A Nation At War: Armed With New Tools and Tactics, Doctors Head to the Battlefield

By Gina Kolatamarch, 3-30-03

From redesigned first-aid kits to a radically new kind of surgery on the front lines, battlefield medicine has changed markedly and, as a result, doctors in the war in Iraq hope to significantly reduce the death rate from battlefield wounds -- a rate that has not budged for 150 years.

Since the Civil War, experts in military medicine say, one of five wounded soldiers has died, half from profuse bleeding. Pentagon doctors hope to change that, and have mobilized an array of innovations.

Some, like putting pressure bandages in first-aid kits, are drugstore cheap. Others, like a new anticlotting drug for internal bleeding, are high-tech expensive, about $7,000 per dose. And some, like sending radically redesigned surgical teams to operate at the front lines, involve tactics and equipment that simply were not available in the last gulf war. These special surgery units were tested in Afghanistan, where they reduced the died-of-wounds rate, the death rate for those who survived long enough for a surgeon to operate, to a fraction of a percent. For the past half-century, it has hovered around 2 percent.

Doctors said it was hard to overestimate the difference.

There was little change from Vietnam to the first gulf war in doctors' instruments, drugs, techniques or tactics. Except for some in the Army, which put surgeons in the front lines in Desert Storm, wounded soldiers received first aid from medics but no surgical care until they were evacuated to a larger hospital.

Continue reading the main story
Now, all the services have small mobile surgical teams scattered throughout the battlefield, where they operate on the most severely wounded as close to the front as possible. They do the minimum operation to stabilize patients for evacuation to a larger hospital. There, they may have another operation to further stabilize them for evacuation to a hospital in Europe.

''Never before in modern warfare have we done things so differently,'' said Lt. Col. Donald Jenkins, a surgeon who is chief of trauma at Wilford Hall Air Force Medical Center in San Antonio.

Many of the patients treated have been Iraqis. ''By Geneva Convention and NATO standards, casualties are taken care of in order of priority, based on injury and illness, not based on uniform,'' Dr. Jenkins said. ''That's been the policy back to our own Civil War at least.''

Col. John Holcomb, a surgeon who directs the Army Institute of Surgical Research in San Antonio, said some of the innovations came from after-action reviews in which doctors analyzed data on why soldiers died, where they died, and how.

Each branch of the service makes its own decisions about which innovations to adopt. For example, the Marine Corps has added a new product, QuikClot, to every marine's first-aid kit, said Lt. Cmdr. Joe DaCorta, who is in charge of expeditionary medicine at the Marine Corps Warfighting Lab in Quantico, Va.

The substance was tested for battlefield use by Dr. Hasan Alam, a trauma surgeon at the Uniformed Services University of the Health Sciences in Bethesda, Md. Dr. Alam said he was haunted by troops who bled to death in Somalia before surgeons could help them.

For Dr. Alam, it meant that ''your buddy has to stop the bleeding, not the medic, not the surgeon.''

So he turned to QuikClot, a product made of the mineral zeolite and sold over the counter by Z-Medica. It looks like cat litter but, sprinkled on a wound, it absorbs water from blood, concentrating the body's own clotting factors and speeding up the formation of a clot.

Z-Medica has supplied 50,000 doses to the military.

Dr. Alam and his colleagues tested the substance on 36 Yorkshire swine, which are close to a person's size. The results have not been published, but Dr. Alam said QuikClot converted wounds that were 100 percent fatal into wounds that were 100 percent nonfatal -- clots formed and none of the animals died.

Although the Marine Corps plans to use it, other branches of the military are not yet convinced. The question is whether to use it, and at what dose. One concern is that heat is generated when QuikClot is poured on a wound, and the fear is that it might burn tissue. ''We don't have a huge amount of data,'' Dr. Alam said. ''We've done two studies.''

Also, the troops must be trained in how to use it and surgeons must be trained about what to expect.

Meanwhile, the Army and the Special Operations forces are taking an additional approach to clotting, Colonel Holcomb said. They will use coated bandages to stop bleeding. One bandage, developed by the Red Cross, used two clotting proteins, fibrin and thrombin, to speed clot formation. The other, made by HemCon of Oregon, uses chitosan, a clot-promoting protein in shrimp shells.

Remaining problems include what to do about severe injuries to the abdomen or pelvis, which may cause rapid and uncontrolled internal bleeding, or bleeding in the brain from a head injury.

''What about an intravenous drug that could accelerate the hemorrhage-control process?'' Dr. Holcomb asked. The Army, he said, is considering using factor VIIa, a clotting drug recently approved for treating hemophilia. Animal studies, he said, indicate that it can work, and trauma centers often use it. The Defense Department and the company hope to conduct a clinical trial.

Military medical experts said the hope, with all of these new products, is that they will keep the wounded alive until they can see a surgeon.

Surgeons will be using a method pioneered a decade ago in trauma centers in cities reeling from an epidemic of drug-fueled violence.

One of its leading innovators was Dr. C. William Schwab, a trauma surgeon at the University of Pennsylvania, who was troubled by the number of patients treated there who died later.

California Today
The news and stories that matter to Californians (and anyone else interested in the state), delivered weekday mornings.


Enter your email address
 Sign Up

Receive occasional updates and special offers for The New York Times's products and services.

SEE SAMPLE PRIVACY POLICY
''We started to see that even though we would get the injury controlled and fixed, even though we put them back together, they would die,'' Dr. Schwab said. Patients would go into shock, their temperatures would drop, their blood would become acidic and coagulate, forming fatal clots.

Dr. Schwab decided to try doing the absolute minimum surgically to stop the bleeding, so doctors could turn their attention to stabilizing the patients. Later, he reasoned, surgeons would complete their repair.

Dr. Schwab named the method damage control, a Navy term he recalled from the 10 years he spent on an aircraft carrier in Vietnam. When a ship was hit, he recalled, the idea was to patch it up and keep it afloat, doing the major repairs later.

He tried it with trauma victims. ''We would control bleeding and any contamination from the GI tract,'' he said. ''Then we would continue to resuscitate them and bring them back in two or three days and do definite surgery.''

To assess the method, he compared patients treated with damage control with similar, seriously injured patients who had had traditional surgery. With damage control, 75 percent survived. With traditional surgery, almost every patient died. A decade later, after further refining of the technique, 90 percent are surviving, Dr. Schwab said.

As the approach spread in trauma centers across the country, military surgeons started showing up at Dr. Schwab's hospital for training.

''What I learned from Bill Schwab was absolutely indispensable,'' said Dr. Jenkins, who spent two years there. ''I took care of people who for sure in my training we would have looked at them and said, 'There is no way this person could survive.' '' Yet survive they did.

But to bring the technique to the battlefield, the military had to make major changes. First, it had to put the surgeons with the frontline troops, so they could do damage control surgery immediately.

The new idea was to keep a small surgical team on the front line, using a portable operating room that is set up in an hour for damage control surgery. From there, patients are stabilized and taken to hospitals for additional surgery days later.

It required making what once was bulky equipment light and portable, said Dr. Paul K. Carlton Jr., the recently retired surgeon general of the Air Force who now directs the Integrative Center for Homeland Security at Texas A & M. Today, Dr. Carlton said, surgeons can carry the equipment they need in a backpack.

For example, frontline units are equipped with sonogram machines the size of cassette recorders, and devices the size of a PDA that can do a complete laboratory analysis on a drop of blood.

Another piece of the plan is to train surgeons and support staff, and once again military doctors turned to urban trauma center. ''They have too many patients,'' Colonel Holcomb said. ''We need patients.''

In Miami, Dr. Tom Knuth, who directs the Army Trauma Training Center at Ryder Trauma Center, is training military general surgeons, plastic surgeons and other specialists and technicians and medics.

''They integrate with the civil staff to manage whatever patients come through the door -- bad motor vehicle crashes, gunshot wounds,'' Dr. Knuth said. ''And they get to work together as a team.'' With the war, the training regimen has been compressed from a month to 10 days.

Dr. Carlton said the war in Afghanistan showed what is possible. Of 250 seriously injured patients, only one died. ''It was the lowest died-of-wounds rate in the history of war,'' he said.

One man suffered a catastrophic wound to his rectum, prostate, anus and bladder. The ghastly injury plunged him into shock immediately, but one of the backpack surgical teams got to him right away and did a damage control surgery. Then, he was put on an airplane equipped as a critical care unit and flown a few thousand miles to another hospital for another surgery to stabilize him. Then he was flown to Germany for reconstructive surgery.

''He's home with his family now,'' Dr. Carlton said. In any other war, he added, ''he would have been dead.''

From: nytimes.com

Read More

Civil War Helped Shape Today's Medical Practices

By Carolyn Kimmel for Body & Mind Magazine, 11-13-12

The words "butcher" and "barbaric" may often be used to describe medical practices during the Civil War, but today's soldiers owe a lot to the forefathers who tended to the sick and wounded in Gettysburg and elsewhere.

"There were definitely medical advances that came out of the Civil War that are benefiting soldiers in Iraq and Afghanistan today," said Peter J. D'Onofrio, president of the Society of Civil War Surgeons, based in Ohio. "When I give talks, I say 'if you get nothing else out of tonight's talk, remember we can't look back at the surgeons of the Civil War and judge them in the context of today's medicine.'"

Our ambulatory and evacuation systems that carry wounded soldiers to help, our understanding of sanitization and even our respect for female nurses all trace their roots to the Civil War, historians say.

“One of our slogans here is ‘Civil War medicine — it’s not what you think,’” said George Wunderlich, executive director of the National Museum of Civil War Medicine in Frederick, Md. “Much of our modern neurology, plastic and reconstructive surgery, even occupational therapy — these people were inventing it and what’s amazing to me is how well they were doing, considering they were inventing it as they went along.”

As the battle unfolded around them, major players in the Civil War realized they were woefully unprepared.

