Sunday, November 10, 2013

Civil War Era Medicine

By Thomas Sweeney, retired physician and long-time avocational Civil War historian

The medical establishments within the U.S. Army and the nascent Confederate Army were almost totally unprepared for either the scope or duration of the conflict. The peacetime U.S. Army possessed only 113 physicians to care for more than 16,000 personnel scattered across the country. The Army’s Surgeon General, Dr. Thomas Lawson, was unable to think beyond the needs of small, frontier post hospitals. Fortunately for the Union, the Medical Department entered a new era under a relatively junior physician, Dr. William A. Hammond, on April 25, 1862. The Confederate Medical department had to begin from scratch.
Contrary to popular belief, nineteenth century military medicine was not always crude and ineffective. Lack of preparedness was the foremost problem, and it was responsible for much otherwise unnecessary suffering. The Civil War brought important advances in both organization and technique. While shortages often crippled the Confederacy’s efforts, by the end of the conflict the medical treatment available to Union soldiers was probably the best in the world. It gave sick and injured soldiers a greater opportunity of recovery than in any previous war.
With the outbreak of war civilian doctors entered the ranks of the Northern and Southern forces in large numbers. While some had served only an apprenticeship with an experienced practicing physician, formal medical education was becoming common. Diploma mills existed, but so did an increasing number of respected medical schools, such as the McDowell Medical College in St. Louis. By modern standards the curriculum in even the best schools was surprisingly brief lasting two years, with the second year being merely a repeat of the first. Not surprisingly, the quality of military surgeons differed considerably. Late in 1861 the U.S. Army Medical Department began giving examinations to weed out unqualified physicians. The Confederacy soon took similar and perhaps even more rigorous steps.
Education and peacetime practice did little to prepare physicians to treat the mass casualties of war. The border troubles labeled “Bleeding Kansas” in the Eastern press gave Missouri a reputation for violence, yet prior to the Civil War relatively few physician within the state ever treated a gunshot wound or performed more than minor surgery, much less attempted the amputation of a limb. The same was true elsewhere. Moreover, once in uniform, few military surgeons considered it to be their duty to address the basic requirements to keep the men healthy to fight, such as proper sanitation, food, and shelter. Civilian organizations, often labeled “sanitary commissions,” sprang up to address these needs, but in Missouri the dynamics of the conflict limited these to the Union side. St. Louis became the center of the regional Western Sanitary Commission, as well as the local St. Louis Ladies Union Aid Society and parallel Colored Ladies Union Aid Society.
In Union and Confederate volunteer service, and in the Missouri State Guard, regulations authorized each regiment a surgeon, an assistant surgeon, a hospital steward with the rank of sergeant major, and several enlisted men serving as orderlies. Each morning at “sick call,” the surgeons listened to soldiers’ complaints and provided treatment. The steward was responsible for supplies and medicine chests. Orderlies were jacks-of-all-trades, men who showed an interest and aptitude in nursing and were appointed by the surgeon. During combat the medical team set up a field hospital close to the action. The assistant surgeon usually manned an aid station treating wounded at the edge of the battlefield until they could be removed to the surgeon’s care at the field hospital. Near the end of 1861 the Union army began consolidating regimental hospitals into division and corps hospitals to handle larger bodies of troops more efficiently, but an Ambulance Corp was not formed until well into 1862. Prior to that wounded were brought from the field either by comrades or by musicians from the regiment’s band, if it had one.
Gunshots accounted for 94 percent of the recorded battle wounds. Injuries from artillery projectiles were less common, while bayonet and sword wounds were quite rare. The most common wounds were to the extremities, with almost equal involvement of the arms and legs. In combat involving muzzle-loading weapons, limbs often remained vulnerable even when a soldier fired from a protected position. Non-extremity wounds almost always resulted in death on the battlefield. Penetrating gunshots to the abdomen or head were about 90 percent fatal, those to the chest about 60 percent.
Contrary to myth, Civil War doctors did not perform excessive numbers of amputations because they were ignorant of, or unwilling to consider, alternatives. Doctors usually performed amputations in cases involving the penetration of a joint, a compound fracture, substantial tissue or bone destruction, or evidence of infection (gangrene). They had to consider the fact that survival rates were much greater when amputations were performed within the first twenty-four hours of injury. This was called primary amputation. Secondary amputations were performed after the 24 hour period and resulted in higher mortality and morbidity caused by bacteria having more time to enter the open wound. Surgeons were aware that the presence of foreign material such as wadding, clothing fragments, or dirt in wounds increased the likelihood complications. Tragically, it was not until just after the war ended that European physician Joseph Lister, using the work of Louis Pasteur, demonstrated the role that bacteria played in wound infection, too late to save the lives of tens of thousands of men in uniform.
One of the war’s most important advances was the popularization of anesthesia. Military surgeons employed ether and chloroform, which had first come into use at the time of the Mexican War, 1846-1848. Both drugs had drawbacks. Highly flammable ether, which took sixteen minutes to take effect, posed a danger when operations were performed by candle or lantern light. Chloroform was nonflammable and worked in about nine minutes, but improper application could result in death. During those nine minutes the patient passed through an excitable stage and might need to be restrained. The process was poorly understood by laymen observers and led to the myth that many operations were preformed without any anesthetic at all, which was rarely the case. Recovering patients received either morphine or opium, which were effective painkillers but addictive.
