Military Medicine

Civil War Disease and Epidemics

In light of current events, I thought it would be poignant to discuss how far we’ve come in the medical field when it comes to disease and epidemics.

Many who get into studying the Civil War quickly learn one of the many “fun facts” of the conflict, which is that more soldiers were taken out by disease than by bullets. Unlike the myth that the battle of Gettysburg started over shoes, this one is true! Disease and sickness were rampant amongst both armies. Bacteria and viruses didn’t care if you wore blue or gray. Many factors played into the staggering fatality rates associated with the bloodiest of all American conflicts.


unnamedyjtyMedical practices and beliefs have been evolving for centuries. In many ways, they’re still evolving. One persistent idea that made it to the 1800s was what is called “Heroic” medicine. This system operates on the theory that the body has what are called “humours”. According to the Greeks, there are four humours: Blood, Yellow Bile, Black Bile, and Phlegm. When one or more of these humours are “out of balance”, illnesses and disorders plague the host. This is a pretty interesting study and I encourage you to look into it if you’re even remotely interested in ancient theories.

Anyway, Heroic medicine was a way for the average person or doctor to try and balance these humours or at least the body’s chemistry to cure diseases. Mostly, these methods include bloodletting, cupping, and blistering. These techniques are used to treat “sthenic diseases”, which are classified by symptoms of increased excitability in the body. Symptoms may include swelling and fever because these are seen as an “over-excited” state of tissue. The logic behind these treatments was to expel or relocate the excitedness in the patient. If there’s a fever, bloodletting would be implemented to get the fever out of the veins. Cupping and blistering were designed to redirect blood away from a swelling or agitated member. In contrast, “asthenic disease” was characterized by a lack of excitement in the body. Depression or lethargy would then be treated with drugs or alcohol, which as you can probably tell, didn’t end well. Neither did prescriptions of laxatives when the patient was already extricating his bowels.

However, heroic medicine began to see a decline in the early to mid-1800s. By the 1850s, many doctors began to see the futility in these methods. Bloodletting or the use of leaches often didn’t help the patient at all or could be blamed for subsequent death after treatment. At one point, bloodletting was so popular that France ran out of leeches for the process and had to have them shipped in from eastern European countries. But, as the old ways were becoming obsolete – save for a few old timers who stuck to what they trusted – a void was left in the medical field to help explain or treat diseases that ran rampant through cities and towns.

2747845693_087a4778c9_zLet’s break down what they believed they understood before the Civil War. They understood that there were some diseases that were spread by physical contact and some that weren’t. This latter group were often the result of what they called “miasmas” or literally toxic air. Any foul smell was thought to carry disease, so places like marshes or swamps where decomposing vegetation created an odor were thought to be riddled with disease. They were, but only because of the mosquitos that carried the diseases. The idea that little bugs or pests could carry contagions was laughable back then, so the supposed fungi in the air from the rotting plants was blamed instead. But it wasn’t restricted to the swamps. Stenches in town were also abhorred. This is likely from a connection between the lack of sanitation in poor neighborhoods. Cleanliness improved the health of the overall community. Yeah, when you get the shit out of the street, things tend to get better. That’s also why many put a high focus on burying the dead quickly and separation of latrines from other public areas. To “prevent” exposure to disease when passing through stinky areas, women would carry perfumed handkerchiefs to press to their noses, thinking this would protect them. Bathing was more frequent in the summers than in the winters, as well, given that people sweated less in the colder season and therefore, were thought to be less prone to sickness.

The people of the 19th century did believe that infection or disease could be spread by touch. Venereal diseases, case in point, were spread by touch and contact with those already contaminated. The best remedy for this was to simply avoid them. They also understood the concept of the virus, even if they didn’t get the idea of bacteria. Many infections were the result of doctor’s not washing their hands between patients or neglecting to clean their instruments. And even then, they blamed the infection on miasmas. They also thought that since odors could “soak” into the fabric of clothes, that the garments of a sick person could also carry a contagion.

