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Medicine and Surgery During the Civil War
Paul S. Sledzik, MS, Curator, Anatomical Collections, National Museum of
Health and Medicine, Armed Forces Institute of Pathology, Washington, DC.
The State of Civil War Medicine
The spring of 1861 saw the opening shots of the Civil War fired on Fort Sumter, South Carolina.
Years of disagreement between the Northern and Southern states over the issues of states' rights,
slavery, and the cultural differences dividing industrial and agrarian economies culminated in war. From
1861 until 1865, Union and Confederate armies and navies drew weapons in hundreds of battles from
Pennsylvania to New Mexico. Nearly 200,000 men lost their lives from enemy fire during the four years of
the war. However, more than 400,000 soldiers were killed by an enemy that took no side – disease.
From our modern perspective, medicine during the Civil War seems primitive. Doctors received limited
medical education. Most surgeons lacked familiarity with gunshot wounds. The newly-developed minie ball
produced grisly wounds that were difficult to treat. The Northern and Southern medical departments were
ill-prepared for removing wounded men from the battlefield and transporting them to hospitals. Systems
to provide hospital care for the sick and wounded had not been adequately developed. Blood typing,
x-rays, antibiotics, and modern medical tests and procedures were nonexistent. Open latrines,
decomposing food, and unclean water were the rule in the camps. Diarrheal diseases affected nearly every
soldier and killed hundreds of thousands of men. Although surgeons used ether and chloroform routinely
as anesthetics, surgery was performed with unwashed hands and unclean instruments, resulting in infected
wounds. The most effective drugs were the pain-killers opium and morphine while many of the other
available drugs were useless or harmful. Despite these limitations, Civil War doctors achieved some
remarkable successes in treating the wounded and comforting the sick.
As the war progressed, doctors on both sides quickly became aware of the scope of medical problems.
They responded by creating medical evacuation systems, designing and building hospitals, and improving
sanitary conditions in the camps. In general, these responses reduced the rates of sickness and death
over the course of the war.
For the Union Army, the staff of the Army Medical Museum, the predecessor of this museum, measured
the effectiveness of the Union medical response. Founded in 1862 by Surgeon General of the Union Army
William Hammond, the Army Medical Museum was a clearinghouse for medical information collected from Union
surgeons. After the war, the staff of the Museum collected information on Union and Confederate medical
care and patient information. This collecting program culminated in the publication of the Medical and Surgical History of the War of Rebellion. These volumes provided
information on the state of medicine and documented the medical histories of tens of thousands of sick
and injured soldiers. Our collection of pathological specimens, medical artifacts, and medical
illustrations and photographs comprise an incomparable resource for the study of Civil War medicine.
Trauma and Surgery
Popular but generally incorrect images of Civil War medicine involve surgery – amputations without
anesthesia, piles of arms and legs, the surgeon as butcher. By modern standards, wartime surgery was
limited. Despite the lack of both surgical experience and sanitary conditions, the survival rate among
those who underwent the knife was better than in previous wars. Amputation was not the only surgical
recourse available. Surgeons also extracted bullets, operated on fractured skulls, reconstructed damaged
facial structures, and removed sections of broken bones.
As bullets hit their victims, shattered bone and shredded flesh became the calling cards of the minie
ball. Most of the surgeons who had come from civilian practices had little or no experience in dealing
with such wounds. They quickly became aware of the surgical options: remove the limb, remove the
fractured portions of bone, or clean the wound and apply a dressing. Union surgeons documented nearly
250,000 wounds from bullets, shrapnel, and other missiles. Fewer than one thousand cases of wounds from
sabers and bayonets were reported.
Anesthesia was an important surgical advance introduced a few decades before the Civil War. Ether or
chloroform was applied to a cloth cone that was placed over the mouth and nose of the patient. The
patient became stuporous in a matter of minutes. This state lasted for more than enough time to perform
an amputation, which took about six minutes to complete. Union surgeons used anesthesia in more than
80,000 operations.
Since anesthesia was available, Civil War surgeons attempted new operative procedures to contend with
some of the severe wounds they encountered. One such procedure, reconstructive surgery of the face,
involved suturing together the soft tissues of the eyelids, nose, and mouth. Sometimes extensive
rebuilding of the underlying bone with splints and surgical fixtures was required. Surgeons performed
more than thirty of these operations.
Although fortunate to be unconscious during surgery, soldiers who underwent the knife often received
a nasty visitor a few days later – infection. Any open wound almost always became infected. The
unwashed hands of the surgeon, the nonsterile surgical instruments used on a succession of men, and the
dirty sponges used on an entire ward of wounded soldiers all introduced infectious bacteria into wounds.
