Home to Southern Comfort

Civil War Medicine               For the Unfortunate Civil War soldier, whether he came from the North or from the South, not only got into the army just when the killing power of weapons was being brought to a brand-new peak of efficiency; he enlisted in the closing years of an era when the science of medicine was woefully, incredibly imperfect, so that he go the worst of it in two ways. When he fought, he was likely to be hurt pretty badly; when he stayed in camp, he lived under conditions that were very likely to make him sick; and in either case he had almost no chance to get the kind of medical treatment which a generation or so later would be routine.        Both the Federal and Confederate governments did their best to provide proper medical care for their soldiers, but even the best was not very good. This was nobody's fault. There simply was no such thing as good medical care in that age -- at least as the modern era understands the expression.        This portion of the "Home of the American Civil War" website attempts to put into perspective some of the medical aspects of the war.

The History of Civil War Medicine

"Caring for the Men"

       WHEN THE WAR BEGAN, the United States Army medical staff consisted of only the surgeon general, thirty surgeons, and eighty-three assistant surgeons. Of these, twenty-four resigned to "go South," and three other assistant surgeons were promptly dropped for "disloyalty." Thus the medical corps began its war service with only eighty seven men. When the war ended in 1865, more than eleven thousand doctors had served or were serving, many of these as acting assistant surgeons, uncommissioned and working under contract, often on a part-time basis. They could wear uniforms if they wished and were usually restricted to general hospitals away from the fighting front.
       The Confederate Army began by taking the several state militias into service, each regiment equipped with a surgeon and an assistant surgeon, appointed by the state governors. The Confederate Medical Department started with the appointment on May 4 of Daniel De Leon, one of three resigned United States surgeons, as acting surgeon general. After a few weeks he was replaced by another acting surgeon general, who on July 1,1861, was succeeded by Samuel Preston Moore. He took the rank of colonel and stayed on duty until the collapse of the Confederacy.
       Dr. Moore, originally a Charlestonian, had served twenty seven years in the United States Army. He has been described as brusque and autocratic, a martinet. He was also very hard working and determined, and he was progressive in his military-medical thinking. Dissatisfied with the quality of many of the surgeons of the state troops, he insisted that to hold a Confederate commission, every medical officer must pass examinations set by one of his examining boards. He disliked filthy camps and hospitals. He believed in "pavilion" hospitals-long, wooden buildings with ample ventilation and sufficient bed space for eighty to one hundred patients. Moore, with the compliance of the Confederate Congress and President Jefferson Davis, began the construction of many such hospitals when field activities demonstrated that the casualties would be high and the war long. Dr. Moore maintained a cooperative relationship with Congress, successive secretaries of war, and President Davis, always subject to the availability of funds from the Confederate Treasury.
        In that era of "heroic dosing" Moore foresaw shortages in drugs, surgical instruments, and hospital supplies. He established laboratories for drug manufacture and took prompt steps to purchase needed supplies from Europe. In the course of time, capture of Union warehouses and hospitals played an increasing role in the Confederate supply. As an additional precaution he procured and distributed widely a book on native herbs and other plants that grew wild in the South and were believed to possess curative qualities. As a result, despite frequent shortages of some drugs, the Confederate record was a good one.
       Meanwhile, in the old Union, Surgeon General Thomas Lawson, an octogenarian, obligingly died only weeks after Fort Sumter. He was replaced by Clement A. Finley, the sexagenarian senior surgeon who had served since 1818 and was thoroughly imbued with Lawson's parsimonious values. Lawson had wanted to keep the Army Medical Department much as it had been throughout his career, which meant that the eighty-seven surviving members of the medical corps had not had the kind of experience that would be needed in a major war. Yet now they were the senior surgeons of a rapidly expanding army.
       Fortunately, immediately after the outbreak of war there was a swarming of humanitarians of both sexes who wanted to be of help to the citizen soldiers. Among the most clamorous was the Women's Central Association for Relief, of New York, all of whose officers were men. Soon there was a strong demand for the creation of a United States sanitary commission, patterned on the British Sanitary Commission, which had been formed to clean up the filth of the Crimean War. The tentative United States commission elected officers; the two most important were the president, Henry W. Bellows, a prominent Unitarian minister, and the executive secretary, Frederick Law Olmsted, superintendent of Central Park. The commission asked for official recognition by the War Department stating that its purpose was to "advise and assist" that department.
       Surgeon General Finley, just beginning his incumbency, had no desire for a sanitary commission, but when that body promised to confine its activities to the volunteer regiments and to leave the regular army alone, he withdrew his objections, Secretary of War Simon Cameron then named a commission of twelve members, of whom three were army doctors.
       The United States Sanitary Commission quickly extended itself to 2,500 communities throughout the North, the Chicago branch being especially proficient. The St. Louis people accomplished great things but insisted on remaining independent under the name of the Western Sanitary Commission. The women of the local branches kept busy making bandages, scraping lint, and sending culinary delicacies to army hospitals. The national organization maintained a traveling outpost with the Army of the Potomac to speed sanitary supplies to the field hospitals of that army. In 1862 and again in 1864 the commission provided and manned hospital ships to evacuate Army of the Potomac sick and wounded to general hospitals as far from the front as New York City.
       Early in the war, and later when it seemed appropriate, the commission persuaded highly respected doctors to write pamphlets on sanitation and hygiene. These were widely circulated among both medical and line officers. Although often erroneous, these pamphlets presented the best thought of that pre-bacteriological era and did some good where surgeons could persuade their colonels to take the advice. In the absence of any medical inspectors, the commission induced a number of esteemed doctors to examine recruit camps and to report on cleanliness and on the professional adequacy of surgeons to hold their commissions.