So, doctors got some things right and some things totally wrong. But, that’s why they call it a medical “practice”. Here is a list of the most common of epidemic diseases that doctors faced in the 19th century:

Yellow-JackYellow Fever – This is one of those diseases that people thought were carried on the air in marshy, hot, humid climates. The south and coastal regions were plagued by outbreaks of yellow fever for decades leading up to the Civil War. Of course, now we know this disease was carried by mosquitoes. It carried a 20-50% mortality rate for those who contracted it since the 17th century. Characterized by jaundice, hemorrhages, too much protein in the blood, and ultimately kidney failure, there was no solid cure. A panic would ensue during yellow fever episodes and people fleeing infected areas were often denied access into neighboring towns, thinking that the sickness would follow them. All doctors could do were pray and treat symptoms, which often proved ineffective.

s1btv7rwngdj34yt7b4lrag5laec9kSmallpox – This was one of the most feared of diseases because, like yellow fever, it had a high fatality rate (20-40%). This was spread from person to person through physical contact. Someone with smallpox would exhibit an extremely high fever, aches and pains, diarrhea, vomiting, and most noticeably puss-filled blisters on the skin that would scab and scar over time. Thankfully, a vaccine was created by taking the puss from these sores on cows (cowpox), then give it to a child who would contract the disease, and then take the puss from those and give it to an adult as a vaccine. However, back then they didn’t have the equipment that we do now. They didn’t administer the vaccines with a needle. The doctor had to make an incision in the skin and push in the vaccine. Once this healed, it created a scar and that was definitive proof that one had received vaccination.

malariaMalaria – The literal translation of “malaria” is “bad air” in Italian. Which, as we discussed before, is what the people of the 19th century blamed for this disease. And just like today, malaria can be a problem for many communities that don’t know how to properly fight it. It’s noted for its “intermittent fever”, which means that the patient will experience periods of heightened fever and chills. Again, bloodletting was the “go to”, as was a new drug called quinine, derived from cinchona tree bark. This was a relatively new thing in the 19th century and was used as a preventative (prophylactic) drug. It was often mixed with whiskey and taken orally. Those who survived malaria were not immune to it as survivors of smallpox or yellow fever, so recurring outbreaks were a real threat. Those who lived in the south or in coastal regions (with mosquitos) were especially at risk.

vampires-tuberculosis-gettyimages-537394866Tuberculosis (Consumption) – This was a surprisingly widespread disease and it’s one that many know about today. Someone with consumption had a generally sickly look about them (thin and pale) and it’s always marked by blood in their persistent cough. We all know that scene in the movies where a person coughs into a handkerchief and pulls back to see the speckles of red. This was not considered a contagious disease, but something they were either born with or developed naturally in the person. Notions of quarantine did exist back then, but TB patients were not subject to these measures, which might have been why it was so widespread. Tonics and a prescription to move to dryer climates might have been all doctors could do for them.

king-choleraCholera – Known as the “poor man’s” disease, cholera was thought to just exist in dirty, unsanitary environments (now we know it’s unclean food and water). Marked by violent spells of vomiting and diarrhea, the disease would dehydrate the patient until they expired. A few different methods were implemented to help, like mercury, which purged the body. The idea was that if the body is naturally trying to get something out, then mercury would help it along. This only made it worse. A saline solution in the bloodstream was really the only way to get the patient hydrated enough to survive the disease.

ForskeligeVeje_ad_hvilkenBroen_kan_inficeres_medTyfusbacillerTyphoid Fever – Like cholera, contaminated food and water were found to be the cause of typhoid fever. The bacteria (which they didn’t know about) was called Salmonella typhi. Symptoms include fever, a general feeling of sickness (malaise), “rose spots” across the chest and abdomen, diminished mental function, and paralysis of the bowel muscles which caused distending (swelling) of the abdomen and therefore brought on diarrhea. A condition known as Peyer’s Patches was common with typhoid and could be linked with the cause of death. This is when perforations or tears occur in the intestines and then leak matter into the body, causing infection and other complications. Due to the fever, typhoid could also bring on bronchitis which can turn into pneumonia. This was just a nasty disease to get, and the doctors could administer mercury or quinine, but there was little else they could do. The bright side is that once you’ve survived it, you had a general immunity. A variation of this was called typhomalarial fever, which was basically the same as typhoid but without the delirium symptom. They would sometimes get confused with one another, along with Typhus.

