Editor's Note: PBS has partnered with Mercy Street's historical consultants to bring fans the Mercy Street Revealed blog. Shauna Devine, Ph.D., is an assistant professor at the Schulich School of Medicine and the Department of History at Western University.

In this blog post, Devine discusses the development of scientific medicine and professional practice during the Civil War years. 

Through the Lens of Mercy Street

The American Civil War, was a war which as one historian wrote, “took place in the very last years of the medical middle ages [i]. Another noted that it was “a war in which army surgeons were merely clumsy, ill-trained doctors, often spurning chloroform and ignorant of the most elementary knowledge of hygiene [ii]."At the centennial of the Civil War medical historian Richard Shryock noted that, other than the efficacious work of the civilian welfare organizations, especially the U. S. Sanitary Commission, the war was generally a medical disaster [iii]. Indeed, until recently, it was generally accepted that the war years revealed the antiquated nature of American medicine. Although, recent scholarship has begun to coalesce around the idea that the Civil War laid the foundation for the post-war medical modernization that followed, the study of Civil War medicine as a specialist discipline within the history of medicine has left a challenging historiography. It thus begs the questions: Did the conditions of war help shape more modern medical and scientific standards in American medicine? Did the war years change ideas about how to practice and structure medicine? Or rather, did the war years retard the development of American medicine?

The degraded standards in medicine and medical education prior to the war have been well documented. In the 1830s and 1840s, in response to the attacks on elitism and the professions in Jacksonian America, most states had abandoned licensing laws and state recognition of medical societies. The American medical community had an almost insignificant proportion of university-educated M.D.s; virtually all practitioners trained by apprenticeships. One result was a deficit of general education and a lack of widespread conviction in the possibility of scientific progress in medical care. By the 1840s, many leaders recognized that competition for students was harming U.S. medical schools and that the spread of M.D. degrees did not necessarily reflect progress in medicine. The absence of legal regulations for medicine not only lowered educational standards but also encouraged the proliferation of competing medical sects, including unorthodox practitioners. There were few hospital facilities for medical teaching, which meant that medical school learning was almost entirely didactic. After decades of struggle, only two states had anatomy acts on the eve of the Civil War and there had been more than 17 anatomy riots in the years leading to the war.  In the absence of better educational models and legal regulations for medicine in the US, elite physicians increasingly looked abroad; but though these physicians wrote widely and made a convincing case for the importance of interventions such as the Paris Clinical School for the improvement of American medicine, they were too few in number to have a significant effect on the country. On the eve of the Civil War, the bulk of American physicians continued to practice bedside medicine, had never used a microscope, and most held a physiological conception of disease.

What has been less well documented were the sources of the dramatic changes that took shape in the postwar period. Beginning as early as 1867 societies and licensing associations established or strengthened licensing laws, the government sponsored epidemiological projects into infectious diseases and reforms were initiated in medical schools.  Just after the war, beginning with Pennsylvania, state after state began passing anatomy acts, making unclaimed bodies available to medical schools for teaching and research. These changes coincided with scientific pressures for reform. But while historians agree that by the end of the nineteenth century, science had become “a third estate within medicine,” the transforming role of the medical sciences during the Civil War in these larger histories has often been relegated to a chapter, even a footnote, or not considered at all.

If historians of the Civil War and nineteenth century American medicine have been skeptical about the impact of the war on American medicine, who can fault them? New estimates show that more than 750,000 men died as a result of the war, a number that would be proportional to 7.5 million people today. However,  if you change the focus and look less at the high rates of death due to infectious disease, the usual approach when evaluating medicine and the Civil War, but rather on the processes more than the outcomes, putting the emphasis on the physicians and how their questions changed through the war, the types of medical challenges that demanded support for newer and more scientific methodologies, and the institutional support provided by the government, it is very apparent that war years were transformative for many members of the profession and for American medicine.

As shown in the first two seasons Mercy Street, within the walls of the hospital we saw a profession striving to understand disease processes and germ theories, preventatives, and the best way to investigate disease. Led by the elite Dr. Foster, a character who might have mirrored the tenacious John Brinton or the scientifically minded Joseph Leidy, viewers saw a profession not knowing all the answers, but posing questions, pondering what they did not understand, and hypothesizing on the nature of diseases and wounds. Mercy Street highlighted many of the medical challenges faced by the profession in these years: typhoid fever, small pox, gangrene, erysipelas, intestinal diseases, soldiers heart, unprecedented types of wound trauma and interesting cases. The wartime hospitals, as deftly shown in Mercy Street, revealed physicians working together trying to master new and unprecedented kinds of medical challenges; they experimented with new therapeutic remedies and pioneered new procedures including facial reconstructions, a blood transfusions, arterial ligations among many others.

