In 1861, civil war broke out between the northern and southern states in America, and the Union Army's medical staff was not prepared to handle large numbers of casualties. In May 1862, reformer Surgeon General William Hammond established the Army Medical Museum to be the first federal medical research facility. The material collected by the Museum during the war would be used to produce the Medical and Surgical History of the War of the Rebellion. This was not the first time that a national medical history of a war had been written, but the American Civil War was of a different order of magnitude and so was its History. The six-volume set planned to discuss every aspect of military medicine encountered during the Civil War and required a large, sometimes stultifying, bureaucracy. The Museum would need to make extensive use of Philadelphia's medical establishment to complete the volumes.
This giant undertaking was a triumph of medical research which eventually took twenty-three years and over 6,000 pages to complete and weighed fifty-six pounds. A product of the nineteenth century's philosophy of natural history, the History is a systematic, statistical compilation of the types of injuries and diseases a military doctor could expect to treat, along with discussions of and examples of treatments. It was not a textbook but rather a reference book, a compendium of experience. By the time it was done, both editions of the six volumes apparently cost well over $100,000. The plates for the second editions of the second and third Medical volumes alone cost $29,510. The project was first assigned to Museum curators Dr. John Hill Brinton and Dr. J.J. Woodward. Brinton had the responsibility to compile the Surgical (i.e. injuries) section and Woodward the Medical (i.e. diseases) section. When Brinton left the Museum, George Otis took over the Surgical section. The curators solicited accounts from surgeons and doctors, including Confederates; the records of the Pension Office were also heavily utilized to follow up cases. Museum pathological specimens were photographed; engravings, lithographs and photomechanical prints were made to illustrate the text. Books, photographs, specimens, equipment - all were purchased although not at the speed the authors would have preferred.
Brinton was well-suited to the task of creating the History. Born and raised in Philadelphia, he had also received his medical degree there from Jefferson Medical College in 1852 and a master's degree from the University of Pennsylvania a year later. After a year of study in Paris and Vienna, the centers of medical education at that time, he returned to practice in Philadelphia. When the war began, he enlisted as a volunteer surgeon. Brinton's colleague, Joseph Javier Woodward was also from Philadelphia. He received his medical degree from the University of Pennsylvania in 1853 and, like Brinton, a master's degree afterwards. He began practicing medicine in Philadelphia and, until the outbreak of the war, conducted research and published several papers on cancer.
Other Philadelphians besides Brinton and Woodward helped establish the Museum. Frederick Schafhirt, a German-trained anatomist, was hired in 1862 to prepare specimens for the collection. He had worked for Professor Joseph Leidy at the University of Pennsylvania and remained with the Museum until his death in 1880. Daniel S. Lamb, who was with the Museum for sixty-five years, joined the staff as a hospital steward on November 3, 1865. Lamb, a native of Philadelphia, spent the war serving in military hospitals. Lamb became the staff pathologist and essentially ran the Museum from 1883 until the entry of America into World War I in 1917. In 1863, Philadelphian J.K. Barnes succeeded Hammond as Surgeon General and supported the project for over a decade.
On June 9, 1862, the History was publicly announced to the Army Medical Department. Hammond's order, Circular No. 5, requested information from medical officers and to promote compliance, the announcement promised to put one's name in print for the ages. Woodward and Brinton had their own ideas on how to proceed. Woodward began looking at statistics, publishing an eight-page survey in late 1863, Circular No. 15: Sickness and Mortality of the Army during the first year of the War. Brinton soon published his statistical survey, Circular No. 9: Consolidated Statement of Gunshot Wounds. Brinton envisioned the surgical history as a chronological work, tracking the war battle by battle so needed reports and maps of the battlefields. Both Brinton and Woodward encountered difficulties in gathering information to research disease and injury. Both men were forced to redesign the medical departments' forms and reporting methods. In later years, Brinton felt that he did not get enough credit for his initial work on the surgical portion, but more so than Brinton, both Otis and Woodward brought an immense breadth of learning to the project, surveying all that was known on a subject before drawing any conclusions. When Woodward wished to ensure the two translations he had, one dating from 1532, were both from the original Greek document on diarrhea, he asked Otis to contact the French National Library for him. The books they collected formed the foundation, under John Shaw Billings' direction, of the National Library of Medicine.