Although more than a thousand military engagements occurred in Missouri, disease killed over twice as many men as bullets. Infections spread rapidly in overcrowded camps. Measles, mumps, rubella, and chicken pox ran rampant, particularly among newly-enlisted soldiers from rural areas who lacked immunities from prior exposure. But even more fatalities resulted from dysentery and diarrhea contracted due to unsanitary conditions. The Western Sanitary Commission worked tirelessly throughout the war to improve conditions in camps, hospitals, and prisons. Science largely ignorant of the cause of diseases and most medications were ineffective. Malaria was the only major disease combated successfully, being treated with quinine, a drug made from the bark of the Peruvian Cinchona tree.
Because of its rail and river connections St. Louis became the most important center for military medicine west of the Appalachian Mountains. Only Washington, D.C., and Richmond, Virginia, played a greater role during the war. The process was driven by necessity. At the beginning of the war there were only two military hospitals in Missouri, one at the St. Louis Arsenal and the other at Jefferson Barracks, south of the city along the Mississippi River. These and the city’s civilian hospitals were overwhelmed by the casualties from early war battles, but before the conflict ended the city was home to fifteen military hospitals and a fleet of hospital boats serving the war effort in the Mississippi River valley.
The campaigning and fighting in the Ozarks, with its poor roads, rugged hills, and lack of adequate water and rail connections, posed particular medical challenges. Early in the war almost all sick and wounded were treated locally, often with the help of the civilian population. The impact on communities could be devastating, as the case of Springfield demonstrates. When Union forces under Nathaniel Lyon occupied the city in July 1861, they set up military hospitals in tents and buildings to accommodate their routine sick personnel. When Lyon was defeated at the nearby battle of Wilson’s Creek on August 10, 1861, the victorious Southerners occupied Springfield and shifted hundreds of casualties (Union as well as their own) to the town, taking over public spaces, churches, and private homes. Men and women came from miles around to help. O. A. Williams, a surgeon for the Missouri State Guard, wrote to John Willsen about the conditions in Springfield shortly after the Battle of Wilson’s Creek.
Headquarters, General Hospital, Missouri State Guard, Springfield, Missouri
Dear John -
I suppose ere this you have had correct information in regard to the fight so I will say nothing about it. I am not in good health – nor in very good spirits. I can see no end to this infernal war… Springfield presents rather a gloomy appearance, every house nearly has been converted into a Hospital. The wounded are generally well. There has been a great many amputations. I have taken off a good many legs and arms – until I am sick and tired… We get nothing to drink (and) little to eat… Give my love to Mary… (and) respects to… friends and tell my enemies to go to hell…
Yours fraternally,
O.A. Williams, Assistant Surgeon 
Witnesses reported that the streets literally stank from the odor of wounded and dying soldiers. Weeks passed before the situation was under control. The Federal wounded that remained were eventually moved to St. Louis by rail road from Rolla. By this time smaller hospitals had been opened at intervals along the rail line in Missouri from Sedalia and Rolla to St. Louis to take care of the less severely wounded and avoid overcrowding of St. Louis Hospitals. The damage to Springfield civilian property was great; the emotional and psychological impact on families whose homes became treatment facilities is impossible to calculate. Springfield changed hands six times during the course of the conflict and was for much of the war a major Union supply depot and hospital center. By mid-war half of the homes were destroyed and more than half of the population was refugees.
The much larger Battle of Pea Ridge, fought on March 7-8, 1862, only a short distance into Arkansas from the Missouri border, was an even greater disaster. Union medical preparations were minimal, while the attacking Confederates made almost none. Although the Union forces were victorious, it proved impracticable to shift the severely wounded from the battlefield to the expanding facilities in St. Louis. There were no navigable rivers nearby, and the closest rail line to St. Louis began at Rolla, 240 miles from the battlefield. The roads to Springfield, the next best option, were severely rutted and without bridges, while guerrillas roamed the surrounding countryside. As a consequence, the closer small communities Cassville and Keitsville, Missouri, were virtually transformed into hospitals. When the news of the battle reached St. Louis the Western Sanitary Commission worked day and night packing medical supplies and shipping them as fast as possible to the scene of the crisis.
As the war in the Ozarks progressed both the military and the Western Sanitary Commission became better at averting crises by anticipating needs and stockpiling supplies at key points. One of these key points was Springfield. Large quantities of medical supplies were stockpiled in that city in anticipation of further battles in the western Ozarks. The Union victory on December 7, 1862, at Prairie Grove in northwestern Arkansas produced over 1,000 wounded, and once again poor roads and the threat of guerrillas made evacuations impracticable. On this occasion, however, Sanitary Commission agents in Springfield immediately dispatched two ambulances and stockpiled medical supplies to Fayetteville, which became the main treatment center. They sent additional supplies within ten days.


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