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CIVIL WAR SESQUICENTENNIAL: by Hawk, Alan Issue: Summer 2013
Medicine and the Civil War
Alan J. Hawk1
Thank God for Jonathan Letterman 2
"There was not a day during World War II that I did not thank God for Jonathan Letterman." -Maj. Gen. Paul Hawley, Chief Surgeon, European Theater of Operations3
In 1918, Maj. William Keen recalled his technique as a surgeon during the Civil War: “We operated in old blood-stained and often pus-stained coats, the veterans of a hundred fights. We operated with clean hands in the social sense, but they were un-disinfected hands. … We used undisinfected instruments from undisinfected plush-lined cases, and still worse, used marine sponges which had been used in prior pus cases and had been only washed in tap water.” 4
Mary Phinney compared what she was observing as a nurse in Germany during the Franco-Prussian War (1870) with her experience during the Civil War: “I have been to other hospitals to-day, and I can hardly contain myself to see the treatment of the wounded. It seems like actual murder. We never treated amputations so badly: —head, hands without any care… I can see now how good our surgeons were.” 5
Too often, perceptions of Civil War medicine mirror the former observation. Surgeons are frequently depicted as incompetent, drunk, never using anesthesia and amputating far too many limbs. In the major motion picture “Dances with Wolves,” a wounded Lt. Dunbar crawls away from the surgeon and saves his leg. All of which begs the question: does the Civil War have any relevance on the modern-day practice of medicine?
Reality was a more complex amalgamation of the above two observations. During the war, 12,3446 U.S. Army surgeons treated 75,904 cases of typhoid with 875 fatalities; 1,161,071 cases of acute diarrhea losing 6,217 patients; 235,585 gunshot wounds with 33,653 fatalities; and 983 cases of concussion with 232 deaths.7 Of the 87,793 gunshot wounds to the upper extremities, surgeons amputated 16,147 limbs and 172 soldiers sustained amputations of two or more limbs. Surgeons administered anesthesia in an estimated 80,000 procedures.8 Experience improved outcomes: had the mortality rate of 25.6 percent in 1861 continued throughout the war, an additional 25,928 soldiers would have died of their injuries.9
Civil War surgeons did not have a concept of infection. They knew that soldiers near swamps and stagnant water were likely to get a fever. They knew that diseases spread from one person to another. They knew that soldiers whose wounds oozed white milky pus, considered a part of the healing process, were more likely to survive than those with watery, foul-smelling pus. They attributed disease to filth and bad odors, called miasmas, but recognized that the explanation was inadequate.
However, their dissatisfaction with prevailing theories did not necessarily lead to acceptance of the germ theory of disease. Although now considered common sense, it is easy to forget how radical the idea that microorganisms cause disease was in the late 19th century. The six-volume Medical and Surgical History of the War of the Rebellion (published 1870-1888), authored by surgeons who had served during the war, described diseases in terms of miasmas and made only two references to the germ theory of disease. The two volumes describing disease in detail were published while other scientists, inspired by Robert Koch’s discovery in 1876 that bacterium caused anthrax, were busily linking germs to other diseases. In one of the volumes, Joseph Woodward expressed his skepticism about the diphtheria bacterium (discovered in 1884), writing “…That the micrococci naturally present in the locality found favorable conditions for their development in the necrosed tissues, and that their multiplication is not a cause but a result of the diseased action.”10 The center of gravity for late 19th century infectious disease research was in Germany, not the United States.
The first attempt to publically present military medicine was the founding of the Army Medical Museum on May 21, 1862. Anatomical specimens from dead and wounded soldiers were cleaned, preserved, mounted, and displayed along with their case histories. Although intended for the medical community, the museum was soon open to the public. Museum staff painstakingly compiled The Medical and Surgical History of the War of the Rebellion from these specimens and case histories, weaving the individual data points into a complex narrative of “lessons learned.”
The Centennial Exposition of 1876 in Philadelphia provided an opportunity to layer an additional narrative onto the existing one. An exhibit hall representing the Office of the Army Surgeon General was a replica of a pavilion hospital, including a ward, as well as exhibits featuring 241 anatomical specimens and 33 surgical patient photographs representing the individual cases. Another room included models of hospital ships, trains, and buildings, describing a national network of hospitals that evolved during the war.11 It was an early depiction of the emergence of health care as a system.
In 1861, the Army medical organization was based on the assumption that a patient recovers faster when treated by a doctor he knows. Regimental surgeons were assigned to garrison hospitals or deployed at the unit level. His staff included an assistant surgeon and an enlisted Hospital Steward to help care for as many as 1,000 men. Surgeons sent patients to general hospitals, usually appropriated warehouses or hotels, only when they were too sick to keep with the regiment. The Regimental Band removed wounded soldiers off the battlefield to the Regimental Hospital. Gradually, regiments consolidated the most seriously wounded into Depot Hospitals, which sometimes included surgeons and patients from opposing armies, to convalesce until well enough to be moved away from the battlefield.