Circular 6
When Otis succeeded Brinton as curator of the Medical Museum in 1864, he also became responsible for the Surgical section of the History. Before the close of the war, Otis realized that Brinton's plan to write a surgical history of each battle would not work due to the sheer amount of information being received. Instead, Otis decided to arrange the Surgical volumes by type of wound and region of the body. The battlefield reports that Brinton had already collected would become an appendix to the first Medical book. He promoted his new plan in the Museum's first major post-war publication, Circular No. 6: Reports on the Extent and Nature of the Materials available for the preparation of a Medical and Surgical History of the Rebellion. In 1865, noted medical publisher J.B. Lippincott of Philadelphia produced the 166 page book which was heavily illustrated with woodcuts and lithographs. The Circular became the blueprint for the History. In keeping with the planned format of the History, Otis wrote the Surgical report while Woodward produced the Medical one. The first edition of 5,000 copies cost well over $6,000 to produce. When Lippincott raised the issue of selling copies of the book, Otis replied that it would continue to be distributed at no charge by the Surgeon General. Circular 6 was aimed at the medical officers of the Army, to whom it was distributed freely, to encourage their continued enthusiasm for, and participation in, the projected History.
Both Woodward and Otis wrote extensive introductions describing their materials and methods before presenting specific examples of information available for the History. Otis began his report by discussing the types and quality of the data available to him and noting how "enormous" it was in comparison with the British and French experience in the Crimea, where the combined armies suffered 653 gunshot fractures of the femur, while over 5,000 such cases were reported to Otis.
Otis laid out Circular 6 the way he anticipated organizing the History. He covered wounds of the body, and examined surgical treatments such as excision and amputation. A brief overview of the medical department staff was followed by a review of the medical resources, including transportation, available to the surgeons. Two-color lithographs by Philadelphian Thomas Sinclair illustrated the Surgical section. Otis ended his report by planning on two large volumes but a third 600-page volume proved necessary to cover the topic adequately.
Woodward followed much the same pattern as Otis. Woodward's primary interest for his first volume lay in statistical work, and he proved the rate of deaths due to disease was also far higher than that from injuries. Facts like these enabled Woodward to state unequivocally the value of the History: "Such a publication, therefore, becomes one of the most important duties of the Medical Department of the army; a duty the evasion or neglect of which would be a grave crime against the army of the United States, and against every American citizen who, in future wars, volunteers in the defence of his country."
Woodward, like Otis, organized the Circular as he would the History. He discussed the mortality rate of the Army and statistically examined the disease rate. He previewed the Medical and Microscopical sections, the two Museum sections under his care, relating details of individual cases. Full color lithographs by Philadelphian F. Moras after artwork by fellow Philadelphian Hermann Faber were included; plates by this team would be published in the third Medical volume twenty-three years later. Woodward closed with a discussion of the design of hospitals during the war. He correctly estimated that three volumes would be necessary while Otis only planned for two.
Circular 6 proved to be extremely popular. Four months later, Lippincott printed a second edition of 2,500 copies. Circular 6 was the last volume that Lippincott, who had printed forms and books for the Museum through the war, would handle; in the future, Museum publications were usually done by the Government Printing Office in Washington.
Technical production
Photography, more than any other form of illustration, made the Museum's publications possible. Less than two hundred pieces of artwork were made for the History, while thousands of photographs were used. Photographs were not directly reproduced though; halftone illustrations were not invented until 1880 and did not become common until after 1890. The photographs of specimens and soldiers still had to be interpreted by the engraver or lithographer. Color was only possible when an artist's work was reproduced via lithography, and the nature of some of the medical illustration required it. Philadelphians made many of these specialized illustrations for the History.
Like the curators, much of the staff working on the History where Philadelphians. One of the Museum's major artists was Philadelphian Edward Stauch. Brinton thought highly of Stauch's work, but unfortunately, Stauch did not survive the war. Stauch's death left a hole in the Museum's ability to produce surgical illustrations. Hermann Faber, another Philadelphian, was the Museum's other main artist. Faber, a trained artist who immigrated to America from Germany, has been described with his sons as "the founders of medical illustration as a profession in this country." He did many illustrations, including steel point engravings, mostly for Woodward's Medical History. After the war, he returned to Philadelphia and continued working for the Museum.
Most of the Army Medical Museum's early photographic work was done by Philadelphian William Bell in the Museum's studios. A professional photographer in civilian life, Bell might have been recommended to Otis by Constant Guillion, the president of the Philadelphia Photographic Society. Enlisting in the Army, Bell served at the Museum from 1865-1868, and then returned to Philadelphia. Like Faber, he continued working for the Museum, writing to Otis soon after leaving the Museum, "I express today to the Army Medical Museum, Negatives and Prints of 'Durkins' Case... the Quality of the Negatives and Prints will I feel assured equal any done while under your Orders in Washington."
