Surgical anesthesia in the Civil War and the present day – whither ether?

 - Harrison Smith-Jaoudi

The adoption of anesthesia as an integral part of major surgery in the Civil War owes much to publication efforts that provided military physicians, many with scant prior training or experience, practical guidance in the form of handbooks and manuals, the most widely distributed of which explained and advised surgical applications of inhalational anesthesia (https://pmc.ncbi.nlm.nih.gov/articles/PMC11191930/). The landmark Medical and Surgical History of the War of the Rebellion (MSHWR) records more than 80,000 instances of inhalational anesthesia, a “conservative figure” for the Union forces that includes 8,900 instances of use in “major operations” (https://pubmed.ncbi.nlm.nih.gov/20503754/). More than 160 years after the end of the war in 1865, it is of interest to see how essential aspects of the then-burgeoning practice of anesthesia appear in the present day. This post looks at one such aspect, the anesthetic agent ether, with an emphasis on merits recognized by Civil War physicians that contribute to its utility in present-day anesthesia.

The earliest attempts to free patients from surgical pain are presumably lost to the historical record, but nerve compression, to take one example, seems to be attested at least from the third millennium BCE in ancient Egypt. From then on, there are anesthetic efforts, some similarly rooted in now-recognizable aspects of human physiology, scattered across time and space, including forms of “refrigeration anesthesia” via the application of ice or snow, as performed by Marco Severino in the 1600s, through various applications of opiates and ethanol, with commensurately various levels of plausibility and success, into the 19th century. Perhaps most intriguing is the soporific sponge, a device applied beneath the surgical patient’s nose from the 9th through 13th centuries. By boiling mandrake leaves, poppies, nightshade, and other herbal components, practitioners managed to infuse the soporific sponge with scopolamine and morphine, two agents that still see anesthetic and perianesthetic application as, respectively, antiemetic and analgesic (https://oce.ovid.com/book?SerialCode=02274621).

Ether, a volatile liquid whose vapors serve as an inhalational anesthetic, may have been known, and some of its potential anesthetic properties recognized, from as early as the 8th century, by the author or authors of the Jabirian corpus in the Islamic Golden Age. In Europe it was perhaps known to Raymond Lully in the 13th century and certainly known, as oleum vitrioli dulce, to Paracelsus and Valerius Cordus in the 16th. Its entrance into the medical limelight as an anesthetic, however, had to wait until the mid-19th century. Following then-unpublicized applications by William Clarke and Crawford Long in 1842, dentist William Morton executed the first public demonstration of ether for surgical anesthesia at the Massachusetts General Hospital, on 16 October, 1846, roughly 15 years before the Civil War began. Experimentation with ether for surgical anesthesia, along with greater interest in nitrous oxide and soon chloroform as alternative inhaled anesthetics, had spread worldwide by the end of the decade (https://oce.ovid.com/book?SerialCode=02274621).

In the Civil War itself, ether did not enjoy universal application, despite the broad uptake of anesthesia in surgical practice. Instead chloroform, the other dominant anesthetic agent of the 1860s, was the sole agent in 76.2% of cases the MSHWR records; by contrast, ether was the sole agent in 14.7% of cases. The two jointly applied in the remainder of cases, an intriguing early demonstration of medical interest in the power of anesthetic agents to complement or compensate one another’s strengths and deficiencies (https://doi.org/10.1177/0310057X0603401S01).

Chloroform’s primary merits were rapidity of induction and emergence, low volume requirements and hence ease of transportability and application in the field, lack of both objectionable odor and superficial respiratory irritation, and, perhaps crucially, lack of flammability – all by contrast with ether. Chloroform, however, posed serious respiratory and cardiac risks in the short term, risks whose principled scientific investigation and impact in ending chloroform anesthesia extended well into the 20th century, but which were clearly known by the time of the Civil War. The difference in perceived safety between the two agents is nicely illustrated by the section on anesthesia in Stephen Smith’s (Union) Hand-Book of Surgical Operations, preserved online (https://archive.org/details/handbooksurgica00smitgoog/page/n41/mode/2up?view=theater), where the instruction that ether should be applied “lavishly” contrasts with the admonishment that “great care must be exercised” in the administration of chloroform. Comments from physicians of the time who compared the two agents show informative parallels to the current day. Surgeon B.B. Breed, for example, wrote that despite chloroform’s widespread and largely successful use, he “employed ether in preference… preferring, both from personal experience and observation the delay and discomfort in its administration to the possible danger from the use of the latter” (https://pubmed.ncbi.nlm.nih.gov/20503754/).

What Breed indicates here, aside from the inductive sluggishness and subjective noxiousness of ether, is its remarkable safety profile, a major contributor to its continued worldwide use. In resource- and training-limited circumstances, in particular, ether is still invaluable, for reasons that largely held in the Civil War era too. For one of many modern enumerations of these reasons, readers can turn to Improvised Medicine: Providing Care in Extreme Environments (2nd ed., 2016); a selection follows. First, both diethyl ether (most common in the Civil War and still commonly used) and divinyl ether (most preferable today) are easy to produce, and in exigency can be repurposed from industrial to medical application. Second, it offers a (comparatively) vast safety margin, i.e., the dose required for satisfactory surgical anesthesia and the dose at which adverse events become likely are so far apart that it has been called “fool proof”, even in inexperienced hands. It supplies “intrinsic analgesia [and] neuromuscular relaxation, is a bronchodilator, rarely potentiates the dysrhythmic effect of sympathomimetic agents, causes little uterine relaxation, stimulates blood flow (helpful in shocky patients), and stimulates respiration” (https://accessmedicine.mhmedical.com/content.aspx?bookid=1728&sectionid=115695659).

Of course there are myriad risks and caveats to be added. Certainly ether is no panacea, and the notion that any agent or procedure in medicine could be fool proof must be taken as hyperbolic. Still, ether is worth the attention not only of anesthesiologists and anesthetists, but of all practitioners with an interest in maintaining some of the advantages of surgical anesthesia when resources and training are limited. A celebration of ether anesthesia seems to be in order – just keep the matches and fireworks in another room.