       Although the Southerners had some local and state relief organizations, they enjoyed nothing similar to the Sanitary Commission in scope or efficiency; yet in the effects of camp disease and unsanitary conditions, the Confederacy and the Union shared common experiences indeed. The two armies had similar experiences as their forces were being trained, usually in an instruction camp as a gathering place for the troops of each state. Medical officers did not know how to requisition drugs and medical supplies. Commissaries did not know how to requisition rations. It has been said that "the Americans are a warlike but unmilitary people," and the first months of the Civil War proved the adage. Too many men, when entering the army after a lifetime of being cared for by mothers and wives, had a tendency to "go native" -to ignore washing themselves or their clothing and, worst of all, to ignore all regulations about camp sanitation, Each company was supposed to have a sink, a trench eight feet deep and two feet wide, onto which six inches of earth were to be put each evening. Some regiments, at first, dug no sinks. In other cases the men, disgusted by the sights and odors around the sinks, went off into open spaces around the edge of the camp. The infestation of flies that followed was inevitable, as were the diseases and bacteria they spread to the men and their rations.
       Soon long lines of soldiers began coming to sick call with complaints of loose bowels accompanied by various kinds and varying degrees of internal discomfort. The medical officer would make a slapdash diagnosis of diarrhea or dysentery an prescribe an astringent. He usually ascribed this sickness to the eating of bad or badly cooked food. Union Army surgeons were to come to use the term "diarrhea-dysentery," lumping all the cases together as one disease. In fact, in many cases it was only a symptom of tuberculosis or malaria, though amoebic and bacillary dysentery-introduced into the South by slaves brought from Africa-was certainly present as well. It caused enormous sickness and many deaths. The Union Army alone blamed the disease for 50,000 deaths, a sum larger than that ascribed to "killed in action." It was even more lethal in the Confederate Army.
       The diets of both armies did not help and were deplorably high in calories and low in vitamins. Fruits and fresh vegetables were notable by their absence, and especially so when the army was in the field. The food part of the ration was fresh or preserved beef, salt pork, navy beans, coffee, and hardtack-large, thick crackers, usually stale and often inhabited by weevils. When troops were not fighting, many created funds to buy fruits and vegetables in the open market. More often they foraged in the countryside, with fresh food a valuable part of the booty. In late 1864, when Major General W. T. Sherman made foraging his official policy on his march from Atlanta to Savannah, his army was never healthier. As the war went on, Confederate soldiers were increasingly asked to subsist on field corn and peas. And the preparation of the food was as bad as the food itself, hasty, undercooked, and almost always fried.
       No wonder, then, that at sick call, shortly after reveille, many men who claimed to be sick were marched by the first sergeant to the regimental hospital, usually a wall tent. There the assistant surgeon examined them, then assigned some to cots in the hospital tent, instructed others to be sick in quarters, and restored a few to light duty or to full duty. The less sick and slightly wounded would be expected to nurse, clean, and feed the patients and to see to the disposal of bedpans and urinals.
       In the event of an engagement, the assistant surgeon and one or more detailed men, laden with lint, bandages, opium pills and morphine, whiskey and brandy, would establish an "advance" or dressing station just beyond musket fire from the battle. Stretcher-bearers went forward to find the wounded and, if the latter could not walk, to carry them to the dressing station. The assistant surgeon gave the wounded man a stout drink of liquor, expecting it to counteract shock, and then perhaps gave him an opium pill or dust or rubbed morphine into the wound. Later in the war the advantages of a syringe to inject morphine became apparent. The assistant surgeon examined the wound, with special attention to staunching or diminishing bleeding. After removing foreign bodies, he packed the wound with lint, bandaged it, and applied a splint if it seemed advisable. The walking wounded then started for the field hospital, officially the regiment hospital tent, although in 1862 and onward there was an increasing tendency to take over a farmhouse, school, or church if such was available. The recumbent went by ambulances, if there were any, for the ride to the field hospital, usually anywhere from three to five miles from enemy artillery and sometimes much farther.
       There, lying on clumps of hay or bare ground, the wounded awaited their turn on the operating table. There was usually little shouting, groaning, or clamor because the wounded were quieted by shock and the combination of liquor and opiate. It was an eerie scene, with a mounting pile of amputated limbs, perhaps five feet high, the surgeon and the assistant surgeon-after a few months both Union and Confederate authorities decided that two assistant surgeons were necessary in a regiment -cutting, sawing, making repairs, and tying ligatures on arteries. The scene was especially awesome at night, with the surgeons working by candlelight on an assignment that might sometimes go on for three or four days with hardly a respite. And there was always the smell of gore.
       The surgeons tried to ignore both the slightly wounded and the mortally wounded in the interest of saving as many lives as possible. This meant special attention to arm and leg wounds. Union statistics showed that 71 percent of all gunshot wounds were in the extremities, probably because of fighting from cover behind trees and breastworks. Wounds of the head, neck, chest, and abdomen were most likely to be mortal, so the amputation cases went first on the operating table. The bullet or piece of shell had to be removed, often with the operator using his fingers for a probe. Between the extensive damage done by the Minnie bullets used to inflict wounds, and the haste and frequent ignorance in treating them, amputation was all too often the "treatment" prescribed.
       Everything about the operation was septic. The surgeon operated in a blood- and often pus-stained coat. He might hold his lancet in his mouth. If he dropped an instrument or sponge, he picked it up, rinsed it in cold water, and continue work. When loose pieces of bone and tissue had been removed, the wound would be packed with moist lint or raw cotton, unsterilized, and bandaged with wet, unsterilized bandages. The bandages were to be kept wet, the patient was to be kept as quiet as possible, and he was to be given small but frequent doses of whiskey and possibly quinine. This was a supportive regime.
       The urgency of operating during the primary period-the first twenty-four hours-was to avoid the irritative period, when infection showed itself. The surgeon seldom had to wait more than three or four days for "laudable pus" to appear. This was believed to be the lining of the wound, being expelled so that clean tissue could replace it and the wound could heal. In the rare cases when no pus appeared, it was called "healing by first intention" and was a complete mystery. Actually the pus was the sign that Staphylococcus aureus had invaded and was destroying tissue.
       As to technique, the amputating surgeons had a choice of the "flap" operation or the "circular," both quite old. The former was quicker but enlarged the wound; the latter, when properly done, opened up a small area to infection. By the end of the war a small majority preferred the flap. The frequency of amputations was much questioned at the time. Yet, considering the condition of the patients, the difficulties of transportation, and the septic condition of the hospitals, amputations probably saved lives rather than limbs.
