Monday, December 1, 2014

Counting the Costs of the Civil War

By Jeffrey Allen Smith and B. Christopher Frueh, November 7, 2013

While the desire to document military exploits and wars is as old as writing itself, the recording of military medical data is a relatively modern phenomenon. Although some initial attempts to chronicle the health of troops occurred in the first half of the 19th century, the first large-scale, wartime medical and behavioral health surveillance effort was conducted during the American Civil War.

This is partly a reflection on the dismal state of the medical profession before the mid-19th century. By the Civil War era, medical practice had improved markedly over the previous century, but it had yet to shake free of all the fetters of its lingering superstitions and misconceptions. For example, with the germ theory of disease still a generation away, it was commonly held that a variety of fevers and diseases, like cholera, were caused by miasma or the foul-smelling “bad” air that emanated from swamps and decomposing matter. On the other hand, medical sophistry notwithstanding, bloodletting had fallen out of fashion and belief in the prophylactic powers of cleanliness and proper hygiene were more widespread thanks in part to the hard work of Florence Nightingale during the Crimean War in bringing sanitation to British war hospitals. One ward’s mortality rate fell over 30 percent because of her efforts.

Thus, with medical advancements showing tangible results in lowering mortality rates and sickness, placing greater effort and funding into a larger systematic wartime recording of military medical data began to seem sensible, and feasible.

The United States Army Medical Department entered the Civil War understaffed and underfunded. This was partially the result of Surgeon General Thomas Lawson, an ossified War of 1812 sawbones, who infamously considered updated medical textbooks a superfluous use of funds. After Lawson died a month into the war, President Lincoln replaced him with Clement Finley, who soon ran afoul of Secretary of War Edwin Stanton in a fiery disagreement.

The choice of Finley’s replacement, William Alexander Hammond, was a stroke of good fortune for the department. Hammond, who had military experience and previously was the chair of anatomy and physiology at the University of Maryland Medical School, set about updating and modernizing the Medical Department. He is credited with increasing standards for army surgeons, reorganizing the ambulance service, founding the Army Medical Museum, expanding support to field and general hospitals and helping to establish the Army Nurse Corps.

Hammond also recognized that the medical record-keeping system for sick and wounded soldiers was “insufficient and defective” and in June 1862, barely a month into his tenure, his office announced a plan to compile the Medical and Surgical History of the Rebellion.

Still, it was not until Nov. 4, 1863, that the War Department issued General Orders No. 355, directing “Medical Directors of Armies in the field [to] forward, direct to the Surgeon General at Washington, duplicates of their reports… after every engagement.” A week later, the Surgeon General’s Office requested “all obtainable statistics and data in connection with past and future operations” and drew “particular attention” to a list of medical topics of elevated importance, the first on the list being “morale and sanitary condition of the troops.”

By January 1864, the scope and focus of the data collected expanded from the battlefield to include general hospitals. “Medical officers in charge of wards” were issued a “Register of Sick and Wounded” and a “Register of Surgical Operations” in which they kept “minutely and in detail, the particulars of all operations performed, or treated in [the] hospital.” These two registers later served as the foundation for the organizational structure of Medical and Surgical History of the Rebellion. A month later, the military began explicitly requesting medical reports for “Sick and Wounded Rebel Prisoners of War” and “White and Colored Troops.” With the inclusion of these medical reports, and a slight modification of a few others, the Surgeon General’s Office had in place a comprehensive system for tracking the medical condition of Civil War combatants by the spring of 1864.

Yet another year would pass before the office started to focus on medical reporting efficiency as well as effectiveness, but Hammond would not be around to see it. Apparently, in his zeal to modernize, Hammond fell victim to the “Calomel Rebellion.” After he banned the medicinal use of mercurial poisons like calomel, army physicians – who stood by these drugs as lifesavers – successfully ousted him from his post.

With Hammond gone, Secretary of War Stanton chose Joseph K. Barnes to serve as the fourth surgeon general in four years. Barnes studied medicine at Harvard University and the University of Pennsylvania before joining the military as an assistant surgeon in 1840. Unlike the previous surgeon generals, Stanton got along well with Barnes, and it showed in the War Department’s increased support of the Medical Department’s activities.

One of these endeavors was the organization of medical records. Bureaucratic delay, ineffectiveness and struggles to conceptualize and implement a final medical recording system notwithstanding, the unprecedented size and scope of the military medical data collected is truly impressive. Still, the struggle to organize the mountains of reports, analyze the data and effectively share it with the world would last longer than the war itself.

In June 1868, as the nation began to come to terms with the significance of the war, Congress commissioned Secretary of War Stanton to prepare for publication “five thousand copies of the First Part of the Medical and Surgical history of the Rebellion, [as] complied by the Surgeon General.”

A decade later the resulting tome, “The Medical and Surgical History of the War of Rebellion, 1861-65,” appeared, consisting of six volumes and totaling approximately 3,000 pages. Based exclusively on military and government medical records, it included statistical data on Union and colored troops broken down into a variety of subcategories. More than 100 separate tables organized by region and army group tracked 150 “diseases,” including “serpent bite,” gunshot wounds, dysentery, diabetes, “dropsy from heart disease” and even alcoholism and suicide. In addition, many of the “diseases” listed in the tables were in subsequent volumes given general descriptions, selective case studies, accounts of treatments and sometimes even illustrative photographs or color plates to further aid in contextualizing their effects on the health of the Civil War soldier.

Newspapers, photographs, diaries and soldiers’ letters all had the ability to create a visceral and real connection to the horrors and heroism of the Civil War. However, these sources could also prove selective and occasionally obscure the larger war. The “Medical and Surgical History” provides something else: an extremely detailed examination of the medical condition and toll taken on soldiers during the Civil War. Here, almost uniquely for the time, there is no euphemism, no soft focus, no attempt to diminish that cold, dispassionate arithmetic reality of the terrible cost borne by Civil War soldiers, both during the war and for decades after.

Image: William Alexander Hammond, physician

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Sources: B. Christopher Frueh and Jeffrey A. Smith, “ Suicide, Alcoholism, and Psychiatric Illness Among Union Forces During the U.S. Civil War,” in the Journal of Anxiety Disorders, vol. 26 (2012).

Jeffrey Allen Smith is an assistant professor of history at the University of Hawaii, Hilo.

B. Christopher Frueh is a professor of psychology at the University of Hawaii, Hilo, a McNair Scholar, the director of research programs at the Menninger Clinic in Houston and, writing as Christopher Bartley, the author of “They Die Alone.”



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