Dr. Mary Walker, Surgeon

From: chnm.gmu.edu

Dr Mary Edwards Walker led an unconventional life for a women of the mid-nineteenth century. She became a doctor when few women were even credentialed in nursing, divorced in an era when women's positions were primarily defined by wifehood and motherhood, advocated dress reform for women and even wore men's full-dress clothing to lecture on women's rights. She often challenged medical orthodoxy—discouraging surgeons, for example from extensive practice of amputation.

Dr. Walker is also the only woman ever awarded the Congressional Medal of Honor.

Born in Oswego New York in 1832, her father urged her to pursue a medical career and in 1855, she graduated from Syracuse Medical College and married a fellow-graduate, but later divorced.

As the Civil War broke out, Dr. Walker traveled to Washington to petition for a commission in the Army as a surgeon. Denied the commisison, she served for several months as a contract surgeon. When she Walker was finally appointed assistant surgeon in the Army of the Cumberland, she made herself a slightly modified officer's uniform that gave her more mobility when treating soldiers and working in field hospitals than women's clothing of the day.

Dr. Mary Walker wearing the Congressional Medal of Honor, advocated dress reform for women and frequently adapted men's clothing for professional and personal comfort and utility.
Dr. Walker was then appointed assistant surgeon of the 52nd Ohio Infantry. She continually crossed Confederate lines to treat civilians. Although she later fought rumors that she was not a qualified doctor, but a Union spy, it is presumed that she passed information during that time. Dr. Walker was taken prisoner in 1864 by Confederate troops and imprisoned in Richmond for four months until she was exchanged, with two dozen other Union doctors, for 17 Confederate surgeons.

After the war, President Andrew Johnson awarded her the Congressional Medal of Honor. Her citation reads, in part,

Rank and organization: Contract Acting Assistant Surgeon (civilian), U. S. Army. Places and dates: Battle of Bull Run, July 21, 1861; Patent Office Hospital, Washington, D.C., October 1861; Chattanooga, Tenn., following Battle of Chickomauga, September 1863; Prisoner of War, April 10, 1864_August 12, 1864, Richmond, Va.; Battle of Atlanta, September 1864. Entered service at: Louisville, Ky. Born: 26 November 1832, OswegoCounty, N.Y.

Citation: Whereas it appears from official reports that Dr. Mary E. Walker, a graduate of medicine, "has rendered valuable service to the Government. and her efforts have been earnest and untiring in a variety of ways," and that she was assigned to duty and served as an assistant surgeon in charge of female prisoners at Louisville, Ky., upon the recommendation of Major_Generals Sherman and Thomas, and faithfully served as contract surgeon in the service of the United States, and has devoted herself with much patriotic zeal to the sick and wounded soliders, both in the field and hospitals, to the detriment of her own health, and has also endured hardships as a prisoner of war four months in a Southern prison while acting as contract surgeon; and
Whereas by reason of her not being a commissioned officer in the military service, a brevet or honorary rank cannot, under existinglaws, be conferred upon her; and
Whereas in the opinion of the President an honorable recognition of her services and sufferings should be made:

"It is ordered, That a testimonial thereof shall be hereby made and given to the said Dr. Mary E. Walker, and that the usual medal of honor for meritorious services be given her.
Given under my hand in the city of Washington, D.C., this 11th day of November, A.D. 1865."

In 1917, when criteria for awarding the Congressional Medal of Honor changed, Dr. Walker's award was rescinded along with more than 900 others. She refused to return it, however, and wore it always. President Jimmy Carter restored the award to her in 1977. As a result of her service to the Union during the Civil War, Mary Walker was paid $766.16 and provided a monthly pension lower than those of most war widows.

Image: Dr. Mary Walker in 1913

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Civil War Surgery

By Pvt. Hugh R Martyr, 20th Maine

The War broke out during a transition period in medical knowledge. Anaesthesia had been used since the 1840's and thus allowed operations to be performed that hitherto would have been impossible. However there was no knowledge or understanding about the spread of infection until the 1870's. Thus, able to carry out major surgery, medical staff unwittingly caused serious problems with infection.

By far, the most common of wounds to be dealt with, were caused by gunshot. The Minié Ball made a hideous wound, often changing shape as it entered the body and dragging in dirty clothing; upon hitting bone it caused shattering which in turn increased the severity of the damage. Approximately 71 per cent of gunshot wounds were on arms, legs, hands or feet.

There was a difference of opinion amongst Union surgeons about the need to amputate damaged limbs or attempt to repair and try to save them, however, for the staff at the field hospitals time was short. If in doubt the limb was removed. Abdominal wounds were far more serious and the percentage of soldiers surviving them was far less than those losing a limb; bowel and stomach wounds being the most serious.

