Civil War medicine & surgical presentation

Civil War’s Contributions To Medicine

Detailed Description

The period of 1861-1865 was a dynamic period in American medicine and, consequentially, proved to be a pivotal event. Significant advancements were instituted that were the foundations contributing to American medicine emerging out of “the late Middle Ages,” as has been said, into a period of progressive achievements. America, subsequently, obtained an equal status with its European counterparts and eventually took a leadership role in the world. The Civil War was a significant catalyst bringing this about.

Two colossal achievements occurred in medicine during the 19th century. The first was the use of anesthesia in surgical procedures which was introduced at the Massachusetts General Hospital, in Boston in 1846. The second occurred during the 1860’s and 1870’s when Pasteur and Koch incontestably demonstrated that microbes caused infection. Their scientific contributions resulted in the acceptance of the “germ theory of infection” which tremendously advanced medical thinking as it demonstrated that there is a specific cause of each disease which can be identified. This opened the door for effective therapeutics in which the actual cause of a disease is addressed rather than an erroneous cause based on speculation or of merely treating the symptoms of a disease. The germ theory also introduced the practice of sterility and aseptic technique in surgery which greatly reduced morbidity and mortality associated with invasive procedures such as surgery.

The Civil War occurred between the two monumental advancements: anesthesia and the germ theory.

Infections due to Bacteria and Lack of Sterility were responsible for more Deaths Among the Troops than the Enemy.

More lives were lost in the Civil War than the sum of those lost in all the other wars Americans have fought. Unfortunately, lack of knowledge of “the germ theory of infection” and the consequent absence of knowledge of the causes of contagious diseases as well as lack of attention to sterility resulting in wound infections were responsible for two-thirds of the deaths in the war being due to infection. Additionally, neither side was prepared at the onset of the war to adequately manage the extensive numbers of injured combatants, and this was, undoubtedly, a factor contributing to the high mortality statistics. Yet, significant principles were put in place during the war which have influenced and benefited the practice of medicine today. There is more information about medicine during the war in the Union Medical Corps data than in the Confederate Medical Corps reports. Unfortunately, Confederate records were burned near the end of the war during the evacuation of Richmond, the capitol of the Confederacy. This resulted in less information being available about medicine in the Confederacy. My primary focus will be directed on the contributions of two individuals in the U. S. Army Medical Corps, Dr. Jonathan Letterman and Surgeon General William Hammond, and their influence on today’s medicine.

Jonathan Letterman, M.D., Medical Director, Union Army of the Potomac. He instituted the “Letterman System.”

Jonathan Letterman, M.D., a career Union Army Surgeon was Medical Director in George McClellan’s Army of the Potomac. He instituted significant advancements in three areas: (1) the evacuation and transport of the wounded, (2) the process of distribution of medical supplies and equipping medical facilities, and (3) improving the quality of medical care and surgery performed on the wounded. His “Special Orders no. 147,” August 2, 186, addressed the problems associated with the evacuation and transport of the wounded. It was signed by General McClellan and created a new entity in the Union’s Army of the Potomac-the Ambulance Corps. This new Corps was composed of non-physician personnel, and it replaced and resolved the chaotic system of evacuation and transport in existence at the beginning of the war. Initially, musicians were used by both the Union and Confederacy as stretcher bearers to evacuate the wounded from the battlefield and transport them to the front aid station and ambulances. This system did not function well. They had signed on to make music, not go onto the battle field and be shot while retrieving the wounded. Transport of the wounded to the field hospital by ambulances was another problem as ambulances in the Union armies were assigned to the Quartermaster Corps. They were used to transport military supplies as well as the wounded with the former often taking precedence over the latter. Letterman’s “Special Order” resolved both the stretcher bearer problem and the transport problem. It called for the ambulances to be transferred to the newly created Ambulance Corps, placed under the Ambulance Corps Commander, and used solely to promptly transport the wounded to field hospitals. Trained stretcher bearers and ambulance drivers were obtained from the enlisted ranks and were assigned to the Ambulance Corps. Their training was directed and supervised by the officers of the Ambulance Corps. The commanding officer of the Ambulance Corps reported to the Medical Director of the Army of the Potomac, Dr. Letterman. Letterman’s innovations resulted in the expeditious retrieval and transport of the wounded to treatment facilities.

After addressing and resolving the problem of evacuation and transport of the wounded, Letterman turned his attention to improving both the provision of supplies to the field hospitals and the medical treatment administered to the wounded. He issued an instructional directive, “Headquarters, Army of the Potomac, Medical Director’s Office, October 30, 1862,” To appreciate Letterman’s thought process and comprehend the significance of his directive, it is helpful to understand the command structure of the Union armies. Both the North and the South utilized the same structure. ( All tables in the presentation including the “Military Command Structure” are best viewed on a computer as a cell phone will distort the columns,)

Military Command Structure

“Army of the …..”