These infections often resulted in gangrene and death.
Surgeons frequently treated arm and leg wounds by amputating. The grisly wounds caused by bullets
and shrapnel were often contaminated by clothing and other debris. Cleaning such a wound was time
consuming and often ineffective. However, amputation made a large complex wound simple. Surgical
manuals taught that an amputation should be performed within two days following injury. The death rate
from these so-called primary amputations was lower than the rate for amputations performed after the
wound became infected. Union surgeons performed nearly 30,000 amputations.
Surgeons treated some shoulder wounds with a technique known as excision, also termed exsection or
resection. The fractured bone section was removed, the tissues sutured, and the limb left to heal.
Excision gave the patient limited use of the arm and usually full use of the hand. Prosthetic braces
worn over the shoulder allowed nearly normal function of the limb for some patients.
Conservative treatment was employed in the cases of flesh wounds or minor bone fractures. The wound
was cleaned of bone fragments, clothing, and other debris and dressed with bandages. Local anesthetic
was often applied. Conservation left the limb intact, but the use of unsterilized instruments, unwashed
hands, and dirty bandages often introduced infection.
Head wounds were not always fatal. A soldier's prognosis was best when bone splinters were removed
and the wound was left to heal. For more severe wounds, trephination was used. Trephination involved
drilling a circular hole into the skull to relieve pressure from bleeding or to remove fragments of bone
pressing on the brain. Trephinations were fatal in over half of the 220 operations performed by Union
surgeons.
Chest and abdominal wounds were nearly always fatal. Treatment of abdominal wounds often involved
pushing in protruding organs and suturing the wound. Food was withheld because fecal material leaking
from the intestines caused contamination. Opium was often administered to halt the action of the
digestive system. Abdominal wounds were fatal in almost 90% of the cases reported by Union surgeons.
Chest wounds were cleaned, and the wound was sutured.
Disease and Hygiene
A fear to which every soldier could admit was death from an enemy bullet, but a greater unseen killer
lurked in the camps. Disease, the product of poor hygiene, inadequate diet, crowded camps, and
unseasoned troops, killed more than 400,000 soldiers. For every life lost to a bullet, disease claimed
two lives. Union surgeons reported more than six million cases of disease, meaning that the average
soldier became sick at least twice each year.
Doctors suspected that something in the odors emanating from swamps, privies, and garbage was the
source of disease, even though the role of microorganisms in transmitting disease was still unknown. At
first, the military commands were slow to acknowledge doctors' demands for fresh air, dry ground, and
healthy food for the troops. However, citizens' groups such as the United States Sanitary Commission
pressured the military to make improvements. These changes reduced the rate of sickness and death by
allowing physicians to introduce and enforce personal hygiene and camp cleanliness as well as other
health-related regimens.
As regiments and companies formed, the soldiers brought with them their health histories as well as
their rucksacks. Soldiers from rural areas who had not been exposed to childhood diseases like
chickenpox, measles, and mumps, readily contracted and died from these illnesses. As each new group of
volunteers arrived in camp, the men with inadequate immune systems were weeded out by disease. Smallpox,
another contagious disease, was often prevented through vaccination programs.
In broad terms, the number of soldiers falling ill and dying from disease decreased over the course
of the war. Improvements in sanitation and diet contributed to this decline. In addition, soldiers with
inadequate immune systems were killed by disease in the early part of the war, leaving men who were less
susceptible to illness. A reduction in the number of new recruits over the course of the war and the
continued service of healthy veteran soldiers also reduced the rates of sickness and death.
The most common diseases encountered during the war were dysentery, typhoid, pneumonia, and malaria.
Dysentery, a form of diarrhea, was known as the "runs" or the "bloody flux." It reduced the body's
intake of energy and minerals from food. In some cases, the disease quickly ran its course, and the
patient survived. When the disease lingered, however, death was more frequent. One-quarter of all
sicknesses reported to Union surgeons were the result of dysentery. A variety of drugs were used to
treat dysentery, and most were ineffective. Typhoid, caused by contaminated food and water, resulted in
fever, diarrhea, and headache. Because these symptoms were similar to dysentery, the treatments were
much the same. Pneumonia killed 20,000 Union troops. It was treated with expectorants and
cough-promoting drugs. Malaria, a disease carried by the Anopheles
mosquito, was prevalent in the south. Quinine was particularly effective in reducing the fever and other
symptoms of this disease.
Volunteer organizations in the North and South improved the soldiers' quality of life. One prominent
group was the U.S. Sanitary Commission (USSC). The USSC worked to reform the U.S. Army Medical
Department and provided private funds dedicated for the care of the sick and wounded. They convinced the
Union medical command to issue orders requiring better sanitation, hygiene, and food for Union troops.
