Civil War Medical Advancements

Welcome to Civics and Coffee. My name is Alycia and I am a self-professed history nerd. Each week, I am going to chat about a topic on U.S history and give you both the highlights and occasionally break down some of the complexities in history; and share stories you may not remember learning in high school. All in the time it takes to enjoy a cup of coffee. 

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Hey everyone. Welcome back. 

When you think about the Civil War, you may have visions of the different uniforms worn by soldiers of the Union and Confederacy, or the piles of men strewn about on a battlefield. For me, one of the things that always comes to mind are the countless photos of medical tents and, later, of the men who were photographed with missing limbs. 

I remember hearing in school how the Civil War was a pivotal moment for medicine and led to a number of advancements, specifically in the surgical field. So this week, I am diving into medical advancements during the Civil War. What were these advancements? How did they come about? And are any of them used today?

Grab your cup of coffee, peeps. Let’s do this. 

Before I begin, I wanted to throw out a content warning about some of the details included in this episode. If you know anything about the war, then you are likely familiar with the devastating toll it took on the body - whether through amputation or scarring from the wounds inflicted on the battlefield. You can’t really talk about the advancements of medicine without sharing at least some detail of the procedures and tools medical personnel used. While I avoid graphic descriptions, I will cover things like post surgical treatments for amputees that may sound a little gross. Having said that, this is not an episode for those who are a little squeamish. I recommend skipping this episode and coming back next week.

And while the focus of the episode is how the Civil War influenced various changes in medicine, I wanted to lay the scene for what the medical field looked like in the run up to the war first. To say that medicine and physicians looked wildly different from our current experiences in the twenty-first century would be an understatement. 

Let’s start with training. In the mid-nineteenth century, medical education in America was still quite limited. There were no prerequisites to entering medical colleges. No extensive exams to study for or a set list of coursework to complete before requesting admission. Those interested in becoming a physician would simply pay a fee and enroll into one of the handful of universities offering medical training. And training is being very generous. Students attending medical school sat through two years of intensive lectures without ever touching a patient. No specialty rotations or, from what I could gather, much physical exposure to the human body. 

To gain clinical experience, physicians would have to travel overseas where medical training was much more advanced. However, there was no financial support for these efforts, meaning only those with the personal means to self-fund their trips were able to benefit from the enhanced knowledge. While the physicians who took advantage of these opportunities often rose to a level of prominence in the medical field, they did not make any moves to make their training more accessible to the thousands of other physicians unable to afford such a luxury. 

This lack of standardized, comprehensive medical training led to a variety of medical approaches and treatments. Some doctors believed in the humoral theory, which meant any illnesses or diseases an individual was suffering from was a result of a physical imbalance in the body. To alleviate the condition, many physicians used techniques such as bloodletting which was seen as a way to cure the imbalance, or overabundance, of fluids inside the body. While germ theory came about around mid-century, it was not something a majority of physicians believed and prescribed to. 

Hospitals, largely seen today as a place of healing and recuperation, had a very different reputation in the nineteenth century. Again, lacking robust education and an agreed upon standard of care and treatment, hospitals were often places where people expected to die and therefore avoided at all costs. While a little melodramatic, given the fact that patients with infectious diseases were frequently placed in the same area as those with minor wounds, it is perhaps understandable why so many people were hesitant to seek treatment at these locations. 

Prior to the Civil War, there were an estimated 55,000 physicians across the United States, most of whom lacked the additional training provided overseas I mentioned earlier. As one doctor studying the medical impacts of the war wrote quote, “it was anyone’s guess as to what was causing disease and was physiologically happening in the body,” end quote and helped contribute to the variety of approaches to medical treatment. Each physician, regardless of their rudimentary education, believed their treatment options were the best and, lacking any licensing or certification requirement, were unmotivated or unwilling to engage with other medical professionals to consider alternative perspectives or knowledge. Also, with a relatively low number of patients, there likely weren't many opportunities to try different theories and treatments. 