I. Corps II. Corps III. Corps

** I. Division II. Division III. Division

Brigade “U” Brigade “V” Brigade ”W”

* Regiment “X” Regiment “Y” Regiment “Z”

* Field Hospital initially at the Regimental level

** Letterman moved the Field Hospital to the Division level

There were several armies in the Union and also in the Confederacy- each was identified with a name. For example, in the North there were the ‘Army of the Potomac,” “Army of Tennessee,” and others. In the South there were the “Army of Northern Virginia,” Army of Tennessee,” and others. The “chain of command” was as follows. There were several corps in each army and each was identified with a Roman numeral. In each corps there were several divisions also identified with Roman numerals or the name of the commanding officer. Each division was composed of several brigades usually identified by the name of the commanding officer. Each brigade contained several regiments, each identified by an arabic number and the state of origin. For example, my great grandfather was in the Army of Northern Virginia, III Corps (Stonewall Jackson/A. P. Hill) , Wilcox Division, Gregg/ McGowan Brigade, 14th Regiment of South Carolina Volunteers. The fundamental fighting unit was the regiment composed of 10 companies and, ideally, 1,000 men. As the war progressed there were extensive reductions in the numerical fighting strength of the regiments on both sides due to attrition from deaths, wounds, disease, capture by the enemy, and desertions.

Initially in the war, each regiment at the time of battle, would have a first aid station at the front manned by an assistant surgeon and a field hospital to the rear out of range of artillery manned by a surgeon. Surgical procedures were performed on soldiers of a regiment at their regimental field hospital. Each of these regimental facilities functioned essentially as an independent unit. In times of battle the regiments of one side would engage regiments of the enemy. Although from a theoretical standpoint it made sense to have the treatment facility at the front close to the action (ie., with the regiment), from logistic and quality of surgical care standpoints this organizational structure proved to be problematic. First. there was the problem of distributing supplies and equipment to these regimental facilities. The Medical Director of a
corps or brigade often had the responsibility of supplying the regimental field hospitals with equipment and supplies. To comprehend the magnitude of the number of regiments that needed to be supplied, at the Battle of Fredericksburg the smallest corps (IX Corps) in the Union Army of the Potomac had 35 regiments and the largest (III Corps) had 46 Regiments. Additionally, there was the problem of maintaining adequate supplies as some regiments would see a lot of action and quickly become depleted of supplies whereas others would see little action. The second problem resulting from the regimental field hospitals was the quality of surgical care. The regimental hospitals where surgical procedures were performed were staffed with surgeons of varying and often inadequate levels of training and abilities. There were three surgeons-a senior and two assistant surgeon-assigned to each regiment of the state military regiments, They were civilian practitioners usually from the local community where the regiment was mustered. They were commissioned by the governor of the state. Although they were examined by their state medical boards which varied in quality of screening, there was essentially no significant vetting of these physicians by the Federal Army Medical Corps before they were put into action. Conversely, surgeons in the regular Army Medical Crops went through an extensive screening process and were commissioned by the President and Congress. Letterman’s “Medical Directive of October 30, 1862 to the Army of the Potomac” solved both the distribution of supplies and equipment as well as the quality of surgical care issues. It created a few large hospitals in each division and transferred the major treatment and performance of surgical procedures from the multiple smaller regimental field hospitals in each corps to the more comprehensive division level hospitals. This move facilitated and helped to resolved the problem related to the distribution of supplies. To improve surgical care, Letterman stipulated that all major operative procedures were to be performed at the division level hospital instead of the regimental facility. Three surgeons at each division hospital were designated to do all operations, and they were selected on the basis of three criteria: “judgment, prudence, and sound skill.” The remaining surgeons assigned to the division hospital would manage the post operative wounds, serve as surgical assistants, manage the illnesses, and attend to administrative duties. Thus, he introduced the concept of “quality control” into surgery. The regimental facilities became first aid centers after the major treatment was transferred to the division hospitals. They were located at the battle front and staffed with a surgeon and an assistant. He instituted the practice of “triage“ into the management of the injured at the regimental aid stations. Today, every major civilian trauma center has a system of triage called the “mass casualty protocol” which insures maximum utilization of resources and personnel in order to achieve optimal results. The “Letterman System,” the name by which his innovations became known, proved to be quite successful and was subsequently instituted in all Union Armies by Congressional mandate in March 1864.

The ‘Letterman System” Proved to be Successful in the Care of Wounded Soldiers.

When we compare the mortality rates of soldiers receiving major wounds caused by firearms during each year of the war, we see a significant reduction in the second year compared to the first year even though the Letterman System was in effect for only part of the 2nd year. There is an impressive decrease in the mortality in the third year when the system was fully in effect in two of the Union armies. I attribute these improved results due, for the most part, to the introduction and utilization of the Letterman System in The Army of the Potomac and Grant’s Army of Tennessee. Interestingly, although it proved to be quite successful early in the war, the Letterman System was not immediately instituted in all Union Armies. As stated earlier, it was introduced initially into the Army of the Potomac by Letterman. Grant, realized its success and incorporated it into his Army of Tennessee. It was not incorporated into all Union armies until mandated by Congress in March 1864. Also, I think the improvement in the quality of physicians being recruited into the military as the result of the strict screening system of Surgeon General Hammond was a contributing factor to the improvement in the mortality statistics. Hammond also inaugurated a program to “weed out’ the physicians whose competence was questionable.

Another approach to demonstrate the effectiveness of his system is to compare the care of the wounded in a battle prior to the Letterman System being put into effect to the care received by the wounded in a battle after its implementation. At the first major battle of the war, the Battle of Manassas (Bull Run) on July 21, 1861, the planning for the care of the Union wounded by Surgeon General Finley and the Medical Director of the army was most inadequate. An individual commented at the time: “The conception was unwise; the plan faulty; the execution was imperfect.”