One of the problems for the wounded was that the transportation from the primary care station to a general hospital was crude and unsanitary; if the wound had not been infected on the battlefield it was almost certainly contaminated en route in ambulance, train or boat. The transportation personnel were more interested in speed of delivery than the comfort of the soldiers in their care.

The officers in charge of advance field hospitals confined the treatment of the wounded to stopping haemorrhage and to bandaging. Tourniquets or compresses were applied, liquor in the form of whiskey or brandy given to counteract shock, and the patient was usually given an opium pill or a dose of morphine. Bandaging of wounds became less common as the war progressed as it was found that they became soiled and contaminated and were causing problems as they were cut away. Splints to be used on fractured limbs were usually cobbled together using fence rails or board, ambulances were furnished with "Smith's Anterior" a suspended splint in ambulances but many staff did not know how to use it correctly. One contribution to medical science was the Hodgen Splint, invented in 1863 by Surgeon J Hodgen. This was a splint that provided room for examination, prevented contraction and allowed drainage of the wounds without disturbing the break. The basic design is still in use today.

The wounded were brought to the field hospital and laid out on straw; the less serious cases would be dealt with by a "dressing surgeon" who together with a medical orderly would operate a triage system passing over the mortally wounded and getting the most needy to the operating table. Pressure of the work load and the primitive conditions of the field units often meant that recommended procedures often were by-passed. It was thought that it was important to operate before infection could set in, but to avoid work whilst the patient was in deep shock. However, there was not the luxury of time available to the surgeons, the operating table had hardly been swilled down after one case before the next was brought in.

The management of the cases after surgery was relatively simple and consisted of rest, the relief of pain by opiates, doses of liquor or quinine to "support the system" and the application of cold compresses to keep down inflammation.

These quick operations broke all the rules of modern asepsis, cleanliness was almost impossible and the field stations soon became a gruesome spectacle as the surgeons worked through the hundreds of cases brought to them. From a Spotsylvania hospital a surgeon wrote home to his wife that he had been steadily operating for four days and that his feet were badly swollen. "It does not seem as though I could take a knife in my hand today. Yet there are a hundred more cases waiting for me. The poor fellows beg for the chance to have an arm or leg taken off. It is a scene of horror as I ever saw."

Pain relief came in the form of opiates; in the state of shock and under the influence of the anaesthetic the pain of the initial surgery was mitigated. It was as shock subsided and infections took hold that the misery of pain was suffered. The poor handling and rough transportation did not help in any way to ease the wounded soldiers plight. Opium was administered in tablet form and often morphine was rubbed into the wound. The hypodermic syringe became more common in the later years of the war and morphine was then injected.

The problem of infection was never really solved; surgeons had little understanding of the healing process and thought that the pus-producing infections were the normal process of tissue repair. When wounds healed without this action as it is now expected to do so, it was thought unusual. Thus large amounts of fatalities occurred due to Septicaemia, Pyaemia and the now unknown "hospital gangrene". The doctors at the time expected this as they were common in the civilian hospitals at the time.

Surgeons reports and letters tell a dreadfully gruesome account of the work that they had to do, the lack of water, the untrained orderlies and the work load are all mentioned time and time again.

I would be wrong to dismiss the efforts of the doctors and medical staff as being poor, throughout the whole of the war huge resources and improvements were made. The medical budget of 1864 exceeded the total amount of money spent on the pre-war army. Medical knowledge was on the verge of major breakthroughs and I consider the numbers of wounded that survived horrific injuries that would even now cause major concern, a testament to the efforts of the Medical Staff and the Sanitary Commission.

Main Sources: Doctors in Blue, by George Washington Adams; Official Records of the Union and Confederate Armies Medical and Surgical History of the War of Rebellion; History of the United States Sanitary Commission.

Pvt. Hugh R Martyr, 20th Maine

The above article first appeared in the ACWS Newsletter, February 2001

SURGERY IN THE FIELD

The wounded soldier who received medical attention in the field (and base hospital) had still to run the considerable risk of surgery. After ambulance facilities were available, field hospitals were sometimes overwhelmed by major battle casualties. The limited number of surgeons worked around the clock and haste and neglect were unavoidable under such circumstances. Anaesthetics, generally chloroform, were available, but there was no notion of aseptic procedure. As W W Keen recalled some years later:

"We operated in old blood-stained and often pus-stained coats with undisinfected hands we used undisinfected instruments and marine sponges which had been used in prior pus cases and only washed in tap water."

