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Samuel Preston Moore: Surgeon-general of the confederacy
PETER OLCH MEMORIAL LECTURE
Samuel Preston Moore: Surgeon-General of the Confederacy Peter N. Purcell, MD, Robert P. Hummel, Jr., MD, Cincinnati,Ohio
Samuel Preston Moore was trained as a military surgeon in the US Army but resigned his commission and was appointed Surgeon-General of the Confederate States Army Medical Department at the beginning of the American Civil War. He reformed the mediocre medical corps by raising recruiting standards and improving treatment protocols and by placing the most capable surgeons in positions of authority. He improved the ambulance corps and directed the construction of many new hospitals for Confederate casualties. He was directly responsible for the barracks hospital design, which is still used today. He established the Confederate States Medical and Surgical Journal and directed a successful effort to develop substitutes for scarce pharmaceuticals from the indigenous flora of the South. He founded the Association of Army and Navy Surgeons of the Confederate States of America. With skill and dedication, Dr. Moore transformed the medical corps into one of the most effective departments of the Confederate military and was responsible for saving thousands of lives on the battlefield.
From the Department of Surgery, Universityof Cincinnati Medical Center, Cincinnati,Ohio. Requestsfor reprintsshouldbe addressedto PeterN. Purcell,MD, Departmentof Surgery,Universityof CincinnatiMedicalCenter, 231 BethesdaAvenue(ML 558), Cincinnati,Ohio45267-0558. Presentedat the 65th AnnualMeetingof the HalstedSociety,High Hampton, North Carolina,September5-7, 1991.
very military conflict holds lessons for the student of E military surgery. Tremendous advances in the evacuation of casualties and the management of shock were made during the Vietnam War. The movement of surgical units further toward the front lines in World War II allowed lifesaving procedures to be initiated more rapidly. Advances during World War I showed the value of intravenous fluid replacement in patients with blood loss [11. Surgeons of the American Civil War, however, have often been criticized for a lack of innovation and progress during this long and costly war. Celiotomy was not performed; thoracotomy was undertaken only rarely; and the majority of extremity injuries were managed by amputation with healing by secondary intention. Whereas much of the criticism of military surgeons of this era is undoubtedly justified, detractors often fail to recognize several constraints under which these surgeons labored. Medical advances had not yet offered them aseptic or even antiseptic technique; although early theory on asepsis was being pursued, it was not yet generally accepted or even attainable under battlefield conditions. Ambulance evacuation systems were primitive at best, and the wounded were often received in very poor condition, sometimes after lying on the battlefield for 2 to 3 days. General anesthesia, contrary to popular opinion, was widely employed, but body fluid replacement was difficult and inefficient. Finally, no US war past or present has presented its surgeons with so huge a number of sick and wounded. For example, during the Korean War, 92,363 US soldiers were killed or wounded in action; in the Civil War, 70,000 casualties were incurred in the Siege of Petersburg alone [2,3]. When considered in this context, the often-criticized practices of the military surgeon of this era seem less barbaric and more reasoned. Knowledge of anatomy was generally good, and quality surgical instruments were available, but many lifesaving procedures awaited acceptance of germ theory and aseptic technique. Innovation and progress in military surgery were not absent in this conflict, however. Many excellent surgeons of the North and South recognized the limitations inherent in their era and worked with those difficulties to provide the best care possible to the soldiers and sailors involved in the conflict. No greater example of such a surgeon existed than the Surgeon-General of the Confederate States of America, Samuel Preston Moore (Figure 1). ANTEBELLUM CAREER Dr. Moore was born in Charleston, South Carolina, in 1813. He was the lineal descendant of Mordecai Moore, personal physician to Lord Baltimore, the founder of
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Figure 1. SamuelPreston Moore, Surgeon-Generalof the Confederate States of America (courtesy of the National Archives).
Maryland [4]. He received his medical degree from the Medical College of South Carolina in 1834. In 1835, he joined the US Army [5]. It was while he was in the Army that he received the practical military surgical training that later served him well. He treated casualties of the Mexican War and the many plains wars against American Indians and soon rose to the rank of major and full surgeon [6]. The discord between the states grew while Moore served, and the secession of his home state on December 20, 1860, placed Moore "in great mental distress and perplexity as to where his duty called him; a condition like that of Col. Robert E. Lee, then also of the United States Army" [7]. Like Lee, Moore decided he could not serve against his fellow Southerners and resigned his commission on February 26, 1861 [6]. He retired to Little Rock, Arkansas, hoping to practice quietly, but "the times were not conducive to repose" [8], and, in June 1861, Jefferson Davis, the newly elected president of the Confederate States of America, requested that Moore accept appointment as Surgeon-General of the Confederacy, a position that placed Moore in charge of all medical activity of the Confederate States Army and Navy. T H E WAR BEGINS Moore took office in Richmond and found a medical corps that could only be described as mediocre. The physical facilities of his office were wanting, as Moore explained in a letter to the Secretary of the Treasury, stating that it was "impossible to transact the business of this 362