Although they were outnumbered, the Confederate troops overran the Union troops. There were a few wagons and teamsters hired by the Union Army to serve as ambulances for the Union wounded. As soon as the drivers saw the Rebels heading towards them and realized what was occurring, they turned the wagons around, applied the whip to their horses, and fled. Washington citizens, looking for entertainment, had come to watch the “spectacle” at Manassas. (The NFL and Major League Baseball were not yet in operation). They jumped into the fleeing wagons as did congressmen who had come to watch. They were joined by the healthy soldiers who could run and catch the wagons. The rapid retreat of the wagons and Union soldiers became known as “The Great Skedaddle.” There were 1,011 wounded and dead Federals left on the field. Those who were ambulatory walked the 27 miles to D.C. Arriving in D.C. a few were placed in the limited hospital facilities available. Some were placed in the Capitol Building and also the Mint. The remaining majority roamed the streets looking for food and medical care. (This caused a ground swell of disgust among the citizens of Washington which stimulated the construction of large pavilion style general hospitals by the government in the major northeast cities). The wounded who remained on the battlefield had been left for the Confederate surgeons to manage. Many, lacking medical care, water, and nutrition, met their death while lying on the battlefield as the Confederate surgeons were overloaded with their wounded. Compare the results at 1st Bull Run just described with those at Gettysburg two years later in early July where the Letterman System was fully in effect. The report of the Medical Director of the XII Corps, McNulty, to Jonathan Letterman shows that the evacuation and treatment of the wounded in his Corps was exemplary.

“It is with extreme satisfaction that I can assure you that it enabled me to remove the wounded from the field, shelter, feed them, and dress their wounds, within six hours after the battle ended, and to have every capital operation performed within twenty-four hours after the wound was received.”

Surgeon McNulty, Medical Director of the XII Corps

Foreign military leaders came to observe the Letterman System, and they incorporated it into their military organizations. Major General Hawley’s tribute to Letterman acknowledges its importance in the United States Army during WW II.

Early Evacuation and Treatment of Wounded Significantly Improves Mortality Statistics.

Comparing mortality statistics in patient undergoing early versus delayed amputation gives insight into the benefit of the Letterman System and prompt surgical treatment. Dr. Larrey, a French military surgeon in the Napoleonic Wars, had recognized and stressed the importance of early amputation as will be presented later. The Civil War corroborated his findings. The mortality statistics in the Civil War of the wounded undergoing early amputation versus delayed amputation shows a significant improvement in the former as opposed to the latter. (See table below).

Civil War Mortality Rates Following Amputation as the Result of the Elapse of Time between Injury and Operation

Number of Cases Mortality

Procedure: 1st 48 hours 16,238 23.9%

Procedure 48 hours to 1 month 5,501 34.8%

(Civil War Medicine, Alfred Jay Bollet, M.D., Gaslen Press Ltd., 2002, p. 152)

Outcomes in both the military as well as the civilian setting improve significantly with early evacuation and treatment of the wounded requiring surgical procedures. This fact underscores the value of the Letterman System and its ability to transport the wounded to an appropriate treatment center promptly and explains the improvement in mortality statistics that was seen after the Letterman System was put into effect. Morbidity and mortality increase with delay in treatment due to two factors. First, as time elapses the bacteria in contaminated wounds multiply exponentially, reach critical mass, and thereby cause putrefaction of tissues. This cascade of events leads to pyemia and sepsis which, in turn, cause death. Early wound care, including amputation, removes the bacteria (i.e., the surgical principle of source control). The fact that physicians at the time lacked knowledge about “the germ theory” of disease and thus were ignorant of sterility, made early amputation (source control) even more important. Also, early source control by surgery was critical at that time as physicians did not have the benefit of the antibiotics to suppress and eliminate bacteria that we have today. Second, nature has provided the body with protective physiological mechanisms that are launched when injury occurs. These mechanisms serve to preserve the life of the individual. Over time these processes become exhausted, break down, and are no longer effective and protective. Therefore, it is important to get early intervention and treatment to correct the physiological derangements caused by the injury while the protective processes are still in effect. (In the trauma world we refer to this “grace benefit” as “the Golden Period.”)

The Development of the Evacuation and Transportation of the Wounded in History.

To appreciate the significance of Dr. Letterman’s contributions to the care of the wounded, it is important to view his system in the context of medical care in the history of war. Throughout history the wounded were largely dependent on a comrade or two dropping from the battle to give them attention. Commanders did not want to see men drop out to give medical care as their goal was to win, and they wanted all the able-bodied fighting help they could muster. Their reputation, military careers, and place in history depended on winning battles, not rendering medical aid. Dr. Ellis informs us that even by the 16th century there was very little concern for the average foot soldier. He states: “In those days, there was no organized medical care for the humble private soldiers of armies in the field. Surgeons were attached to the individual generals and to other important personages, and might, if they wished, give what aid they could to the common soldier in their spare time.” A surgeon, Ambrose Pare (1510-1590), was attached to the Mareschal de Montejan, the Colonel-General of the French infantry. Pare was a surgeon who provided care to the foot soldiers and used the opportunities provided by war to develop the technique of ligation of blood vessels. (Click on his name to go to the page that describes his major contribution to surgery and care of the wounded. (A History of Surgery, Harold Ellis CBE, FRCS, Greenwich Medical Media. Ltd., 2002, p. 129).

