The Physical Examination

By J.P. Rogers, 2-16-13

One of the last major events to take place at the Camp of Instruction at Jamaica was the physical examinations of the soldiers of the Eighth Connecticut.  Oliver writes to Abbie that “the men are not troubled with clothes while undergoing this examination.”[i] Civil War Surgeons faced a daunting challenge when attempting to weed out those recruits not fully medically fit for duty with the limited nature of the physical examinations in relation to modern physical examination standards. One former soldier, writing after the war, described the process:

The next step was a medical examination to determine physical fitness for service. Each town had its physician for this work. The candidate for admission into the army must first divest himself of all clothing, and his soundness or unsoundness was then decided by causing him to jump, bend over, kick, receive sundry thumps in the chest and back, and such other laying-on of hands as was thought necessary. The teeth had also to be examined, and the eyesight tested, after which, if the candidate passed, he received a certificate to that effect.[ii]

This old soldier’s memory notwithstanding, during the early part of the war filling the ranks of the regiments was more important than the medical readiness of the recruits and physicians often turned a blind eye to many disqualifying conditions. Induction physical examinations used the pass rate as a measure of success ensuring that recruits with all their limbs, good teeth (for tearing rifle cartridges) and adequate sight/hearing would be retained for service. As one regimental surgeon put it, “Many of [the soldiers] ought never to have come out, having broken constitutions or bodily defects which entirely disqualify them for the life of a soldier.”[iii] In fact, some of the examinations were so superficial that women were able to enlist pretending to be men.

The purpose of these examinations for the Connecticut troops was unclear coming some five weeks after the organization and activation of the regiment. It may have been related to the fact that in August of 1861 the Army began to make an attempt to weed out many of the volunteers who were not physically qualified by requiring additional and more methodical examinations. This included follow up exams for those regiments already in service. Oliver’s emphasis on “this” when referring to the examination seems to indicate that a previous examination had occurred at some point in the past likely during the recruiting of the companies of the regiment. However, it is clear from his letter that the earlier examination did not include disrobing when standing before the physician. Also, the commander and/or the regimental surgeon may have had concerns about the physical condition of some of the soldiers. Whatever the situation driving the requirement for the new physical scrutiny of Oliver and his comrades, at least five soldiers from the Eighth Connecticut were discharged for being found to be physically unfit within a few days of this examination as indicated by the company rolls.

Some officers left on account of ill health ; a few were dismissed;”others,” wrote an officer, “strong men physically, found themselves entirely unfitted for the profession of arms, and bore the mortification of resigning that others might take their places.[iv]

In the case of Private Case’s physical examination, he expressed a great deal of concern about the possibility of being dismissed from the regiment due to the lingering signs of some previous illness that he does not specify. He wrote to his sister, Abbie, that the doctor “questioned me pretty close about that breaking out on my shoulders – there is hardly anything left but the scars.” Obviously, Abbie was familiar with this illness because Oliver wrote that “if he had seen it two months ago [which places it prior to his enlistment while he was still living at home in Simsbury] I would have gotten thrown overboard…”[v] It’s unclear from the information that Oliver provides in his surviving letters the exact cause of the “breaking out” on Oliver’s shoulders. Based on the common aliments of the time, several possibilities exist including something as simple as dermatitis or a more complex condition such as a past bout of chicken pox which would explain the presence of scarring during the exam.

Whatever the condition, the crisis of possible discharge was quickly overcome by Oliver explaining to the examining physician that the scars were “nothing but a little breaking out and had not been there a great while.”[vi] This obviously satisfied the doctor and Oliver was allowed to continue his service in the 8th CVI. In a tragic irony, this would be the first of several recorded instances of Oliver experiencing a close encounter with potential discharge from service.

Image: The excitement of the recruiting station often obscured the need for a thorough physical examination.

From: olivercromwellcase.wordpress.com

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History Affects Morphine: The Hypodermic Needle

From: itech.dickinson.edu, 4-30-08

“Ah! Pierce me one hundred times with your needle fine
And I will thank you one hundred times, Saint Morphine,
You who Aesculapus has made a God.”
- Jules Verne
(Poem taken from In the Arms of Morpheus by Barbara Hodgson)

Despite its impact on the science of pharmacology, morphine had limited medical impact until the invention of the hypodermic needle in the 1840s/1850s

A number of individuals are associated with the invention of the hypodermic needle, but among them, Alexander Wood, a Scottish physician, is perhaps the most prominent

Wood used morphine in conjunction with his newly invented needle to treat a patient with neuralgia, otherwise known as a sharp pain in the nerves; unfortunately, Wood also used his device on both he and his wife, and both became addicted. In fact, Wood’s wife became the first woman to die of a narcotic drug overdose

In light of this, however, Wood found that upon injection, morphine’s results were both immediate and much more powerful, certainly a success; such success led to a rise in the medical use of morphine, especially in the realm of surgery and anesthesia

Unfortunately, though, morphine administered through hypodermic needle was not thought to be addictive, and thus it further proliferated the drug, increasing use and addiction

Interestingly, it is worth noting that shortly after the time of the hypodermic needle’s inception, there began a debate over whether the effects of morphine post-injection were localized or not; and while many believe the effects to be non-localized – hence the name hypodermic – the debate actually continues to this day

Image: historical perspective: old syringes

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Euphemia Goldsborough: Confederate Nurse and Smuggler from Maryland

By Maggie MacLean, 12-8-14

Euphemia Goldsborough exemplifies the Southern woman committed to the Confederacy. Against all odds and at great risk to her own personal safety, she smuggled necessities into Southern hospitals and Northern prisons. Her story is one of courage, compassion and endurance.

Early Years
Euphemia Goldsborough was born June 5, 1836 at Boston, the family farm on Dividing Creek in Talbot County, Maryland. Euphemia was one of eight children born to Martin and Ann Hayward Goldsborough. She studied at a girls' boarding school in Tallahassee, Florida during the 1850s, and then joined her family at their new home in Baltimore, Maryland.

Leading up to the Civil War, Marylanders had mixed feelings about secession and the Confederacy. Less than thirteen percent of Maryland's population were slaves, and a similar number were free blacks. Although her family did not own slaves, and her records show no clear position on slavery, Goldsborough and her family sided with the South.

As tensions continued to rise between Union and Confederate supporters, 20,000 Maryland men enlisted in the Confederate army, including many of Goldsborough's friends, but her father and brother remained in Maryland. Her family aided the Confederacy by offering their home as a refuge for Confederate soldiers traveling North and as a stop for blockade runners to pick up and drop off illegal goods like mail and supplies to be sent through the Union lines.

Nursing at Antietam
When the War began, Euphemia Goldsborough was 25 years old and had become a devoted southern sympathizer. In September 1862, word reached Baltimore about the need for medical help at the Battle of Antietam near Sharpsburg, Maryland. Goldborough left the safety of her home for Frederick, Maryland, to nurse the wounded Confederate soldiers who had been taken there. Women who chose to become nurses were judged harshly by society, and they exposed themselves to diseases, injury from battle and sexual harassment.

At that time all medical positions, including nurses, were considered male occupations, but with so many injured and dying soldiers in makeshift hospitals greatly in need of care, social objections to female nurses were soon overcome. Goldsborough wrote extensively of her experiences in a diary. She also kept what she called a hospital book, which included signatures and messages written by patients under her care.

Eight Weeks at Gettysburg
In July 1863, news traveled to Baltimore about a very bloody battle in Gettysburg, Pennsylvania. By the time Goldsborough reached that town, General Robert E. Lee, commander of Confederate forces, had fled the area, leaving 5,500 wounded behind with little medical support.

Union troops, with almost 15,000 wounded of its own, had inadequate means to care for the southern soldiers. To make matters worse, Union commander General George Meade left the area to pursue the retreating Confederates, taking substantial medical supplies and personnel with him. This left the Union wounded with only 106 surgeons and 30 ambulances.

Prisoners of war also made up a significant percentage of Gettysburg's total casualties. Of the estimated 51,000 casualties suffered during the three-day battle, approximately 17,500 were POWs. Of this number 5,365 were Union and 12,200 (6,800 wounded and 5,400 not wounded) were Confederates.

Goldsborough traveled to Gettysburg and was assigned to care for wounded soldiers at a makeshift hospital at Pennsylvania College, now called Gettysburg College. Tasks assigned to her and other nurses included preparing food and dressings, administering to the wounded and reading the burial service over those who passed away.

