1861–1865
During the American Civil War, the Union had the equivalent of 1,556,678 three-year enlistments, compared with roughly 1,083,000 for the Confederacy. Over 620,000 men perished, a figure that tops the total fatalities of all other wars in which Americans have fought. During the war, the average soldier could expect to become sick 5 or 6 times. This placed a tremendous burden on the medical departments of the North and the South.
The Beginning of the Conflict
"The U.S. Military Medical Department was totally unprepared for a conflict the size of the Civil War in 1861 since it was geared to garrison medical needs". "At the outbreak of the Civil War there was in the United States Army neither plan, personnel, nor equipment for collecting the wounded from the battlefields; caring for them in hospitals; or transporting them to the rear. The Army of King William in Ireland, the army that fought the Battle of the Boyne, had a fairly complete systems of hospitals; including base hospitals, evacuation hospital, and marching (field) hospital. This was in 1691. But the memory of these things had perished. No ambulances were used in the Mexican War, or in the later Indian campaigns on the plains".
By 1861 and the approach of the conflict, the U.S. Army Medical Department was still geared to the needs of a peacetime army of 15,000 soldiers scattered, quite literally, from the Atlantic to the Pacific and from the Mexican to the Canadian borders. On January 1, 1861, there were a total of 115 physicians in the U.S. Army Medical Department, including Colonel Thomas Lawson, the Surgeon General, who was over 80 years old and who had been in the service since the War of 1812. Of these 115 doctors, three surgeons and twenty-one assistant surgeons resigned to join the Southern army, and three assistant surgeons were dismissed for disloyalty. Five surgeons and eight assistant surgeons from states that had seceded stayed on with the Union Army. Thus the U.S. entered the Civil War with a total of 98 medical personnel. Colonel Lawson,"who considered the purchase of medical books an extravagance . . . but who is credited with having secured the passage of the Act of 1847 which conferred army rank upon the surgeons" , died on May 15, 1861 and was replaced by Colonel Clement A. Finley, another relic of the War of 1812. Finley was of the same mold as his predecessor and made little change in the department except for the introduction of medical cadets and the hiring of civilians for general hospitals to serve as nurses. He also proposed strengthening the Medical Department in numbers as well as in efficiency.
Because Finley was a product of a conservative era and a devotee to routine, he soon ran afoul of the U.S. Sanitary Commission, who petitioned for his removal. The Sanitary Commission did not accuse Finley or the Medical Department of malfeasance or misfeasance, but of non-feasance because they did nothing at all. Because of the pressure brought to bear, Finley retired on April 14, 1862. Supported by the Sanitary Commission, William A. Hammond was formally appointed Surgeon General with the rank of brigadier-general by General Orders No. 48 dated April 28, 1862.
Surgeon General Hammond immediately began to reorganize and revitalize the Medical Department. Through Hammond's efforts and some of his subordinates, most notably Jonathan Letterman, Medical Director of the Army of the Potomac, the U.S. Medical Department was transformed into an efficient and effective corps for providing medical assistance to the sick, injured, and wounded Union soldiers in the field and hospitals. These two men, Hammond and Letterman, effected a highly developed ambulance and field-relief system to meet the needs of wound emergencies in the field, efficient evacuation to behind-the-lines hospitals for more detailed surgery, and then further transference to permanent hospitals for convalescence. They developed an effective, compact, and elastic field medical supply service, reduced the amounts of medicines to be carried to what was necessary, and decreased the number of wagons to what was needed for efficient supply transportation. Many of the ideas and systems developed by these two medical genius's served as models for other armies throughout the world and many of Letterman's evacuation ideas were used by the U.S. Army through the Korean Conflict of this century. Surgeon General Hammond envisioned and then started the collections of records, reports, and materials for the Medical and Surgical History of the War of the Rebellion and an Army Medical Museum. These two projects were carried forward and completed by Hammond's, successor, Joseph K. Barnes. In a few crowded months Hammond rejuvenated and propelled the Army Medical Corps into more vigorous action. He initiated or requested every major improvement that was carried out during or for thirty years after the Civil War, but because he lacked diplomacy and because his outspoken personality clashed with that of Secretary of War Edwin M. Stanton, he was soon to be eased out of his position. Hammond was maneuvered out of Washington on August 30, 1863, to New Orleans so that he could "give his special attention to medical affairs" in the South Atlantic and Gulf Department. On September 3, 1863, Stanton appointed Barnes to be the Acting Surgeon General during Hammond's absence. Hammond never returned to office.