Standardizing the Charts: Exploring the Civil War Legacy of William Hammond on Medical Recordkeeping

- Yousuf Latif

Today’s world of modern American medicine is heavily data based – from even before a patient enters the site of care to after they leave, patient data is being collected and categorized in the electronic medical record (EMR). Age, address, vitals, medications, pre-existing conditions, family history, procedure records, progress notes, and more can be added to the chart with every visit. While EMR interfaces may differ, much of the information collected today is standardized across practices throughout the country. This was not always the case, however, and one of the crucial pivot points towards the standardization and collection of patient data can be attributed to the American Civil War, and the efforts that took place under the tenure of Surgeon General William A. Hammond. Dr. Hammond took office in 1862, and at this time, the union army was struggling with disease and disorganization both in its hospitals as well as in its recordkeeping. Hammond and his subordinates’ reforms during the war standardized, medical records, and transformed medical notes from ad hoc physician notes into a more formal and structured system that influenced both military and civilian health records thereafter.

Prior to the Civil War, there were some efforts to compile records on sickness and mortality, however, there was little standardization and these statistics were not collected at regular intervals, or at a scale comparable with the Civil War. One such example from 1856 was The Statistical Report on the Sickness and Mortality in the Army of the United States, published by the office of the Surgeon General of the US Army. Although it was one of the earlier large reports, it was actually fairly involved, and included data on mortality as well as sickness by specific illness down to the regimen level (1). However, this was not a routine report – instead it covered a somewhat arbitrary sixteen year period – and the report acknowledges that its input data was at times lacking. Types of records varied by physician, there were no standard forms used, diagnoses were often vague or non-exhaustive, and often times data was either discarded or not collected. Civilian hospitals before the war also had little to no central reporting, as there was not national framework to guide them.

As Surgeon General, Hammond began to lay the foundations to correct some of these issues in data collection. In his role he directed for departmental surgeons to consolidate and send monthly reports of the sick, wounded, and killed in action to the Surgeon General’s office. His push for the collection of these reports, as well as bed cards and case histories allowed for the creation of the Medical and Surgical History of the War of the Rebellion report – an impressively detailed medical record of the war (2). Hammond also issued Circular No. 2, which in addition to establishing the Army Medical Museum also directed medical offers to “diligently collect and forward to the office of the Surgeon General all specimens of morbid anatomy, surgical or medical, which may be regarded as valuable; together with projectiles and foreign bodies removed; and such other matter as may prove of interest in the study of military medicine and surgery”(3). Hammond also required that physicians sent case histories with the samples they sent, in order for these records to better advance science and be able to be instructive to future army medical practitioners. (4). Other key reformers in the Civil War also helped to standardize the information that the healthcare system collected. Jonathan Letterman, the medical director of the Army of the Potomac, required that assistant-surgeons submitted reports of each case seen in the hospital, including the patient name, rank, company, hospital site, detail of the injury, the treatment given, and the eventual outcome. This data would be used to make tables detailing by unit the location of wounds, type of weapon that caused the injury, and treatment operation performed. Letterman also began to require that army medical directors made monthly reports to be delivered to the Office of the Surgeon General that noted issues faced and deficiencies that needed correcting, as well as to compile reports on hospital supply levels (4).

While the reforms and pushes for standardization in record keeping during this time were not always perfectly followed, they were a seminal moment towards the standardization of forms and the more regular recording of medical information. In the years that followed, army reporting became embedded in Army medical practice, and reporting of sickness and mortality became more standardized and regular through the eventual adoption of annual reports and standardized disease categories (5). While the story of Civil War medicine often focuses on battlefield amputations and early medical practices, an unsung part of its legacy is in the paperwork. Hammond and his department took the disorganized practice of notekeeping and set forth an expectation of uniform and detailed medical records. These were a turning point in American medical record keeping – this expectation never disappeared, and eventually made its way from military medicine to the civilian world. Hammond’s reforms ushered the way to our modern reporting standards that expect health data to be uniform, centralized, and used to guide policy.


References

1. Coolidge, R. H. (n.d.). Statistical Report on the Sickness and Mortality in the Army of the United States, Compiled from the Records of the Surgeon General’s Office; A Period of Sixteen Years, from January, 1839, to January, 1855.AMEDD Center of History & Heritage. https://achh.army.mil/history/book-mexicanwar-casualtystats-mexwarstats 

2. Love, A. G., Hamilton, E. L., & Hellman, I. L. (n.d.). Tabulating Equipment and Army Medical Statistics. AMEDD Center of History & Heritage. https://achh.army.mil/history/book-misc-tabulatingequipandarmymedstats-chapter2 

3. Price, D. (2021, April 24). The Civil War and the Army Medical Museum. National Museum of Civil War Medicine. https://www.civilwarmed.org/army-medical-museum/ 

4. Barr, G. (n.d.). Writing a Better System into Place: How Record-keeping During the Civil War Transformed Military Medicine in the United States. Galter Health Sciences Library & Learning Center. https://galter.northwestern.edu/news/writing-a-better-system-into-place-how-record-keeping-during-the-civil-war-transformed-military-medicine-in-the-united-states?category=75 

5. Marble, S. (2025a, April 20). U.S. military medical surveillance: Two centuries of progress. MSMR. https://pmc.ncbi.nlm.nih.gov/articles/PMC12091953/ 

The American Civil War and the Making of the Modern Emergency Medical Technician

- Kyle Zielinski

The Emergency Medical Technician (EMT) is a pre-hospital medical professional that specializes in stabilizing patients with acute illness or injury in the field until they can be transported to a higher-level facility like a hospital. In the modern era, EMTs treat patients in ambulances to minimize the time between incident and advanced care at hospitals and clinics.

It almost seems second-nature to think that triage should be performed by a peripheral care provider, like an EMT, during a rapid, coordinated transportation effort to a larger healthcare facility. In reality, this rapid response procedure was not developed until the American Civil War during the mid-to-late-nineteenth century. The modern emergency medical technician operates on principles proposed hundreds of years ago by a military and health care pioneer named Jon Letterman.

In the early days of the Civil War, wounded were left for dead on the battlefield. Battlefield medicine was disorganized and chaotic in part because the war was not expected to last longer than a few weeks. Medical supply shortages were common and poorly executed rescue efforts would often leave the wounded stranded for days after the battle had ceased. Once rescued, the organizational structure of surgeons and hospitals was not much better. The concept of triage had not yet been employed by the Union and the Confederates: the injured would be treated based on the order in which they suffered their wounds, not by the severity of their injuries.

Then came along Jonathan Letterman, a surgeon who eventually rose to the ranks of major and was assigned medical director for the Army of the Potomac in June 1862. Prior to his arrival, regimental musicians would double as stretcher bearers and ineffectively carry the wounded off the battlefield. After a failure to rapidly recover the wounded from the battlefield at Second Manassas, General George McClellan gave Letterman free reign to make changes to battlefield medical services that still influence how emergency care is delivered in the 21st century.