“They never anticipated the war lasting that long or that kind of carnage,” D’Onofrio said.
As a result, they were writing medical procedure manuals as they went, inventing protocol and demanding better, more expedient care than was ever seen on the battlefield prior to 1862.

“By today’s standards, people think it was pretty primitive, but there was a lot of progress made during the Civil War,” said John Heiser, historian at the Gettysburg National Military Park.

Today’s soldier’s well-executed journey from battlefield to life-saving medical attention began with a war surgeon named Jonathan Letterman from Washington, Pa., who was medical director of the Army of the Potomac, the major northern army.

“Letterman is considered the father of battlefield medicine. He put all the parts of modern emergency medicine as we know it today into a chain,” Wunderlich said. “The movement of troops from injury to a medic to a field hospital to a general hospital to a bigger hospital is exactly how troops are moved today.”

Prior to this, when a soldier was injured, he would be helped off the field by several fellow soldiers who were not trained to give aid.

Letterman introduced the four-wheeled, horse-drawn wooden ambulance, piloted by trained drivers and carrying stretchers and medical supplies to the field, D’Onofrio said.

“Letterman also set up aid stations about 50 to 100 yards behind the firing line, hopefully in a wooded area or ravine, where basic first aid could be given. Then the soldier could be taken by ambulance to a field hospital, which might be a half mile to a mile away,” he said.

The improvements were readily apparent — at the battle of Antietam, there were only one or two first aid stations whereas at Gettysburg, there were more than 271 such stations, Wunderlich said.

Our triage system — a quick assessment to determine priority for treatment based on severity of injury — also came out of the Civil War.

During the Battle of Gettysburg, nearly every barn, building and home was turned into a makeshift field hospital to care for the more than 23,000 wounded soldiers left behind. Letterman’s new administrative plan assured good communication among field hospitals, and his insistence upon a surgical team composed of the most experienced surgeons in the military division meant better care, Wunderlich said.

“We’re still following Letterman’s plan,” D’Onofrio said. “You usually have a medic with a unit who will patch up the wounded soldiers as best they can and they will be helicoptered out to one of the permanent bases in, say, Afghanistan, or later transported to Germany or to Walter Reed [Army Medical Center] in Washington. That helicopter is the equivalent of that wooden ambulance and that tiered system of evacuation is from Letterman.”

“The concept of moving someone swiftly to a place where they could be better cared for came from the Civil War,” agreed G. Craig Caba, Civil War author and member of the Harrisburg Civil War Round Table.

At the National Museum of Civil War Medicine, which specializes in training military medical professionals, Letterman’s principles of 150 years ago are still taught as best practices, Wunderlich said. “You can have all the technology in the world, but if you can’t get the patient there while he’s still alive, it’s no good,” he said.

Sanitary conditions are standard protocol in medical facilities today, but in Civil War times, scientists Joseph Lister and Louis Pasteur had yet to link bacteria with infection.

“For every one soldier killed outright, two died from disease and infection,” D’Onofrio said. “Doctors knew about these things; they just didn’t know what caused them.”

Consequently, army surgeons amputating limbs — the preferred remedy of the day especially when bone was shattered — in a makeshift field hospital didn’t give a thought to bacteria, Heiser said. They might even use the same instrument on multiple patients.

“The amputation might be successful, but could he survive the possibility of gangrene or infection that might set in?” Heiser said.

An understanding of the correlation between sanitization and diseases and infection came out of the Civil War, historians said.

Some of the advances were stumbled upon, Heiser said. For example, some hospitals that had washed bandages in hot soapy water, out of desperation to reuse them, noted their infection rates were lower than most and realized they had unwittingly been sanitizing bandages, he said.

The medical realities of the Civil War led to a greater interest in the field of medicine, Caba said. He owns an 1864 edition of Samuel D. Gross’s “System of Surgery,” a thick, yellowed directory on everything from gangrene to amputation. Who knows but a Civil War doctor might have referred to this very volume even as shells exploded around his field tent, Caba said.

“You began to see greater numbers at medical schools and greater numbers of females going into nursing,” he said. “This was really the first time that you began to see women respected for the medical care they offered. They were called angels of mercy. Fifty years later, at reunions, men would still be giving them three cheers.”

At the time of the Civil War, there were only 600 trained nurses in the nation and all of them were Catholic nuns, D’Onofrio said. During the war, some 5,000 to 6,000 women came forward to serve as nurses for the North; records for the South were lost in a later fire in Richmond, he said.

“Few of them were formally trained, but remember back then, women took care of the family when they were sick or injured so they had that experience,” he said.

All Americans, soldier or civilian, are benefiting from the medical services introduced during the Civil War, historians said.

“We didn’t have ambulance services and emergency rooms in hospitals until well after the Civil War. Why not? The answer is because of the war,” Wunderlich said. “The Civil War changed the expectations of hundreds of thousands of men who went through a medical system that was changing, and they are ones who instigated these improvements in major cities across the country.”

Image: A field exhibit at The National Civil War Museum in Harrisburg depicts Civil War medical practices.

From: pennlive.com

Read More

Combat Medicine: Battlefield Surgery

By Becker Staff, 10-20-10

The demands of treating the many wounded and sick during military conflicts have put great pressure on caregivers, physicians, and surgeons in every age. The unique difficulties and situations of wartime medicine, however, have sometimes led to important medical advancements. Surgery, especially, has developed remarkably from work being done on combat wounds since the time when Galen advanced his knowledge of human anatomy by studying the gladiatorial injuries he treated. Paracelsus also found his time spent traveling with various armies across Europe to be essential for his education in surgical techniques. In the Rare Books Collection of the Bernard Becker Medical Library are numerous books in which surgeons describe how their work with wartime casualties helped lead to the development of better surgical care for everyone.

The library’s books on wartime surgery reveal tremendous advancements in surgical technique, often spurred on by the conditions of military conflict, but they also make it clear that modern war has continued to become more destructive.

In fact, the man who helped to make surgery a respected medical specialty in the 16th century worked out many of his most important techniques on injured soldiers. In his first book, which discussed treatments for gunshot wounds, the French surgeon Ambroise Paré described how he had discovered that the contemporary method of cauterization with boiling oil led to more pain, infection, and amputation than simply cleaning wounds with a turpentine-based solution. Paré would go on to develop arterial ligatures and many techniques for securing shattered limbs. His work and writings brought him great fame, so that he ended up serving the kings of France and his books on surgical techniques were published many times. The library has several early editions of his collected works.

Surgical techniques continued to improve over the next two centuries, but little was done to ensure the delivery of effective medical care during combat even as armies became larger and their weapons more horrific. Only when the French Republic put together a huge force of citizens did military administrators seek to improve surgical conditions on the battlefield. Dominique Jean Larrey stands out as the organizing genius of this period of war across much of Europe. He created a force of quick ambulance carriages for the French that delivered the wounded to military field hospitals as close to battles as possible, where a triage system determined who needed the most immediate care. Since surgeons still had to deal with the tremendous risk of infection from bullets and shrapnel, the most frequent surgery remained immediate amputation, a procedure that Larrey helped to perfect. The Becker Library holds several editions of these memoirs of his years spent improving medical care during the Napoleonic Wars.

Military medicine and surgery continued to improve over the course of the nineteenth century, especially after the international disasters of the Crimean War encouraged further development of medical institutions. Surgery still had to be quick and infection remained the major killer, but surgeons now had an effective infrastructure of field units and hospitals to care for the wounded. By the time of the American Civil War, surgeons often used chloroform as an anesthetic to allow them to perform precise surgeries on unconscious patients, while the use of morphine helped to ease the pain of injuries. Frank Hamilton wrote a short pamphlet on modern surgery at the beginning of the war to advise surgeons. After his experiences over the course of the conflict, he followed that up with a huge text in 1865, highlighting all the advances in medical practices for the battlefield including the transport of the wounded, specific surgical techniques, and methods of effective bandaging to ensure proper healing. Hamilton would go on to become a famous surgeon who attended presidents.

In 1861, the renowned Philadelphia surgeon, Samuel D. Gross also produced an important manual on military surgery for the army’s use in the coming conflict. His guide proved invaluable to surgeons in the field. Their work clearly had become an essential part of the war effort, for in 1862 the Confederate government in Richmond, Virginia ordered a pirated copy of the Gross book to be produced for their military doctors. And then they demanded another reprint a year later. Like the Hamilton book, this text discusses the use of chloroform for battlefield surgery and describes the best techniques for ligation and amputation to deal with the dreadful wounds of modern warfare that were likely to lead to infection and gangrene.

By the 1870s, a new understanding of what causes infection led to the development of aseptic surgery. Reducing the risk of infection through aseptic surgery and antiseptic wound cleaning revolutionized surgery by making it much safer. So, the development of anesthesia and aseptic operating rooms meant that surgeons could perfect difficult, detailed procedures for work on specific conditions. Soon afterwards, x-ray imagery offered a guide to the surgeons’ hands before any operation had even started. The Boer War witnessed the first applications of these new technologies which had dramatic results for battlefield medicine. Now wounded soldiers had much better chances of surviving and making it home in one piece. This book shows the new level of care being given with x-rays that showed every bullet fragment and surgeries that allowed perforated intestines and fractured skulls to be repaired.

During World War One, the force of the new artillery and the unsanitary conditions of trench warfare made the work of surgeons and other medical caregivers on the frontlines very difficult. And while advancements such as motorized ambulances and transfusions meant that more lives could be saved, surgeons also had to deal with new concerns such as trenchfoot, gas poisoning, and flamethrower burns. De Tarnowsky’s book was meant to be a field manual for all of the medical situations one would face at the front, so it includes discussions of complicated bladder surgery under anesthetic and the best methods to stitch up a wounded face for later plastic reconstruction, as well as gunshots and fractures.