       Men wounded in the abdomen by gunshot frequently died of peritonitis if they had not already bled to death from serious arterial injuries. Wounds of the head and the neck were frequently mortal. Some surgeons in both armies experimented for a while in sealing chest wounds. They would plug the wound with collodion, relieving the dreadful dyspnea-breathlessness-of the patient, but sealing in such infections as entered with the bullet. These cases were likely to be mortal, but the operator seldom knew because the patient was soon evacuated to a general hospital. As for the frightful-looking sabers and bayonets, they inflicted barely 2 percent of the wounds, most of which usually healed.
       Surgical fevers disheartened the doctors. Four or five days after a wound operation, the patient would be recovering well, producing copious pus. Then suddenly the pus stopped, the wound dried, and the patient ran a terrific fever. Despite drugs, the patient would very likely be dead in three or four days. The diagnosis was blood poisoning. Erysipelas also affected both armies. With a case mortality Of 40 percent, it received serious attention. It was recognized by a characteristic rash, and it was thought by some to be airborne, with the result that both Unionists and Confederates took steps to isolate erysipelas patients in separated tents or wards. The surgeons were in the dark as to how to treat this affliction, but it was noted that if iodine was painted on the edges of a wound, its further extension was stopped.
       Civil War surgeons had not only iodine but carbolic acid as well, and a long list of "disinfectants" such as bichloride of mercury, sodium hypochlorite, and other agents. The trouble was that the wound was allowed to become a raging inferno before disinfectants were tried. However, one of the good features of Civil War surgery was that anesthetics were almost always used in operations or the dressing of painful wounds. It was practically universal in the Union, and despite mythology, anesthetics were very seldom unavailable in the Confederacy. The almost universal favorite was chloroform, probably because ether's explosive quality made it dangerous at a field hospital operating table, where there was always the possibility of enemy gunfire.
       With the coming of the big battles of 1862, both armies more or less simultaneously evolved larger and better field hospitals. First, regimental hospitals clustered together as brigade hospitals with some differentiation of duty for the various medical officers and with the chief surgeon of the brigade in charge. Soon brigade hospitals clustered into division hospitals, and by 1864 in most field armies there were corps hospitals. There the best surgeons would operate; one surgeon would be in charge of records, another of drugs, another of supplies, and yet another would direct and treat the sick and lightly wounded who were the nurses.
       In time for Antietam, the Army of the Potomac, under its medical director Jonathan Letterman, developed the Letterman Ambulance Plan. In this system the ambulances of a division moved together, under a mounted line sergeant, with two stretcher-bearers and one driver per ambulance, to collect the wounded from the field, bring them to the dressing stations, and then take them to the field hospital. It was a vast improvement over the earlier "system," wherein bandsmen in the Union command, and men randomly specified in the Confederacy, were simply appointed to drive the ambulances and carry the litters. Frequently the most unfit soldiers were detailed, which often meant that, not being good fighters, they were little better as medical assistants. Often in the first year of the war they got drunk on medicinal liquor and ignored their wounded comrades in order to hide themselves from enemy fire.
       Such improved organization was copied or approximated in the other field armies despite loud opposition from the Quartermaster Corps, which wanted to keep control of ambulances and drivers, and from some field commanders, of whom Major General Don Carlos Buell of the Army of the Ohio was notable for non-cooperation.
       In general, the Union forces in the West were spared battlefield relief scandals by the fact that major battles were fought on the banks of rivers, whence wounded arid sick could be evacuated by river boats to Mound City, Illinois, St. Louis, and other cities with general hospitals in the safety and secure supply of the North. After the relatively prompt fall of Memphis, that city became the site of several general hospitals. The evacuating boats, however, might I be maintained by individual states or by the United States Sanitary Commission or the Western Sanitary Commission, which led to confusion. The state boats, especially those from Ohio and Indiana, were so persistent in their "raiding" the evacuation hospitals for Buckeyes and Hoosiers that General Grant had to forbid their removing any patients.
       After losing control of their rivers, the Confederates made considerable use of railroads in evacuating men from field hospitals to general hospitals. They had no special hospital cars and felt fortunate when they could use passenger rather than freight cars. They became adept at maintaining dressing and supply stations where wounds could be tended and the patients fed. The Union Army, too, increasingly used railroads for evacuating men north. After the Battle of Chattanooga, a real hospital train was regularly used to move the sick and wounded from Chattanooga to Louisville. Some of the cars were equipped with two tiers of bunks, suspended on hard-rubber tugs. At the ends of such cars would be a room for supplies and food preparation. The locomotive assigned to this train was painted scarlet, and at night a string of three red lanterns burned on the front. Confederate cavalrymen never bothered this train.
       The truth was that the military commanders, both Confederate and Union, hated to see fighting soldiers separated from the army; the fear was they would never return. The South was well aware it was fighting a much larger people. The Union generals were well aware that as the invaders, on the offensive, they needed a majority of the men on the battlefield. They also realized that the deeper they penetrated the South, the greater the number of men needed to garrison important points and to guard ever-longer supply lines. And so there was never an actual separately enlisted and separately trained hospital corps in either army.        When Edwin M. Stanton took over as Lincoln's Secretary of War early in 1862, he realized that Dr. Finley, now a brevet brigadier general, would have to be replaced as surgeon general. Taking the advice of the Sanitary Commission, he appointed William A. Hammond, then a junior assistant surgeon. A Marylander, Hammond had served eleven years as an assistant surgeon before he resigned and became a professor in the University of Maryland Medical School. He was to accomplish many good things and to make many good suggestions during the fourteen months he served as surgeon general. It was obvious to him and to his supporters in the Sanitary Commission that the army needed a group of medical inspectors, chosen for merit and possessing enough rank to give orders to hospital commanders. It was obvious that the makeshift general hospitals-hotels, warehouses, schools, churches-should be rapidly replaced by pavilion hospitals designed for their function. It was obvious that corps and division hospitals should become official and that something like the Letterman Ambulance Plan should be extended throughout the army. It was obvious that the quartermaster should not be able to remove ambulances nor line officers be able to remove experienced attendants from the medical field details.
       Eager to educate his department in the best ideas of the time, General Hammond wrote a full length textbook on military hygiene. He brought about the writing of Joseph J. Woodward's admirable The Hospital Steward's Manual. He gave every encouragement to the many medical societies that had sprung up in the army, ordering that interesting scientific specimens should be forwarded to Washington for inclusion in an Army Medical Museum. He began the collection of what has become the world's largest medical library.
