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.151 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.152 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.153 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.154
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.155 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.156 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.157 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.158 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.159 Dr. Gordon Buck, while serving as a contract surgeon for the Union Army, performed the first total facial reconstruction in history.160 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.161 Woodward is also credited with the independent discovery of using aniline dyes to stain tissues for microscopic analysis.162
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.163 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.164 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.165
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.166
With the cessation of hostilities, the Union Army and its military medical service were demobilized. By the end of 1866, the Union Army had been reduced to a force of only 30,000 men.167 The army and its skeleton medical corps were scattered among 239 military posts stretching from Alaska to the Rio Grande. By 1869, the entire medical service comprised no more than 161 medical officers, and
the frontier posts were forced to rely on civilian contract surgeons, which increased to 282.168 Although a young doctor could make more money in military service than he could in the first few years of his own practice, the shortage of military doctors remained a chronic problem. One reason was that the army maintained much higher entrance and training requirements than were generally found for civilian physicians.169
In 1862, Surgeon General Hammond ordered the establishment of the Army Medical Museum in Washington, D.C., to collect and study artifacts and information relevant to military medical care. In 1865 when John Shaw Billings (1836–1913) became director of the Library of the Surgeon General’s Office of the Army, he soon built it into the largest military medical library in the world, and the collection remains so today.170 After the war, Congress established a pension system for disabled soldiers that was far more generous and comprehensive than anything seen in Europe.171 The pension system was chosen over an asylum system of permanent care because it provided the disabled soldier with more freedom and mobility.
A number of significant advances in military medicine resulted from the Civil War. For the first time an accurate medical record system was established that made it possible to track casualty records for every soldier. One consequence was the U.S. government’s publication of the massive six-volume Medical and Surgical History of the War of the Rebellion (1870–1888), which remains the standard against which all such works are judged. The army also developed the first effective military medical system for mass casualties, complete with aid stations, field and general hospitals, ambulance and theater-level casualty transport, and the staff to coordinate it. It was the best military medical system ever deployed and remained a model for other countries for decades. The introduction of the pavilion hospital was so effective at reducing disease mortality that it became the standard design for military and civilian hospitals for the next seventy-five years. Wide use of anesthesia, primary amputation, the splint, and debridement of necrotic tissue were the first effective doctrines for wound management. Thousands of physicians learned these techniques through hard experience and carried them into their civilian practice, elevating the general level of medical care available to the nation. Effective sanitary measures, especially in hospitals, reduced disease and death. The advent of microphotography made the American military medical establishment receptive to the discoveries of Pasteur and Lister when they appeared a few years later. Nurses were used on a wide scale for the first time. The terrible slaughter of the Civil War ironically marked one of the most progressive periods in the development of military medicine until the twentieth century.
THE INVENTION OF MILITARY PSYCHIATRY
Fear and psychiatric debilitation are constant companions in war. Battle is one of the most threatening, stressful, and horrifying experiences that man is expected to endure. Even in relatively small engagements, the participants often suffer a wide range of psychiatric conditions that, if pressed by events, lead to mental collapse.172 Severe emotional response to battle is neither a rare nor an isolated event. One of the most outstanding medical developments of the Civil War was the emergence of the neurological profession in America and, along with it, the beginning of military psychiatry as a major subdiscipline of military medicine.173 Military psychiatry dates from the Civil War when neurologists made a systematic attempt to link damage to the brain to emotional behavior, but it did not become a separate discipline until the Russo-Japanese War of 1905.
Psychiatry was still in its infancy at the time of the Civil War, but neurologists recognized that soldiers could become debilitated from purely emotional forces. At that time, the discipline focused on the physiology of the brain and attempted to link disruptions of that physiology to behavioral disorders. Fewer than a dozen mental hospitals existed in the United States, but none served patients who developed mental disorders in war. Care of the mentally ill rested with the handful of superintendents of these mental asylums. The movement for humane treatment of the mentally ill that began in France fifty years before was only beginning to take root in the United States.174 The military itself had no psychiatrists and continued to take the traditional view that soldiers who broke in battle were cowards or had “weak” characters. By 1860, American military psychiatry had not come very far since the Revolution, and the discipline was considerably behind developments in Europe.175
Almost immediately after the outbreak of the Civil War, medical officers had to deal with the problem of psychiatric casualties. The War Department had rejected the offer by a group of superintendents of insane asylums to treat the problem on the battlefields, and treatment of psychiatric casualties fell to army physicians and surgeons. Their experience gained with psychiatric cases led to the birth of neurology in the United States and hardened further the tendency of medical practitioners of the day to regard soldiers’ mental problems as caused by damaged physiology of the brain. The Turner’s Lane Hospital in Philadelphia treated what were called “nervous diseases” during the war, but even the neurologists had to admit that a range of disorders that afflicted the soldiers had no sound physiological explanation. At the doctors’ urging, the Government Hospital for the Insane in Washington, D.C., admitted the psychiatric casualties to specific wings in 1863. The men preferred to call it St. Elizabeths Hospital, after the land on which it was built.
