Chapter 1 "It was like the days when there was no King in Israel" When William Williams Keen, an assistant surgeon for the Fifth Massachusetts Infantry, walked into Sudley Church, he was startled by what he saw. The small house of worship, located on the northern fringe of the Bull Run battlefield, had been transformed into a field hospital for Union troops. This makeshift treatment facility, along with its outbuildings, was overflowing with the wounded and dying. The church's pews were piled outside, and the building's floor was covered with hay and blankets for emergency bedding. Buckets of dirty water, wooden boxes with surgical instruments, and paper packages containing beeswax-coated sutures and dressings were strewn about. The operating table, little more than a few boards laid on crates, stood in front of the pulpit. A bloodied communion stand served as a resting spot for the weary. Both inside and outside the hospital, medical activity was frenetic and groans filled the air. From their perch in a small upstairs gallery, those with minor injuries craned their necks to observe the physicians, aided by a number of local women, go about the messy work of cutting. Amputations were performed in full view of the assembled, with blood splattering those too near, including the next victim of the surgeon's scalpel. Keen, assisting at an amputation of a shoulder, quickly realized that the operating surgeon had little knowledge of the anatomy of the upper arm. To keep the soldier from bleeding to death, Keen had to tell the surgeon where to cut and sew. In his memoirs, Keen explains that his clinical discomfort was compounded by the unnerving realization that "up to that time, and, in fact, during the entire [Bull Run] engagement, I never received a single order from either Colonel or other officer, Medical Inspector, the surgeon of my regiment, or any one else." Keen acknowledged, "It was like the days when there was no King in Israel, and every man did that which was right in his own eyes." Indeed, just two weeks earlier, twenty-four-year-old Keen had been a first-year medical student at Philadelphia's Jefferson Medical College. Keen, who later became professor of surgery at his alma mater and eventually fifty-second president of the American Medical Association (AMA), had begun the study of medicine only in September 1860 and was hastily recruited to join the army's medical corps several months later. "My preceptor, Dr. John H. Brinton, had received a telegram from a former student (let us call him Smith) who had graduated in March 1861, and was Assistant Surgeon of the Fifth Massachusetts, saying that he was going to leave the regiment." Under orders to replace this assistant surgeon, Brinton "very kindly offered the place to me." Immediately, Keen confided his concerns about his clinical capabilities to Brinton. The preceptor replied, "It is perfectly true that you know very little, but, on the other hand, you know a good deal more than Smith." With just fourteen days of military service to guide him, Keen considered himself to be "as green as the grass around me as to my duties on the field." The battle at Bull Run had not gone well for the Union troops. With defeat imminent, the North's evacuating columns moved rapidly by Sudley Church as Keen applied a splint and eight yards of bandage to a man who had been shot in the upper arm. The passing soldiers yelled, "The rebs are after us," and Keen's charge, despite a potentially mortal wound, "broke away from me," Keen noted, "rushing for the more distant woods. As he ran, four or five yards of the bandage unwound, and I last saw him disappearing in the distance with this fluttering bobtail bandage flying all abroad."1 With Keen ordered to retreat to Washington, it became obvious to all concerned that no exiting strategy or armed protection had been arranged for the field hospital's wounded. By early evening, with Confederate forces swarming over the church grounds, the three hundred or so Union injured, along with several medical personnel, faced a very uncertain fate. If ever an event served as a harbinger of medical misery, it was this July 21, 1861, First Battle of Bull Run (Manassas, in Southern parlance). Evidence of much that was wrong with mid-nineteenth-century American medicine, Bull Run, with its 750 killed, 2,494 wounded, and more than 1,500 missing, was essentially a savage military engagement fought by poorly trained troops who received treatment from inadequately prepared physicians in a chaotic setting. According to one contemporary account, "The conception was unwise; the plan faulty; the execution imperfect."2 From the wretched state of the wounded to the disorganized scattering of surgeons over the rolling battlefield, Bull Run became a tragic lesson in military medical hubris. With few available surgical supplies and no plans in place to evacuate casualties, the injured lay for days on the ground where they fell, suffocating on their own vomit and delirious from infection. Many received neither medical attention nor so much as a mouthful of water. "The profession, as the conservator of life, asks in the name of the Republic why the wounded were not brought off the field, and why the hospital was not guarded?" editorialized one physician. "It asks why the surgeons were not sustained and protected in the discharge of their duty?"3 By