Table 10. Amputations in the Union Army (29,980 Reported Cases)
The improved kinetic power of the rifle bullet made amputation the most common battlefield operation during the Civil War. Of the 174,200 gunshot wounds to the arms and legs suffered by Union soldiers, 29,980 required amputation.117 Confederate soldiers suffered 25,000 primary amputations (meaning as soon as possible after wounding) and the Union Army 20,993.118 More limbs were lost in this war than in any other conflict fought by the United States, including World Wars I and II, Korea, Vietnam, Iraq, and Afghanistan. The old debate about primary versus secondary amputation reappeared. Within two years, experience had shown that the soldier’s chances of survival increased with primary amputation. The mortality rate for primary amputation was 26 percent compared to 52 percent for secondary amputation.119 Interestingly, however, 26,467 wounds of the extremities complicated by injury to the bone were treated “by expectation” (leaving the wound alone to heal itself) with a mortality rate of only 18 percent, which was much lower than the rate for either primary or secondary amputation.120
In the first year of the war, hemostasis was achieved mostly through the tourniquet and cautery, but both methods were dangerous to the patient. As the minimally trained surgeons gained more experience, however, they more commonly used ligature and pressure dressings to control bleeding. One of the war’s beneficial medical effects was that it gave thousands of surgeons experience in ligature, a training they could practice in civilian life. The common practice, however, was to leave the ends of the ligature long and extending outside the body. These loose ends proved to be excellent avenues for infection, producing septic conditions that led to secondary hemorrhage. The mortality rate for such secondary infections was 62 percent.121 The usual array of infections—tetanus, hospital gangrene, and various streptococcus infections—were ever present. In the early days, the mortality rate in some hospitals was as high as 60 percent. As surgeons gradually began using debridement and bromine solution applications, the mortality rate from wound infection fell to 3 percent near the end of the war.122
The Union blockade caused shortages of medical supplies that forced Confederate surgeons to develop alternatives that proved beneficial in fighting wound infection. Both sides cleansed wounds with sea sponges kept in buckets of water near the operating table. Used repeatedly after being squeezed in the dirty water, these sponges were major sources of disease transmission. A shortage of sponges in the South forced Confederate surgeons to use cotton rags instead. Since the rags were recycled, cleaned, boiled, and ironed, they served as relatively sterile wound dressings. The same was true of the bandages. With bandages in short supply, practitioners used raw cotton, but to manufacture the product, it was necessary to oven bake the cotton, producing a sterile bandage. While Northern surgeons used unsterile harness-maker’s silk for ligatures and sutures, silk was not available to the Southern surgeons, who used horsehair for the same purposes. To make the horsehair sufficiently pliable for surgical use, they had to boil it. By happy accident, the boiling process produced sterile sutures.123 Nonetheless, wound infection, especially in the general hospitals, remained a major problem. William W. Keen (1827–1932), who served as a surgeon in the Army of the Potomac, noted, “It was seven times safer to fight all through the three days of Gettysburg than to have an arm or leg cut off . . . and be treated in a city hospital.”124
Military surgeons of the Civil War used chloroform and ether anesthesia on an unprecedented scale. Military physicians used no fewer than eighty thousand applications of anesthesia. Official records show that anesthesia was used in 8,900 operations within general hospitals, of which 6,784 involved chloroform and 811 involved ether alone. In 1,305 cases, they used a combination of ether and chloroform. Remarkably, only thirty-seven deaths were attributed to anesthesia.125 They also made advances in immobilizing limbs, with plaster of Paris widely used for this purpose. Having studied in Europe, Dr. Gordon Buck (1807–1877) brought the technique to America, and the first application to immobilize a limb was accomplished in 1855. Dr. Nathan Little is generally credited with introducing the technique to the military medical community during the Civil War.126 In 1863, Union surgeon John Hodgen (1826–1882) introduced the famous Hodgen splint, which is still used today in fractures of the lower femur.