bureau ... in one single room, crowded to overflowing with employees, soldiers and visitors on business" [9]. The few surgeons who made up the corps were mostly US Army officers who, like Moore, had resigned their commissions and joined the Confederacy, As the first bloody battles of the war occurred, it became obvious that the war would not be a short one and that many more surgeons would be needed. Here, Moore first displayed the quality of leadership he would exhibit throughout his tenure and that undoubtedly saved many Confederate lives over the course of the war. He instituted rigorous examinations of medical corps officer candidates and was surprisingly successful in eliminating many incompetent physicians from the corps [10,11]. This was a particularly difficult task considering the desperate shortage of surgeons. While maintaining his high standards, Moore eventually appointed 834 surgeons and 1,668 assistant surgeons to the Army; 92 surgeons and assistant surgeons were appointed to the Navy [12]. The term "surgeon" in military parlance did not necessarily indicate that the appointee had received formal postgraduate surgical training but that he was considered qualified to practice military surgery. Moore also demonstrated superior leadership in setting the tone of the early Medical Department. Many of the surgeons, although enthusiastic, were independent, unruly, and opposed to the discipline inherent in military activity. Moore tenaciously fought to maintain order and obedience to treatment protocols and documentation requirements among his subordinates. This policy ranks as one of his most astute acts as an administrator because, by insisting on proper accounts of illnesses, injuries, treatments, and treatment outcomes, he was able to institute improved therapeutic regimens for injured and sick soldiers [13-16]. Another early administrative policy that showed great foresight was Moore's practice of placing his fellow former Union officers in positions of authority. He realized that these men had experience both in the treatment of military casualties and in the administration of military hospitals that would be invaluable in battle. With this action, Moore ensured that the Medical Department would have a strong backbone of experienced leaders throughout the long and bloody conflict [12]. It was with this well-led but poorly equipped and chronically understaffed medical corps that Moore faced the task of caring for 600,000 Confederate troops (against the 2,800,000 troops of the Union Army) who during the war experienced 3.6 million cases of injury and disease (every soldier was sick or injured an average of six times in the war), as well as the 270,000 Union prisoners of war (POWs) [8,9]. The battle injuries were chest or abdomen in 19%;head, face, or neck in 12%; and extremity in 65% [12]. MID-WAR: HEAVIEST FIGHTING As the war progressed, predictions of a short conflict with light casualties faded, and, to the surprise of almost everyone involved, both sides suffered thousands of casualties. There were several reasons for the unexpectedly
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Figure 2. Coverplate, The Confederate States Medical and Surgical Journal (courtesy of the National Archives).
high number of losses. Particularly in the early battles, leaders of both sides made the mistake of using 18thcentury tactics, including bayonet charges, against what were essentially 20th-century weapons [17]. For the first time, true massed artillery was employed against infantry. The first practical fully automatic weapon, the Gatling gun, was introduced and was partially responsible for the fact that 90% of battle wounds were caused by firearms. Breech-loading rifles with much higher rates of fire were used by both armies. Finally, a new rifle bullet, the Minie ball, was used extensively. A 58-calibre conical projectile, the ball was heavier and more accurate than the round musket ball. It also flattened upon impact much more easily, resulting in more damage to soft tissue and bone. The use of the Minie ball necessitated many of the amputations performed by the military surgeons of both armies. These factors made the battlefield highly lethal; there were 97 wounds per 1,000 American troops in the Civil War, as compared with 27 per 1,000 in World War II [17]. The Battles of Bull Run in July 1861 and August 1862 caused thousands of casualties that were managed poorly by the medical departments of both sides, mainly due to the inadequate ambulance facilities available. Unfortunately, these battles were only rehearsals for the Battle of Antietam. On September 17, 1862, General Robert E. Lee, commander of the Army of Northern Virginia, fought Major General George B. McClellan, commander of the Army of the Potomac, on the bloodiest single day of the entire war. Twenty-three thousand men were killed or wounded, 11,000 of them Confederates [18-20]. Early in the war, Moore had instituted a reform of the ambulance evacuation system [21] so that by Antietam a plan for evacuation to field hospitals and temporary facilities in Shepherdstown, Virginia, had been planned; the vast number of wounded, however, quickly overwhelmed
the surgeons, and injured men often waited days for treatment. An eyewitness described the scene in Shepherdstown: Horsemen galloping about, wagons blocking each other, and teamsters wrangling; and a continued din of shouting, swearingand rumbling in the midst of which men were dying, fresh woundedarriving, surgeons amputating limbs and dressing wounds, women going in and out with bandages, lint, medicines, food. An ever-present sense of anguish, dread, pity, and, I fear, hatred--these are my recollections of Antietam [12]. Disasters like Antietam underscored the importance of medical evacuation and hospitalization and prompted Moore to increase the efficiency and facilities of the medical corps. He initiated several major hospital construction projects [22], the most famous being Chimborazo Hospital in Richmond. Opened in October 1861, Chimborazo was built in "barracks" fashion at Moore's direction. The hospital was composed of 5 separate divisions, each division consisting of 30 buildings. Each building contained 1 ward with 40 to 60 patients [23]. Patients were grouped by injuries or diseases. From November 1, 1861, to November 1, 1863, Chimborazo admitted 47,176 patients, of whom only 3,031 died, an excellent record for the time [24]. Although the barracks hospital system improved ventilation and lowered construction costs, it had the added advantages of cleanliness and lower infectious disease transmission rates. Many other Confederate hospitals were built in barracks fashion, and the system was soon adopted by the Union medical department. Many exampies of these military hospitals are still in use today, and the development of the barracks hospital is considered one of Moore's major contributions [25]. The medical corps was again tested to its limits on July 1, 1863, when the Battle of Gettysburg, the greatest