* Please note: Becker Briefs pages may contain links, email addresses or information about resources which are no longer current.

Image 1: Frank Hastings Hamilton. A Treatise on Military Surgery and Hygiene. New York: Bailliere Brothers, 1865. xxWO 800 H217t 1865

Image 2: Confederate States of America. A Manual of Surgery: Prepared for the Use of the Confederate States Army, by Order of the Surgeon-General. Richmond: Ayres & Wade, 1863. xxWO 800 C748m 1863

From: becker.wustl.edu

Read More

The Garthright House Served as a Union Field Hospital at the Battle of Cold Harbor

By Mark, 10-28-16

At the time of the Civil War, Miles and Margaret Garthright lived in a two story home a few miles east of Richmond, Virginia. While the location near the city was no doubt convenient in peacetime, it was very much in harm’s way during the war, and was on the battlefield of two major battles during two campaigns.

The house was on the edge of the June 27th, 1862 Battle of Gaines Mill, one of the Seven Days Battles of the Peninsula Campaign on 1862. It was more in the middle of the action two years later during General Ulysses S. Grant’s Overland Campaign, specifically, during the Battle of Cold Harbor from the end of May into early June of 1864. Cold Harbor is probably most infamous for the ill advised Union assault against entrenched Confederate positions on June 3rd, when the Federals suffered over 6,000 total casualties. Units from both the 2nd and 6th Corps charged through the property during that fateful assault.

The Federals turned the building into a field hospital, forcing the Garthright family into the basement. As the historical marker on the site notes, blood from the wounded dripped through the floorboards and into the basement. Some 97 Union soldiers died there and were hastily buried in the Garthright’s yard. In 1866, the bodies were removed to the Cold Harbor National Cemetery across the road. After the Union army moved on from Cold Harbor, the Confederates also used the house as a hospital.

Portions of the Garthright House date to the 1700′s. The house was damaged by a fire in 1970 and was restored, and is a part of the Richmond National Battlefield Park. The house is an exterior exhibit only and the interior is not open to the public.

Image: Garthright House, Richmond National Battlefield Park

From: ironbrigader.com

Read More

Battlefield Medicine and Diet

By Robert Sterling, Historical Research and Narrative

And what killed Billy Yank and Johnny Reb? It was not the fighting at Gettysburg and the ghastly charge of Confederate troops under General Pickett across the open Pennsylvania fields, but the toxic manure on the camp streets of a stationary army during the hot summer months. It was not General Grant�that obstinate man from Galena, Illinois�burrowing through the impenetrable woods, but General Diarrhea penetrating the bowels of infected soldiers. It was not that long gray line stationed behind the stone wall at Fredricksburg, but that incessant "blue line" squatting at the 'sinks' with constipation. It was not the sharp slashes received from the cavalry swords of General Forrest's men, but the pricking of the needle-nosed mosquito as it transferred fatal malaria into the soldier, indiscriminately infecting the blue and gray alike. Forget about the glamour of war.

Today, six score and fifteen years later, however shocking the killed-in-action and died-of-disease statistics appear on the printed sheet, it is all the more horrifying when analyzed. After the war, tabulations reveal that at least 110,070 Union men had died on the battlefield. More than twice that number, 224,586 (of 6,000,000 cases of sickness) had succumbed to diseases. With Confederate dead, the human loss totaled 620,000.

Illinois endured a 30 percent higher loss of men than the Union, in proportion to the number serving, and southern Illinois was the home of four of the five regiments with the highest losses due to diseases. Why did western states and the southern portion of Illinois sustained greater disease casualties?

Physical examinations for recruits were required but not always administered. The enlistment of more than four hundred women suggests some laxity in requiring the recruit to strip for a thorough physical examination. An early Sanitary Commission report postulated that almost 75 percent of the recruits discharged for disabilities should not have been allowed to enlist in the first place. Regulations also directed medical officers to "vaccinate when it is required." Such a discretionary guide was rarely invoked. It has been speculated that men from rural areas, that is, western troops, and southern Illinois in particular, were especially vulnerable to infantile diseases: measles, mumps, and scarlet fever. At Camp Douglas, the prisoner-of-war facility in Chicago, almost 10 percent of all Confederate deaths occurred in a single month from a measles epidemic.

Once in camp, the novice soldier did not overly concern himself with cleanliness. Billy Yank's mother would have viewed with horror the accumulation of camp garbage, nearness of latrines to food preparation sites, manure piles on camp streets, and general filth.

Again, regulations recommended a weekly bath and required non-commissioned officers to observe their men washing hands and faces daily. It was not an easy duty for a nineteen-year-old corporal to command a forty-five year-old private. Said one soldier, "The first thing an army in the field does is to foul its own water supply and the second is to infect its food by the swarms of flies bred in the garbage dumps and manure heaps."

The typical Illinois regiment did not adopt any special arrangements to accommodate its culinary needs. Usually, the men prepared their own food, especially while on the march, or organized a "mess" of four to eight to pool the provisions supplied by the regimental quartermaster.

Fewer than half of the 119 regular (three-year) Illinois regiments assigned individuals�cooks�at the company level to the specific task of food preparation. In those forty-eight units, the "ration rustler" procured staples either from the subsistence department, or a sutler, or foraged.

An army manual mandated that the daily ration should consist of twelve ounces of salt pork (or fresh beef), one pound of flour (made into hard tack), one vegetable (usually beans), and coffee. The following widely popular doggerel indicates the general extent of poor Civil War nutrition:

The soldiers' fare is very rough,
The bread is hard,
the beef is tough; If they can stand it, it will
be, Through love of God, a mystery.
Beans killed more than bullets

Camp filth was ahead, only slightly, of the inept food preparation and unbalanced diet as the major health menace. The soldier's frying pan was more lethal than his musket. Although he was issued 20 percent more rations than European soldiers, shoddy preparation and poor diet produced massive illness. The explanation generally given for this major killer�"beans killed more than bullets"�may exaggerate, but the problem was worsened by a prevailing medical theory that purgatives must be administered to rid the body of its "ill-humors."

"My bowels moved 18 times in three hours," one soldier wrote home. The Medical Department reported nearly two million cases of diarrhea and dysentery during the conflict and an astounding 57,265 deaths. Although surgeons and soldiers classified it as the "flux", it was a one-celled animal� Entamoeba Histolytic� usually found in unsanitary conditions and introduced into the body by contaminated food and water.

Early in the war, the favorite purgative administered to diarrhea patients was calomel, a violent laxative that was probably therapeutically useless. Ultimately, this drug, chloride of mercury, was the excuse for eliminating the efficient, but brazen, Surgeon General William A. Hammond. The talented Hammond's long list of accomplishments was exceeded only by his long list of enemies. When the controversial Hammond issued an order banning the use of calomel, a court martial found him guilty of actions unbecoming of an officer and cashiered him.

An incredible example of over-medicating was the case of Private John Leopold of the Seventy-forth Pennsylvania, who entered a Philadelphia hospital after suffering from "chronic diarrhea" for three months. During a two-week stay, his medication included lead acetate, opium, aromatic sulfuric acid, tincture of opium, silver nitrate, belladonna, calomel, and ipecac. He died.

More common was the case of Private Daniel Newall, Company B, Eighty-eighth Illinois. The twenty-eight-year-old farmer from Tonica, Illinois, was honorably discharged with "severe and obstinate chronic diarrhea." The losses in Newall's northern regiment were light compared with the 120th Illinois Infantry from southern Illinois. Stricken in November 1862 with small pox, measles, and pneumonia, the unit lost 265 of 844 men. Add another 148 sent home with disabilities, and the non-battlefield losses represented an astonishing 49 percent of the original unit. This percentage does not include large losses in the infamous Andersonville prisoner-of-war camp. The 116th from Macon County lost 100 (of 239 disease-related deaths) in sixty days while digging a canal in the swamps near Vicksburg.

It weighed but a little over an ounce, and it passed through the air at a modest speed�not fast enough to be sterilized� but its destruction was indescribable. The mini ball, or conical lead bullet, tore through the soldier's tough skin, passed a few inches into the body and, its energy spent, stopped. It took with it bits of wool, skin, hair, and dirt. The soldier's damaged body tissue was several inches larger on all sides than the bullet's track. The mini ball produced 94 percent of all battlefield injuries; in 71 percent of all cases the arms, legs, hands, or feet had been hit. "When balls are lost in the capacity of the belly one need not amuse himself by hunting for them," wrote a hard-nosed surgeon.

The accepted surgical protocol was amputation, done quickly. The Sanitary Commission advised immediate amputation with as little delay as possible; later statistics supported the recommendation.

Usually the finger was used to probe the wound and assess bullet location and bone damage. Before Pasteur or Lister, washing the hands in soapy water was considered ample cleanliness. As one surgeon recalled, "we operated with clean hands in a social sense, but they were undisinfected hands... We used undisinfected instruments. .. and still worse, used marine sponges which had been used in prior pus cases and had only been washed in tap water." Patients were sedated with either chloroform or ether, and when supplies of those were unavailable, with whiskey. And, without anesthetic whatsoever, the soldier might quite literally 'bite the bullet,' that is, bite on a bullet during the operation. With the soldier "surgically asleep" the cutting and sawing began.

The surgeon then "removes the limb, ligates the vessels and when all oozing has ceased, secures the stump by points of suture placed at intervals of one inch." The amputation was over in less than fifteen minutes. One of the leading surgical advances of the war was the technique used in stopping the flow of blood. Too, the surgeons abandoned the ancient theory of producing "copious bleeding" by deliberate bloodletting by the leech or lancet. Some surgeons carried the heinous-looking spring-activated '"fleam" seated in its appropriately named holder called "the coffin." The fleam was a metal knife encased in a shell. When the trigger was pressed, the blade would slash into the vein to produce copious bleeding. Pain control was best facilitated by a generous use of opium or morphine. The surgeon "should have his pockets well stored with opium for immediate use" going onto the battlefield, wrote one surgeon.

