Hand-colored lithograph of the Second Battle of Bull Run, August 29, 1862. Keen was present at the first battle—in 1861—as a volunteer medical officer. Library of Congress.
Initially, both the Union and Confederate armies immediately distributed any medicines purchased. Later, the Union Army purchased raw materials, such as cinchona bark for quinine, for processing at its own or contract laboratories. The South, with no drug-manufacturing centers, was forced to smuggle medicines, capture them, or invent alternatives. When Keen required medicine for his patients, medical purveyors—usually a military officer or physician—bought drugs on the market or obtained them from one of many depots, and then shipped them; medical storekeepers took receipt and stored medicines until needed; surgeons wrote prescriptions; and in the Union Army hospital stewards filled them. With a rank equivalent to a sergeant the hospital steward was an apothecary who supervised lesser hospital staff and occasionally performed minor surgery. As the war progressed, purveyors for the Union Army learned which wholesalers or companies delivered trustworthy and reliable products. The most influential laboratories serving the Union Army included Charles Pfizer and Company, Edward R. Squibb, Schief¬felin and Company, Powers and Weightman (many years later to become Merck), Rosengarten and Sons, and John Wyeth—many of which still dominate the industry today.
These developments formed the background of a desperate war. A year after Bull Run, Keen found himself back for the Second Battle of Bull Run. He set up a field hospital at nearby Centreville “and soon afterward began to distribute the instruments, blankets, medicines, stimulants, etc., I had brought. . .. Before I left Washington I had been directed to be rather sparing in distributing these, and I obeyed orders.” He regretted his parsimony when a regiment of Virginia Confederate Cavalry overran the field hospital. Keen was forced to hand over the key to the storehouse of “medicines, stimulants, operating cases, and . . . more valuable things that I had brought along—how their eyes widened and their faces were wreathed in smiles as the doctor, after a rapid survey of the boxes on the walls, turned to the colonel and said, with an expletive: ‘There is more good whiskey in this little smoke-house than there is in the whole city of Richmond!’”
Stranded with about 100 wounded men without supplies, Keen surveyed the misery. Some pitying Confederates even donated canned soup. He received important assistance from two Northern quasi-governmental relief organizations, the U.S. Christian and U.S. Sanitary Commissions, both of which showed up with food. While others prepared soup, Keen “took a bottle of morphine and [his] pocket penknife and did not worry over any superfluous exactitude in doling out the blessed relief which morphine brings to men in pain. All of this was done in total darkness, with two or three slim lanterns, in a drizzling rain, and in six inches of Virginia mud.” Keen faced rampant infections owing to severe internal injuries. “Wounds of the abdomen involving the viscera were almost uniformly fatal. . . . Opium was practically our only remedy [for abdominal surgery] and death the usual result.”
In 1862 Jonathan Letterman, medical director of the Army of the Potomac, ordered Keen to commandeer two Washington, D.C., churches and convert them into hospitals in five days. Keen complied, but the army way of doing things remained obscure. “I was not lacking in ordinary intelligence and was willing to work, but I was utterly without training. . . . As to drugs I did not know whether to order six ounces or a gallon of laudanum, an ounce or two or a pound or two of opium.”
The pharmacopoeia at Keen’s disposal, which centered on the Supply Table, presented a sophisticated constellation of substances. Nineteenth-century understanding of the origins of disease is both familiar and strange; the restoration of balance within bodily systems, a relic of humoral theory (in which black bile, yellow bile, blood, and phlegm made up the humors), still informed much of medicine. The category of “fevers” represented a type of disease rather than a symptom. Some diseases, such as typhoid and typhus, were not easy to distinguish, and as a result received identical treatments.
In the hospital Keen wrote prescriptions in Latin, the universal custom, and gave them to the steward to compound. To a 21st-century pharmacist, some of the substances popular then, like Dover’s Powder and calomel—the former containing opium, the latter, mercury—have no recommended therapeutic purpose. Some, like antimony- and lead-based drugs, are downright dangerous, while others remain in use—such as iodine and quinine. With no laboratory methods available to establish drug usefulness through testing, no systematic antisepsis, and no germ theory, Keen worked within a system of medical knowledge based on observation of symptoms rather than causes.