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single battle of the war, began. In the next 3 days, 50,000 men--23,000 of them Confederates--were killed or wounded [18]. Aided by the Richmond Ambulance Committee, an independent organization composed of private citizens and men exempt from military duty, the medical corps enjoyed greater success in evacuating its casualties from this battle than from Antietam [25]. LATE WAR: DESPERATION AND SCARCITY After the defeat of the Army of Northern Virginia at Gettysburg and the almost simultaneous surrender of Confederate forces at Vicksburg, Mississippi, it became evident that the Confederacy would lose the war. Fighting continued, however, until May of 1865 [18]. During this increasingly desperate period, Moore continued to direct the medical corps and, in fact, made some of his most important contributions to the corps' effectiveness. The Confederate medical corps suffered greatly under the Union's embargo of medical supplies, which included pharmaceuticals, surgical instruments, and medical literature. In order to maintain a means of disseminating professional information to the surgeons of the corps, Moore established the Confederate States Medical and Surgical Journal (Figure 2), which was edited by James Brown McCaw and published in Richmond from January 1864 until February 1865 when siege and a paper shortage prevented its publication [12,26]. The standards of the Journal were very high. Topics ranged from the proper treatment of injuries caused by firearms and shrapnel to hospital gangrene, arterial hemorrhage, surgical ophthalmology, treatment of traumatic aneurysm, and disease prevention in military camps [26]. Today, it makes fascinating reading. For example, a case history is submitted of an individual who experienced a bullet wound to the chest, the projectile striking his heavy English pocket watch and driving it into his hemithorax. The patient nearly died, but, after 2 weeks, the wound had formed adhesions and eventually a fistula. Nothing was seen of the watch until the patient began expectorating the watchworks in his sputum, a phenomenon that continued until he had expelled every piece of the watch except the hands. He was healthy over the next 5 years and was eventually lost to follow-up [26]. The Journal was uniformly welcomed and avidly read by Confederate medical personnel. It received a favorable review by The Lancet [27], but a reviewer at The American Medical Times of New York was not impressed, saying "... the report, thus far, is a most uninteresting detail of cases, and proves but too plainly that our Southern brethren are not making progress" [26]. Moore also directed the publication of a much more complete version of A Manual of Military Surgery for the Use of Surgeons in the Confederate Army, which had first been published by J. J. Chisolm in 1861. The second and third editions, published in 1864, contained detailed information on the treatment of war wounds, preventive medicine, proper camp arrangement, hospital management, and many other aspects of military medicine. The Manual was highly respected by both sides and was considered by the English press to be the best handbook of 364
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military surgery produced by either the Union or the Confederacy [24]. As the Northern stranglehold on the Confederacy grew stronger, supplies of all kinds became scarce. Stores of pharmaceuticals, which had never been plentiful, diminished at an alarming rate. Moore realized that the South's rudimentary pharmaceutical industry would never succeed in the production of drugs that had previously been imported. He therefore directed a massive effort to discover drug substitutes among the indigenous plants of the South. Although many of the common drugs of the day were later proven useless, several, such as quinine, opium, morphine, colchicine, belladonna, and digitalis, were effective. Quinine, in particular, was priceless in the many malarial regions of the South. At Moore's direction, Francis Petre Porcher of Charleston Medical College wrote "Resources of Southern Fields and Forests, Medical, Economical and Agricultural, Being Also a Medical Botany of Southern States with Practical Information of the Properties of the Trees, Plants and Shrubs" [28]. This booklet, along with the "Standard Supply Table of the Indigenous Remedies for Field Service and Sick in General Hospital," published in the Confederate States Medical and Surgical Journal [26], lists the medicinal properties of over 400 Southern plants. For example, blood root and wild cherry were believed to be effective substitutes for digitalis; dogwood was known to have diuretic properties; wild jalep was used as a replacement for ipecac; and a concoction known as "old indigenous" was used as a quinine substitute: dogwood bark, poplar bark, and willow bark dissolved in alcohol at two pounds of mixed bark to one gallon of whiskey [4,12,28,29]. The treatment was very popular but, unfortunately, not effective at preventing malaria. Greater success was obtained with opium, which was extracted from poppy plants grown by Confederate women at the Surgeon-General's direction [29], and chloroform, which was crudely but successfully produced in the South. Ethanol, very commonly used for medicinal purposes at the time, was produced in many distilleries throughout the Southern states, and Moore was often faced with the complex task of negotiating the various state laws that forbade its manufacture [12]. By combining smuggling with local production and substitution, Moore was able to keep the medical corps supplied with the necessary drugs of the day. In fact, several Confederate surgeons said that, while supplies were often short, morphine and chloroform were nearly always available, and Moore reported to the Confederate Secretary of War in February 1865, "... no fear need be entertained that the sick and wounded of the army will suffer for the want of the essential articles of the supply table" [12]. In a similar fashion to the establishment of pharmaceutical production, Moore developed several cottage factories, often staffed by the walking wounded of the ranks, to produce surgical instruments. Copies of captured Northern instruments, as well as original designs, were produced, many of which were used by Confederate surgeons in the field [29].