Nearly all wounds became infected. In the case of chest or abdominal wounds, surgeons probed with their fingers, prescribed morphine and tried to stop external bleeding. Otherwise there was little that could be done. Death within three days from haemorrhage and/or infection was the normal result. The average Union mortality from gunshot wounds of the chest was 62 percent of cases and from wounds of the abdomen, no less than 87 percent. By way of contrast, only about 3 percent of all American wounded failed to survive in World War II.

The chances for survival following an injury to the extremities were better though not good. Joints were resected and limbs amputated with alarming frequency, often in an attempt to prevent the spread of infection. It was usually the ensuing infection, which caused death. The so-called "surgical fevers" included tetanus, erysipelas, hospital gangrene, and septicaemia.

MEDICAMENTS

Medical supplies were transported to the battle areas as part of the general field train, and carried to the front lines in ambulances, or on pack mules, or on the shoulders of the regimental hospital stewards.

The major effective drugs in use were quinine and morphine. Whiskey was frequently administered to the wounded to induce "reaction", and as the solvent for quinine sometimes administered daily as a suppressant of malaria. Chloroform, sometimes mixed with small amounts of ether, served as an anaesthetic. Among other drugs used were opium, pepsin, various emetics and cathartics, iodine, and calomel.

Dysentery, one of the most important diseases from the viewpoint of both high morbidity and mortality, was treated with oil of turpentine, among many other substances, and ipecac was administered for enteritis; probably neither of these was very effective.

The paratyphoid fevers were not separately recognised and diagnosed; the term "typhomalarial fever" was used to describe debatable cases of prevalent remittent fever.

The lack of preventive measures and specific therapy for treatment of the various diseases became a major factor in the outcome of some battles, and at times, of entire campaigns.

AMBULANCE CORPS

The original organisation of the medical serve offered inadequate provision for the removal of the great numbers of casualties from collecting points to hospitals in rear echelon areas. On September 7, 1862, in a letter to Secretary of War Stanton, Surgeon General William A Hammond requested the formation of an ambulance corps. The corps, complete with animals, personnel, and supplies, was first established under the guidance of Dr Jonathan Letterman, Medical Director of the Army of the Potomac.

On the Confederate side, the task of transporting the wounded was complicated by the difficulty of running supplies and equipment through the northern blockade of southern Atlantic ports and the lower Mississippi River.

As in the North, the duties of Confederate surgeons included supervising the moving of the wounded from the battle lines to facilities in the rear. Toward the end of the war, the entire transportation system of the Confederacy, including their ambulance organisation, collapsed for want of the necessary equipment and supplies.

The above articles first appeared in the ACWS Newsletter, June 1999

Image: Left femur of a Confederate soldier with a gunshot fracture

From: acws.co.uk

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Medicine in the Civil War

From: utoledo.edu

When the Civil War began in April 1861, medicine was approaching what Surgeon General William Hammond called "the end of the medical Middle Ages." In Europe, the work of Koch and Pasteur was just beginning and American physicians had little knowledge of the cause and prevention of disease and infection. The Army Medical Department, which was responsible for the care of the sick and wounded in the North, was unprepared. The staff of 90 doctors was experienced in dealing with the health problems of small military outposts, but had no idea of how to deal with large scale medical and logistical problems.

Early in the war it became obvious that disease would be the greatest killer. Two soldiers died of disease (dysentery, diarrhea, typhoid, and malaria) for every one killed in battle. Soldiers from small rural areas suffered from childhood diseases such as measles and mumps because they lacked immunity. Outbreaks of these "camp and campaign" diseases were caused by overcrowded and unsanitary conditions in the field. To remedy this, the U.S. government created the U.S. Sanitary Commission in June 1861.

The commission was directed by Frederick Law Olmstead. Preaching the virtues of clean water, good food, and fresh air, the commission pressured the Army Medical Department to improve sanitation, build large well-ventilated hospitals, and encourage women to join the newly-created nursing corps. Despite the efforts of the Sanitary Commission, some 560,000 soldiers died from disease during the war.

Second to disease as a cause of death was battlefield injuries, totaling some 200,000 casualties. The overwhelming number of wounded created problems in removing them from the battlefield. As late as 1862 there was no ambulance corps on either side. In August of that year, however, Union General George B. McClellan authorized the creation of a trained ambulance corps for the Army of the Potomac, and other armies, both Union and Confederate, soon did the same.

Risks from surgery were great. Doctors in the field hospitals had no notion of antiseptic surgery, resulting in extremely high death rates from post-operative infection. Surgeons ignored anesthesia, instead relying on the "surgical shock" of battle, when the patient's heart rate was greatest, to amputate.

