MEDICAL HISTORY: Medical Advances of the American Civil War

Nitin Sil, MD

The American Civil War has always been recognized by historians for its watershed effect on social and military evolution. History, however, has been less than kind with its perception of the era’s medicine. Images of amputation without anesthesia and surgery without respect to germ theory come readily to mind. Yet in reality the conduct of the Civil War had a profound effect on the art of medicine.

More than 600,000 Americans died during the Civil War--more than every other war the country has fought before or since, combined. At the beginning of the war, a strained and outdated medical system was ill prepared for and quickly inundated by a seemingly endless stream of wounded. Over the war’s four long years, old ways were abandoned. Advances in procedures and medical doctrine rivaled advances in clinical thought. These advances combined to reshape the medical community. From this devastation arose what we perceive today as the foundation of modern medicine.

On April 13, 1861, the bombardment of Fort Sumter by Southern forces sent both sides into a frenzy of enlistment. Yet despite the patriotic fervor, the medical system lay practically dormant. Most doctors of that time were rural family practitioners who did not need a state medical license or board certification. In many cases, their medical education was limited to one year of study with no formal residency or didactic learning. Teaching hospitals were nearly a nonentity, and even the Surgeon General, Dr. Thomas Lawson, considered medical books an “unnecessary extravagance.”

Most medical dogma was rooted in the teachings of antiquity. Sickness was often felt to be based on humoral imbalances, and bloodletting was still one of the primary methods of treatment. Even surgery was considered taboo and rarely attempted. Boston’s Massachusetts General Hospital recorded on average 39 surgical procedures annually between 1836 and 1846. Ambulances and mass medical evacuation systems had not been organized or even considered. Germ theory was still 20 years in the future, and as thousands of men organized into base camps for war, no vaccination or sanitation systems were employed.

As naive and unprepared as medicine was, its state of readiness only paralleled the state of military tactics. In July of 1861, a horrified nation learned of the death toll at the First Battle of Bull Run. Almost 3,000 soldiers gave their lives to inept and outdated methods of leadership based on tactics of the Napoleonic Era.

The death toll at Bull Run was soon overshadowed by nearly every other major engagement, as military tactics lagged behind advances in weaponry. At the Battle of Fredericksburg in December 1862, 18,000 soldiers were killed, due in part to advances in the rifled musket that greatly extended its killing range. At the Battle of Antietam, earlier that year, more than 22,000 died in a single day--Sept. 17--largely due to the development of the Minie ball. This conical .63 caliber projectile was relatively quick to reload and on impact could shatter vast tracts of bone and tissue. A major culmination of the war’s destruction occurred at the Battle of Gettysburg on the first three days of July 1863. When the carnage was over, more than 50,000 soldiers were dead.

The rise in casualties was soon matched by medical innovation. By the second year of the war, both sides had initiated calls for medical reform. Physicians were required to pass board examinations, and standards of practice were introduced. Recruitment camps were required to begin vaccination protocols, and soldiers were rejected on the basis of physical illness. Doctors were given the ability to hold military rank and could allocate orders to assist in the retrieval and care of patients stranded on the battlefield. In certain cases, these orders could supersede those of their officer peers. This innovation was further expanded when Dr. Hunter Holmes McGuire, a Confederate field surgeon, championed the idea that medical personnel were to be treated as noncombatants. His concept was later ratified by the Union Army and was soon integrated into the foundations of what would become the Geneva Convention.

As Northern troops began to occupy the cities of the South, new methods of sanitation were introduced. When General Ben Butler assumed the command of occupied New Orleans in April 1862, he set up field hospitals, began a refuse disposal system, and vigorously employed the newly discovered drug, quinine. As a result, the years of Union occupation in New Orleans brought significantly lower levels of yellow fever and malaria.

These changes in sanitation and treatment were paralleled by better systems of medical logistics. An ambitious hospital building program began, and by 1863, more than 400,000 medical beds were available. Facilities that specialized in various types of surgery and rehabilitation were constructed. Inspection systems were developed and then used to maintain standards of care. As a result, hospitals saw a mortality rate of less than 10%. Trains were formed with hospital cars that could accommodate the transfer of patients. Early horse-drawn ambulances were constructed with suspension systems for more secure transport, along with on-board medical kits to treat soldiers in the field. Ships that had been initially used for military cargo were refitted to hold the wounded. By 1863, vessels were designed from the keel up with operating rooms and isolation wards, and were staffed by nautical doctors and nurses.

Surgery also experienced a renaissance. As the number of wounded increased, doctors had to create more efficient surgical methods. They devised new saws and chain devices, and they refined operating rooms, scalpels and instruments. By 1864, several subspecialties of surgery had emerged, including plastic, orthopedic, abdominal, thoracic, ocular and even neurological. For the first time, blood transfusions became ubiquitous, and prosthetic parts were created on a grand scale. Contrary to popular media, anesthesia was used and documented in over 80,000 surgeries. Medical literature even recorded the comparison trials of different types of anesthesia. Compared to their 1861 counterparts, surgeons in 1865 had gained unprecedented advantages in medical knowledge, experience and treatment options.

Two percent of the population of the United States died during the Civil War; two-thirds died from disease rather than battlefield injuries. While initially unprepared, the medical system was able to adapt over a period of four years. By war’s end in 1865, newly built hospitals continued to provide services to thousands of wounded. The wartime innovations of hospital ships, ambulances and hospital trains continued to develop. Perhaps most importantly, medical professionals began to appreciate and expand on their wartime education. Medical dogma that had previously restrained advancement was questioned, and the need to discover, refine and evolve became the new paradigm.

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Dr. Sil is a hospitalist at Kaiser San Rafael.

Email: nitin.a.sil@kp.org