease, in particular all manner of fevers. To restore humoural balance and hence promote recovery of the patient, intervention was required. The older methods of bleeding and purging were no longer practised since empirical study had shown them to be inefficacious. Inducing perspiration (“sweating it out”), was still practised but by the mid-19th century, physicians were turning increasingly to pharmaceutical remedies.
In the 1860s it was believed that the so-called “bodily poisons” were caused by three factors – diet, environment and climate. These factors determined, and therefore could also alleviate, the poisons, with climatic conditions being the most important of them. Climate and the atmosphere were seen as both a cause and a transmitter of disease. Most fevers and many other diseases were believed to be spread by foul or poisonous air, referred to as miasma or noxious effluvia. It was believed that the atmosphere became poisoned through animal or vegetable decomposition, from swamps, or from the human body in the form of breath or excrement (especially where there was overcrowding). Swamps and vegetable decomposition caused malaria and dysentery, while human beings themselves generated typhoid and typhus.
The humours, it was believed, were weakened or excited by bodily poisons, the doctor diagnosing the condition of the patient’s humours by his symptoms. Where fever, diarrhea or rapid pulse was displayed, the humours were reasoned to be over-stimulated and this was associated with dysentery and malaria. The “cure” was to administer doses of calomel (a laxative) or ipecacuanha (an emetic – something that induces vomiting). Where feebleness, delirium, constipation or a thin pulse was in evidence, the humours were supposedly weakened and this was taken as a sign of typhoid or typhus, requiring a stimulant such as quinine, camphor, alcohol or turpentine or an astringent such as tannic acid, silver nitrate or lead acetate. These so-called medicines were aimed at reducing symptoms, which they sometimes achieved, and restoring humoural balance, which was an impossibility because of faulty conceptualisation. None of these remedies were actually curative.
Working within a flawed theoretical framework, the diagnostic reliance on symptoms could lead to mistreatment, particularly for typhoid, typhus, dysentery and malaria. Civil War physicians did not have a reliable method of distinguishing between the various fevers displayed in all of these conditions, so neither could they differentiate between the diseases. Typhus and typhoid have different causes, but very similar symptoms, while malarial fevers can resemble either, and dysentery may sometimes look like recurring malaria. Little wonder then that misdiagnosis was common, while some of the drugs being used could confuse the picture further. For example, if typhus or malaria sufferers were treated with calomel and quinine, their symptoms often became those of typhoid or dysentery. The reason for that was that these toxic pharmaceuticals caused ulceration and haemorrhaging of the intestine. At this point the treatment would be directed towards these new symptoms, the physician unaware that he was now addressing the side effects of his own “remedy”.
Physicians of the 1860s had no awareness of the existence of micro-organisms, nor that bacteria were the cause of infections. It was not until 1876 that Robert Koch isolated bacteria and came up with germ theory in 1879. Similarly, in the realm of surgery, it was 1867 before Joseph Lister used the research of Louis Pasteur to demonstrate that infections could be spread by touch and that antiseptics were necessary for use on surgeons’ hands and instruments.
However, by learning from empirical experience, surgeons and doctors actually stumbled upon many practices which were effective in reducing disease and infection without understanding why this was so. Overcrowded wards and foul-smelling wound discharges produced terrible stenches in hospitals, and believing that this was an example of a noxious miasma, some doctors ordered that the air be deodorised with alcohol, nitric acid, iodine or carbolic acid. All of these chemicals are effective disinfectants and anti-bacterial agents, so their use for the wrong reason provided a degree of protection from disease and infection. However, surgeons benefitted less from this practice since they still did not sterilise their instruments and only washed their hands in the most cursory of manners, if at all. Ironically, the infectious nature of gangrene was recognised, leading not only to isolation of such cases where feasible, but also to the use of disinfecting bromine and nitric acid on gangrenous suppurations. There appears also to have been some use of carbolic acid to clean out other types of infected wounds, but because of the underlying theory of miasma, of disease being carried through the air, the connection with surgical instruments and surgeons’ hands carrying infection was not made. Thus the application of disinfectant was often made after the infection had already been introduced and taken hold. With this unfortunate flaw in their understanding, some types of injuries consistently resulted in a tragically high death rate. Gunshot wounds to the chest proved fatal in 62% of cases treated by surgeons, while wounds to the abdomen had an 87% mortality rate. These inadvertent improvements in dealing with disease and infection which arose from empirical observations and practices that produced favourable results, pushed medical development forward in a very haphazard and juddering way.