Amputation of a wounded arm or leg was the most common operation, due largely to the .58 calibre Minie ball ammunition used during the war. This heavy conical-shaped bullet of soft lead distorted on impact causing large, gaping wounds filled with dirt and pieces of clothing. Its heavy weight shattered any bone it contacted. Because of the severity of the wounds and the overwhelming case load, surgeons usually elected for fast and easy amputation over trying to remove the bullet and save the limb.

While the efforts of the Army Medical Department during the Civil War did little to bring immediate relief for the victims, many medical advances did result from the war experience. Doctors treating hundreds of thousands of cases of dysentery, diarrhea, typhoid, malaria and gunshot wounds compiled copious notes that would aid researchers after the war. These case studies were later published between 1870 and 1888 under the title Medical and Surgical History of the War of the Rebellion. Medical army officers recognized that enforcing sanitary standards in the field could reduce the spread of disease. And the numerous cases of post-operative infections such as hospital gangrene led to increased study in ways to prevent it, eventually leading to the use of bromine.

But the largest medical achievements of the Civil War were in the areas of field hospital organization and personnel. At the beginning of the war, staffs were haphazardly organized on an "as needed" basis. But these staffs were usually too small, and healthy soldiers had to be left behind to care for the sick and wounded. Anyone, regardless of medical skill, could volunteer as a nurse. Hospital facilities were established in existing unsanitary buildings or erected wherever convenient. By war's end this all changed. Military hospital staffs became more permanent. In 1861, Dorothea Dix was appointed Superintendent of the United States Nursing Corps, and the idea of professional nursing was born. Finally, hospital facilities were improved by the use of large, well-ventilated hospital tents and more permanent, cleaner "pavilion hospitals."

Image: The brutality of the battlefield produced huge numbers of casualties, as seen in this rendition of the attack on Knoxville.

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Private William McCarter of the Irish Brigade Hospitalized After Fredericksburg

By Patrick Young, Esq., 1-4-13

Private William McCarter was badly wounded during the Irish Brigade’s disastrous attack on the stone wall during the Battle of Fredericksburg in Virginia. He lay bleeding on the field for hours before nightfall made possible his still-dangerous escape to the rear.

The Northern army had a medical corps consisting of doctors and assistants, but most of the wounded were brought off the field by members of their own regiments who went back to try to collect friends. These Union soldiers would often pass by other wounded men, reserving their aid for men of their own units alone. McCarter was helped by two Irish Brigade comrades who recognized him in the dark. They put him on a horse-drawn ambulance. The ambulance was overloaded with twelve men when it took off to try to find medical care. The men were offered no first aid and two of them died before the vehicle reached the city of Fredericksburg, a short ways away.

When McCarter got to Fredericksburg, Union soldiers were wandering about aimlessly in the streets. Some broke into houses and looted them. A number were getting drunk on whiskey they had stolen. McCarter was dropped off at a house that served as a make-shift hospital. More than fifty “mangled victims” of the fighting were in the one room. The men did not see a doctor until the next morning. By then, a wounded man lying near McCarter had died.

A severely overworked doctor was finally able to see McCarter. He dug the bullet out of the soldier’s shoulder, but first he had to cut away much of McCarter’s uniform to get at his wound. When McCarter had to evacuate north by foot the next day, he did so with his wounded arm naked and exposed to December’s cold. He and thousands of other wounded men walked to a rail depot where they waited hours without shelter for a train to take them north. “[T]he wounded men crouched and huddled together and…some of them died from the exposure,” he recalled.

McCarter next went to a makeshift hospital made up of a collection of tents. There was so much blood and so many severed body parts that he later described it as looking like a “village of butcher shops.”  The surgical tent left a lasting impression:

Lying around were cases of ugly looking surgical tools, including the saw and the knife. In the back end of each tent a hole was made. Through it amputated arms or legs were thrown out upon the ground outside.

When trains finally arrived, the wounded rushed to get on. There was no order to the loading and the healthier men shoved aside the severely wounded. “It was simply every man for himself,” McCarter wrote, “I saw three men killed by falling under the car wheels as a locomotive began to move.” When McCarter was finally evacuated he was taken by a four hour train ride to Aquia Creek. Along the way, nine of McCarter’s wounded comrades died.

McCarter and hundreds of other wounded men on the train were taken off and hauled onto a steamship that was to take them to Washington. Few comforts were provided the suffering men and McCarter was forced to rest on the cold floor of the ship, when an unexpected source of comfort came to him. A woman, a Catholic nun, a Sister of Mercy comforted him, fed him and found him a warm place to sleep. This was McCarter’s first experience with these women, many of whom were immigrants like himself.