There was a serious lack of clothing for the wounded Confederates, and the federal government would not allow them to have shoes or boots, supposedly to prevent them from escaping. Goldsborough smuggled boots into the hospital at Pennsylvania College, hanging by their shoelaces from the hoops of her skirt. She was certain that the boots would bump against something and reveal her scheme, but she returned to the hospital safely.

One of the soldiers Goldsborough cared for at the College hospital was Lt. A.J. Peeler of the 5th Florida Brigade, which was part of General R.H. Anderson's Division of General A.P. Hill's Third Corp. The Florida Brigade had arrived late afternoon of the first day and went into position on Herr's Ridge.

In the early morning of July 2, Anderson's Division was ordered to Seminary Ridge and was positioned on the edge of Spangler Woods. Late in the afternoon the Floridians led General Lee's assault on the Union line on Cemetery Ridge. A fellow soldier describes the actions of Lt. Peeler of the 5th Florida:

"A braver man than Lieut. Peeler never breathed. He dashed up and down the line, hurrahing, and encouraging the men on, and keeping the line dressed on Wilcox. He was wounded by a grape-shot and stunning him awhile, but after recovering, he advanced cheering on the men, and setting them an example worthy of imitation... until he was again shot down by a minie ball, wounding him seriously in the head, he was carried to the rear where he fell into the hands of the enemy."

After Lt. Peeler's capture by Union soldiers, he was confined to College Hospital and later Camp Letterman Hospital while he recovered from his wounds. A.J. Peeler wrote the following in Euphemia Goldsborough's journal, which she called a hospital book:

Camp Letterman
Genl. Hospl., Gettysburg Pa., U.S.
Aug. 4th, 1863

Miss Goldsborough,
In placing my autograph in your book, I cannot allow the opportunity to pass of at the same time expressing for myself and my wounded and sick comrades the heart-felt gratitude we feel for your kindness to us here and at the College Hospital. Prisoners and strangers in a strange land, many whose fevered brows you bathed and to whose wants you have ministered with such indefatigable attention will long treasure in their hearts and memory your name and kind deeds with a feeling of sacred friendship.

I hope the fortunes of war may never be such as to throw us together under similar circumstances again but if such should be the case I can only hope that I may meet with one like yourself whose social attractions as a lady and cheering words and kindly sympathy has contributed so much to beguile the many weary hours of my almost unendurable situation. For I assure you our "College days" are the green spot of the days of my captivity.

The greatest sacrifice you have made was to have humbled your proud spirit to meeting as social equals and treating with respect those whose conduct in the war have shown them to be enemies of "Woman", oppressors of woman, and destitute of manliness and true honor. May the day soon come when this unhappy war shall close with triumph to our arms and cause and when your friends, the "Florida Boys" shall have the pleasure of greeting you in the sunny south, the "land of flowers" where by every means in their power they will be happy to show by acts what they feel at heart - their appreciation of your kind attention.

Lt. A.J. Peeler
Perry's Florida Brigade

After the opening of the improved medical facility at Gettysburg named Camp Letterman, Goldsborough could have gone home, but she chose to stay in Gettysburg and work at the new hospital. There she was assigned to 100 men, split evenly with 50 Confederate and 50 Union soldiers, whom she treated as equals. She worked tirelessly, laboring day and night, only stopping when sleep was absolutely necessary.

Goldsborough's work there culminated with the treatment of her favorite patient, Sam Watson of the 5th Confederate Regiment out of Texas whose right arm had been amputated. She described Watson as, "One of the most attractive boys I ever saw." Watson's condition seemed dire at first, but he improved, almost teasing her with a chance of recovering. Unfortunately, Watson succumbed to his injury and died September 13, 1863.

After countless hours spent caring for Watson and his subsequent death, Goldsborough was exhausted, and she returned Baltimore. At home, she wrote Watson's parents a condolence letter, expressing the significant impact Watson had on her life. Her sister described her as "never the same joyous girl again."

Along with painful memories, however, came endless gifts and words of gratitude from her patients. Her hospital books were filled with the signatures of patients she had treated, and soldiers often wrote messages and poems of gratitude next to their signatures. One soldier even carved her a beautiful wooden ring.

Goldsborough and her family continued their work with what was known as the Confederate Underground, by smuggling mail, clothing, medical supplies and food into the South and into Confederate prisons in the Baltimore area. Of everything she smuggled, mail was the most precious, especially for men in the Confederate army from Maryland, a Union state. They were completely isolated.

Arrest and Imprisonment
Goldsborough also helped prisoners of war escape and return to the South. Baltimore was under strict Union control, and officials soon became suspicious of Goldsborough's activities and intercepted a letter that included her name and address. This led to her arrest by Union soldiers on the charge of aiding the escape of a Confederate prisoner in the middle of the night of November 23, 1863.

Euphemia Goldsborough, who claimed her crimes were "feeding the hungry and clothing the naked," was found guilty of treason and was sentenced to banishment from the Union for the remainder of the war. If she returned North before the war was over, she would be considered a spy and shot on sight.

Under heavy guard, she was only allowed to carry two trunks and $225 in Federal money, and she was strip searched before her journey South, writing in her diary:

"...before starting was stripped of all my clothing, minutely examined by two Yankee women, open doors with all around Yankee soldiers laughing and jesting at my expense. If I live for half a century I can never forget the humiliation..."

Even under these dangerous conditions, she smuggled some dispatches with her to Richmond through a secret compartment in the lap desk she carried in one of her trunks, which were eventually forwarded to Confederate President Jefferson Davis. She was put on a steamboat bound for Virginia on December 4, 1863.

Exile in Virginia
Goldsborough was received warmly upon her arrival in Richmond, where she began organizing her diary. She remained in Richmond for the rest of the war, working at the Treasury Department in the mornings and in a hospital in the afternoons. Throughout her stay there she continued her struggle to provide needed supplies and medicine in addition to caring for the wounded in area hospitals. After the war, she returned to Baltimore.

Marriage and Family
In 1874 thirty-eight-year-old Euphemia Goldsborough married Charles Perry Willson, a native of Frederick County, Maryland and widower of one of her closest friends. They settled in Summit Point, West Virginia. She became stepmother to his five children, and gave birth to three more. Two sons died in childhood, but her daughter Ann grew to adulthood. Their descendants still live in Summit Point.

Euphemia Goldsborough died of cancer March 10, 1896. Her obituary accurately states that, "Into every Federal prison in the United States where Confederate soldiers were confined went articles of comfort, both of food and raiment, to the suffering prisoners, while she worked day and night to procure funds to further that purpose."

Goldsborough was inducted in the Maryland Women's Hall of Fame in 1995, the first Confederate woman to be so honored.

SOURCES
Archives of Maryland: Euphemia Goldsborough
Book Reveals Maryland Woman's Role in the Confederate Underground
Exile to Sweet Dixie: The Story of Euphemia Goldsborough, Confederate Nurse and Smuggler, Eileen Conklin

Image: Euphemia Goldsborough at age 38

From: civilwarwomenblog.com

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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

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Clara Barton: American Red Cross Founder

From: womensmemorial.org

The suffering of wounded and sick soldiers moved Clarissa Harlowe Barton, who later became famous as Clara Barton, founder of the American Red Cross, to become involved in war relief work. At the start of the war, Barton was a 39-year-old spinster, one of a small number of women working full time as a copyist in the US Patent Office in Washington, DC. When Barton learned that in many cases the wounded suffered because military hospitals were short of supplies, she used her own money to purchase pickled vegetables and homemade jellies to supplement the standard military diet of hardtack and salt pork. She also collected bandages, salves, medicine, bed sheets and even tobacco and whisky to help boost the soldiers’ morale.

Because it wasn’t proper for a single lady to visit Army camps and hospitals unescorted, Clara took her 50-year-old married sister, Sally Vassall, with her on her visits to local military hospitals. But Clara wanted to do more; she wanted to nurse soldiers who fell on the battlefields. For months, however, her fear that she would shame her family prevented her from trying to get to the front. Finally, Clara’s 80-year old father, a veteran of the War of 1812, freed his daughter of her worries. On his deathbed, he instructed her to go and do what she could to help the wounded. “The soldiers will know you are a decent woman as soon as they lay eyes on you,” he said.