 We met Dr. Hale a physician with minimal medical training prior to the war, who was transformed by the experience. He, like many war-time physicians, studied and sat for the difficult entrance exams, peered through new microscopes, performed autopsies and carefully packaged up medical and surgical specimens along with hand-written case reports for the new Army Medical Museum as a matter of official policy. Indeed, as the war proceeded and the bodies and range of diseases accumulated, as shown in the many case histories and contemporary publications, the transforming role of the medical sciences, particularly in the ways that American medicine was studied, structured, practiced, recorded and understood during and after the war reveals a transformative practical and educational experience for many American physicians—one that transcended any other domestic or international opportunity in the 1860s.

So what was the impact of the Civil War on American Medicine? I do not want to suggest here that because of the Civil War, American medicine was triumphing over all medical challenges in the postwar period. In the 1860s there were no simple answers about disease germs, and debates between opponents and proponents of the germ theory and laboratory medicine raged for at least two decades after the war. American physicians were challenged by smallpox epidemics, yellow fever, malaria, cholera, typhoid, and typhus fever, and these diseases were on the increase with the rise of immigration in the Progressive Era. In other words, medicine was not and could not be transformed overnight. Medical reforms would continue to take shape as part of the "coming of age of American universities" in the 1870s, which variously included more money, better leadership, and increasing support for academic medicine and new ideas. At the same time, states slowly began passing new anatomy laws or strengthening old ones, and the American Medical Association, state licensing boards, local medical societies, and new specialist associations had to define or redefine the larger goals of the profession in the context of their own associations. The war years, however, were important in preparing physicians for this transition. Through their wartime experience, many physicians saw the need but also the efficacy of more stringent requirements in medicine; they were exposed to new scientific techniques and gained a practical experience that could not be overestimated.

More than 12,000 physicians served in the Union Army and then went home--they delivered babies, treated farm injuries, vaccinated patients, and treated the flu or cases of epidemic disease. Physicians had seen the value of a science-based practice in the Civil War hospitals--this might have meant being part of the bromine or disinfection debates for managing gangrene and erysipelas or cholera. Some physicians prepared multiple specimens, performed autopsies, or countless amputations and surgeries; others managed diseases such as dysentery, tetanus, and smallpox. Physicians were daily exposed to new medical challenges, and they consulted readily with one another; they saw the possibilities of medical science and experimental methods (crude as they were in the 1860s) and the efficacy of sanitary science, which developed alongside new ideas about contagion. Some of these physicians would go to local medical society meetings, they would engage with other physicians, and during and after the war they were asking increasingly complex questions. Before the authority of the German model of medical science took shape in America, these questions and debates were facilitated through a well-tested infrastructure--not only the new Army Medical Museum and the publications of the Surgeon General's Office but also medical journals and meetings of medical societies--which got stronger through the war, along with new local public health boards, which were also formed during the war and then reshaped after.

Mercy Street was a television drama, and must be evaluated as such. However, the larger aim of the show was to tell what producer Lisa Wolfinger referred to as the “less well known medical story of the Civil War”; not the more familiar Gone with the Wind story, which highlighted medical chaos, or Dances with Wolves where the main character escaped in a flurry from the “incompetent” doctor to avoid having his leg amputated. But in reality, by year two of the war, physicians in consultation would have examined the wound, determined whether an amputation was necessary or if the wound might heal with diet, stimulants, rest and local application of therapeutics. If physicians believed the wound might get infected, performing a secondary amputation would give time for the infection to set in and the amputation would be performed though infected tissue thus aiding the spread of disease leading to almost certain death. Kevin Costner’s character after escaping the physician may very well then have succumbed to his wound. Physicians learned through experience when a primary amputation should be performed and this knowledge saved countless lives.

Understanding the complex questions that physicians faced during the Civil War, the response to these challenges, and the way in which this knowledge was produced and transmitted was a crucial stage in the development of scientific medicine in the nineteenth century. The context of what constituted the medical sciences continued to evolve in the postwar period, and numerous former Civil War physicians were important as causes and beneficiaries. Mercy street was a bold drama that aimed to bring the story of Civil War medicine to life and the entire team succeeded admirably.

— Shauna Devine

Sources

[i] George Worthington Adams, Doctors in Blue: The Medical History of the Union Army in the Civil War (Baton Rouge: Louisiana State University Press, 1952, 1980); he may have been quoting William Hammond but the source is not documented.

[ii] Peter J. Parish, The American Civil War (New York: Holmes & Meier Publishers, 1975). See also Robert Bruce, The Launching of American Science, 1846-1876 (New York: Alfred A. Knopf, 1987).

[iii] Richard Shryock, “A Medical Perspective on the Civil War." American Quarterly 14 (1962): 161-73.