Two important developments in the care of the wounded took place during the Napoleonic Wars when methods for evacuation and transportation were introduced by Drs. Percy and Larrey. Dr. Percy, a French military surgeon, developed the use of trained stretcher bearers to evacuate the wounded. This was an important advancement. Dr. Larrey, also a prominent French military surgeon, introduced the use of the “flying ambulance” which could transport the wounded. These two innovations were most significant in providing prompt care to the wounded. Additionally, Dr. Larrey, as has been mentioned, recognized and emphasized the importance of “early amputation” when it was indicated. Dr. Letterman followed in the tradition of these two great military surgeons.

A significant advancement in medical care of the wounded in the Union armies occurred, as previously mentioned, when Congress mandated that the Letterman System be instituted in all armies. The system is evident and utilized today in the transport and treatment of trauma victims at major designated civilian trauma centers as well as the military.

Amputation was Used Extensively in Managing the Severely Damaged Extremity. Also, Conservative Management was Attempted.

A large number of amputations of injured extremities were performed on both sides of the conflict during the war. The wounded were, for the most part,generally willing to undergo amputation which is somewhat surprising as surgery was not the advanced and accepted form of therapy it is today. Assuredly, there were lives saved by amputation where the individual was hemorrhaging to death. Also there were wounds where the extremity was so mangled, it would forever be useless and amputation was indicated. Perhaps their willingness can be explained on their religious upbringing and background. “A wave of Protestant revivals known as the Second Great Awakening swept the country during the first third of the 19th century.” (Battle Cry of Freedom, James McPherson, Oxford University Press, 1988, p. 8.). Consequently, people would be familiar with the Bible and the passage in Matthew 5:29-30 which instructs “… It is better for you to lose one part of your body than for your whole body to be thrown into hell. And if your right hand causes you to stumble, cut if off and throw it away. It is better for you to lose one part of your body than for your whole body to go into hell.” There were attempts to treat some damaged limbs with fractured bones conservatively (non-operative) as reported from various medical facilities in the Confederate States Medical and Surgical Journal and the Union Surgeon General’s reports. Some of these involving the lower extremities were successful but required prolonged hospitalization and bed rest for the bones to heal. Also there were attempts to excise the damaged bone and get the ends of the divided bones to heal rather than amputate the extremity in an attempt to save it. When successful, it preserved the limb. However, it often resulted in a “flail extremity” due to non-union of the two ends of the bone and, consequently, the limb was useless. (Excision of damaged bone was successful in preserving a functioning extremity on occasion when it involved the head of the humerus or the head of the femur). Consequently, attempting to salvage the extremity with conservative treatment or excision was, in most but not all situations, abandoned in favor of amputation. Conservative management or excision of a segment of damaged bone required the arterial supply to be intact to carry oxygenated blood to the tissues below the site of injury and an intact venous system to carry blood away. Otherwise the cells would die resulting in gangrene necessitating amputation. Also it required the nerves necessary to have a functioning extremity be intact. Many of these attempts to salvage the limbs failed as the individuals died from infection due to bacterial contamination of the wound.

State of Western Medicine Before the War.

In order to understand the significance of the contributions of Surgeon General Hammond, it is worth reviewing the state of western medicine, in general, and American medicine, in particular, both before and during the war. This will also provide an understanding and appreciation of the challenges physicians encountered and endured when providing care to the wounded. Compared to the medical knowledge we have today, there was a paucity of scientifically based medical knowledge available to them. Yet, they had to manage extensive injuries created by the most devastating weapons the world had produced until that time. Also, it will enhance one’s awareness of the war’s contributions to the advancement of the science of medicine that ensued after the war. Finally, comparing medicine at the onset of the war to that of today, one can appreciate how far medicine has progressed since the war.

Western Medicine’s Heritage from Antiquity

As Lester King M.D. (The Growth of Medical Thought, page viii) points out “The history of medicine is part of the history of ideas. The medical world is indeed a microcosm which reproduces in parvo a vast macrocosm of concepts and ideas.” The early Greek philosophers were interested in the natural world and speculated (a priori reasoning) as to it’s structure and composition. Following in the same tradition Hippocrates and the Hippocratic school (400 B.C), developed concepts about the causes and therapeutics of disease. Their great contribution to medicine was to recognize the cause of disease was due to factors in the natural world and, thus, was capable of being understood by humans using reason. Prior to Hippocrates concepts concerning the etiologies of diseases were based on superstition-they were inflicted on humans by angry and vengeful gods or, as in the case of epilepsy, were due to the individual being possessed with a demon. However much of their thinking and conclusions were also based on a priori reasoning . Their ideas remained prominent in the thinking of western medicine into the 19th century. Henry Sigerist, the renown medical historian, gives us insight into the high esteem given to the ancients by the western world down trough the ages: “To be called a second Hippocrates or to be called the Hippocrates of his time was the highest title of honor that could possibly be bestowed on a Western physician, and whenever something went wrong in medicine, when theory and practice did not harmonize, or when fantastic theories came up and began to dominate the field, the cry ‘Back to Hippocrates’ was heard.” (A History of Medicine, Volume II, Henry E. Sigerist, Oxford University Press, 1961, p. 260). This explains the persistence of the retrospective approach to medical practice that persisted into the early 18th century and in some cases into 19th century which seems illogical to us today with our reliance on the prospective, scientific method of investigation for answers to medical issues. Recognition medicine’s adherence to the past and it’s reluctance to change brings to mind a poignant observation stated by the philosopher Bertram Russel: “The search for something permanent is one of the deepest of the instincts leading men to philosophy. It is derived, no doubt, from love of home and desire for a refuge from danger.“ (A History of Western Philosophy, Bertram Russell, Simon & Schuster, 1972, p. 45. History is replete with examples demonstrating that it is more comfortable for humans to stay ‘in the home of antiquated outdated beliefs and rely on archaic authority figures” than confront the unpleasantness of having to accept one’s lack of knowledge about a subject. Admitting ignorance is uncomfortable as we are forced to start thinking “outside the box” and begin the arduous process of investigation in order to arrive at the truth. (Foot Note #1). Perhaps, the realization of this characteristic in human nature will help us to understand why physicians until the modern era in history clung to the past in their medical thought and therapeutic practice, and we can be more understanding and less critical. The ancients’ concept of disease which persisted with many physicians was identified as the “humoral theory” and stipulated disease resulted from an imbalance of body humors. Four of the humors that were dominate in their thinking were: black bile, yellow bile, sanguine (blood), and phlegm. By the 18th century, however, the humoral theory was beginning to give way to other speculative and erroneous theories of disease causation in the leading medical centers in Europe. Another theory of the cause of disease was “miasma” which identified airborne poisons and toxins emitted by decomposing organic matter as the cause of disease. Miasma had been around since early times and had a large number of proponents in the 19th century. The therapeutic modalities in vogue in the 19th century, referred to as “heroic therapy,” were also handed down from the ancient Greeks: venesection (bleeding), gastrointestinal purging with cathartics, blister formation and cupping, inducing emesis, diet, and diuretics. (George Washington was subjected to each of these harsh “treatments” as he lay dying in December 1799 from a severe throat infection as reported by his physicians in the “Times” of Alexandria, Virginia shortly after his death). Venesection was fast fading by the time of the Civil War, but other aspects of heroic therapy were still in vogue during the war; especially the use of purgatives. Referring to the past for answers in medicine was termed “library medicine.”