As he soon found out, the Sisters of Mercy had volunteered to take over the care of the men on the ship. McCarter remembered that during the trip they did “everything in their power to alleviate the terrible sufferings of the cargo of our wounded, sick and dying soldiers.” Over the coming weeks he would be cared for by many Sisters of Mercy. Their ministrations would be offered to native-born and immigrant soldiers alike of all religious backgrounds.  In coming articles, we’ll look at how these immigrant religious women helped create the nursing profession in the United States and changed attitudes about women in medicine.

Image: Field hospital at Savage’s Station in 1862.

From: longislandwins.com

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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

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Effects of the Minie Ball on Civil War Combat

by Mike Rinehart

During the Civil War the generals of both sides used old battlefield tactics which called for the men to march in tight formations (shoulder to shoulder) and attack the enemy across open ground.  This made the attacker an easy target for the defender.  These tactics worked great during the Revolutionary War when rifles were only effective under 100 yards.  The Civil War changed that.

The French army officer Claude-Etienne Minié invented the bullet that would bear his name in 1849. The Minié bullet, a cylindrical bullet with a hollow base that expanded when fired, proved lethally accurate over relatively long distances, and was soon used to devastating effect by the British army against Russian forces during the Crimean War. After the outbreak of the American Civil War in 1861, both Union and Confederate soldiers used the "minnie" bullet (as they called it) in their muzzle-loading rifles.

This bullet had a devastating effect on troops.  When it hit a soldier it often shattered or splintered bones in the process.  Here is the actual bone of a Civil War soldier that was struck by a Minie Ball. Notice how the bullet penetrated the bone rendering the bone useless and unhealable.

Since the bone could not recover, if a bone was stuck in the way above, a surgeon had no choice but to remove the wounded limp be it a arm or a leg.  If the limb was not removed the patient would automatically suffer a infection and die anyway.

The KEY thing to understand is the weapons of the Civil War were way ahead of the tactics (battle strategies) that the generals used.  Look at the sketch below.  This was the usually attack formation that both sides used.  The plan is for these men to march (walk) across a open field to an enemy waiting for them on the other side of a field.  This formation worked fine in the American Revolution or even in the Mexican War when armies used smoothbore muskets which were ineffective at any target over 100 yards away.  The Minie Ball gave the advantage to the defenders because by adding the accuracy and range this formation will soon be eaten alive by enemy fire.  This led to many of the high casualties of Civil War battles.

Here is a actual photograph of some Civil War surgeons posing how an amputation would take place.  Usually more people would be utilized to hold the patient down while the limb (a leg in the photo) would be SAWED off.  This process was dangerous and sometimes would kill the patient since in these days or primitive technology the surgeons would not clean their tools.  This would spread infections.  More soldiers would die of disease in the Civil War than via any other method. Some of them perished because of infections resulting from amputations.

Civil War medical kits looked like the following.  Notice the saw that today somebody would use to saw wood with.  Imagine that cutting into your bone!!  Yes I know it is a dreadful thought!

Hopefully you see now that war isn't all glory like it is portrayed in movies and in video games.  War means death, mutilation and suffering.

From: rossfordschools.org

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Jonathan Letterman, Doctor (1824–1872)

From: biography.com

QUICK FACTS

NAME: Jonathan Letterman
OCCUPATION: Doctor
BIRTH DATE: December 11, 1824
DEATH DATE: March 15, 1872
EDUCATION: Jefferson Medical College
PLACE OF BIRTH: Canonsburg, Pennsylvania
PLACE OF DEATH: San Francisco, California
NICKNAME: "Father of Battlefield Medicine"

Though not as well known as Ulysses S. Grant, Jonathan Letterman played an important role in winning the Civil War for the Union and is known today as the "Father of Battlefield Medicine."

Synopsis
Born in Canonsburg, Pennsylvania, Jonathan Letterman followed his father’s profession and became a doctor. During the American Civil War, he instituted several crucial medical procedures to efficiently remove battlefield casualties, immediately assess their condition and provide short- and long-term care, saving thousands of lives in the process. After the war, Letterman moved to San Francisco, California, where he practiced medicine and served as coroner. He died on March 15, 1872.

Early Life and Military Service
Jonathan Letterman was born in Canonsburg, Pennsylvania, on December 11, 1824. The son of a surgeon, Letterman followed in his father’s footsteps. He graduated from Jefferson Medical College in 1849, assuming the rank of assistant surgeon in the Army Medical Department that same year. From 1849 to 1861, he served in several military campaigns against Native American tribes in Florida, Minnesota, New Mexico and California.

Field Doctor in the Civil War
At the outbreak of the Civil War, Jonathan Letterman was assigned to the Army of the Potomac and was soon named medical director of the entire army, rising to the rank of major. Upon his first assignment, Letterman recognized that the typical field soldier was suffering from a number of health conditions, scurvy being one of them. He successfully addressed this problem by introducing fresh vegetables into their diet. But addressing the problems of battlefield casualties wasn’t going to be so easy.

