Caring for the Men
The History of Civil War Medicine

When the war began, the United States Army medical staff consisted of only the surgeon general, thirty surgeons, and eighty-three assistant surgeons. Of these, twenty-four resigned to "go South," and three other assistant surgeons were promptly dropped for "disloyalty." Thus the medical corps began its war service with only eighty seven men. When the war ended in 1865, more than eleven thousand doctors had served or were serving, many of these as acting assistant surgeons, uncommissioned and working under contract, often on a part-time basis. They could wear uniforms if they wished and were usually restricted to general hospitals away from the fighting front.

The Confederate Army began by taking the several state militias into service, each regiment equipped with a surgeon and an assistant surgeon, appointed by the state governors. The Confederate Medical Department started with the appointment on May 4 of Daniel De Leon, one of three resigned United States surgeons, as acting surgeon general. After a few weeks he was replaced by another acting surgeon general, who on July 1,1861, was succeeded by Samuel Preston Moore. He took the rank of colonel and stayed on duty until the collapse of the Confederacy.
 
Although the Southerners had some local and state relief organizations, they enjoyed nothing similar to the Sanitary Commission in scope or efficiency; yet in the effects of camp disease and unsanitary conditions, the Confederacy and the Union shared common experiences indeed. The two armies had similar experiences as their forces were being trained, usually in an instruction camp as a gathering place for the troops of each state. Medical officers did not know how to requisition drugs and medical supplies. Commissaries did not know how to requisition rations. It has been said that "the Americans are a warlike but unmilitary people," and the first months of the Civil War proved the adage. Too many men, when entering the army after a lifetime of being cared for by mothers and wives, had a tendency to "go native" -to ignore washing themselves or their clothing and, worst of all, to ignore all regulations about camp sanitation, Each company was supposed to have a sink, a trench eight feet deep and two feet wide, onto which six inches of earth were to be put each evening. Some regiments, at first, dug no sinks. In other cases the men, disgusted by the sights and odors around the sinks, went off into open spaces around the edge of the camp. The infestation of flies that followed was inevitable, as were the diseases and bacteria they spread to the men and their rations.

Soon long lines of soldiers began coming to sick call with complaints of loose bowels accompanied by various kinds and varying degrees of internal discomfort. The medical officer would make a slapdash diagnosis of diarrhea or dysentery an prescribe an astringent. He usually ascribed this sickness to the eating of bad or badly cooked food. Union Army surgeons were to come to use the term "diarrhea-dysentery," lumping all the cases together as one disease. In fact, in many cases it was only a symptom of tuberculosis or malaria, though amoebic and bacillary dysentery-introduced into the South by slaves brought from Africa-was certainly present as well. It caused enormous sickness and many deaths. The Union Army alone blamed the disease for 50,000 deaths, a sum larger than that ascribed to "killed in action." It was even more lethal in the Confederate Army.

The diets of both armies did not help and were deplorably high in calories and low in vitamins. Fruits and fresh vegetables were notable by their absence, and especially so when the army was in the field. The food part of the ration was fresh or preserved beef, salt pork, navy beans, coffee, and hardtack-large, thick crackers, usually stale and often inhabited by weevils. When troops were not fighting, many created funds to buy fruits and vegetables in the open market. More often they foraged in the countryside, with fresh food a valuable part of the booty. In late 1864, when Major General W. T. Sherman made foraging his official policy on his march from Atlanta to Savannah, his army was never healthier. As the war went on, Confederate soldiers were increasingly asked to subsist on field corn and peas. And the preparation of the food was as bad as the food itself, hasty, undercooked, and almost always fried.

No wonder, then, that at sick call, shortly after reveille, many men who claimed to be sick were marched by the first sergeant to the regimental hospital, usually a wall tent. There the assistant surgeon examined them, then assigned some to cots in the hospital tent, instructed others to be sick in quarters, and restored a few to light duty or to full duty. The less sick and slightly wounded would be expected to nurse, clean, and feed the patients and to see to the disposal of bedpans and urinals.