Of course, that all changed with the Civil War. With the carnage that came as the result of canonfire and close combat, thousands of doctors had to learn how to quickly and effectively treat patients. It is estimated that throughout the conflict, roughly 12,000 physicians treated millions of patients for both the Union and Confederate armies. During this incredible surge, doctors honed their skills and learned new techniques to increase the success rate of their procedures. Amputation, one of the most common surgical procedures throughout the war, unfortunately benefitted from the sheer volume of patients who needed one. In the war, a surgeon was considered skilled if they could perform the procedure in under three minutes. Since many amputations were performed without the benefit of anesthesia, it is no wonder that time became the central consideration of a doctor’s skill. 

Given the thousands of opportunities to practice, surgeons developed two techniques for post-surgical treatment. The first method involved leaving the amputation wound open until new skin formed to cover. While open, medical personnel would clean frequently, therefore minimizing the chance of infection. Of course, the rate of skin growth is painfully slow and this was not always an aesthetically pleasing treatment plan. The second option was much easier to handle visually, but brought a set of risks of infection. Instead of leaving the wound open, surgeons would ensure their cut left leaving excess skin that would then be used to fashion a bandage. While this definitely avoided the unpleasant look of an open surgical wound, it left the patient at risk for infection as there was no way to clean it. 

The volume of amputations also prompted a boom for the prosthetics industry. Prosthetics were available before the war, but designs were limited and questionably functional. After the war, hundreds of people, including war veterans, developed their own version of fake limbs, making minor adjustments based on their experience and intended use. 

And while there were enhancements and developments in various surgical specialties during war, including the emergence of plastic surgery, the real advancements in medicine came from the logistical approach to treating and caring for patients and was at least partially the result of the total and epic failures of the existing medical infrastructure. After the battle of Bull Run, it became crystal clear just how medically unprepared the Union was to treat its injured soldiers. Prior to the Civil War, there were just 113 doctors on staff to care for just over 16,000 soldiers. While the fatalities of Bull Run were not overwhelming for either side, it demonstrated the chaos surrounding battlefield medicine. This prompted the leader of the voluntary Women’s Central Association of Relief, a man by the name of Henry Bellows, to lobby for the organization to provide quote “advice and assistance” end quote to the Union army on things like medical care and general welfare. Their efforts prompted the creation of the U.S. Sanitary Commission, which was approved by Abraham Lincoln on June 13, 1861 and would operate through most of the war, shutting down on July 4, 1865. 

However, we can thank two men whose ideas and techniques saved lives and forever altered the course of military medicine and public health.

The first was William A. Hammond who became the Surgeon General for the Union in 1862. Born on August 28, 1828 in Annapolis, Maryland, Hammond was the son of a doctor and began studying medicine at 16, earning his M.D. at the University of the city of New York by the time he was 20. He joined the U.S. army after only a year of medical practice where he became the Assistant Surgeon and Medical Director at Fort Riley in Kansas in July of 1849. Hammond left the army briefly, only to rejoin after the breakout of the Civil War in 1861. 

Once he became the Surgeon General, Hammond instituted a number of reforms and standards to help improve patient care. First, he required that any of the physicians enlisting through the army go through training in public health, surgery, and hygiene. He also prohibited the use of purgative medications, a controversial decision considering that many of the army doctors at the time prescribed to the humoral theory and trusted the medicinal impacts of purgatives. And in case you do not know what purgative means, these were medications that induced vomiting, or diarrhea - with the idea being that eliminating excess fluids from the body would cure the patient’s ailment. 

Hammond also helped establish our modern hospital. If you’ve ever visited someone at the hospital, you’ve likely had to visit a specific floor or wing that is filled with similar patients. Think the maternity ward for new moms or the post-op area for patients recovering from surgery. That is thanks to Hammond, who pushed for a quote unquote pavillion style layout where there was a central space for admittance and then offshoots, or wings, from the central area to separate patients by condition and therefore eliminating the spread of infectious diseases. 

