1.9 ETAPA DE CONSTRUCCIÓN
1.9.2 FASE DE CONSTRUCCIÓN
during the war, it is helpful to know something of how the medical corps was organized to provide for the sick and wounded. It is a shocking fact that early in war, virtually no general hospitals had been established. Surgeon General Lawson had established the first general hospital in Washington, DC, in January 1861, and when war
broke the Medical Department cobbled together a hodgepodge of such facilities in the nation’s capital.2The debacle at the first Battle
of Bull Run on July 21, 1861, created a public outcry. Hacks, stable boys, and assorted lowlifes hired out to transport injured men from the field either broke into liquor stores and got drunk, fled in fear, or both. The rest of the medical corps was no better. The entire army’s medical care was supported by regimental hospitals that shadowed their units on the march. There was no ambulance corps, and litter- bearers were usually regimental musicians pressed into service to carry the wounded off the battlefield. These musicians knew little about and cared even less for their newly imposed duties. Medical care for Union troops early in the war was a shameful mess.
Jonathan Letterman (1824-1872), who replaced Charles S. Tripler as medical director of the Army of the Potomac in June 1862, changed all of that by reforming the medical corps at the division level. Letter- man established a functional ambulance corps that answered to him directly, rather than to regimental line officers; he ordered a hospital supply wagon for each regiment, and a wagon for bulk supplies for every brigade; and he created a field hospital system for each division (see Figure 5.1). Letterman’s extensive reforms in the medical supply and distribution systems, along with his reorganization of the medical personnel within them, yielded results, first at the Battle of Fred- ericksburg and later throughout the war.3
Letterman’s contributions put in place a reliable three-tiered hos- pital system that served the Union troops during the war. Field hospi- tals provided the most immediate care to their units. They were to be located at or near points of engagement and were officially described as “temporary shelters for sick and wounded in the field.”4Next came
post hospitals “intended for the sick and wounded belonging to the garrison of the post, and of such prisoners as may be there confined.”5
Finally, the larger and more permanent general hospitals were “in- tended for the reception of sick and wounded soldiers belonging to all arms of the service, and serving in all parts of the United States.”6
These division hospitals were under the general administration of the surgeon general and his office and were “entirely independent in their internal arrangements and discipline.”7
In terms of pharmacy care this translated into a network of regi- mental hospital stewards (or those designated to function as de facto stewards) either in the field and post hospitals (see Figure 5.2). When
FIGURE 5.1. The Autenrieth wagon (left) was introduced late in the war and served as an effective portable apothecary. The “hospital tent and wagon” (right) shows a hospital steward and his assistant at work. Illustrations courtesy of the National Library of Medicine, History of Medicine Division.
large numbers of a particular regiment were wounded or ill and sent to the general hospital, the steward often was assigned to general hos- pital duty. In any case, the medical director could detail his stewards wherever he felt the need greatest. Although this system was a tre- mendous improvement over what the army had before, it was not per- fect, as hospital steward Charles Beneulyn Johnson described his reg- imental hospital setup with the 130th Illinois Infantry Volunteers:
In the field the Regimental Hospital Department was allowed two small tents for the officers, medicines, etc.; another small tent for the kitchen department and supplies, and a larger one for the sick. This last, known as the hospital tent, was about fourteen feet square and was capable of containing eight cots with as many patients.
In the field we almost never had sheets and white pillow cases, but made use of army blankets that were made of the
FIGURE 5.2. Hospital stewards of the 2nd Division, 9th Corps camped at Peters- burg, Virginia. Photo courtesy of the National Library of Medicine, History of Medicine Division.
coarsest fiber imaginable. In warm weather the walls of the tent were raised, which made it much more pleasant for the occu- pants.
However, the policy that obtained was to send those who were not likely to recover quickly to the base [general] hospi- tals, though this was not always to the patient’s best interests, for these larger hospitals were oftentimes centers of infection of one kind or another, especially of hospital gangrene [pyemia], which seldom attacked the wounded in the field.8
Johnson went on to describe the medicine employed in the field hospitals. During a campaign Johnson’s materia medica was re- stricted to “standard remedies” such as opium, morphine, Dover’s powder, quinine, rhubarb, Rochelle salts, Epsom salts, castor oil, sugar of lead, tannin, select tinctures, syrup of squills, whisky, as- sorted wines, and a few other items.9 These were unpacked and
placed on makeshift shelves of box lids; when marching orders were again received, the medicines were quickly put up in their boxes and packed with “old paper” to prevent breakage.10Johnson pointed out
that most medicines of that day were in powdered or liquid dosage forms; the powders would be mixed with water, and in the case of quinine, Dover’s powder, and tannin the resulting concoction was a bitter brew.11
Although the previously mentioned medicines were among the most common on hand, actually getting these drugs when and where needed was another matter. Because medicines were quite costly to supply and replace, army regulations on their care and maintenance were spelled out clearly. Each regimental surgeon was to keep a Reg- ister and Prescription Book and a careful record of “all cases excused from duty on account of sickness during the day.” Each incident was to be continued until the final disposition of the case could be re- ported. On each entry any prescription given was to be entered into the book.12This not only provided a record of the health of each regi-
ment, it also permitted the surgeon or hospital steward to review the usage of various items in the standard supply table, make an inven- tory of amounts on hand, and issue a requisition to the medical pur- veyor, who in turn filled the order from his stock or found another de- pot or subdepot that could provide the requested item or items.
