Alfred Jay Bollet

Galen Press, $44.95, pp 512 

ISBN 1 883620 08 2

See www.galenpress.com to order

Rating:

The American civil war of 1861-5 saw truly horrifying casualtiessome 360 000 deaths among the Union troops and 200 000 among the Confederate army. Together these equalled the total loss of life of US troops involved in all conflicts before and since. Out of these 560 000 deaths, there were two from disease for every one in battle. In addition, of course, were the tens of thousands of cripples, amputees, and chronically sick veterans.

The medical details of the war were extremely well documented in the six volume Medical and Surgical History of the War of the Rebellionpublished by the Surgeon General's Officewhich gives detailed statistics and case reports and which is profusely illustrated. In spite of this, most of us have a somewhat distorted image of the medical and surgical aspects of the war. Only snippets about it appear in our textbooks of medical history, and we are biased by films such as Gone with the Wind and Run with the Wolves, with the portrayal of brutal amputations performed without anaesthesia.

This hiatus in our knowledge has now been ably filled by Dr Alfred J Bollet, professor of medicine at Yale, who has documented for us, in this well written and nicely illustrated book, the facts and figures of the medical aspects of the war, together with numerous vignettes of the leading physicians and of their patients, both famous and unknown.

The facts are that there was indeed chaos in the early months of the war (as has happened so frequently in wars before and since), as the tiny regular medical services were overwhelmed by the vast influx of recruits herded into insanitary tented camps, and were then swamped by massive casualties in the first bloody battles. Recruitment of large numbers of civilian doctors relieved this shortage and, surprisingly quickly, they learned to cope with the new pathology of warfare; many went on to become leaders of the profession.

American ingenuity rapidly overcame the intense shortage of hospitals. Enormous, well designed pavilion type structures were built by both the north and south. For example, the Confederacy built six permanent hospital complexes in and around the southern capital of Richmond with more than 20 000 beds.

(Credit: LIBRARY OF CONGRESS) Patients in ward of Harefield Hospital, Washington DC, during the civil war

Specialist hospitals and departments to deal with specific problems of war appeared for the first time. The best known of these was Weir Mitchell's neurological centre in Philadelphia, where new syndromes of causalgia and phantom limb were characterised and where Jacob Da Costa described "soldier's heart"the first psychogenic illness of warfare to be recognised.

While surgeons were hampered by the lack of knowledge of the bacterial nature of wound infection (Lister's work was not to be published until two years after the end of the war), the physicians were equally disadvantaged by the absence of effective drugs, apart from morphia and quinine. Indeed, the "blue pill," calomel, and tartar emetic, the mainstays of their medical treatment, all contained mercury and did more harm than good.

The author, with his profound experience as a physician, gives an excellent account of the pandemics of the war. Chronic diarrhoea was almost universal and caused more deaths than any other disease. One physician opined that no Confederate soldier had a fully formed stool during the entire course of the war. Bollet argues that most of these cases resulted from vitamin deficiency. The basic army rations were poor, mainly consisting of hard tack biscuits and black coffee. Fresh fruit and vegetables were rarities. Scurvy and pellagra (with its typical four Dsdermatitis, dementia, diarrhoea, and death) were common. The diarrhoea would often be cured when a reasonable diet could be supplied.

Dr Bollet has done us a service by putting before us this fascinating account of the medicine and surgery practised in the American civil war, by clearing up many of our misconceptions, and by explaining to us the syndromes encountered in those long, bloody, and disease infested campaigns.

Harold Ellis, emeritus professor of surgery University of London.