In 1862, U.S. Surgeon General William Hammond put out a call to medical field officers in the Union Army: Send any specimens of morbid anatomy that might be valuable to military medicine and surgery. It might seem like a strange request, but the medical profession was in the midst of change—from a system based on tradition to one based on evidence.
“When there’s a war, there are evolutionary changes, not necessarily revolutionary changes,” says Jeff Reznick, a historian at the National Library of Medicine in Bethesda, Maryland. Medicine in the United States did some significant evolving during the Civil War. Prior to the war, humoral theory—where an imbalance between the body’s “humours” caused illness—still formed the basis of medical practice. The idea of a germ wasn’t even on physicians’ radar. More than 12,000 physicians served during the Civil War on both sides. Together, they treated patients in the millions, and sometimes they had to get creative and veer off from the teachings of classical physicians.
“The real lasting impact was the change in mindset of both doctors and the people who they were treating,” says NLM historian Ken Koyle. Writing this week in the New England Journal of Medicine, Koyle and Reznick argue that the war instigated these lasting changes in mentality that forever altered the American medical profession:
Early Field Medics
When Hammond became surgeon general of the Union Army in 1862, he shook things up. At the beginning of the war, the requirements for becoming an army physician or surgeon were minimal at best. Hammond instituted mandatory training in public health, hygiene and surgery for all Union Army medical officers. His call for specimens also provided a textbook of case studies to train doctors after the war. (Today, the collection of body parts, fluids, case notes and imaging slides is housed at the National Museum of Health and Medicine in Maryland.)
The term “combat medic” didn’t exist during the Civil War or for decades afterward. Instead, enlisted men were pulled from the ranks to serve as “hospital stewards”. Although these men received some first-aid training, there was really one main requirement: “They had to be able to read doctors’ notes,” says Reznick. As casualties mounted, attendants and nurses took on more responsibilities, especially triaging patients—noting who needed to be treated and who could wait. Some even received a more formal crash course in medicine.
Perhaps unsurprisingly, one of the most common surgeries conducted during the war was amputation. “The hallmark of a good surgeon was one who could remove a limb in less than three minutes,” says Koyle. “It was effective, but it was brutal.” Working in the field, surgeons learned two key techniques: Leave the wound open and clean it regularly until new skin formed, or close the wound with a flap of skin. The second option was more aesthetically pleasing but came with the potential for painful infection, because it sealed pathogens inside the body—though doctors might not have realized the cause at the time. Later on, when physicians became aware of the concept of germs, this served as the basis for modern closed amputation techniques.
The war also saw the emergence of distinct fields of surgery, with the development of plastic surgery in particular. New York surgeon Gurdon Buck famously photo-documented a series of facial reconstructive surgeries on a Union private named Carlton Burgan in 1862. Burgan had taken mercury pills to treat his pneumonia, but the pills had instigated a bout of gangrene that had taken out his right cheekbone. Buck used dental and facial implants to help Buck’s face regain its shape.
With amputations becoming increasingly common, the Civil War added to a growing population of people in need of prosthetics, and more patients demanded greater variety. “Prosthetics during this time were created out of experience,” says Reznick. While craftsmen constructed most prosthetics, veterans began trying their hand at designing for specific injuries. For example, a Confederate soldier named James Hanger lost his leg at the battle of Philippi, West Virginia, in 1861. After returning home to Virginia, he designed a prosthetic leg with rubber bumpers on the ankle, and he later added a rubber foot. The design presaged modern prosthetic legs with a soft heel and solid ankle.
Hanger patented the designed and dubbed it the “Hanger limb”—one example among a flood of patents for new prosthetics. In the 12 years following the war, 133 patents were filed for prosthetics compared to just 34 in the 15 years prior.
Airy Hospital Architecture
At the beginning of the war, field hospitals were set up in whatever buildings were available at a safe distance from battlefields. But as casualties mounted, doctors needed more space to house patients, so armies began building.
When Hammond took over as surgeon general, he promoted “pavilion” hospital architecture: a central hub with spokes. Each spoke housed a ward for different diseases and conditions, such as typhoid or malaria, to prevent their spread. Doctors may not have known about germs, but they did associate fresh air with good health. Thus, these hospitals were also constructed with lots of ventilation. “By 1865, over 200 hospitals of this kind had been built, with over 135,000 beds,” says Koyle.
At the beginning of the war, the business of getting injured soldiers off the battlefield was arduous and time consuming. It could take days and even up to a week for the wounded to reach a field hospital. Ambulance drivers were completely disorganized and would sometimes flee the battlefield in fear before even picking up any injured men.
In August of 1862, a physician named Jonathan Letterman set up the first ambulance system in the Union’s Army of the Potomac. With the support of Hammond, he instituted a three-step system for evacuating soldiers from the battlefield and established the Ambulance Corps. Their first stop was a field dressing station, where tourniquets were applied and wounds were dressed. Then they moved to a field hospital, where doctors performed emergency medical procedures. Finally, ambulances would transport patients to a large hospital far from the battlefield for long-term treatment. The U.S. military uses the same basic system today.
Restocking the Pharmacy
On one level, the war buffered pharmaceutical knowledge because the influx of patients allowed doctors to figure out the best dosage rates for known medications like quinine, used to treat malaria. The war also highlighted the meds that just weren’t working—although not everyone was happy about the change in attitudes.
One of Hammond’s most controversial moves as surgeon general was to remove mercury- and antimony-based medications, like calomel and tartar emetic, from the formulary, or army pharmacy. These purgative medicines had been prescribed for centuries for everything from headaches to malaria, rooted in the principles of humoral medicine. Patients vomited dramatically, but the medication didn’t actually do anything. To make matters worse, these medications came with side effects like mercurial gangrene.
By removing them from military pharmacies, Hammond didn’t outlaw their use, but he did prevent battlefield doctors from ordering new supplies. With mounting evidence against mercurial meds, some doctors embraced the change, while others dug in their heels. “There was resentment and there was resistance to it,” says Koyle. “The need for evidence wasn’t really embraced by a lot of doctors.” The controversy added fuel to growing opposition against Hammond, and he was replaced as surgeon general in 1864.