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In an effort to further promote professional communication and perhaps with the hope of maintaining contact among military surgeons after the surrender, Moore established the Association of Army and Navy Surgeons of the Confederate States of America in August 1863 [30]. The Association met regularly for the remainder of the war and occasionally thereafter, discussing matters of surgical as well as patriotic interest [28]. The Civil War ended on May 26, 1865. Moore took the oath of amnesty on June 22, 1865, and retired in Richmond. He became very active in public education and Richmond community life but never practiced medicine again. He was a popular public figure in the city for the remainder of his life, known as an exemplary Southern gentleman. He died on May 31, 1889 [30]. CONCLUSION Military surgery is a distinct branch of the profession, requiring not only technical skill and judgment but discipline, leadership, and calm in the midst of turmoil and tragedy. Moore embodied these qualities, serving with skill and honor in the most costly of American wars. He is still remembered for the development of the barracks hospital system and for his recognition of the value of diligent documentation in illuminating the best treatment of injury and disease. No less important during the war was his determination to set high standards for the personnel of the medical department, to improve the battlefield evacuation system, to enhance professional communication using journals and manuals, and to spur research in native pharmaceuticals when imported ones became scarce. Although his army lost a great and terrible war, Moore won his battle to make the medical department professional and effective. The best estimated mortality statistics of the war reflect impressively on Moore and the medical corps. Estimated mortality for all Confederate soldiers was 9% versus 12% for the Union soldiers, whereas mortality for the 270,000 Confederate-held POWs was 8% versus 12% for Union-held POWs [12,31]. Moore was remembered with respect by his colleagues. A surgeon who served under him later described him as "above medium stature, well-formed, erect and of soldierly bearing; he had regular, handsome features, not austere, but subdued by thought and studious habits" [12]. President Jefferson Davis said in his history of the Confederacy, "It would be quite beyond my power to do justice to the skill and knowledge with which the medical corps performed their arduous task" [12]. Moore shouldered the heavy responsibilities of his office with honor and never forgot that his first duty was to the injured soldier; no more can be asked of any military surgeon. REFERENCES 1. Bowen TE, editor. Emergency war surgery. Washington, DC: US Government Printing Office, 1988: 3.
2. Reister FA. Battle casualties and medical statistics: U.S. army experience in the Korean War. Washington, DC: The Surgeon General, 1973: 3. 3. BrooksS. Civil War medicine. Springfield: Charles C. Thomas, 1966: 70-132. 4,. Mellwaine HR. Samuel Preston Moore. Surg GynecolObstet 1924; 39: 666-9. 5. Steinfeld JL, SummersN, SchoenbergBS. Southernmedicinein the Civil War. South Med J 1980; 73: 497-8. 6. Wiese ER. Life and times of Samuel Preston Moore, surgeongeneral of the Confederate States of America. South Med J 1930; 23: 916-22. 7. Lewis SE, Rutherford ML. Surgeon General Samuel Preston Moore and the officersof the medical departments of the Confederate states. Richmond, VA: Monument Committee, 1911. 8. Lewis SE. Southern historical society papers. 1911; 29: 274-9. 9. Cunningham HH. Doctors in gray; the Confederate medical service. Baton Rouge, LA: Louisiana State Press, 1958: 28. 10. MooreSP. Authorization to appear for examination. The Virginia Historical Society. 11. Moore SP. Letter to Assistant Surgeon George M. Caperton. Richmond, VA: The Virginia Historical Society, Dec. 29, 1861. 12. Hall CR. Medical life. 1935; 42: 453-83. 13. MooreSP. Circular #ST-9-1, Surgeon-General'soffice.Richmond, VA: The Museum of the Confederacy, 1863. 14. Moore SP. Circular #444, Surgeon General's office. Richmond, VA: The Virginia State Archives, 1863. 15. Moore SP. Circular #951, Surgeon General's office. Richmond, VA: The Museum of the Confederacy, 1863. 16. Moore SP. Circular #25, Surgeon General's office. Richmond, VA: The Virginia State Archives, 1863. 17. Garfield RM, Neugot AI. Epidemiologicanalysis of warfare: a historical review. JAMA 1991; 226: 699-702. 18. Catton B. The Civil War. New York: American Heritage, 1985: 130-50. 19. Welsh D. The Civil War: a complete military history. New York: Galley Books, 1981. 20, Newman R, Long EB. The Civil War: the picture chronicle. VoL II. New York: Grossett and Dunlap, 1956. 21. Moore SP. Letter to SH Stout. Regarding ambulance corps. Richmond, VA: The Virginia Historical Society. Oct. 25, 1863. 22. Stout SH. Letter to Surgeon-General Moore. Richmond, VA: The Museum of the Confederacy. Apr. 8, 1863. 23. Cunningham HH. Doctors in gray; the Confederate medical service. Baton Rouge, LA: Louisiana State Press, 1958: 50-2. 24. Sherman R. Julian John Chisolm, M.D.: Confederatesurgeon. Am Surg 1986; 52: 1-8. 25. Cunningham HH. Doctors in gray; the Confederate medical service. Baton Rouge, LA: Louisiana State Press, 1958, 120-2. 26. Sharpe WD, editor. The Confederate States Medical and Surgical Journal (reprinted). Metuchen, NJ: The ScarecrowPress Inc, 1976: 5-9. 27. Fuller HW. Medical annotations. Lancet 1864; 1: 443-6. 28. Wiese ER. Life and times of Samuel Preston Moore, SurgeonGeneral of the ConfederateStates of America. South Med J 1930; 23: 5-8. 29. Cunningham HH. Doctors in gray; the Confederate medical service. Baton Rouge, LA: Louisiana State Press, 1958: 150-2. 30. Moore SP. Circular to associationof army and navy surgeons. Richmond, VA: The Museum of the Confederacy, 1863. 31. Williams C. Samuel Preston Moore, Surgeon-General of the Confederate States Army. Virginia Med Monthly 1961;88: 622-8.