Next, Clara had to find an Army sponsor, an officer willing to sign the military passes she would need to travel to the battlefield. Persistently, she visited numerous officers until she finally spoke with COL Daniel H. Rucker, head of the Quartermaster Depot in Washington, DC. When Clara told him that she had collected “three warehouses of supplies,” Rucker wrote her a pass allowing her to take the supplies she had collected to the front at Fredericksburg, VA. She reached Fredericksburg after the battle, but was able to assuage much suffering by passing out food, medicine and bedding supplies. After that, Barton never again had trouble getting a military pass.

During the Battle of Antietam, Barton worked in a surgery ward set up in a farmhouse close to the front lines. The farmhouse was under fire much of the time. Confederate shells burst overhead, crashed into the surrounding trees and exploded in the nearby barn and outbuildings. Stray bullets peppered the walls of the farmhouse. One of these bullets ripped through the sleeve of Barton’s dress. The farmhouse floor shook so much that the operating tables jarred and rolled while Barton and the doctor struggled to keep their patients on them. Barton’s first battle did nothing to discourage her; she continued to nurse at the battles of Marye’s Heights, the Wilderness Campaign, Hilton Head and Battery Wagner. After the war, Clara Barton worked to establish the American wing of the International Red Cross.

The information found in this article comes from "A Women of Valor: Clara Barton and the Civil War" by Stephen B. Oates published in New York, by The Free Press in 1994.

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Medical and Surgical Care During the American Civil War, 1861–1865

By Robert F. Reilly, MD

Abstract
This review describes medical and surgical care during the American Civil War. This era is often referred to in a negative way as the Middle Ages of medicine in the United States. Many misconceptions exist regarding the quality of care during the war. It is commonly believed that surgery was often done without anesthesia, that many unnecessary amputations were done, and that care was not state of the art for the times. None of these assertions is true. Physicians were practicing in an era before the germ theory of disease was established, before sterile technique and antisepsis were known, with very few effective medications, and often operating 48 to 72 hours with no sleep. Each side was woefully unprepared, in all aspects, for the extent of the war and misjudged the degree to which each would fight for their cause. Despite this, many medical advances and discoveries occurred as a result of the work of dedicated physicians on both sides of the conflict.

The Civil War was fought in over 10,000 places and was the bloodiest war in the history of the United States. Two percent of the population at the time (approximately 620,000) died during the conflict (1). More Americans died in the Civil War than in all other wars combined. As hard as it is to believe, these numbers may actually be an underestimate of the death toll, given that much of the data regarding deaths of Confederate soldiers was destroyed when Richmond burned on April 2, 1865. More recent estimates based on comparative census data put the figure closer to 752,000 (2). Countless other soldiers were left disabled. The year after the war ended, the state of Mississippi spent 20% of its annual budget on artificial limbs for its veterans (3).

Many misconceptions exist regarding medicine during the Civil War era, and this period is commonly referred to as the Middle Ages of American medicine. Medical care was heavily criticized in the press throughout the war. It was stated that surgery was often done without anesthesia, many unnecessary amputations were done, and that care was not state of the art for the times. None of these assertions is true. Actually, during the Civil War, there were many medical advances and discoveries (Table 1).

Twice as many soldiers died of disease during the war than in combat (3). This was a marked improvement compared with the Mexican War (1846–1848), where there were 7 to 10 deaths from disease for every death in battle. It was not until World War II that weapons killed more Americans than disease. The war left about 1 in 10 able-bodied Union soldiers dead or incapacitated, versus 1 in 4 in the Confederate Army (3).

WHY DID SO MANY DIE?
Soldiers died from two general causes: battlefield injuries and disease. Contributing factors to combat-related deaths were inexperienced surgeons; the lack of a coordinated system to get the injured off the battlefield quickly; wound infections, since sterile technique was not yet recognized as important; and battlefield tactics that did not keep pace with advances in weaponry. Contributing factors to disease-related deaths included poor sanitation and overcrowded camps; the ignoring of sanitation by line officers; inadequate pre-enlistment screening of recruits; poor diet; lack of immunity to childhood diseases; and few specific treatments for disease.

Army Regulation 1297 set out criteria for preinduction physical exams:
"In passing a recruit the medical officer is to examine him stripped; to see that he has free use of all his limbs; that his chest is ample; that his hearing, vision and speech are perfect; that he has no tumors, or ulcerated or extensively cicatrized legs; no rupture or chronic cutaneous affection; that he has not received any contusion, or wound of the head, that may impair his faculties; that he is not a drunkard; is not subject to convulsions; and has no infectious disorder; nor any other that may unfit him for military service (4)."

That was the requirement; however, the reality was that many exams early in the war were of poor quality. Governors needed to fill quotas, and examining physicians were paid per recruit. If you could walk, carry a gun, and had front teeth and a trigger finger, you could enlist. Front teeth were needed in order to tear open the cartridge containing gunpowder and the bullet. Dental care was poor in the 1860s, and this was a frequent cause of rejecting a recruit. It was the origin of the term 4F (missing 4 front teeth). The system was so poor that it is estimated that about 250 women served as soldiers during the war (5). The quality of physical exams improved with the Civil War Military Draft Act of 1863, when fines and prison sentences were put in place for physicians who were derelict in their duties, resulting in many more recruits being rejected from service.

To better comprehend medical care delivered during this period, it is important to understand the medical infrastructure at the time. The first medical school was established in the United States in Philadelphia in 1765. There was no prerequisite preparation for admission, no entrance exam, and no state medical licensing boards. Medical school was 2 years in duration. In the first year, lectures were given in two 4-month semesters. The second year was a repetition of the first. Students did not have any clinical experience prior to graduation. Medical schools at the time were more like proprietary schools. There was a large entrance fee and as a result very few students ever failed (6). The Flexner Report was still 50 years in the future, which required 2 or more years of college and a 4-year curriculum. In 1862, there were only six colleges of pharmacy in the US. Most doctors prescribed, compounded, and dispensed their own medications.

The germ theory of disease would not be established until 1870 and Koch's postulates in 1890. Disease was thought to be a result of either direct or indirect inflammation (7). Indirect inflammation was thought to be caused by excess blood flow to a tissue, a theory promulgated by a prominent 18th-century physician, Benjamin Rush. This led to the concept that bloodletting might be beneficial. By the time of the Civil War, bloodletting had largely fallen out of fashion.

Before the war, the United States had a peace time army of 16,000 soldiers. There were 113 doctors in the army. At the start of the war, 24 went south and 3 were dismissed for disloyalty (8). At the end of the war, there were over 12,000 doctors in the Union Army and over 3000 in the Confederate Army. Before the war, the largest military hospital was at Fort Leavenworth, which had 40 beds. The only hospital in Washington, DC, before the war was a two-story six-room building used to isolate smallpox patients.

The first major battle of the war fought at Bull Run in Manassas, Virginia, on July 21, 1861, illustrates how woefully unprepared the Union was from a medical standpoint at the start of the war. Fortunately, at Bull Run, casualty figures were not large compared with future battles (North, 481 killed, 1011 wounded; South, 387 killed, 1582 wounded) (9). Despite this, many problems were encountered. There was no military ambulance corps. Ambulances were driven by civilians who fled when the first shots were fired. If they left the ambulances behind, healthy soldiers stole them to flee back to Washington, DC. Not a single wounded soldier returned to Washington, DC, in an ambulance (10). Tragically, wounded soldiers remained on the battlefield for days, the first two spent in the rain. Incredibly, Surgeon General Finley did not order medical supplies until after the battle was over.

ORGANIZATION OF BATTLEFIELD MEDICAL CARE
How medical care was delivered on and off the battlefield changed during the war. Early on, stretcher bearers were members of the regimental band, and many fled when the battle started. Soldiers acting as stretcher bearers rarely returned to the front lines. As the war evolved, stretcher bearers became part of the medical corps. At the battle of Antietam, there were 71 Union field hospitals. As the war went on, these were consolidated. There were ambulances here that were used to bring the wounded to temporary battlefield hospitals, which were larger, often under tents, and out of artillery range. Later in the war, patients were transported to large general hospitals by train or ship in urban centers. These did not exist when the war began. There was no military ambulance corps in the Union Army until August of 1862. Until that time, civilians drove the ambulances. Initially the ambulance corps was under the Quartermaster corps, which meant that ambulances were often commandeered to deliver supplies and ammunition to the front. Jonathan Letterman set up his own ambulance corps in the East under General George McClellan. Medical directors chose all the soldiers for their services. Ambulances could not be used for other purposes, and only the ambulance corps was allowed to remove wounded from the battlefield. Letterman was responsible for a number of organizational improvements within the Army of the Potomac and was given a free hand by McClellan to implement them.