While on an inspection trip, Hammond learned that he was being investigated by a civilian committee, appointed by Stanton, and headed by a personal enemy. Under the circumstances, Hammond demanded a court-martial. A court-martial was convened in January, 1864, which lasted four months. Hammond was charged with conduct to the prejudice of military discipline and conduct unbecoming an officer and gentleman. At the end of the trail, Hammond "was found guilty, dismissed from the army, and prohibited from ever holding office under the United States." He was eventually exonerated and placed on the Army's retired list with the rank of Brigadier General in 1879.
Joseph K. Barnes was officially appointed Surgeon General on August 18, 1864 and held that office until June 30, 1882. Fortunately for the Union Medical Corps, Barnes continued with many of the projects that Hammond had either started or recommended including the Army Medical Museum, the Army Medical Library, and during the post-war years started the publication of the Medical and Surgical History of the War of the Rebellion, which was identified in Europe as the first major academic accomplishment by United States Medicine.
Qualifications and Effectiveness of the Army Surgeons
The man of medicine who served in the Civil War was, whether he liked it or not, first and foremost a "surgeon" and was always referred to as such. Though his first knife may well have been government issued, he learned the tricks of the trade in due course and sometimes became quite an expert…Nearly all the older doctors of the period had received their medical education on an apprenticeship basis, but the younger men – those who made up the bulk of the army surgeons – usually held a medical school diploma …in addition to an office internship.
In the beginning of the Civil War, the Regimental Surgeon was appointed either by the Governor of the state or by the regiment's Colonel. Many, many doctors were not in the least bit qualified to perform surgery, but 'joined up' in order to perfect their skills. Many a poor soldier fell into the hands of these incompetent doctors and many needless amputations were performed on the soldiers. Under Surgeon General Hammond applicants for Federal commissions were given searching examinations which demanded knowledge of the latest developments in sanitation and hygiene. An examination given by the Army Medical Board in the fall of 1862 began with an oral interrogation, from one to two hours long, testing the candidate's knowledge of history, geography, zoology, literature, natural philosophy, and languages. A three-hour written examination followed in which seven or eight questions had to be answered from each of the following "branches": surgery, anatomy, practice of medicine, pathology, physiology, obstetrics, medical jurisprudence and toxicology, materia medica, chemistry and hygiene. Quite a number failed to survive these examinations and in the summer of 1862 the members of the examining board were informed by the Secretary of War that more candidates must be passed or the board would be broken up. They acted upon this advice, and to the subsequent surprise of their chairman the service was found not to have suffered. The passing of such examinations did not seem to correlate with actual performance.
In evaluating the physician of the Civil War period, we must look at him in the context of his times, not ours. Judged by the medical standards of the 1990s, even the best of the Civil War doctors would be found deplorably ignorant and badly trained. However, judged by the standards of their time, American physicians were some of the best trained in the world. Nearly all had diplomas from medical schools. As recently as the second quarter of the Century, most American physicians were trained through an apprenticeship.
A course at a better institution might cover two years of nine months each, topped off with a term of service as assistant to an active practitioner. The second year was usually given over to a repetition of the first year's lectures. In neither year was laboratory or clinical instruction given real attention. In many states dissection was legally prohibited.
By the end of the fiscal year 1865 slightly more than 12,000 doctors had seen service either in the field or in hospitals. These doctors had been organized into seven categories:
- Surgeons and Assistant Surgeons of the Regular Army in before the outbreak of the war (115, of whom one retired, 24 resigned to join the Confederacy, and three were dismissed for disloyalty).
- Surgeons and Assistant Surgeons of Volunteers (547).
- Regimental Surgeons (2,109) and Assistant Surgeons (3,882) commissioned by State Governors.
- Acting Assistant Surgeons, U.S. Army (5,532), the great majority being "contract" surgeons.
- Medical officers of the Veterans Corps.
- Acting Staff Surgeons (75).
- Surgeons and Assistant Surgeons of the Colored Troops.