       Finley and Hammond secured Congressional authority to augment the regular Army Medical Department by several hundred men, first called brigade surgeons, later surgeons of volunteers, a group that contained unusually prestigious doctors. They were used chiefly as staff assistants. As for the increase in regimental surgeons and assistant surgeons, the Medical Department was to have little say. Higher authority had found it desirable to increase the army by a persistent raising of new regiments rather than by filling up the depleted ranks of the old ones. This maintained the state governors in their unfortunate practices of selecting and commissioning the surgeons and assistant surgeons. The surgeon general could only attempt to reject unfit professionals by extensive use of reexaminations and "plucking" boards.
       General Hammond felt frustrated. Secretary Stanton leaned heavily on General Henry Halleck for military advice, and this usually supported the ideas of the old regular army medics who were jealous of Hammond, the interloper who had been promoted over their heads from captain to brigadier general. In addition, Hammond won the enmity of a large proportion of the American medical profession through his banning of the two mercurials, calomel and tartar emetic, from the army drug table. He may have been correct in his idea that these drugs were being overused, but this seemingly arrogant action lost him the sympathy of many medical colleagues.
       As a result, Hammond was effectively replaced by Joseph K. Barnes, of the surgeon general's office, in September 1863 - It was almost a year before a court-martial of docile surgeons, although finding him "not guilty" on other counts, did vote Hammond guilty of, "conduct unbecoming an officer and a gentleman." He had to leave the army.
       Even where successful, Hammond was only partially so. After the medical inspector bill passed, Secretary Stanton decreed that half the inspectors were to be "political" appointees. When the ambulance corps bill of 1864 became law, what was essentially the Letterman Ambulance Plan was extended to all the armies. The Army Medical Department was to have the privilege of choosing the enlisted men to be put on ambulance and stretcher-bearer detail, and they could not be withdrawn, but there was still no ambulance corps per se.
       Confederate Medical Department organization was very much what Surgeon General Moore thought it should be. Congress gave him a considerable body of medical inspectors and hospital inspectors, the former operating within the field armies and the latter in the general hospitals of each state, with the medical director of each state responsible for its hospitals. There was some debate with the quartermaster general about ambulances, but this was generally over the lack of them. Farm wagons most often constituted the ambulances of the Confederacy. Although Moore had much the same "arrogant" personality traits as did Hammond, he usually obtained prompt obedience to orders rather than conflict.
       Both armies experimented with "special" hospitals, with admission limited to patients with the same disorders. The Confederates established several venereal hospitals and some ophthalmic hospitals. The Unionists began a venereal hospital at Nashville and the famed neurological hospital, Turner's Lane, at Philadelphia, where W. W. Keen is believed by some to have founded neurology in America.
       In contrast, a "general" hospital did not limit its admissions. The sick and the wounded were evacuated to general hospitals so that empty beds could be made available in field installations when a new rush of wounded was expected. Buildings adapted for use as general hospitals were usually considered unsatisfactory because of the inadequate plumbing, the bad ventilation, and the "crowd poisoning" and "mephfluvia" which that generation thought bred and spread disease. Moore and Hammond believed a large building program of pavilion hospitals in 1862 was the answer. To the best of their abilities both sides carried this out, and followed it by still bigger construction programs in 1863 and 1864. The Union pavilions were longer than their Confederate counterparts. Some were as long as 120 feet, with a width of 14 or 15 feet, with a longitudinal ventilator along the 12- to 14-foot roof. This, along with floor ventilation, made the patients too cold and was later closed by wooden slats.
       At the inner end, each pavilion, North and South, had toilets, sometimes flush and sometimes, seats over a sloping zinc trough in which water was supposed to run continuously. Reports show that often the water supply was insufficient and that toilets were flushed only after many usings.
       Frequently the pavilions were built as though they were spokes spreading from a hub. The buildings at the hub were operating rooms, kitchens, offices, pharmacies and supplies, "dead house," ice house, and other services. The grounds were usually joined by a wooden roadway on which food could be hauled or the wash taken up and delivered by a steam-powered vehicle.
       The staff, aside from the medical officers and hospital stewards, was mostly made up of the convalescents. They were frequently weak and weary, often snappish and irritable. They did not like the dirty work they performed. They wanted to go home. The surgeon-in-charge, as the hospital commander was titled, was often in a dilemma. If he returned the patient to his regiment too soon, the man might relapse or die on the road to his unit. If he tried to hold on to the man too long, he might be forcibly returned to his regiment; and if he prevailed upon an inspector to give a medical discharge, he would be losing an attendant who had learned something about his work, and would be forced to rely on a new man who knew nothing. Union and Confederate surgeons-in-charge faced the same problem, although occasionally in Southern hospitals there were hired blacks of both sexes. These people were considered only marginally successful. Some attempts in the North to use cheap male labor as hospital attendants proved unsatisfactory, the men being undisciplined, a "saucy lot" who even stole from the patients.
       The brilliant results of Florence Nightingale in cleaning up the Crimean hospitals had been widely noted, with the result that early on it was decided that a corps of female nurses should be added to the army, with Dorothea Dix their superintendent. Miss Dix was widely known as a reformer of jails and as the "founder" of several state mental hospitals. Devoted and hard working, she was disorganized, unyielding in controversy, and deeply in the grip of Victorian ideals of propriety. Allowed to choose the nurses and to set the rules, she announced that her appointees must be at least thirty and plain in appearance, and must always dress in plain, drab dresses and never wear bright-colored ribbons. They could not associate with either surgeons or patients socially, and they must always insist upon their rights as the senior attendants in the wards.
       It was not long before outraged surgeons virtually went to war with Miss Dix's nurses, frustrating them, insulting them, trying to drive them from the hospitals. These were strong-minded middle-class American women, accustomed to ruling within the home and to receiving the respectful attention of their husbands and male acquaintances. For the most part they had no nursing training. The surgeons complained that they often substituted their own nostrums for the drugs prescribed and that they sometimes were loud and interfering when attempting to prevent amputations.