The most common psychiatric condition that military physicians had to confront was “nostalgia,” a cluster of symptoms resulting from emotional fatigue that made it impossible for the soldier to continue to fight. Nostalgia was marked by excessive physical fatigue, an inability to concentrate, an unwillingness to eat or drink that led at times to anorexia, feelings of isolation and frustration, and a general inability to function in a military environment. Swiss armies first reported the condition in 1569, and Swiss military physicians described it again in 1678.176 German physicians of the same period called the condition heimweh (homesickness), French military doctors termed the same symptoms mal du pays, and the Spanish, who noted their soldiers’ suffering an outbreak of nostalgia in Flanders during the Thirty Years’ War, called it estar roto (literally, to be broken).177 Even then military doctors recognized that the source of the symptoms was emotional and not physical, noting that “imagination alone can cause all this.”178 Nostalgia again was recognized and widely reported during the eighteenth century among the armies of France, Italy, Germany, and Austria. In one instance, a unit of Scottish Highland troops in 1799 succumbed to the condition almost to a man. To trigger the onset of symptoms, the report noted, the Highlanders only needed to hear the sound of the bagpipes. Nostalgia was reported among Napoleon’s troops at Waterloo, during the retreat from Moscow, and in the Egyptian campaign, where it became so serious among the officer corps that it threatened to cripple the army.179
During the Civil War, autopsies performed on nostalgia patients confirmed that besides producing emotional turbulence, nostalgia was capable of producing physiological symptoms of disease. Tragically, nostalgia itself was often fatal, especially if a wound or lack of nutrition weakened the soldier’s general resistance. When it did not kill, nostalgia often drove the soldier insane. In the first year of the Civil War, military physicians diagnosed 5,213 cases of nostalgia, or 2.34 cases per thousand.180 By the end of the war, almost 10,000 cases had been diagnosed among Union soldiers. In addition, physicians diagnosed a range of illnesses that are now known to stem from emotional turbulence and included “exhausted hearts,” paralysis, severe palpitations (called “soldier’s heart” at the time), war tremors, self-inflicted wounds, and various states of nostalgia.181 Military doctors diagnosed the more severe psychiatric conditions as “insanity”—today the condition is termed “psychosis”—and it accounted for 6 percent of all medical discharges granted by the Union Army.182 Physicians also identified a number of cases that they diagnosed as “feigned insanity,” a condition in which emotional turbulence produced severe symptoms for which a physiological cause could not be found. The
se conditions included lameness, blindness, deafness, local paralysis, and lower back pain.183 Today, military psychiatrists call these conditions “conversion reactions.” Psychiatric symptoms became so common among Union soldiers that field commanders pleaded with the War Department to provide some form of screening to eliminate recruits susceptible to psychiatric breakdown. In 1863, the Union Army instituted the world’s first military psychiatric screening program for recruits. It proved no more helpful than it would later in World War I, and the number of psychiatric cases continued to increase.
Meanwhile, only a handful of physicians in the country—the superintendents of civilian mental asylums—had any experience in dealing with psychiatric patients, but none of these doctors saw military service during the war. Accordingly, military physicians were often at a loss when treating cases of insanity. With a long historical precedent in the armies of Europe, their particularly cruel solution in the first three years of the war was simply to muster out those soldiers diagnosed as suffering from severe psychiatric problems. Union and Confederate soldiers with psychiatric symptoms were escorted out of the main gates of their respective army camps and turned loose to fend for themselves. Others were put on trains with no supervision, the name of their hometown or state pinned to their tunics. Others were left to wander about the countryside until they died from exposure or starvation or were arrested for committing crimes. By 1863, the number of insane or shocked soldiers wandering around the country was so large that the public demanded an end to the military’s practice of expulsion. That same year, the military began sending psychiatric cases to the hospital for the insane in Washington.
As noted earlier, the Union Army had discharged nearly ten thousand soldiers suffering from nostalgia by the end of the war. The number suffering from “epilepsy” and forms of hysterical paralysis was probably twice as large, while those discharged for “general insanity” reached several thousand. Although the problem of psychiatric breakdown among soldiers reached major proportions by the war’s end, not a single article or book on the subject was published in the postwar years.184 The General Hospital for the Insane closed its military psychiatric facilities, and the government made no effort to involve the doctors who treated civilians with mental illness in helping the psychiatrically wounded. The veterans’ problems were conveniently forgotten, and except for the advances in neurology, battle shock and psychiatric debilitation were no longer of concern to the military. The failure to learn from this experience returned to haunt the American Army when it took the field again in World War I.
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