One of Letterman’s most important innovations in battlefield medicine was establishing the first Ambulance Corps. Men were trained to operate wagons and act as stretcher bearers to recover the wounded from battle. In its infancy, the distribution of medical supplies among the wagons was not equal. Letterman established a standardized protocol to ensure that all necessary medical supplies were on each wagon instead of individual wagons carrying certain supplies for specific injuries or ailments. Even today, EMTs and paramedics utilize checklists to ensure that each ambulance contains the necessary medical supplies for any emergency. Modern protocols are particular about inventory locations within the ambulance to expedite the response in an emergency.

Once rescued by ambulance corpsmen, Civil War soldiers were evacuated according to Letterman’s new facility organizational structure. The Letterman system comprised three stations: the field dressing station, field hospital, and a large hospital. The field dressing station is where the wounded were administered initial treatment, often found close to battle lines, and protected by natural defenses. A single regimental surgeon would operate the field station and apply rough dressings and offer pulls of whiskey. The field hospital was the second station in the evacuation system that was located close to the battlefield in homes or barns. Additional treatment and emergency surgery such as amputation was performed at field hospitals. Large hospitals were the final station, located a distance from the battlefield and intended to provide more long-term care of wounded soldiers. The three-tiered system proposed by Letterman is analogous to the modern health care system which undoubtedly took inspiration from his successes. Today, civilians experiencing a minor emergency such as a traumatic bone fracture may receive rapid treatment at an urgent care clinic, like the field dressing station. Most individuals who are seen at an urgent care can transport themselves to the facility as it is not a life-threatening event. In more serious medical emergencies, one may be transported to the emergency department at a local hospital where advanced care can be administered, and surgical suites are available for emergency surgery. The local hospital in this case is analogous to the field hospital of the Civil War. In extreme cases, individuals involved in severely traumatic incidents may be transported to high-level trauma centers by ambulance or helicopter. These facilities have superior resources to deal with high-level emergencies just as the large hospitals did in the Civil War. But who decides what emergency goes where?

Triage is the process used by medical professionals and first responders to determine the order of priority for providing treatment so those who can benefit most from it receive it first. Letterman was not the first to propose this process–its first documented use was in France during the early 1800s by Dominique-Jean Larrey. Jon Letterman applied the system he saw in Europe to medical response in the American Civil War. The Letterman Plan was a structured approach to caring for the wounded. Those who were lightly wounded were sent back to battle; those with more significant wounds were evaluated and sent to the appropriate station. Often, soldiers would follow the logical escalation of services, from field hospital to brigade hospital to general hospital. Although the process isn’t entirely the same today, the principles from the Letterman Plan are evident in emergency response protocols used by EMTs and paramedics. The Simple Triage and Rapid Transport (START) algorithm is used for scene management when the number of patients exceeds the number of first responders. The goal is to triage patients, determine their need for transport, and communicate with dispatch to free up resources.

The EMT in the 21st century is an invaluable contributor to emergency medical response. Many of the principles and processes used by EMTs and first responders, such as ambulances, the tiered healthcare system, and triage can be traced back to the Civil War. Jonathan Letterman was a pioneer in battlefield medicine whose contributions have extended far beyond the battlefield and have greatly outlived the American Civil War.

**

References:

1. The development of Triage. National Museum of Civil War Medicine. (2017, October 2). https://www.civilwarmed.org/surgeons-call/triage1/

2. EMTprep. (n.d.). https://emtprep.com/resources/article/utilizing-start-triage

3. Jonathan Letterman. American Battlefield Trust. (n.d.). https://www.battlefields.org/learn/biographies/jonathan-letterman

4. National Institutes of Health. (n.d.). Following the rear: Travails of the Union Army’s Ambulance Corps – Circulating Now from the NLM Historical Collections. U.S. National Library of Medicine. https://circulatingnow.nlm.nih.gov/2019/08/02/following-the-rear-travails-of-the-union-armys-ambulance-corps/

5. Regimental Dressing Stations. Regimental Dressing Stations ~. (n.d.). http://civilwarrx.blogspot.com/2015/08/regimental-dressing-stations.html

6. U.S. Department of the Interior. (n.d.). Jonathan Letterman (U.S. National Park Service). National Parks Service. https://www.nps.gov/articles/000/jonathan-letterman.htm

Clara's Cross

- Suraj Singh

In 1881 Clara Barton formed the American Red Cross (ARC), an organization dedicated to providing relief to those in need. (1) This was among many of her humanitarian efforts. She was a nurse during the Civil War helping the wounded and procuring supplies. She established the Missing Soldiers Office ultimately finding thousands of men that had fallen out of contact. She started her own school. During the Franco-Prussian War, she fed soup to those experiencing illness and/or homelessness and organized the seamstresses of Strasbourg to make clothes for locals in need. Surplus clothes were traded for food from neighboring farming towns. She developed the first emergency kit for mass production. Barton empowered the desperate. Recent criticism of the modern ARC, however, calls into question whether the organization has remained true to its founder’s vision.

According to the American Red Cross, “The relationship between the American Red Cross and the federal government is unique. We are an independent entity that is organized and exists as a nonprofit, tax-exempt, charitable institution pursuant to a charter granted to us by the United States Congress. Unlike other congressionally chartered organizations, the Red Cross maintains a special relationship with the federal government.” (2) This unique legal standing has not shielded the ARC from controversy – the criticisms are numerous. In the aftermath of Hurricane Katrina, for example, the ARC received approximately 60% of the $3.6 billion donated by Americans in response to the disaster and was later investigated for fraud and theft. (3) Financial mismanagement forced several ARC executives to resign. (4) In 2010, The ARC spent almost $125 million on internal expenses – a quarter of the money received by donations in response to the earthquake in Haiti. (5) Richard Rieckenberg, a former Red Cross disaster expert, says the charity cares about the “Appearance of aid, not actually delivering it…They were not interested in solving the problem — they were interested in looking good. That was incredibly demoralizing.” (4) Clearly the behind-the-scenes workings of the ARC are complex and controversial.

