Ambulance train, early 1860s. New York Public Library.
A few months after the Civil War began, on July 4, 1861, a group of patriotic young volunteers stood in the shadow of the Capitol, waiting to be sworn into the Union Army on a 90-day enlistment. Among them was William W. Keen. Less than three weeks later, and with only nine months of medical training, Keen stood clueless, in his blue uniform with the green sash of a medical officer, near the battlefield at Bull Run in Virginia.
“It was an exceedingly hot day, and we marched and halted in the thick dust under a broiling sun until about noon. . . . During the entire engagement, I never received a single order.” Inside a church he and fellow soldiers placed two boards on boxes in front of a pulpit for an operating table. Hearing that the Confederates were about to overrun the makeshift hospital, Keen’s patient, a soldier with a fractured humerus from a Minié ball (a powerful new rifled bullet), jumped up and ran for the woods, his bandage unraveling from his arm as he went. Keen later wrote, “My experience in this battle is a good illustration of the utter disorganization, or rather want of organization, of our entire army at the beginning of the war.”
Had Keen received an adequate briefing before battle, he would still have been left frustrated with a medical infrastructure unchanged in its essentials since the Mexican War of the 1840s. His experience typified the Federal government’s lack of preparedness in wartime. In fact, the lack of infrastructure, particularly ambulances, meant that many Bull Run casualties waited for days on the battlefield before soldiers or civilians removed them to hospitals.
At Bull Run, Keen received a crash course in misery. Battlefield hospitals were triage centers: stacks of amputated limbs marked the surgeons’ tents. Soldiers with severe abdominal or chest injuries were left to die: no surgical intervention was possible without the sure consequence of infection. The soldier’s life may have been punctuated with combat terror, but disease and illness afflicted far more troops than did battlefield wounds. Germ theory and antisepsis entered medicine only after the war. Counting deaths from wounds or disease, the war claimed between 600,000 and 700,000 lives, more than the number of soldiers killed in all other American wars combined. Beyond battlefield wounds, soldiers suffered malnutrition (including scurvy), dysentery, typhus, typhoid, respiratory illnesses, rheumatism, and outbreaks of malaria, yellow fever, and even smallpox (despite the prevalence of vaccination).
By the end of the war a radical reorganization of the medical field had occurred. The Medical Department could boast of an ambulance system, a sequence of care facilities from battlefield surgery to general hospitals, evacuation of the sick and wounded by train, and a nascent nursing profession. A new system—of government-funded pharmaceutical research and manufacturing—had taken hold. The demand for new chemical and botanical sources for medicines and for the production of reliable vaccines accelerated laboratory-based research and guided postwar pharmacology—including the growth of major manufacturing firms John Wyeth and Eli Lilly. In addition, Civil War pharmacology produced competing therapies and bitter disagreements that brought the Union Army surgeon general to court-martial and established the position of one of the most versatile and effective medicines of the late 19th century: quinine.
On July 21, however, Keen was unable to benefit from these future developments. During the fall of 1861 he went to Philadelphia to complete his formal studies, which at that time required a year of anatomy classes, which was then repeated and followed by several years of apprenticeship with an established physician. Keen returned to the army to find the medical service invigorated. The military had created a cadet corps, a comprehensive examination procedure, and a training school, and decided rank and assignments based on merit. Although Keen had a good knowledge of materia medica—pharmacy—the army’s organization of medicine might have impressed him with its diversity and complexity. Physicians generally relied on the Supply Table—the army’s standard table of drugs, their effects, and their preparation for use. During the war the army created a system that began with acquiring raw materials (eventually creating its own laboratories), included quality control, continued with the preparation and distribution of medicines to armies in the field or to hospitals, and went on to a method of prescribing and dispensing to ill soldiers.