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Samuel Preston Moore: Surgeon-General of the Confederacy Peter N. Purcell, MD, Robert P. Hummel, Jr., MD, Cincinnati,Ohio
Samuel Preston Moore was trained as a military surgeon in the US Army but resigned his commission and was appointed Surgeon-General of the Confederate States Army Medical Department at the beginning of the American Civil War. He reformed the mediocre medical corps by raising recruiting standards and improving treatment protocols and by placing the most capable surgeons in positions of authority. He improved the ambulance corps and directed the construction of many new hospitals for Confederate casualties. He was directly responsible for the barracks hospital design, which is still used today. He established the Confederate States Medical and Surgical Journal and directed a successful effort to develop substitutes for scarce pharmaceuticals from the indigenous flora of the South. He founded the Association of Army and Navy Surgeons of the Confederate States of America. With skill and dedication, Dr. Moore transformed the medical corps into one of the most effective departments of the Confederate military and was responsible for saving thousands of lives on the battlefield.
From the Department of Surgery, Universityof Cincinnati Medical Center, Cincinnati,Ohio. Requestsfor reprintsshouldbe addressedto PeterN. Purcell,MD, Departmentof Surgery,Universityof CincinnatiMedicalCenter, 231 BethesdaAvenue(ML 558), Cincinnati,Ohio45267-0558. Presentedat the 65th AnnualMeetingof the HalstedSociety,High Hampton, North Carolina,September5-7, 1991.
very military conflict holds lessons for the student of E military surgery. Tremendous advances in the evacuation of casualties and the management of shock were made during the Vietnam War. The movement of surgical units further toward the front lines in World War II allowed lifesaving procedures to be initiated more rapidly. Advances during World War I showed the value of intravenous fluid replacement in patients with blood loss [11. Surgeons of the American Civil War, however, have often been criticized for a lack of innovation and progress during this long and costly war. Celiotomy was not performed; thoracotomy was undertaken only rarely; and the majority of extremity injuries were managed by amputation with healing by secondary intention. Whereas much of the criticism of military surgeons of this era is undoubtedly justified, detractors often fail to recognize several constraints under which these surgeons labored. Medical advances had not yet offered them aseptic or even antiseptic technique; although early theory on asepsis was being pursued, it was not yet generally accepted or even attainable under battlefield conditions. Ambulance evacuation systems were primitive at best, and the wounded were often received in very poor condition, sometimes after lying on the battlefield for 2 to 3 days. General anesthesia, contrary to popular opinion, was widely employed, but body fluid replacement was difficult and inefficient. Finally, no US war past or present has presented its surgeons with so huge a number of sick and wounded. For example, during the Korean War, 92,363 US soldiers were killed or wounded in action; in the Civil War, 70,000 casualties were incurred in the Siege of Petersburg alone [2,3]. When considered in this context, the often-criticized practices of the military surgeon of this era seem less barbaric and more reasoned. Knowledge of anatomy was generally good, and quality surgical instruments were available, but many lifesaving procedures awaited acceptance of germ theory and aseptic technique. Innovation and progress in military surgery were not absent in this conflict, however. Many excellent surgeons of the North and South recognized the limitations inherent in their era and worked with those difficulties to provide the best care possible to the soldiers and sailors involved in the conflict. No greater example of such a surgeon existed than the Surgeon-General of the Confederate States of America, Samuel Preston Moore (Figure 1). ANTEBELLUM CAREER Dr. Moore was born in Charleston, South Carolina, in 1813. He was the lineal descendant of Mordecai Moore, personal physician to Lord Baltimore, the founder of
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Figure 1. SamuelPreston Moore, Surgeon-Generalof the Confederate States of America (courtesy of the National Archives).
Maryland [4]. He received his medical degree from the Medical College of South Carolina in 1834. In 1835, he joined the US Army [5]. It was while he was in the Army that he received the practical military surgical training that later served him well. He treated casualties of the Mexican War and the many plains wars against American Indians and soon rose to the rank of major and full surgeon [6]. The discord between the states grew while Moore served, and the secession of his home state on December 20, 1860, placed Moore "in great mental distress and perplexity as to where his duty called him; a condition like that of Col. Robert E. Lee, then also of the United States Army" [7]. Like Lee, Moore decided he could not serve against his fellow Southerners and resigned his commission on February 26, 1861 [6]. He retired to Little Rock, Arkansas, hoping to practice quietly, but "the times were not conducive to repose" [8], and, in June 1861, Jefferson Davis, the newly elected president of the Confederate States of America, requested that Moore accept appointment as Surgeon-General of the Confederacy, a position that placed Moore in charge of all medical activity of the Confederate States Army and Navy. T H E WAR BEGINS Moore took office in Richmond and found a medical corps that could only be described as mediocre. The physical facilities of his office were wanting, as Moore explained in a letter to the Secretary of the Treasury, stating that it was "impossible to transact the business of this 362