Large general hospitals were established by September of 1862 (11). These were in large cities, and soldiers were transported there by train or ship. At the end of the war, there were about 400 hospitals with about 400,000 beds. There were 2 million admissions to these hospitals with an overall mortality of 8%. In the South, the largest general hospital, Chimborazo, was in Richmond, Virginia. It was built out of tobacco crates on 40 acres. It contained five separate hospitals, each made up of 30 buildings. There were 150 wards with 40 to 60 patients per ward. The census was as high as 4000. They treated about 76,000 patients with a 9% mortality (12).

COMBAT-RELATED INJURIES
Before interpreting the data regarding combat-related injuries, it is important to recognize limitations in the reporting. In order to be reported, a soldier had to be either transported to or make it back to a field hospital, and this may have resulted in an underreporting of deaths from cannon fire. As shown in Table 2, most injuries resulted from the Minié ball invented by the French officer Claude-Etienne Minié in 1849. The Minié ball is a 0.58-caliber bullet that is slow moving and is made from soft lead. It flattens on impact and creates a wound that grows larger as the bullet moves deeper into tissues. It shatters bone above and below impact and usually does not exit. Because of its relatively slow muzzle velocity, it brought bits of clothing, skin, and bacteria into the wound. The majority of gunshot wounds occurred in the upper and lower extremities, but the fatality rate from these wounds was low (Table 3). Only 18% of wounds were to the abdomen, but these were more often fatal from intestinal perforation in the preantibiotic era.

Distribution of wounds among those listed as killed in battle or admitted to hospitals*
Commanders in the field were also slow to adjust their tactics in keeping with advances in weaponry. In the Revolutionary War era, smooth bore muskets were accurate only up to about 50 yards and were difficult to reload quickly, making rapid repetitive firing difficult. However, newer rifled muskets in use after the first year of the war were accurate up to 500 yards, and troops could easily fire them at a rate of 3 times a minute and sometimes faster. In the Revolutionary War, men could charge a fixed entrenched position with the possibility of success, whereas in the Civil War this same tactic was sure to fail. This was evidenced by the catastrophic failures of Picket's charge at Gettysburg in the East, and Hood's charge at Franklin, Tennessee, in the West. Six high-ranking Confederate generals were killed at the battle of Franklin, where over 1750 men died in a 5-hour period, with another 5500 wounded or captured (13).

Perhaps the most famous example of a lack of appreciation for the improvement in weaponry by those in high command occurred at the Battle of Spotsylvania Courthouse. John Sedgwick was the highest ranking Union general killed in the war. While directing troop movements at Spotsylvania Courthouse, he scolded his men for dodging bullets from sharpshooters concealed in the distant woods. “I am ashamed of you dodging that way. They couldn't hit an elephant at this distance” (14). Moments later a bullet fired from more than 500 yards struck him in the head, killing him instantly.

SURGICAL PROCEDURES
Three of every four surgical procedures performed during the war were amputations. Each amputation took about 2 to 10 minutes to complete. There were 175,000 extremity wounds to Union soldiers, and about 30,000 of these underwent amputation with a 26.3% mortality. The further from the torso the amputation was carried out, the greater the survival (Table 4). As the war went on, it was noticed that if amputation was done within 24 hours, mortality was lower than if performed after more than 48 hours. Only about 1 in 15 Union physicians was allowed to amputate. Only the most senior and experienced surgeons performed amputations. These changes were put into effect because of the public perception that too many amputations were being performed. Amputations were not carried out using sterile technique, given that Lister's classic paper on antisepsis did not appear until after the war in 1867 (15).

Anesthesia was first introduced in the United States in the 1840s. During the Civil War, it was used in over 80,000 cases. Chloroform was preferred because it had a quicker onset of action, could be used in small volumes, and was nonflammable. During the war there were only 43 anesthesia-related deaths. Anesthesia was fairly light (stage II) leading to the misperception that it was not being used.

Postoperative wound infections, when they developed, were a serious problem in the preantibiotic era. Laudable pus was thick and creamy (thought to be due to Staphylococcal infection) and associated with a better prognosis than malignant pus, which was thin and bloody (thought to be due to Streptococcal infection). Hospital gangrene was a peculiar type of necrotizing fasciitis that was first seen in the larger general hospitals. It was probably a result of a Streptococcal infection since nurses taking care of these patients occasionally developed erysipelas, but the exact organism remains unknown. A large percentage of patients with it died (45%) (8). Treatment was to dissect away dead tissue and inject the wound margins with bromine under anesthesia. The wound was then packed with a bromine-soaked dressing and the patients isolated in separate tents with a separate bandage supply. Nurses dressed these patients' wounds last and washed their hands in chlorinated soda between patients.

NONCOMBAT-RELATED DEATH AND ILLNESS
A variety of factors contributed to a high rate of noncombat-related illness, including overcrowded and filthy camps. Latrines were often not used or were drained into drinking water supplies or not covered daily. Food quality was poor from several standpoints. It was poorly stored, poorly cooked, and lacked enough vitamin C to prevent scurvy. The Army of the Potomac eventually added a number of rules: camps had be pitched on new ground and drained by ditches 18 inches deep, tents had to be struck twice a week to sun their floors, cooking had to be done only by company cooks, all refuse had to be burned or buried daily, soldiers had to bathe twice a week and change clothing at least once a week, and latrines had to be 8 feet deep and covered by 6 inches of dirt daily.

There were few useful medications at the time, and about two thirds of all drugs were botanicals. In 1860 Oliver Wendell Holmes stated at the annual meeting of the Massachusetts Medical Society, “I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind,—and all the worse for the fishes” (16). Medications that were helpful included quinine for malaria, morphine, chloroform, and ether, as well as paregoric. Many others were harmful. Fowler's solution was used to treat fevers and contained arsenic. Calomel (mercurous chloride) was used for diarrhea. Mercury is excreted in high concentration in saliva. This led to excessive salivation, loss of teeth, and gangrene of the mouth and cheeks in some patients. There were several famous cases of calomel toxicity. One involved Louisa May Alcott, the author of Little Women, and the second Carleton Burgan. He was one of the first people to undergo plastic surgery in the United States. Dr. Gurdon Buck performed a series of five operations using skin from his forehead to rebuild his cheek and side of his nose.

Physicians at the time had an extraordinary workload. The following was excerpted from a letter Dr. Daniel Holt wrote to his wife, Euphrasia:

You cannot imagine the amount of labor I have to perform. As an instance of what almost daily occurs, I will give you an account of day-before-yesterday's duty. At early dawn, while you, I hope, were quietly sleeping, I was up at Surgeon's call and before breakfast prescribed for 86 patients at the door of my tent. After meal I visited the hospitals and a barn where our sick are lying, and dealt medicines and write prescriptions for one hundred more; in all visited and prescribed for, one hundred and eighty-six men. I had no dinner. At 4 o'clock this labor was completed and a cold bite was eaten. After this, in the rain, I started for Sharpsburg, four miles distant, for medical supplies (17).

The soldier's diet consisted of fresh or pickled beef. It was heavily salted and frequently needed to be soaked prior to cooking and was often spoiled. Salt-cured pork was often rancid and mostly fat. Coffee and hard tack were staples of the diet. Hard tack was a large biscuit that was often dipped in coffee to make it more palatable. There was very little in the way of fresh fruits or vegetables. Desiccated vegetables were often substituted, but the process led to the loss of biologic activity of vitamin C and unfortunately to many potentially preventable cases of scurvy. Scurvy had been known to result from lack of fresh foods and greens in the diet based on an observation made by Johann Bachstrom in 1734. The case fatality rate of many diseases worsened as the war went on, perhaps as a result of malnutrition and dietary deficiencies.

