[2]Gordon Dammann, Alfred Jay Bollet, Images of Civil War Medicine, Demos Medical Publishing, LLC.2008[3] Shauna Devine, Learning from the W

On April 12, 1861, under the order of Confederate President Jefferson Davis, the Southern Army began to bombard the Sumter Fortress, which was still controlled by the Northern Army, and the American Civil War broke out since then. When both sides carried out mobilization activities to send soldiers to the front line, neither of them expected the war to last for four years, nor did they expect it to affect millions of the United States. In the north, the number of enlisted soldiers reached 2.1 million; in the south, about three-quarters of white men who reached the age of military service became soldiers.

Every long war of great scale is a bloody meat grinder that keeps rotating. In "This Crucifixion Kingdom", Drew Foster pointed out that from 1861 to 1865, more than 600,000 people died in the civil war, which is equivalent to the total number of deaths from the US military in the War of Independence, the 1812 War, the American-Mexico War, the Spanish-American War, World War I, World War II and the Korean War. Compared with the killing of war, what is even more shocking is the death caused by disease. The number of soldiers who died of illness was as high as twice as many as those who died of combat injuries. A soldier therefore said in fear that the death caused by illness is "as terrifying as death on the battlefield, but there is no glory brought by death on the battlefield."

A group of retired veterans in the Civil War, many of whom have undergone amputation surgery

The heavy casualties caused by the American Civil War forced people to find ways to improve the success rate and cure rate of surgery, reform the first aid system and field hospitals, and thus medicine has developed. These developments were continued after the war, thus improving the overall medical level of the United States. Some scholars have even proposed that the Civil War actually laid the foundation for the modernization of American medicine.

American medical development before the war

American medical level before the civil war was not high, and it was even lower than that of European countries such as Britain and France. This is not surprising. After all, Europeans came to North America in large numbers to engage in colonization activities in the 17th century, and by the outbreak of the civil war in 1861, it was less than a hundred years since the United States achieved independence.

The backwardness of American medicine is first reflected in the shortcomings of medical education. Before 1800, there were almost no professional medical schools in the United States, and the inheritance of medical knowledge was mainly maintained by the traditional apprenticeship system. Students who are interested in medical science can only travel across the ocean to study in major European medical centers such as Edinburgh, London, and Paris. After entering the 19th century, private medical schools began to emerge in Philadelphia , New York, Cambridge and other places. However, in order to compete for students, these schools have continuously lowered their admission standards, even reaching the point where they can enter the school by paying money. At that time, not only did there be no standardized entrance exams, but there was no need for cultural tests.

Medical School courses usually include anatomy, botany, chemistry, pharmacy, and surgical medicine. Although the course is rich and there is no shortage of modern science knowledge, the problem is that students lack internship opportunities. Most schools do not have affiliated hospitals and have little cooperation with other hospitals, so teaching can only be conducted through pure classroom explanations. It is very likely that students have not been admitted to the hospital until graduation, let alone participating in surgery or examining patients.

Jefferson Medical College in Philadelphia

The social prejudice and cultural factors at that time were not conducive to the development of medicine. Surgery is an important branch of modern medicine, and the treatment of war trauma requires a surgeon in particular. But in the United States before the Civil War, the development of surgical medicine encountered many obstacles. First, surgeons are often discriminated against as craftsmen rather than professionals than physicians. This situation still did not improve until the civil war. The surgeon has a low status in the military and has no military rank, so he is included in the ranks of quarantine officers and priests in the army. In addition, due to the influence of religious culture, Americans uphold the belief that the dead are restless and are unwilling to contribute their bodies to medical uses. Medical students have to look for bodies from the cemetery, and the harvest is naturally limited. It was not until 1831 that two states passed legislation allowing medical schools to dissect the ownerless body. Anatomy is the basis of modern medical training. Without it, there is no way to start with the improvement of medical level.

By the 1830s and 1840s, efforts to improve medical standards were hit again. Andrew Jackson, who was elected president in 1828, is known for advocating populism, and advocates believing in and serving civilians.Under the influence of Jackson's democracy, doctors who need to receive long-term professional training, professional skills and professional authority are easily classified as elites that oppose civilians and are hostile and resisted. Many states thus abolish their medical licenses and no longer recognize the Medical Association. This means that at that time, only a medical diploma was needed without any internship or professional assessment, and the situation was equivalent to today's law students who were majoring in law could become lawyers without taking the judicial examination. The lack of professional standards and groups not only reversed the medical level, but also promoted the prosperity of other non-modern schools of medicine. Later proved to be pseudoscience, homeopathy and eclectic therapy that are no different from placebo are popular.