The USSC and other groups funded hospital trains and ships, provided doctors and nurses to help wounded
soldiers, and held "sanitary fairs" to raise money for medical supplies and equipment.
The acceptance of female nurses significantly changed Civil War medical care. Army physicians
initially feared that women would be unable to work amid the difficult conditions of field and general
hospitals. Nurses like Dorothea Dix and Clara Barton persuaded the public and the medical command that
they were able to provide effective and compassionate care. Many African American women like Sojourner
Truth and Harriet Tubman also served as nurses. In June of 1861, Dorothea Dix was appointed the
"Superintendent of Female Nurses." Soon after, Congress legislated that nurses be paid forty cents per
day. To reduce problems while caring for patients, Dix required her nurses to be over thirty years of
age, healthy, and "plain almost to repulsion in dress, and devoid of personal attractions."
The role of women sometimes extended beyond nursing. Mary Walker was the first woman to serve the
U.S. Army as a contract physician. Contract physicians, also called Acting Assistant Surgeons, were
civilian doctors who were contracted by the medical commands to supplement the work of military
physicians. Many years after the war, Walker was awarded the Congressional Medal of Honor for her Civil
War service.
Evacuation and Hospitalization
The first battles revealed gaping holes in the capabilities of the medical commands to evacuate
wounded men from the battlefield, render immediate care, and arrange long-term hospitalization. Outdated
military regulations relied on regimental musicians to remove the wounded. Surgeons were required to
treat only men from their assigned regiment, but even then they were soon overwhelmed by the chaos of
battle. In some cases, days passed before men were removed from the battlefields. Townspeople became
nurses, their carts and wagons served as ambulances, and their homes outfitted into makeshift hospitals.
The public and military medical personnel grew outraged by these conditions. Their reactions forced
significant changes in evacuation and hospital systems. Troops were organized and trained to recover and
transport wounded men in ambulances. New types of ambulances were designed and built. Railcars and
ships were outfitted to move the wounded from field hospitals to general hospitals. Large general
hospitals holding thousands of patients and hospitals specializing in particular diseases and medical
conditions were built. Surgeons planned the location of evacuation points and field hospitals before
battles commenced. The procedures developed during the Civil War-rapid evacuation, assessment in the
field, and transportation to a hospital far from the battle lines-are still in use by the American
military.
Once evacuated from the battlefield, wounded soldiers were evaluated at the field hospital. Three
categories were used-the walking wounded, the wounded requiring immediate care, and the wounded beyond
help. The injuries of the walking wounded were dressed and their pain eased with opium. Morphine and
opium were given to the fatally wounded. Immediate care usually involved amputation or bullet
extraction. Care at the field hospital could take days. The wounded were then evacuated to larger
division and general hospitals.
Field hospitals were established in tents, barns, houses, or other protected locations with access to
water. Hastily erected rows of tents also served this purpose. Wounded soldiers were brought to field
hospitals on stretchers, in two-wheeled ambulances, or with the help of a fellow soldier.
Once evaluated and cared for at the field hospital, wounded men were transported to general hospitals
in trains and hospital ships. Large numbers of wounded men could be loaded on these trains and ships,
given care, and transported directly to general hospitals. Hospital trains could carry hundreds of
patients. Many contained kitchens and well-spaced bunks to provide better patient care. Ships were used
to transport soldiers to general hospitals and as floating hospitals themselves. Later in the war, Union
ships stopped at Southern ports to pick up wounded and transport them up the Atlantic coast to hospitals
in Washington, Philadelphia, and New York.
With the influx of large numbers of sick and wounded soldiers, the cities of the Eastern and Southern
coasts became centers for large general hospitals. New hospitals were designed and built. Others were
created from existing buildings. A belief that "bad air" caused certain diseases suggested that
increased airflow would reduce sickness. As a result, new hospitals maximized the ventilation of the
wards.
Some hospitals specialized in the care of certain injuries or medical conditions. For example,
Turner's Lane Hospital in Philadelphia became the Union Army's hospital for the care of neurological
disorders. The Confederate medical command favored the construction of very large hospitals. With 8000
beds and 250 surgeons, Chimborazo Hospital in Richmond was one of the largest.
Two military physicians were largely responsible for the changes in evacuation and the institution of
hospital systems during the war. Union surgeon Jonathan Letterman, medical director for the Army of the
Potomac, was instrumental in establishing regimental aid stations, field hospitals, and division level
hospitals. He also authorized training for ambulance companies responsible for moving wounded men from
the battlefield to the field hospital. Dr. Samuel Stout, of the Confederate medical service,
established aid stations, devised mobile field and general hospitals (the origins of the MASH unit), and
championed hospitals with large, open wards. He also organized effective evacuation systems for wounded
Confederates. The changes instituted by Stout and Letterman – rapid evacuation, assessment in the
field, and transportation to a hospital far from the battle lines – provided sick and wounded soldiers a
process of care still used by the American military.