Benjamin Rush M.D. and American Medicine in the Early 19th Century.

American medicine during the early 19th century was firmly under the influence of Benjamin Rush, M.D. (1746-1813). He was considered to be the “American Hippocrates.” He was a signer of the Declaration of Independence. He believed disease resulted from “morbid excitement due to convulsive activity in the blood vessels.” As bizarre as this theory sounds today, it is not totally anomalous to the thinking of some in medicine at the time. At the end of the 18th century several physicians including John Hunter, a distinguished Scottish surgeon and scientist, had written about the inflammation of blood vessels as being the “basic disease.” It did not elicit much response. After the French Revolution, the medical centers in Paris became the leading centers in Western Medicine. In fact, Americans who wanted to get the best medical education went there. Near the 1820’s the idea of phlebitis (inflammation of veins) became popular in Paris. The concept was advanced by Breschet and later by Dance and Cruveilhier. (Medicine at The Paris Hospital 1794-1848, Irwin Ackerknecht, The Johns Hopkins Press, 1967, p. 80.) Rush was a strong advocate of “heroic therapy,” especially venesection. However, by time of the mid-century, his ideas and influence diminished being replaced with various “subjective” and inaccurate concepts of disease by practitioners. As mentioned previously, the enthusiasm for venesection was fading, but the other modalities of “heroic therapy” persisted into the Civil War period. As an example, the Confederate General Joe Johnston was wounded during the Peninsula Campaign in the Spring of 1862 and received “heroic therapy.” (Robert E. Lee took command of General Johnston’s Army which subsequently became ”the Army of Northern Virginia.“)

Progress in Medicine Lagged Behind the Advancement of Other Natural Sciences into the 19th Century.

• Physician during the war had an abundance of medications at their disposal for illness in addition to the use of “heroic therapy.” In 1860 there were 871 medications listed of which 2/3 were botanicals. (Civil War Pharmacy, Michael A. Flannery, Southern Illinois University Press, 2017, p. 30). Some were definitely helpful such as the opium derivatives for pain and quinine for malaria. Bromine and iodine were useful as disinfectants for infected wounds (physicians observed empirically they were beneficial but lacking knowledge about “the germ theory” didn’t know why) and the anesthetic agents-chloroform, ether, and nitrous oxide were available. Then, there were medications which were of no benefit. Finally, there were those that were definitely harmful such as tartar emetic (induce vomiting and containing antimony), calomel (a mercury containing purgative), and mercury for syphilis. The latter harmful agents were used extensively during the war. Significant progress had been made in the natural sciences during the previous centuries as there were universally accepted and scientifically determined valid laws to explain phenomena. Francis Bacon (1561-1625) had introduced the “scientific method” approach to investigating Natural Philosophy (we call it science today) which was based on observation, empiricism, and inductive reasoning. It led to scientific discoveries which could be agreed upon by most. For example, in physics Newton’s law of gravitation accounted for the observations that objects fall to the ground and planets revolve around the sun. In contrast, medicine lagged behind the natural sciences as it was not based upon an established, universally accepted, and scientifically valid principle for each observation. Advancement in the understanding of the etiology of infectious diseases was restrained by the thought process of many physicians. They advocated that each disease had multiple etiologies, and, consequently, each physician had his individual and erroneous set of causes to explain a disease. Also, lacking a scientific basis for treatments, there was no consensus concerning therapeutic modalities.

Medicine Evolves To Become Recognized as a Science.

