An Ambulating Hospital: or, How the Hospital Train Transformed Army Medicine

When the hour of need comes, imperious exigencies allow little opportunity for reflection and experiment on the means best adapted to meet the requirements . . . and, unless provisions for their succor have matured beforehand, the comfort of the disabled must be sacrificed to inexorable military necessities.

—Assistant Surgeon George Otis, Report on a Plan for Transporting Wounded Soldiers by Railway in Time of War

The shelling of Fort Sumter caught the U.S. Army unprepared for war. Neither Surgeon General Thomas Lawson nor any other military leader had planned for a large-scale conflict. Even in peacetime, the Medical Department was seriously under staffed. Only one hundred fourteen doctors cared for the 16,000 men serving in the U.S. Army in 1861, primarily in garrison hospitals. In combat, they were deployed at a regimental level, the basic combat unit, and assigned only two trained personnel—an assistant surgeon and a hospital steward. The regimental commander could detail additional soldiers if necessary. After the battle, the surgeon established a hospital near the battlefield to care for patients until they had recovered sufficiently either to return to their units or to be sent to general hospitals in the rear. Military surgeons preferred to treat patients at the regimental level to minimize hospital epidemics and because it was believed that a patient recovered better when treated by a doctor he knew. The sick and wounded received no further medical support except in general hospitals, which surgeons used only reluctantly because they lost control over their men and because the facilities were often converted hotels or warehouses in which infections claimed many lives. After the battle, regimental hospitals consolidated the seriously wounded into depot hospitals where they remained until they were well enough to be moved. While the system arguably may have worked for the Old Army, the scale of the American Civil War quickly would expose its inadequacies. ¹

The mid-nineteenth century was a transitional period in the history of medicine, with many practitioners questioning the prevailing doctrine. The therapies of heroic medicine, such as bloodletting and purging (using laxatives), fell out of favor as a result of clinical observations. Physicians attributed the primary cause of disease to miasmas emanating from sewage, cesspools, or rotting vegetable matter. As a result, preventative medicine emphasized sanitation. Adequate ventilation and fresh air was considered essential to good health. Discoveries that changed the face of medicine occurred only after the war, especially two years after the conflict when Joseph Lister published the results of his new antiseptic technique, which dramatically reduced postoperative infection. Eleven years after the war, Robert Koch proved the germ theory of disease by showing that bacteria caused anthrax.

While the Civil War had little impact on medical theory, it was the war in which the American military learned how to handle casualties. The Medical Department evolved from a group of individual regimental surgeons into national system for handling the sick and wounded. Most histories of Civil War medicine give much credit to Jonathon Letterman for creating the organizational structure to move casualties further to the rear allowing front line hospitals to accept fresh casualties. Although not envisioned by Letterman's plan, which did not include moving casualties out of the combat zone, the ultimate reason for his system's success was a nationwide network of railroads, hospital ships, and general hospitals that evolved through the efforts of individual civilian and military surgeons, railroad men, and philanthropists. The practice of medicine was transforming from an activity of individual physicians into a system that included multiple, specialized healthcare providers. And transportation would assume an important linchpin in this new system.

The beginning of specialized medical transportation for the U.S. Army resulted from lessons learned from the Crimean War. On April 2, 1855, Jefferson Davis, then secretary of war, dispatched Maj. Richard Delafield, Maj. Alfred Mordecai, both of the U.S. Army Corps of Engineers, and Capt...