The ARC has responded to tarnishing events and statements with increased transparency, clearer communication, and effective adaptation to new policies. The ARC now maintains a webpage titled “Where Your Money Goes,” that states “The Red Cross is proud that an average of 90 cents of every dollar we spend is invested in delivering care and comfort to those in need. The remaining 10 cents helps keep the entire Red Cross running by supporting routine, but indispensable, day-to-day business operations. These operations include the enterprise-wide computer, telecommunications, volunteer management, HR, and payroll systems for nearly 18,000 employees and approximately 275,000 volunteers, as well as fundraising, communications, and other support services.” (6) It follows that at some point in the organization’s history the proportion of the funds spent on delivering care and comforting those in need was not 90 cents of every dollar. Further, the ARC has been previously criticized for not allowing men who have sex with men to donate blood. As the Food & Drug Administration policies regarding MSM blood donations have changed from a lifetime ban for donating blood in an effort to decrease the spread of HIV/AIDS, to a one-year since last intercourse ban, to a three month since last intercourse ban during the COVID-19 pandemic, to the current policy of no time-based deferral, the ARC has adapted to and adopted changing policies in an effort to be more inclusive. (7-8)

Today the ARC occupies a volatile space – the intersection of calmness and disaster. The organization addresses the needs of the people in a forever-changing world. Since President Chester signed the Geneva Treaty and the ARC received its first congressional charter in 1900, the ARC has adapted to new challenges by expanding the range of aid and services. Today the ARC supplies approximately 40% of the nation’s blood. (9) The organization teaches and certifies professionals in life-saving skills such as CPR, AED, Lifeguarding, and Child Care. The ARC provides shelter, food, and health services for disasters including and not limited to natural, hazardous, and transport variants. The ARC has also maintained its alignment with the US military, offering support for civilians and service members nationally and internationally in response to disaster, pandemic, and war. An amazing show of goodwill and community is the fact that “90% of the Red Cross workforce are volunteers.” (10) It is evident that despite the ARC’s tumultuous history involving mismanagement and irresponsible spending, support for the organization is strong.

Like any other business or organization, growing pains are inevitable. To strive for and achieve new heights, an endeavor must assume some risk. Accountability, balance, communication, and division of labor are just a few of the instruments necessary for growth. It would be unreasonable to assume that all these mechanisms function optimally for an organization of even the highest moral caliber. The same can be said for the ARC. An organization’s past does not necessarily determine its future. In the case of the ARC, hopefully stumbles in the past guide decisions of the future.

Would Clara be proud of the ARC today? The answer is uncertain. In terms of the distance the organization has travelled, and the scope and shape of the aid and services now offered – likely the answer is yes. The ARC’s current mission statement is to prevent and alleviate “human suffering in the face of emergencies by mobilizing the power of volunteers and the generosity of donors.” (11) The means of accomplishing this mission has been and inevitably will be questioned; however, Clara Barton’s goal of aiding those in need continues to be achieved.

**

References:

1. Over 140 Years of Compassionate Service. Red Cross Web site. https://www.redcross.org/about-us/who-we-are/history.html. Accessed September 15, 2023

2. Our Federal Charter. Red Cross Web site. https://www.redcross.org/about-us/who-we-are/history/federal-charter.html. Accessed September 15, 2023

3. Strom S. Red Cross Faces Internal Charges of Misappropriation of Hurricane Funds, Goods. Philanthropy News Digest Web site. https://philanthropynewsdigest.org/news/red-cross-faces-internal-charges-of-misappropriation-of-hurricane-funds-goods. Updated 2006. Accessed September 15, 2023

4. Elliott J, Eisinger J, Sullivan L. The Red Cross’ Secret Disaster. ProPublica Web site. https://www.propublica.org/article/the-red-cross-secret-disaster. Updated 2014. Accessed September 15, 2023

5. Sullivan Laura, Elliott J. Report: Red Cross Spent 25 Percent Of Haiti Donations On Internal Expenses. NPR Web site. https://www.npr.org/2016/06/16/482020436/senators-report-finds-fundamental-concerns-about-red-cross-finances. Updated 2016. Accessed September 15, 2023

6. How the Red Cross Spends Your Donations. Red Cross Web site. https://www.redcross.org/donations/how-the-red-cross-spends-your-donations.html. Accessed September 15, 2023

7. Shmerling MD R. The FDA relaxes restrictions on blood donation. https://www.health.harvard.edu/blog/the-fda-relaxes-restrictions-on-blood-donation-202305192936. Updated 2023. Accessed September 15, 2023

8. LGBTQ+ Donors. Red Cross Blood Web site. https://www.redcrossblood.org/donate-blood/how-to-donate/eligibility-requirements/lgbtq-donors.html. Accessed September 15, 2023

9. Pandemic a Crisis for Two Years; How the Red Cross is Helping. Red Cross Web site. https://www.redcross.org/about-us/news-and-events/news/2022/pandemic-a-crisis-for-two-years-how-the-red-cross-is-helping.html. Updated 2022. Accessed September 15, 2023

10. Become a Volunteer. Red Cross Web site. https://www.redcross.org/volunteer/become-a-volunteer.html#step1. Accessed September 15, 2023

11. Mission & Values. Red Cross Web site. https://www.redcross.org/about-us/who-we-are/mission-and-values.html. Accessed September 15, 2023

Amputations in the Civil War - The Destructive Weapons that Stained the Battlefields Red and the Young Doctors Who Rose to the Challenge of Caring for the Injured

- Maiko Sho

The Civil War was a turbulent time in American history where advancements in warfare technology enabled bloodier battles among thousands of young men who fought valiantly for their country, in a time when the medical profession was not yet equipped to handle such mass destruction. The Civil War occurred between April 12, 1861 and April 9, 1865, and during this time there was a total of 620,000 soldier deaths reported. Of these, 2/3 died of disease, as the germ theory was not yet widely accepted and antiseptics did not yet exist. Furthermore, a total of 80,000 surgeries were performed over these 4 years, and over ¾ of all surgeries, over 60,000 cases, consisted of amputations.

In contrast to today’s amputations, which are often required for patients suffering from end-stage complications of peripheral vascular diseases such as diabetes and other causes of gangrenous infections, amputations during the Civil War were performed on otherwise healthy young soldiers, with the average Union soldier being only 25.8 years old.

What made the Civil War a particularly bloody and destructive war was the birth of destructive new technology, including new rifled muskets and artillery that increased the accuracy and distance that bullets could travel, and most notably the Minié ball. The Minié ball was invented in 1849 by French captains Claude Etienne Minié and Henri-Gustave Dolvigue. In contrast to the traditional round musket ball, the Minié ball had a conical shape with a hollow base at the bottom, allowing for gas to expand when the rifle was fired such that it would shoot out of the barrel rotating at high speed, resulting in greater accuracy. Made of 0.58 or 0.69 caliber lead, the Minié ball was larger than most bullets used today. To quote William Todd Helmuth, he said of the Minié ball,

None but those who have had occasion to witness the effects produced upon the body by these missiles, projected from the appropriate gun, can have any idea of the horrible laceration that ensues. The wound is often from four to eight times as large as the diameter of the base of the ball, and the laceration so terrible that mortification [gangrene] almost inevitably results. […] The effects are truly terrible; bones are ground almost to powder, muscles, ligaments, and tendons torn away, and the parts otherwise so mutilated, that loss of life, certainly of limb, is almost an inevitable consequence.

