Bernard John Dowling Irwin and the Development of the Field Hospital at Shiloh

Military Medicine, May 2006 by Fahey, John H

The field hospital remains a centerpiece of casualty care evacuation systems, dating back to the Civil War. Dr. Bernard John Dowling Irwin is credited with establishing the first tent field hospital during the battle of Shiloh. However, controversy regarding this claim exists because of the confusing practice of using the term "field hospital" to refer to facilities with different capabilities. By examining the specific levels of care available on the battlefield, I review the evolution of the different types of field hospitals, focusing on the increasingly complex capabilities that evolved in the spring of 1862 in the Western Theater. I conclude that Irwin's hospital was the first practical demonstration that sufficient inpatient care could be provided on the battlefield, eliminating the need to evacuate unstable patients.

Introduction

One hundred years ago, the Journal of the Association of Military Surgeons announced that "the Commissioners for marking the Battlefield of Shiloh have designated with a suitable tablet the location of the first tent field hospital, established by General (then Captain) B.J.D. Irwin."1 Irwin had been commended at the time of the battle by both his line commander and his medical director,2,3 and Surgeon General John Moore had written that "it would appear from a review of the papers in this office that the first regular tent field hospital was organized during the battle of Shiloh, April, 1862, by Dr. B J.D. Irwin."4

Despite the tablet's inscription that his hospital was "the greatest boon in war" (Fig. 1), not all historians have agreed with the significance of Irwin's hospital. Percy Ashburn, writing in the 1920s, dismissed Irwin as having done no more than misappropriate tents from those who had been taken prisoner during the first day's fighting,5 whereas historian Stacy Allen suggested that the first tent hospital was actually established 6 weeks earlier at Fort Donelson.6

Two aspects of Irwin's hospital have generated the most discussion, viz., its size and its use of tents. Louis Duncan, who believed that mobility was the critical element of a successful field hospital, made unfavorable reference to the large field hospitals established by Queen Isabella of Spain in the 148Os when he stated that "Irwin's hospital was no more a real field hospital than was Isabella's."7 In contrast, Edgar Hume, in his history of army medicine, praised Irwin for his innovative "tent hospital designed for the care of a large number of patients in an emergency."8

Hume drew attention to the other area of controversy regarding Irwin's hospital, namely, that it was the first "tent hospital." Tents had been used in combat for centuries9,10 and were standard medical inventory at the regimental level before the Civil War. Therefore, the issue is not whether Irwin was the first to use tents but what he used them for. As Irwin was to write later, "I do not claim to have invented tents for use but I do claim to have been the first to demonstrate its practical advantages for field hospitals."" The key question thus becomes the following: what did Irwin mean by "field hospital?"

One explanation for the lack of consensus regarding Irwin's accomplishment may be that the term "field hospital" was applied to facilities with widely differing clinical capabilities. Mary Gillett summarized the frustrations of many historians when she wrote that "the terminology used to classify hospitals during the Civil War was confused and confusing."12 In the official reports and correspondence of the participants, the term "field hospital" was applied equally to austere regimental units containing a few cots and to huge divisional and corps-level establishments capable of providing inpatient care to thousands of patients.

Levels of Care

Because the term "field hospital" was applied indiscriminately to a variety of facilities with differing capabilities, it would be useful to Identify the specific clinical capabilities being provided on the battlefield and to determine which were applicable to Irwin's facility. Military planners have long used the concept of echelons of care to identify and to quantify the escalating capabilities of care in wartime to provide appropriate logistical support.13,14 Examining this classic military concept might provide some tools for reviewing the different levels of care being provided on the battlefield at Shiloh.

Casualty evacuation schemes usually start at the point of injury on the battle line and proceed rearward through increasingly capable health care platforms attached to ever-larger echelons of command. The classic system with five levels of care emerged at the end of the Civil War (Fig. 2). It has been in use for >100 years (Fig. 3) and, with modifications, is still in use today (Fig. 4).15 Each of the levels of care is characterized by a specific clinical capability, with a corresponding unique logistical requirement that enhances the care at that level and builds on previous levels.

Table I lists the five basic levels of care existing at the end of the Civil War. The first two levels of care could usually be provided by units on the battlefield, with resources organic to their units. More-robust care, such as field inpatient care, required additional resources provided by supporting elements assigned to rearward commands; definitive care and specialized care usually required that the patient be evacuated from the field to a larger city.