When the Civil War began, the world was undergoing vast changes in medical knowledge. The old "heroic therapies" such as bleeding, cupping, and the use of leeches had fallen out of favor by 1860, and were being replaced with experimental (and not always successful or beneficial) medical treatments. Treating wounds and illnesses with medication had become common—opiates, stimulants, sedatives, diuretics, purgatives, and more were widely available and used. The first pills had been made in the early 1800s. The stethoscope and the hypodermic syringe were new. The use of anesthetics had begun in the 1840s; they allowed more extensive surgeries that previously had been impossible.
At the same time, the causes and transmission of diseases was a subject of debate. Vaccines and various treatments were still in their early stages. There was no understanding of microbiology, of the nature of germs and bacteria. Most epidemic diseases were blamed on "miasma" and "effluvia," unseen contagions that were in the air causing diseases and infections. Sanitation was in its very early stages, and the outrageously unhygienic surgical conditions were rarely blamed for their disastrous effects.
The war itself ushered in a new era in medical understanding at the expense of many lives. For a soldier recovering from a wound or struggling with an illness, Civil War medicine could be a blessing or a curse.
Anesthetics and General Medications
Anesthetics were widely used in both the North and the South for serious operations and for the treatment of painful wounds. The surgeon J. H. Brinton wrote of using chloroform on patients in a Nashville hospital: "when patients are first brought here it is often necessary to place them under the influence of chloroform while their wounds are being prepared, and obtund the pain caused by the remedies applied; afterward it is not refused them if the dressing is likely to be painful" (Barnes 1870–1888, vol. 3.2, p. 846). Although no exact number can be known, it is estimated that anesthetics were used in about 80,000 instances. Out of a group of nearly 9,000 cases cited in the Medical and Surgical History of the War of the Rebellion, chloroform was used 76.2 percent of the time, ether in 14 percent, and a mixture of the two in 9.1 percent (p. 887). Chloroform was safer than ether, but both were toxic; as the Union surgeon C. J. Walton stated: "While I could not dispense with chloroform, I must protest against the extravagant and indiscreet use of it. It is a most potent agent, and should be used with the utmost caution" (Barnes 1870-1888, vol. 3.2, p. 888). Surgeons agreed that it should be used only as long as necessary, and then, "its administration should be discontinued… toxical effect" (Barnes 1870-1888, vol. 3.2, p. 888). Both were carefully administered to soldiers by a cloth or sponge held over the nose and mouth. In the Southern army, where anesthetics could be harder to get, Surgeon J. J. Chisolm developed an inhaler that used less chloroform, and administered it directly into the nostrils via two nose pieces (Barnes 1870–1888, vol. 3.2, pp. 888–889).
PTSD and the Civil War Soldier
Posttraumatic stress disorder (PTSD) did not become a diagnostic category in American psychiatry until the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980, after the condition had been studied systematically in veterans of the Vietnam War (1965-1975). Veterans of World Wars I (1914-1918) and II (1939-1945) were more likely to be diagnosed as suffering from "shell shock" or "traumatic war neurosis."
Until the early 2000s, however, no one had studied the mental and physical aftereffects of combat in Civil War veterans. In 2006 a team of researchers at the University of California, Irvine, published the results of their study of 17,700 Civil War veterans who had received standardized medical examinations over their postwar lifetimes by U.S. Pension Board surgeons. The results indicated that Civil War veterans suffered profoundly from posttraumatic stress, probably more so than veterans of later wars, for several reasons:
- The youth of Civil War soldiers. Between 15 and 20 percent of Union volunteers were between the ages of nine and seventeen. The researchers found that these young veterans were 93 percent more likely than the oldest soldiers (thirty-one or older) to experience both physical and psychiatric problems after the war, and to die at early ages.
- Loss of friends and family. Companies in Civil War armies were often made up of men from the same town, neighborhood, or extended family. This fact meant that a soldier whose company suffered heavy losses in battle was far more likely to grieve the loss of several close friends and relatives than his twentieth-century counterparts. Veterans from companies that lost large percentages of soldiers in battle were 51 percent more likely than other veterans to suffer heart attacks, stomach disorders, or mental illness after the war.
- The psychological impact of close-quarter or hand-to-hand combat, which was a common field tactic in the Civil War.