In the event of an engagement, the assistant surgeon and one or more detailed men, laden with lint, bandages, opium pills and morphine, whiskey and brandy, would establish an "advance" or dressing station just beyond musket fire from the battle. Stretcher-bearers went forward to find the wounded and, if the latter could not walk, to carry them to the dressing station. The assistant surgeon gave the wounded man a stout drink of liquor, expecting it to counteract shock, and then perhaps gave him an opium pill or dust or rubbed morphine into the wound. Later in the war the advantages of a syringe to inject morphine became apparent. The assistant surgeon examined the wound, with special attention to staunching or diminishing bleeding. After removing foreign bodies, he packed the wound with lint, bandaged it, and applied a splint if it seemed advisable. The walking wounded then started for the field hospital, officially the regiment hospital tent, although in 1862 and onward there was an increasing tendency to take over a farmhouse, school, or church if such was available. The recumbent went by ambulances, if there were any, for the ride to the field hospital, usually anywhere from three to five miles from enemy artillery and sometimes much farther.

There, lying on clumps of hay or bare ground, the wounded awaited their turn on the operating table. There was usually little shouting, groaning, or clamor because the wounded were quieted by shock and the combination of liquor and opiate. It was an eerie scene, with a mounting pile of amputated limbs, perhaps five feet high, the surgeon and the assistant surgeon-after a few months both Union and Confederate authorities decided that two assistant surgeons were necessary in a regiment -cutting, sawing, making repairs, and tying ligatures on arteries. The scene was especially awesome at night, with the surgeons working by candlelight on an assignment that might sometimes go on for three or four days with hardly a respite. And there was always the smell of gore.

Everything about the operation was septic. The surgeon operated in a blood- and often pus-stained coat. He might hold his lancet in his mouth. If he dropped an instrument or sponge, he picked it up, rinsed it in cold water, and continue work. When loose pieces of bone and tissue had been removed, the wound would be packed with moist lint or raw cotton, unsterilized, and bandaged with wet, unsterilized bandages. The bandages were to be kept wet, the patient was to be kept as quiet as possible, and he was to be given small but frequent doses of whiskey and possibly quinine. This was a supportive regime.

As to technique, the amputating surgeons had a choice of the "flap" operation or the "circular," both quite old. The former was quicker but enlarged the wound; the latter, when properly done, opened up a small area to infection. By the end of the war a small majority preferred the flap. The frequency of amputations was much questioned at the time. Yet, considering the condition of the patients, the difficulties of transportation, and the septic condition of the hospitals, amputations probably saved lives rather than limbs.

Surgical fevers disheartened the doctors. Four or five days after a wound operation, the patient would be recovering well, producing copious pus. Then suddenly the pus stopped, the wound dried, and the patient ran a terrific fever. Despite drugs, the patient would very likely be dead in three or four days. The diagnosis was blood poisoning. Erysipelas also affected both armies. With a case mortality Of 40 percent, it received serious attention. It was recognized by a characteristic rash, and it was thought by some to be airborne, with the result that both Unionists and Confederates took steps to isolate erysipelas patients in separated tents or wards. The surgeons were in the dark as to how to treat this affliction, but it was noted that if iodine was painted on the edges of a wound, its further extension was stopped.

Civil War surgeons had not only iodine but carbolic acid as well, and a long list of "disinfectants" such as bichloride of mercury, sodium hypochlorite, and other agents. The trouble was that the wound was allowed to become a raging inferno before disinfectants were tried. However, one of the good features of Civil War surgery was that anesthetics were almost always used in operations or the dressing of painful wounds. It was practically universal in the Union, and despite mythology, anesthetics were very seldom unavailable in the Confederacy. The almost universal favorite was chloroform, probably because ether's explosive quality made it dangerous at a field hospital operating table, where there was always the possibility of enemy gunfire.