There is no doubt that the backwardness of American medicine needs to bear certain responsibility for the high casualty rate of the civil war. However, if the problem is completely blamed on this, it may be biased. In fact, American medicine is not the shortest piece of wood. The more important reason why doctors failed to save more soldiers was the overall lag in the development of world medicine at that time. It was not until 1864 that bacteria were discovered by Pasteur and 1865 that Lister proposed to eliminate surgical infections through disinfection that the success rate of treatment of surgical trauma was greatly improved. No wonder William Hammond, chief of military medicine during the Civil War, lamented that the Civil War was a war that "departed at the end of the Middle Ages of Medicine".

William Hammond was an important promoter of battlefield medical reform during the Civil War and the founder of the Army Medical Museum

The chaos at the beginning of the war

Be prepared for any danger, and the battle will be in danger. This sentence is very suitable for describing civil war. When the storm broke out on the banks of the Niufeng River in Virginia, gradually swept the society from soldiers to civilians, both the north and the south thought that the other party would not be serious, so they were completely unprepared for its time and scale. South Carolina Senator James Chesnart declared that he could drink all the blood shed by the Confederate declaration of independence alone. Even though the Northern and Southern Army had fought several times, people still believed that the conflict would end soon. In other words, no one has prepared war personnel, materials and logistics services based on the specifications of the four-year war. The consequence of

is the shortage and overload of battlefield medical services. Although the federal army in the north had always established a field medical system, the size of the federal army before the Civil War was not large, and even during the Independence Revolution, the total number of people never exceeded 30,000. In addition, the military revolution has not prospered for many years, most military doctors have low levels and lack understanding of the complexity of large-scale wars. Therefore, this system is completely unable to meet the huge demands of the civil war. This was fully demonstrated in the first Niubenhe Battle in 1861. A few days after the battle ended, a large number of slightly injured federal soldiers still staggered on the way back to Washington, and countless soldiers were abandoned on the battlefield due to their serious injuries. In the south, where the industrial foundation is weak and the economic development level is relatively backward, the problem is even more serious.

At the beginning, both the south and the north used railways and water to transport the injured to the rear hospital for treatment, but none of these injured were given enough attention and care. Sometimes the carriages are filled with soldiers of varying degrees of injury, but there is not enough medical supplies, food and water. The wounded had to spend a few days on the road before arriving at the rear hospital, and some died in groan. The ambulance train has thus become a veritable death train.

The American Civil War was the first large-scale war in the railway era. Trains were used to transport soldiers and wounded. In order to quickly improve medical capabilities, the Northern Federation and the Confederate recruited a large number of doctors, even to the point where they would rather be insignificant than lack. However, due to the various reasons mentioned above, the doctor's gap could not be filled for a long time. The doctors who entered the army had different levels, and some had even just left the school gate. Some scholars bluntly say that this war is full of poor doctors who lack training, who often forget to use chloroform and do not remember the most basic hygiene knowledge. Doctors often cause soldiers to be infected by the use of unclean medical devices and bandage supplies.

An amputation surgery in the Battle of Gettysburg

Enterprise doctors need to bring their own medical devices. If they have other medical supplies or drugs, they have to buy them first and then apply for reimbursement from the government. The chaos of medical standards, equipment, and drugs eventually turned into a nightmare, causing a large number of unnecessary casualties.

Another source of chaos is the backwardness of the organizational system. Before the Civil War, the US military was accustomed to setting up field hospitals in regiments. Each regiment set up a field hospital, equipped with a doctor, a doctor assistant, and a medical manager. In the first year of the war, both the north and the south followed this system. However, actual combat has proved that such an arrangement is not conducive to the full potential of medical services. If the unit is too fragmented, it will cause tight or misalignment of the supply of medical supplies and personnel configuration. It is very likely that the materials of Group A are extremely short of, but Group B has a lot of redundancy. The same is true for personnel. After entering the war, a group of soldiers often appeared with a large number of wounded soldiers, and the doctors were exhausted, while the doctors in another group did nothing.