proclaiming his indignation, this doctor drew attention to a concern that was developing among America's physicians over the part they would play in the nation's civil conflict. But medical doctors were not the only ones anxious about the government's role in the rapid expansion of military medicine. Every day, ordinary citizens attempted to reckon with the growing number of battlefield and illness-related deaths, as well as the attendant suffering that soldiers endured. One New York woman wrote, "We ought to remember that for every one that falls on the battlefield or suffers a languishing death in the hospitals, some friends mourn and weep their lives away."4 After Bull Run, America's physicians called for organizational reforms and urged President Lincoln, the United States Congress, and state legislatures to respond to the medical tragedies of the internecine struggle. "The lives of thousands of citizens, the strength of the State, and the efficiency of the armies of the Republic, demand new, enlightened, and liberal legislation," wrote one physician activist.5 The doctor's concerns were well-founded. What would happen to sick and wounded soldiers if politics controlled camp and battlefield medical care? Who would be held accountable: politicians, physicians, or society as a whole? In 1860, many Americans had a romantic idea of war that ignored the day-to-day medical horrors of armed conflict. This was revealed when, following the fall of Fort Sumter in April 1861, Abraham Lincoln issued a proclamation calling for seventy-five thousand state militiamen to provide ninety days of voluntary national service to put down the secessionists. Patriotic fervor swept the land as citizens rallied to the cause and all manner of physicians enthusiastically offered their services. According to an article in The New York Times, even renowned medical professors forsook "their luxurious chairs to join the hardships of a soldier's life," leaving "a practice worth tens of thousands, that they may go to alleviate the sufferings of the camp."6 From the most humble hamlets to the largest cities, state military regiments were organized, funds raised, flags unfurled, food stocked, and equipment supplied, but little consideration seemed to be given to the medical realities of military life. These early volunteer troops followed the well-established militia tradition whereby a prominent businessman or a politically influential individual would, under a governor's authority, recruit a fighting force and, in return, be named the unit's commander, usually with a rank of "colonel." This often meant that an individual of wealth or celebrity became a wartime leader simply by purchasing uniforms and providing supplies to a ragtag collection of men and sometimes boys. As one young Pennsylvanian recruit wrote home to his mother in the summer of 1861, "Col. Roberts has showed himself to be ignorant of the most simple company movements. There is a total lack of system about our regiment. . . . Nothing is attended to at the proper time, nobody looks ahead to the morrow, and business heads to direct wanting. . . . We can only be justly called a mob & not one fit to face the enemy."7 President Lincoln directed state governors to also appoint a surgeon and an assistant surgeon for each of the new volunteer regiments, "after having passed an examination by a competent Medical Board . . . the appointments to be subject to the approval of the Secretary of War."8 Despite the law's intent, when companies of one hundred men and even whole regiments of one thousand individuals consisted entirely of enlistees from a single village, township, county, or city, it frequently came down to little more than asking the amiable local doctor to accompany the troops. "He may have been a good family medical attendant in the town where he resided and perhaps has given some attention to domestic hygiene, but he knows nothing of the habits of soldiers; of their diet; of the sites, choice, and ventilation of tents," groused one physician. Furthermore, the same doctor added, even if he enjoyed an enviable reputation as a surgeon, he may "never have met an accident peculiar to the field of action."9 Eventually, the (Northern) United States Army would maintain on its payroll more than eleven thousand physicians. However, during the opening weeks of what was by all accounts to be a limited military affair, there was little more than a handful of "experienced" army surgeons and a multitude of "inexperienced" physician volunteers. Disorder and frustration ruled the day, as revealed in Charles Tripler's official report to the surgeon general. Tripler, who was named medical director of the North's Army of the Potomac immediately following Bull Run, told of how "the Secretary of War had accepted what were termed independent regiments, the colonels of which asserted a right to appoint their own medical officers." The result of this decidedly arbitrary recruitment process was often total confusion: "Colonels of state regiments refused to receive the medical officers appointed in conformity with the law and went so far as to put these gentlemen out of their camps by force," wrote Tripler. Furthermore, Tripler complained that these "irregularities created great embarrassment and confusion in organizing my department, and many regiments were thus left with surgeons as to