       As time passed, younger and less self-righteous nurses began to appear in the army, furnished by the Western Sanitary Commission or some other relief agency. Some surgeons learned to suppress their male-chauvinist behavior. In September 1863, the War Department approved a new nurse policy that, although ostensibly a victory for Miss Dix, really defeated her. Under this edict, hospital commanders could send away Dix-appointed nurses but were forced to accept Dix-appointed replacements unless the surgeon general authorized the appointment of someone the surgeon-in-charge preferred. The surgeon general was always willing.
       In fact, the female nurses were much liked by the patients and were not so much nurses as mother-substitutes. They wrote letters for their "boys," read to them, decorated the wards with handsome garlands, and sometimes sang. Both armies used small contingents of Catholic nuns in certain general hospitals. They came from the Sisters of Charity, the Sisters of St. Joseph, the Sisters of Mercy, and the Sisters of the Holy Cross. Having been teachers, some lacked previous hospital experience, but surgeons liked them because they had been bred to discipline. The patients liked them too, but called them all Sisters of Charity.
       Hospital food improved perceptively when women matrons took over the supervision of kitchens. These women came from various sources, many supplied by the United States Christian Commission, a large organization that donated delicacies to hospitals but considered the saving of souls, by passing out religious tracts, its principal mission.
       Because of the great fame of Clara Barton, and some women like her, an impression prevailed that women functioned in hospitals in the field. This was seldom the case. Miss Barton might best be described as a one-woman relief agency. However, the strong-minded but winning "Mother" Mary Ann Bickerdyke became so popular that in 1864 General W. T. Sherman officially appointed her to his own corps hospital.
       Women could be found serving in various ways in Confederate hospitals, too, but the bulk of them were hired black cooks and washerwomen. In the conservative South there was a widespread feeling that a military hospital was no place for a lady, Only in Richmond were there significant numbers of women working in the city's many hospitals.
       Richmond was indeed the hospital center of the Confederacy, with twenty hospitals in 1864 after many of the makeshift type had been closed and replaced by pavilion structures. The queen of them was Chimborazo, which had beds for 8,000 men and was often called the largest hospital on the continent. It was organized into four divisions, each with thirty pavilions. There were also five soup houses, five ice houses, "Russian" baths, a 10,000-loaf per day bakery, and a 400-keg brewery. On an adjacent farm the hospital grew food and grazed three hundred cows and several hundred goats. Almost as amazing was Jackson Hospital, which could care for 6,000 patients in similar ways. Elsewhere than Richmond, general hospitals were neither so large nor so grand, but there were many of which the Confederates were proud. By late 1864 there was a total of 154 hospitals, most located close to the southern Atlantic coast. They began to close down, often because of enemy action, early in 1865.
       Washington and its environs was the natural hospital center of the Union Army because of its proximity to major battlefields. This proved unfortunate because the city had always been considered a sickly place, chiefly because of the large open canal that stretched across town and into which much sewage was dumped. Also, the metropolitan community had many standing pools in which anopheles mosquitoes bred. The intestinal disease and malarial rate of the hospitals were a natural result.
       At the end of 1861 Washington had only 2,000 general hospital beds. The great slaughters of the Peninsular campaign, with the Second Battle of Bull Run immediately after, followed shortly by Antietam, flooded the hospitals of the Washington area and Baltimore and Philadelphia as well. Adaptation went so far as converting the halls of the Pension Office, with cots among the exhibitions, the Georgetown jail, and the House and Senate in the Capitol. From August 31 to the end of 1862, 56,050 cases were treated in Washington. Many of these adaptations were closed in 1863, replaced by modern pavilion hospitals. At the end of 1864 the city contained sixteen hospitals, many of them large and fine. There were seven at nearby Alexandria and one each at Georgetown and Point Lookout, Maryland. Outstanding was Harewood, said to resemble an English nobleman's estate, with professionally landscaped grounds, flower gardens, and a large vegetable garden. Its building consisted of fifteen large pavilions with appropriate service buildings and some tents.
       The Western showpiece was Jefferson Hospital at Jeffersonville, Indiana, just across the river from Louisville. Built in the winter of 1863-64 with 2,000 beds, later increased to 2,600, at war's end it had plans for 5,000 beds. Its most interesting architectural feature was a circular corridor 2,000 feet long from which projected twenty-four pavilions, each 175 feet long.
       By the last year of the war there were 204 Union general hospitals with beds for 136,894 patients. This proved to be the maximum. In February 1865 the United States began closing down its hospitals.
       The many men and women, North and South, who served in the hospital and sanitary services during the war were justly proud of their achievements. The morbidity and mortality rates of both armies showed marked improvement over those of other nineteenth-century wars, particularly America's last conflict, the war with Mexico. In that war go percent of the deaths were from nonbattle causes. In contrast, in the Civil War some 600,000 soldiers died, but in the Union Army 30.5 percent of them died in or from battle, and in the Confederate Army the percentage ran to 36-4. Clearly, the physicians and sanitarians had held down the disease mortalities to levels that their generation considered more than reasonable. Better, they made some few halting strides in treatment and medication, and considerable leaps in the organization of dealing with masses of wounded and ailing soldiers. It was a ghastly business for doctors and patients alike; yet without the medicos in blue and gray, much of the young manhood of America at mid century might not have survived for the work of rebuilding.

Source: The National Historical Society's The Image of War: 1861-1865 Volume IV "Fighting For Time" article by George W. Adams

Medical Care, Battle Wounds and Disease

       The Civil War was fought, claimed the Union army surgeon general, "at the end of the medical Middle Ages." Little was known about what caused disease, how to stop it from spreading, or how to cure it. Surgical techniques ranged from the barbaric to the barely competent.
       A Civil War soldier's chances of not surviving the war was about one in four. These fallen men were cared for by a woefully underqualifled, understaffed, and undersupplied medical corps. Working against incredible odds, however, the medical corps increased in size, improved its techniques, and gained a greater understanding of medicine and disease every year the war was fought.
       During the period just before the Civil War, a physician received minimal training. Nearly all the older doctors served as apprentices in lieu of formal education. Even those who had attended one of the few medical schools were poorly trained. In Europe, four-year medical schools were common, laboratory training was widespread, and a greater understanding of disease and infection existed. The average medical student in the United States, on the other hand, trained for two years or less, received practically no clinical experience, and was given virtually no laboratory instruction. Harvard University, for instance, did not own a single stethoscope or microscope until after the war.