Abraham Lincoln: The Final Casualty of the War
On the evening of April 14th, 1865, President Abraham Lincoln attended a play at Ford's Theatre in
Washington. John Wilkes Booth entered the presidential box and fired a single bullet from a derringer
into the back of Lincoln's head. As Booth escaped from the theater, Dr. Charles Leale made his way
through the audience to Lincoln's box. Leale quickly assessed the wound as fatal. The president was
moved to a boarding house located across the street from Ford's Theatre. Several physicians attended
Lincoln, including U.S. Army Surgeon General Joseph K. Barnes of the Army Medical Museum. Using a
probe, Barnes located some fragments of Lincoln's skull and the ball lodged six inches inside his brain.
Lincoln, who never regained consciousness, was comforted until his breathing stopped at 7:20 a.m. on
April 15th.
The entry from the Medical and Surgical History of the War of the Rebellion reads:
CASE. – A. L-----, aged 56 years, was shot in the head, at Washington, on the evening of April 14th,
1865, by a large round ball, from a Derringer pistol, in the hands of an assassin. Dr. Charles A. Leale
being close at hand, went instantly to the wounded man, whom he found "in a profoundly comatose
condition...the breathing exceedingly stertorous." No pulsation was perceptible at the right wrist.
When the head was examined, I passed my fingers over a large firm clot of blood [that] I easily removed,
and passed the little finger of my left hand through the perfectly smooth opening made by the ball, and
found that it had entered the encephalon. As soon as I removed my finger, a slight oozing of blood
followed, and his breathing became more regular and less stertorous. After the administration of a small
quantity of brandy and water...the patient was removed to a neighboring house... His clothing was
removed, and he was placed in bed. His extremities were cold. He was covered with warmed blankets, and
bottles of hot water were applied to the lower extremities. It was now about eleven o'clock at night,
the wound having been inflicted about half past ten. His family physician, Dr. Robert H. Stone, and
Surgeon General Barnes, and Assistant Surgeon General Crane, arrived presently... The Surgeon General
accordingly kept the external wound open by means of a silver probe, until, a Nelaton's probe being
brought, he made an exploration of the course of the ball. A splinter obstructed the track at the depth
of about two and a half inches. An inch and a half further on the bulb came in contact with a foreign
body, which proved to be the disc from the occipital forced out by the ball; passing beyond this the ball
was detected, at a distance of over six inches from the entrance wound... it was decided that no attempt
should be made to remove it or the foreign bodies, further than to keep the opening free from coagula,
which, when allowed to form and remain for a very short time, would produce signs of increased
compression, the breathing becoming profoundly stertorous and intermittent, and the pulse more feeble and
irregular. The protracted death-struggle ceased at twenty minutes past seven o'clock on the morning of
April 15th, 1865.
Civil War Medicine Bibliography
- Adams, GW. Doctors in Blue: The Medical History of the Union Army in the
Civil War. Henry Schuman, New York, 1952.
- Bengston BP, Kuz JE (eds). Photographic Atlas of Civil War Injuries.
Medical Staff Press, Grand Rapids, MI, 1996.
- Bollett AJ. Civil War Medicine: Challenges and Triumphs. Galen Press,
Tucson, Arizona, 2001.
- Cunningham, HH.. Doctors in Grey: The Confederate Medical Service.
Peter Smith, Gloucester, MA, 1970.
- Dammann, G. Pictorial Encyclopedia of Civil War Medical Instruments and
Equipment. Vols. I and II. Pictorial Histories Publishing Company, Missoula, Montana, 1983,
1988.
- Denney, RE. Civil War Medicine: Care & Comfort of the Wounded.
Sterling Publishing Co., New York, 1994.
- Freemon FR. Gangrene and Glory. University of Illinois Press,
Champaign, Illinois, 2001
- Freemon FR. Microbes and Minie Balls: An Annotated Bibliography of Civil War
Medicine. Associated University Presses, London and Toronto, 1993.
- Gillett MC. The Army Medical Department, 1818-1865. US Army Center for
Military History, Washington, DC, 1987.
- United States Army Surgeon General's Office. The Medical and Surgical History
of the Civil War. Wilmington, NC: Broadfoot Publishing Company, 1990. 15 volumes. Originally
published by the Army Medical Museum as The Medical and Surgical History of the War
of the Rebellion between 1870 and 1888.
Internet Resources
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