Psychiatry had not become a separate medical specialty at the time of the Civil War, although mental illnesses of various types were certainly recognized, and hospitals for the treatment of the mentally ill had existed in the United States since the early nineteenth century. In 1844 thirteen superintendents of what were then called insane asylums formed the Association of Medical Superintendents of American Institutions for the Insane. In 1921 the name changed to the American Psychiatric Association.
Civil War battlefield surgeons did not use terms such as "battle shock" or "PTSD" for posttraumatic symptoms in the soldiers they treated; instead, they used phrases such as "nervous disease" or "irritable heart syndrome" for psychiatric disorders resulting from combat stress. There was also a relatively new psychiatric hospital just for veterans—St. Elizabeths Hospital in Washington, DC. This institution had been founded by Congress in 1855 as the Government Hospital for the Insane, or GHI. Dorothea Dix (1802-1887), the social reformer whose work led to the foundation of the first public mental hospitals in Pennsylvania and North Carolina, was also responsible for the establishment of the GHI. Dix instructed the hospital to provide "the most humane and enlightened curative treatment of the insane of the Army, Navy, and District of Columbia" (The United States Congressional Serial Set 1855, p. 10).
The GHI provided psychiatric treatment for several hundred Union soldiers both before and after the war; many were eventually buried on its grounds. During the war soldiers were referred to the hospital after being evaluated by battlefield surgeons for malingering and deception. After the end of the war the increase in the number of mentally ill veterans led Congress to pass an act on July 13, 1866, that permitted the GHI to admit all men who had served as Union soldiers in the Civil War and were found insane within three years of discharge by reason of mental illness related to military service. Many of these veterans needed custodial care for the rest of their lives; Dr. Charles H. Nichols, the first superintendent of the hospital, saw to it that they received the best care possible at the time. He said, "The patriotic sacrifices of the military patients will always entitle them to our best endeavors to promote their comfort and their restoration to health" (Report of the Department of the Interior 1849, p. 174).
St. Elizabeths received its present name informally during the Civil War, as some soldiers who were treated there for physical injuries hesitated to use "Government Hospital for the Insane" for their return address when writing to loved ones back home. They called the hospital "St. Elizabeths" after the name given to its grounds by the original colonial landowner in 1663. Congress finally made the name change official in 1917.
rebecca j. frey
Kanhouwa, Surya. "A Century of Pathology at Saint Elizabeths Hospital, Washington, DC." Archives of Pathology and Laboratory Medicine 121 (1997): 84-90.
Pizarro, Judith, Roxane Cohen Silver, and JoAnn Prause. "Physical and Mental Health Costs of Traumatic War Experiences among Civil War Veterans." Archives of General Psychiatry 63 (2006): 193-200.
Report of the Department of the Interior. Washington: United States Government Printing Office, 1849, p. 174.
The United States Congressional Serial Set. Washington: United States. Government Printing Office, 1855, p. 10.
Opium and morphine were seen as essential medications. They were available as pills or powder. Morphine could be injected as well, and small amounts of opium could be taken with alcohol in a solution called laudanum (Bollet 2002, pp. 238–239). Opiates seemed effective in treating a variety of symptoms, and so the drugs were liberally prescribed for everything from battlefield wounds to dysentery, and even for more common complaints such as headaches. It is estimated that the Union used about 10 million opium pills plus about 3 million ounces of opium powder and other opium mixed concoctions (Bollet 2002, p. 240). The Confederacy likewise prescribed opiates, but perhaps not as liberally: Because of the Union blockade, they were often hard to come by, so some Southerners turned to growing and harvesting their own poppies to create opium (Jackson 1863, pp. 103–104).
The use of antiseptics to prevent infections could not be relied on during the Civil War because general medical knowledge and practice at the time did not take sanitation into account. Surgeon W.W. Keen remembered that: "we used undisinfected instruments from undisinfected…cases, and still worse used marine sponges which had been used in prior pus cases and had been only washed in tap water" (Adams 1952, p. 125). Under such unsanitary conditions, a soldier recovering from surgery could expect infection to set in. However, antiseptics were available. Surgeons used "not only carbolic [acid], but many of the other chemicals that rank high as antiseptics" such as iodine, bromine, alcohol, and many other acids (Adams 1952, pp. 127–128). The problem was knowing exactly when to apply the treatment, and infected wounds usually had gone beyond repair before an antiseptic was applied.
Because of the often unsatisfactory effects of other medical treatments, proper diet became a treatment unto itself. Depending on the disease, each hospital made an effort to supply soldiers with food that would nourish them and aid in their recovery.