bureau ... in one single room, crowded to overflowing with employees, soldiers and visitors on business" [9]. The few surgeons who made up the corps were mostly US Army officers who, like Moore, had resigned their commissions and joined the Confederacy, As the first bloody battles of the war occurred, it became obvious that the war would not be a short one and that many more surgeons would be needed. Here, Moore first displayed the quality of leadership he would exhibit throughout his tenure and that undoubtedly saved many Confederate lives over the course of the war. He instituted rigorous examinations of medical corps officer candidates and was surprisingly successful in eliminating many incompetent physicians from the corps [10,11]. This was a particularly difficult task considering the desperate shortage of surgeons. While maintaining his high standards, Moore eventually appointed 834 surgeons and 1,668 assistant surgeons to the Army; 92 surgeons and assistant surgeons were appointed to the Navy [12]. The term "surgeon" in military parlance did not necessarily indicate that the appointee had received formal postgraduate surgical training but that he was considered qualified to practice military surgery. Moore also demonstrated superior leadership in setting the tone of the early Medical Department. Many of the surgeons, although enthusiastic, were independent, unruly, and opposed to the discipline inherent in military activity. Moore tenaciously fought to maintain order and obedience to treatment protocols and documentation requirements among his subordinates. This policy ranks as one of his most astute acts as an administrator because, by insisting on proper accounts of illnesses, injuries, treatments, and treatment outcomes, he was able to institute improved therapeutic regimens for injured and sick soldiers [13-16]. Another early administrative policy that showed great foresight was Moore's practice of placing his fellow former Union officers in positions of authority. He realized that these men had experience both in the treatment of military casualties and in the administration of military hospitals that would be invaluable in battle. With this action, Moore ensured that the Medical Department would have a strong backbone of experienced leaders throughout the long and bloody conflict [12]. It was with this well-led but poorly equipped and chronically understaffed medical corps that Moore faced the task of caring for 600,000 Confederate troops (against the 2,800,000 troops of the Union Army) who during the war experienced 3.6 million cases of injury and disease (every soldier was sick or injured an average of six times in the war), as well as the 270,000 Union prisoners of war (POWs) [8,9]. The battle injuries were chest or abdomen in 19%;head, face, or neck in 12%; and extremity in 65% [12]. MID-WAR: HEAVIEST FIGHTING As the war progressed, predictions of a short conflict with light casualties faded, and, to the surprise of almost everyone involved, both sides suffered thousands of casualties. There were several reasons for the unexpectedly
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Figure 2. Coverplate, The Confederate States Medical and Surgical Journal (courtesy of the National Archives).
high number of losses. Particularly in the early battles, leaders of both sides made the mistake of using 18thcentury tactics, including bayonet charges, against what were essentially 20th-century weapons [17]. For the first time, true massed artillery was employed against infantry. The first practical fully automatic weapon, the Gatling gun, was introduced and was partially responsible for the fact that 90% of battle wounds were caused by firearms. Breech-loading rifles with much higher rates of fire were used by both armies. Finally, a new rifle bullet, the Minie ball, was used extensively. A 58-calibre conical projectile, the ball was heavier and more accurate than the round musket ball. It also flattened upon impact much more easily, resulting in more damage to soft tissue and bone. The use of the Minie ball necessitated many of the amputations performed by the military surgeons of both armies. These factors made the battlefield highly lethal; there were 97 wounds per 1,000 American troops in the Civil War, as compared with 27 per 1,000 in World War II [17]. The Battles of Bull Run in July 1861 and August 1862 caused thousands of casualties that were managed poorly by the medical departments of both sides, mainly due to the inadequate ambulance facilities available. Unfortunately, these battles were only rehearsals for the Battle of Antietam. On September 17, 1862, General Robert E. Lee, commander of the Army of Northern Virginia, fought Major General George B. McClellan, commander of the Army of the Potomac, on the bloodiest single day of the entire war. Twenty-three thousand men were killed or wounded, 11,000 of them Confederates [18-20]. Early in the war, Moore had instituted a reform of the ambulance evacuation system [21] so that by Antietam a plan for evacuation to field hospitals and temporary facilities in Shepherdstown, Virginia, had been planned; the vast number of wounded, however, quickly overwhelmed
the surgeons, and injured men often waited days for treatment. An eyewitness described the scene in Shepherdstown: Horsemen galloping about, wagons blocking each other, and teamsters wrangling; and a continued din of shouting, swearingand rumbling in the midst of which men were dying, fresh woundedarriving, surgeons amputating limbs and dressing wounds, women going in and out with bandages, lint, medicines, food. An ever-present sense of anguish, dread, pity, and, I fear, hatred--these are my recollections of Antietam [12]. Disasters like Antietam underscored the importance of medical evacuation and hospitalization and prompted Moore to increase the efficiency and facilities of the medical corps. He initiated several major hospital construction projects [22], the most famous being Chimborazo Hospital in Richmond. Opened in October 1861, Chimborazo was built in "barracks" fashion at Moore's direction. The hospital was composed of 5 separate divisions, each division consisting of 30 buildings. Each building contained 1 ward with 40 to 60 patients [23]. Patients were grouped by injuries or diseases. From November 1, 1861, to November 1, 1863, Chimborazo admitted 47,176 patients, of whom only 3,031 died, an excellent record for the time [24]. Although the barracks hospital system improved ventilation and lowered construction costs, it had the added advantages of cleanliness and lower infectious disease transmission rates. Many other Confederate hospitals were built in barracks fashion, and the system was soon adopted by the Union medical department. Many exampies of these military hospitals are still in use today, and the development of the barracks hospital is considered one of Moore's major contributions [25]. The medical corps was again tested to its limits on July 1, 1863, when the Battle of Gettysburg, the greatest