A similar phenomenon of improvement by serendipity occurred in camp and hospital layouts and design. It was within the training camps that the first epidemics appeared. Bringing together large numbers of young men, many of whom had never come in contact with childhood diseases, especially recruits from rural areas, gave rise to large-scale outbreaks of measles, chickenpox and mumps, all of which are far more aggressive and dangerous in adults. In the field camps, as well as the febrile illnesses mentioned above, there were also epidemic outbreaks of smallpox, pneumonia, influenza, tuberculosis, scarlet fever, cholera and even dengue fever. Within these camps hygiene and sanitation practices were appallingly bad.
Latrines and animal slaughter pens were placed far too close to the tents, water supplies became contaminated by the disposal of latrine contents upriver from where drinking water was drawn. Large numbers of soldiers, particularly those from rural areas, often relieved themselves just yards from their tent. Fecal transmission of disease as well as contamination of spring waters was therefore guaranteed. Other camp practices and conditions further contributed to endemic sickness – such as men sleeping in their clothes or wearing the same garments for weeks on end leading to lice infestations which encouraged typhus; or lack of nutritious foods (especially fresh fruit and vegetables); or inadequate rest. These made the troops susceptible to disease and less capable of fighting it off. Once more it was the belief that noxious effluvia was emitting from all this filth and smell that led physicians and members of the US Sanitary Commission to recommend less crowding and better ventilation in tents, and the moving of latrines to more distant locations. On occasions armed patrols were formed to escort men found defecating within the camp to the latrines, but it was a difficult discipline to instil since the high incidences of diarrhea, or the “Tennessee trots”, meant that a 200-yard sprint was simply out of the question when the urge suddenly arose.
Field and general hospitals were initially fetid places where overcrowding, poor sanitation and negligible hygiene practices caused foul smells to linger within them. Surgeons also believed that pus corpuscles floated about like dust, so greater ventilation became a guiding principle in the design of newer hospitals. A building program of military general hospitals began in December 1861. Previously the army had used a handful of commandeered private hospitals, but mostly had to make do with inadequate conversions of churches, warehouses and other large structures. By 1863 there were 151 of these new general hospitals providing nearly 60,000 beds.
The introduction of the pavilion hospital, based partly on the design of a tent, was inspired by a desire to inhibit miasmas and were more spacious. A fortuitous effect of the pavilion design was that it broke the whole hospital up into many separate ward buildings, each containing fewer patients per square metre than previously which cut down the spread of infection greatly. Far better supplied with kitchens, laundries and bathhouses, a further positive innovation was the introduction of icehouses where fresh fruit and vegetables could be stored. This improved the diet of the patients, banished scurvy, and reduced recovery time substantially.
At the start of the conflict, field hospitals were often referred to as regimental hospitals since each one was assigned and organised at that level. However, when a large engagement occurred involving dozens of regiments, this led to chaos and inefficiency in the handling of the wounded. From the second half of 1862, field hospitals were organised on a divisional or corps basis with designated equipment geared to the anticipation of very large numbers of wounded being brought into them. These tented compounds not only provided better medical attention, but possessed the organisation and expertise to assess the condition of the injured and decide where they should next be sent, whether back to their regiment or on to a general hospital.
It has been claimed – with good cause – that the Civil War was “the war in which the American military learned how to handle casualties”. After the disaster of Bull Run, increased provision of better ambulances began and the ambulance drivers were put under the command of the Medical Corps (instead of the Quartermaster Corps).However, the events of the Peninsular Campaign of June 1862 when thousands died needlessly through lack of medical attention, showed that there were still major failings in first aid and triage, the removal of the wounded from the battlefield, and the transportation of patients from field to general hospitals. Those tasked with getting the injured off the killing fields to safety had no medical skills, since the job was still being carried out by teamsters and regimental bandsmen, some of the latter just boys. Ambulance drivers were usually civilians hired by the Quartermaster Corps, many of whom fled when under fire. The appointment of a new Army Medical Director, Jonathan Letterman, a man with the same energy and doggedness as William Hammond, quickly led to the formation of a dedicated and separately organised Ambulance Corps made up entirely of enlisted men, a move long canvassed by the US Sanitary Commission.