Common medical treatments included turpentine, ingested or applied to wounds and irritated skin; diaphoretics, including potassium nitrate, tartar emetic, and a combination of ipecac and opium called "Dover's powders," to induce sweating in order to cool fevers; calomel, a powder used as a purgative or laxative; and ipecac, which was prescribed heavily to induce vomiting. Many of the medicines were dangerous and toxic, such as the several compounds formed from mercury. Many were used irresponsibly, as when a patient suffering from dehydration might be given a diuretic.
Due to the Union blockade, obtaining certain medications was often difficult in the South. The Regulations for the Medical Department of the C.S. Army suggested more than sixty "Indigenous Remedies for Field Service and Sick in General Hospital." Among the items listed are hemlock and American hellebore as sedatives; and stimulants from parts of junipers, sassafras, lavender, and horsemint (CSA War Department 1863, p. 62). Citizens throughout the South were urged to grow and donate these indigenous plants to aid the Confederate army.
Perhaps one of the most used medications was quinine. An 1864 New Hampshire newspaper declared it "king of the medicines" ("Quinine and Its Substitutes," March 4, 1864), and it was so effective in treating malarial diseases that the Daily Cleveland Herald suggested "that every person who has a friend in the army send him a dollar's worth of quinine" to be drunk in coffee each morning so as to avoid "chronic diarrhea, fever and ague, and bilious fever" ("Quinine for the Army of the Potomac," July 22, 1864). Quinine was used far more frequently than any opiates, as it seemed to not only treat, but also to prevent malaria and reduce general fevers.
A soldier wounded on the field of battle had a long road ahead of him. His first stop would usually be a makeshift dressing station, where medical officers would check wounds for hemorrhaging, apply simple bandaging and tourniquets, and ply the soldier with either alcohol or opium or both to ease pain and forestall shock. A wound might either be plugged with lint, or have lint applied outside as a pad. His next stop would be a field hospital, where he would sit on the ground awaiting his turn to be seen. Attendants might prioritize those with treatable, but serious wounds, and treat those with lesser wounds—those with mortal wounds were regularly passed over in favor of more treatable wounds. Once upon the operating table, anesthetic would be administered, and wound-specific operations would begin.
General wound care sought to stop bleeding and seal the wound, to ease pain, and to stop infection. Wounds were packed with lint or sometimes sealed with a solution made of beeswax called cerate. "Astringents" applied to wounds would help blood clot (Bollet 2002, pp. 233–234). Ligation, an operation that involved tying off major arteries, was perfected during the war, and ligation of a vessel was lauded as a way to avoid amputation from gangrene. Wounds in which a bone was shattered might be excised instead of amputated by removing part of the destroyed bone, hoping that the bone would heal and bond over the break. However, recovery from such an operation was difficult, and usually resulted in a loss of function of the limb (Bollet 2002, p. 147).
Wounds to the head and torso were more likely to be mortal than wounds to the extremities. In a survey of 3,717 abdominal wounds, 87 percent were fatal (Barnes 1870-1888, vol. 2.2, p. 202), though when the intestines were not punctured, recovery was more likely. Head injuries did not fare much better: "Of one hundred and eighty-six cases of balls penetrating the cranial cavity, one hundred and one were fatal" (Barnes 1870–1888, vol. 1, p. 316). Operations to remove objects from the skull had about a 50 percent mortality rate, whereas cases where the object was left in had similar results. When deciding whether to attempt to save a probably mortally wounded man with a long, complicated, and dangerous surgery, or to save several men with treatable wounds, surgeons usually chose the welfare of the many over the one.
Injuries to the extremities comprised about 70 percent of the total injuries (Barnes 1870-1888, vol. 3, p. 691). When the bones of an extremity were shattered, or the tissue damaged beyond repair, amputation was the preferred treatment. Amputations were quick and usually successful, and anesthetic was almost always used. However, due to unsanitary operating and wound management conditions, infection was common, and there often were complications in recovering from the operation. Mortality rates increased in cases where the amputation was closer to the body trunk, and when there had been a long interval between injury and surgery.