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single battle of the war, began. In the next 3 days, 50,000 men--23,000 of them Confederates--were killed or wounded [18]. Aided by the Richmond Ambulance Committee, an independent organization composed of private citizens and men exempt from military duty, the medical corps enjoyed greater success in evacuating its casualties from this battle than from Antietam [25]. LATE WAR: DESPERATION AND SCARCITY After the defeat of the Army of Northern Virginia at Gettysburg and the almost simultaneous surrender of Confederate forces at Vicksburg, Mississippi, it became evident that the Confederacy would lose the war. Fighting continued, however, until May of 1865 [18]. During this increasingly desperate period, Moore continued to direct the medical corps and, in fact, made some of his most important contributions to the corps' effectiveness. The Confederate medical corps suffered greatly under the Union's embargo of medical supplies, which included pharmaceuticals, surgical instruments, and medical literature. In order to maintain a means of disseminating professional information to the surgeons of the corps, Moore established the Confederate States Medical and Surgical Journal (Figure 2), which was edited by James Brown McCaw and published in Richmond from January 1864 until February 1865 when siege and a paper shortage prevented its publication [12,26]. The standards of the Journal were very high. Topics ranged from the proper treatment of injuries caused by firearms and shrapnel to hospital gangrene, arterial hemorrhage, surgical ophthalmology, treatment of traumatic aneurysm, and disease prevention in military camps [26]. Today, it makes fascinating reading. For example, a case history is submitted of an individual who experienced a bullet wound to the chest, the projectile striking his heavy English pocket watch and driving it into his hemithorax. The patient nearly died, but, after 2 weeks, the wound had formed adhesions and eventually a fistula. Nothing was seen of the watch until the patient began expectorating the watchworks in his sputum, a phenomenon that continued until he had expelled every piece of the watch except the hands. He was healthy over the next 5 years and was eventually lost to follow-up [26]. The Journal was uniformly welcomed and avidly read by Confederate medical personnel. It received a favorable review by The Lancet [27], but a reviewer at The American Medical Times of New York was not impressed, saying "... the report, thus far, is a most uninteresting detail of cases, and proves but too plainly that our Southern brethren are not making progress" [26]. Moore also directed the publication of a much more complete version of A Manual of Military Surgery for the Use of Surgeons in the Confederate Army, which had first been published by J. J. Chisolm in 1861. The second and third editions, published in 1864, contained detailed information on the treatment of war wounds, preventive medicine, proper camp arrangement, hospital management, and many other aspects of military medicine. The Manual was highly respected by both sides and was considered by the English press to be the best handbook of 364
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military surgery produced by either the Union or the Confederacy [24]. As the Northern stranglehold on the Confederacy grew stronger, supplies of all kinds became scarce. Stores of pharmaceuticals, which had never been plentiful, diminished at an alarming rate. Moore realized that the South's rudimentary pharmaceutical industry would never succeed in the production of drugs that had previously been imported. He therefore directed a massive effort to discover drug substitutes among the indigenous plants of the South. Although many of the common drugs of the day were later proven useless, several, such as quinine, opium, morphine, colchicine, belladonna, and digitalis, were effective. Quinine, in particular, was priceless in the many malarial regions of the South. At Moore's direction, Francis Petre Porcher of Charleston Medical College wrote "Resources of Southern Fields and Forests, Medical, Economical and Agricultural, Being Also a Medical Botany of Southern States with Practical Information of the Properties of the Trees, Plants and Shrubs" [28]. This booklet, along with the "Standard Supply Table of the Indigenous Remedies for Field Service and Sick in General Hospital," published in the Confederate States Medical and Surgical Journal [26], lists the medicinal properties of over 400 Southern plants. For example, blood root and wild cherry were believed to be effective substitutes for digitalis; dogwood was known to have diuretic properties; wild jalep was used as a replacement for ipecac; and a concoction known as "old indigenous" was used as a quinine substitute: dogwood bark, poplar bark, and willow bark dissolved in alcohol at two pounds of mixed bark to one gallon of whiskey [4,12,28,29]. The treatment was very popular but, unfortunately, not effective at preventing malaria. Greater success was obtained with opium, which was extracted from poppy plants grown by Confederate women at the Surgeon-General's direction [29], and chloroform, which was crudely but successfully produced in the South. Ethanol, very commonly used for medicinal purposes at the time, was produced in many distilleries throughout the Southern states, and Moore was often faced with the complex task of negotiating the various state laws that forbade its manufacture [12]. By combining smuggling with local production and substitution, Moore was able to keep the medical corps supplied with the necessary drugs of the day. In fact, several Confederate surgeons said that, while supplies were often short, morphine and chloroform were nearly always available, and Moore reported to the Confederate Secretary of War in February 1865, "... no fear need be entertained that the sick and wounded of the army will suffer for the want of the essential articles of the supply table" [12]. In a similar fashion to the establishment of pharmaceutical production, Moore developed several cottage factories, often staffed by the walking wounded of the ranks, to produce surgical instruments. Copies of captured Northern instruments, as well as original designs, were produced, many of which were used by Confederate surgeons in the field [29].
