The American Civil War, fought between 1861 and 1865, was a war that existed on the boundary
between old and new – though not yet the fully modern and industrial warfare that would
characterize the 20th century.
The Civil War was nonetheless a far cry from the past.
The development of new weapons, new methods of communication and transportation, and a
new concept of total war that encouraged all Americans to contribute to the war effort,
collectively marked the Civil War as a military campaign that looked forward to the experience
of World War I, rather than looking back to the Revolution.
The Civil War irrevocably changed the nature of warfare in the United States, and nowhere
is that clearer than in the experience of the soldiers who fought the war and the doctors
who tried to save them.
The Civil War was in a word – devastating.
Four years of fighting between Union and Confederacy proved deadlier than any single America war
that had come before – or since.
In fact, the total number of American deaths during the Civil War – roughly 600,000 – was
greater than the sum of all U.S.-involved wars combined, until Vietnam.
And that’s just the number of deaths – injuries went beyond that with estimates placing the
number of wounded soldiers somewhere around a half million.
The sheer number of dead, dying, and wounded bodies left on the battlefields of the Civil
War were staggering, and it far exceeded the ability of mid-19th century doctors to cope.
Medicine was going to have to adapt to keep up with the brutal lethality.
One reason the Civil War was so deadly was the introduction of new industrial weaponry.
Prior to the War, American soldiers typically carried muskets – single-bullet guns that
had a theoretical range of 250 yards but were in practical reality only accurate to about
80 yards.
These guns were also notoriously difficult and time consuming to load, so most fighting
took place at close range, with the bayonet often being the weapon of choice in close
combat.
This had the effect of limiting the number of casualties – a category that includes
death, injury, and permanent disability, as well as soldiers listed missing in action
– in early wars.
A new slate of weapons used during the Civil War began to change that.
Arguably the biggest change was increased military reliance on the rifle, which was
responsible for approximately 90 percent of the battlefield injuries during the Civil
War.
The primary difference between the rifle and the musket is that the inside of the rifle’s
barrel is carved with a series of grooves, called rifling.
As the gun was fired, these grooves would spin the bullet in a spiral fashion – much
like throwing a football, which served to increase the distance and accuracy of the
shot when compared with earlier firearms.
But these early rifles were still slow loading, primarily because of the necessarily tight
fit between bullet and barrel.
In order to spin properly, the bullet had to be in close contact with the side to the
barrel, where the rifling was, which made them difficult to load.
Bullets had to be shoved into the barrel, often using a mallet or other tool, which
took precious time and limited their utility on the battlefield.
That limitation disappeared with the invention of the Minie ball in the 1840s.
The Minie ball or Minni ball, as it is sometimes called, was a cone-shaped bullet with external
grooves made of soft lead that would expand outward under the pressure of gunpowder combustion.
This allowed for a smaller bullet that was more easily loaded into the barrel of the
gun, but still benefitted from tight contact with the inside of the barrel once fired.
This new rifle and bullet combination was accurate up to a thousand yards, leading to
its widespread military adoption, and dramatically changing the nature of war.
Combined with other advances, like the repeating rifle – a rifle that could be fired more
than once before reloading, the Gatling gun – a rapid-fire weapon that many consider
a precursor to the modern machine gun, and iron-clad warships armed with gun turrets.
The modern weaponry of the Civil War increased the danger that soldiers faced.
In fact, a soldier was 13 times more likely to die during the Civil War than during the
Vietnam War – and even non-lethal injuries were more devastating thanks to this new weaponry.
The soft lead of the Minie ball flattened or shattered when it hit a human target, increasing
both the surface area of the damage and the threat of contamination in the wound.
They shattered bones and ripped through ligaments, leaving severe damage and increased risk of
infection in their wake.
After a battle it was not uncommon for hundreds or even thousands of wounded soldiers to be
left needing the services of just a few doctors.
As a result, battlefield surgeons had to deal with trauma on an unprecedented scale, which
forced them to adapt.
Surgeons quickly learned that the best chance for survival after a Minie-ball injury was
amputation, which made it the most common surgical procedure performed on these battlefields.