The men of the Ambulance Corps were trained in basic first aid, and their organisational skills were quickly displayed at the disastrous Battle of Fredericksburg in December 1862. There they removed many thousands of wounded from the battlefield in just twelve hours, rather than the three or four days it had taken at most major engagements up to that point. Wearing distinctive uniforms, Ambulance Corps soldiers proved to be reliable under fire, often removing the wounded from the field while the battle was still raging. There is no way of knowing how many lives they saved, but the quicker a wounded man received treatment, the greater his chances of survival; and with their rescuers trained to staunch bleeding, this must have made a huge difference. So impressive was their performance on the field and their overall organisational efficiency, that European observers recommended the adoption of the American system for their own armies. By the outbreak of the Franco-Prussian War in 1870, both the Germans and the French were using the Union model.
The Battle of Fredericksburg also saw a hugely successful evacuation of 6,000 wounded men by rail to Washington where the general hospitals were better equipped than the field hospitals and where convalescence, which might take many weeks, could take place. Amazingly, not a single fatality occurred during this transportation of so many sick men in the middle of winter. Eventually specialised hospital trains were commissioned, as were hospital ships which had the added advantage that operating theatres could be accommodated within them that were more stable than Elisha Harris’s railroad-car version. Bringing the wounded back to their homeland so quickly was a rare event in war up to that point. While it was true that it was much easier in a civil war to do this, nevertheless it set a precedent for future wars. The hospital train revolutionised military healthcare by moving the patient to the physician, rather than leaving the physician with the patient at the battlefield.
Additionally, transporting the injured back to an area well outside the war zone in such large numbers contributed to the emergence of specialised medicine. Philadelphia’s Turner’s Lane hospital began to specialise in nervous and neurological disorders, Desmarres Hospital in Chicago became the institution for the treatment of eye diseases and injuries, while New York City became the centre for treating amputees.
In the area of nursing, throughout the war there was no concerted attempt to introduce proper, systematic training. Although standards of care, hygiene and sanitation rose greatly thanks to the efforts of the army of nurses who tended to the wounded in the field and general hospitals, everything was learned on the job or else passed on by those who had been doing it longest. The principal innovation was the acceptance of women taking on the role of nursing. Almost immediately after the attack on Fort Sumter in Spring 1861, Dorothea Dix, previously famed for efforts to reform insane asylums, began recruiting volunteer female nurses. Although Lincoln, Hammond and the male-dominated executive of the US Sanitary Commission did much to support the efforts of women to be accepted by the conservative ranks of the Army Medical Bureau, without the work of strong-willed women themselves (such as Clara Barton and Mary Ann Bickerdyke, and their Southern counterpart, Sally Louisa Tompkins), such progress would have been greatly curtailed.
While the new role of women as nurses within the military excited a lot of interest at the time and figures prominently in present-day literature on the Civil War, even by 1865 women still only made up 20% of the nursing strength of the Union army. At any one time as many convalescent soldiers as women would be fulfilling the role in the general hospitals.
While involvement in nursing undoubtedly advanced the cause of women’s emancipation and gave them an opportunity to enter into the medical arena, it was very much at the ground-floor level. The Medical and Surgical History ” This belittling portrayal of the self-sacrificing efforts of these women is contradicted by the many memoirs written not just by former Civil War nurses, but by army officers, surgeons and the patients whom they tended. Resistance to women training to be qualified doctors continued till deep into the 20th century. After the Civil War, it remained a struggle for women to maintain, far less advance, their roles. The first training school for nurses was not set up till 1873 by Elizabeth Blackwell, the first woman in the United States to have qualified as an M.D. (in 1849) and still one of only a handful when the Civil War began.s Medical College to train women as physicians.
There was one area where one can see almost nothing in the way of positive development. This was the use of pharmacological treatments. It was noted above that the use of certain drugs could obscure the underlying pathogen (organism or substance that causes a disease) but that was only one of their drawbacks. Rhonda Kohl has commented aptly, “By modern standards, the Civil War pharmacopoeia consisted almost entirely of deadly poisons.”