Engravings were made from photographs taken of museum specimens to illustrate the History, the Catalogue and other publications of the Museum. This was by far the most common way the Museum published its photographs. While the Museum's engravers' work was considered technically excellent, they could not achieve the time-saving technique of printing a photograph on wood for early publications such as Circular 6. Otis wrote to William Washburne of Lippincott & Co. requesting advice from Philadelphia's wood engravers on photoengraving. He had tried contracting some of the work to Lippincott and Co., but the Museum's engravers felt that their work was better. After engraving, the wood block was sent to Philadelphia or New York to be electrotyped. The wood block engraving was pressed in wax and then copper or nickel was electrolyzed to cover the wax and produce the electrotype printing plate. The electrotype block, which could be set in with the type for the book to be printed, was easier and cheaper to use than lithographs or photomechanical prints, which had to be individually printed and then bound into the typeset pages. However, the fine detail of Woodward's microscopic photographs meant A. E. Lent of Philadelphia and Faber engraved directly on steel.
Lithography was the choice for reproducing artwork and photographs in publications. Many lithographers were used by the Museum. Both John Cassin of Bowen & Co. and Thomas Sinclair in Philadelphia did two-color chromolithographs for Circular 6. Otis wished the lithographs to be exact in a medical sense with correct coloration of tissue and injuries, but he had aesthetic requirements as well. Otis sent this sketch to a lithographer, stating, "I find the flesh tints too highly colored, the face especially too florid. The man had been confined to a hospital for more than a year and was probably pale and less fleshy than would be inferred from your representation of his remaining leg. The gray of the cap and jacket has too much blue in it. You must give the regular pepper and salt dirty Confederate gray. In the stump you should follow the drawing sent you quite closely. Do not omit the eight dots which represent the scars of the punctures through which the stitches passed."
Sinclair and Julius Bien of New York city did most of the chromolithograph plates for the Surgical volumes. They were the only lithographers Otis used after the first edition of the first Surgical volume. He wrote to the Surgeon General that "I can learn of no other lithographers willing and competent to undertake the work." Woodward had his chromolithographs done by F. Moras of Philadelphia. The colors were supervised on contract by Hermann Faber, who had done the original artwork a decade earlier while at the Museum.
For the second books in both series, Otis and Woodward began using woodburytype photomechanical prints in place of black and white lithographs. The woodburytype looks extraordinarily like a photograph, tipped-in on the page. Walter B. Woodbury patented the process in 1864 and John Carbutt bought the American rights. In Philadelphia, he established the American Photo-Relief Printing Company, and in 1871, he was able to begin printing. Carbutt began working for the Museum that year, printing a plate for Woodward's Report on an Improved Method of Photographing Histological Preparations by Sunlight.
Like the lithographers, Carbutt printed the plate page titles, tipped in the photograph and returned a completed page for binding by the printers. Surprisingly enough the cost for a reproduction as either a lithograph or a woodburytype was about the same. Otis preferred to use woodburytypes, writing to Carbutt, "...I have regarded this process as most valuable for scientific illustrations, and have wished to largely avail of it." Unfortunately, in early 1875, Woodward began finding problems with his prints lifting off the paper support and while first editions of the History were illustrated mostly with the woodburytypes, the second had many of them replaced by another photomechanical process or lithographs.
The first volumes
For five years after the war ended, the two men continued working on the first book in each of their respective specialties. Otis pointed out to inquirers, "The Medico-chirurgical history of the British Army in the Crimea was not published, if you recollect till 1858, while the French statistics on the same subject only saw the light a few months ago." Finally, 1870 saw the publication of the initial parts of the Medical and Surgical volumes.
In June 1868, Congress had appropriated money and authorized the Government Printing Office to print five thousand copies of each volume. and by November 1870 the books were completed. In his introduction Barnes noted that these volumes included the first long-term follow-ups of cases; this work thus set the stage for the development of modern medical studies conducted on groups over a period of years. Otis concurred with Barnes, stating that, "through private correspondence with invalided soldiers and their surgical advisers... More than fifteen hundred cases have been examined...." Otis also credited the "former medical officers of the Confederate army" for providing much information. Occasionally, Otis would even advertise in newspapers for information on specific cases.
Otis had changed the format and content of his volumes in the five years since Circular 6 was published in 1865. Rather than choosing a broad subject such as amputation, each area of the body had its wounds described and treatments discussed. Otis began his book with a daily chronological summary of the battles and engagements the Army fought. Wounds of the upper body followed, but due to space limitations, only the head, face, spine, and chest were included. When President Abraham Lincoln was assassinated in 1865, he was included as a Civil War casualty when Otis gave him a semi-anonymous entry in the History.
Whenever possible, the clinical histories were credited to the doctor who had treated the patient, preferably in his own words. After the information was presented, Otis discussed it, drawing conclusions and pointing out relevant facts. He was still planning to finish the Surgical section in two volumes, but had been forced to move some material to the second Surgical volume due to space considerations. Otis' initial volume was heavily illustrated with woodblock engravings, lithographs and chromolithographs of patients and specimens. He was confident that the study of the war wounded would advance medical science.