The most common sickness among soldiers was gastrointestinal disorders. There were 711 cases per 1000 soldiers per year (18). The rate was higher in the West, where sanitation was worse. The mortality rate of acute diarrhea and dysentery was 3 to 17 per 1000 per year, while that of chronic diarrhea and dysentery was 126 to 162 per 1000 per year (19). There were no cholera outbreaks.

Malaria was also frequent: 224 of every 1000 Union soldiers seeking medical treatment were diagnosed with the disease (20). It was particularly common in southern states such as Arkansas and Mississippi. William H. Van Buren discovered in 1861 that quinine could be used prophylactically to prevent malaria. Southern states did not have a large enough supply to use it in this way. Although the cause of malaria was unknown at the time, it was known that its incidence could be reduced by locating camps away from stagnant water, sleeping in closed rooms, and sleeping on elevated ground or upper floors of buildings. Digging ditches or canals and sleeping outdoors were known to increase risk.

Yellow fever was a major problem in the South, killing over 10,000 people (21). There were more outbreaks in Texas during the war than in any other state. Epidemics occurred in summer and autumn months. It was known as the stranger's disease since it often affected newcomers to the area. Those that were infected and survived acquired lifelong immunity. Outbreaks would often occur after a ship arrived from a Caribbean port. It could be prevented by quarantining newly arrived ships in most cases. Attempts at its prevention by Benjamin Butler in New Orleans may have been the first example of a medical incentive plan. Butler, with urging from his superior officer Rear Admiral David Farragut, told Dr. Jonathan M. Foltz: “In this matter your orders shall be absolute. Order off all you may think proper [ships to quarantine], and so long as you keep yellow fever away from New Orleans your salary shall be one thousand dollars per month. When yellow fever appears in this city your pay shall cease.” Dr. Foltz quarantined all ships for 40 days 70 miles below the city, and this virtually eliminated yellow fever in New Orleans (22).

There were over 75,000 cases of typhoid fever in the Union Army during the war. It resulted from exposure to fecally contaminated food and water, as well as flies. It killed 17% of affected soldiers in 1861 and 56% by 1865 (23). Typhoid fever was especially common in Washington, DC, where it claimed the life of Abraham Lincoln's son Willie.

Measles outbreaks were also common. There were at least 67,000 cases in the Union Army, with more than 4000 deaths. Of the 1200 soldiers in the 12th North Carolina, 800 developed measles during a 4-month period in 1861 after arriving in a West Virginia camp (24). Farmers made up 48% of the Union Army, and rural populations often had very little immunity to childhood diseases. Epidemics were common at the time of an influx of new troops, especially early in the war. The death rate was almost twice as high in African Americans as in whites, 11% versus 6%.

A smallpox vaccine had been invented by Edward Jenner 70 years before the war, but a large percentage of the population was not vaccinated. The annual incidence of smallpox was 5.2 cases per 1000 in whites and 35.1 per 1000 in African Americans (25). Cases were quarantined. Because vaccine material was in short supply during the war, material was aspirated from the pustules of vaccinated people. This unfortunately resulted in the transmission of many cases of syphilis.

References
1. Civil War Trust. Civil war casualties. Available at http://www.civilwar.org/education/civil-war-casualties.html.
2. Hacker JD. A census-based count of the Civil War dead. Civ War Hist. 2011;57:307–348. [PubMed]
3. Foote S. The Civil War: A Narrative. Vol. 3. New York: Random House; 1958. pp. 1040–1041.
4. Grace W. The Army Surgeon's Manual: For the Use of Medical Officers, Cadets, Chaplains, and Hospital Stewards: Containing the Regulations of the Medical Department, All General Orders from the War Department, and Circulars from the Surgeon-Generals Office from January 1st, 1861 to April 1st, 1865. New York: Bailliere Brothers; 1865. Available at http:archive.org/stream/62510310R.nlm.nih.gov/62510310R_djvu.txt.
5. Blanton D, Cook LM. They Fought Like Demons: Women Soldiers in the Civil War. New York: Random House; 2002. p. 7.
6. Freeman FR. Gangrene and Glory: Medical Care During the American Civil War. Urbana, IL: University of Illinois Press; 1998. pp. 28–29.
7. Wilbur CK. Civil War Medicine. Guilford, CT: Global Pequot Press; 1998. p. 3.
8. Mitchell SW. On the medical department in the Civil War. JAMA. 1914;62:1445–1450.
9. Rutkow IM. Bleeding Blue and Gray: Civil War Surgery and the Evolution of American Medicine. New York: Random House; 2005. pp. 21–28.
10. Adams GW. Doctors in Blue: The Medical History of the Union Army in the Civil War. Baton Rouge, LA: Louisiana State University Press; 1952. p. 26.
11. Beller SP. Medical Practices in the Civil War. Charlotte, VT: OurStory; 1998. pp. 57–62.
12. Bollet AJ. Civil War Medicine: Challenges and Triumphs. Tucson, AZ: Galen Press; 2002. p. 223.
13. McDonough JL, Connelly TL. Five Tragic Hours: The Battle of Franklin. Knoxville, TN: University of Tennessee Press; 1983. p. 3.
14. McMahon MT. The death of General John Sedgwick. Available at http://www.civilwarhome.com/sedgwickdeath.htm.
15. Lister J. On the antiseptic principle in the practice of surgery. Br Med J. 1867;2:246–248. [PMC free article] [PubMed]
16. Holmes OW. Currents and Counter-Currents in Medical Science with Other Addresses and Essays. An Address Delivered Before the Massachusetts Medical Society at the Annual Meeting, May 30, 1860. Cambridge, MA: University Press; 1861. p. 39.
17. Holt DM. A Surgeon's Civil War: The Letters and Diary of Daniel M Holt, M.D. Kent, OH: Kent State University Press; 1994. p. 34.
18. Adams GW. p. 226.
19. Bollet AJ. pp. 284–285.
20. Adams GW. p. 227.
21. Bell AM. Mosquito Soldiers: Malaria, Yellow Fever and the Course of the American Civil War. Baton Rouge, LA: Louisiana State University Press; 2010. pp. 41–44.
22. Foltz CS. Surgeon of the Seas: The Adventurous Life of Surgeon General Jonathan M. Foltz in the Days of the Wooden Ships. Indianapolis, IN: Bobbs-Merrill; 1931. p. 253.
23. Bollet AJ. pp. 272–274.
24. Buist JR. Some items of my medical and surgical experience in the Confederate Army. Southern Practitioner. 1903;25:574–581.
25. Bollet AJ. p. 290.

From:  ncbi.nlm.nih.gov

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History & Economics of Tobacco

From: healthliteracy.worlded.org

Tobacco has a long history in the Americas. The Mayan Indians of Mexico carved drawings in stone showing tobacco use. These drawings date back to somewhere between 600 to 900 A.D. Tobacco was grown by American Indians before the Europeans came from England, Spain, France, and Italy to North America. Native Americans smoked tobacco through a pipe for special religious and medical purposes. They did not smoke every day.

Tobacco was the first crop grown for money in North America. In 1612 the settlers of the first American colony in Jamestown, Virginia grew tobacco as a cash crop. It was their main source of money. Other cash crops were corn, cotton, wheat, sugar, and soya beans. Tobacco helped pay for the American Revolution against England. Also, the first President of the U.S. grew tobacco.

By the 1800's, many people had begun using small amounts of tobacco. Some chewed it. Others smoked it occasionally in a pipe, or they hand-rolled a cigarette or cigar. On the average, people smoked about 40 cigarettes a year. The first commercial cigarettes were made in 1865 by Washington Duke on his 300-acre farm in Raleigh, North Carolina. His hand-rolled cigarettes were sold to soldiers at the end of the Civil War.

It was not until James Bonsack invented the cigarette-making machine in 1881 that cigarette smoking became widespread. Bonsack's cigarette machine could make 120,000 cigarettes a day. He went into business with Washington Duke's son, James "Buck" Duke. They built a factory and made 10 million cigarettes their first year and about one billion cigarettes five years later. The first brand of cigarettes were packaged in a box with baseball cards and were called Duke of Durham. Buck Duke and his father started the first tobacco company in the U.S. They named it the American Tobacco Company.

The American Tobacco Company was the largest and most powerful tobacco company until the early 1900's. Several companies were making cigarettes by the early 1900's. In 1902 Philip Morris company came out with its Marlboro brand.

