Infectious Diseases Case of the Month Case #41

4th of July Special Edition

July 1-3, 2013 marks the sesquicentennial of the Battle of Gettysburg in the American Civil War. To celebrate the 4th of July, the Case of the Month commemorates this occasion with this "case" from American History.

Fresh from a stunning victory at Chancellorsville and an earlier victory at Fredericksburg, the Army of Northern Virginia under the generalship of Robert E. Lee had crossed the Potomac River and invaded Pennsylvania in hopes of a climactic victory over the Union Army of the Potomac.

Though neither side intended to make battle at the crossroads town of Gettysburg, battle is indeed what they found there when elements of the two armies first clashed on July 1, 1863. The battle raged over three days culminating in the Pickett-Pettigrew Charge of July 3, 1863, successfully repulsed by Union soldiers on the high ground of Cemetery Ridge.

The cost and carnage of this battle was appalling with an estimated 50,000 casualties (dead, wounded, captured and missing) over the course of the three day battle. Although it wasn't necessarily appreciated as such at the time, this battle has since come to be known as the "High Water Mark" of the Confederacy.

In November of 1863 President Abraham Lincoln traveled to the Gettysburg Battlefield to participate in the dedication of a cemetery for the fallen of this battle. He attempted to make sense of the tremendous sacrifice that this battle and the Civil War in general was asking of its participants. He did so in what is probably the most famous address in American history, the Gettysburg Address. Lincoln's beautiful prose echoes down to this day.

As would be demonstrated even more horrifically fifty years later in World War I, battlefield tactics of the Civil War lagged far behind the killing technologies available at the time. This led to the horrendous battlefield casualty totals as occurred at Gettysburg. Indeed, in the course of the Civil War there were an estimated 620,000 deaths from all causes on both sides. Not only was killing efficient but medical care was rudimentary compared to modern medical care.

Death occurred not only as a consequence of battlefield injury, but also as in all wars, as a consequence of disease. This is the basis for the Case question below...

Of the following which caused the most deaths in the American Civil War?
Diagnosis: Killed in Action/Died of Wounds

Of the choices given, killed in action/died of wounds caused the most deaths.

This was a bit of a "trick question," however, as in aggregate death to disease was far more common than death due to battlefield injury during the Civil War.

The author of this case vignette had six great-grandfathers or great grand uncles who fought in Union armies during the Civil War. To their great good fortune, all but one survived the war. The unfortunate exception was John Bartholomew who died at age 26 at Helena, Arkansas far from home and not long after his enlistment. He died not of combat but of disease. At left are pictured documents concerning his enlistment and death.

His circumstances are instructive as two thirds of deaths of Civil War soldiers were due to disease not to battle injuries. Many deaths occurred just as did John Bartholomew's - not long after enlistment when soldiers from isolated rural areas were placed in close quarters with many other non-immunes and were exposed to childhood diseases such as measles, mumps, and chicken pox. Those who did not succumb to these childhood diseases might then be exposed to subsequent "camp diseases" such as smallpox, pneumonia, and erysipelas. Sanitary conditions were often poor to nonexistent leading to typhoid fever and diarrheal illnesses. For all these reasons the winter of 1862 along the lower Mississippi near Helena, Arkansas where John succumbed was a time and place most ripe for disease. An inventory of John Bartholomew's meager possessions at the time of his death provides a poignant look at this just one of many untimely deaths that occurred throughout this period.

Union Civil War surgeons kept meticulous records whose compilation was published after the war by the Surgeon General describing the causes of illness and death of Union soldiers. Confederate records were destroyed by fire and in the process of the Confederate government fleeing Richmond in April 1865, but it is believed that causes of death were similar for the Confederate forces. Of 2.2 million Union soldiers who served during the Civil War there were 62,916 killed in action, 40,789 who died of wounds, and 221,791 who died of disease (see table). It is estimated that of 750,000 who served in the Confederate armed forces, 250,000 died, and of these, 160,000 died of disease or wound infection.

Studying the Medical and Surgical History of the War of the Rebellion (the official Union record) is interesting for the insight that can be gained as to what little was known of the causes of infectious diseases at that time. Infectious diseases were classified as "zymotic" ("miasmatic" or "enthetic") or parasitic (see example page from the MSHWR). Medical care was rudimentary, and concepts of surgical antisepsis were likewise lacking leading not uncommonly to fatal post-amputation wound infections (see more).

Careworn by the war's carnage and his responsibilities, Abraham Lincoln also had firsthand knowledge of the grievous nature of infectious disease. In 1862 he and Mary suffered the loss of their eleven year old son, Willie, to typhoid fever, and earlier a three year old son, Eddie, had died of tuberculosis. Interestingly, just after giving the Gettysburg Address Lincoln was afflicted with a minor case of smallpox.

Death to infectious disease was no stranger to anyone in the mid-nineteenth century whether they were in Civil War armies or not, but soldiers suffered increased disease incidence and mortality because of the factors that have been described in this vignette. It was not until World War I that death due to disease did not exceed that due to battlefield trauma in the wars in which the United States has engaged (see graphic).

Little is known about the short life of John Bartholomew. As we observe the sesquicentennial of the Battle of Gettysburg and the Civil War, we might think of John Bartholomew and the many others who died lonely deaths so far from home sacrificing so much so that this nation "shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth."

Happy 4th of July!

Ref: Sartin, JS, Infectious diseases during the Civil War: the triumph of the "third army," Clin Inf Dis: 1993; 16:580-584


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