Typhus – Again, little pests can be blamed for this one. The bacteria Rickettsia was carried in fleas and caused headaches, rash, high fever, and neurological issues. Again, like typhoid, it could lead to bronchitis or pneumonia. Typhus and typhoid are generally treated the same because they portray similar symptoms and at one point, they were classified as the same disease.

Of course, there are many more including meningitis and respiratory illnesses, but the above were some of the most common and widely known.

Here Comes War

At the outbreak of the Civil War, men and boys from all over the country flocked to the enlistment offices. Almost half of these recruits were from rural or small communities, typically farmers or other general laborers. Before the war, many soldiers had never traveled more than twenty or so miles outside of their hometown. These men were about to be thrown in with thousands more who came from different walks of life and had experienced different illnesses throughout their years. As a result, the new soldiers were exposed to disease on a level that had never really been experienced before. Because of their relatively sheltered upbringing, soldiers did not have immunities to common diseases. Childhood illnesses like measles were popping up in these crowded, fetid training camps and the doctors – bless their hearts – had more than they could handle.

unnamed1Some, like John B. Gordon, weren’t oblivious to this trend. “It was amazing to see the large number of country boys who never had the measles. They ran through the whole catalogue of complaints that boyhood and even babyhood are subjected. They had everything except teething, nettle-rash, and whooping cough. I rather think some of them were afflicted with the latter disease.”

Soldiers with preexisting conditions like TB were also admitted into the army due to the lack or improper screening at the time of their enlistment. The majority of the population believed that this would be a 90-day war and as long as the men could march and carry a gun, they were deemed fit for service. So, men who were just on the edge of becoming ill, or might have been a carrier of some disease, were crammed into tents with a dozen or so other guys who were then exposed. This did improve as the war went on and in 1863 and 1864 with the new drafts, recruits were screened more meticulously and denied entry into the army if they were found to be even remotely ill or deficient in some medical way.

A report written by a Committee on Military Medicine wrote two weeks before the battle of Bull Run (Manassas) about their take on how the soldiers would fare in the coming years. “From the facts which have been presented, it is very evident that the lives of military men are much more endangered by disease than by wounds received in battle. It is then one of the highest duties of any army surgeon to make himself well acquainted with the correct principles of military hygiene, and to exert his influence to the greatest possible extent on promoting health…”

unnamedStress and the exertion of marching put a tax on the body and could leave soldiers more vulnerable to disease. Rest was vital to the health of an army and especially those convalescing from illness. Sanitation was also a culprit. Back home on the farm, men would relieve themselves in an outhouse or just anywhere they pleased. With a family of four (or ten), that may not be a problem, but when tens of thousands of men are taking a piss or defecating wherever they want, controlling cleanliness was near impossible. Officers in charge of these men didn’t know better, because the general stench of an army camp was something they came to expect. They thought it was normal for camps to be this filthy and it was considered a “patriotic odor”.

Doctors and the later established Sanitary Commission would work hard to instruct the armies how to prevent these diseases, since there was certainly no class at West Point to instruct future troops on the basics of camp cleanliness. Latrines or “sinks” were established to try and centralize the waste. A large hole was dug and it would need to be filled in after some time passed to cover the waste. Often, the hole wasn’t dug deep enough, or it wasn’t properly covered. Soldiers detested the smell (miasma) of the areas and would go off into the bushes or into the river instead.

fieldhospitalThat led to another problem. Soldiers generally knew that you shouldn’t shit where you get your water. But, they still had the problem of other soldiers contaminating the water upriver, which flowed downriver to other soldiers filling their canteens. This bacterium would then bring on the most rampant disease of the whole war.