During Civil War battles, Letterman and his fellow doctors had to deal with casualty levels far greater than expected. As an example, the Second Battle of Bull Run (Second Manassas, August 28–30, 1862) produced nearly as many U.S. casualties as the entire Revolutionary War. This was due, in part, to the combination of improved weaponry and outdated battle tactics. Another problem was the appalling inefficiency in dealing with casualties. Wounded men were left to fend for themselves unless carried off by a fellow soldier. Oftentimes, they would lie for days on the battlefield to suffer from exposure and thirst. It took more than a week to remove the wounded from the Second Bull Run battlefield.

Major Improvements in Medical Procedures
Jonathan Letterman made several changes to reduce the number of deaths after a battle. First, he established an ambulance corps with trained stretcher bearers to pick up the wounded and bring them to hospital clinics. He also instituted a triage system with prioritized treatment based on the degree of a soldier’s injury and likelihood of survival. Letterman developed a three-stage process for treating soldiers after evacuation with a field-dressing station next to the battlefield to quickly dress wounds and stop bleeding; a field hospital close by, usually in homes or barns, where emergency surgery could be performed; and a large hospital located away from the battlefield that would provide long-term treatment.

Proof of the effectiveness of these methods was made evident just two weeks after their implementation. The Battle of Antietam (Sharpsburg, September 17, 1862) is considered the bloodiest single-day battle in American history. There were more than 23,000 casualties, 12,000 of them Union soldiers. Under Letterman’s command, medical personnel were able to remove all wounded Union troops from the field within 24 hours, probably saving thousands of lives.

Later Life
During the remainder of the war, Jonathan Letterman served for a brief period as Inspector of Hospitals for the U.S. Army and then resigned in December 1864. He moved to San Francisco, where he continued to practice medicine and was elected coroner from 1867 to 1872. Upon the death of his wife, Letterman became severely depressed and died of intestinal disease on May 15, 1872, at age 47. He was buried at Arlington National Cemetery. In 1911, the Army hospital at the Presidio in San Francisco was named in his honor.

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Medicine in the American Civil War

From: military.wikia.com

In the war, both armies researched advancement in the development of battlefield recovery techniques. In the Union, a new medicinal wing was created under the jurisdiction of a “Medical Director of the Army”, the first field hospitals, small tents with a few tables or beds for the wounded, were developed, and a system of transport of the wounded to general hospitals was created, the first wooden ambulances which could hold up to around 4 wounded laying down, 1 or 2 medical officials, and a driver for the horses. The Confederacy advanced mainly by learning from Union camps they overtook, but generally had a less established medical service largely as a result of its more limited resources, vast rural areas, limited medicinal knowledge, and fewer medical professionals. The most common battle injuries were simple flesh wounds that led to amputations of limbs due to lack of better techniques for preventing the fatal spread of gangrene.

Background
Before the Civil War, the armies tended to be small, largely because of the logistics of supply and training. Musket fire, renowned for its inaccuracy, kept casualty rates lower than they might have been. The advent of railroads, industrial production, and canned food allowed for much larger armies, and the Minié ball rifle brought about much higher casualty rates. The work of Florence Nightingale in the Crimean War brought the deplorable situation of military hospitals to the public attention, although reforms were often slow in coming.

Union
The hygiene of the camps was poor, especially at the beginning of the war when men who had seldom been far from home were brought together for training with thousands of strangers. First came epidemics of the childhood diseases of chicken pox, mumps, whooping cough, and, especially, measles. Operations in the South meant a dangerous and new disease environment, bringing diarrhea, dysentery, typhoid fever, and malaria. There were no antibiotics, so the surgeons prescribed coffee, whiskey, and quinine. Harsh weather, bad water, inadequate shelter in winter quarters, poor policing of camps and dirty camp hospitals took their toll. This was a common scenario in wars from time immemorial, and conditions faced by the Confederate army were even worse.