Three out of every four surgeries performed during the Civil War were amputations, and
generally speaking – the sooner an amputation was performed after an injury, the higher
the patient’s chance of survival.
But that was difficult in the early years of the Civil War.
One of the primary issues lay in the surprisingly difficult task of getting wounded and dying
soldiers off the battlefield and to medical care.
Throughout 1861 and 1861, wounded soldiers were often left on the battlefield as noted
by Dr. Frank Hamilton in his 1861 letter describing the first battle of Bull Run.
He describes how wounded soldiers were scattered the whole distance from Centerville to Washington
and left with no one to carry them to medical attention.
Delay in treatment and exposure could turn even the simplest of wounds deadly, leaving
armies on both sides in crisis.
Something had to be done.
In 1862, Surgeon General William Hammond appointed Major Jonathan Letterman as medical director
of the Union Army of the Potomac.
The 37-year old officer was charged with improving the way the army cared for the wounded on
the battlefield.
The changes he advanced would become known as the Letterman Plan and they played a role
in the Union victory that was equal to that of any battlefield commander.
Letterman inherited the responsibility of caring for a Union army of almost a hundred
thousand soldiers, some 30 percent of which were listed as sick or wounded and unfit for
duty.
Within 2 years he had dramatically reduced the mortality rate among his soldiers and
established a groundwork for battlefield trauma care that is still used today.
There were 3 primary components to the Letterman Plan.
First, Letterman promoted use of a tiered system of care that involved evaluating injuries
and sorting them according to severity.
First used by Napoleon’s army, this process became known as triage – from the French
word, trier, which means ‘to sort’.
It created a system to ensure that those soldiers with the most life-threatening, but treatable,
injuries would be attended to first.
This rapid and tiered deployment of resources reduced the number of deaths due to exposure
or thirst and increased the survival rate of surgery, particularly amputations.
Second, he developed an evacuation system involving 3 separate stations – a first-aid
station on the battlefield, where wounds were assessed and initial treatments were received;
a field hospital located near the battlefield but out of artillery range, where emergency
surgeries or additional stabilizing treatments could be performed; and large general hospitals
located in towns away from the battlefield, where injured soldiers could receive long-term
care.
By the end of the War in 1865, there were approximately 400 hospitals with nearly 400,000
beds to serve these wounded soldiers.
There were 2,000,000 admissions to these hospitals, with an overall mortality rate of only 8 percent,
which reflects a staggering improvement in military medical care when compared to the
beginning of the War.
Third, Letterman established an ambulance system to remove wounded soldiers from the
battlefield, using specially equipped wagons and specially trained medics to transport
injured soldiers from the battlefield to the field hospital.
These ambulance systems were under the complete control of the medical corps.
This was important because it meant that those ambulances could only be used for medical
purposes – not to transport supplies or healthy soldiers – ensuring that they were
available when needed.
These ambulances allowed drivers to transport multiple soldiers at once – a considerable
improvement over the traditional stretcher.
These soldiers would be taken to the first-aid station, where they were assessed by medical
personnel and either treated and sent back to the battlefield or taken by ambulance to
the field hospital for surgery.
Thus Letterman’s changes brought much-needed discipline to the military medical corps.
Still, these advancements could only go so far in the middle of the 19th century, when
medical knowledge was still desperately limited.
The germ theory of disease or the idea that disease is caused by microscopic organisms
wouldn’t be established until 1870, and the transformative emphasis on antisepsis
and sterility that resulted from these discoveries was nowhere in sight in the 1860s.
Medical training, too, was limited – typically involving only 2 years of lecture-based education
and virtually no hands-on clinical experience prior to graduation, meaning that most Civil-War
surgeons had never even seen a gunshot wound much less treated one.
And the development of anesthesia in 1846 allowed for longer, more complicated surgeries
to be performed.
The equipment used was far from sterile and infections were common.
The Civil War was still the deadliest war in American history, but the changes that
Letterman brought to the Union Army of the Potomac medical corps saved lives and transformed
military medicine – a feat that shouldn’t be underestimated.
Thank you for your time.