Copious amounts of mercury-based purgatives such as calomel or “blue pill” were administered. It was believed that purgatives removed “noxious” material from the intestinal tract while enhancing mucous membrane secretions which promoted inner cleanliness. While mercury did indeed act as a strong purgative, its most critical actions were destructive ones. Apart from generating intestinal lesions and inflammation which may worsen the diarrhea it was being used to combat, it can lead to colitis, kidney failure, dementia and personality changes. Mercury compound in the form of calomel was very widely prescribed in the early years of the war, especially for the treatment of dysentery, but it became a virtual panacea for some physicians, used in the treatment of almost anything. As a result of the reporting-back system and the gathering of statistics on medical cases, the Medical Bureau began to see that it was not an effective remedy, that it was in fact counter-productive and may have become an unthinking fallback for lazy, or more likely overworked, doctors. In May 1863 Hammond authorised its removal from the army’s pharmacopoeia.
Another favourite “remedy” was Dover’s Powder, a mixture of opium and ipecacuanha which was intended to make the patient sweat out their bodily poisons (but only after the usual obligatory purgative). Ipecacuanha can cause nausea, abdominal pain and diarrhea. A further stock remedy was the use of astringents (bunger-uppers) to combat diarrhea, often administered in the form of an enema. These astringents included lead acetate, sulphate of copper and silver nitrate, all poisonous metals. Silver nitrate is particularly toxic and fast-acting, leading to acute gastroenteritis, convulsions, coma and death; lead acetate also causes severe gastroenteritis, induces pain, nausea and vomiting, corrodes kidneys and liver, attacks the central nervous system and damages the brain. Where gastric problems caused a patient to grow weak, doctors would usually administer a stimulant – if the patient were lucky this could be a concoction with a whisky base; if they were unlucky it might be tannic acid or turpentine. More commonly used as a paint thinner, turpentine’s extreme toxicity manifests variously as further gastroenteritis, vomiting blood, kidney failure, damage to the nervous system, convulsions, coma and death. Unfortunately surgeons viewed it as the only treatment for typhoid, using it at every stage of the disease. All of these destructive and largely useless treatments were officially approved and recommended.
Those suspected of suffering from typhus probably fared worst of all in the Civil War pharmacological nightmare. After the bowels had been “cleansed” with a mercury potion, then sulphuric acid or tannin was likely to be administered – both highly corrosive. To counteract the pain, camphor was given orally, but this is yet another poisonous and abrasive chemical which causes not only vomiting and diarrhea, but also mental confusion, hallucinations and numbing of the central nervous system. To counteract the delirium caused by typhus (and by camphor!), quinine, opium and alcohol, which are all gastric irritants, were administered. To combat the weak pulse which typhus sufferers typically exhibit, turpentine and ipecacuanha were also given. That any patient suffering from typhus could survive this chemical assault seems amazing – but the fact was that Civil War doctors found this the most problematic of all diseases to diagnose. Consequently we don’t actually know the mortality rate for typhus since so many misdiagnoses and changes of diagnosis occurred in these cases. Where it was recorded in the Department of Tennessee, the death rate was an alarming 45%.
The second most widespread of all recorded diseases (after pneumonia) was malaria, accounting for 1,300,000 cases in the Union army. Of these only 10,000 died, but it was a severely debilitating condition – and a recurring one. For suspected cases, physicians administered quinine, which is indeed the correct pharmacological therapy, but the dosage of the time would be considered too large by a factor of at least three, nowadays. This dosage level causes diarrhea and gastric inflammation – which in turn would lead to the regimens of astringents and turpentine. Quinine could only ever suppress the symptoms of malaria, neither curing nor preventing it. Throughout the Civil War, the connection between malaria and humidity, and even swamps, was made, but the actual pathogenesis, the mosquito, was not identified until the 1890s.
Almost all the pharmacological therapies, except quinine and morphine, were not only useless, but in many cases positively harmful. In almost every instance they were designed to combat or alleviate symptoms, not to tackle the root cause. This was largely the result of a lack of knowledge of microbiology and germ theory. Pharmacology was working without a sound base and on dangerously false premises. It was generally about as reliable as astrology in its scientific method, accuracy and efficacy. Nevertheless, it did give a boost to the emerging pharmaceutical industry. 19 tons of quinine were dispensed during the war years plus substantial amounts of effective anaesthetic chemicals and painkillers, in addition to all the useless (but lucrative) pharmacological preparations. From a few companies largely clustered in Philadelphia before the war, the pharmaceutical industry expanded into a multi-million-dollar industry, equipped to produce genuinely useful products from around the 1880s.
