Off Grid Medicine: Civil War

I often talk about situations where the family medic is thrown back to an earlier era medically due to some long-term major catastrophe. But what was it like? In this article, we’ll take the American Civil War(1861-1865) as an example. What were the doctors like? What did they do when faced with injuries and disease off the grid?

During the 1860s, most doctors had not yet made the connection between bacteria and disease. British physician John Snow (not that Jon Snow, Game of Thrones fans) is credited as one of the first modern advocates of epidemic research. Snow was present during a number of cholera outbreaks in London. He also debunked the conventional wisdom that “swamp vapors” spread malaria.

Snow believed that cholera was caused by cells smaller than human epithelial cells. These turned out later to be the bacterium Vibrio cholerae. In recognizing the bacterial origin to the disease, Snow recommended the boiling and filtering of water, setting the precedent for today’s boil-water advisories in disaster settings.

The Civil War

The American Civil War was a bloody affair between northern states (The Union) and southern states (The Confederacy). Both armies inflicted hundreds of thousands of casualties on the other over the course of four years.

Caring for wounded and ill soldiers was substandard in many cases, with many more dying from disease than from bullets or shrapnel. Diarrheal diseases like typhoid and dysentery claimed many lives. Outbreaks of measles, smallpox, malaria, and pneumonia were also common.

Medical providers had not yet realized the importance of sterile surgical procedures, frequent wound dressing changes, and good hygiene and sanitation.  As a result, two soldiers died from illness for every one that died from battlefield trauma. Non-fatal medical issues such as dental problems and tinea cruris (“jock itch”) were also ever-present.

FACTORS LEADING TO CAMP ILLNESSES

A number of factors led to the high incidence of sickness in Civil War camps. Some of the better-known are:

• Deficiencies in physical evaluation of new recruits. The fates of some soldiers were sealed even before any action. Many that were inducted into the armies would have been rejected for service in modern times.
• Inadequate sanitation. Medical knowledge was not advanced enough to recognize common causes of infection. Camp hygiene was neglected. Living areas were often littered with rotting food and heaps of manure. Insects, rats, lice, and other vermin ran rampant. Mosquitoes carrying malaria presented a particular danger.
• Exposure to “foreign” microbes. Soldiers from rural areas on both sides didn’t have immunity to the diseases that city-dwellers tolerated. Exposure to infectious diseases meant death for many.
• Inappropriate clothing. An especially acute problem in the Southern army, extremes of temperature weakened immune systems and predisposed many to potentially life-threatening issues like heat stroke and hypothermia. Common colds and influenza cases more frequently progressed to pneumonia.
• Lack of or failure to properly prepare food and disinfect questionable water, which exposed many soldiers to infectious diseases. In fact, 99.5 percent of soldiers suffered from chronic diarrhea at one point or another during their time in the military. The lot of the prisoner-of-war was worse, as typhoid and dysentery were constant issues.
• Complications from medical procedures. Amputations and other procedures performed during the Civil War often led to infections that caused fevers. Bacteria would spread through the bloodstream (septicemia) and became life-threatening.

CIVIL WAR DOCTORS

In most cases, Civil War doctors underwent two years of medical school. Education was so rudimentary, however, that even Harvard’s medical school didn’t carry a single stethoscope or microscope during the conflict. This was despite the fact that the stethoscope was invented 50 years earlier and microscopes were invented in the late 1600s.

There was no standard process of evaluation for admission to medical schools. Medical boards admitted many with little to no qualifications.

The Union army had about 10,000 surgeons (4,000 for the Confederates), but most had woefully little experience with battlefield trauma. Many had never even seen a gunshot wound.

As a result, death rates from procedures performed by physicians were high, especially compared to modern times. You could expect a 70  percent death rate or more for penetrating trauma to the chest or abdomen. Amputations carried a 25 percent mortality rate due to infection.

This was before the era of surgical gloves, so bare, dirty fingers were often used as probes, introducing bacteria and debris into wounds.  Doctors operated in stained coats and some images from the time show them smoking cigars. Piles of severed arms and legs can be seen in the background.

Another little-mentioned handicap was the lack of effective lighting. With the battle over near dusk, many surgeries had to be performed at night. This was before the electric light was invented, so a lantern held by an orderly was often the only option.

CIVIL WAR NURSES

Nursing was originally a profession reserved for males, but the lack of staffing led to the formation, in the North, of a sanitary commission. Ten of thousands of women joined the nursing profession to care for wounded and ill soldiers. Besides nursing care, they help keep field hospitals clean and wrote letters home for incapacitated patients.

In the South, the lack of medications was a particular problem. They relied mostly on captured supplies from the North. Ladies sympathetic to the Confederates would smuggle drugs by sewing them into their petticoats or become proficient in herbalism.  

MEDICAL TREATMENT

In their effort to treat their patients, doctors improvised often. For diarrheal disease, opium was used. For severe constipation, a mixture of mercury and chalk known as “blue mass” was given.

For scurvy, doctors prescribed citrus fruits or green vegetables.

Pneumonia and other respiratory issues were treated with opium, quinine, and mustard plasters.

(Note: A mustard plaster is a poultice of mustard seed powder spread inside a protective dressing and applied to the body to stimulate healing. It was a part of conventional medical therapy up until the early-mid-twentieth century.)

Malaria was treated with quinine when available; Turpentine was considered as an alternative.

Jock itch could be treated by washing or with herbal remedies such as pokeroot.  

Whiskey and other forms of alcohol also were used to treat pain and clean wounds.

ANESTHESIA

Anesthesia in the form of ether or chloroform (a mixture of acetone and bleach) was first used in the late 1840s.  It was used hundreds of thousands of times during the Civil War. Contrary to popular belief, more than 90 percent of operations used some form of anesthesia. In the hands of experienced providers, it was considered to be safe.

The anesthetic was applied to a cloth held over the patient’s mouth and nose and was removed after it took effect. Only a tiny amount was necessary to induce loss of consciousness. Chloroform was especially prone to cause skin blisters if too much was used or the skin was directly contacted.

ADVANCES IN MEDICINE DURING THE CIVIL WAR

In the midst of the carnage, some advances were made. Large cities in the North and South built substantial military hospitals to deal with the large number of soldiers who needed continued care. The one in Richmond, Virginia was able to handle 4,500 patients at a time.

A major advancement can be credited to Union surgeon Jonathan Letterman. Letterman devised protocols for the intake and treatment of casualties. This system was connected by the first efficient ambulance corps and rapid distribution of medical supplies to field hospitals established at division camps. His system improved mortality rates and allowed more complex procedures to be performed. Letterman also pioneered the institution of improved medical records systems.

To highlight the results of Major Letterman’s efforts, the mortality rate of the Army of the Potomac had been 33 percent in 1862’s Peninsular Campaign; the mortality rate among 14,000 Union wounded after the battle of Gettysburg in 1863 was only 2%. No official report of the battle mentioned Letterman’s contribution, making Jonathon Letterman the unsung hero of the battle.

TODAY

Today, our knowledge of antiseptics, antibiotics, water and food disinfection, and sterile technique has given us an advantage over our Civil War counterparts, even if we’re thrown off the grid due to some long-term disaster. Still, the family medic must be vigilant if they are  to keep things together, even if everything else falls apart.

Joe Alton MD

Dr. Bones in class

P.S. It was during the civil war that camp doctors received the nickname “sawbones,” as much of their time was spent amputating damaged limbs. This was, over time, shortened to “bones” (Star Trek fans will remember that’s what Captain Kirk called Dr. McCoy). Ever since I became involved in the preparedness community, my nickname became “Dr. Bones”!