Safe behind its ocean barriers, the United States paid scant attention to the wars that raged abroad during the early 19th century, taking little notice of the lessons that might have been learned from the European experience with mass killing. With few opportunities for its own military medical establishment to acquire field experience, the U.S. Army’s military medical service remained primitive. In 1802, the U.S. Army Medical Corps comprised only two surgeons and 25 orderlies. By 1808, the number of surgeons had increased to seven and surgical assistants to 40. There was no ambulance corps during the War of 1812; after the battle wagons were sent to search for the wounded. There were no hospitals, either, and the wounded were treated in temporary shelters near the battlefield. Even these primitive facilities were dismantled when the war ended. In 1818, Congress finally authorized the appointment of Dr. Joseph Lovell to head the medical corps as surgeon general.
At the start of the Mexican War in 1846, the American medical corps consisted of one surgeon general and 71 medical officers. Statistically, the Mexican War was the deadliest ever fought by an American army. Of the 100,182 soldiers committed to the campaign, 1,458 were killed in action and another 10,790 died of disease, a disease mortality rate of 11 percent. This compared to a similar rate of 6.5 percent for the Civil War, 2.7 percent for the Spanish-American War, and 1.6 percent for World War I. The single medical contribution of the Mexican War was the first use of anesthesia by a military surgeon in combat. The medical service was once more reduced in strength when the war ended. At the outbreak of the Civil War, no one on either side was remotely prepared for the magnitude of the slaughter, forcing both sides to endure a medical catastrophe that was unprecedented in military history.
The Shocking Casualties of Total War
The Civil War was the first modern war in which the productive capacities of the industrial state were completely integrated into the war effort. The number of combat engagements was the largest in history to that time, and exponential increases in the killing power of weapons produced rates of casualties beyond the imagination of military medical planners. In a four-year period, 2,196 combat engagements were fought, in which 620,000 men perished—360,000 in the Union Army and 260,000 in the Confederate Army. Some 67,000 Union soldiers were killed outright, 43,000 died of wounds, and 130,000 were disfigured for life, often with missing limbs; 94,000 Confederate soldiers died of wounds.
The minie ball (actually a bullet) caused 94 percent of all wounds, artillery shell and canister accounted for 6 percent, and the saber and bayonet fewer than 922 wounds, of which only 56 were fatal. Some 35 percent of all wounds were to the arms, 35.7 percent to the legs, and wounds to the head and trunk accounted for 18.4 percent and 10.7 percent, respectively. In a statistical sense, the Civil War was the most life-threatening war ever fought. The chances of not surviving the war were one in four, as compared to one in 124 in the Korean War.
The staggering increase in the number and seriousness of wounds was due to the .58-caliber rifle-barreled firearm, which was capable of propelling a bullet 950 feet per second to a range of 600 yards. The heavy, soft, unjacketed lead bullet flattened out on impact, producing severe wounds and carrying pieces of clothing into the wound. When the bullet struck a bone, its weight and deformation shattered the bone or severed it completely from the limb. The old tactic of massing troops to deliver mass fire, once made necessary by the inaccuracy and limited range of the musket, persisted, making troop formations extremely vulnerable to long-range rifle fire. The deployment of troops over greater frontages also increased the dispersal of the wounded, making it difficult to locate, treat, and evacuate them. The Civil War medical officer faced problems of wound management that were unique for the time.
More Limbs Lost Than in Any Other American War
The improved kinetic power of the rifle bullet made amputation the most frequently performed battlefield operation. Of the 174,200 gunshot wounds to the arms and legs suffered by Union soldiers, 29,980 required amputation. Confederate soldiers suffered 25,000 primary amputations. The mortality rate for primary amputation was 26 percent, compared to 52 percent for secondary amputation. Another 26,467 wounds of the extremities that were complicated by an injury to the bone were treated by expectation (left alone to heal), with a mortality rate of 18 percent. More limbs were lost in the Civil War than in any other American conflict before or since.