       When the war began, the Federal army had a total of about 98 medical officers, the Confederacy just 24. By 1865, some 13,000 Union doctors had served in the field and in the hospitals; in the Confederacy, about 4,000 medical officers and an unknown number of volunteers treated war casualties. in both the North and South, these men were assisted by thousands of women who donated their time and energy to help the wounded. It is estimated that more than 4,000 women served as nurses in Union hospitals; Confederate women contributed much to the effort as well.
       Although Civil War doctors were commonly referred to as "butchers" by their patients and the press, they managed to treat more than 10 million cases of injury and illness in just 48 months and most did it with as much compassion and competency as possible. Poet Walt Whitman, who served as a volunteer in Union army hospitals, had great respect for the hardworking physicians, claiming that "All but a few are excellent men...
       Approximately 620,000 men-360,000 Northerners and 260,000 Southerners-died in the four-year conflict, a figure that tops the total fatalities of all other wars in which America has fought. Of these numbers, approximately 110,000 Union and 94,000 Confederate men died of wounds received in battle. Every effort was made to treat wounded men within 48 hours; most primary care was administered at field hospitals located far behind the front lines. Those who survived were then transported by unreliable and overcrowded ambulances-two-wheeled carts or four-wheeled wagons-to army hospitals located in nearby cities and towns.
       The most common Civil War small arms ammunition was the dreadful minnie ball, which tore an enormous wound on impact: it was so heavy that an abdominal or head wound was almost always fatal, and a hit to an extremity usually shattered any bone encountered. In addition, bullets carried dirt and germs into the wound that often caused infection.
       Of the approximately 175,000 wounds to the extremities received among Federal troops, about 30,000 led to amputation; roughly the same proportion occurred in the Confederacy. One witness described a common surgeon's tent this way: "Tables about breast high had been erected upon which the screaming victims were having legs and arms cut off. The surgeons and their assistants, stripped to the waist and bespattered with blood, stood around, some holding the poor fellows while others, armed with long, bloody knives and saws, cut and sawed away with frightful rapidity, throwing the mangled limbs on a pile nearby as soon as removed."
       Contrary to popular myth, most amputees did not experience the surgery without anesthetic. Ample doses of chloroform were administered beforehand; the screams heard were usually from soldiers just informed that they would lose a limb or who were witness to the plight of other soldiers under the knife.
       Those who survived their wounds and surgeries still had another hurdle, however: the high risk of infection. While most surgeons were aware of a relationship between cleanliness and low infection rates, they did not know how to sterilize their equipment. Due to a frequent shortage of water, surgeons often went days without washing their hands or instruments, thereby passing germs from one patient to another as he treated them. The resulting vicious infections, commonly known as "surgical fevers," are believed to have been caused largely by Staphylococcus aureus and Streptococcus pyogenes, bacterial cells which generate pus, destroy tissue, and release deadly toxins into the bloodstream. Gangrene, the rotting away of flesh caused by the obstruction of blood flow, was also common after surgery. Despite these fearful odds, nearly 75 percent of the amputees survived.
       While the average soldier believed the bullet was his most nefarious foe, disease was the biggest killer of the war. Of the Federal dead, roughly three out of five died of disease, and of the Confederate, perhaps two out of three. One of the reasons for the high rates of disease was the slipshod recruiting process that allowed under- or over-age men and those in noticeably poor health to join the armies on both sides, especially in the first year of the war. In fact, by late 1862, some 200,000 recruits originally accepted for service were judged physically unfit and discharged, either because they had fallen ill or because a routine examination revealed their frail condition.
       About half of the deaths from disease during the Civil War were caused by intestinal disorders, mainly typhoid fever, diarrhea, and dysentery. The remainder died from pneumonia and tuberculosis. Camps populated by young soldiers who had never before been exposed to a large variety of common contagious diseases were plagued by outbreaks of measles, chickenpox, mumps, and whooping cough.
       The culprit in most cases of wartime illness, however, was the shocking filth of the army camp itself. An inspector in late 1861 found most Federal camps 'littered with refuse, food, and other rubbish, sometimes in an offensive state of decomposition; slops deposited in pits within the camp limits or thrown out of broadcast; heaps of manure and offal close to the camp." As a result, bacteria and viruses spread through the camp like wildfire. Bowel disorders constituted the soldiers' most common complaint. The Union army reported that more than 995 out of every 1,000 men eventually contracted chronic diarrhea or dysentery during the war; the Confederates fared no better.
       Typhoid fever was even more devastating. Perhaps one-quarter of noncombat deaths in the Confederacy resulted from this disease, caused by the consumption of food or water contaminated by salmonella bacteria. Epidemics of malaria spread through camps located next to stagnant swamps teeming with anopheles mosquito. Although treatment with quinine reduced fatalities, malaria nevertheless struck approximately one quarter of all servicemen; the Union army alone reported one million cases of it during the course of the war. Poor diet and exposure to the elements only added to the burden. A simple cold often developed into pneumonia, which was the third leading killer disease of the war, after typhoid and dysentery.
       Throughout the war, both the South and the North struggled to improve the level of medical care given to their men. In many ways, their efforts assisted in the birth of modern medicine in the United States. More complete records on medical and surgical activities were kept during the war than ever before, doctors became more adept at surgery and at the use of anesthesia, and perhaps most importantly, a greater understanding of the relationship between cleanliness, diet, and disease was gained not only by the medical establishment but by the public at large. Another important advance took place in the field of nursing, where respect for the role of women in medicine rose considerably among both doctors and patients.

Source: The Civil War Society's "Encyclopedia of the Civil War"

 

THE CIVIL WAR ARMY SURGEON AND HIS WORK

       HOWEVER brilliant the tactics and strategy, it should be remembered that an essential factor in all warfare must be the physical efficiency of the man behind the gun. Despite this fact, historians give but slight attention to the medical men whose ability and self-sacrifice largely make possible the military reputation of others. Although the surgeons are regarded as non-combatants, their efficiency must always have a powerful influence upon military tactics. The Nation selects its popular heroes wholly for service on the battlefield. But it should not be forgotten that it is only through the unwearying and unobtrusive efforts of the surgeons that men and armies are kept in fighting trim and physically able to execute the will of the commanders. In any critical inquiry into battles and campaigns, the careful student will not overlook the fact that the conflict under consideration might not have occurred at all, nor in the place where it actually did occur, nor might the military tactics have been the same, had not one or the other force been weakened by preventable diseases or rendered more or less immobile by the crippling incubus of the wounded, for whose removal and care no adequate provision had been made before the conflict occurred.
