Bellevue

by David Oshinsky

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  “War is the normal condition of mankind; peace is the abnormal condition,” Bellevue’s Frank Hamilton observed in his influential tome, A Treatise on Military Surgery and Hygiene, published in 1865. “This statement is not flattering to a people claiming Christianity and boasting of its civilization; but it is nevertheless true.” Having seen the worst that war had to offer in his early service at Bull Run—from poor planning to outright cowardice—Hamilton devoted himself to correcting the battlefield flaws that left him helpless in the field. Well connected—his brother-in-law chaired the Senate Committee on Military Affairs—he rose to become medical inspector of the Union Army, a post with a bully pulpit built in. A food faddist, Hamilton brought changes to the atrocious army diet of salt beef, beans, and hardtack (rocklike crackers known to the men as “worm castles”) by demanding fresh fruits and vegetables to ward off scurvy, dysentery, and explosive diarrhea. “The art of cookery,” he insisted, “is as important as the art of defense.”

  Little escaped his eye. “Drawers may be necessary in the winter, but are not needed in the summer,” he wrote of the proper field attire, noting that “it is sometimes advantageous to change the sock from one foot to the other, so that their seams or folds should press upon new points.” But no amount of preparation, no attention to detail, could spare the country from the slaughter that followed. Combined Union and Confederate deaths in the Civil War totaled close to 750,000, with disease and infection taking twice as many lives as battlefield wounds. Much of the carnage resulted from improved weaponry at the front. New artillery pieces lobbed bigger shells longer distances with greater accuracy, and a revolutionary bullet—known as the Minié ball after its creator, French army captain Claude Minié—allowed the average soldier to regularly hit a target a fair distance away. More easily loaded, the hollow Minié spun from its barrel, increasing its power and velocity—and thus the damage it could do.*

  The war became Hamilton’s private laboratory, allowing him to observe and experiment on a scale that not even chaotic Bellevue could match. In terms of surgery, where his real expertise lay, Hamilton offered recommendations for every imaginable injury, from arrow wounds to gunshots of the “male organs,” which, he admitted, “presented a great variety of complications.” His instructions for amputation, complete with diagrams, became a bible of sorts for surgeons in the field.

  Over time, in novels and memoirs, a portrait emerged of the terrified soldier—tied to a stretcher, prepared with a shot or two of whiskey, a piece of wood or metal between his teeth (thus the phrase “bite the bullet”), writhing in pain as an arm or leg is sawed off and tossed into an ever-growing pile of body parts on the floor. Union surgeons performed about thirty thousand amputations during the war, but most did, in fact, involve anesthesia. With luck, the patient avoided the two primary dangers of the operating table: blood loss and infection. Surgeons learned that the odds depended partly on body location. Amputating a hand or a foot, far from the trunk, was far less dangerous than amputating at the hip. Soldiers with gaping chest and stomach wounds rarely survived. The treatment in these cases was to make the victim comfortable—with morphine, if possible—until he died.

  Anesthesia marked the first half of a surgical revolution. The second half—antisepsis—had yet to arrive. For most doctors, the concept that one could lessen the chances of infection by scrubbing his hands, wearing gloves, and sterilizing his tools seemed vaguely absurd. “We operated in old-blood-stained and often pus-stained coats…with undisinfected hands,” a Union surgeon recalled of the typical operation of the time. American medicine in the 1860s had yet to grasp that people shared their world with billions of invisible organisms, and that what a surgeon didn’t see around the operating table was what normally caused the most harm.

  Frank Hamilton was a perfect example. Read today, his instructions are a virtual guide to death by infection. “In attempting to remove a ball by incision, the surgeon ought, if practicable, to seize upon it with the thumb and fore-finger and hold upon it firmly until the incision is made and the removal accomplished,” he wrote at one point, adding: “Sometimes it is more convenient to entrust this duty to an assistant.” His concluding remarks were firmer still: “Indeed, under almost all circumstances, we prefer the finger as being the most intelligent guide as causing, on the whole, as little pain as any other method of exploration.” Nowhere in the 674 pages of A Treatise on Military Surgery and Hygiene is anyone encouraged to wash his hands.

