Between Flesh and Steel (32 page)

Letterman's field ambulance system would not have worked as well as it did had it not been integrated into a larger network of casualty evacuation linking the field hospitals to the general hospitals in the rear. They also used the excellent Northern railway network to move casualties from collection points behind the battlefields to the general hospitals. The hospital cars varied in quality from first-class heated passenger coaches to unheated boxcars with little more than straw on the floors. By the end of the war, the Northern railways had transported 225,000 sick and wounded men from the battlefields to the general hospitals.
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The Union medical service also used coastal steamers and river steamboats to transport the sick and wounded. The Union contracted these hospital ships from civilians and initially gave the quartermaster corps control of them. Later in the war, the medical corps assumed control of these assets and used them exclusively for medical purposes. In 1862, the Union Army contracted for fifteen steamboats for use on the Mississippi and Ohio Rivers and seventeen ocean-going vessels for use along the Atlantic coast. In the last three years of the war, 150,000 casualties had been transported by boat to general hospitals.
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The first systematic use of the hospital ship was at the Battle of Fort Henry in February 1862 when the
City of Memphis
transported 7,000 casualties to hospitals along the Ohio River.
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The army purchased its first ship, the
D. A. January
, to serve as a hospital ship, and the crew saw its first action after the Battle of Shiloh in April 1862. The ship had a 450-bed hospital, bathrooms, laundry, baking and cooking facilities, and a full complement of surgeons and nurses. By the end of the war, the
January
had transported 23,738 patients on the Ohio, Missouri, and Illinois Rivers. The mortality rate among its
wounded passengers was only 2.3 percent, better than most land-based hospitals of the day.
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The first naval nurses in America were the Catholic Sisters of Mercy, who served aboard the first U.S. Navy hospital ship, the USS
Red Rover
, and tended the wounded after the siege of Vicksburg.
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The ship also had African American women nurses aboard.

Letterman's field ambulance system proved so successful that in March 1862 Surgeon General Hammond recommended that all Union armies adopt it. The army high command dragged its feet for two years before Congress in March 1864 forced it to institute the system for all Union commands. It was only by the end of the war that the system was fully implemented. The United States had gradually developed a military medical system adequate enough to treat the casualties that a modern war produced only to see it demobilized with the rest of the army less than a year after the war ended. With the army returning to garrison and frontier duties, a mass casualty system was no longer needed.

Letterman also changed the structure of the field hospital system by turning the old regimental hospitals into frontline aid stations, or the equivalent of the modern battalion aid clearing point. Treatment of the wounded at these aid stations was limited to controlling bleeding, bandaging wounds, and administering opiates for pain. Limiting the functions of these aid stations enabled the medical personnel to hold the slightly wounded close to the front for their possible return to duty. Behind the aid stations, Letterman placed mobile surgical field hospitals. Controlled by division, the most competent medical personnel were assembled at these hospitals to perform major operations. These hospitals were the critical link, missing for most of military medical history, between the frontline aid stations and the rear area general hospitals. Behind these mobile field hospitals were the general hospitals, and the field ambulance corps, the railways, and hospital ships tied the whole system together. Letterman was also concerned about the manpower loss due to hasty and needless evacuation. To prevent it, all medical officers were ordered to hold the less severely injured at their respective hospitals. Letterman instituted systematic inspections of all patients to screen those held for possible return to duty before deciding what patients to evacuate.
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Letterman's third major contribution to the Union medical service was the establishment of medical supply and equipment tables for medical units. Until this reform, the service obtained medical equipment and supplies from the quartermaster through the usual military supply system. Under the pressure of war, however, medical
units rarely received what they needed. Letterman arranged supply tables equipping all units from corps through regiments with “basic loads” of medical provisions. Each unit was supposed to carry supplies for thirty days. A purveyor accompanied the army and was responsible for continually replenishing medical supplies. With each medical unit requiring specific amounts of supplies, the purveyor could now plan in advance to fill the requirements of each unit. For the first time, an army had developed a relatively modern medical supply service that worked well under field conditions.
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Most units in the Union Army were volunteer units that the states created. The state governors then commissioned the great number of surgeons and physicians that served in the war to provide medical support to state regiments. With few standardized licensing procedures for medical certification, it was not surprising that competency was a problem. Few of the physicians entering the state regiments had any surgical training. Indeed, the educational training of a physician or surgeon at this time entailed only one year of formal schooling and one year as an apprentice to a practicing doctor. Many of the “medical schools”—including Harvard University at the time—were little more than diploma mills.
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For reasons that remain unclear, all medical schools in the South, with the exception of the University of Virginia, were closed shortly after the outbreak of war, thus depriving the Confederate armies of a vital source of trained medical talent.
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As the war wore on, however, many of the marginally competent physicians and surgeons on both sides became excellent practitioners as a consequence of their battlefield experience.

About 13,000 physicians and surgeons served with the Union forces. Of these, Congress appointed about 250 regular army surgeons and assistant surgeons to serve as staff and administrators. Congress commissioned approximately 547 Surgeons of Volunteers, also called “brigade surgeons,” to assist the corps of regular army surgeons. Governors appointed some 3,882 regimental surgeons and assistants to provide medical support to state regiments. Most saw service in the regiments, aid stations, and mobile field hospitals. The army hired 5,532 contract civilian surgeons to staff the general hospitals in the major cities. These physicians and surgeons often divided their time between private practice and military service. An additional 100 doctors staffed the Veteran Reserve Corps to provide aid to the disabled, and 1,451 surgeons and assistants served with the 179,000 black troops in 166 regiments.
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One of the Union surgeons, Dr. Mary Edwards Walker (1832–1919), a graduate of Syracuse Medical College, served in the army as a nurse until finally appointed as an
assistant surgeon. She became the first woman in American history to hold such a position.
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She was also the first to earn the Congressional Medal of Honor for her wartime service at Fredericksburg and Chickamauga, among other duties.