From the commencement of the war to the end of the fiscal year 1865 the Medical Department casualties numbered 335 as follows:
- 29 killed in battle
- 12 killed by accident
- 10 died of wounds
- 4 died in rebel prisons
- 7 died of yellow fever
- 3 died of cholera
- 270 died of other diseases
Civilian Volunteers
A class of battlefield surgeons unmentioned by soldiers of the time, but who made a very bad impression upon the uniformed medical officers, were the civilian volunteers who come flocking down South, after major engagements, to lend a hand with the operative work. Medical men were exempted from the draft and this may have led to mixed motives. Adventure and an opportunity to get surgical experience may have joined with patriotism to bring them to the battlefields.
This extemporized civilian service soon showed grave defects. In their lack of organization and discipline, and specific responsibility, the civilians were merely in the way…many had refused assignments to Washington hospitals, insisting upon their right to "cut and carve" on the battlefield. They were charged with performing needless operation merely to perfect their technique and with wandering off from work that might prove fatiguing or uninteresting.
After Gettysburg had once more demonstrated the flaws of the "civilian-auxiliary" system, Surgeon General Hammond secured the cooperation of the State governors in an improved plan. Each State formed a reserve surgeons corps, whose members would be vouched for by the governor and would come in answer to a telegram. The real improvements of the new plan lay in its remaining provisions: every reserve surgeon was to have the pay of a contract surgeon while away from home (most of the earlier volunteers had been unpaid); he must serve a minimum of 15 days unless released by the military authorities; and he must consider himself subject tot he orders of the Medical Department. This program answered the very real need of an emergency personnel.
Beginnings of an Ambulance System and Field-Relief System
As soon as an army has taken to the battlefield, no medical function is more important that taking care of the wounded soldier. These injured soldiers must be collected, taken to aid stations, transported to the field hospitals for more definitive treatment, fed and cared for. Hospitalization would be within the army's line are they were evacuated to a general hospital in one of the major cities. The successful performance of all of these areas requires intricate organization, vast stores of supplies, and highly trained personnel. None of these were in place in 1861.
After the disasters of 1861 and 1862, the administration achieved a workable basis, an efficient ambulance system was in place, at least in the Army of the Potomac, and brigade and division hospitals were replacing the individual regimental hospital. All of these improvements were carried forward in 1863 and 1864 and by 1865 the American ambulance and field hospital systems had become models of their kind.
When Jonathan Letterman succeeded Charles Tripler as Medical Director of the Army of the Potomac in July, 1862, he immediately began the task of reorganizing the Army of the Potomac's Medical Department. His plan included an ambulance corps with a captain in charge of each army corps, a first lieutenant for each division, a second lieutenant for each brigade, and a sergeant for each regiment all of whom were under the control of the medical directors. All the ambulances were organized into division and sometimes corps trains. The army ambulance service and organization became law on March 11, 1864 with the passage by Congress of the Ambulance Corps Act, which provided a basis of ambulance organization for a great number of armies down to the first decades of the twentieth century. The act provided for two-horse ambulances:
|
Unit |
No. Of Ambulances |
No. Of Men |
|
Regiment |
3 |
500+ |
|
Infantry |
2 |
200-500 |
|
Infantry |
1 |
200- |
|
Cavalry |
2 |
500+ |
|
Cavalry |
1 |
500- |
|
Artillery |
1 |
Battery |
|
Headquarters |
2 |
|
;
It also provided for two army wagons for each division ambulance train.
By the summer of 1864 the field-relief system administered immediate medical attention vias ambulance hospitals. Minor wounds, sunstroke cases, and day-to-day sickness were cared for by a small detail of surgeons and attendants who represented a highly mobile hospital unit. Under battle conditions, full division hospitals were set up which usually employed four operating teams of three men each. Depot hospitals would be established at some central point to receive the disabled, clearing the field division hospitals of patients whose most urgent needs had been cared for by thorough examinations and emergency surgery. Dressing stations were set up close to the battle line to administer rough dressings, whisky, and opium pills, after which the wounded were removed to the division hospitals.
Rev. T.H. Robinson describes in a very clear manner the organization and working of a typical division field hospital as follows:
When, after a march, the hospital is camped for the night, or to await a battle, the hospital tents are pitched in three rows, to represent the three brigades of the division, each brigade under the charge of the Surgeon-in-Chief of the brigade. The camp is pitched in the form of a hollow square – the surgeon's tents on one side, the hospital tents on another, the kitchen on the third side, and near by it the provost guards and the pioneers, and on the fourth side are arranged the hospital wagons. In the centre of the square, under a large tent, are placed the operating tables where amputations are performed.