Drug application during the war was quite primitive because physicians of the period knew little about the specific effects of drugs. Except for calomel (mercurous chloride), which was so heavily prescribed that Surgeon General William Hammond (1828–1900) forbade its use as dangerous, most drugs did little harm if little good. The most indispensable and well-known drugs included morphine, opium, and quinine. Morphine was usually dusted directly on the wound and occasionally injected hypodermically. The hypodermic syringe appeared in the 1850s, but only 2,093 syringes were issued to the Union Army during the war. That their use had any medical significance is unlikely. Yet, Silas Weir Mitchell (1829–1914) noted that at the army hospital for nervous diseases, Turner’s Lane Hospital in Philadelphia, more than forty thousand doses of morphine were given hypodermically to patients in a single year.127 A significant addiction problem resulted from the Union Army’s wide use of opium pills and other addictive opium-based prescriptions. Records show that ten million opium pills were administered to patients during the war, along with 2,841,000 ounces of other opium-based preparations, such as laudanum, opium with ipecac, and paregoric. By contrast, only 29,828 ounces of morphine sulfate were administered.128 While not all addicts in the country were former soldiers, the United States had 200,000 drug addicts by 1900.129
A number of antiseptics were widely used, including potassium permanganate, sodium hypochlorite, bromine, iodine, turpentine, and creosote. Lister had not yet made his important discovery regarding antisepsis, and none of these preparations were used in wound treatment. They were, however, commonly used as deodorants in hospitals and did have the unintended effect of providing better sanitary conditions in the hospital wards.
As in all past wars, disease was the most common killer of Union and Confederate soldiers. Both armies were armies of volunteers, and in the early years of the war the armies performed little more than perfunctory medical examinations of their recruits. A normal day’s load for physicians examining recruits was between forty and fifty examinations a day. The quality of recruits, often motivated by patriotic fervor and the enlistment bounty, was less than desirable. In 1861, a Union Sanitary Commission report noted that three-quarters of the soldiers who had been discharged from the Union Army were so physically unfit that they should never have been allowed to enlist in the first place.130
Most recruits came from largely rural populations. Their isolated locations had prevented them from developing immunities to a wide range of childhood diseases. Once they were brought together in the close quarters required of military life, many fell ill.131 Their poor physical conditions and few immunities were compounded by generally poor nutrition from military rations and the general stress of military life. Scurvy was endemic, and outbreaks of cholera, typhus, typhoid, and dysentery took a generally heavy toll.132 Although tetanus mortality was high—89–95 percent— relatively few cases of tetanus arose because most battles did not occur in the richly manured soil of overworked farmland. Most cases of tetanus were contracted in field hospitals, when barns and stalls served as temporary surgical hospitals and aid stations.133 Disease killed approximately 225,000 men in the Union Army and 164,000 in the Confederate ranks. It is estimated that disease killed five times as many men as were slain by weapon fire.134
The Union Medical Department was totally unprepared for war. Its head, Surgeon General Thomas Lawson (1789–1861), was a sick and dying man who economized on expenditures by refusing to purchase medical books for the military. The small 26,000-man army was scattered along the frontier and had no military medical service to speak of. The regular army in 1860 had only thirty surgeons and eighty-three assistant surgeons, and twenty-four of them resigne
d to serve with the Confederacy.135 Medical supplies consisted of a few incomplete surgical kits and clinical thermometers. The country had no general hospitals, and the largest post hospital, located at Fort Leavenworth, Kansas, had only forty-one beds.136