  It is unfair, of course, to judge someone by the standards of later times. “Civil War surgeons had to work without knowledge of the nature of infection and without drugs to treat it,” wrote one student of the field. “To criticize them for this lack of knowledge is equivalent to criticizing Ulysses S. Grant and Robert E. Lee for not calling in air strikes.” Still, few physicians used the clinical experience of the war to greater advantage than Frank Hamilton. His inventions included a serrated bone cutter, a special forceps to remove bullet fragments, and various splints to treat difficult fractures. His precise guidelines for bone settings helped many to walk without a limp, and he would even become a pioneer in the use of plastic surgery for severe facial injuries. He was, an admirer gushed, the “Surgeon Extraordinary of the Union Army.”

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  Hamilton returned to Bellevue in 1864 a national hero. With Union forces on the offensive, he took up his old position as professor of military surgery and fractures, training medical students and interns for the final push of the war. Most were in awe of him. “I cannot recall learning anything from [other Bellevue surgeons],” a student noted. “They were irregular in attendance and entrusted almost everything to the internees. But Hamilton came regularly and punctually, usually on a large iron-grey charger and equipped with riding boots and spurs.”

  Among these students was twenty-three-year-old Charles Augustus Leale from Westchester County, New York, his portrait showing a slight man with long sideburns and a faint mustache. Graduating from Bellevue Hospital Medical College in 1865, Leale had been commissioned as an assistant surgeon at a military hospital in Washington, D.C., on the eve of the Confederate surrender, arriving in time to hear President Lincoln deliver a public address—it would be his last—from the White House balcony. “I was profoundly impressed with his divine appearance,” Leale recalled, “as he stood in the rays of light, which penetrated the windows.”

  Leale saw Lincoln a few nights later when he bought a ticket to the comedy Our American Cousin at Ford’s Theatre on the evening of April 14. Leale heard a commotion and then watched as the assassin John Wilkes Booth leaped to the stage. “I instantly arose and in response to cries for help and for a surgeon,” he wrote, “I crossed the aisle and vaulted over the seats to the President’s box…With the calmest deliberation and force of will I…walked forward to my duty.”

  These words come from a speech Leale delivered in 1909, forty-four years after the event. Leale had rarely spoken of it before then, claiming the need to honor the privacy of the fallen president. But 1909 marked the centennial of Lincoln’s birth, and Leale finally agreed “to give the detailed facts as I know them.” Relying on what he claimed were his personal notes from 1865, Leale placed himself at the center of the drama, put there, he insisted, by Mrs. Lincoln herself. “I grasped [her] outstretched hand in mine, while she cried piteously to me, ‘Oh, Doctor! Is he dead? Will you take charge of him? Do what you can for him. Oh, my dear husband!’ ”

  The president was slumped over, his eyes completely closed. Having seen a dagger in Booth’s hand, Leale checked Lincoln’s body for stab wounds, but found none. “I lifted his eyelids and saw evidence of a brain injury,” Leale noted. “I quickly passed the separated fingers of both hands through his blood matted hair to examine his head, and I discovered his mortal wound.” Calling upon his recent training—Leale had faithfully attended Hamilton’s lectures—he “removed the obstructing clot of blood,” pressed his fingers down the president’s throat to open t
he larynx, performed mouth-to-mouth resuscitation, and vigorously pumped the chest until “a feeble action of the heart and irregular breathing followed.”

  Charles Augustus Leale, a few months removed from medical school, held the fate of the Republic in his hands. “Many looked on,” he said, “but not once did anyone suggest a word or in any way interfere with my actions.” It was Leale, in his telling, who ordered the president moved to a house across the street from Ford’s Theatre, believing that the longer trip to the White House would surely kill him. It was Leale who sent for the surgeon general, then for Lincoln’s personal physician, minister, and family. It was Leale who prolonged “the life of President Lincoln for nine hours” before drawing “a white sheet over the martyr’s face.”