By contrast with pharmacology, surgery had a better record during the Civil War, notwithstanding its vulnerability to ignorance of germ theory and the dramatic horrors of battlefield amputations which colour almost all accounts of its practice. Apart from the increased casualties caused by the greater accuracy and range of rifled muskets, from a surgical perspective there was a further major implication.Made of soft lead and relatively
large, Minié bullets caused wounds more destructive than previous musket rounds. While the latter tended to enter and exit the body cleanly, Minié bullets normally flattened and deformed when they hit their target. They ripped tissue, shattered bones and, if they passed all the way through, left a much larger exit than entrance wound. More often than not, the bullet would not pass all the way through because of its large calibre, its impact distortion and the low muzzle velocity of the Springfield rifles which fired most of them. Even being hit by a ricocheting Minié ball could do terrible damage to a man. The bullet carried clothing shreds and dirt into wounds, almost inevitably causing infection from even minor wounds.
The result of a Minié ball hitting the bone in an arm or leg was almost invariably amputation, and one in six of all wounds were to those extremities. The effect was like a wedge which not only split and shattered bone creating compound fractures, but caused fragments of that bone to shear off and bury themselves deep in surrounding flesh thus causing further tissue tearing and haemorrhaging. In excess of six inches of bone in the arm or leg could be splintered by a strike, so it is not surprising that 75% of all wounds to the extremities resulted in amputation. Some 60,000 limb removals were carried out by Union surgeons over the four years of war.
It is clear, however, that there occurred in the field of surgery better diagnoses leading to more appropriate treatment, and improved techniques The vast reservoir of experience accrued by the army surgeons not only made them better doctors, but the gathering together of their experiences and observations into the pages of The Medical and Surgical History allowed this knowledge to be passed on to the next generation of physicians. It is interesting to note that many of these surgeons’ accounts of their wartime experiences contain incidences of their own failures as well as of success in their treatments. While surgical skills improved, the ambit of surgery advanced very little during the Civil War. Most was carried out hurriedly at field hospitals and consisted of amputations, removal of foreign objects, bone-setting and general patching-up. Even in the general and specialist hospitals, little in the way of reconstructive surgery was done apart from some basic dental and ocular work.
During the 1864 summer advance on Richmond by the Union army under the newly-appointed General Ulysses S. Grant, refusal of orders, desertion and general low morale began to escalate. Whereas previously whenever the army was given a mauling by the Confederates, its commander would pull his forces back behind the nearest large river to lick their wounds, recover and refit, Grant instead pressed forward again and again. Casualties mounted ever higher till they were running at 10,000 per week – yet the fighting continued unabated and uninterrupted for two whole months. During the calamitous battle of Cold Harbor, when the Union army suffered 7,500 casualties in a mere two hours, the first incidence occurred of Northern soldiers going into battle with slips of paper pinned to their uniforms displaying their name and the address of their next of kin so that their bodies could be identified after the carnage that they now anticipated. This was just one of the reactions which the sheer intensity of the fighting and the lack of let-up produced. It also magnified the instances of men freezing in combat, developing uncontrollable shaking, exhibiting extreme fatigue or retreating deep into themselves in a near-catatonic state.
It was Silas Weir Mitchell, a pioneer in the emerging discipline of neurology, working at Turner’s Lane Hospital in Philadelphia which had been set up by Hammond to take war casualties, who recognised these symptoms as a genuine medical condition – rather than the widely held view that such men were either cowards, malingerers or lunatics. His diagnosis came to be called shell shock or battle fatigue, and is nowadays termed combat stress reaction.
A similar conclusion was reached by Jacob Mendes da Costa, also working at Turner’s Lane, who realised that the increasing number of soldiers who presented with symptoms resembling heart disease were in fact suffering from psychological stress – a phenomenon which was so widespread that it was known as “soldier’s heart”. While Mitchell oversaw the wards specialising in neurological injuries due to gunshot wounds, amputations and acute exhaustion, da Costa’s ward dealt with cardiac problems which were often called exhausted heart or irritable heart. Trained at the same medical school at about the same time, both men came to the same conclusion – that rest and removal from the source of stress were the way to treat the victims. Their similar diagnoses and therapeutic prescriptions helped each of their emerging specialisations to accrue credibility at a time when the boundaries between psychiatry, neurology and even cardiology were still uncertain and fluid. Mitchell also instigated the study of phantom limbs, the perception of a missing arm or leg as present and painful after amputation, a further contribution to the establishment of psychology as an accepted medical discipline.