They were selling their cigarettes mainly to men. Everything changed during World War I (1914-18) and World War II (1939-45). Soldiers overseas were given free cigarettes every day. At home production increased and cigarettes were being marketed to women too. More than any other war, World War II brought more independence for women. Many of them went to work and started smoking for the first time while their husbands were away.

By 1944 cigarette production was up to 300 billion a year. Service men received about 75% of all cigarettes produced. The wars were good for the tobacco industry. Since WW II, there have been six giant cigarette companies in the U.S. They are Philip Morris, R.J. Reynolds, American Brands, Lorillard, Brown & Williamson, and Liggett & Myers (now called the Brooke Group). They make millions of dollars selling cigarettes in the U.S. and all over the world.

In 1964 the Surgeon General of the U.S. (the chief doctor for the country) wrote a report about the dangers of cigarette smoking. He said that the nicotine and tar in cigarettes cause lung cancer. In 1965 the Congress of the U.S. passed the Cigarette Labelling and Advertising Act. It said that every cigarette pack must have a warning label on its side stating "Cigarettes may be hazardous to your health."

By the 1980's, the tobacco companies had come out with new brands of cigarettes with lower amounts of tar and nicotine and improved filters to keep their customers buying and to help reduce their fears. The early 1980's were called the "tar wars" because tobacco companies competed aggressively to make over 100 low tar and "ultra" low tar cigarettes. Each company made and sold many different brands of cigarettes.

In 1984 Congress passed another law called the Comprehensive Smoking Education Act. It said that the cigarette companies every three months had to change the warning labels on cigarette packs. It created four different labels for the companies to rotate.

Since the 1980's, federal, state, local governments, and private companies have begun taking actions to restrict cigarette smoking in public places. The warning labels were the first step. Tobacco companies cannot advertise cigarettes on television or radio. It is against a law that was passed by Congress in 1971. Many cities across the U.S. do not allow smoking in public buildings and restaurants. Since 1990, airlines have not allowed smoking on airplane flights in the U.S. that are six hours or less. State taxes on cigarettes have increased.

As it becomes more difficult for tobacco companies to sell their products in the U.S., they are looking outside. U.S. tobacco companies are now growing tobacco in Africa, South America (Brazil and Paraguay), India, Pakistan, the Phillipines, Greece, Thailand, and the Dominican Republic. Fifty percent (50%) of the sales of U.S. tobacco companies go to Asian countries, such as Thailand, South Korea, Malaysia, the Phillipines, and Taiwan.

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Soldier's Disease

From: drvitelli.typepad.com, 2-6-11

The American Civil War (a.k.a. The War Between the States) was long and terrible. Beginning in 1861, the four-year war is still the deadliest in American history with an estimated 620,000 soldiers killed and an indeterminate number of civilian casualties. Approximately ten percent of all Northern males and 30 per cent of all Southern males were killed in the fighting and the social and political costs left their mark on the United States for generations afterward. 

As one of the first "modern" wars with heavy artillery and other weapons of mass destruction, physicians on both sides of the conflict were faced with unprecedented medical challenges in dealing with wounded soldiers.  Military surgery was still in its infancy and antiseptic practices were largely unknown so casualties remained high despite the best efforts of doctors and nurses.

To deal with patient suffering, doctors relied on two medical innovations that had only become available a few years previously:  the hypodermic needle and morphine sulphate. First developed in 1804, the opium derivative received its name from the Greek god of dreams, Morpheus, and widely advertised to physicians as a safe and effective analgesic.  Given that surgery was often traumatic due to the lack of proper anesthesia, the use of morphine (spurred on by the development of the hypodermic needle in 1857) began to spread. Opium pills were also widely dispensed when hypodermic needles were unavailable. During the Civil War, solders were often dosed with enormous amounts of morphine or opium to kill the pain of amputations and other surgeries. 

While the potential for addiction was already known at the time, simple humanitarian concerns ensured that soldiers remained liberally dosed with morphine and whatever other analgesics were available.

Anecdotal accounts of Civil War doctors on both sides dispensing opium seem descriptive enough. One Confederate doctor, William H. Taylor, gave a plug of opium to every patient reporting pain depending of whether or not they were constipated.  A Union doctor, Nathan Mayer, diagnosed patients from horseback.  If the wounded soldier needed morphine, Mayer would pour out an "exact into his hand and had the patient lick it off  (not a recommended method, by the way). 

Since medical epidemiology was still unknown, actual statistics relating to morphine addiction remain scarce.  Some sources have suggested that as many as 400,000 veterans were left addicted to morphine due to their wartime experiences.  These addicts were readily identified by the characteristic leather thong around their necks to which a small bag was attached.  The bag carried a supply of morphine sulphate tablets as well as  a hypodermic needle.  Upon their discharge from the army, this was all that was given to the returning soldiers to ease their return to society (no Veterans' Administration services in those days).  In recognition of the medical issues that these veterans faced, the term "Soldier's disease" was coined  (as opposed to "Soldier's Heart" which was an early name for Posttraumatic Stress Disorder). 

But how prevalent a problem was Soldier's Disease?  As some historians have noted, there were few descriptions of widespread morphine addiction during the 19th century.  The existence of thousands of morphine addicts in the United States following the end of the Civil War would have likely made far more of an impact than later medical authorities noted.  Veterans certainly had good reason to conceal their addiction since public exposure might have cost them their service pension (drug addiction was not a recognized medical condition).  The greatest social impact of the war and the addicts who survived it was likely from 1865 to 1900 when most addicts had died off. 

While the explosive growth of opium addiction from 1865 to 1895 was certainly noted,  the few drug addiction surveys undertaken during this period showed that women were more likely to be addicts than men.  Many of these women addicts had become addicted to the opiates that had been legally prescribed for them by their physicians (often as treatment for "female problems").  

Although 19th century newspaper editorials expressed alarm over substance use, it almost always focused on opium and the insidious "opium dens" which were seen as a threat to American society (there were often racist overtones to these editorials given that they focused on how "white women" could be ensnared into smoking with "Chinese men").

Despite concerns relating to morphine addiction (and the thousands of addicts who had supposedly been released into society after the war), physicians continued to prescribe morphine for their patients.  As a catch-all medical solution for a wide variety of problems (which could range from headaches to diarrhea),  hypodermic-wielding physicians likely created more addicts than the typical opium den.   In an 1880 medical text titled The Hypodermic Injection of Morphia, the author stated that "here is no proceeding in medicine that has become so rapidly popular; no method of allaying pain so prompt in its action and permanent in its effect; no plan of medication that has been so carelessly used and thoroughly abused; and no therapeutic discovery that has been so great a blessing and so great a curse to mankind than the hypodermic injection of morphia".   

Not only did the demand for morphine create a steady market for the drug, it also created a strong demand for hypodermic needles as well.  The 1897 Sears and Roebuck catalogue advertised a hypodermic kit (including a syringe, two needles, two vials, and a carrying case) for a mere $1.50 (quite a bargain, really).   Patent medications, largely unregulated at the time, were advertised for the treatment of a wide variety of complaints and, naturally, morphine and opium were popular ingredients.  The self-medication that these patent medications made possible certainly aggravated the problem of substance abuse but the lack of formal government controls helped drive sales.

It seems inevitable that alternatives to morphine would become available as medical researchers learned more about the chemical composition of opium.  Codeine was first isolated in 1832 by French chemist, Pierre Robiquet, although it proved not to be as popular as morphine.  The real breakthrough came in the 1870s when  English chemist C.R.A. Wright first isolated the opiate compound that would later be marketed under the brand name of heroin.  When Bayer Pharmaceuticals released their product some time later (the name heroin was taken from the German word for heroic, heroisch), it was billed as a perfectly safe alternative to morphine. 

And heroin was hardly the only new product available.  With the development of chloroform, nitrous oxide, and various other anesthetics, pain-free surgery and dentistry became all the rage. At the same time, however, there was a growing fear of the social dangers surrounding opiates (including morphine and heroin).  Following the Spanish-American War and the American annexation of the Philippines in 1898,  public alarm over opium addiction became even more widespread.   As a result of U.S. pressure,  the first International Opium Commission was held in Shanghai in 1909.  A second meeting was held in 1911 and the first comprehensive policy regulating opiate use was signed.