  The 1909 speech caused a minor sensation. Reporters, accepting Leale’s version of events at face value, showed no interest in seeing the notes he claimed to have. Did they actually exist? In 2012 a researcher at the National Archives in Washington stumbled upon the twenty-one-page report that Leale had dictated in the hours following Lincoln’s death. It’s a remarkable piece of history—a meticulous hour-by-hour account of a hopeless medical struggle—revealing that Leale was, indeed, the first doctor to reach the stricken president. Finding Lincoln “in a profoundly comatose position,” Leale did check the body for stab wounds before locating the fatal bullet hole behind the ear. From this point forward, however, the 1865 report bears little resemblance to the speech Leale delivered in 1909.

  Two points stand out. First, Leale’s 1865 report makes no mention of the heroics he supposedly performed—opening Lincoln’s throat, giving him mouth-to-mouth resuscitation, or pumping his chest. How could Leale have omitted such vital details from his report, written hours after the assassination? And why did he choose to add them to his account in 1909? The likely answer to both questions is that Leale was determined to go down in history as having used all measures to save Lincoln’s life—whether he did so or not. Since a procedure like chest compression was rarely employed in America in the 1860s, he probably did not.

  In his 1865 report, moreover, Leale said that he had placed his finger deep into Lincoln’s wound to look for dangerous bullet fragments. In doing so, he was following the common practice laid out by his famous mentor. “The natural structure of the brain is so soft and fragile that when we introduce a probe it is almost impossible to determine whether we are following the track of the ball or not,” Frank Hamilton wrote in his treatise on military surgery. “The finger is the safer instrument.” But Leale made little mention of this in his 1909 speech, for good reason. The coming of Germ Theory and antiseptic medicine in the 1870s had ended the practice of sticking an unwashed digit into an open wound. No respectable physician in 1909 would have attempted such a potentially fatal maneuver. As such, Leale likely deleted the reference to meet modern standards of practice—and thus preserve his good name.

  Leale claimed in his 1865 report that Lincoln’s personal physician, Dr. Robert Stone, was satisfied with the early treatment the president had received. This probably is true. Leale appears to have faithfully carried out Frank Hamilton’s instructions for dealing with the sort of wound Lincoln had suffered: stay calm, make the patient comfortable, look for clots, stem the bleeding, and feel gently for the bullet, using one’s finger if need be. In the end, embellishments aside, Leale had served the president well under immensely trying conditions, doing everything he had learned to save a mortally wounded man. Leale didn’t pronounce Lincoln dead on the morning of April 15, 1865, as he later claimed; that job fell to the surgeon general. But he did remain with Lincoln till the end, feeling for his pulse and gently massaging his hand. Asked why, Leale replied that common compassion demanded no less. “Sometimes recognition and reason return just before departure,” he said. “I held his hand firmly to let him know, in his blindness, that he had a friend.”

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  Word of the assassination spread quickly over the wires. In New York City, where so many had vilified the president for so long, the mood seemed especially grim. “Lincoln’s death—thousands of flags at half mast—& on numbers of them long black pennants,” wrote the poet Walt Whitman. “Business public and private all suspended, & the shops closed—strange mixture of horror, fury, tenderness, & a stirring wonder brewing.” Lawyer George Templeton Strong, no friend of the president, was haunted by deep feelings of loss. “I am stunned as by a fearsome personal calamity…,” he confessed in his diary. “We shall appreciate him at last.”

  Bellevue’s iconic surgeon Valentine Mott, now eighty, was “overwhelmed” by the news. A friend and great admirer of the president, Mott had just completed an exhausting stint as chairman of a federal commission investigating the mistreatment of “starved and tortured” Union prisoners released early from Andersonville, Belle Isle, and other Confederate POW camps. “In the whole of my surgical experience, not excepting the most painful operations on deformed limbs, I have never suffered so much in my life at the sight of anything,” he admitted. “It unnerved me. I felt sick.”

  Mott was back in New York City recovering from the experience when the assassination occurred. “He regarded it as an omen of ill import,” a friend recalled, “[and] was never himself again afterwards.” A fever soon developed, sending Mott to bed. Visitors to his Gramercy Park mansion thought him “despondent” and “sick at heart,” though not deathly ill. Even his former Bellevue colleague Austin Flint, a superb diagnostician, could find no physical symptoms beyond exhaustion.