Woodward, in contrast with Otis, continued his plan of doing a volume "consist[ing] of a series of statistical tables presenting a summary view ... with regard to the Sickness of the Army, the Deaths, and the Discharges from service." He could do so because, unlike a surgical case that could take years for the final resolution of the injury, most medical cases ended relatively quickly. By doing the statistical work first, Woodward was able to report the primary cause of death in the Union Army was diarrhea and dysentery. As a result, he would concentrate the whole of the second Medical volume on those diseases (although he had planned to discuss all types of disease in the second volume and save a 'somewhat detailed account of the General Hospital System' for the third volume). Woodward did not use any illustrations in his first volume except for charts and graphs. His volume closed with a 365-page appendix of the battlefield reports and maps that Brinton had planned to use in his surgical history.
Writing during a memorializing age when much of Washington was being filled with statues of war heroes and the Army Medical Museum was a popular attraction, Surgeon General Barnes earnestly hoped, that "this Medical and Surgical History of the War, [is] not only a contribution to science, but an enduring monument to the self-sacrificing zeal and professional ability of the Volunteer and Regular Medical Staff." In 1875, Congress authorized the printing of a second edition of five thousand copies of the initial volumes of the History, reserving four thousand for its own use and giving only one thousand to the Surgeon General. This distribution system was not the best. When a contributor to the Museum contacted Otis for a copy of the History, Otis "referred him to his [Congressman] Mr. Morrison, but as he apprehended, being a republican, his application was unsuccessful." Surprisingly, extra copies of the second edition were still in stock in the Surgeon General's Library during World War II.
Continuing the project
The second Surgical book came out in 1876, six years after the first volume and eleven years after the end of the war. The rest of the History had been authorized by Congress in June, 1872, but Otis and his staff were unable to complete the remaining 1800 pages in the two years for which they had appropriations. In 1875, Congress again funded printing, including a second edition, which was printed at the same time as the first, for a total of 10,000 copies. Six presses ran for four weeks at the Government Printing Office in early 1876 to print both editions. Continuing his survey of war wounds by body area, Otis covered injuries of the abdomen, pelvis, back and upper extremities (arms and hands) in this book. The amazing scope of the book can be seen from the 88,741 cases of wounds of the upper extremities reviewed, 817 of them in detail.
Woodward followed Otis by three years and put his second book out in 1879, "with much labor and after serious interruptions" such as the 1876 Centennial Exposition held in Philadelphia. The topic of diarrhea and dysentery had proven larger than he had expected in 1870. The "alvine fluxes," as Woodward referred to them, took up the entire volume, forcing him to move to a third book the rest of the diseases that affected the army. Woodward's 314-page exploration of the pathology and almost 200-page discussion of treatments, including local bloodletting, antimony, castor oil, opium, alum, arsenic, and enemas, are a massive statement of medical knowledge at the time of the war.
Neither Woodward nor Otis survived to complete the final volumes in their series. Upon Otis' death in 1881, his third volume was finished by Dr. David L. Huntington, another University of Pennsylvania graduate, in 1883. Woodward died in 1884, and the third Medical volume was finally published in 1888.
It is difficult to say how useful the History was. Some dismissed it as a "mere compilation of other people's writings," but there was enough interest in the set to require a second edition even before the first had been distributed. Contemporary reviews of the volumes were favorable. The Philadelphia Medical Times had a typical response, "We think that a just pride will be felt by the American medical profession, and indeed by our countrymen generally, in these admirable volumes."
Although Otis frequently referred to himself as the editor of his volumes, this simplistic view does not acknowledge the great knowledge that both Otis and Woodward brought to their task and the massive amount of information they digested and interpreted. Woodward laid some of the foundations for pathology and histology in his work, while Otis clearly showed that a conservative approach to surgery aided the patient. The careful and extensive research that both did, reviewing literally everything written on a topic and listing every case seen, would never be equaled again and is certainly not possible now. The philosophy of the History survived though. The wars of the twentieth century led to the fifteen-volume Medical Department of the United States Army in the World War, the large series The Medical Department U.S. Army World War II and individual volumes on both the Korean and Vietnam wars. The Textbook of Military Medicine series, currently being produced by the Surgeon General's Office, mostly draws lessons from the Vietnam War, but displays its lineage by including information on gunshot wounds abstracted from the History. The History, intended as a reference work and a monument, succeeded as both and remains a unique resource, even now that advances in medicine and surgery have made much of its hard-won knowledge obsolete. As we have seen, it could not have been done without the contributions of Philadelphia's medical establishment.