Consequently, medical practice was more-or-less up to the individual practitioner’s inclinations, and one could consider medical practice, at the time, to be basically an art – or what the Greek, Aristotle, referred to as “techne“ (craft). However, there appeared on the horizon a resolution of this “deadlock.” Between 1835 and 1840, European researchers demonstrated a few instances of a specific cause of a specific disease: scabies due to an insect, syphilis due to a ‘special ferment,’ muscardine due to a fungus, trichinosis due to an encapsulated worm in muscle, trichomonas of the vagina due to a protozoan, and various skin disorders, each due to specific fungi. (“The Rise of Causal Concepts of Disease,” K. Codell Carter, Ashgate Publishing Limited, 2003, p. 25). Just as “rosy-fingered Dawn” announced the beginning of day and the end of night and darkness in Homer’s “Iliad”, these discoveries were harbingers of a new era in which medicine would evolve out of a state of ignorance into one of knowledge, understanding, and progress. Accurately identifying each disease entity with a single specific etiological agent led to the practitioner’s ability to understand the manifestations and the process of the disease. This knowledge created the opportunity to implement therapeutics based on rationality and scientifically proven benefit and also to institute preventive measures. Thus, the modern era of the scientific-based practice of medicine was ushered in making it more of a science and less of an art. Tremendous strides were made in the advancement of medicine as a science during the last one-third of the 19th century when Louis Pasteur and Robert Kock demonstrated unequivocally that microorganisms were the cause of infectious diseases, i.e. “the germ theory.” As previously mentioned, the germ theory established the fundamental concept in medicine that each disease was due to a specific cause. It laid a unifying foundation for building a consensus in the thinking among medical practitioners regarding the etiology of infectious disease which, in turn, made possible the discovery of antibiotics that occurred in the twentieth century. It also advanced and solidified the “cause and effect” process in medical understanding.

William Hammond, M.D. Effected A Paradigm Shift in Medicine-From Backward Looking to Forward Thinking

The state of medical thought and practice in America was destined to undergo change when William Hammond, M. D., was appointed Surgeon General of the Medical Corps in 1862. He replaced the older and generally incapable Clement Finley, M.D. who was described by George Templeton Strong as being “utterly ossified and useless.” As Letterman’s contributions significantly changed the approach to management of the military and civilian wounded, so Hammond’s institution of innovative and progressive programs in the Army Medical Corps was helpful in redirecting the course of medicine in America. A paradigm shift in the approach to medicine emerged that is in effect today. Prior to the war Hammond had been a surgeon (all physicians in the military at the time were referred to as surgeons) in the U.S. Army Medical Corps. He resigned to accept an academic position at the University of Maryland School of Medicine. After the war commenced, he rejoined the military and was made Surgeon General being promoted above more senior ranking physicians. He established the use of empiricism (observation and experimentation) to gather data and inductive reasoning to derive principles from the data. This “scientific method” was outlined by Francis Bacon in “Organum Novum” and published in 1620. As mentioned previously, it was responsible for the great achievements in the natural sciences that occurred in the 16th and 17th centuries. He established the organization, categorization and analysis of medical data using the U.S. Army case reports as a data source. These activities led to elucidating the various aspects of disease and also generating new medical knowledge. He had previously performed experiments studying nutrition, reportedly, using himself as a subject. He was regarded as a man of science as he looked forward to investigation to glean answers to medical questions rather than take a retrospective approach looking to the past for answers. Furthermore, he was regarded as a very capable physician by his peers. He was a strong advocate for the education and training of physicians as well as establishing strict criteria for their qualification to practice.

During his initial tour of duty in the Army, he visited Europe and became knowledgeable about Pavilion hospitals, their design and construction. His understanding of the Pavilion hospital proved to be most beneficial during the construction of the Union hospitals after the war began.

The Crimean War, Florence Nightingale, and the Pavilion Style Hospitals.

The pavilion style hospital was a product of a war prior to the Civil War, the Crimean War (1853-1856), and Florence Nightingale. Russia had invaded Crimea and was opposed by Britain, France, Sardinia, and the Ottoman Empire. During the first year of the war there was an excessively high mortality in the British Army. Florence Nightingale and a team of nurses were sent to access the problem. She reported that there was a paucity of supplies and medical personnel, and there was significant malnutrition of the troops. She added that the hospitals were extremely overcrowded, filthy, and disease laden. Consequently, measures were put in place to alleviate these conditions, and the mortality rate dropped significantly thereafter. Florence did not believe in the theory of contagious disease and specific disease states. She believed “filth, disorder, and contaminated atmosphere were responsible for hospital fevers and infection.” (ie., miasma). Her “influence led to a “cleaner and in general more human hospital environment-towards better sanitation, adequate ventilation, improved diet, competent nursing.” (Rosenberg, “Explaining Epidemics and Other Studies in the History of Medicine,” Cambridge University Press, 1992, pp. 90-108.)

As a result of Florence Nightingale, the pavilion style hospital was inaugurated and subsequently adopted in Europe. It emphasized large wards providing adequate space between patients, windows to provide cross ventilation of each ward with fresh air, open space between wards which were arranged radially around a central structure to allow the ingress of fresh air between the wards, and strict attention to sanitation and hygiene.

Surgeon General Hammond Constructs Pavilion Hospitals for the Union Wounded.

