Monday, June 12, 2017

Review of Flannery - "CIVIL WAR PHARMACY: A History, Second Edition"

[Civil War Pharmacy: A History (Second Edition) by Michael A. Flannery (Southern Illinois University Press, 2017). Softcover, photos, tables, notes, biblio essay, index. 335 pp. ISBN:978-0-8093-3592-3.$34.50]

Hopefully, the studies of Civil War surgery and medicine published over the past few decades have helped dispel the popular myth of army surgeons as incompetent sawbones largely immune to scientific curiosity and progress. On the other hand, in contrast to the many fine published works on Civil War medicine and surgery, just about everything related to pharmacy—the drugs; the persons and firms involved in the development, manufacture, and distribution of therapeutics; and the duties and challenges of those that dispensed these chemical and botanical agents directly to the soldiers in the field—has been less well represented in the literature. Michael Flannery's Civil War Pharmacy (2004) went a considerable distance toward bridging the gap, but new scholarship, along with some omissions noted by reviewers, has led Flannery to update his award-winning book. The resulting Civil War Pharmacy: A History, Second Edition incorporates current work in the field while also adding two new chapters on battlefield pharmacy and naval pharmacy.

In 1861, there were only six established schools of pharmacy in the U.S. As a regulated profession, pharmacy was in its infancy, as was the pharmaceutical industry as a whole. Most pharmacists prepared their own remedies and learned their craft through apprenticeship (or were self-taught). Even so, Flannery contends, with some justification, that the pharmacy trade and practice in the country were not as backward in comparison to their western European counterparts, and domestic drug manufacturing much more complex, than the more dismissive critics have asserted. The author also cites in his introductory section noticeable regional differences in antebellum American pharmacy. Predictably, production was even more scaled-down and dispersed in the South than in the North, but most readers would probably be surprised to learn that several southern states were pioneers in regulatory law.

The book fully describes the official duties and responsibilities of those within the army tasked with ordering and maintaining drug supplies and distributing them to the soldiers in the field. Of these two positions—medical purveyor and medical storekeeper—the latter were by 1862 law tested for both pharmaceutical knowledge and business management acumen prior to appointment. Wider were the duties of hospital steward. Over time, these bled into almost every aspect of army hospital and surgical care, but pharmacist was the post's chief responsibility. One steward was attached to every general hospital as well as to each company in the field (although approved numbers were never achieved and less than a handful were typically assigned to each regiment).

Through national aid organizations like the U.S. Sanitary Commission, women played a key role in raising funds for the purchase of drugs and medical supplies. Supplementing medicines obtained through official army channels, these additions to the pharmacopeia were a godsend to the sick and wounded. Flannery also presents evidence that female nurses and volunteers, though faced with strong opposition from Union army surgeons and hospital stewards, were involved in drug preparation, dosing, and administration. Many also applied their own experiences in home remedies to the benefit of grateful soldiers. As the book shows, the Confederacy's lack of a similar national aid organization meant that its own sick and wounded were placed at a significant disadvantage in comparison.

Flannery's research led him to the conclusion that pharmaceutical manufacturing and distribution in the North were both efficient and adequate to the needs of the army. According to the author, fears that government labs would stifle private industry proved to be unfounded, and there's little data to support allegations of price fixing and war profiteering even when, in the case of quinine, only two firms were responsible for essentially the entire supply.

Citing considerable evidence, the book marks the year 1863 as the turning point in the South's ability to meet its pharmaceutical needs. Until that time importation and native manufacturing were sufficient, but the tightening of the blockade and the failure to find native substitutes meant that the disparity in sickness levels between Union and Confederate regiments widened even further. While plagued by nutritional deficiencies not suffered by their Union opponents (which resulted in debilities almost unique to Confederate soldiers, like pellagra and night blindness), the author is generally impressed with Confederate efforts to maintain the health of its soldiers with far less resources available. Making the procurement challenge even more difficult, the drugs that did make it through the blockade also had to serve the civilian population.

The officially approved medicine chest for the armies contained a long list of manufactured and plant-based agents ranging from highly beneficial to downright harmful. Several figures and tables catalog these therapeutics, but Flannery wisely limits his most detailed analysis to those drugs used to treat the most common ailments (diarrhea, dysentery, fevers, respiratory illnesses, and digestive problems). The book contains a long and useful discussion of the procurement, manufacture, and efficacy of quinine preparations, which were truly effective against malaria but also misused as a kind of general therapy. The popular view of Civil War hospitals being helpless in the face of infection is successfully challenged by the book's well documented account of the startling effectiveness of bromine and iodine disinfectants (especially the former) in reducing post-operative mortality and managing wound infections. This revealing look at disinfectants is the salient feature of the Second Edition's new chapter on battlefield medicine. The surgical anesthesia section is also quite good. While appropriately noting widespread institutional stubbornness when it came to using mercury-based products, Flannery does cite a small core of enlightened opposition within the army. The author singles out for special recognition one brave dissenter in particular, Union Surgeon General William A. Hammond, who was court-martialed and cashiered for directing the army to remove mercury from its medicine chest.

The new navy chapter is largely descriptive in nature, with little discovered in the way of distinctive differences between army and naval pharmacy. It does praise (appropriately, it seems) the efficiency of the naval laboratory, which preceded the army's facility by a decade. Problems emerged here and there during the war, but the well-established Bureau of Medicine and Surgery and its lab together did a fine job of meeting the significant challenges of supplying and managing the pharmaceutical needs of the Union Navy's far flung fleets.

Flannery's contention that the war was a key event in the wider development of the pharmaceutical industry in the U.S., with many individuals involved in wartime research and production becoming household names by their association with the many eponymous firms that would rise to prominence in the following decades, is a persuasive one. Unlike the small arms industry, the drug companies were able to maintain and even expand their wartime economies of scale. The book makes scant mention of Civil War connections to the parallel post-war patent medicine industry boom, but it's likely the author felt such a large tangential topic outside the scope of this study.

Michael Flannery's Civil War Pharmacy represents a very thorough introduction to a significant and often misunderstood topic. On a macro level, the book effectively charts the evolution and economic transformation of the pharmaceutical industry before, during, and after the Civil War. At the ground level, the study affords readers a detailed picture of the organization and practice of pharmacy in the Union and Confederate armies and navies. The roles of several of the war's most significant therapeutic agents are discussed at length, and many prevailing beliefs and myths convincingly challenged. This volume is a very important addition to the Civil War medical literature, but it is also hoped that a wider readership will be exposed to the book's many corrective features regarding the nature of Civil War pharmacy and the progressiveness of its practitioners.

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