In contrast to the improved technology of warfare, military tactics remain unchanged. Soldiers charged head-on in tight linear formation toward enemy lines, only to be met by newly developed ammunition with increased firepower, accuracy and certain bloodbath. Unfortunately, these ruthless battle tactics continued long after the Civil War, until the end of the First World War.

Unfortunately for soldiers of the Civil War Era, the technology of warfare far surpassed the technology of medicine. At the beginning of the Civil War, most states’ medical licensing laws had been repealed, such that there was no official licensing system in place for one to be called a physician. It is interesting to take a look back in time to see the development of physician training. Before 1800, medical training was mostly an apprenticeship. Students paid a fee of roughly $100/year to live with a practicing physician and learn the trade by observation and apprenticeship. At the turn of the 19th century, while a few medical schools opened their doors, mistrust grew due to practices such as grave robbing and few entrance requirements. Furthermore, although examination boards for licensing physicians began at this time, they were for profit and more than willing to allow any examinee to take the exam without regulation for completion of necessary prior coursework. The wave of egalitarianism that overtook American culture around the 1830’s further dysregulated the formal institution of medical education and effectively shut down any institutionalization of medical practice, undoing the work of the past several decades. People believed that anyone who desired to be a physician should be able to do so, and that patients should also be allowed to freely choose who they wanted their physician to be.

Therefore, by the time the Civil War was in full force and countless badly maimed soldiers were in desperate need of a physician, those available were mostly young doctors, many without licenses, serving to meet the rapidly growing need for medical practitioners. Prior to the war, they had barely any experience of surgical procedures and those who had had mostly experienced “occasional trauma, lancing boils, and pulling teeth.” Overwhelmed by the immense number of casualties and limited by time and tools, surgeons did not have the luxury of performing detailed reconstructive operations and instead, often operated under frenzied conditions. Nevertheless, surgical amputations were the mainstay of treatment, improving mortality rate from 75% in untreated patients to 25% in amputated patients.

The carnage and bloodbath that ensued on the Civil War battlegrounds was something that no physician of the era was prepared for, and yet many young physicians and nurses stepped up to meet the need of caring for the wounded. These years brutally uncovered the truth, laying bare the paucity of knowledge and utter systematic disorganization of medical care that existed at the time, but also highlighted the talents of brave individuals who served the country in a time of great need. Ultimately, these years of struggle reinforced the great need for improvement and set the stage for the birth of modern medical education, innovation, and practices that were to come in the following decades.

Opiates and the Civil War

- Thomas Peacock

Opium was one of the most widely used medications of the 1800s, and the results of this use were devastating. Opium was first identified as the active ingredient in poppy seeds in 1806, and it was purified shortly thereafter. Morphine, as the purified substance was called, began to be widely used as a medication after the hypodermic needle was invented in 1853, which was just before the Civil War. This, along with the repeated mass casualty events of the war, created the perfect storm of morphine use and subsequent abuse, which led directly to America’s first major opioid crisis.

During the war, morphine had plenty of important and medically justified uses, even by today’s standards. The Civil War was a brutal affair, and there were many battle-related injuries. The surgery of choice for gunshot wounds to extremities were amputations. Contrary to popular belief, anesthetics of the day were not a shot of whiskey and biting down on a stick, but a combination of chloroform and morphine, which was widely used as a local anesthetic. The problem is that these were incredibly painful surgeries and required repeat dosing of morphine to keep the pain under control. Strict guidelines regulating its prescription and use did not exist at the time. In addition, morphine was marketed as a “less addictive” form of opium when it was first purified, much like the marketing practices of oxycodone, the harbinger of the modern opioid epidemic. Many of the battles of the Civil War depended simply on manpower because of the battlefield tactics at the time. Given the rate of casualties during battles, this manpower was a scarce resource. Soldiers were asked to return to the front line after major wounds that did not require amputation, such was the case of John Goolrick, who was shot in the left leg during the siege of Petersburg. He was prescribed morphine, and shortly thereafter returned to fighting.

In addition to the value of pain relief that morphine provided, the “side effects” of morphine were used as an indication for prescription during the war. For example, one of the most common killers during the war was diarrhea, and there were around 57,000 deaths and 1,528,098 cases of that disease alone. When we prescribe opiates for pain relief now, we warn patients to maintain a high fiber diet and take stool softeners because of risk of constipation. This effect was used for symptom relief in these patients. This was also the case for soldiers with a cough, as opiates are also an effective cough suppressant. However, such liberal prescription of a highly addictive drug set the stage for what happened after the war.

Soldiers who left the war addicted to morphine were not treated with empathy and kindness required for addiction treatment in the years following the war. It was not even addressed as an addiction, and it was known to the public as “opium slavery” or “morphine mania.” The harshness of the terms used to describe addiction gives a glimpse to the stigma and social isolation that former soldiers suffered. It was viewed as unmanly and weak-willed. As a result, former soldiers often suffered with their addiction in silence, for fear of being shunned by society. Treatment options for opioid addiction were not particularly enticing, as well. They included quitting morphine “cold turkey” and dealing with the devastating symptoms of withdrawal as well as a stay in a mental asylum. Discharge from mental hospitals were not frequent, and they functioned more like prisons than treatment centers. Even after undergoing torturous treatment, relapse was common.

The plight of the post-war addict is exemplified by the story of the aforementioned John Goolrick, through letters to his wife’s family. It is rare to have an honest account of the struggle caused by addiction because of the stigma of the time, as it was largely hidden from peers. Despite his addiction, he became a lawyer after the war in Fredericksburg, Virginia, and maintained a social life in the community alongside his wife. However, his addiction grew stronger as time wore on, and almost 30 years after the war ended suffered a mental breakdown due to morphine which prevented him from practicing law. The Goolrick’s social circles began to fall apart as the townspeople learned of his addiction, furthering the troubles that they were facing at home. Even a man of prominent social stature was not given sympathy in that time, the stigmas surrounding addiction were too strong. Goolrick was eventually institutionalized, which also carried a stigma. As we know, institutionalization and withdrawal of morphine are not effective strategies to reach remission, and John wound up relapsing several times in his life. This is a great example of how morphine addiction was stigmatized, and the isolation only worsened the condition of those addicted.

