Bleeding Blue and Gray: Civil War Surgery and the Evolution of American Medicine


A landmark chronicle of Civil War medicine, Bleeding Blue and Gray is a major contribution to our understanding of America’s bloodiest conflict. Indeed, eminent surgeon and medical historian Ira M. Rutkow argues that it is impossible to grasp the harsh realities of the Civil War without an awareness of the state of American medicine at the time.

At the outset of the war, the use of ether and chloroform remained crude, and they were often unavailable in the hellish conditions at ...

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A landmark chronicle of Civil War medicine, Bleeding Blue and Gray is a major contribution to our understanding of America’s bloodiest conflict. Indeed, eminent surgeon and medical historian Ira M. Rutkow argues that it is impossible to grasp the harsh realities of the Civil War without an awareness of the state of American medicine at the time.

At the outset of the war, the use of ether and chloroform remained crude, and they were often unavailable in the hellish conditions at the front lines. As a result, many surgical procedures were performed without anesthesia in the compromised setting of a battleground or a field hospital. This meant that “clinical concerns were often of less consequence,” writes Rutkow, “than the swiftness of the surgeon’s knife.”

Also, in the 1860s, the existence of pathogenic microorganisms was still unknown–many still blamed “malodorous gasses” for deadly outbreaks of respiratory influenza. As the great Civil War surgeon William Williams Keen wrote, “we used undisinfected instruments from undisinfected plush-lined cases, and still worse, used marine sponges which had been used in prior pus cases and had been only washed in tap water.”

Besides the substandard quality of wartime medical supplies and techniques, the combatants’ utter lack of preparation greatly impaired treatment. In 1861, the Union’s medical corps, mostly ill-qualified and poorly trained, even lacked an ambulance system. Fortunately, some of these difficulties were ameliorated by the work of numerous relief agencies, especially the United States Sanitary Commission, led by Frederick Law Olmsted, and tens of thousands of volunteers, among them Louisa May Alcott and Walt Whitman.

From the soldiers who endured the ravages of combat to the government officials who directed the war machine, from the good Samaritans who organized aid commissions to the nurses who cared for the wounded, Bleeding Blue and Gray presents a story of suffering, politics, character, and, ultimately, healing.

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Editorial Reviews

Publishers Weekly
During a 39-day period in the spring of 1865, 45,000 Union soldiers were killed or wounded. The wounded received the best care available at the time-care that by current standards is horrifying. In this fast-moving and informative book, Rutkow (Surgery: An Illustrated History) recreates the experience of the common Civil War soldier: it "was more sharply defined by agony, butchery, and loneliness than anything else." Simple gunshot wounds necessitated amputation; lack of antiseptics meant more soldiers died from postoperative infection than from their wounds. Communicable diseases ravaged the armies on both sides of the conflict. Rutkow charts the progress of the military medical system during the course of the war, focusing on the struggles (against political opposition) of Sanitary Commission director Frederick Law Olmsted to establish a humane and scientific system of care for the fallen. As Rutkow shows, such medical developments as the construction of hospitals and the specialization of surgery aided in the "professionalization of American medicine." With plenty of historical context, Rutkow's book should appeal beyond hardcore Civil War aficionados to a larger readership interested in a gritty, compelling story well told. 16 pages of photos not seen by PW. Agent, Janklow & Nesbit. (On sale Apr. 19) Copyright 2005 Reed Business Information.
Library Journal
This is different from other recent histories that focus on medicine during the war (Alfred Jay Bollet's Civil War Medicine; Frank R. Freemon's Gangrene and Glory) because it also reviews political and social changes that had significant impact upon war medicine. Rutkow (surgery, Univ. of Medicine & Dentistry of New Jersey; Surgery: An Illustrated History) is a respected expert on the history of American surgery whose work has been mainly in the area of Civil War medicine. Rutkow particularly highlights the work of the U.S. Sanitary Commission and its role in the war. Owing to limited sources, he does not spend much time on Confederate medicine. While the text is accessible to the casual reader, this book is written for students of the war and those interested in the history of medicine. For general and academic libraries.-Eric D. Albright, Tufts Univ. Health Sciences Lib., Boston Copyright 2005 Reed Business Information.
Kirkus Reviews
An absorbing account of how American medicine was changed forever by the efforts to bring good medical care to men on the battlefields of the Civil War. Rutkow (Clinical Surgery/Univ. of Medicine and Dentistry of New Jersey), the author of several histories of surgery, focuses here on medical care on the Union side during the Civil War, for it was the Northern experience, he notes, that most affected the future practice of American medicine. He paints a vivid picture of the state of medicine before the war, when medical schooling was haphazard, a hodgepodge of therapies vying for supremacy. While no great scientific innovations occurred during the Civil War era-germ theory came later, and anesthesia was still largely unavailable-the war brought discipline and standards to a fractious profession and transformed the administration and organization of military medical care. In particular, Rutkow tells the story of the powerful United States Sanitary Commission, a civilian relief agency established at the start of the war. Under the guidance of Frederick Law Olmstead, the Commission set standards for military camp sanitation, advocated an independent ambulance service, and fought for a strong Surgeon General, William Hammond. Among Hammond's successes was the reform of the US Army's Medical Department and the redesign of military hospitals, changing forever the public's notion of what a hospital could be. While Rutkow captures the sweep of action on battlefields and the bloody aftermath of battles, he also reveals the political infighting that went on at the same time. His cast includes politicians with personal grievances, generals with petty animosities, doctors and nurses with ambitionsand jealousies, and, of course, soldiers with gruesome wounds. Great storytelling that both Civil War buffs and fans of medical history will surely relish.
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Product Details

  • ISBN-13: 9780375503153
  • Publisher: Random House Publishing Group
  • Publication date: 4/19/2005
  • Pages: 416
  • Product dimensions: 6.60 (w) x 9.40 (h) x 1.30 (d)

Meet the Author

Ira M. Rutkow is a clinical professor of surgery at the University of Medicine and Dentistry of New Jersey. He also holds a doctorate of public health from Johns Hopkins University. Dr. Rutkow’s Surgery: An Illustrated History was a New York Times Notable Book of the Year. He and his wife divide their time between New York City and the Catskills.
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Read an Excerpt

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

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