       At the outbreak of the war, the national army was inadequate to meet military needs, especially those relating to the critical Indian situations west of the Mississippi, which had been developed in large part by the influx of gold-seekers and colonizers into that territory. It is not to be wondered at, then, that the war should have found the military establishment of the United States deficient as regards its medical organization and equipment.
       At the opening of hostilities between the States the personnel of the Medical Department of the regular army was composed of one surgeon-general with the rank of colonel, thirty surgeons with the rank of major, and eighty-four assistant surgeons with the rank of first lieutenant for the first five vears of service, and thereafter with the rank of captain, until promoted to the grade of major. There was no hospital corps, but the necessary nursing and other hospital assistance were performed by soldiers temporarily detailed to hospital duty from organizations of the line of the army, and here it may be parenthetically remarked that the qualifications and character of the soldiers so detailed were usually far from satisfactory.
       The Medical Department, with the above personnel, formed one of the coordinate branches of the general staff of the army as it existed in 1861. Its members were not permanently attached to any regiment or command, but their services were utilized whenever required. Although a separate regimental medical service still existed in many foreign armies, as it did in our militia, experience had demonstrated that our national system of a separate department was better adapted to the needs of troops when scattered over an immense area, and usually serving in small and isolated commands. The latter requirements explained the unusually large proportion of surgeons necessary at the time, amounting to about one per cent. of the total strength.
      This little force of one hundred and fifteen trained medical officers theoretically available at the beginning of the war was, however, materially depleted. Many of its members were of Southern birth and sympathy, and no less than twenty-seven resigned from the army at the outbreak of hostilities. Three who so resigned entered into the practice of their profession, declining to assist either against their Southern kindred or their friends in the Northern States and former military associates remaining under the old flag. But the remaining twenty-four merely transferred their services to the military forces of the Confederacy, where they were promptly given the positions of responsibility and power which their previous experience and training warranted. These men formed the nucleus about which the Medical Department of the Confederacy was created, building it up along the administrative lines to which they were accustomed, and even adopting the same blank forms and reports, as, for example, that for the sick and wounded, which they had formerly used in the Federal service. ]In many particulars the organization was identical.
       Among these men was Doctor Samuel P. Moore, who had completed a quarter of a century of service as a medical officer of the regular army when he resigned his commission as a major and surgeon, to ally himself with his native State of South Carolina. Shortly after his resignation he accepted the position of surgeon-general of the Confederate forces, which he held during the entire duration of the war. Among his former medical associates in the regular army who became his trusted assistants in the Medical Department of the Confederacy, were such able men as Surgeons De Leon, Madison, Haden, Johns, Langworthy, Potts, Fauntleroy, Ramseur, and others, without whose extensive knowledge, training, and experience in things military, the Confederate medical service might very likely have achieved less high efficiency.
       But the army Medical Department, always a corps d'elite, still contained able men after the resignation of Surgeon Moore and his Southern associates. A mere handful in number, it made up in quality what it lacked in quantity, and furnished the germ from which developed the vast medical service which came to be required. It included many men whose natural administrative and military abilities, in many cases developed by the experiences of the war with Mexico, if employed in other than the direction of non-combatants, would probably have made them national figures in the military history of the United States.
       Some of the names on this medical roll of honor from the regular army are those of Finley, Hammond, Barnes, Crane, Murray, Moore, Sutherland, Baxter, Sternberg, and Forwood, all of them surgeons-general during or after the war. Others were Letterman, Smart, Woodward, Huntington, Otis, Woodhull, Smith, Greenleaf, and others whose great services might be mentioned. Many of these men became figures of national importance in a medical and surgical sense. Some in their time were recognized as the highest authorities the A,orld over in respect to the professional subjects with which they had been particularly identified.
       Contrary to the usual idea of the general public, army medical officers have many important duties outside the actual professional treatment of sick and wounded. Far-reaching health measures, under the direction of the commander, are in their hands. Vast hospitals must be organized, equipped, supplied, and administered, to which sick and wounded by the hundreds of thousands must be transported and distributed. This latter problem can advantageously be met only in the light of broad knowledge of military organization, methods, and purposes. There are subordinates to be enlisted, equipped, cared for, trained, and disciplined. An elaborate system of records, upon the accuracy of which the whole pension system of the Government rests, must be maintained. And upon the handful of trained regular medical officers the responsibility for efficient direction of the above-mentioned business management of the Medical Department had, at the outset of the Civil War, to devolve. From it, as a nucleus, there developed a scheme of organization of the medical service for war which remains the prototype upon which similar organization in all the armies of the world is now based, while administrative methods were worked out which still remain our standard for the management of similar conditions and emergencies.
       To the support of this little group, insignificant except in ability, the outbreak of the war promptly brought a vast number of the better type of medical men of the Northern States. Some of these physicians and surgeons had already achieved great fame and success in the practice of their profession, and their enrolment for the assistance of their country gave powerful incentive to similar action on the part of others of equal or less prominence. The younger medical men, lately graduated, flocked to the colors almost en masse, not only from motives of patriotism, but also because the practical training to be gained in the vast military hospitals was far more comprehensive and valuable than could be gained in any similar civil institution or walk of life. When, at the conclusion of the war, they undertook the practice of their profession in civil life. they found that their military experience placed them at once among the foremost of the local physicians and surgeons.
       To give even brief mention of the self-sacrifice and achievements of the ten thousand medical men who, thus to aid their country, gave up the relative ease and the greater financial rewards of practice in civil life for the dangers and hardships of war, would require volumes. But it would be unfair not to recall the names of a few, whose services may have been of no whit greater value than those of others, who, for lack of space, must remain unmentioned, but whose professional standing during and after the war was such as to render them worthy of selection as representatives of the great volunteer medico-military class to which they belonged. Among such may be mentioned the names of Doctors Agnew, Ashhurst, Bacon, Bartholow, Bowditch, Bryant, Buck, Da Costa, Goulev, Gross, Hamilton, Hodgen, Pancoast, Sbrady, Tyson, and Weir.