In the first years of the war, control of bleeding (hemostatis) was achieved mostly through the use of tourniquets and cauterization, methods dangerous to the patient when practiced by physicians with limited experience. As the physicians gained experience, pressure dressings and ligature became the primary methods for controlling bleeding. But ligature often led to infection. The mortality rate for these secondary infections was 62 percent. The usual array of infections—tetanus, erysipelas, gangrene, and various streptococcus infections—was always present, and the mortality rate in hospitals from such infections reached 60 percent in the early days of the war. By the end of the war, this had fallen to 3 percent. Hospital infection remained a major problem on both sides throughout the war, however. William W. Keen, a surgeon in the Union Army, observed in his memoirs that “it was seven times safer to fight all through the three days of Gettysburg than to have an arm or leg cut off and be treated in a hospital.”
Battlefield Drugs and Anesthetics
For the first time in history, anesthesia was used on an unprecedented scale by military physicians. No fewer that 80,000 applications of anesthesia were administered. General hospital records show that anesthesia was used in 8,900 operations, of which 6,784 used chloroform and 811 used ether. In 1,305 cases, a combination of the two was used. Remarkably, only 37 deaths were attributed to anesthesia. Advances were also made in the immobilization of limbs using plaster of Paris. In 1863 the famous Hodges splint, still used today in the fracture of the lower femur, was introduced by Union surgeon John Hodges.
The use of drugs was primitive at best. Calomel (mercurous chloride) was so heavily prescribed that the Surgeon General forbade its use as dangerous. The most useful drugs were morphine, opium, and quinine, the latter as a preventative for malaria. Morphine was usually dusted directly on the wound, and only occasionally injected hypodermically. The hypodermic syringe appeared in the 1850s but was used only rarely in the Civil War—at least on the physically wounded. Dr. Silas Weir Mitchell noted that in the army hospital for nervous diseases, more than 40,000 doses of morphine were given hypodermically to psychiatric patients in a single year. A staggering 10 million opium pills were given to patients during the war, along with 2,841,000 ounces of other opium-based preparations such as laudanum, opium with ipeac, and paregoric. In all, 29,828 ounces of morphine sulphate were administered. Not coincidentally, by 1900 there were 200,000 drug addicts in America.
Disease: The Number-One Killer
Disease was the number-one killer of soldiers on both sides during the Civil War. Most recruits were physically unfit for the rigors of war. Three-quarters of the Union soldiers discharged from the army in 1861 were so unfit that they should never have been allowed to enlist. Most recruits came from isolated rural towns, and this isolation prevented them from developing immunity to a wide range of common childhood diseases. Being brought together in the close quarters required of military life, many fell ill with diseases to which they had never previously been exposed. Poor physical condition, few immunities, poor nutrition, and the general stress of military life reduced resistance to disease. Scurvy was endemic, and outbreaks of cholera, typhus, typhoid, and dysentery took a heavy toll. Disease killed approximately 225,000 men in the Union Army and 164,000 men in the Confederate ranks. It is estimated that disease killed five times as many men as weapons fire.
The Union Army Adapts its Medical Corps
The Union medical service was completely unprepared for war. In 1860, the 26,000-man army was scattered along the frontier and had no military medical service to speak of. The army had only 36 surgeons and 83 assistant surgeons, 24 of whom resigned to join the Confederacy. Medical supplies were in short supply, and there were no army general hospitals. There was no ambulance service to locate and evacuate the wounded. The incumbent surgeon general was Thomas Lawson, a sick and dying man who economized on expenditures by refusing to purchase medical books and supplies.
In the 1850s, then-Secretary of War Jefferson Davis had ordered two officers, one of whom was Captain George B. McClellan, to prepare a study of medical lessons learned from the Crimean War. The report recommended the creation of an army ambulance corps. But by 1860, no such corps had been established. For the first two years of the war, there were no systematic provisions to evacuate the wounded. At the Battle of Bull Run, wagons had to be commandeered from the streets of Washington to transport the wounded. In the Peninsular Campaign, a Union Army corps of 30,000 men had ambulance transport sufficient for only 100 casualties.