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In an effort to further promote professional communication and perhaps with the hope of maintaining contact among military surgeons after the surrender, Moore established the Association of Army and Navy Surgeons of the Confederate States of America in August 1863 [30]. The Association met regularly for the remainder of the war and occasionally thereafter, discussing matters of surgical as well as patriotic interest [28]. The Civil War ended on May 26, 1865. Moore took the oath of amnesty on June 22, 1865, and retired in Richmond. He became very active in public education and Richmond community life but never practiced medicine again. He was a popular public figure in the city for the remainder of his life, known as an exemplary Southern gentleman. He died on May 31, 1889 [30]. CONCLUSION Military surgery is a distinct branch of the profession, requiring not only technical skill and judgment but discipline, leadership, and calm in the midst of turmoil and tragedy. Moore embodied these qualities, serving with skill and honor in the most costly of American wars. He is still remembered for the development of the barracks hospital system and for his recognition of the value of diligent documentation in illuminating the best treatment of injury and disease. No less important during the war was his determination to set high standards for the personnel of the medical department, to improve the battlefield evacuation system, to enhance professional communication using journals and manuals, and to spur research in native pharmaceuticals when imported ones became scarce. Although his army lost a great and terrible war, Moore won his battle to make the medical department professional and effective. The best estimated mortality statistics of the war reflect impressively on Moore and the medical corps. Estimated mortality for all Confederate soldiers was 9% versus 12% for the Union soldiers, whereas mortality for the 270,000 Confederate-held POWs was 8% versus 12% for Union-held POWs [12,31]. Moore was remembered with respect by his colleagues. A surgeon who served under him later described him as "above medium stature, well-formed, erect and of soldierly bearing; he had regular, handsome features, not austere, but subdued by thought and studious habits" [12]. President Jefferson Davis said in his history of the Confederacy, "It would be quite beyond my power to do justice to the skill and knowledge with which the medical corps performed their arduous task" [12]. Moore shouldered the heavy responsibilities of his office with honor and never forgot that his first duty was to the injured soldier; no more can be asked of any military surgeon. REFERENCES 1. Bowen TE, editor. Emergency war surgery. Washington, DC: US Government Printing Office, 1988: 3.
2. Reister FA. Battle casualties and medical statistics: U.S. army experience in the Korean War. Washington, DC: The Surgeon General, 1973: 3. 3. BrooksS. Civil War medicine. Springfield: Charles C. Thomas, 1966: 70-132. 4,. Mellwaine HR. Samuel Preston Moore. Surg GynecolObstet 1924; 39: 666-9. 5. Steinfeld JL, SummersN, SchoenbergBS. Southernmedicinein the Civil War. South Med J 1980; 73: 497-8. 6. Wiese ER. Life and times of Samuel Preston Moore, surgeongeneral of the Confederate States of America. South Med J 1930; 23: 916-22. 7. Lewis SE, Rutherford ML. Surgeon General Samuel Preston Moore and the officersof the medical departments of the Confederate states. Richmond, VA: Monument Committee, 1911. 8. Lewis SE. Southern historical society papers. 1911; 29: 274-9. 9. Cunningham HH. Doctors in gray; the Confederate medical service. Baton Rouge, LA: Louisiana State Press, 1958: 28. 10. MooreSP. Authorization to appear for examination. The Virginia Historical Society. 11. Moore SP. Letter to Assistant Surgeon George M. Caperton. Richmond, VA: The Virginia Historical Society, Dec. 29, 1861. 12. Hall CR. Medical life. 1935; 42: 453-83. 13. MooreSP. Circular #ST-9-1, Surgeon-General'soffice.Richmond, VA: The Museum of the Confederacy, 1863. 14. Moore SP. Circular #444, Surgeon General's office. Richmond, VA: The Virginia State Archives, 1863. 15. Moore SP. Circular #951, Surgeon General's office. Richmond, VA: The Museum of the Confederacy, 1863. 16. Moore SP. Circular #25, Surgeon General's office. Richmond, VA: The Virginia State Archives, 1863. 17. Garfield RM, Neugot AI. Epidemiologicanalysis of warfare: a historical review. JAMA 1991; 226: 699-702. 18. Catton B. The Civil War. New York: American Heritage, 1985: 130-50. 19. Welsh D. The Civil War: a complete military history. New York: Galley Books, 1981. 20, Newman R, Long EB. The Civil War: the picture chronicle. VoL II. New York: Grossett and Dunlap, 1956. 21. Moore SP. Letter to SH Stout. Regarding ambulance corps. Richmond, VA: The Virginia Historical Society. Oct. 25, 1863. 22. Stout SH. Letter to Surgeon-General Moore. Richmond, VA: The Museum of the Confederacy. Apr. 8, 1863. 23. Cunningham HH. Doctors in gray; the Confederate medical service. Baton Rouge, LA: Louisiana State Press, 1958: 50-2. 24. Sherman R. Julian John Chisolm, M.D.: Confederatesurgeon. Am Surg 1986; 52: 1-8. 25. Cunningham HH. Doctors in gray; the Confederate medical service. Baton Rouge, LA: Louisiana State Press, 1958, 120-2. 26. Sharpe WD, editor. The Confederate States Medical and Surgical Journal (reprinted). Metuchen, NJ: The ScarecrowPress Inc, 1976: 5-9. 27. Fuller HW. Medical annotations. Lancet 1864; 1: 443-6. 28. Wiese ER. Life and times of Samuel Preston Moore, SurgeonGeneral of the ConfederateStates of America. South Med J 1930; 23: 5-8. 29. Cunningham HH. Doctors in gray; the Confederate medical service. Baton Rouge, LA: Louisiana State Press, 1958: 150-2. 30. Moore SP. Circular to associationof army and navy surgeons. Richmond, VA: The Museum of the Confederacy, 1863. 31. Williams C. Samuel Preston Moore, Surgeon-General of the Confederate States Army. Virginia Med Monthly 1961;88: 622-8.
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