The effect of addiction in the aftermath of the Civil War had an impact on the medical industry. Understandably, soldiers who suffered from addiction often blamed the providers who prescribed the medication in the first place. This fostered a sense of distrust in surgeons and medical providers as we understand them today. This phenomenon still happens today, as we saw the distrust in pharma and medical practice rear its head publicly with the anti-vaccine movement. However, this sentiment was a much bigger problem back in the late 1800s and early 1900s, as modern medicine did not have a monopoly on patient care as it largely does today. Methods that we may see as fringe or experimental now were vying for public support, and the first opioid crisis helped them gain steam. It is interesting to think about how this crisis could have completely changed the landscape of medicine as we view it today.

Opium was one of the few medications that were available to physicians during the Civil War that was effective at treating the many maladies that soldiers suffered from. As a result, the medication was overprescribed, leading to large scale addiction in soldiers returning from battle. This had devastating effects on those soldiers’ lives and changed how we practice medicine.

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Sources cited

https://virginiahistory.org/learn/opiate-addiction-civil-wars-aftermath

https://library.medicine.yale.edu/blog/great-risk-opium-eating-how-civil-war-era-doctors-reacted-prescription-opioid-addiction

https://michaelshouse.com/opiate-rehab/history-of-opiates/#:~:text=The%20earliest%20reference%20to%20opium,opium's%20usefulness%20as%20a%20narcotic.

https://www.pbs.org/mercy-street/uncover-history/behind-lens/disease/#:~:text=At%20the%20beginning%20of%20the,to%20these%20most%20disabling%20maladies.

https://www.c-span.org/video/?477833-1/civil-war-veterans-opiate-addiction

European Influences on Antiseptic Efforts During the American Civil War

- Bradley Nelson

The American Civil War was a devastating conflict that pushed the boundaries of medical science and practices in the midst of carnage and casualty. During this period of time in history, the practice of antisepsis and prevention of infection emerged as an important aspect of medical care for wounded soldiers. Although the war was fought in America, the medical practices were influenced by the greater international community, particularly from Europe. This paper will delve into the European influences that lead to advancements in the field of antiseptic science during the Civil War period and beyond.

Louis Pasteur (1822-1895) was a French scientist whose work revealed that microorganisms were the cause of both fermentation and disease. His work on the study of fermentation began while he was working at the University of Lille, studying problems related to alcohol production at a local distillery. This investigation led by Pasteur introduced new ideas related to microbiology, for instance the fermentation of butyric acid. Eventually, in 1857, he presented evidence that specific organisms were responsible for different kinds of fermentation. This concept laid the groundwork for what is known as germ theory.

Joseph Lister (1827 -1912), known as the “father of modern surgery”, was an English surgeon best known for his contributions to founding the concept of antiseptic surgery. Before Lister’s time, suppurative, infected wounds were thought to be an expected stage of wound healing. Building upon the work of Louis Pasteur, Lister proposed that the same process driving microbial fermentation was involved with the septic transformation of surgical wounds. He tested this hypothesis using carbolic acid on compound fracture wounds, which was highly successful in preventing sepsis and gangrene. Lister’s discovery of carbolic acid, and the principle of his discovery, shaped the way sepsis was prevented during the civil war period and beyond.

“The hospitals, with their festering sores, putrid wounds, were enough to fix certain odors forever” - Walt Whitman once said to describe the scene and smells of Civil War hospitals. Whitman later discovered that this smell was not due to the decomposing flesh wounds, but rather the strong scent of the carbolic acid used by the physicians to treat the wounds. Controversy ensued over the use of antiseptic disinfectants - previously the American paradigm was to fight foul odors with fresh air and pleasant fragrances to counteract the odor from infection. The abnormal smell induced skepticism and opposition to the use of such disinfectants. Nevertheless, the influence of Joseph Lister was felt and carbolic acid was used, although not frequently and not in a controlled manner, as an antiseptic by Civil War physicians.

Ignac Semmelweis (1818-1865) was a Hungarian obstetrician who was considered to be the “father of handwashing”. Before his time, childbed fever was a significant public health threat and major contributor to maternal mortality during childbirth. Much like the surgical infections questioned by Joseph Lister, childbed fever was commonly thought to be due to “miasma” or unhealthy smell/vapor. Semmelweis initially hypothesized that certain “death particles” from bodies and tissues stuck to the hands of physicians and were responsible for the high incidence of childbed fever. He tested this hypothesis and established a strong, temporal relationship between handwashing practices and a lower mortality rate due to childbed fever. Once again, this notion was met with great skepticism by the medical institution and society at large. The criticism was so strong that Semmelweis ended up in a mental asylum after suffering terrible bouts of depression and paranoia.

Despite the unfortunate ending to the story of Ignac Semmelweis, his efforts and discoveries about hand hygiene did have an influence on Civil War medicine, albeit mainly indirectly. His work contributed to germ theory, which had an increasingly important impact as the war went on. As the acceptance of germ theory emerged and civil war medical personnel became more aware of its relevance, sanitation and hand hygiene became more of a priority and Semmelweis’ work helped shape antisepsis precautions during the war.

In summary, the influences of European physicians and scientists on antisepsis efforts and techniques during the civil war were fairly significant. The ideas from Pasteur related to germ theory, ideas from Lister related to antiseptic wound care, and ideas from Semmelweis related to hand hygiene all contributed to reductions in infection related complications amongst Civil War soldiers, particularly as the war progressed. The exchange of medical information and knowledge between Europe and the United States proved to have a large impact on the changes to antisepsis efforts throughout the war and the development of medical practices today. The Civil War, in some ways, represented a demand for answers given the high mortality rates due to infection.

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Sources:

Pitt D, Aubin JM. Joseph Lister: father of modern surgery. Can J Surg. 2012 Oct;55(5):E8-9. doi: 10.1503/cjs.007112. PMID: 22992425; PMCID: PMC3468637.

Tyagi U, Barwal KC. Ignac Semmelweis-Father of Hand Hygiene. Indian J Surg. 2020 Jun;82(3):276-277. doi: 10.1007/s12262-020-02386-6. Epub 2020 May 21. PMID: 32837058; PMCID: PMC7240806.

https://www.britannica.com/biography/Louis-Pasteur/Vaccine-development

https://www.civilwarmed.org/disinfection/

Evolution of plastic surgery during the Civil War

- Nyrah Humayun

According to Stark’s article (see References below), there was not a lot of consistent advancement in the field of plastic surgery before the Civil War (1). However, advancement in this field was crucial during this time in history. Stark presents that 10 percent of Civil War wounds were due to head and neck injuries (1). The head and neck region is quite a sensitive area with a lot of nerves and muscles, as we have learned in Anatomy. To be able to reconstruct this region could not only prove important to the physical and mental health of Civil War soldiers but also important for survival of those wounded in the Civil War.