       Under the agreement of the Geneva Convention, medical officers are now officially neutralized. This status cannot free them from the dangers of battle, in which they, of course, must share, but operates to exempt them from retention as prisoners of war. Such was not the case in the first year of the Civil War, when surgeons were captured and immured in military prisons like combatant officers. Medical officers were thus often forced to nial@e the hard choice of deserting the wounded under their care, often including patients from both sides who were urgently requiring attention, or of remaining and submitting to capture, with all the rigors and sufferings that this implied.
       But General Jackson, after the battle of Winchester, in May, 1862, where he had captured the Federal division hospitals, took the ground that as the surgeons did not make war they should not suffer its penalties, and returned them unconditionally to their own forces. The neutral status of the surgeons, thus recognized f or the first time, was subsequently formally agreed upon between Generals McClellan and Lee, though later the agreement was for a time interrupted. The idea that those engaged in mitigating the horrors of war should not be treated like those who create them, met with instant popular approval in both North and South, was subsequently advanced in Europe, and the humanitarian idea developed in this country was advocated until officially taken up by the great nations and agreed upon by them under the Geneva Convention.
       In connection with the foregoing, the record of the casualties among the regular and volunteer Federal medical officers during the Civil War is of interest. Thirty-two were killed in battle or by guerillas; nine died by accident; eighty-three were wounded in action, of whom ten died; four died in Confederate prisons; seven died of yellow fever, three of cholera, and two hundred and seventy-one of other diseases, most of which were incidental to camp life or the result of exposure in the field.
       The medical and surgical supplies for the Federal hospital establishments not accompanying troops were practically unlimited as to variety and amount. But with the material taken into the field with troops, considerations of transportation were paramount. Generally speaking, ammunition was forwarded first, rations second, and medical supplies third. Owing to the tremendous number of men engaged, it was early demonstrated that road spaces occupied by marching troops had to be studied so that organizations could be moved and deployed as rapidly as possible. Nothing except the barest necessities could be brought to the front where large armies were contending. In spite of every effort, transportation always tended to increase. For example, when Grant entered upon his Wilderness campaign, it is said that his trains contained between five thousand and six thousand wagons, which, on a single road, would have made a column over fifty miles long. The first tendency of new troops is to overload, and to this neither the Civil War as a whole nor its medical service in particular proved exceptions. All finally came to realize that the nature and degree of sanitary relief which could be provided for troops at the front must partake of a compromise between what might be desirable and what was possible.
       At the beginning of the war, each regimental surgeon was furnished with a suitable equipment for his regiment for field service, in quantities regulated by the supply table. This table, which was revised about a year later, seemed to contemplate the medical and surgical outfitting of regiments on the basis of independent service, and when they became brigaded much of the equipment so supplied was found to be not only unduly heavy and cumbrous but also unnecessary.
       The medical and surgical material available on the firing line was practically that carried by the surgeon in his case, known as the " surgeon's field companion,"and by his orderlv in the "hospital knapsack," a bulky, cumbersome affair weighing, when filled, about twenty pounds.
       Wounds were expected-nay, encouraged-to suppurate, and that they could heal without inflammation was undreamed of by the keenest surgical imagination. Their repair was always expected to be a slow, painful, and exhausting process. Nothing in the nature of antiseptics was provided. The cleanliness of wounds, except in respect to the gross forms of foreign matter, was regarded as of little or no importance. Even the dressings carried into action were few and scanty; where the soldier of the present carries on his person an admirable sterile dressing for wounds as part of his military equipment, in the Civil War the injured man covered his wounds as best be might with a dirty handkerchief or piece of cloth torn from a sweaty shirt. Elastic bandages for controlling hemorrhage were unknown, the surgeon relying, except in the case of larger vessels, on packing the wound with astringent, coagulant, and generally harmful chemicals. Medicines were carried in pill form, often largely insoluble and uncertain in result, or else in liquid form, difficult to carry and liable to loss. Soluble tablets were unknown. Crude drugs, like opium, were carried in lieu of their concentrated active principles, like morphine, now almost exclusively employed. Not a single heart stimulant of those regarded as most effective by modern medical science bad place in the surgeon's armament carried in the field. A little chloroform was carried, but the production of surgical anesthesia was still a relatively new procedure, and several hundred major operations were reported during the war in which no anesthetic was employed.
       In the first part of the war, each regiment had a hospital of its own, but the medicine-chest, mess-chest, and bulky hospital supplies were transported in wagons of the field-train, and hence were usually far in the rear and inaccessible.
       Panniers containing the more necessary dressings medicines, and appliances were devised to be carried along into action by pack-mules, but they were inconvenient and heavy, and were generally brought up in the ambulances after the fighting. Special wagons for medical supplies were then devised.
       Surgical instruments were furnished by the Government to, each medical officer, who receipted for and was responsible for them. They were contained in four cases, one for major operations, one for minor operations, one a pocket-case, and one a field-case to be carried by the surgeon on his person into action. The instruments were well assorted, but they were used indiscriminately and without more than superficial cleansing upon both flesh and festering wounds, with the result that they habitually conveyed infection.
       Under the surgical practice of the time, germs of blood poison, gangrene, and lockjaw were conveyed into the body. Moreover, it was the custom for the surgeons to undertake the most severe operations at the front, often under fire, under conditions in which even a pretense of surgical cleanliness could not have been maintained, even if the knowledge of the time bad been sufficient to cause it to be attempted. What we would now term " meddlesome surgery " was not peculiar to the army but was characteristic of general surgical practice of the time. In fact, toward the end of the war the best surgeons in the country were probably those with the military forces, and the admirable results which they frequently achieved bear evidence, not only of their accurate anatomical knowledge and surgical dexterity but of the amount of injury and infection which the human organism can resist.

Source: "The Photographic History of the Civil War, Volume IV"
Article by Edward L. Musnson, M.D. Major, Medical Department, United States Army