When the war began, there were no plans in place to treat wounded or sick Union soldiers. After the Battle of Bull Run, the United States government took possession of several private hospitals in Washington, D.C., Alexandria, Virginia, and surrounding towns. Union commanders believed the war would be short and there would be no need create a long standing source of care for the armies medical needs. This view changed after the appointment of General George B. McClellan and the organization of the Army of the Potomac. McClellan appointed the first medical director of the army, surgeon Charles S. Tripler, on August 12, 1861. Tripler created plans to enlist regimental surgeons to travel with armies in the field, and the creation of general hospitals for the badly wounded to be taken to for recovery and further treatment. To implement the plan, orders were issued on May 25 that each regiment must recruit one surgeon and one assistant surgeon to serve before they could be deployed for duty. These men served in the initial makeshift regimental hospitals. In 1862 William A. Hammond became surgeon general and launched a series of reforms. He founded the Army Medical Museum, and had plans for a hospital and a medical school in Washington; a central laboratory for chemical and pharmaceutical preparations was created; much more extensive recording was required from the hospitals and the surgeons. Hammond raised the requirements for admission into the Army Medical Corps. The number of hospitals was greatly increased and he paid close attention to aeration. New surgeons were promoted to serving at the brigade level with the rank of Major. The Surgeon Majors were assigned staffs and were charged with overseeing a new brigade level hospital that could serve as an intermediary level between the regimental and general hospitals. Surgeon Majors were also charged with ensuring that regimental surgeons were in compliance with the orders issued by the Medical Director of the Army.

In the Union skilled, well-funded medical organizers took proactive action, especially in the much enlarged United States Army Medical Department, and the United States Sanitary Commission, a new private agency. Numerous other new agencies also targeted the medical and morale needs of soldiers, including the United States Christian Commission as well as smaller private agencies such as the Women's Central Association of Relief for Sick and Wounded in the Army (WCAR) founded in 1861 by Henry Whitney Bellows, and Dorothea Dix. Systematic funding appeals raised public consciousness, as well as millions of dollars. Many thousands of volunteers worked in the hospitals and rest homes, most famously poet Walt Whitman. Frederick Law Olmstead, a famous landscape architect, was the highly efficient executive director of the Sanitary Commission.

States could use their own tax money to support their troops as Ohio did. Following the unexpected carnage at the battle of Shiloh in April 1862, the Ohio state government sent 3 steamboats to the scene as floating hospitals with doctors, nurses and medical supplies. The state fleet expanded to eleven hospital ships. The state also set up 12 local offices in main transportation nodes to help Ohio soldiers moving back and forth.

Field hospitals were initially in the open air, with tent hospitals that could hold only six patients first being used in 1862; after many major battles the injured had to receive their care in the open. As the war progressed, nurses were enlisted, generally two per regiment. In the general hospitals one nurse was employed for about every ten patients. The first permanent general hospitals were ordered constructed during December 1861 in the major hubs of military activity in the eastern and western United States. An elaborate system of ferrying wounded and sick soldiers from the brigade hospitals to the general hospitals was set up. At first the system proved to be insufficient and many soldiers were dying in mobile hospitals at the front and could not be transported to the general hospitals for needed care. The situation became apparent to military leaders in the Peninsular Campaign in June 1862 when several thousand soldiers died for lack of medical treatment. Dr. Jonathan Letterman was appointed to succeed Tripler as the second Medical Director of the Army in 1862 and completed the process of putting together a new ambulance corps. Each regiment was assigned two wagons, one carrying medical supplies, and a second to serve as a transport for wounded soldiers. The ambulance corps was placed under the command of Surgeon Majors of the various brigades. In August 1863 the number of transport wagons was increased to three per regiment.

Union medical care improved dramatically during 1862. By the end of the year each regiment was being regularly supplied with a standard set of medical supplies included medical books, supplies of medicine, small hospital furniture like bed-pans, containers for mixing medicines, spoons, vials, bedding, lanterns, and numerous other implements. A new layer of medical treatment was added in January 1863. A division level hospital was established under the command of a Surgeon-in-Chief. The new divisional hospitals took over the role of the brigade hospitals as a rendezvous point for transports to the general hospitals. The wagons transported the wounded to nearby railroad depots where they could be quickly transported to the general hospitals at the military supply hubs. The divisional hospitals were given large staffs, nurses, cooks, several doctors, and large tents to accommodate up to one hundred soldiers each. The new division hospitals began keeping detailed medical records of patients. The divisional hospitals were established at a safe distance from battlefields where patients could be safely helped after transport from the regimental or brigade hospitals.

Although the divisional hospitals were placed in safe locations, because of their size they could not be quickly packed in the event of a retreat. Several divisional hospitals were lost to Confederates during the war, but in almost all occasions their patients and doctors were immediately paroled if they would swear to no longer bear arms in the conflict. On a few occasions, the hospitals and patients were held several days and exchanged for Confederate prisoners of war.

The U.S. Army learned many lessons and in 1886, it established the Hospital Corps. The Sanitary Commission collected enormous amounts of statistical data, and opened up the problems of storing information for fast access and mechanically searching for data patterns.