Jonathan Letterman's reform

The chaos continued from 1861 to 1862. After the Second Battle of Niu Benhe and the Battle of Sharpsburg, public opinion's dissatisfaction with the military's medical services reached its peak. Ironically, when it was required to carry out medical reforms in the federal army, northern public opinion quoted Confederate troops as an example, but in fact, the battlefield medical performance in the South was not better than that in the North.

Amid the voices of demanding reform, the US Health Commission (USSC) has made the most powerful statement. The U.S. Health Commission was founded in 1861 and is a charity based on the British private field medical organization during the Crimean War. Shortly after its establishment, the Health Commission had contact with the troops in the north and south and expressed its willingness to aid, but they were both coldly rejected. After the first Niubenhe Battle, under pressure from public opinion, the federal military had to agree to let the Health Commission participate and provide volunteer services. The Health Commission quickly organized an independent investigation, inspected the military camps in various places, assessed the health conditions and the level of doctors, and made recommendations on medical standards and the appointment and removal of doctors. Not only that, the Health Commission also purchased a large number of medical supplies, recruited and trained many doctors and nurses, greatly alleviating the chaos in the early stages of the war.

Founder of the U.S. Health Commission

In the summer of 1862, at the strong suggestion of the Health Commission, the new military chief William Hammond appointed Jonathan Letterman as the medical director of the Potomac Army. Letterman was born into a medical family and graduated from Jefferson Medical College in Philadelphia in 1849. He joined the army after graduation and had become an experienced military doctor by the time of the Civil War. Combining more than a decade of field medical experience and drawing on British practices in the Crimean War, Letterman made drastic reforms to the medical services of the Potomac Army.

Jonathan Letterman on the battlefield (the person on the far left)

Letterman first canceled the regiment-level field hospital and promoted the setting unit to division. In this way, the resource dispersion and messy caused by the small set-up units can be corrected. Then, under the premise of concentrated resources, an ambulance system was established. Specifically, each legion is equipped with an ambulance convoy, and the captain is directly responsible to the corps doctor's commander, rather than to the front line commander as before. Then, under the captain, an ambulance convoy at the division level and brigade level was set up, and it was stipulated that frontline commanders were not allowed to use ambulances without permission. The advantage of this is that the responsibilities of military doctors and soldiers are clearly defined. In the past, soldiers often had to give up their posts to help the lost military doctors transport the injured. Frontline commanders or quarrestrial officers often requisition ambulances to transport other supplies, which makes it impossible for the ambulance to play a role in evacuating the injured from the front line in a timely manner. The ambulance system played an active role in the initial trial of the Battle of Sharpsburg, and was quickly promoted. Even the Confederate troops imitated and established their own ambulance system.

Ambulance in the Civil War

Letmann will next rectify the field hospital.He required that field hospitals must be established in a protected area before each battle, with divisions, each hospital ensured that there was a chief physician, three clinicians, nine assistant physicians, and a medical manager responsible for food and cover. In addition, there are many trained soldiers serving as nurses or quartermasters. The doctors who were originally serving in the regiment were temporarily transferred to field hospitals for service, leaving behind an assistant military doctor and a special stretcher to be responsible for the frontline first aid bandage and transport of wounded personnel. Letterman may have been inspired by the Confederate Army's approach and vigorously promoted mobile tents, making field hospitals easier to build.

In this way, a complete battlefield first aid system will be established. After the soldier is injured, the regiment-level military doctor will first undergo a preliminary emergency bandage, and then be sent to the division-level field hospital through an ambulance and will be classified by the chief doctor and handed over to the clinician for corresponding treatment. Soldiers who need subsequent treatment will be transferred to the rear general hospital.

The far-reaching impact of the war

The soldiers who once entered the field hospital during the Civil War and survived the war were shuddered by this experience. In the memories of these soldiers, "butcher" and "demon" are common words. After all, most people had not seen the operating room until they participated in the Civil War and lacked enough medical knowledge. The residual limbs caused by the shells, the torn wounds, the gushing blood, and the scene of the scalpel cutting made them feel frightened.