After losing control of their rivers, the Confederates made considerable use of railroads in evacuating men from field hospitals to general hospitals. They had no special hospital cars and felt fortunate when they could use passenger rather than freight cars. They became adept at maintaining dressing and supply stations where wounds could be tended and the patients fed. The Union Army, too, increasingly used railroads for evacuating men north. After the Battle of Chattanooga, a real hospital train was regularly used to move the sick and wounded from Chattanooga to Louisville. Some of the cars were equipped with two tiers of bunks, suspended on hard-rubber tugs. At the ends of such cars would be a room for supplies and food preparation. The locomotive assigned to this train was painted scarlet, and at night a string of three red lanterns burned on the front. Confederate cavalrymen never bothered this train.       

Both armies experimented with "special" hospitals, with admission limited to patients with the same disorders. The Confederates established several venereal hospitals and some ophthalmic hospitals. The Unionists began a venereal hospital at Nashville and the famed neurological hospital, Turner's Lane, at Philadelphia, where W. W. Keen is believed by some to have founded neurology in America.

The staff, aside from the medical officers and hospital stewards, was mostly made up of the convalescents. They were frequently weak and weary, often snappish and irritable. They did not like the dirty work they performed. They wanted to go home. The surgeon-in-charge, as the hospital commander was titled, was often in a dilemma. If he returned the patient to his regiment too soon, the man might relapse or die on the road to his unit. If he tried to hold on to the man too long, he might be forcibly returned to his regiment; and if he prevailed upon an inspector to give a medical discharge, he would be losing an attendant who had learned something about his work, and would be forced to rely on a new man who knew nothing. Union and Confederate surgeons-in-charge faced the same problem, although occasionally in Southern hospitals there were hired blacks of both sexes. These people were considered only marginally successful. Some attempts in the North to use cheap male labor as hospital attendants proved unsatisfactory, the men being undisciplined, a "saucy lot" who even stole from the patients.

Women could be found serving in various ways in Confederate hospitals, too, but the bulk of them were hired black cooks and washerwomen. In the conservative South there was a widespread feeling that a military hospital was no place for a lady, Only in Richmond were there significant numbers of women working in the city's many hospitals.

Richmond was indeed the hospital center of the Confederacy, with twenty hospitals in 1864 after many of the makeshift type had been closed and replaced by pavilion structures. The queen of them was Chimborazo, which had beds for 8,000 men and was often called the largest hospital on the continent. It was organized into four divisions, each with thirty pavilions. There were also five soup houses, five ice houses, "Russian" baths, a 10,000-loaf per day bakery, and a 400-keg brewery. On an adjacent farm the hospital grew food and grazed three hundred cows and several hundred goats. Almost as amazing was Jackson Hospital, which could care for 6,000 patients in similar ways. Elsewhere than Richmond, general hospitals were neither so large nor so grand, but there were many of which the Confederates were proud. By late 1864 there was a total of 154 hospitals, most located close to the southern Atlantic coast. They began to close down, often because of enemy action, early in 1865.

By the last year of the war there were 204 Union general hospitals with beds for 136,894 patients. This proved to be the maximum. In February 1865 the United States began closing down its hospitals.

The morbidity and mortality rates of both armies showed marked improvement over those of other nineteenth-century wars, particularly America's last conflict, the war with Mexico. In that war go percent of the deaths were from nonbattle causes. In contrast, in the Civil War some 600,000 soldiers died, but in the Union Army 30.5 percent of them died in or from battle, and in the Confederate Army the percentage ran to 36-4. Clearly, the physicians and sanitarians had held down the disease mortalities to levels that their generation considered more than reasonable. Better, they made some few halting strides in treatment and medication, and considerable leaps in the organization of dealing with masses of wounded and ailing soldiers. It was a ghastly business for doctors and patients alike; yet without the medicos in blue and gray, much of the young manhood of America at mid century might not have survived for the work of rebuilding.
Source: The National Historical Society's The Image of War: 1861-1865 Volume IV "Fighting For Time" article by George W. Adams

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