According to Rogers, “During the Civil War a few surgeons started to think of achieving better results for their reconstructive procedures that were pleasing, acceptable, or at the very least, provided a better appearance or function” (2). This was important in helping the soldiers try to get back to as normal of a life as they could despite the injuries they suffered. Rogers presents the injuries that some of the Civil War soldiers faced, such as that of Carleton Burgan who had a slough on the gum that evolved into sloughing that “nearly reached the orbit and the entire upper maxilla was exposed. The parts were gradually able to heal healthfully, but the entire right superior maxilla, the vertical plate of the palate bone, and a narrow strip of the left maxilla, all of which quite separated from the healthy bone, were removed” (2).

There are some pictures of Burgan in the article, and the extent of his injuries is quite intense to the point where I am not sure how he was able to eat or even breathe. Therefore, wounds like this could definitely affect the physical and mental health of someone injured in war. According to Rogers, Burgan’s wounds caused problems with both speaking as well as chewing; however, Dr. Gurdon Buck’s plastic surgery operations were able to ameliorate his condition (2). Rogers in this article uses language such as “Despite his very severe facial and palate deformities, Burgan married Elizabeth Meyers,” to indicate how severe some of these facial wounds were (2). Based on this, facial wounds had the potential to take a toll on a soldier’s physical as well as mental health.

In a different article, Rogers discusses Dr. Reed B. Bontecou’s photography of wounded soldiers during the Civil War (3). This article contains several intense images of the different kinds of wounds people faced during this time (3). Rogers also discusses Dr. Buck in this article, saying that he was “accepted as the first American in medical history to have ordered photographs to be taken of several wounded soldiers in the Civil War, demonstrating their pre-operative facial defects and the ultimate results of his skillful plastic surgery—“skillful” being a word that one can certainly apply to Buck’s surgery” (3). Therefore, plastic surgery was a way of reducing the physical and mental burden of peoples’ wounds during the Civil War.

Facial plastic surgery proved to be essential for survival of soldiers in the Civil War. According to Stark, most people who had a fatal facial wound also had fractures of the facial bones, and treatment involved a combination of removing bone fragments, stopping bleeding, and using adhesives to bring tissue together (1). Furthermore, according to Stark, some of the procedures they were able to do back then were excision of part of the mandible and maxilla, bone debridement, and ligation of the common carotid, external carotid, facial artery, lingual artery, and internal jugular vein (1).

It is quite remarkable that they were able to do all this back then, especially being able to stop bleeding and being able to ligate these vessels. They used all the tools available to them at the time to do quite a bit of reconstructive work in a sensitive area with lots of structures and blood vessels, which is even more remarkable considering that there hadn’t been that many advancements in the field of plastic surgery.

To summarize, the evolution of plastic surgery during the Civil War was remarkable. It transformed peoples’ lives by improving their physical and mental health as well as increasing survival. Furthermore, the kinds of methods used to salvage the head and neck area after a wound were highly advanced given the tools and resources they had. It was an exciting opportunity to explore this topic, especially also since we are currently learning about the head and neck region in class and in Anatomy lab.

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References

1. Stark, Richard B. Plastic surgery during the Civil War. Plastic and Reconstructive Surgery 16(2):p 103-120, August 1955.

2. Rogers, B. O. (2002). Rehabilitation of wounded civil war veterans. Aesthetic Plastic Surgery, 26(6), 498-519. doi:https://doi.org/10.1007/s00266-002-1518-8

3. Rogers, B. Reed B. Bontecou, M.D.—His Role in Civil War Surgery and Medical Photography. Aesth. Plast. Surg. 24, 114–129 (2000). https://doi.org/10.1007/s002660010020

The First Civil War Amputation

- Richard Hum

A near infinite number of events had to have occurred to bring us to where we are today. Sometimes, our daily routine becomes so normal that we forget that our current lives are simply a microcosm of the entire history of humanity. What we eat, how we sleep, and how we communicate are just a few snapshots of our days, completely dependent on those who lived before us. I often wonder, how much different life could be if certain people were not born into existence? What if there was no Galileo to explore the laws of inertia, kinematics, and falling bodies? Would Einstein have ever won his Nobel prize for his discovery of the photoelectric effect? What if we didn’t have Shakespeare, how empty our art and literature would be. Or even Michael Jordan, who’s shoes could be seen on every kid in the early 2000’s, enabling Nike to be the 143-billion-dollar company it is today. And finally, James E. Hanger, the first amputation patient in the civil war. What if on that fateful June 3rd, 1861, that cannonball that tore through his leg in the Battle of Philippi never hit him, or worse, killed him? What would our technology in prosthetic limbs look like today - the industry that serves thousands of veterans, cancer survivors, and trauma patients every year?

Born on February 25, 1843 in Churchville, Virginia, James Edward Hanger was enrolled in Washington College of Lexington, now known today as Washington and Lee University. Soon after enrolling, his life changed forever when he joined the army, enlisting in the Churchville Calvary, where multiple cousins and his two older brothers were already serving. Only two days after being placed on guard duty near the Baltimore and Ohio Railroad in West Virginia, the Battle of Philippi blossomed. Although this battle was only considered a small and maybe insignificant skirmish in the grand scheme of the Civil War, it will have forever changed the life of Mr. Hanger.

During the battle, Hanger was taking cover in a barn when a six-pound cannonball crashed through the barn siding and impacted his left leg near the knee. Severely injured, Hanger underwent immediate lifesaving surgery at the hands of the 16th Ohio’s surgeon, Dr. James D. Robinson and Dr. George W. New of the 7th Indiana Infantry. The surgery that he underwent is what unfortunately coined the common nickname for surgeons (Sawbones), the circular amputation. Hanger is considered one of the very first amputee patients in the entire Civil War, one of over 50,000 in the span of a little bit over four years.

A few months later, Hanger was transferred back home to Norfolk, Virginia, a man missing his left leg because of the medical technology at the time, an unsatisfactory prosthetic leg to replace it. Prosthetics in the 19th century were made of inflexible wood and metal had a multitude of problems, ranging from expensive, uncomfortable, and dysfunctional. Patients were left extremely crippled, and in the words of Hanger, “I cannot look back upon those days in the hospital without a shudder. No one can know what such a loss means unless he has suffered a similar catastrophe. In the twinkling of an eye, life’s fondest hopes seemed dead. I was prey of despair. What could the world hold for a maimed, crippled man.” However, despite his seemingly desolate future, and little to his knowledge, James E. Hanger would go on to change his life and the lives of millions of people for decades to come.