  On April 24, 1865, Lincoln’s funeral train reached Jersey City on its long journey to Springfield, Illinois. The coffin was ferried across the Hudson River to Manhattan the next morning, then placed in a hearse led by six gray horses and driven through the streets as church bells tolled and cannons thundered. It was the largest procession New York City had ever seen, and it came within a few blocks of Mott’s Gramercy Park mansion en route to the railroad depot. Mott could hear the mourners pass by, but felt too ill to join them. He died the following day—“a victim,” it was said, “of the same blow that robbed the nation of its chief.”

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  * Until recently, the accepted figure for Civil War deaths was 618,000, with 360,000 on the Union side and 258,000 on the Confederate side. A recent study, however, using the latest detailed census data, has increased that number by 20 percent, and hints that the figure may be even higher. J. David Hacker, “A Census-Based Count of the Civil War Dead,” Civil War History (December 2011), 307–48.

  6

  “HIVES OF SICKNESS AND VICE”

  Is war good for medicine?” The answer for most observers over the centuries has been a clear, if sometimes grudging, yes. Trauma care, nursing, pain relief, disease control, evacuating the wounded—all have advanced dramatically through trial and error on the battlefield. “He who would become a surgeon,” Hippocrates advised long ago, “should join an army and follow it.”

  The Civil War was no different. It came at a pivotal time for medicine, as old certainties crumbled and new ideas took hold. Anesthesia now was commonplace, as we’ve seen, and the “age of heroic medicine” was fading fast. Indeed, one of the lesser-known bureaucratic struggles of the Civil War involved the order by Surgeon General William A. Hammond to ban calomel and other violent purgatives from the army’s medical supply chain—a move that angered many older physicians. At thirty-four, the brash, demanding Hammond also required applicants for the post of regimental surgeon to take a written examination, which most of them promptly failed. The dismal test results—Hammond privately described them as the “vague and confused” ramblings of illiterates—led him to propose a solution whose time had not yet come: a medical college for career officers.

  Such efforts came at great personal cost. Until Hammond’s appointment, the position of surgeon general had been something of a sinecure, filled by men of modest distinction. The pace of reform and criticism pouring from his office was unprecedented. In 1864, with a long and growing list of
old-guard critics at his heels, Hammond was court-martialed and found guilty of “conduct unbecoming an officer and a gentleman” for allegedly purchasing inferior supplies for the troops—a trumped-up charge that would be discredited long after the war had ended. His army career in shambles, Hammond moved to New York City, opened a lucrative private practice, and accepted a position at Bellevue Hospital Medical College as the first professor of neurology—“diseases of the mind and nervous system”—in the United States.

  As surgeon general, Hammond had been among those demanding change. But from a strictly medical standpoint, the war brought few breakthroughs of lasting note. Despite the use of anesthesia, surgical methods barely advanced, postoperative infections were rampant, and dangerous vapors, or miasmas, still explained the transmission of most diseases. One expert aptly described the Civil War as the final conflict of “the medical middle ages.” Its awful fate, wrote another, was to have occurred on the cusp of a curative revolution, just “ahead of the medical care it required.”

  Still, Hammond’s impact was substantial. He’d been recommended for the job by the U.S. Sanitary Commission, a privately funded group of reformers devoted to improving the health of the troops. As such, Hammond focused on the daily conditions in the field. He understood the dangers of bringing thousands of men together in close quarters, where facilities were crude and personal habits often revolting. He knew that many had never used a latrine, or been vaccinated against smallpox, or taught the importance of bathing and washing their clothes. For Hammond, there were more lives to be saved beyond the surgical tent than within it—through education, nutrition, and hygiene.

  It seems fitting that he wound up at Bellevue following the war. The best medical handbooks for Union officers had been developed there, and the treatment of wounded soldiers had been a top priority. No civilian hospital had done more for the war effort than Bellevue, and none would put its lessons to better use.