Dysentery is an advanced form of diarrhea. Nicknamed the “Virginia Quickstep” and “Tennessee Trots”, it debilitated soldiers just as much as bullets would. Soldiers were practically set up for this sickness due to their poor diet while on the march and spoiled rations. Once the bacteria was in the stool, it had the potential – as above explained – to spread the disease through the army. And this disease is no respecter of rank. Even General Robert E. Lee came down with dysentery at one point or another. Out of 1,000 soldiers, 20 would die of dysentery or diarrhea before the war came to its end in 1865. But this may be an understatement. Due to its frequency, dysentery wasn’t always tracked as closely and some soldiers didn’t report to the hospital for it, which left a gap in the record keeping for this disease.

Lincoln-ButlerSanitation and quarantine methods were put to the test in 1862 in Louisiana. New Orleans was struck the hardest by yellow fever in the decades leading up to the Civil War and they used this fear of disease to their advantage when General Benjamin “Beast” Butler came to occupy their city. While the citizens hadn’t had a major outbreak in years, they used their own form of fear mongering to make the Federal troops complain about staying in the Crescent City. Butler responded by setting up a checkpoint on the outskirts of the city along the Mississippi. Every ship was tested for yellow fever and if they were found to have just one sick person, the ship was quarantined for 40 days. This is actually what “quarantine” translates to. It was thought after the 40 days, a contagious disease would die out. Butler also cleaned up the city. Literally. The health of the community improved by leaps and bounds, but no New Orleans citizen liked Butler any better for it. He was still a Yankee, after all.

PSX_20190511_102813Armies camped in the south or along the coast – like the Carolinas – came to understand the full destructive force of malarial diseases. During the hot summer months and while marching through swampy terrain – like Louisiana – scores of troops would be struck down by diseases like malaria and yellow fever. Many tried to fight off the miasmas by building plenty of campfires, believing that the smoke would purify the air. What it actually did was ward off the mosquitoes, but it got the desired outcome. Quinine became a doctor’s best friend, along with “blue mass” which was basically a wad of mercurous chloride (calomel) they kept in their pockets. It’s hard to believe, but they also had pills, which were invented in 1807. One called the “blue pill” was a mix of mercury, honey, sugar, licorice, rosewater, and powdered rose. Mercury, along with being crazy-poisonous, also caused necrosis of the gums, which was incredibly painful and caused teeth to become loose and fall out.

Along with mercury and quinine, regimental doctors had an arsenal of curatives with them. Turpentine was used for a variety of reasons. Topically, it could counter a skin irritant. Orally, it could “help” with diarrhea. Castor oil was used as a laxative to help with constipation (thanks, hardtack). For general nausea, they could prescribe ipecac to empty the stomach of what was making them queasy. Digitalis was another aid for reducing a fever. Colchicine was also used for those older soldiers with painful arthritis or gout. Speaking of pain, there’s one medicine I hadn’t mentioned yet. It might as well be like the proverbial elephant in the room.

civilwar-doverspowders_1Opium and morphine were used throughout the war to alleviate pain. Not just for those who had been shot, but those who had ongoing painful conditions (like arthritis and rheumatism) and soldiers suffering from “nostalgia” or homesickness – which we would classify as depression today. Opiates came in pill and powder form which could be mixed with alcohol to create solutions like laudanum. The morphine powder could also be applied by rubbing it directly into the wound, like vaccines. While it worked marvelously to make soldiers forget they were in any pain, it could also develop “Old Soldier’s Disease”, which was a dependence or addiction to narcotics that would follow them through the war. Some studies show that this wasn’t entirely the war’s fault, but it certainly didn’t help.

FEA2_2_for_web_0While the doctors and surgeons had the best of intentions, the soldiers often didn’t trust them or their remedies. Soldiers might turn to homeopathic solutions they knew well to combat their diseases, which sometimes worked and sometimes didn’t. Soldiers trying to vaccinate themselves for smallpox would end up giving themselves syphilis as they contaminated one another. Confederates experimented with drugs and medicines as the strangle-hold of the blockade made their supplies run thin. One thing that worked more often than not was a change of diet. If a soldier came down with scurvy, a diet of fruit and vegetables was strictly adhered to – among other things. The same went for diarrhea.