Many scholars have not had a high evaluation of the medical services of the Civil War, and some people bluntly call it a medical disaster. Nevertheless, after the chaos in the early stages of the war, both the north and the south tried their best to save the wounded soldiers, thus leaving behind a valuable legacy. Letterman's reform was regarded as a model by later generations. The ambulance system and field hospital system he transformed were promoted and used, so he was called the father of American battlefield medical care. The ambulance later entered the city and became part of civilian medical care

Amendment convoy during the Civil War

0Civil War had a huge impact on the design and functions of the post-war hospital. In the early days of the war, the location selection of comprehensive hospitals was relatively casual and lacked reasonable building space. Tent hospitals on the battlefield show the advantages of simplicity and mobility, but have limited uses. So the medical department began to absorb the achievements of European hospital reform and build a Nightingale-style hospital that focuses on ventilation and hygiene. After the war, these experiences became the standard for building civilian hospitals. In addition, the previous hospitals were mainly used for charity to accommodate sick poor people. The Civil War has made many Americans feel timely treatment and careful care in the hospital for the first time, which has greatly changed their perception of the hospital. This is of great significance to the future development and improvement of hospitals.

A hospital in Washington adopts the typical style of the second half of the 19th century, with windows on both sides of the house for easy ventilation

According to scholars' statistics, from 1861 to 1866, the total number of casualties in the Northern Federation army reached 6.455 million. The emergence of a large number of casualties forced doctors to constantly deal with wounds and diseases, completing unprecedented numbers of surgeries. In the process, they saw all kinds of injuries, applied the latest medical tools, and painfully realized the limitations of medical development. At that time, the bacteria had not been discovered, and doctors were helpless about the diseases and worsening of injuries caused by bacterial infections. Drew Foster pointed out that almost three-quarters of soldiers suffered from diarrhea every year during the war; as of 1865, the incidence of diarrhea and dysentery was as high as 99.5%. Gangreno is extremely popular, and most field hospitals have to prepare special wards or tents for such patients.

Battlefield doctors use the resources they can use to save the wounded soldiers with all their might. Ether and chloroform anesthesia that had been invented before the war were more effective, and quinine was also promoted. Military doctors found that if amputation is required, the surgery must be completed within 48 hours, and the faster the better. Although they do not know the principle of bacterial infection, they learned from experience that surgery may cause "red, swelling, pus and blood", and if these phenomena have occurred in the injured, the surgery will be difficult to perform.

Gangrene caused by bacterial infection was extremely common during the Civil War

These painful experiences improved the overall level of doctors, promoted the progress of medical knowledge, and more importantly, created an environment for the development of post-war medical science. Medicine has escaped from the shadow of Jackson's era and reestablished a professional and scientific hierarchical system. The status of surgery has begun to improve, and at the same time, medical schools have more and more emphasis on practical operations. At the call of doctors, most states have passed legislation to use ownerless bodies for anatomy teaching. In addition, in order to learn from the lessons, the Chief of Military Medical Medicine Hammond organized the collection of pathological specimens from various battlefields, and all included in the Army Medical Museum later established. The museum will develop into the Armed Forces Pathology Institute and is one of the most important pathology research institutions in the United States.

The deceased cannot be pursued. For the living, the only thing that can be done, may be as Jonathan Letterman said, is to find meaning from the death of war.

References:

[1] Written by Drew Foster, translated by Sun Hongzhe and Zhang Juguo, "This Kingdom of Suffering", Yilin Publishing House, 2016.

[2] Gordon Dammann, Alfred Jay Bollet, Images of Civil War Medicine, Demos Medical Publishing, LLC.2008

[3] Shauna Devine, Learning from the Wounded, The University of North Carolina Press, 2014

[4] Gordon W. Jones, The Medical History of the Fredericksburg Campaign: Course and Significance, Journal of the History of Medicine and Allied Sciences, Vol. 18, No. 3 (July, 1963), pp. 241-256

[5] Dale C. Smith, Military Medical History: The American Civil War, OAH Magazine of History, Vol. 19, No. 5, Medicine and History (Sep., 2005), pp. 1719

[6] Courtney R. Hall, The Rise Of Professional Surgery in The United States: 1800-1865, Bulletin of the History of Medicine, Vol. 26, No. 3 (MAY-JUNE, 1952), pp. 231-26