Following his relocation from the field hospital to a general facility, the soldier's most feared disease might appear in a few days: hospital gangrene. Spreading from the size of a dime to eight or ten inches in diameter, the gray-coated rotting tissue soon turned black, emitting a vile odor and demanding attention. Early in the war, the cure was to cut away and ligate large arteries or burn it out with nitric acid till "you could see smoke rise, the flesh sizzle and crisp up, and all this time the patient's screaming in agony," recalled a doctor. By 1863 Dr. Middleton Goldsmith had introduced a treatment using lint soaked in bromine applied to the area after diseased tissue had been cut away. It was a major breakthrough, and hospital gangrene dropped to a low of 2.6 percent.

Army regulations required a board of not less than three officers "to examine applicants for appointment of assistant surgeons." Although some western states issued commissions without examinations, in Illinois, policy called for intensive interrogation of the prospective doctor. Nonetheless, although Dr. John Young of the Sixty-sixth Illinois failed to pass such examination, he remained the only chief surgeon in the unit for another six months before Dr. Pogue of Edwardsville replaced him.

Committed to the venerable Hippocratic Oath to be "loyal to the profession of medicine" and practice with honor, the Illinois surgeon steadfastly served his troops. A mere fourteen of the first appointed surgeons resigned within a year of the regiment's organization. More than a third of the three-year Illinois regiments had no chief surgeon turnovers. Indeed, the chief surgeon did not change but once for 85 percent of all the state's infantry regiments.

The surgeon's duties were not without danger. Drs. J. D. Haslett, Fifty-ninth Illinois, and Horace Porter of Chicago, 105th Illinois, were killed in battle during the Atlanta campaign. Dr. Shubal York of Paris, Fifty-fourth Illinois, was "murdered" by Copperheads during the infamous Charleston Riot early in 1864. At least forty northern surgeons were killed in the line of battle.

High battlefield losses produced an almost insurmountable task for the surgeons. Dr. Sam Hamilton of Monmouth and Dr. Emil Gulich of Alton, Ninth Illinois, probably thought it could not get any worse after the Fort Donelson engagement on the morning of February 16, 1862, than when 165 wounded from their regiment needed immediate medical attention. But less than two months later the same regiment, mainly from St. Clair County, and the same two doctors counted more than 300 injured after bloody Shiloh.

Who could have anticipated the astronomical numbers lost in some of the battles? At Fort Donelson just five regiments alone, with no more than a dozen doctors, had 809 injured men. At Shiloh less than twenty doctors had the herculean work load of assisting 1,416 wounded soldiers. At Gettysburg only 106 medical officers remained after both armies withdrew, (taking many of the surgeons with them) to attend to the nearly 20,000 Union and Confederate injured.

But assistance arrived as soon as the conflict commenced. Although the War Department did not officially recognize the status of female nurses until well into the war, the impact of these "angels" was immediate. Instructed by the Superintendent of Female Nurses, the ubiqitous Dorothea Dix, to present themselves as "devoid of personal attractions," the female became synonymous with "nurse."

Indisputably the hospital morale-builder was a godsend to the troops. As Louisa Alcott explained, the duties included "serving rations, giving medicine, and sitting on a very hard chair, with pneumonia on one side, diphtheria on the other, five typhoids on the opposite, and a dozen dilapidated patriots, hopping, lying, and lounging about, all staring more or less at the new 'nuss.'" All of this for forty cents a day.

Her name will always be associated with the American Red Cross, but Clara Barton also set up an elaborate relief program for supply distribution for the sick and wounded. Lincoln called upon this woman of mercy to prepare a bookkeeping record of burial locations, war prisoner sites, hospital enrollment and discharges, and communications with families. 'Mother' Mary Bickerdyke, the Catholic Sisterhoods, and later the Army Nurse Corps, also made lasting contributions.

The Civil War was the cataclysmic event that moved the country toward modernity and hastened the evolution of new medical theories and practices. The following medical practices ended with the Civil War: purging the body of liquids; indifference to sanitation; disdaining the use of vaccine; overuse of opium; laxity in expediting the transfer of wounded soldiers from the battlefield to the hospital; and resistance to female nurses. Myriad discoveries and improvements were prompted by the great conflict: the relationship between filth and disease, the procedure for amputations, the construction of hospitals organized with specialization wings, the birth of psychosomatic medicine, and the reevaluation of the impact of drugs.

From: lib.niu.edu

Read More

From The Front Lines to the Hospital

Manassas National Battlefield Park

For the wounded near the front, their first recourse for care lay at the numerous aid stations scattered across the battlefield. Farmhouses, barns, and outbuildings provided places for the wounded to be gathered until they could be sent to the main hospital in the rear.

"The whole region of country between Boonsboro and Sharpsburg is one vast Hospital. Houses and Barns are filled with them, and nearly the whole population is engaged in waiting on and ministering to their wants."
Hagerstown Herald-Mail September 24th, 1862

The Stone House, a private home and tavern at the intersection of two major roads, became prominent as an aid station during not just one, but two major battles. During the First Battle of Manassas, Union battle lines swept past the house, leaving the dwelling to shelter wounded men brought inside amid the fighting. During Second Manassas, since the house lay more firmly in Union hands, Federal personnel were better able to give aid to the wounded, creating a more established field hospital. To mark the building's new purpose, Northern surgeons hung a red flag from a second floor window.

Despite the distinctive identifying flag, the Stone House did not escape hostile fire unscathed, underscoring the risks that wounded troops faced at forward aid stations. As Confederate forces mounted a massive counterattack on August 30th, a wounded Union soldier was attempting to reach the house for aid when an artillery shell hit the building, "knocking a hole that looked as big as a bushel basket" in the house's western face. The private continued rearward, determined to find a safer shelter. Scenes like this were common in the fear and confusion of a battle. Throughout the Maryland Campaign, many homes, stores, churches, schools, and barns served as aid stations.

Hospitals and Homes

After the Maryland Campaign, Frederick was inundated with wounded soldiers, whose sheer numbers overwhelmed the capacity of the existing hospital on the Hessian Barracks grounds. Additional buildings were taken over for hospital purposes and organized into seven General Hospitals, under the care of seven separate sets of surgeons. A total of 27 buildings were used, mainly churches, schools, hotels and large meeting halls. In addition, two hospital camps were set up in tents on the outskirts of the city and many private homes housed wounded officers.

Many local citizens helped tend to the wounded soldiers on the battlefield, some arriving as early as the evening of the Battle of Antietam. They gave freely of their time, food, money, and compassion. The scale of the relief effort cannot be overstated. One pregnant woman in town had torn the family's clothing and bedding into strips for bandages, packed water and goose grease into containers, and headed out to assist the wounded with her young children in tow. When families returned home and found their houses and barns taken over for hospitals, they often helped care for the injured soldiers. Local women also volunteered at large field hospitals. They brought food and delicacies, bandaged wounds, helped write and deliver letters, and read to the soldiers to help lift their spirits.

All of the hospitals, with the exception of General Hospital #1 on the Hessian Barracks grounds, were closed by March of 1863 and the buildings returned to their former uses. However, it took much longer for the soldiers and civilians who witnessed such carnage, pain, and death to recover from the psychological wounds of war.

Image: Stone House: Manassas, Virginia

From: nps.gov

Read More

Field Relief Work at Gettysburg

By Jane E. Schultz

On Independence Day in 1863, a Saturday, it was raining in Gettysburg, Pennsylvania, as burial details and medical officers took account of the recent battle. Some 50,000 men had fallen in three days, 8,000 of them killed outright and the rest in need of medical attention. Civilians working independently or under the auspices of the US Sanitary Commission, a relief organization established in 1861 to lend a hand to the Army Medical Department, poured into town as overtaxed surgeons worked around the clock and local citizens came up for air. By Sunday, with so many bodies left to bury and 3,000 horse carcasses littering the roads and fields, relief workers arriving from Washington, Philadelphia, and Baltimore could smell decay from miles away and recorded their revulsion at the stench.

The prospect of providing timely aid to so many was daunting. No one had anticipated this many casualties, and the medical corps was ill prepared. The germ theory was not yet widely understood, so few surgeons practiced antisepsis, which meant that patients with fair chances of recovery sometimes contracted blood poisoning or gangrene and died. Anesthesia, on the other hand, was routinely administered to those undergoing painful procedures. Gettysburg surgeons handed out opium pills to men awaiting amputations, and when morphine and chloroform were in short supply, whiskey substituted. Advances in medicine were slow to come, despite the overwhelming availability of military bodies presenting themselves to practitioners. Competition among medical sects and disagreements about licensure created professional mistrust, which served neither patients nor practitioners well. Even though Britain had begun to train nurses in 1860 in the wake of the Crimean War, nurses in the United States did not begin to professionalize until 1870, and most of those detailed to nurse during the war—convalescent men and middle-aged women—had little training other than what domestic life had taught them.