This was the ideal or “official” protocol for obtaining medicines. Actual wartime situations, however, often dictated that surgeons and stewards go outside these regular channels to obtain desperately needed drugs. The Army Surgeon’s Manual tacitly admitted to this fact by stating “when a private physician is required to furnish medi- cines, he will be allowed, besides the stipulated pay, from 25 to 50 per cent on it, to be determined by the Surgeon General.”13 Acquiring
drugs from supplies other than the medical purveyor, while not the norm, was not an unheard-of occurrence. Spencer Bonsall sometimes had to get medicines—and writing paper—for his 81st Pennsylvania Volunteers where he could obtain them, even recording his diary on the letterhead stationery of John B. Hall of Fredericksburg, Virginia, “wholesaler and retail dealer of drugs, medicines, chemicals, dyes, paints, oils, window glass, perfumery, etc., etc.”14
The reasons why a surgeon or steward might have to obtain medi- cines from a civilian source were many and varied. A few typical ex- amples include breakdowns in supply, poor communications, pilfer- age, substandard quantity, and quality of the drugs provided. E. McClellan, assistant surgeon at Fort Monroe, Virginia, wrote franti- cally to the purveyor’s office in Baltimore in the summer of 1864 that he needed “as soon as possible” (among other things) 100 ounces of quinine and 600 bottles of brandy, and that surgeon McCormick needed 400 bottles of castor oil, 600 pounds of sulfate of manganese, and 600 bottles of sherry “for immediate use.”15John C. Carter writ-
ing from the purveyor’s subdepot in West Virginia complained about “erasures” made by surgeon J. V. L. Blaney to his requisition, and certain “discrepancies between [the] packer’s list and supplies re- ceived.”16Similarly, an annoyed J. H. Janway noted the “discrepan-
cies between invoices and packer’s lists of medicines” that had been shipped to him.17 Sometimes it was more than a “discrepancy”—
whole orders occasionally turned up missing. The assistant surgeon for the 51st Pennsylvania Volunteers located at Weldon R. R., Vir- ginia, reported that he never received his requisition for supplies, al- though he did receive invoices. He believed them to be in the hands of the quartermaster at Annapolis.18
A major problem was—predictably enough—with “stimulants” or alcohol. F. H. Patton, acting medical purveyor at Harpers Ferry, com- plained of a “discrepancy of 48 bottles of whiskey” and stated, “the frequent losses of stimulants during transportation demands investi-
gation.”19 There was no doubt what happened to surgeon J. H.
Shields’ stimulants for the 1st Delaware Cavalry. He found his order “50 bottles short, one barrel having been broken in to.”20If liquor was
not missing, it was sometimes substandard, as when E. Buck wrote in disgust to the Baltimore purveyor’s office that the sherry he received was in his opinion “adulterated with whiskey and water”; he called for a “board of survey for the purpose of having it inspected.”21
Beyond these problems was the ordering system itself. It will be recalled from Chapter 4 that three-month orders to the main purvey- ors’ depots were encouraged, with other orders placed to the subde- pots as needed. This looked good on paper but frequently failed in practice. The subdepots often could not provide the needed items from their limited stocks, especially if a major battle had been fought or, more frequently, a major epidemic of dysentery, fever, or influ- enza had struck the region. This sent subdepot purveyors scrambling to their main suppliers and placed undue strains on a supply system already severely taxed. This led not to a situation of absolute drug shortages but rather to selective surfeits in those substances least needed at the time. Typical was hospital steward John N. Henry’s complaint that he had plenty of medicines “not needed but little that is needed.”22
As exasperating as these problems could be, they were the excep- tions to a system that ran reasonably well. To assume that the purvey- ors could provide every medicine on demand in every instance to an army of nearly a million men without some loss, damage, theft, or quality issues would be unrealistic. None of these problems were en- demic to the system, however, and when issues of quality, quantity, and delivery were raised, the army seemed to take notice and address the grievance. The fact that all the incidents mentioned above oc- curred in the last two years of the war should be sufficient to prove the point that certain inefficiencies could never completely be eradicated from an otherwise reasonably efficient medical supply system.
But who could supply the products in such massive quantities? As in the past, the medicines of the U.S. Army war machine were fueled at first entirely by the private sector. As battle lines were drawn and men were mobilized, the business community took notice. No less in- terested were those leaders of the relatively small and fledgling phar- maceutical industry.
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