Wednesday, June 24, 2015

At War With Ourselves


The Civil War brought misery to the Republic and extraordinary challenges to the Army Medical Department. It produced a casualty evacuation and treatment doctrine that continues today, and it drew the tapestry of evolving medical specialties into sharper relief. The fields of medical logistics, pharmacy, hospital administration, records administration, and statistical reporting grew as they contributed to the effectiveness of the department. Technology in such matters as instruments and ambulances advanced. And the work of sanitary commissions reflected a climate for change highlighted by politically charged public oversight of military medical activities.

The revolution in organization was all the more striking because the state of medical art had not changed that much from earlier days. Clinicians made increasing forays into a scientific understanding of health and disease, but the causes of disease were maddeningly perplexing. Fingers were not yet pointed at such things as germs and mosquitoes. Both sides, Blue and Gray, shared a common military medical heritage. Sick call for Confederate soldiers in the Army of the Tennessee was held immediately after reveille, and their treatment depended upon whatever the medical officer happened to have. Dr. William H. Taylor, a Southern surgeon, said his medical practice became very simplified in the field. "In one pocket of my trousers I had a ball of blue mass, in another a ball of opium. All complainants were asked the same question: 'How are your bowels?' If they were open I administered a plug of opium, if they were shut I gave a plug of blue mass [a commonly used medication whose principal ingredient was mercury]."

The use of anesthesia, typically chloroform, was common, but surgeons were in a quandary between the desire to use techniques made possible by anesthesia and the threat of infection that would follow if they did. Certainly their surgical techniques were not elegant: "We groped for bullets with roughened porcelain-tipped probes, the mark of lead on the probe recording the locality of the ball." Field hospitals were marked by piles of amputated limbs.

The opening of the war gave little hint that progress of any sort lay ahead. The Army numbered only some twenty thousand soldiers when fighting began at Fort Sumter in April 1861, and the Medical Department was also very small-only 113 uniformed physicians, of whom 24 resigned to join the Confederacy. But the number of medical officers mushroomed to 3,000 as the department expanded to 204 general hospitals operating 136,894 beds.

Care of the wounded became an early preoccupation of the public. The pioneering efforts of Florence Nightingale and French and English sanitary commissions did not go unnoticed. Women formed soldiers' aid societies throughout the United States to provide organized help to the Union effort. One of those groups, the Woman's Central Association of Relief for the Sick and Wounded of the Army, combined with other groups to form the United States Sanitary Commission, which soon won a presidential mandate to conduct its inquiries. Like its Crimean War predecessors, the Sanitary Commission served as an external catalyst for change, becoming known as Lincoln's "fifth wheel" and acting as a gadfly to the War Department. It furnished supplies and volunteer assistance to the Medical Department and brought public opinion to bear on its operations. Its special investigators included experts in emerging disciplines related to medicine such as chemistry, physiology, and statistics, scientific specialties that would eventually be incorporated into the Medical Service Corps.

Members of the commission presented charges of Medical Department mismanagement on their first visit to the surgeon general, and from then on the commission and the department routinely clashed. The commission pushed for well-stocked medical depots, a large ambulance corps under direct medical control, and the construction of hospitals using the latest European innovations. In pursuing those aims it influenced the dismissal of one surgeon general, Brig. Gen. Clement A. Finley, and the selection of his replacement, Brig. Gen. William A. Hammond. The commission also earned the unrelenting animosity of perhaps the most powerful man in Washington next to President Abraham Lincoln, Secretary of War Edwin M. Stanton. In the West, the Western Sanitary Commission also kept pressure on the Medical Department, forcing changes to the Army's medical supply table over the objections of the Western Department's medical director.

Medical support deficiencies, while perhaps not discernible in peacetime, became deadly in war. In 1862 the department's inadequacies came under scathing attack in the Congress where there were charges of the "grossest mismanagement" of Army hospitals, demands for the employment of medical inspectors, and calls for General Finley's removal. Army physicians were called self-satisfied old men (Surgeon General Lawson had been seventy-two and in bad health when Fort Sumter fell) who had removed themselves from the practice of medicine and were out of touch with contemporary practice. What was reported in Congress was experienced firsthand by the writer Louisa May Alcott (she later would publish Little Women). Alcott volunteered for duty as a nurse at an Army hospital in Washington, D.C., in 1862. There she worked in "famine and filth" among "violent odors that assaulted the human nose." It was, said one soldier who also worked in a Union hospital, "our terrible Hospital Service."

Yet, while Stanton accused the Medical Department of "general imbecility," it would not be fair to ascribe all medical support failures solely to the department's ineptitude. After all, Army doctrine at the time was designed for fielding small detachments in the Indian campaigns, and the military buildup for the Civil War was dependent upon the formation of volunteer regiments (roughly equivalent to today's battalions). Regiments provided for their own medical support, so medical officers quite naturally were concerned primarily with their own units, not others. The medical system in support of the regiments was sketchy, and there was no overall plan for evacuation and hospitalization of casualties in successive steps back to the general hospitals. There was no doctrine to unite people, equipment, and facilities into an integrated system of support.

The impact of this structural disarray was compounded by the lethality of Civil War battlefields. Though most individual weapons were muzzle-loading muskets, barrels had been rifled to increase the accuracy of fire and amplify its range. Rifled muskets fired the so-called minié ball-not a ball at all, but a heavy, conical bullet that did great damage when it smashed into flesh and bone. Late in the war breech-loading rifles completed the revolution in weapons by giving a greater rate of fire. Yet tactics failed to keep pace with technological progress, and soldiers attacking in tight formations across open fields were simply mowed down. The resulting carnage ruthlessly exposed the inadequacy of the evacuation and hospital systems.

Image: U.S. Sanitary Commission Lodge for Invalid Soldiers, Alexandria, Virginia


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