There was no ambulance service. In the 1850s, Secretary of War Jefferson Davis (1808–1889) had ordered two military officers, one of whom was Capt. George B. McClellan (1826–1885), to prepare a study of the lessons to be learned from the Crimean War. McClellan’s report included a section on ambulance trains and medical supplies and recommended creating an army ambulance corps. A committee was appointed to accept designs for medical transport vehicles, but by 1860, the army had rejected all the designs and had not created an ambulance corps.137 For the war’s first two years, neither side had a systematic way to evacuate the wounded. After the disaster at the First Battle of Bull Run (July 1861), where vehicles had to be commandeered from the streets of Washington to move the wounded, individual field commanders improvised what little medical transport they could. Toward the end of the Peninsula campaign, an army corps of thirty thousand men had an ambulance transport system sufficient for only a hundred casualties. At the Battle of Wilson’s Creek (August 1861), the wounded could not be moved for six days owing to the lack of ambulances. In November 1861, Gen. Ulysses S. Grant (1822–1885) and his forces at Belmont, Missouri, had to abandon their wounded because they did not have ambulances.138 Ambulance transport in the Confederacy was even worse. In 1863, Confederate medical officers reportedly had only thirty-eight ambulances in the entire Army of the Mississippi. As the war continued, the situation worsened. In 1865, not a single ambulance could be found in the combat brigades of the armies of West Virginia and East Tennessee.139
Meanwhile, the appalling medical conditions of the Union Army provoked a public outcry, much as similar conditions had provoked public outrage among the British during the Crimean War. In 1861, Dr. Henry Bellows (1814–1882), a Unitarian minister from New York, led a committee that created the U.S. Sanitary Commission, which made recommendations to improve medical treatment. Its first suggestion was to fire Surgeon General Lawson and replace him with Dr. William Hammond. Upon assuming his position, Hammond appointed Dr. Jonathan Letterman (1824–1872) as surgeon general of the Army of the Potomac. Making several contributions to the Union’s medical service, Letterman quickly set about reorganizing the system and creating an ambulance corps.
Letterman’s ambulance corps was built around the Larrey model, and each army corps had its own dedicated medical transport assets. Each division, brigade, and regiment had its own medical officer responsible in a direct chain of command to the corps medical officer, who was responsible for coordination at all levels. The chief surgeon within each division controlled the ambulance corps, and he assigned all details regarding parking, roll call, stable call, veterinary services, and police duty to a line officer of the division. Each regiment received three ambulances and a complement of drivers and litter bearers, and each division had its own ambulance train of thirty vehicles. The ratio of ambulances to men averaged 1 to 150.140
Letterman established a trained corps of ambulance drivers and litter bearers and gave them a distinctive uniform and insignia. He specified that only medical personnel could remove the wounded from the battlefield, a regulation designed to reduce the manpower loss that normally resulted when soldiers left the line to transport their wounded comrades to the aid station. Ambulance wagons were removed from the quartermaster’s control and were to be used only for medical transport. Ambulances traveled in the front of the column to ensure they would be easily reached once the battle commenced. The first test of Letterman’s ambulance system came at the Battle of Antietam Creek (September 1862). Union forces suffered ten thousand wounded scattered over a six-mile area, but the system reached and evacuated most of them within thirty-six hours. Three months later at Fredericksburg (December 1862), the system worked so well that the wounded piled up at the aid stations faster than they could treated.141 Within twelve hours, all of the nearly ten thousand Union wounded had been located and cleared through the aid stations.