Surgeon General Hammond oversaw and directed the extensive construction of the new, state-of-the-art pavilion style Union Army hospitals being built in the large northern cities during the Civil War, and he designated certain ones to be specialty centers devoted to a specific disease category. These specialty hospitals, in turn, generated physician “specialists” who would ask the pertinent questions about a disease and perform the experiments and studies leading to the advancement of medical knowledge. These advancements , in turn, pulled American medicine out of the “rut” it was in prior to the war and place it on the road leading to progress. As an example, he designated the Turner’s Lane Hospital in Philadelphia under Silas Weir Mitchell, M.D. to specialize in neurological injuries, and it became a renown neurological center. Prior to the Civil War all physicians were general practitioners. The emergence of specialists opened the door for medical research. Following the French Revolution, specialty hospitals were created in Paris which helped to make it the leading center of western medicine in the first half of the 19th century.

The Army Medical Museum and “The Medical and Surgical History of the War of the Rebellion”

Hammond instituted a medical museum consisting of pathological specimens of disease and war-related injuries for the study of disease processes. Using the U.S. Army as a base source, he accumulated a large amount of data of various diseases for analysis and war injury speciments. The many acquisitions, scientific research activities, clinical studies, reports of data from the war, and innovative endeavors he put in place formed the bases for the post-war landmark multivolume publication “The Medical and Surgical History of the War of the Rebellion.” Surgeon General Hammond was one of the significant and instrumental factors in changing the focus of American medicine from the antiquated retrospective approach in the antebellum period to a prospective modern approach in the postbellum period. (Foot Note #1)) This helped to lay the foundation for the significant achievements in medical knowledge that were to follow.

Medical Advances in the Civil War Influenced Many Aspects of Today’s Healthcare: Nursing, Hospitals, Pharmacy, & Surgery

The Civil War was a significant contributor to several changes and advancements in the broad category of “health care” in America. It created an appreciation for the value of nursing and thereby established nursing as a recognized profession. As a result, nursing schools were built and the RN degree was established. It also helped to pioneer the hospital system we have today. As indicated previously, the extensive number of sick and wounded needing care during the war resulted in the massive construction of state-of-the-art pavilion hospitals under Surgeon General Hammond’s supervision. Their success was recognized by the civilian sector and led to the construction of similar civilian hospitals after the war. Prior to the war, medical care was given in the home where nursing care was administered by family members. Consequently, following the war medical care was transferred from the home to the well-equipped hospital with trained nursing services. The hospital later evolved into the center for access to today’s complex diagnostic and therapeutic services. It had an impact on the development of the pharmaceutical industry and also on the advancement of the pharmacist from the status of tradesman to that of a recognized professional. Finally, and most significant, the war experience expanded the knowledge base and ability of the physicians who served in both the North and South. In the words of two veteran physicians of the war as quoted in H. H. Cunningham’s “Doctors in Grey”



“I have lost much, but I have gained much, especially as a medical man. I return home a better surgeon, a better doctor.”

“… the doctor was ‘more practically efficient and useful, at the bedside now, than perhaps he has ever been before, and the whole country is now furnished with a medical corps which the war has thoroughly educated and reliably trained.”

The Civil War Laid a Foundation for the Development of Surgery

The knowledge and experience physicians gained during the war supplemented by the use of anesthesia greatly enhanced the development of surgery and the public’s acceptance of surgery as a treatment modality. Statistics at the Massachusetts General hospital during different time periods yields the following data on the number of operations performed each year during a given time period:

Pre-Anesthesia (1836-1846) 39 per annum

Post-Anesthesia & Pre-Civil War (1847-1857) 189 per annum

Post-Civil War (1894-1904) 2,427 per annum

(Civil War Medicine, Challenges and Triumphs, A.J. Bollet, Galen Press Ltd., 2002, p. 83”)

The Public’s Acceptance of Surgery-not Population Growth-Explains the Increase in Surgical Procedures after the Civil War

The United States underwent a tremendous population growth during the 19th Century. James McPherson says that in 1803 at the time of the Louisiana Purchase the population approximated that of Ireland. After 1850 the population surpassed that of Britain and was exceeded by only France and Russia. He adds that during the first half of the century America’s population grew faster than Europe by a multiple of 4 and the world average by a multiple of 6. (The Battle Cry of Freedom, James McPherson, Oxford University Press, 1988, p. 9). The population expansion continued in the second half of the century with the Irish, German, and Italian immigrations as well as immigration from other European countries.

One could attribute, in part, the increases in operative cases at the Massachusetts General Hospital after the introduction of anesthesia and again after the Civil War to the population expansion. However, this does not explain the whole story as the operative case load appears to have expanded to a greater degree than the population. Comparing the statistics of the operative case load of the Post-Civil War period to those of the Post-Anesthesia & Pre-Civil War period, we see an increase by a multiple of 12.84. Thus, I think the predominate explanations for the increase in operative cases which indicate acceptance of surgery by the public are as follows: (1) the effective use of anesthesia which made possible pain-free surgery (F. N. # 2), (2) the increased level of surgeons’ competence gained from their war experience. (3) the post-war expansion of medical knowledge that was a product of medical research programs such as had been initiated and promulgated by Surgeon General Hammond during the war. (4) most important, the acceptance of the germ theory of infection and the incorporation of sterility into the performance of surgical procedures. Aseptic technique in surgical procedures greatly reduced the incidence of post operative infections which was a major cause of mortality with surgical procedures both prior to as well as during in the Civil War. This led to better and more favorable outcomes for the patients which, in turn, led to public acceptance.

An English surgeon, Sir John Eric Ericksen visited this country and wrote an interesting assessment of American medicine and surgery in the “Lancet“ (a prestigious British medical journal) in 1874:

“Medicine…stands prominent as probably the best-educated, certainly the most scientific, and consequently…the most respected of the professions.