In locating a hospital the requisites are – 1, pure water; 2, wood; 3, good ground, dry and even surface; also, if possible, near a wood where boughs may be obtained for beds…Each brigade of the division has its own operating table in the centre of the hollow square. This table is under the charge of the chief surgeon of the brigade, who is held responsible for all operations performed. He has two assistant surgeons, making three to each table, also a steward to assist and to keep record of operations and to dispense medicines to the sick. There are also other stewards placed in charge of the sanitary stores and of the medical wagons, who are ready at all times to fill the prescriptions of the surgeons…In addition to it (the division hospital) there is also an outpost hospital, established on every field of battle in time of engagement…To it wounded men picked up by stretcher-bearers on the field are brought, the wound examined, temporarily dressed, hemorrhages of blood stopped, and then they are placed in ambulances that come up to this point, and borne back to the division hospital. Each man is sent to the brigade to which he belongs, the wound is at once re-examined, the slight ones attended to in tents, the more severe taken to the operating tables. No amputations are allowed on the field or in out-post hospitals.
Wartime Surgery
The repair of the torn and mangled bodies of the soldiers and the treatment of infected wounds have always been the primary concern of wartime surgery. Surgery during the Civil War was in a transition period. Anesthesia had come in the 1840s (chloroform in 1847 and ether in 1842 or 1846, depending on who you accept as the discover). Operations, previously forbidden by the shock and sensibilities of patients, were now possible. But the revolutionary modern techniques of antisepsis and asepsis were not to come until the decade after the war. Consequently, the surgical meddling and experimentation which anesthesia had invited were paid for in an appalling ratio of wound infections accompanied by an even more appalling mortality rate. The annual rate was fifty-three (53.2) per 1,000 numerical strength – of which about forty-four (44.6) were from disease and accident, and nine (8.6) from wounds received in action.
The nature of the surgery in any war will be determined in good part by the methods and weapons of combat, and particularly the size, shape, and material of the projectiles. The typical Civil War soldier would be hit in the arm or leg by a soft lead conical-shaped bullet, called a Minié ball, fired from a rifled musket. His chances of survival were seven to one, although the soldier would go through a dangerous and uncomfortable period of infection and be discharge with a useless or missing limb. One of the curious things about the Civil War was the small number of men injured by other than small arms. A table of all reported wounds, classified according to cause, shows 94 per cent to have been bullet wound, 5.5 per cent to have been cause by artillery fire, torpedoes and grenades, and less than .4 per cent inflicted by saber or bayonet. In contrast, more than three-fourths of all gunshot wounds in the first World War were caused by shell fire.
Bullets, then, were the overwhelming cause of Civil War battle wounds, accounting for approximately a quarter of a million patients, of whom 14 per cent died. Of the 144,000 cases where the type of missile could be ascertained the Minié ball cased 108,000 wound, the old-fashioned round ball 16,000 wounds, and shell fragments 12,500. Cannon balls were responsible for only 359 cases, and explosive bullets for 130.
The muskets balls of the Civil War made far worse wounds than modern steel-jacketed cartridges. The old led bullet, traveling at a low velocity, readily lost shape on impact, frequently lodged in the tissues, often carried with it particles of clothing and skin, and almost invariably left an infected wound. The round ball was slightly less dangerous than the conoidal one, as it might sometimes glance off a bone, instead of shattering two or three inches of it; but each ball made a large wound, which, if the bullet spread, presented a violently lacerated appearance and a track enlarged out of all proportion tot he caliber of the projectile. The modern bullet, in contrast, travels at such high velocity that it is sterilized by heat, and being steel-jacketed does not change its shape, but drills a neat, aseptic hole through tissue and bone alike, usually passing completely out of the body. If the soldier is not killed at once, he will suffer less pain than his Civil War prototype, will bleed less, and his wound will be less likely to become infected.
Considering the difficulties of chest and abdominal operations in the pre-antiseptic era, the soldier may be considered lucky in having received 71 per cent of their wounds on arms, legs, hands or feet, and only 18 per cent on the torso…Injuries of the head, face, and neck represented 10.77 per cent of all gunshot wounds; on the torso, chest wounds were almost three times as frequent as abdominal wounds.