In conclusion, the older view of the medical services as a “dismal failure” can no longer be held tenable, certainly not as far as the Union army was concerned. It is true that the first year of the war showed up many severe failings, but this was to be expected given the unimaginable growth in size of the armies. If the measure of success is keeping the patient alive, then the Union Medical Corps and its surgeons did a good job given the state of knowledge of the age. Their surgical techniques improved, amputation frequency declined and general wound-care standards rose. Civil War surgeons’ manipulative skills and the quality and design of their instruments were praised by European contemporaries. Undoubted improvements and innovations occurred in hospital provision, design and operation. The same can also be said for nursing, ambulance services, the procedure of getting the wounded treated as quickly as possible and their subsequent dispersal to appropriate specialist and convalescent locations.
Where there was much less success was in the treatment of disease and infection, in large measure because of a lack of knowledge of what caused them and how transmission operated. Linked to this was an inability to diagnose or differentiate between some of the most deadly of these diseases. The difference between diseases and symptoms was not fully realised – diarrhea and fevers were not always recognised as the result of an underlying condition, but seen as diseases in their own right. Medical pathology was still incomplete, lacking as it did some crucial concepts, above all germ theory. This impacted upon the understanding of hygiene and contagion, with critical implications for medical and surgical practices. Where medical provision was at its poorest was in its pharmacological practices. Here the treatment could be worse than the illness. The dispensing of poisons and heavy metals as medicines was a disaster.
Overall, the impact of the Civil War upon the development of medicine was enormous. Although there was not a huge amount of innovation beyond areas wholly and exclusively military (for example, retrieval of the wounded from the battlefield, a separate Army Ambulance Corps, and mobile hospitals – none of which have much application in civilian society), nevertheless there were several which are worth noting. It was within the Army Medical Corps that we see the invention of inhalers for chloroform, interdental splints for jaw fractures and the introduction of trephines (circular bone saws) for use on depressed skull fractures. Arm and leg splint improvements emerged from wartime practices, as did the realisation that ligatures (stitches) were much more effective, and less dangerous, than tourniquets for stopping bleeding and helping bullet entrance and exit wounds to heal faster than the older method of leaving them open. The restriction of the liberal use of mercuric calomel played an important role in the abandonment of the idea that purging was therapeutic, while disinfectants began to be used more widely (even if for the wrong reason). Cleanliness, sanitation, hygiene and ventilation all made great strides forward between 1862 and 1865.
The use of separate wards in military hospitals for different conditions not only helped with combating the spread of disease, it also contributed to the emergence of medical specialisation. Doctors who spent most of their time treating, say, yellow fever patients, soon became the recognised experts in that field. This augmented the trend mentioned above of the evacuated wounded being sent to specialist hospitals in northern cities. Furthermore, with the need for greater expertise came the need for better medical – training leading to substantial postwar improvement in the standard of medical teaching as well as an expansion in the number of faculties. New disciplines, such as neurology, were fostered and moved American medicine to the forefront of research and development (as well as the forefront of good practice) – something which most definitely was not the case before the Civil War.
Before the Civil War, all American hospitals were charities, of which the majority were also underfunded repositories for housing the urban poor when they fell ill. People tried to avoid being admitted to such places which were patently dumping grounds for those unable to look after themselves. Too often they were where people went to die rather than to be healed. However, despite the death rate of the Civil War hospitals, the great majority of those treated there lived to return home and probably saw their stay as contributing to their recovery. Since almost everyone in post-war America knew someone who had been in hospital, this contributed to a more positive public attitude towards hospitals than had previously been the case. It also bolstered public confidence in medicine and doctors in general, thus further raising the status of the profession as a whole, and making it more attractive to students considering a professional career.
Many of these improvements and advances resulted from changes to medical procedures, or from refined surgical techniques or from administrative reforms, and it is an undoubted fact that change occurred faster than it would have done had there not been a major war. Significantly, innovation and experimentation were effectively being tried out on a huge captive sample unavailable under any other circumstances. How often do doctors get the chance to test new treatments and procedures in largely uncircumscribed conditions and without the threat of malpractice or blame? Regardless of the tragic circumstances of these cumulative gains, a great reservoir of future potential beyond the immediate benefits had been built up, just awaiting the opportunity to burst out in many fruitful directions.