This personalized approach to medicine, which mirrored civilian health care, was overwhelmed by more efficient weapons of warfare. During battle, some Regimental Hospitals were inundated while others were idle. Jonathan Letterman, Medical Director of the Army of the Potomac, persuaded Gen. George McClellan to create a dedicated, trained team of litter bearers, ambulance drivers, and medical logisticians. He repurposed Regimental Hospitals as dressing stations, sending wounded requiring surgical attention to newly-created Division Field Hospitals. Letterman had created a health care system.
This system proved its value at the Battle of Antietam, where almost 9,420 wounded soldiers were evacuated from the battlefield and under shelter by evening. Other Army units soon established organizations to handle the wounded. By December 1862, the War Department decreed that all patients be moved to a general hospital in their own state, if requested. The system expanded beyond the bounds envisioned by Letterman into the national hospital network depicted in 1876.
The network forced surgeons to share patient care with a burgeoning medical staff. More than 24,000 men and women served as nurses, including 3,214 contract nurses, and volunteers, including Harriet Tubman, Walt Whitman, Louisa Alcott, and nuns from the Sisters of Charity.12 The U.S. Sanitary Commission and the Christian Commission provided doctors, consultants, nurses, and social workers. The concept of the health care team was emerging.
These hospitals allowed surgeons to specialize as patients with similar conditions were concentrated. Turner’s Lane Hospital treated nervous disorders, identifying and documenting conditions such as facial nerve paralysis and phantom limb syndrome. Desmarres Hospital in Chicago specialized in diseases of the eye and ear. The Confederate Army established an eye hospital near Athens, Georgia.13 The concept of medical specialization was emerging.
By the end of the Civil War, military medical care had evolved into the complex system depicted in 1876 at the exposition in Philadelphia, and became the model for how a military force should care for its casualties. Echelons of care allowed patients to be concentrated to receive optimal treatment. Accommodating new technology, these concepts formed the basis of the system Maj. Gen. Hawley commanded during World War II as well as to manage casualties of the current war in Afghanistan.
These developments affected the practice of civilian medicine. In 1868, Dr. Samuel Gross, President of the American Medical Association, advocated establishment of nursing schools.14 Dr. Edward Dalton, surgeon with the Army of the Potomac, created municipal ambulance service in New York City, the origins of 911.15 The organizational concepts developed during the war continue to influence the practice of medicine today.
1 National Museum of Health and Medicine, U.S. Army Medical Research and Materiel Command, 2500 Linden Lane, Silver Spring, MD 20910
2From the National Museum of Health and Medicine. The opinions or assertions herein are those of the author and do not represent the views of the Department of the Army, Navy or Air Force or of the Department of Defense.
3 Letter (undated) from MG Paul Hawley to Rev. Henry Riddle cited in Bollet, Alfred, Civil War Medicine, Challenges and Triumphs, (Tuscon: Galen Press, 2002): 97.
4 Keen, William “Military Surgery in 1861 and in 1918,” Annals of the American Academy of Political and Social Science, Vol. 80, Rehabilitation of the Wounded (Nov., 1918), pp. 11-22.
5 Munroe, James, Adventures of an Army Nurse in Two Wars, (Boston: Little, Brown & Co.): 232.
6 Otis, George and Huntington, David, The Medical and Surgical History of the War of the Rebellion, 1861-’65 (MSHWR), Part III, Vol. II, Surgical History, (Washington: Government Printing Office, 1883): 902.
7 Woodward, Joseph, MSHWR, 1861-‘65, Part I, Volume I: Medical History (Washington: U.S. Government Printing Office, 1870): Tables C and CX and Otis, George, MSHWR, Part I, Volume II: Surgical History (Washington: U.S. Government Printing Office, 1870): xxv.
8 Otis, George and Huntington, David, MSHWR, Part III, Vol. II, Surgical History: 887, tables CLXIII and CLXXII.
9 Freeman, Frank, Gangrene and Glory, Medical Care during the American Civil War (Madison: Fairleigh Dickinson Press, 1998): 214.
10 Smart, Charles, MSHWR, Part III, Volume I: Medical History (Washington: U.S. Government Printing Office, 1888): 741.
11 Woodward, Joseph, International Exhibition Hospital of the Medical Department, U.S.A. Philadelphia 1876 (bound copy of six pamphlets) and “List of articles exhibited by the Army Medical Museum at the Centennial Exposition at Philadelphia in 1876,” Otis Historical Archives, National Museum of Health and Medicine, Record Group OHA 12, Box 1.
12 Bollet, Civil War Medicine: 411.
13 Bollet, Civil War Medicine: 227-8.
14 Gross, Samuel, Autobiography of Samuel D. Gross, M.D., Vol. 2. (Philadelphia: W. B. Sanders, 1893):207.
15 Bell, Ryan, The Ambulance: A History, (Jefferson: McFarland & Co., Inc., 2009):57-60.
Medicine and the Civil War, by Hawk, Alan, Civil War Book Review, (Summer 2013).