Surgery in the United States certainly stands at a very high level of excellence. The hospital surgeons throughout the country have struck me as being alike practical, progressive, and learned in a very high degree. In practical skill and aptitude for mechanical appliances of all kinds, they are certainly excelled by no class of practitioners in any country.” Two Centuries of American Medicine, Bordley III and Harvey, W.B. Saunders Company, 1976, p.95.)

My Presentation- in Summary

It takes a “Promethean” individual to cause a paradigm shift that pushes away the barriers to progress that are embedded in the unquestioning nature of humans that results in adherence to the routines of life, persistence in stagnant thought processes, and remaining devoted to obsolete authority figures. These visionary individuals, being dissatisfied with the status quo, comprehend a better state of being and have the ability to effect changes that result in an improved existence for mankind. In my opinion Surgeon General Hammond was just such a “Promethean” individual. These individuals go on a quest to obtain an object (“the Holy Grail”) for the benefit of mankind as described by Joseph Campbell in his book “The Hero with a Thousand Faces.“ Campbell identifies the quest as “the Hero’s Journey” and characterized “the journey” as being difficult and dangerous which may in the end be rewarded with punishment. (George Lucas, filmmaker and devotee of Joseph Campbell, used Campbell’s “hero’s journey” as the theme for his multi-trilology, “Star Wars.”) Prometheus, the Greek mythological figure seeking to improve the life of man, embarked on the “hero’s journey.” He went to the home of the gods, took fire, and brought it back to earth. His humanitarian act angered Zeus. Zeus had him chained to a rock and each day sent an eagle to devour part of his liver. During the night the liver wound regenerate. Eventually Hercules came to Prometheus’ rescue and freed him from his chains. As I develop in my presentation, Hammond instituted many changes that placed medicine on a path leading from its ineffective and sometimes harmful state to a productive future for the benefit of his fellow man. He, like Prometheus, paid a price. His nemesis from the beginning of his tenure as Surgeon General was the demi-god, Secretary of War, Edwin Stanton. Hammond “insulted” the backward, old-time military surgeons as well as the backward practicing civilian physicians when he issued a circular eliminating the use of tartar emetic and calomel in the military. These agents were harmful and being abused by “old school” civilian and military physicians. Also, there were the “grudges” held against him by the “old guard physicians” in the Army who were senior to Hammond and were passed over when he was made Surgeon General. Stanton saw his opportunity “to strike.” Hammond’s reward for his efforts and accomplishments to improve medical care was to be court martialed and removed from the military. He, after several appeals, was able to have the guilty verdict reversed and his name cleared his by an act of Congress and order by President Hayes. He was placed on the army’s retired list and promoted to brigadier general. (Bleeding Blue and Gray, Ira Rutkow, Stackpole Books, 2005, pp. 213-216, 236). It was later demonstrated that tartar emetic and calomel were harmful. Hammond was correct!

Surgeon General Hammond and Letterman have long been gone, but the accomplishments they bequeathed to mankind, like that of Prometheus, have lived on for the benefit of all.

(2). Anesthesia Provides “Time” to the Surgeon as Well as “Absence of Pain” to the Patient

Acknowledgement of the “germ theory” of infection, for certain, opened the door for the advancement of surgery. It brought sterility into the practice of medicine and promoted aseptic technique in surgical procedures. This greatly reduced the surgical complication of infection and the associated morbidity and death. Consequently, surgical outcomes were improved and surgery became more acceptable to the public. This advancement made it possible for the benefits of anesthesia to follow. The contribution that anesthesia made to the advancement and improved results (outcomes) of surgery was the time it provided for the surgeon to do meticulously demanding and prolonged procedures. This aspect doesn’t get the proper recognition it deserves, in my experience. Prior to the age of anesthesia, “the best surgeon” in the eye of the public was often the fastest. Speed and accuracy in surgery do not necessarily go “hand-in hand.” There comes a point where speed results in the sacrifice of accuracy in the technical performance of a procedure. The factor recognized to be the greatest determinate of bad surgical outcomes is post-operative complications. The elderly-many having comorbid conditions such as diabetes, hypertension, heart disease, lung disease, kidney disease, and atherosclerosis- are particularly vulnerable, They compromise the group cohort which has the highest mortality from post-operative complications. One of my mentors preached, “the elderly can tolerate operations, they can’t tolerate complications.” Technical errors made in the surgeon’s haste to finish can lead to complications and, consequently, devastating problems. Anesthesia made it possible for the surgeon to make sure he had “dotted all the ‘i’s and crossed all the t’s “ before closing the procedure. In addition anesthesia contributed to the expansion and development of time-consuming procedures. For example, vascular surgical procedures, with which I have experience, can require several hours. Arterial reconstructive procedures in small arteries of lower extremities, in addition to being time consuming, require such precision that a stitch placed a millimeter off can jeopardize the outcome of a procedure. Thus, I think that the expansion of more complex surgical procedures coupled with acceptable outcomes resulted in the public’s willingness to turn to surgery as a therapeutic modality. Anesthesia coupled with the incorporation of aseptic technique in surgical procedures made it possible.

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Interestingly in regards to tartar emetic and calomel, it was later shown that he was correct. They were harmful.

Jonathan Letterman and William Hammond are not with us today, but the changes they wrought, like that of Prometheus, have remained for the benefit of mankind. Their sacrifices were not in vain.