By the summer of 1863, the surgeon generals’ offices of both the Union and the Confederacy had learned a great deal about triage and the rapid deployment of critical medical services. Though he was satisfied that the Union ambulance service had succeeded in removing 12,000 soldiers from the Gettysburg field by July 4—a significant improvement over the chaotic evacuations of 1861 and 1862—Army of the Potomac Medical Director Jonathan Letterman still lacked shelter tents and supplies to distribute among the thousands of men laid out on stretchers. Rebel wounded left behind in the retreat needed immediate attention as well, but too few Confederate medical officers had stayed behind, and Letterman was soon ordered to move on, leaving only about a hundred Union surgeons to clean up the mess. Men and women from the Sanitary Commission started to arrive on the 4th while local women, like Sallie Myers, and those attached to regiments, like Amanda Farnham, who had marched thirty miles with the 6th Corps, had witnessed the entire conflict. Charlotte McKay of Massachusetts rode atop forage in an army wagon and found the 2nd Corps hospital in the Jacob Schwartz farmhouse, where she fed double amputees and swatted the flies and mosquitos bedeviling convalescents. Already 800 Union and 300 Confederate soldiers were scattered about the house and the grounds, some under a stand of apple trees. Mary Morris Husband of Pennsylvania, an ample woman of 43 and a veteran of Antietam’s Smoketown Hospital, secured a ride to town on General Meade’s mail wagon and started cooking for men in the 3rd Corps hospital. In the absence of stoves, such women slung iron cauldrons over campfires to make soup, distributed fresh clothing, and dressed minor wounds. Altogether the Commission spent $75,000 at Gettysburg in the month of July—equal to approximately $100 million in today’s dollars.

Gathering equipment, livestock, and wounded men in haste, Lee’s Army of Northern Virginia retreated south toward Emmitsburg, Maryland, with the object of reaching the Potomac. Yankee artillery and cavalry pursued the nineteen-mile-long train of Confederates and inflicted further damage. Coming in the opposite direction was a band of thirteen sisters of charity from Emmitsburg, who described a harrowing journey of dodging corpses in a carriage with blood-spattered wheels. The sisters were from an order known for its nursing mission. Once in Gettysburg, they took up residence in McClennen’s Hotel and went to work in the courthouse, the churches, and the local college, dressing the wounds of men from both armies who had not already landed in one of the several corps hospitals ringing the town. On her way out to soldiers who had not yet found shelter, Sister Camilla O’Keefe noticed a sign in the woods that read, “17,000 wounded down this way.”[1] Here she and her band encountered men, whose wounds were crawling with maggots, lying on the ground; both the nuns and their charges battled lice.

Many surgeons expressed gratitude for the services of female volunteers, even those whom Army Nursing Superintendent Dorothea Dix had barred from the environs on account of their youth. The tireless proponent for the reform of mental illness ultimately appointed more than 3,000 women as nurses during the war, but Surgeon General William Hammond would circumvent her authority less than three months after Gettysburg by encouraging surgeons to appoint their own female staff. Given the press of sick and wounded, it was surely more practical to put surgeons in charge of hiring, and more than 20,000 Union women ultimately provided domestic and medical relief during the war with at least 10,000 Southern women, many of them slaves, providing the same services.

One of those whom Dix turned back was 23-year-old Cornelia Hancock of New Jersey, who tagged along with her surgeon brother-in-law, flouting Dix’s injunction; her first glimpse of Gettysburg was a pile of amputated arms and legs. Given her Quaker background, it is surprising how quickly Hancock acclimated: “You will think,” she told her mother in her third week as nurse, “it is a short time for me to get used to things.” Anxious to allay family disapproval, she wrote to another, “I am better than I am at home. I feel so good when I wake up in the morning.”[2] Sophronia Bucklin, a seamstress from Auburn, New York, also in her twenties, was similarly barred but to no avail. Upon arrival, Bucklin encountered a line of stretchers a mile and a half long, with rain pelting those awaiting their turn with the surgeons. Passing the night on a bare iron bedstead, she “fished up” her shoes with the handle of her umbrella in the morning and learned “how much, which at home we call necessary, can be lopped off, and we still be satisfied.”[3] Nursing Southern soldiers was not easy for her. She saw weaknesses of character, as did Emily Bliss Souder of Baltimore, who branded the rebels crybabies. Imperious in their observations of the enemy, Union nurses like Georgeanna Woolsey, a blue-blooded New Yorker with six siblings in the war effort, still insisted that relief workers treated Northerners and Southerners alike—with sympathy and delicacy—and that the men’s weakened state fostered a surprising spirit of conciliatory brotherhood in hospital tents.

With so much work to be done, few medical officers worried about the scores of women who came to town in the second week, hauling baskets of food and bedding. But there were those like Franklin Dyer, surgeon of the 19th Massachusetts assigned to the 2nd Corps, who wanted the women to disappear, presumably because they disrupted surgical focus. Dyer observed that six months earlier at Fredericksburg, a colleague had told him that the famed Clara Barton “plagued me so that I had to get her out of the cook house and put one of my own men in charge.”[4] Like other sleep-deprived surgeons, Dyer’s patience was fraying and he found no solace in the high prices that the people of Gettysburg were charging for food from their larders. Prejudices aside, there was little anyone could do to prevent civilians—some who wanted to help and others who wanted to gawk—from flooding the town.

At the start of each day, stewards set out vials of chloroform and morphine sulfide, anticipating the amputations that would begin as soon as ambulances could deliver up their harvest of wounded flesh. Confederate Surgeon Simon Baruch of the 3rd South Carolina Battalion used whatever came to hand for operations in the field: wagon tailgates, wooden doors spanning barrels, even a church communion table. After the Confederate retreat on July 3 left him to fend for hundreds of wounded Rebels on his own, he was the grateful recipient of Union mules and a wagonload of medicinal and commissary goods sent by Jonathan Letterman—an indication that medical cooperation sometimes trumped political partisanship. Throughout the three days of the battle, field surgeons were forced to move their dressing stations to keep up with the fluctuating line of fire while more experienced practitioners operated in houses and barns impressed by corps medical officers. Wounded men were sometimes caught in the crossfire, and medical staff were wounded and killed by stray bullets or shrapnel. When Pennsylvania hospital steward Spencer Bonsall’s horse was shot out from under him, the thousand-pound animal collapsed on top of him, causing a lengthy hospitalization. Assistant Surgeon Morgan Baldwin of the 32nd Massachusetts reported that on July 2 alone, his medical unit was compelled to move three times. At the last place, a soldier with exposed intestines begged him for help, but the man would die in several hours and Baldwin’s superior berated him for wasting his time on a dead man. Later that night, as he returned to the Weikert farmhouse to assist with amputations, he witnessed hogs on the loose, feeding on the deceased. It was not a good day.

In the days following the battle, vendors selling coffins and offering passage to relatives who had come to find their soldiers’ bodies descended upon the town, increasing stress for medical staff and relief workers who were suffering from physical as well as emotional fatigue. Northern civilians attempted to secure information concerning the whereabouts of their loved ones’ graves, and some 1,500 of them succeeded in getting their boys disinterred and transported back home. Others searched in vain or arrived too late for parting words, despite the Sanitary Commission’s efforts to make available the location of the wounded. Southerners, if they ventured to Gettysburg at all, were advised to avoid the notice of vengeful Northern citizens. One of these, Margaret Bissell, upon coming to bury her husband, discovered that he had been interred en masse in a trench of more than a hundred bodies.

By early August, Camp Letterman—a fully supplied tent hospital—had been established on the outskirts of Gettysburg, and the men who remained in temporary corps hospitals were transferred to the new facility to die in some cases of secondary infections and subsequent amputations or to recover. Joshua Lawrence Chamberlain of Maine, one of the lucky ones and a rhetoric professor at Bowdoin College, led the regiment credited with stopping Confederate forces at Little Round Top, and went on, despite a bullet to the foot, to become governor of Maine. As a young member of the medical corps remarked on July 3, “A surgeon could get more experience here in one night than he could get back home in years.”[5] Inevitably the horrific aftermath of the Battle of Gettysburg made Americans beg for closure. Even if it provided abundant living material for surgeons-in-training and advanced the science of evacuation, it did not spare caregivers trauma, despite what pundits claimed was a glorious turn in Union fortunes. If anyone had foreseen the casualties that were to come as a result of fighting in 1864, then those same caregivers might have understood that Gettysburg merely prepared them for worse.

[1] Unpublished narrative of Sister Camilla O’Keefe, St. Joseph’s Archives, Emmitsburg, Maryland.

[2] Cornelia Hancock to her mother, July 26, 1863; and Cornelia Hancock to her sister, August 6, 1863, in Letters of a Civil War Nurse: Cornelia Hancock, 1863–1865, ed. Henrietta Stratton Jaquette (Lincoln: University of Nebraska, 1998), 15.

[3] Sophronia Bucklin, In Hospital and Camp: A Woman’s Record of Thrilling Incidents among the Wounded in the Late War (Philadelphia: John E Potter, 1869), 145.

[4] J. Franklin Dyer, The Journal of a Civil War Surgeon, ed. Michael B. Chesson (Lincoln: University of Nebraska, 2003), xxiv.

[5] Clyde Kernek, Field Surgeon at Gettysburg: A Memorial Account of the Medical Unit of the 32nd Massachusetts Regiment (Indianapolis: Guild Press, 1993), 68.

Jane E. Schultz is a professor of English and an adjunct professor of American Studies, Women's Studies, and Medical Humanities at Indiana University-Purdue University Indianapolis. She is the author of Women at the Front: Hospital Workers in Civil War America (2004).

From: gilderlehrman.org

Read More

A Field Hospital at the Battle of Perryville, Kentucky

From: tm4me.org

Dr. Charles Todd Quintard 's description of a field hospital at the Battle of Perryville, Kentucky:

"When the wounded were brought to the rear, at three o’clock in the afternoon, I took my place as a surgeon…and throughout the rest of the day and until half past five the next morning, without food or any sort, I was incessantly occupied with the wounded.  It was a horrible night I spent,--God save me from such another….

"About half past five in the morning of the 9th, I dropped—I could do no more.  I went out by myself and leaning against a fence, I wept like a child.  And all that day I was so unnerved that if any one asked me about the regiment, I could make no reply without tears…The total loss of the Confederates …was 510 killed, 2,635 wounded and 251 captured or missing, and of this loss a great part was sustained by our regiment (the Rock City Guards from Nashville)."