whose competency nothing was known. In other instances, regiments, or parts of regiments, were sent on without their medical officers, the colonels assuming authority to leave them at home under various pretexts."10 Often serving as mere rubber stamps for the political whims of governors, their political backers, and the well-to-do, the boards' physician appointees also demonstrated gross variations in their levels of competency. "The State Boards of Medical Examiners have proved, in many instances, either negligent, or culpably ignorant of their duties," complained an editorial in the widely circulated American Medical Times. "We may estimate by hundreds the number of unqualified persons who have received the endorsement of these bodies as capable Surgeons and Assistant-Surgeons of regiments. Indeed, these examinations have in some cases been so conducted to prove the merest farce."11 Professional concern mounted as the government's ability to organize an efficient medical corps was called into question. "It is no holiday service that is expected now, and no qualifications short of the highest should authorize the government to entrust the care of the health of our troops to any man. There should be no favoritism here," exclaimed a physician in the Boston Medical and Surgical Journal. "Shall it be said that our friends and brothers, whose patriotism calls them to the field at this trying hour, shall be subjected to the dangers of surgical inexperience as well?"12 Even on the front page of prominent newspapers, pleas were made that only "skillful men" be allowed to retain commissions as volunteer surgeons. To compound difficulties, a natural antagonism existed between physician volunteers and their full-time army counterparts. With few knowledgeable personnel to instruct medical recruits as to the military code of behavior, difficulties soon arose due to a fundamental failure to grasp the difference between civilian practice and a military way of life. According to one participant, "In the vast majority of volunteer organizations, the surgeon has no one to instruct him in his duties; and not apprehending, as was very natural to a civilian, the importance of a rigid adherence to prescribed forms, he was very apt to deem them a species of red-tapeism, to be discarded by men of energy."13 This failure to appoint appropriately qualified medical men was partly responsible for one of the earliest health-related scandals of the war: the tragicomic physical examination of those recruits serving for ninety days. According to the War Department's General Order No. 51, all regimental surgeons were expected to examine the men in the following manner: In passing a recruit the medical officer is to examine him stripped; to see that he has free use of all his limbs; that his chest is ample; that his hearing, vision, and speech are perfect; that he has no tumors, or ulcerated or extensively cicatrized [scarred] legs; no rupture or chronic cutaneous affection; that he has not received any contusion, or wound of the head, that may impair his faculties; that he is not a drunkard; is not subject to convulsions; and has no infectious disorder, nor any other that may unfit him for military service.14 However, during the organizational morass of late spring and early summer 1861, this proviso was sometimes, perhaps for political purposes, ignored. "So notorious was the neglect of its behests, or the incompetency of those who pretended to obey it," noted medical director Tripler, "that another general order from the same authority was demanded and issued . . . which threatened to make the derelict officers pecuniarily responsible for disregarding it."15 Haste was the operative word, and endless abuses of Order No. 51 led to ridiculously unbalanced ratios of sick to healthy. According to Tripler, the physician of the Sixty-first New York Infantry (also known as the Clinton Guard) reported that "he had a large number of broken-down men: many sixty to seventy years old," most of whom had "hernia, old ulcers, epilepsy, and the like."16 Tripler told of one brigade surgeon who found that in many of the regiments under his purview, there had been absolutely no medical examination prior to the soldiers' enrollment. The Fifth New York Cavalry (also known as the First Ira Harris's Guard) had as many as eighty men with ruptures and neurologic conditions out of its total force of a few hundred. One private wrote home to his parents about how his examining doctor palpated his collarbone and said, "You have pretty good health, don't you?" The soldier-to-be replied that he felt fine, and the examiner remarked, "You look as though you did." Such was the sum and substance of his physical examination, and upon further inquiry regarding "fits or piles," the new recruit was pronounced ready for service.17 It seemed, according to Tripler's evaluation, "as if the army called out to defend the life of the nation had been made use of as a grand eleemosynary [charitable] institution for the reception of the aged and infirm, the blind, the lame, and the deaf, where they might be housed, fed, paid, clothed, and pensioned, and their townships relieved of the burden of their support."18 Excerpted from Bleeding Blue and Gray: Civil War Surgery and the Evolution of American Medicine by Ira M. Rutkow All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.