For a good part of the war, however, men were put in charge of cooking their own meals or cooking meals for others. Back then, men were not that proficient in the kitchen. This led to the welcoming of women into the medical field, because they knew how to properly prepare healthy meals for the convalescing men. Phoebe Pember, the matron of Chimborazo Hospital in Richmond, Virginia had made chicken soup for some of her patients and saw decent outcomes. The big aim was to get the sick better so they could go back to join their regiments and not tie down resources that could be used for other patients with more distressing issues (bullet wounds, amputations, etc.)

imagesHospitals were also revolutionized by all the new things they were learning about diseases. Hospitals used to not be clean places and they certainly aren’t the massive structures we see today. The Civil War caused hospital facilities to rethink their organization and steps they needed to take to get the soldiers on the mend. To combat “miasmas”, open windows and fresh air were essential. They also implemented the method of quarantine and separated the sick patients from those who were simply wounded. Even in the field, they practice isolation of diseased soldiers. During the battle of Chancellorsville, the famous 20th Maine had 90 of its members sick with smallpox. They were kept from entering the field and sat out the whole battle.

20160129_012957_710300burnsarchive_disease_1.jpg.1280x720_q85Just like today, many didn’t like the idea of mandatory isolation or quarantining the sick AND the healthy for the sake of the whole community. Economists and politicians argued against it, saying that it would be detrimental to commerce and infringed upon personal civil liberties. Sound familiar? Still, disease and infection had the power to bring down the highest generals and politicians in the world. For the longest time, it was believed that Thomas “Stonewall” Jackson became a casualty of pneumonia after his arm was amputated in May of 1863. Willie Lincoln, the president’s son, was struck down by typhoid in 1862 during an epidemic that swept through Washington. Even Abraham Lincoln himself was said to have come down with a type of smallpox (what the doctors soften into “varioloid”, a mild case of smallpox).

But let’s take a step back to what I said before. Disease killed more Civil War soldiers than bullets. I’ve always heard this, but wondered about the actual breakdown of those statistics. Here’s what I found: (mind you, these are rough numbers)

Total Fatalities in the Civil War: 624,511 (364,511 Union, 260,000 Confederate)
Total Fatalities by battle: 204,100 (110,100 Union, 94,000 Confederate)
Total Fatalities by disease: 388,580 (224,580 Union, 164,000 Confederate)

The remaining balance between deaths by battle and deaths by sickness shows up as deaths in prisoner camps, death by accident, and other non-battle causes.

Which of the diseases were deadliest? I couldn’t find a complete answer in my research. However, this gives a decent idea of what a white solider in the Union army would most likely die from during the war. (this is not a complete list of ALL diseases, just the big ones, and does not include Confederate or black soldier statistics due to incomplete records)

Civil War Disease Chart

These numbers are sobering. These numbers illustrate how many people suffered and died from something that could have been preventable if they had the knowledge we have today. The lessons we can pull from this are simple. Wash not just your hands, but your whole body. Eat a healthy, balanced diet and make sure everything is cooked all the way through (as much as I love eating cookie dough, it’s not smart). If there is a safe way to vaccinate, just do it. If you believe that you are sick or might be on the verge of getting sick, separate yourself from others so you don’t get them sick too. This advice is as useful to us today as it was 150-some-odd years ago.


“Civil War Medicine: Challenges and Triumphs” by Aldred Jay Bollet, M.D.

Extra Reading

“Passions and Tempers: A History of the Humours” by Noga Arikha
“Doctors in Gray” by H.H. Cummingham
“Doctors in Blue” by George Worthington Adams
“Gangrene and Glory” by Frank Freeman
“Notes on Nursing” by Florence Nightingale
“Surgeon in Blue : Jonathan Letterman, the Civil War Doctor Who Pioneered Battlefield Care” by Scott McGaugh
“Richmond’s Wartime Hospitals” by Rebecca Barbour Calcutt

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