Doctor Quintard, Chaplain C.S.A. and Second Bishop of Tennessee, edited by Sam Davis Elliott,  Louisana State University Press, Baton Rouge.  2003

Read More

Antietam: Aspects of Medicine, Nursing and the Civil War

By John Tooker, MD, MBA, FACP

Abstract
Robert E. Lee's Army of Northern Virginia met the Army of the Potomac under George B. McClellan at Antietam Creek near Sharpsburg, Maryland on September 17, 1862. Before the day was done, nearly 23,000 men were killed, wounded, or missing, memorializing Antietam as the bloodiest single day in American military history. Dr. Jonathan Letterman, the Medical Director of the Army of the Potomac, Clara Barton, the “Angel of the Battlefield,” and Dr. Hunter McGuire, Chief Surgeon to and Medical Director of General Stonewall Jackson's Corps, were among the nursing and medical personnel engaged on that historic day. These three individuals provided medical and nursing care to the casualties at Antietam (and other Civil War battles), but perhaps more importantly, developed systems of casualty management that brought order and humanity to the battlefield. These models of care continue today in modern military medicine.

Introduction
The War Between the States provides an unfortunate but ideal opportunity to explore the evolution of battlefield medicine through the contributions of several individuals—Dr. Joshua B. Letterman, Clara Barton, and Dr. Hunter Holmes McGuire—to improving the medical care of soldiers on both sides of the conflict. Civil War casualties surpassed all other American wars in percentage of combatants killed in action, wounded and dead from all causes (particularly disease). The absolute total killed in action, wounded and dead from other causes in the war was also very high, about equivalent to World War II (1). Several factors accounted for the increased casualties: improved accuracy, range and power of the armaments employed, battlefield tactics of the day and poor public health conditions.

Tactics and Weapons
Many of the formally trained General officers of both armies received military education and training at the U.S. Military Academy, where they were instructed in battle tactics by Dennis Hart Mahan, the West Point professor of military science from 1830–1871 (2). Concentration of forces, rank and file battle formation, close quarters combat and an emphasis on flanking were military doctrine of the time, borrowed in large part from the Napoleonic experience. These battle tactics and the devastating power of the rifles and artillery used during the war resulted in very high numbers of killed and wounded in action. The basic infantry weapon was the Springfield rifled musket, accurate at 500 yards, firing a .58 caliber minie ball, which was actually a rifled bullet, not a smooth bore ball (3). Cannon were both smooth bore and rifled, improving in range, power and accuracy throughout the war. These cannon fired a variety of projectiles from solid shot to exploding shells, canister and chain, fired at close range with devastating effect (4). Enfilade fire, directed along the length rather than the breadth of a formation during a flanking maneuver, was particularly effective and lethal at Antietam.

Battlefield Medicine and Surgery at the Beginning of the Civil War
To put the Civil War in perspective, the U.S. population at the war's beginning was about 34 million. Nearly 4 million men, more than 11 percent of the entire American population, were engaged in the war (1). Most came from rural backgrounds, lacked immunity to communicable disease and were unprepared to be concentrated in close, unsanitary quarters, making them susceptible to illnesses such as dysentery, measles, smallpox and malaria. Military surgeons had little understanding of the causes of communicable disease and most treatments were ineffective. Basic necessities, particularly in the Confederacy later in the war, such as shoes, clothing, food and clean water, were in short supply. On average, the Confederate soldier was estimated to be ill or injured about 6 times over the course of the war (5,6). The viewpoint of the average soldier is more telling than statistics. From Pvt. Alexander Hunter, Company A, 17th Virginia Infantry on arrival at Hagerstown near Sharpsburg, Maryland before the Battle of Antietam: “Another day's march brought us to Hagerstown where the cornfields and orchards furnished our meals. The situation, in a sanitary point, was deplorable. Hardly a soldier had a whole pair of shoes. Many were absolutely bare-footed, and refused to go to the rear. The ambulances were filled with the foot-sore and sick” (7).

Most Civil War military surgeons were graduates of unregulated two-year medical schools. At the beginning of the conflict, most had never treated a gunshot wound, and very few were experienced in evaluating and treating the injuries of war. Although general anesthesia became available in 1846, most surgeons were untrained in surgical techniques and had not performed surgery. Lister's theory of sepsis and subsequent antiseptic techniques were not applied to surgical and post-operative care until after the war. While chest, abdominal and neurological surgery were rarely possible, treatment of extremity injuries was possible and necessary. Amputation was commonly practiced and became the primary surgical skill of the Civil War battlefield surgeon (5,6). The organization of medical care in 1861 when the war began was centered on the role of individual physicians rather than systems of care designed to handle mass casualties. Both armies were shocked at the high casualty rates and unprepared for the management of these casualties.

Prior to the onset of hostilities in 1861, the Medical Department of the Union army was small, numbering only one Surgeon General, thirty Surgeons, and eighty-four Assistant Surgeons. Some of these surgeons resigned their Union commissions to join the Confederate Medical Department. By the end of the war four years later, the Union Medical Department expanded to more than 10,000 surgeons (6).

The Medical Department of the Confederate States of America was established in February, 1861 by the “Act for the Establishment and Organization of a General Staff for the Army of the Confederate States of America” of the Provisional Congress. The act provided for a medical department of one Surgeon General, four surgeons, and six assistant surgeons. By the end of the war, the South had about 4,000 military surgeons (8).

Antietam
With the Peninsula campaign over and Richmond no longer threatened, Lee was in command of the Army of Northern Virginia. He turned his attention to northern Virginia, defeating the Army of the Potomac under Pope in July, 1862 at Second Manassas. As Pope retreated to Washington, Lee seized the initiative, crossing the Potomac into Maryland, just south of Frederick, with 55,000 men (9,10). Lee's grand strategy was to liberate Maryland, gather recruits sympathetic to the Confederate cause and, obtain much needed supplies. Jefferson Davis entertained the possibility that if Lee could defeat the Union on northern soil, the Confederacy might gain European recognition, perhaps providing much needed supplies and assistance in lifting the Union blockade of southern ports.

Lee drafted his plan of battle, Special Order 191, for his commanding generals on September 9, 1862. After Lee vacated Frederick, advancing toward Hagerstown, Maryland, a copy of S.O. 191 was found in a field by a corporal of the 27th Indiana, wrapped around three cigars (10). General George B. McClellan, now in command of the Army of the Potomac, had Lee's battle plan. He pursued Lee with 77,000 men, closing the gap between the armies near Sharpsburg, Maryland, where Lee chose to turn and face McClellan across Antietam creek (9,10).

On the morning of September 17, 1862, 130,000 soldiers were ready for battle. The day dawned gray and misty, but soon cleared. McClellan's battle plan was to turn both flanks and roll up Lee's army. Beginning at 6:00 AM with a Union assault through Miller's Cornfield, the battle proceeded roughly north to south along a three-mile long and half-mile wide front. The 30 acres of the Cornfield would change hands 6 times in three hours with 10,000 casualties. Union General Joseph Hooker reacted to the slaughter: “…the slain lay in rows precisely as they had stood in their ranks only a few minutes before” (9). The ferocious assaults and counter assaults at close quarters with musket and cannon, from the Cornfield to the north through the Sunken Road (also known as Bloody Lane) to the southern salient of Burnside's Bridge, lasted about twelve hours. The dramatic arrival of A. P. Hill's division from Harper's Ferry, just in time to attack the left flank of Union General Ambrose Burnside's forces, saved Lee's army from annihilation (9,10).

The battle ended as abruptly as it had begun. Total casualties on both sides, killed, missing and wounded, were about 23,000—more Americans died on September 17, 1862, than on any other day in the nation's military history (1,11), including World War II's D-Day. Lee expected McClellan to attack with much superior numbers on the following day, September 18th, but the attack did not come and there were no hostilities that day. The ambulance corps of both armies worked to clear the field of the injured and dead. The night of the 18th, Lee withdrew the Confederate forces west across the Potomac at Shepherdstown, Virginia (now West Virginia), ending the immediate hope that the Confederates could win on northern soil. The South also lost any possibility that any European countries would support their cause. Shortly thereafter, Lincoln issued the Emancipation Proclamation, changing the strategic focus of the war from preserving the union to abolishing slavery.

Dr. Jonathan Letterman
Jonathan Letterman was a native Pennsylvanian, graduating from Jefferson Medical College in Philadelphia in 1849, soon followed by military service as a U.S. Army Medical Department Assistant Surgeon in the Seminole Indian Wars with Stonewall Jackson. Assigned to the Army of the Potomac in June 1862, Major General McClellan promoted Letterman to the post of Medical Director of the Army of the Potomac. By September, Letterman had devised an efficient and, for the times, modern system of mass casualty management, beginning with first aid adjacent to the battlefield, removal of the wounded by an organized ambulance system to field hospitals for urgent and stabilizing treatment, such as wound closure and amputation, and then referral to general hospitals for longer term definitive management. This three-stage approach to casualty management, strengthened by effective and efficient transport, earned Letterman the title of “The Father of Battlefield Medicine” (12). While simple in design, the orderly and organized execution of a casualty management plan in the confusion of war, with very large numbers of casualties, was a massive undertaking. Each battle required advance planning and marshalling of vital resources, such as skilled and trained first aid attendants near the battlefield, ambulance attendants and drivers, wagons, mules, nurses, surgeons, medical supplies, clean water, food and firewood. Communications among the cooperating parties were difficult, and, of course, the rate at which casualties were received could not be controlled. Letterman's official battle report outlines in detail the logistical challenges of providing medical support to the army (12).

The management of casualties was organized at the unit level—first aid at the regimental level with triage to the mobile field hospitals at the division and corps level. The ambulance corps was established by U.S. Army Special Order 147 in August of 1862, following the Seven Days Battle that ended the Peninsular Campaign in July of 1862. Letterman's model of casualty management became the standard for the Union Army by an act of Congress in March 1864. At First Manassas in 1861, with about 5,000 combined dead and injured soldiers, it took a week to get the casualties off the field. At Antietam, with about 23,000 dead and wounded, all the casualties were removed from the battlefield in 24 hours (13,14).