In the United States, anti-drug lobbyists began agitating from more stringent safeguards.  Hamilton Wright was appointed as America's first Opium Commissioner in 1908 and, after attending the Shanghai meeting, would comment that "Of all the nations of the world, the United States consumes most habit-forming drugs per capita. Opium, the most pernicious drug known to humanity, is surrounded, in this country, with far fewer safeguards than any other nation in Europe fences it with".    Once again, drug abuse was linked to racial unrest as Wright went on to comment that "cocaine is often the direct incentive to the crime of rape by the Negroes of the South and other sections of the country" (while cocaine is not an opiate, the drug reformers insisted on classifying it as a narcotic as part of their platform). 

Newspaper editors and academics alike weighed in on the dangers of drug addiction and the horrendous social costs involved.   Racism was readily apparent and the editorials were filled with accounts of "drug-crazed, sex mad negroes" and "Chinamen" seducing white women on drugs. Various drug "experts" testified on the proliferation of drug-addicted "Negroes" stalking and attacking white women while under the influence.     

By 1914, forty-six states had passed legislation regulating or banning opium, morphine, or heroin. The fact that World War One had just broken out in Europe became a factor as well since experts began raising concerns about the cases of Soldier's  Disease that had arisen from the Civil War and the possibility of American involvement in the new year leading to more cases.  

In 1915, Jeannette Marks published a highly influential article in the American Journal of Public Health describing the "hydra-headed drug curse" following the Civil War and expressed alarm that the problem would shortly resurface.  She was also the first to suggest that there had been as many as 400,00 morphine addicts following the war although she was given to exaggeration (she had also estimated there being 4,000,000 drug addicts in the U.S. in 1915).    

While other experts disputed her estimate, the consensus that drug regulation was needed seemed clear enough.  After quiet deliberation, the Harrison Narcotics Tax Act was signed into law on December 17, 1914. Technically focusing on taxing narcotics (again, cocaine was included), the act also imposed still penalties for the sale and importation of all narcotics.  Although morphine and other opiates could still be prescribed by a physician, the anti-drug era had begun in force.  

As for Soldier' Disease, its popularity as a diagnosis began to level off during the 20th century when substance abuse in the military became better understood.  Despite the role of the diagnosis in helping to shape U.S. drug policy and the numerous wars that have been fought in the past century, the use of a distinct diagnosis for returning soldiers addicted to pain medication has been largely discarded in the clinical literature.   While drug experts continue to disagree on the actual number of Civil War morphine addicts (the estimates range from 45,000 to 400,000).  Still, the controversy remains over how any valid estimate could ever be made given the lack of reliable data from that era. 

What isn't in dispute however, is that substance abuse among military personnel continues to be a political minefield regardless of the actual medical needs of soldiers dealing with chronic pain or posttraumatic stress.  Despite research initiatives by the National Institute on Drug Abuse and the Department of Veteran's Affairs,  the substance abuse problems that returning soldiers face are still waiting to be solved.

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Suicide and the Civil War

Kathleen Logothetis Thompson

While Post-Traumatic Stress Disorder (PTSD) was not yet diagnosed in the 1860s, soldiers have always faced the physical and psychological consequences of soldiering. Combat stress manifests itself in many ways, suicide being the most shocking reaction to the stresses of war. Civil War soldiers had social and cultural tools to help them cope with the experiences of camp and battle, but in some cases those tools broke down, leading to psychological stress or suicide. Statistically, suicides were few in the armies. The Union army reported only 391 official suicides during the war (approximately 0.02% of Union soldiers) and there is no official number for Confederate suicides. While the official numbers are low it is very likely that the actual rate was higher through unreported or misreported suicides and veterans suicides after the war.

Suicide is a very personal experience, often seen as sudden and unexplainable to outside observers, so it is very difficult to pinpoint the cause, especially 150 years later. However, two experiences had a definite connection to mental stress and suicide: injury in battle and becoming a prisoner of war. Because most soldiers distrusted the army medical system, the fear of injury sometimes outweighed the fear of dying in battle. Injuries in combat also shook soldiers out of the adrenaline-induced state that allowed men to fight for hours, causing the body and the mind to react to the shock of battle in the midst of combat, not later when the fighting was over. At Fredericksburg, Thomas H. Evans of the 12th US Regulars reported passing over the battlefield on Marye’s Heights immediately after the engagement, hearing a shot, and then finding a body with a rifle lying across it, powder burns on the clothing, and the head shattered from the chin upwards. Evans wrote: “He had probably mistaken our approach for a body of the enemy, and in his agony and horror of becoming a wounded prisoner, had blown out the remains of his life by his own act.”

The Fredericksburg soldier had reason to fear becoming a prisoner of war, for they were another group that faced particular traumas. The foundations that soldiers clutched to manage their wartime experiences completely broke down in the environment of prisoner camps. Deprivation, monotony, cruelty, disease, and death forced some prisoners to sink into apathy and face long-standing psychological and physical issues and others to consider or commit suicide. Francis Amasa Walker wrote of his time as a prisoner of war that he suffered “a period of nervous horror such as I had never before and have never since experienced, and memories of which have always made it perfectly clear how one can be driven on, unwilling and vainly resisting, to suicide. I remember watching the bars at my window and wondering whether I should hang myself from them.” Walker resisted such temptation, but others could not, despite the restrictions of available materials in the prison camp. Crossing the “dead line” was an apparently popular form of committing suicide; this was a perimeter set up at many prison camps that marked the point prisoners could not pass without being shot by the guards. There is no question that these men wanted death; one soldier stepped over the line and challenged the sentry to shoot him, after two failed shots he yelled at the guard to do his duty and the third shot hit him in the head, killing him instantly.

When we say goodbye to Tom Fairfax, he has recovered from his physical wounds but still suffers from the mental stress of his experiences. He is caught between returning to the frontlines where he will re-experience the stress and trauma of combat and camp life and transportation to a POW camp where he faces an environment that broke many soldiers during the war. In the end he chooses to take his own life instead of facing either. It is important to note that even though Mercy Street chose to represent psychological casualties of the Civil War through a suicidal character, most traumatized soldiers suffered silently due to the cultural and medical constraints of the time.

About the Author:
Kathleen Logothetis Thompson graduated from Siena College in May 2010 with a B.A. in History and a Certificate in Revolutionary Era Studies.  She earned her M.A. in History from West Virginia University in May 2012. She is currently pursuing her PhD at West Virginia University with research on mental trauma in the Civil War.  In addition, Kathleen was a seasonal interpreter at Fredericksburg & Spotsylvania National Military Park and is co-editor for Civil Discourse, a blog of the long Civil War Era.

From: mercystreetpbs.com

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Civil War-Era Women Physicians

By Alfred Jay Bollet, M.D.

        It is unclear how many women were working as physicians in the United States before the Civil War. In the mid-1800s, medical students commonly learned from a preceptor without attending a formal medical school. At least one woman, Margaret Cannon Osborne, is known to have acquired her education in this manner and entered practice, and there may have been others like her. Also, many women learned medicine from their husbands or fathers in this fashion and then assisted in their practices. An unknown number of women attended medical school during this period dressed in male attire and went on to practice medicine pretending to be men.

        While many male and female practitioners who graduated from unorthodox medical schools applied for admission to the Medical Corps of both armies, they were rejected. In desperation, a delegation of male homeopaths appealed directly to President Lincoln, but he would not support their application for army appointments.

        Aside from Dr. Blackwell, at least two women who attended orthodox (allopathic) medical schools served as physicians during the war. Although some details of the career of Dr. Mary Edwards Walker (1832-1919) are vague, there is no doubt that she heroically served the Union cause. Born in Oswego, New York, she became a physician during the 1840s or 1850s, graduating from Syracuse Medical College at some point. She struggled in her attempts to practice medicine in Cincinnati, and, when the Civil War began, she was allowed to work in the Union army only as a nurse. In 1864, after three years as an army nurse, a regiment from Ohio hired her as a contract physician. As such, she was able to pass back and forth through the Union and Confederate lines. This allowed her to function as a spy, reporting her observations to Union officers. In October 1864, she received an army commission as an assistant surgeon and functioned in that official capacity until the war ended. Captured while treating a Confederate soldier on a battlefield, she spent four months in a Confederate prison.