However, not everyone was a fan of the Surgeon General, including Secretary of War Edwin Stanton. The two men continued to butt heads until the Secretary stripped Hammond of his post, reassigning him to oversee sanitary conditions in Louisiana. Understandably upset over the demotion, Hammond demanded he either be reinstated or face charges via a court martial to clear his name. Unfortunately for Hammond, Stanton had a number of admirers and Hammond was found guilty over irregularities regarding medical supply purchases and discharged from the army. He would later contest the judgment and have his record cleared in 1879. 

The other man who made a significant impact to the processes of treating patients was Jonathan Letterman. Born in 1824 and also a song of a doctor, Letterman graduated Jefferson Medical College in 1849. He became an assistant surgeon in the Army’s Medical Department and was assigned to the Army of the Potomac at the start of the war. In June 1862, Letterman promoted to major and was made the Medical Director of the Army, an appointment conferred upon him by soon to be ousted Surgeon General William Hammond. 

In his letter to Letterman, Hammond wrote out his expectations, including quote: “You will, in conjunction with Assistant Surgeon Dunster, U. S. Army Medical Director of Transportation, arrange for the safe, effectual, comfortable, and speedy transportation of such sick and wounded as in your opinion should be removed from the limits of the army to which you are attached” end quote. And that is exactly what Letterman did. 

After the second battle of Manassas, Letterman began reassessing how the army transported those wounded on the battlefield. For the early part of the war, civilians were the ones driving ambulances. Untrained for the sounds and sights of military combat, civilians would often flee at the sound of gun fire, leaving the injured on the battlefield. Under Letterman’s direction, patient transport was streamlined. First, Letterman established the Ambulance Corps which carved out a specific set of enlisted men who would be responsible for medical transport. No longer would the military rely on the untested bravery and efficiency of civilians. He also developed a triage system for assessing injuries quickly to ensure resources went to those who had a decent chance of survival. His ranking system was pretty blunt, but clear. Patients were classified as either beyond hope, slightly wounded, or surgical. Medical staff would work on surgical patients first, then the slightly wounded and, if the patient was still alive, beyond hope. This system of triage actually served to save a number of patients, including those classified as beyond hope and is still a system used today. 

Letterman also created specific patient transport guidelines. Known unsurprisingly as the Letterman plan, it included a tiered system of sorts. 

First, patients would be taken to a dressing station, usually pretty close to the field of battle. The next stop was the field hospital, which was further back from the front lines and most out of harm’s way. The final stop was a physical hospital, located far from the war front where soldiers could stay for long term recuperation and treatment. Letterman tested his system in the battles of Antietam and Fredericksburg in the latter part of 1862. It was successful, leading the military to adopt the protocol in March of 1864. And for any of you former or current active military members, this process likely sounds familiar as it is the same used by the military today. Given his contributions, Letterman is referred to as the Father of Modern Battlefield Medicine. 

These two men and the processes they put in place helped save countless lives. While the Civil War remains the bloodiest conflict in United States history with death toll estimates ranging from 620,000 to more than 750,000, I found myself wondering just how many more might have perished without their interventions. 

Outside of wounds inflicted on the battlefield, the other major cause of death was disease. This was also partially the result of the early disorganized transportation system and undertrained medical professionals. While twice the number of soldiers died from disease than battlefield injuries, this actually represented an improvement from prior conflicts. For example, during the Mexican American War in 1848, the ratio was 7 to 10 soldiers lost to disease for every 1 who died from a combat related injury. 

While Hammond and Letterman arguably had the largest and most significant impact to the medical profession, there were several other improvements during the war including the creation of specialty hospitals, the development of neurosurgery, and the use of quinine to prevent malaria. The Civil War also established a set of treatment standards to ensure patients received similar care. 

The Civil War caused a tremendous loss of life, but it also helped advance the field of medicine in the United States in several ways. From implementing standards to collecting specimens to create a medical museum for future research, the sheer volume of patients during the war allowed for physicians to hone their skills, develop new techniques, and improve their protocols for better outcomes - forever altering the face of medicine. 

Thanks, peeps. I’ll see you next week.

Thanks for tuning and I hope you enjoyed this episode of Civics & Coffee. If you want to hear more small snippets from american history, be sure to subscribe wherever you get your podcasts. Thanks for listening and I look forward to our next cup of coffee together. 

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