It is said that Hanger would spend hours in a day, locked in his bedroom, requesting his family members to provide him with oak barrel staves, rubber, and nails. To them, he was writhing in pain and maybe even going a little crazy. However, little did they know that he was designing a new prosthetic limb. One that was more comfortable and functional, having multiple joints that allowed him bend at the knee and ankle. He patented his creation the “Hanger Limb.” Over the following years, Hanger and his brothers would open a shop in Staunton and become the leading supplier of prosthetic limbs to Confederate veterans. By 1910, the Hanger prosthetic business boomed out of Virginia, occupying Baltimore, Pittsburg, St. Louis, Atlanta, and Washington D.C. It even grew its base oversees, providing limb prosthetics to allied soldiers in Paris and London.

James E. Hanger died in 1919 and left behind him a legacy that will forever impact the world as we know it. Today, his billion-dollar company that occupies over 75 branches in the United States and Europe combined has aided in over half a million patients worldwide. So again, I ask the question: what would our world be like today, if on that fateful June day in Virginia had that cannonball not been fired?

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Sources

1. https://www.britannica.com/biography/Galileo-Galilei
2. https://www.britannica.com/question/What-is-Albert-Einstein-known-for
3. https://www.macrotrends.net/stocks/charts/NKE/nike/net-worth
4. https://corporate.hanger.com/about/our-history/je-hanger-story/

5. https://www.battlefields.org/learn/articles/story-james-e-hanger-amputee-turned-entrepreneur

Do you have what it takes to become a Civil War surgeon?

- Jack Dowd

Gaining access to medical schools in the twenty-first century is a seemingly impossible task to countless pre-meds across the country. A stable and well respected career draws students to college with dreams of one day donning a white coat. In one study of 16,000 students across 102 institutions between 2006 and 2009 only 16.5% of students intended to be pre-med finished college with required prerequisite coursework (Zhang et. al, 2020). That does not even account for the fact that only 45.2% of medical school applicants ever matriculate into medical school (Zhang, 2021). You would think that things would be easier today, with 155 allopathic medical schools in the United States, compared to that of only 99 medical schools existing prior to 1865 (Slawson, 2012) yet medical education then did not look like what it is today.

The bloodiest war in US history, a war in which more Americans died than all other wars combined, had a woefully underprepared medical care team on both sides (Reilly, 2016). Not only were infrastructure and technology lacking for treatment and recovery, doctors who were performing operations were raised in a medical education system much different than the hypercompetitive atmosphere surgeons today train in. That said, less than 12% of the 3,500 colonial physicians during the war actually held a medical degree (Ludlow, 1944). Most medical knowledge at the time was passed down through apprenticeships, demonstrations and didactic lectures. Today’s standardized lectures and tests were a foreign concept and brought about through decades of evolution of modern medical education. Medical schools themselves only came about as supplementary education to that of a preceptorship position, which training-doctors would work in for two to five years before taking on their own practice. As medical schools became more formalized towards the mid 1800s, a standardized path to a medical degree was developed. Future doctors had to complete two years of classes, followed by three years of preceptorship similar to what we refer to as “residency” today (Slawson, 2012). Interestingly enough, although one had to be 21 years of age to attain a medical degree, previous college experience was not required (Norwood, 1944). In fact, only a high school degree was required for application.

Before arriving at Georgetown University School of Medicine, I heard the phrase “getting accepted is the toughest part”. After a fast 12 months, I have reached the conclusion that was false. That said, that saying may have been passed down from medical students from the days prior to the civil war, where each semester was only 16 weeks and the second year was a repeat of the first (Slawson, 2012). It is interesting to hypothesize why that could be. Perhaps what was known in the 1850’s was only a small fraction of what is in the First Aid for Step 1 book sitting in front of me. More likely, it was due to the perceived value of preceptorship and the need for practicing physicians instead of students.

I would be remiss not to highlight the difference in cost between medical education today compared to that of pre-civil war time as it is a constant source of pain for me as I debate if I can afford to order an Uber instead of walking. Currently, Georgetown University School of Medicine has an estimated cost of attendance over $70,000. Medical school in the 1850’s cost about $120 a year for tuition or about $4800 in today’s money. In addition, preceptorship could cost about $100 a year as well after your two years of classes (Moore, 1946). In one of the greatest similarities between medical school then and medical school now, it required a wealthy upbringing to be able to afford to pursue a career in medicine as you surrendered years of salary and hours you could be contributing to your household.

It is important to acknowledge that all providers during the civil war were not graduates of US medical schools, and that this picture of medical education during the civil war is only a part of the story of those who served as surgeons in the Union Army. Medical education has come a long way since the mid 1800’s and as we work towards our ultimate goal of becoming physicians and surgeons it can be empowering to reflect on the training of those who came before us. Acceptance may have been more lenient, cost may have been lower and the requirements for earning your medical degree may have been less stringent but those who graduated from medical school and served in the civil war helped shape the history of our country and paved the way for the medical advances we practice with today such as prosthetics.

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Citations:

1. Zhang C, Kuncel NR, Sackett PR. The process of attrition in pre-medical studies: A large-scale analysis across 102 schools. PLoS One. 2020;15(12):e0243546. Published 2020 Dec 28. doi:10.1371/journal.pone.0243546

2. Zhang D, Li G, Mu L, et al. Trends in Medical School Application and Matriculation Rates Across the United States From 2001 to 2015: Implications for Health Disparities. Acad Med. 2021;96(6):885-893. doi:10.1097/ACM.0000000000004033

3. Slawson RG. Medical Training in the United States Prior to the Civil War. Journal of Evidence-Based Complementary & Alternative Medicine. 2012;17(1):11-27. doi:10.1177/2156587211427404

4. Reilly RF. Medical and surgical care during the American Civil War, 1861-1865. Proc Bayl Univ Med Cent. 2016;29(2):138-142. doi:10.1080/08998280.2016.11929390

5. Ludlow AI. Medical Education in the United States before the Civil War. Bull Med Libr Assoc. 1944;32(4):533.

6. Norwood WF. Medical Education in the United States Before the Civil War. Philadelphia, PA: University of Pennsylvania Press; 1944.

7. Moore TE Jr. The early years at Harvard medical school. Bull Hist Med. 1946;19:530-561.