Letterman’s field ambulance system would not have worked as well as it did had it not been integrated into a larger network of casualty evacuation linking the field hospitals to the general hospitals in the rear. They also used the excellent Northern railway network to move casualties from collection points behind the battlefields to the general hospitals. The hospital cars varied in quality from first-class heated passenger coaches to unheated boxcars with little more than straw on the floors. By the end of the war, the Northern railways had transported 225,000 sick and wounded men from the battlefields to the general hospitals.142
The Union medical service also used coastal steamers and river steamboats to transport the sick and wounded. The Union contracted these hospital ships from civilians and initially gave the quartermaster corps control of them. Later in the war, the medical corps assumed control of these assets and used them exclusively for medical purposes. In 1862, the Union Army contracted for fifteen steamboats for use on the Mississippi and Ohio Rivers and seventeen ocean-going vessels for use along the Atlantic coast. In the last three years of the war, 150,000 casualties had been transported by boat to general hospitals.143 The first systematic use of the hospital ship was at the Battle of Fort Henry in February 1862 when the City of Memphis transported 7,000 casualties to hospitals along the Ohio River.144 The army purchased its first ship, the D. A. January, to serve as a hospital ship, and the crew saw its first action after the Battle of Shiloh in April 1862. The ship had a 450-bed hospital, bathrooms, laundry, baking and cooking facilities, and a full complement of surgeons and nurses. By the end of the war, the January had transported 23,738 patients on the Ohio, Missouri, and Illinois Rivers. The mortality rate among its wounded passengers was only 2.3 percent, better than most land-based hospitals of the day.145 The first naval nurses in America were the Catholic Sisters of Mercy, who served aboard the first U.S. Navy hospital ship, the USS Red Rover, and tended the wounded after the siege of Vicksburg.146 The ship also had African American women nurses aboard.
Letterman’s field ambulance system proved so successful that in March 1862 Surgeon General Hammond recommended that all Union armies adopt it. The army high command dragged its feet for two years before Congress in March 1864 forced it to institute the system for all Union commands. It was only by the end of the war that the system was fully implemented. The United States had gradually developed a military medical system adequate enough to treat the casualties that a modern war produced only to see it demobilized with the rest of the army less than a year after the war ended. With the army returning to garrison and frontier duties, a mass casualty system was no longer needed.
Letterman also changed the structure of the field hospital system by turning the old regimental hospitals into frontline aid stations, or the equivalent of the modern battalion aid clearing point. Treatment of the wounded at these aid stations was limited to controlling bleeding, bandaging wounds, and administering opiates for pain. Limiting the functions of these aid stations enabled the medical personnel to hold the slightly wounded close to the front for their possible return to duty. Behind the aid stations, Letterman placed mobile surgical field hospitals. Controlled by division, the most competent medical personnel were assembled at these hospitals to perform major operations. These hospitals were the critical link, missing for most of military medical history, between the frontline aid stations and the rear area general hospitals. Behind these mobile field hospitals were the general hospitals, and the field ambulance corps, the railways, and hospital ships tied the whole system together. Letterman was also concerned about the manpower loss due to hasty and needless evacuation. To prevent it, all medical officers were ordered to hold the less severely injured at their respective hospitals. Letterman instituted systematic inspections of all patients to screen those held for possible return to duty before deciding what patients to evacuate.147
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Letterman’s third major contribution to the Union medical service was the establishment of medical supply and equipment tables for medical units. Until this reform, the service obtained medical equipment and supplies from the quartermaster through the usual military supply system. Under the pressure of war, however, medical units rarely received what they needed. Letterman arranged supply tables equipping all units from corps through regiments with “basic loads” of medical provisions. Each unit was supposed to carry supplies for thirty days. A purveyor accompanied the army and was responsible for continually replenishing medical supplies. With each medical unit requiring specific amounts of supplies, the purveyor could now plan in advance to fill the requirements of each unit. For the first time, an army had developed a relatively modern medical supply service that worked well under field conditions.148
Most units in the Union Army were volunteer units that the states created. The state governors then commissioned the great number of surgeons and physicians that served in the war to provide medical support to state regiments. With few standardized licensing procedures for medical certification, it was not surprising that competency was a problem. Few of the physicians entering the state regiments had any surgical training. Indeed, the educational training of a physician or surgeon at this time entailed only one year of formal schooling and one year as an apprentice to a practicing doctor. Many of the “medical schools”—including Harvard University at the time—were little more than diploma mills.149 For reasons that remain unclear, all medical schools in the South, with the exception of the University of Virginia, were closed shortly after the outbreak of war, thus depriving the Confederate armies of a vital source of trained medical talent.150 As the war wore on, however, many of the marginally competent physicians and surgeons on both sides became excellent practitioners as a consequence of their battlefield experience.
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