The mass casualty management system that Letterman devised was extensively utilized after Antietam, perhaps no better than at Gettysburg. There were more than 50,000 casualties, dead and wounded during the three day battle in early July, 1863. At the close of the battle, 22,000 wounded Union and Confederate soldiers were treated according to the Letterman model. A large general hospital, Camp Letterman General Hospital, was constructed at Gettysburg to provide care to the wounded long after the armies had moved on. Once the general hospital closed, those needing continuing hospitalization were shipped to larger hospitals in Philadelphia, Baltimore, Washington and Richmond (15).

Clara H. Barton
Clara Barton was born in Massachusetts in 1821 and raised in a socially conscious family, influenced by her parents who favored abolition and championed women's rights. An avid learner, Barton received both home and formal education, becoming a teacher in Massachusetts. She returned to formal education at the Clinton Liberal Institute in New York State, a respected school overseen by the Unitarian Universalist Church. She then moved to Bordentown, New Jersey and, pursuing public service, established the first free public school in New Jersey. Barton left teaching in 1854, moved to Washington, D.C. and was working in the U.S. Patent Office there at the beginning of the war.

In response to the declaration of war at Fort Sumter in early April, 1862, the Union mobilized to defend Washington, D.C. The 6th Massachusetts Infantry, passing through Baltimore on April 19th, 1862, was attacked by southern sympathizers. Several soldiers were killed and others injured. The wounded were taken to the Senate Chamber of the U.S. Capital where they were personally cared for by Barton, beginning her involvement in the Civil War.

Partly because of her experience with the 6th Massachusetts Infantry, Barton was keenly aware that the U.S. Army Medical Department was unprepared for the treatment of casualties. She successfully petitioned the military, with the help of U.S. Senator Henry Wilson of Massachusetts, to assist in bringing supplies and personal aid to battlefields in 1862, a substantial logistical problem. Volunteers, such as Barton, provided an invaluable service early in the war until larger charitable organizations, such as the U.S. Sanitary Commission, were able to assist the Union Army on providing basic necessities, sanitation and medical support for the troops (16).

Among the battles that Barton attended were Cedar Mountain, Second Manassas, Antietam, and Fredericksburg. At Antietam, Barton waited with Burnside's Ninth Corps as the only woman. She arrived on the northern edge of Miller's Cornfield around noon on September 17th with wagons of supplies while the battle was still being fought. The surgeons she personally assisted were astonished to see her but gratified. It was there that she earned the title of “The Angel of the Battlefield” from a Union surgeon, Dr. James Dunn (17).

Dr. Hunter Holmes McGuire
Hunter Holmes McGuire was born in Winchester, Virginia, in 1835, the son of a respected physician and surgeon, Dr. Hugh Holmes McGuire. Hunter received his initial medical degree from Winchester Medical College (Virginia) in 1855 and, three years later, entered Jefferson Medical College in Philadelphia. McGuire showed signs of leadership at an early age. In 1859, following John Brown's execution in the aftermath of the ill-fated raid on the arsenal at Harper's Ferry, Brown's body was brought to Philadelphia and became a source of friction between the northern and southern medical students. McGuire organized the withdrawal of several hundred southern medical students from Jefferson, many of whom enrolled in the Medical College of Virginia in Richmond as did McGuire. Following graduation, McGuire returned to Winchester and in 1861 enlisted in the Confederate Army as a private. The Confederate Surgeon General soon reassigned McGuire as the medical director of the Army of the Shenandoah under Thomas J. (Stonewall) Jackson. McGuire served continuously with Jackson as his medical director and as a trusted confidant and surgeon. Jackson was shot through the left arm and right palm at Chancellorsville by friendly fire in May of 1863. McGuire skillfully amputated Jackson's arm and personally cared for him until Jackson's death eight days later.

As the medical director, McGuire organized the medical service of the Army of the Shenandoah in 1861, beginning with hospital administration, operating procedures and transport. His “genius for efficient organization” (18,19) soon extended to the battlefield where he organized the treatment of casualties much as Letterman had done. After initial treatment, adjacent to the battlefield by the Regimental Infirmary Corps, the Ambulance Corps transported the wounded to Reserve Corps or mobile field hospitals for urgent treatment, and then to general hospitals in the rear and finally, for those needing extended care, to hospitals in Richmond and other major cities. As in the case of the Army of the Potomac and Letterman, McGuire was also responsible for the challenging logistics of supply and transport.

Legacies
Dr. Jonathan B. Letterman resigned his commission in December, 1864, completing his service to the Union Army and moved to San Francisco where he practiced medicine and served as a coroner. His memoir, Medical Recollections of the Army of the Potomac, was published in 1866. Letterman died at the young age of 48 on March 15, 1872 and was later interred in Arlington National Cemetery. The Army Hospital at the Presidio was named Letterman General Hospital in 1911, honoring the military physician who pioneered the care of battle casualties.

Clara H. Barton was asked by President Lincoln as the war ended to assist in locating and identifying the missing in action, including the thousands of unknown who died in military prisons. Before her work was finished, more than 22,000 missing soldiers were identified (16). She is most known for her role in founding the American Red Cross, following a trip to Europe where she became familiar with the Geneva Convention and the International Red Cross. Because of concerns that any international intervention in U.S. Wars would be a violation of the Monroe Doctrine, the American branch of the International Red Cross was not authorized by Congress until 1882 (16,17,20).

Dr. Hunter Holmes McGuire was a prisoner of war at Waynesboro in March of 1865. Paroled by General Sheridan, McGuire continued service with Lee's army until the war ended at Appomattox in April, 1865. He returned to Richmond as a professor of surgery in July, 1862, leading to a distinguished academic surgical career. He was a founder of the University College of Medicine in Richmond in 1892, later merged with the Medical College of Virginia. Highly respected by his peers, McGuire was elected president of the Southern Surgical association and the American Medical Association (18). Today, The Hunter Holmes McGuire Veteran's Administration Medical Center, is named in his honor.

DISCUSSION
Lindberg: Bethesda: I very much enjoyed your presentation. Just a minor footnote to the Baltimore incident. I think it said that the first six federal casualties of the war occurred in Baltimore, because of the local feelings you referred to. They had another peculiarity there at the time—namely, two railroad stations, more or less like Pennsylvania Station, Grand Central in New York, which wouldn't communicate with each other. So passengers had to get off one train and walk three or four blocks to the other station, and that's where the shooting occurred. That also made Lincoln, when he was on his way to inauguration, his staff refused to allow him to be exposed to exactly that circumstance, and he came in the darkness of night at 2 a.m.—a move he regretted for the rest of his life. He felt embarrassed about that. But in order to get federal troops to Washington they actually brought them by boat to Annapolis, because they didn't dare go through Baltimore. Still a tough place.

Tooker: Philadelphia: Thank you.

REFERENCES
1. Statistical Summary; America's Major Wars. The U.S. Civil War Center (Louisiana State University Libraries Special Collections) Available at: http://www.cwc.lsu.edu/other/stats/warcost.htm.
2. Snell K. Influence of Napoleon on Civil War Tactics and Strategy. Available at: http://www.civilwarhome.com/napoleontactics.htm.
3. Civil War Small Arms. National Park Service, U.S. Department of the Interior. Available at: http://www.nps.gov/archive/gett/soldierlife/webguns.htm.
4. Artillery at Antietam. National Park Service, U.S. Department of the Interior. Available at: http://www.nps.gov/archive/anti/artilery.htm.
5. Civil War Medicine (Ohio State University Department of History) http://ehistory.osu.edu/uscw/features/medicine/cwsurgeon/introduction.cfm.
6. Caring for the Men: The History of Civil War Medicine. Available at: http://www.civilwarhome.com/medicinehistory.htm.
7. Eyewitness to Battle. Antietam Battlefield, National Park Service, U.S. Department of the Interior. Available at: http://www.nps.gov/anti/historyculture/eyewitness-to-battle.htm.
8. Cunningham HH. Vol. 3. Baton Rouge: Louisiana State University Press; 1958. Doctors in Gray: The Confederate Medical Service; p. 21.
9. Robertson JI., Jr Stonewall Jackson: The Man, The Soldier, The Legend New York: Macmillan. 1997:584–624.
10. Freeman DS. New York: Simon and Schuster; 1998. Lee's Lieutenants: A Study in Command (Abridgement by Sears, S.W.) pp. 335–371.
11. Antietam Battlefield, National Park Service, U.S. Department of the Interior. Available at: http://www.nps.gov/anti/historyculture/casualties.htm.
12. Letterman J. Part 1. Vol. 19. Washington DC: US Government Printing Office; 1880–1901. Official Report. US War Department, The War of the Rebellion: a Compilation of the Official Records of the Union and Confederate Armies (OR), 128 vols; pp. 106–117. [AotW citation 164]. Available at: http://aotw.org/exhibit.php?exhibit_id=73.
13. Surgeon Jonathan Letterman. Available at: http://aotw.org/officers.php?officer_id=919.
14. Blagg CR. Triage. Napolean to the Present Day. J Nephrology. 2004;17:629–632. [PubMed]
15. Camp Letterman General Hospital, Gettysburg National Military Park. National Park Service, U.S. Department of the Interior. Available at: http://www.nps.gov/archive/gett/gett/tour/sidebar/letterman.htm.
16. Evans GE. Clara Barton. Teacher, Nurse, Civil War heroine, Founder of the American Red Cross. International History of Nursing Journal. 2003:75–80. [PubMed]
17. National Park Service, U.S. Department of the Interior. Clara Barton-Angel of the Battlefield. Available at: http://www.nps.gov/archive/anti/clara.htm.
18. Stonewall's Surgeon Dr. Hunter Holmes McGuire: Surgeon, Physician, Teacher, Patriot Goellnitz, J Southern Historical Society Papers. Available at: http://www.huntermcguire.goellnitz.org/biography2.html.
19. Hassler WW. Dr. Hunter Holmes McGuire: Surgeon to Stonewall Jackson, the Confederacy and the Nation. Virginia Cavalcade (Virginia Sate Library) 1982;XXXII:52–61. [PubMed]
20. Skocpol T, Munson Z, Karch A, et al. Patriotic Partnerships: Why Great Wars Nourished Civic Volunteerism. In: Katznelson I, Shefter M, editors. Shaped by War and Trade: International Influences on American Political Development. Princeton University Press; 2001.