The general hospitals—designated as such because they treated the wounded regardless of what unit they were from—were located in the major cities along well-established water and rail routes. By 1862, a building program was undertaken in the North to provide hospital facilities for the rapidly growing lists of casualties. A year later, the Union Army had established 151 general hospitals with 58,715 beds. Two years later it had 204 such hospitals with a capacity of 136,894 beds.
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These hospitals ranged in size from small to 100-bed units, which the South commonly established next to railway crossings, and to the large Mower General Hospital in Philadelphia with 4,000 beds. The largest hospital on either side was the 8,000-bed Chimborazo Hospital in Richmond. With 150 single-story pavilions organized into five divisions, each with forty to fifty surgeons and assistant surgeons per division, it was the largest military hospital ever built in the Western world.
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The range of injuries that military medical practitioners confronted prompted the development of hospitals specializing in specific medical conditions. There were special hospitals for orthopedics and venereal diseases, and the famous Turner's Lane Hospital in Philadelphia acquired a worldwide reputation for its expertise in nervous disorders. St. Elizabeth's Hospital in Washington became the world's first military hospital for combat psychiatric cases.
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It had long been recognized that large hospitals were conducive to infection and disease and that better ventilation and isolation reduced these problems. The pavilion-style hospital evolved as the best design for reducing infection and improving ventilation and isolation. These hospitals consisted of a series of long single-story buildings, each isolated from the next but connected by corridors. High ceilings with vents at the top and sufficient windows provided adequate ventilation. Normally connected to the central semicircular corridor, these sixty-patient building units were sometimes unconnected, providing excellent isolation for specific disease wards. The pavilion hospital design is generally credited to Dr. Samuel Moore (1813–1889), the Confederate surgeon general, who supposedly obtained the idea from British hospitals used in the Crimean War.
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More accurately the design is much older and generally reflects the arrangement that the Romans utilized.

Both armies in the Civil War used female nurses, a precedent that the Russians first set and the British soon followed in the Crimean War. The special place of
women in Southern culture militated against allowing women to work in military hospitals; consequently, female nurses were not used on a large scale. In the North, however, 3,214 nurses served in military hospitals under the control of Dorothea Dix (1802–1887), who had been appointed as the Union Army's superintendent of women nurses.
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An even larger female corps of cooks, cleaners, and general attendants—some of whom were African American—supported this nursing corps. Large numbers of Catholic Sisters of Mercy, Sisters of St. Joseph, and Sisters of the Holy Cross also served in this capacity. Dix did not trust Catholics but found that because the sisters were accustomed to discipline and obedience, they made excellent workers.
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Having gained valuable experience in treating the sick, all three of these religious orders remained in the hospital business after the war. Clara Barton (1821–1912), one of Dix's regular nurses, went on to found the American Red Cross.

The prevalence of facial injuries encountered during the war stimulated the emergence of the new medical subdiscipline of plastic surgery. Civil War surgeons performed six reconstructions of the eyelid, five of the nose, three of the cheek, and fourteen of the lip, palate, and other parts of the mouth.
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Dr. Gordon Buck, while serving as a contract surgeon for the Union Army, performed the first total facial reconstruction in history.
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Another Civil War surgeon, Joseph J. Woodward (1833–1884), became the first person to link the new technology of the camera to the microscope and published the first microphotographs of disease bacteria in 1865. In 1870, while working for the newly formed Army Medical Museum, Woodward became the first person to take microphotographs, using artificial illumination.
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Woodward is also credited with the independent discovery of using aniline dyes to stain tissues for microscopic analysis.
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A comprehensive history of the Confederate medical service is yet to be written. The great Richmond fire of 1865 destroyed almost the entire archive of the Confederacy's medical records. For the most part, however, the Confederate medical service was organized and operated almost as a copy of the Union system, although shortages of personnel and equipment nearly crippled it from time to time. The total number of medical officers in the Confederacy was 3,236—1,242 surgeons and 1,994 assistant surgeons. There were 107 officers in the naval medical corps, including 26 surgeons and 81 assistant surgeons.
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The Confederate general hospital system was every bit as good as what operated in the North. Chronically short of ambulance wagons in the first few years of the war, the South made greater and more efficient use of steamboats and rail to transport their wounded. Early in the war
(1861), Surgeon General Moore established high qualifications for those wishing to enter the medical service and, in a truly revolutionary step, examined those physicians already in the service for competency, forcing significant numbers to resign.
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Shortages of quinine and chloroform plagued the South until the end, and Confederate disease losses might have been reduced had they embarked upon a smallpox vaccination program earlier in the war. The South recognized dentistry as a separate medical discipline and encouraged its growth. As secretary of war before hostilities broke out, Jefferson Davis had tried to convince the U.S. Army to establish a separate dental corps but failed. The South had a much more comprehensive dental care program than did the North, which contented itself with shipping to the artillery toothless soldiers who could no longer bite the end from their cartridge packets.
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Gen. Thomas J. “Stonewall” Jackson (1824–1863) introduced one of the more significant military medical contributions of the South when in 1862, he ordered all Union medical officers held by his command to be released and, henceforth, treated as noncombatants. By June of that year, both Robert E. Lee and McClellan agreed to a similar practice. Medical personnel were no longer subject to capture and, if taken, were supposed to be allowed to treat their wounded and immediately released. All medical personnel held in Union and Confederate prison camps were freed in 1862, and exchanges of captured medical personnel continued until the end of the war. Jackson's actions had anticipated the Red Cross regulations dealing with medical personnel that the first Geneva Convention adopted a few years later.
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