For more than a century after the medical departments of the Continental Army (1775) and Navy (1798) were established, American military medical professionals shared a problem with their counterparts around the world: Most wartime deaths weren’t caused by war. During the Revolutionary War, for example – according to the estimate of Dr. James Thacher, a surgeon in the Massachusetts 16th Regiment – about nine American colonials died of disease for every Continental Army soldier killed in battle.
At the same time, battle wound casualty rates were high, mostly because of logistical problems. The evacuation and treatment of wounded soldiers and sailors were functions that, like the transport of ammunition or the building of breastworks, were integrated into line commands, which were necessarily more focused on winning battles than on treating the wounded.
The American Civil War was a watershed event in U.S. military medical history because this flaw in the delivery of combat casualty care was dramatically exposed – as has been the case many times since – by improvements in weaponry. The carnage wrought by the conical “Minié ball,” breech-loading rifles, and the more accurate artillery of the Civil War immediately overwhelmed the ability of regiments and their poorly equipped physicians. At the war’s outset, the Union Army and Navy combined had slightly more than 100 physicians, most of them attached to specific regiments and many with no experience in battlefield trauma – and almost 30 of these physicians promptly resigned to join the Confederacy. The Army Medical Department was decentralized, with no clear chain of command, and direct battlefield evacuation was under the command of the Army Quartermaster Corps, whose primary duties were supply and provision.
The first major battle of the war, the First Battle of Bull Run, was a disastrous defeat for Union forces and a debacle for its medical personnel. Some 2,708 Union soldiers were killed or wounded, and in the chaos, the stretcher-bearers fled the battlefield. The wounded could not accompany the Army’s panicked retreat to Washington, D.C.; some remained on the battlefield for days afterward, while the ones who could stand and walk covered the 27 miles by themselves.
By the 1890s, Smith wrote, “the majority of militia surgeons had not been mobilized since the end of the Civil War, a quarter-century earlier. How were the new ideas and trauma surgery experiences to be communicated to those who might need them? To Senn, and to most other physicians of the later 19th century, the answer was a medical society.”
These early failures were dramatically reversed when President Abraham Lincoln, over the objections of Secretary of War Edwin Stanton, named 34-year-old William A. Hammond Surgeon General of the Army. Hammond’s many sweeping reforms of Army medicine included better transport of the wounded: He removed this function from the Quartermaster Corps and placed it under the Medical Corps, with its own drivers and bearers. He named his colleague Jonathan Letterman, with the rank of major, as the medical director of the Army of the Potomac.
Letterman designed a system of forward aid stations at the regimental level that borrowed from principles devised by Napoleon’s physician, Baron Dominique-Jean Larrey, who used a method known as “triage” to determine the priority of patients for treatment. For the first time ever, Letterman applied management principles to battlefield medicine, instituting standard operating procedures for the intake and treatment of casualties. At division and corps headquarters, Letterman established mobile field hospitals. These points were connected to each other, and to the battlefield, by a transport system also innovated by Larrey: horse-drawn “flying ambulances” manned by early versions of medics and corpsmen.
Under Letterman’s system of combat casualty care, Union mortality rates decreased significantly. After successful performances at Antietam, Fredericksburg, and Gettysburg, the system was adopted by Congress in 1864 as the official procedure for intake and treatment of battlefield casualties for all of the Union armies.
Meanwhile, as the Navy underwent a significant expansion, the service commissioned its first hospital ship, the USS Red Rover, in December 1862. Red Rover’s medical complement included 30 surgeons and nurses.
Despite advances in combat casualty care, diseases – contracted on the march, in encampments, in surgical tents, or prison camps – killed twice as many Union and Confederate soldiers as did battle wounds. While more proficient and organized, American battlefield surgeons did not yet understand the germ theory of infection, and so didn’t practice the antiseptic protocols common today. They often operated in old clothes stained with the blood of other patients; dressed wounds with torn-up rags; and failed to sterilize or clean instruments.
The Civil War’s greatest medical advance was perhaps the widespread use of anesthesia for surgical patients: tens of thousands of patients were given anesthesia on both sides. About 94 percent of Civil War wounds were caused by bullets, and the prevalence of gangrene, and the tendency of the Minié ball to shatter bone, made amputation the preferred surgical procedure.
The predominance of gunshot wounds led Samuel Preston Moore, Surgeon General of the Confederate States Army, to organize an “Association of Army and Navy Surgeons” and call for papers examining several questions relating to the incidence, treatment, and healing of these wounds. Moore’s organization, which continued to exist until World War I – when its members joined with the Association of Military Surgeons of the United States (AMSUS) – is considered the world’s first military medical society.
To stay abreast of advances in weaponry and the different aspects of future wounds, association members would need to remain engaged in original research and propose new ideas and methods for treating trauma; field dressing; transport/evacuation of the wounded; and field medical facilities.
Before the 1908 creation of the Medical Reserve Corps, the Army made use of civilian contract surgeons. These physicians organized themselves as the Association of Acting Assistant Surgeons in 1888 for the purpose of collecting military medical data and lobbying for legislation that would elevate their status among the commissioned medical officers with whom they worked.
Among the most eminent surgeons in the American militia was Dr. Nicholas Senn, a professor at Rush Medical College and the Chicago Polyclinic Medical School. Senn, who also served as Surgeon General of both the Wisconsin and Illinois National Guards, had conducted several experiments in his private laboratory relating to the causes of surgical infection, and he developed a particular interest in the wounds of war. The science of trauma medicine was rapidly evolving, with the advent of germ theory and antiseptic and aseptic surgery.