Treating Diseases and Infections
Diseases of all kinds ran rampant through both armies. Out of a selection of 304,369 deaths cited in Medical and Surgical History of the War of the Rebellion, about 61 percent were caused by disease. The most common form of disease was diarrhea and dysentery. Although they did not have the highest mortality rate, they were the most widespread (the terms diarrhea and dysentery were often used to mean the same thing). The Union reported about 1,739,135 cases (Barnes 1870-1888, vol. 2.1, p. 2) and the Confederacy, though lacking an exact number, could also say that it was also the most common affliction (Bollet 2002, p. 284). Treating dysentery was not always easy. Assistant Surgeon James DeBrulen commented: "chronic diarrhea has been extremely common in the hospital, and in many cases so rebellious as to defy all modes of treatment we could devise" (Barnes 1870-1888, vol. 2.1, p. 42). In some stages, dysentery was curable, noted the surgeon William Wright, but in others it became "indominable [sic]: the cases in which a judicious course of treatment was pursued before emaciation" usually had favorable results; after emaciation had set in, most cases were fatal (Barnes 1870-1888, vol. 2.1, p. 62). There was little consensus on a cure, but doctors combated dysentery with nearly every medicine available: mercurials, opiates, and sulphate of copper, nitric acid, purgatives, Dover's powder, turpentine, mucilage, ipecac, quinine, bismuth, and many more. Opium and purgatives (laxatives) generally were the most relied upon. One doctor stated that "opiates and the ordinary astringents have been worse than useless," whereas another confidently stated that "I have used opium extensively…in combination with astringents" and had wonderful results. One agreed-upon treatment was a strict diet: "only bland and uni-rritating food" such as "milk, whey, eggs, mucilages, essence of beef, chicken soup" as well as a diet of fresh vegetables and peanuts (Barnes 1870-1888, vol. 2.1, p. 45). At Rock Island prison hospital patients were given beef tea and bromide of potassium, and out of 2,629 cases, only 159 died (Barnes 1870-1888, vol. 2.1, p. 53). Soldiers would be afflicted with dysentery for varying amounts of time. Private Joseph Westurn of New York fought the disease from July until December, continually relapsing and requiring a new treatment each time ( Barnes 1870-1888, vol. 2.1, p. 46).
Nearly as widespread as dysentery were fevers. Malarial fevers sprang up yearly, especially in swampy areas, and were treated with multiple doses of quinine a day. Typhoid fevers were treated with turpentine and cold compresses, whereas the diarrhea that came with it was fought with opiates, Dover's powders, and other diaphoretics to lower the patient's body temperature.
Other than diseases, infections from wounds and operations plagued both armies. A wound received on the battlefield would be primed for infection from the start. Unsanitary surgical techniques propagated the problem. Surgeons did their best to remove foreign bodies from wounds, realizing the problems they caused. They would slough off infected tissue—not because they knew it bred infectious bacteria, but because they simply knew it was beneficial in some way. Hospital gangrene and erysipelas were constant fears. These infections spread through the body quickly and often led to secondary amputations, with high mortality rates. Doctors found bromine to be a successful treatment for gangrene later in the war, and the infection was mostly eradicated by the end of the war.
The evolution of medicine through the experience of war had a tremendous effect. For humanity in general, the Civil War ushered in the sanitary age of medicine and helped refine the prescription of medication and important surgical techniques. Surgeons' basic observations on the spread of diseases and infections would be validated by Joseph Lister's bacteriology work in 1865. Doctors experimented with new procedures such as plastic surgery, the treatment of chest, abdominal, and head wounds, and blood transfusions; all of these would continue to be perfected after the war. Experimenting with medications led to better understanding of appropriate use and dosage. Overall mortality rates fell drastically during the war, and would continue to do so afterwards as Americans, and the world, learned from the experience of the war.
Barnes, Joseph K. Medical and Surgical History of the War of the Rebellion. 3 vols. Washington, DC: Government Printing Office, 1870-1888.
Bollet, Alfred J. Civil War Medicine: Challenges and Triumphs. Tucson, AZ: Galen Press, 2002.
Confederate States of America War Department. Regulations for the Medical Department of the C.S.Army. Richmond, VA: Author, 1863.
Jackson, H. W. R. The Southern Women of the Second American Revolution. Atlanta, GA: Intelligencer Steampower Press, 1863.
Otis, George Alexander. Reports on the Extent and Nature of the Materials Available for the Preparation of a Medical and Surgical History of the Rebellion. Philadelphia: J.B. Lippincott, 1865.
"Quinine and Its Substitutes." New Hampshire Statesman, Concord, NH, March 4, 1864.
"Quinine for the Army of the Potomac." Daily Cleveland Herald, Cleveland, OH, July 22, 1864.
United States Sanitary Commission. The Soldier's Friend. Philadelphia: Author, 1865.
J. Douglas Tyson
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