        While in the army, Dr. Walker wore the same military uniform as male physicians, but kept her hair long so that people would know that she was a woman. After the war, she continued to wear male attire and was active in women's rights movements. In 1897, she tried to establish a colony for women only, calling it "Adamless Eden." Her militancy caused most people, including her family, to shun her, and she died poor and alone in Oswego.

        Her dangerous Civil War exploits led to her being awarded the Medal of Honor. However, after the criteria for awarding such medals were revised, the Board of Medals officially revoked the medal and asked her to return it. She reportedly said, "They can have it over my dead body." She died the next day, February 21, 1919. In 1977, the award was officially reinstated.

        Dr. Esther Hill Hawks (1833-1906) was another army physician. After marrying Dr. John Milton Hawks, Esther Hill Hawks studied his medical books and decided to go to medical school. Graduating from New England Medical College for Women in 1857, she practiced in various locales with her husband. He was an ardent abolitionist, and, after Hilton Head and the surrounding areas were occupied by Union forces, he obtained a job providing medical care and running a plantation set up for freed slaves along the coast of South Carolina. Esther joined him there and helped provide medical care to the blacks. She also worked as a contract physician in General Hospital Number 10, which was established for black soldiers in Beaufort, South Carolina. Hawks helped care for soldiers from the 54th Massachusetts Colored Infantry after its famous ill-fated attempt to take Morris Island under Col. Robert Shaw. After the war, she continued to work in the area, caring for former slaves and teaching school.

        Dr. Elizabeth Blackwell was the first woman known to have received a regular medical degree in the United States. She was born in Bristol, England, but at the age of nine moved with her family to the United States, living first in New York City and then in Cincinnati. She taught school in Henderson, Kentucky, but, in 1844, she decided to study medicine. After being refused admission to many medical schools, she was finally accepted at Geneva (New York) Medical College in 1847. (The first medical school for women was established in 1850 in Philadelphia.)

        When she received her M.D. degree in 1849, it provoked a great deal of press coverage in the United States and abroad; her biographers state that most people considered her "either mad or bad." Despite the negative attitude toward her in most of the press, the British humor magazine Punch commented on her graduation:

Young ladies all, of every clime,
Especially of Britain,
Who wholly occupy your time,
In novels or in knitting,
Whose highest skill is but to play,
Sing, dance, or French to clack well,
Reflect on the example, pray,
Of the excellent Miss Blackwell.

        After Blackwell graduated, she was unable to find a hospital in the United States that would admit her for further training. She went to Paris, where she met with the leading physicians of the era, including Dr. Pierre Louis. None of them would accept a woman for training, and Louis advised her to enroll for midwife training. Taking his advice, she trained at La Maternité in Paris in 1849.

        When Blackwell then received an appointment at St. Bartholomew's Hospital in London, she received congratulations from Florence Nightingale, and they began a lifelong friendship. Blackwell encouraged Nightingale to enter nursing, even though her family strongly opposed such a move.

        Blackwell returned to New York in 1850 and set up a private dispensary. Joined by her sister and Dr. Marie Zakrzewska (who had both obtained medical degrees at the Western Reserve University Medical School in Cleveland) and other women, she established the New York Infirmary for Women and Children on Bleeker Street in May 1857.

        In 1868, they started the New York Medical College for Women at New York Infirmary. Blackwell insisted that it be staffed by women and have a curriculum and standards more demanding than most other medical schools at the time. It was financially supported by Quakers.

         In 1869, Blackwell returned to England to campaign for the acceptance of women into the medical profession. She became the first woman ever admitted to the Medical Register of the United Kingdom and a professor at London School of Medicine for Women, which had just been founded. She remained on the faculty until 1907, when an accident enfeebled her. She was buried in England after she died in 1910.

From: Civil War Medicine: Challenges and Triumphs
©Galen Press, Ltd., Tucson, AZ, 2002

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Dr. Mary Edwards Walker, First (And Only) Female MOH Recipient

By Siggurdsson, 7-29-11

Mary Edwards Walker was born in Oswego, New York on November 26, 1832. She was the fifth of six children and the youngest daughter. She worked on her family's farm through most of her young life, usually wearing men's clothes as they were not as restricting. She received an elementary education, taught by her mother. She attended Syracuse Medical College, graduating in 1855 as one of the country's first women doctors. She married a classmate named Albert Miller. They set up a joint medical practice in nearby Rome, NY but they were not very successful.

When the American Civil War began in 1861, Mary Walker volunteered to serve in the Union medical corps as a civilian. At first, she was restricted to working as a nurse, as the concept of a female surgeon was not widely accepted. Walker worked on the battlefield after the First Battle of Bull Run/Manassas and at the Patent Office Hospital in Washington, DC early in the war. Later, she worked as an unpaid field surgeon after the battle of Fredericksburg (December of 1862), and later in Chattanooga, TN after the battle of Chickamauga (September of 1863). At this time, she was appointed a "Contract Acting Assistant Surgeon (civilian)" by the Army of the Cumberland. By this appointment Mary Walker became the first ever female U.S. Army Surgeon

By way of explanation, a "contract surgeon" was a doctor hired to give medical care to soldiers on the battlefield or in field hospitals. During the Civil War, the Union Army had about 10,000 surgeons, of which only about 3000 were members of the military. The remainder were civilians hired to fill the need for so many soldiers fighting in the war. They were usually given the title of "assistant surgeon," and their usual jobs involved amputations.

Sometime later Walker was appointed assistant surgeon of the 52nd Ohio Infantry Regiment. She spent much time crossing the line to help Confederate civilians displaced from their homes by the war. Walker often "appropriated" Federal supplies to help these unfortunates. She was captured by Confederate troops in April of 1864, and sent to a prison in Richmond, VA, accused of being a Union spy (a charge she vehemently denied). She was released in August of 1864 in a prisoner exchange for a Confederate officer. Walker made her way back to the Army of the Cumberland, seeing service during the battle of Atlanta (July-September of 1864). She was then appointed a supervisor of a women's prison in Louisville, KY and later placed in charge of an orphanage in Tennessee.

After the war, Mary Walker persuaded Generals William T. Sherman and George H. Thomas to petition Congress to award her a Medal of Honor for her service during the war. Their efforts were successful, when on November 11, 1865 President Andrew Johnson signed a special law awarding "Dr. Mary E. Walker" a Medal of Honor. The citation reads:

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 [sic], 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, Oswego County, 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 soldiers, 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 existing laws, 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."

After the war, Mary Walker became a member of a small but vocal group of women who sought equality for women in many areas where they were still considered subservient to men, among them voting rights. She also lectured on the temperance circuit, and became an advocate for freeing women from the restrictive clothing of the Victorian era. Walker herself wore men's clothing whenever possible [note the photograph heading this post]. She was arrested several times for impersonating a man.

In 1916, Congress created a pension act for Medal of Honor recipients, further creating separate Army and Navy Honor Rolls. This act also placed greater restrictions on the eligibility requirements for awarding Medals of Honor. The Army then determined to review all the Medals of Honor which had been awarded since 1862, using the newly restrictive eligibility. As a result, when the review board released its findings in 1917, 911 recipients had their names removed from the Army Medal of Honor Roll. Among these 911 recipients were: 29 men who had been part of the honor guard escorting Abraham Lincoln's casket back to Illinois; 864 men of the 27th Maine Infantry Regiment, for re-enlisting in mid-1863; five civilian scouts (including William F. Cody aka "Buffalo Bill;" 12 miscellaneous awards; and, Mary Walker. These persons were not required to return their medals – as has often been stated – but were stricken from the Honor Roll and became ineligible for a pension.

Mary Walker took this review rather personally, and wore her Medal of Honor everywhere in public. She died February 21, 1919 at the age of 86. She was buried wearing her black suit instead of a dress. While here funeral was a rather plain affair, her casket was draped by an American flag.

Footnote #1: In 1977, President Carter reinstated her Medal of Honor. This act provoked a further review of other Medal recipients' revoked status. Twelve years later, "Buffalo Bill" Cody's Medal of Honor was also reinstated.

Footnote #2: A World War II Liberty ship, the SS "Mary Walker" was named for her. A U.S. Army Reserve center in Walker, Michigan also bears her name. Finally, the Whitman-Walker Clinic in Washington, DC was named for her and poet Walt Whitman, who served as a nurse in hospitals in the Washington area during the Civil War.

From: burnpit.us

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