From: ncbi.nlm.nih.gov

Read More

The Ghastly Work Of The Field Surgeons

From: civilwarhome.com

      Here are three descriptions of the work of the surgeons, all of them tending to bear out the complaints of the Baroness von Oinhausen. These descriptions of heartlessness could be matched in letter after letter, diary after diary, North and South. One Kentucky editor charged that the doctors had " slain more of our troops than all of Lincoln's minions " and a Richmond one characterized the Medical Department as "unfeeling,'shameful and brutal." We must remember however that it is the exceptionally bad conduct that gets recorded; routine work is taken for granted. On the whole the surgeons and nurses did about as well as they could. Certainly many of those who worked all through the war, at great peril to themselves, were distinguished members of a distinguished profession.

        The first of these critics, Samuel Nichols, was an Amherst College student who enlisted in the 37th Massachusetts Volunteers; served through the war; and later edited the Pittsfield (Massachusetts) Sun. The second is the famous politician and reformer Carl Schurz, who commanded the XI Corps at Gettysburg. The third is Augustus Brown, Captain in the 4th New York Heavy Artillery.

A. THE HEARTLESSNESS OF THE SURGEONS

Hd. Qtrs- 37th Regiment Mass. Vols.
Camp near Stafford Court House
Nov. 23rd 1862

My Dear Cousin Phebe:

        As yet only four of our number have died and some six have been discharged, two of the latter of whom were officers. Lieut. Eli T. Blackmer, a son of the Blackmer that moved from Hodges Corner in Warren, is discharged and has gone to his home in Chicopee. His health is much impaired, and his discharge was merited. Everything here concerning sickness and its management seems so repulsive that the thought of being sick or of having one of your friends in the Hospital, is filled with gloom. I will relate an instance. It is probably an instance more censurable to those having charge than usually occurs; but if the whole history of this war were brought to light more such facts would be revealed, in my mind, than would be pleasing to men (no, brutes) whose duty it is to look after the physical health of the soldier.

        In our regiment was a man, private of course, who came under my notice while we were at New Baltimore, a little over one week since. He was emaciated and almost spiritless. He, to be sure, was not as cleanly as he should have been; but I know that it requires much exertion where water is scarce (and it always is in the vicinity of an army like ours) to keep decent. He looked as though he had been sick for some time. He like many others had acquired a dislike to reporting himself to the surgeons, as they have an idea the surgeons are destitute of feeling and unjust. I will not say how far this feeling is just. He at length came with those of his company who reported sick that day to the Surgeon's office within a few steps of where I sleep. I stood at the mouth of my tent and saw and heard the treatment each patient received. This fellow was treated as the rest. He took his turn and came to the front of the Doctor's tent, and received the customary question, "What's the matter with you?" (pretty question for a doctor). "What are you here for? Let's see your tongue. Shall return you to duty."

        He was returned to duty. He refused to do duty and as punishment was sentenced to stand on the barrel (a very severe punishment), and added to this, to hold a heavy stone in his hand, two hours on and two off. This was the Doctor's work and not the Colonel's. I admit that it was the Colonel's duty to stop an unjust punishment if he saw one being exacted, but he would probably refer the whole case to the Doctor. To continue my story: after this I watched that young man. All energy seemed absent from him, and he acted as if he was unable to stir. I went to him and advised him to go to the Surgeon again, knowing that by tiring out the M.D. he might receive attention. I could not induce him. I saw during my conversation that he was really sick; and I was anxious to find out what ailed him, knowing if I did, I could find him medicine. I went to another regiment to get a doctor with whom I was acquainted to come and see him; but the regiment had moved that morning, and so I let the matter go for the time being. Two mornings after I saw him again at the Doctor's tent. With the usual flourishes he was reported for duty, and the next morning he was brought to the Hospital to die almost immediately. The same day he was buried with soldier's honors; and with the last volleys fired over his grave died all feelings of remissness or regret, if any such feelings were entertained.
-UNDERHILL, ed'., "Your Soldier Boy Samuel"

B. CARL SCHURZ WATCHES THE SURGEONS AT WORK AFTER GETTYSBURG

        To look after the wounded of my command, I visited the places where the surgeons were at work. At Bull Run, I had seen only on a very small scale what I was now to behold. At Gettysburg the wounded-many thousands of them-were carried to the farmsteads behind our lines. The houses, the barns, the sheds, and the open barnyards were crowded with the moaning and waiting human beings, and still an unceasing procession of stretchers and ambulances was coming in from all sides to augment the number of the sufferers. A heavy rain set in during the day-the usual rain after a battle and large numbers had to remain unprotected in the open, there being no room left under roof. I saw long rows of men lying under the eaves of the buildings, the water pouring down upon their bodies in streams. Most of the operating tables were placed in the open where the light was best, some of them partially protected against the rain by tarpaulins or blankets stretched upon poles.

        There stood the surgeons, their sleeves rolled up to the elbows, their bare arms as well as their linen aprons smeared with blood, their knives not seldom held between their teeth, while they were helping a patient on or off the table, or had their hands otherwise occupied; around them pools of blood and amputated arms or legs in I heaps, sometimes more than man-high. Antiseptic methods were still unknown at that time. As a wounded man was lifted on the table, often shrieking with pain as the attendants handled him, the surgeon quickly examined the wound and resolved upon cutting off the injured limb. Some ether was administered and the body put in position in a moment. The surgeon snatched his knife from between his teeth, where it had been while his hands were busy, wiped it rapidly once or twice across his blood-stained apron, and the cutting began. The operation accomplished, the surgeon would look around with a deep sigh, and then-"Next!"

        And so it went on, hour after hour, while the number of expectant patients seemed hardly to diminish. Now and then one of the wounded men, would call attention to the fact that his neighbor lying on the ground had given up the ghost while waiting for his turn, and the dead body was then quietly removed. Or a surgeon, having been long at work, would put down his knife, exclaiming that his hand had grown unsteady, and that this was too much for human endurance-not seldom hysterical tears streaming down his face. Many of the wounded men suffered with silent fortitude, fierce determination in the knitting of their brows and the steady gaze of their bloodshot eyes. Some would even force themselves to a grim jest about their situation or about the "skedaddling of the rebels." But there were, too, heart-rending groans and shrill cries of pain piercing the air, and despairing exclamations, "Oh, Lord! Oh, Lord!" or "Let me die!" or softer murmurings in which the words "mother" or "father" or "home" were often heard.

        I saw many of my command among the sufferers, whose faces I well remembered, and who greeted me with a look or even a painful smile of recognition, and usually with the question what I thought of their chances of life, or whether I could do anything for them, sometimes, also, whether I thought the enemy were well beaten. I was sadly conscious that many of the words of cheer and encouragement I gave them were mere hollow sound, but they might be at least some solace for the moment.
-BANCROFT AND DUNNING, eds., The Reminiscences of Carl Schurz

C. THE HORRORS OF THE WILDERNESS

        Tuesday, May 10th [1864]. Heavy cannonading from 8 A.M. to 1 P.M. The Pontoon train has been sent back to Fredericksburg, apparently to get it out of the way, and the army horses are put on half-rations, that is, five pounds of food. Ambulances and army wagons with two tiers of flooring, loaded with wounded and drawn by four and six mule teams, pass along the plank, or rather, corduroy road to Fredericksburg, the teamsters lashing their teams to keep up with the train, and the wounded screaming with pain as the wagons go jolting over the corduroy. Many of the wounds are full of maggots. I saw one man with an arm off at the shoulder, with maggots half an inch long crawling in the sloughing flesh, and several poor fellows were holding stumps of legs and arms straight up in the air so as to ease the pain the rough road and the heartless drivers subjected them to. These men had been suffering in temporary field hospitals, as no opportunity had been afforded to send them to the rear until we got within reach of the road running to Fredericksburg.

        And this reminds me of a scene I witnessed a day or two since which seemed to me to cap the climax of the horrors of war. Passing along a little in the rear of the lines when a battle was raging in which in battalion was not engaged, I came upon a field-hospital to which the stretcher-bearers were bringing the men wounded in the conflict. Under three large "tent flies," the center one the largest of all, stood three heavy wooden tables, around which were grouped a number of surgeons and their assistants, the former bareheaded and clad in long linen dusters reaching nearly to the ground, which 'were covered with blood from top to bottom and had the arms cut off or rolled to the shoulders. The stretcher-bearers deposited their ghastly freight side by side in a winrow on the ground in front of the table under the first tent fly. Here a number of assistants took charge of the poor fellows, and as some of them lifted a man on to the first table others moved up the winrow so that no time nor space should be lost. Then some of the surgeons administered an anaesthetic to the groaning and writhing patient, exposed his wound and passed him to the center table. There the surgeons who were operating made a hasty examination and determined what was to be done and did it, and more often than not, in a very few moments an arm or a leg or some other portion of the subject's anatomy was flung out upon a pile of similar fragments behind the hospital, which was then more than six feet wide and three feet high, and what remained of the man was passed on to the third table, where other surgeons finished the bandaging, resuscitated him and posted him off with others in an ambulance. Heaven forbid that I should ever again witness such a sight!

Read More