With rare exceptions the medical officers in charge of the aid or dressing stations, i.e. the assistant surgeon, confined their surgical activities to the checking of hemorrhage and simple bandaging. Tourniquets were twisted on the limbs of bleeding men; in rare instances an artery might be tied. Liquor, in the form of whiskey or brandy, was given to counteract shock, as was an opium pill or morphine…Upon arrival at the field hospital the wounded man would find himself one of a large number of men lying on the ground or upon piles of straw and waiting their turn on the operating table. The less seriously wounded would be attended by the "dressing surgeon" and would then be let alone…The operating team of each brigade would ordinarily pass over both the slightly and the mortally wounded….Placing the patient upon an operating table, always a crude affair and sometimes merely a door torn from its hinges, the surgeons would begin what was expected to be a painful examination by the administration of a general anesthetic; but sometimes a simple bullet wound would be probed while the patient was fully conscious, and shrieks and groans would alarm those waiting their turn. Attempts would be made to stanch dangerous hemorrhages, and if the examination showed an operation to be necessary it would be performed immediately…General Carl Schurz described an operation at Gettysburg as follows:
Most of the operating tables were placed in the open where the light was best, some of them partially protected against the rain by tarpaulins or blankets stretched upon poles. There stood the surgeons, their sleeves rolled up to their elbows, their bare arms as well as their linen aprons smeared with blood, their knives not seldom held between their teeth, while they were helping a patient on or off the table or had their hands otherwise occupied…As a wounded man was lifted on the table, often shrieking with pain as the attendants handled him, the surgeon quickly examined the wound and resolved upon cutting off the injured limb. Some ether was administered and the body put in position in a moment. The surgeon snatched his knife from between his teeth…, wiped it rapidly once or twice across his bloodstained apron, and the cutting began. The operation accomplished, the surgeon would look around with a deep sigh, and then – "Next!"
Disease and Its Treatment
In the nineteenth century, disease exacted a heavy toll when large groups of men were gathered closely together under conditions of stress and poor sanitation. In the Civil War, it killed twice as many men as battle. The conflict thus provided millions of cases of various diseases for study, but Union surgeons, like their counterparts everywhere, were still unable to distinguish harmless organisms from those causing disease – the developments that would make this possible were yet to come.
Except for offering supportive care, doctors could do little during the Civil War to help those stricken with diseases other than malaria. Except for improved sanitation, they could do little to prevent diseases other than small pox, but their renewed appreciation for sanitation undoubtedly contributed to a marked drop in the disease rate in the postwar Army as compared with the prewar force. Despite voluminous records, medical officers made no significant progress during the Civil War toward finding ways in which to prevent or cure the diseases that ravaged the Union army.
Conclusions
From the standpoint of the man in uniform, the administrative reforms within the Medical Department were of great importance. In 1861, like all things military in the United States, that department was hopelessly amateurish, riddled with incompetence and thoroughly unprepared. By 1865 it was a large, smooth-functioning organization, spending more money than the Army had spent in the last year of peace, and controlling a system of hospitals more imposing than anything seen down to that time. The field-relief system had evolved from the near-anarchy of regimental hospital and ambulance units to the integrated division and corps hospitals and ambulance trains. The medical supply system had evolved from a single disturbing point and an annual issue, to a network of purveyors' depots throughout the country and a plan under which every unit was kept constantly supplied.
Through the Army, American doctors, for the first time, had the opportunity to organize and control large general hospitals. They had discovered, to their cost, that cleanliness was important, and that surgical infections might be kept from spreading if sanitary precautions were observed. They had found that women nurses could be of use; and the women, or at least the more perceptive among them, had learned that training and discipline are essential to the woman hospital nurse. Both doctors and nurses had learned that attention to the patient's morale is medically sound.
Whether the kind of surgical practice which war gives the already-competent surgeon is valuable, may be argued. But it is impossible to deny that war experience made operating surgeons out of a large number of rural physicians who had in the past referred surgical cases to city specialists. In the spread of operational surgery which the "aseptic" era was soon to usher in, this training with the knife was important.
The effect of the war upon the health of the men who participated was, on the whole, bad. Many a veteran carried with him for years, or for life, the sequelae of his army diseases. The population movements incidental to the war, and the return home of infected soldiery, seem to have had a deleterious effect on civilian health. Fortunately, however, the end result of the war experience was a preparation of both the medical mind and the public mind for the great era of sanitary reform.
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