Confederacy
The Confederacy was quicker to authorize the establishment of a medical corps than the Union, but the Confederate medical corp was at a considerable disadvantage throughout the war primarily due to the lesser resources of the Confederate government. A Medical Department was created with the initial army structure by the provisional Confederate government on February 26, 1861. President Jefferson Davis appointed David C. DeLeon Surgeon General. Although a leadership for a medical corp was created, an error by the copyist in the creation of the military regulations of the Confederacy omitted the section for medical officers, and none were mustered into their initial regiments. Many physicians enlisted in the army as privates, and when the error was discovered in April, many of the physicians were pressed into serving as regimental surgeons.

DeLeon had little experience with military medicine, and he and his staff of twenty-five began creating plans to implement army-wide medical standards. The Confederate government appropriated money to purchase hospitals to serve the army, and the development of field services began after the First Battle of Manassas. The early hospitals were quickly overrun by wounded, and hundreds had to be sent by train to other southern cities for care following the battle. As a result of the poor planning, Davis demoted DeLeon and replaced him with Samuel Preston Moore. Moore had more experience than DeLeon and quickly moved to speed the implementation of medical standards. Because many of the surgeons in the regiments had been pressed into service, some were not qualified to be surgeons. Moore began reviewing the surgeons and replacing those found to be inadequate for their duties.

Initially the Confederacy employed a policy of furloughing wounded soldiers to return home for recovery. This was a result of their lack of field hospitals and limited capacity in their general hospitals. In August 1861, the army began the construction of new larger hospitals in several southern cities and the furloughing policy was gradually halted. The earliest recruits for surgeons were required to bring their own supplies, a practice that was ended during 1862. The government began providing each regiment with a pack with medical supplies including medicines and surgical instruments. The Confederacy, however, had limited access to medicinal supplies and relied on their blockade-running ships to import needed medicines from Europe, supplies captured from the North or traded with the North through Memphis. Anesthetics were not in as short supply as medical instruments, something highly prized. Field hospitals were set up at the regimental level and located in an open area behind the lines of battle and staffed by two surgeons, one being senior. It was the responsibility of the regimental surgeons to determine which soldiers could return to duty and which should be sent to the general hospitals. There were no intermediary hospitals, and each regiment was responsible for transporting its wounded to the nearest rail depot, where the injured were transported to the general hospitals for longer term care. In some of the lengthier battles, buildings were seized to serve as a temporary secondary hospital at a divisional level where the severely wounded could be held. The secondary facilities were staffed by the regimental surgeons, who pooled their resources to care for the wounded and were oversaw by a divisional surgeon.

Care
The most common battlefield injury was being wounded by enemy fire. Unless the wounds were minor, this often led to amputation of limbs to prevent infection from setting in; anti-biotics had not yet been discovered. Amputations had to be made at the point where the wound occurred, often leaving men with stub limbs. Skin was taken from the amputated limb to cover the wound and stitched to the stump. Men were generally partially sedated with chloroform or alcohol before surgeries. When properly done, the patient would feel no pain during their surgery, but would not be totally unconscious. Stonewall Jackson, for example, recalled the sound of the saw cutting through the bone of his arm, but recalled no pain. Infection was the most common cause of death of injured soldiers.

It has been said that the American Civil War was the first "modern war" in terms of technology and lethality of weapons, but that it was simultaneously fought "at the end of the medical Middle Ages." Very little was known about the causes of disease, and so a minor wound could easily become infected and take a life. Battlefield surgeons were under qualified and hospitals were generally poorly supplied and staffed. The most common battlefield operation was amputation. If a soldier was badly wounded in the arm or leg, amputation was usually the only solution. Surprisingly, about 75% of amputees survived the operation. Contrary to popular belief, few soldiers experienced amputation without any anesthetic. Heavy doses of chloroform were administered; in fact, a few soldiers died of chloroform poisoning, rather than their wounds.

If a wound produced pus, it was thought that it meant the wound was healing, when in fact it meant the injury was infected. Roughly three in five Union casualties and two in three Confederate casualties died of disease.

Women
North and South, over 20,000 women volunteered to work in hospitals, usually in nursing care. They assisted surgeons during procedures, gave medicines, supervised the feedings and cleaned the bedding and clothes. They gave good cheer, wrote letters the men dictated, and comforted the dying.

The Union Army nurse superintendent was Dorothea Lynde Dix, while Clara Barton, Mary Livermore, Mary Ann Bickerdyke, and Annie Wittenmeyer played leadership roles.

Aftermath
Based on their experiences in the war, many veterans went on to develop high standards for medical care and new medicines. The modern pharmaceutical industry began developing in the decades after the war. Colonel Eli Lilly had been a pharmacist; he built a pharmaceutical empire after the war. Clara Barton founded the American Red Cross to provide civilian nursing services in wartime.

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