A Bird's-Eye View of Appalachian Medical History

The year is 1780, and you are an Overmountain Man, the term used for Appalachian colonists who travelled east toward the Atlantic to fight with the patriots in the Revolution.  Although the Declaration of Independence has already been written and signed, the fight for official freedom has not yet been won.  You arrive in what is now Cherokee County, South Carolina in early October.  Even though the Loyalists have caught wind of the impending attack, your militia catches the opposing military off guard.  At 3 p.m. on October 7th, the Battle of Kings Mountain begins.  Just over an hour later, the Loyalists retreat with over two hundred men lost and almost as many wounded.  You and nine hundred of your fellow soldiers emerge victorious and are now one step closer to legal independence from the crown.

Unfortunately, you are one of only twenty-eight American soldiers wounded during the battle.  The final hours of your life are spent in agony as you lay bleeding on a bumpy cot in a makeshift medical tent.  If you are lucky, you will receive medical care from one of the ten percent of Revolutionary War medics who were officially trained as doctors at one of two medical schools in the colonies rather than a teenaged apprentice.  Either way, you are lucky that you lose too much blood before infection can set in and prolong your suffering.  Most others who die in pursuit of political independence from England will not do so from battle wounds themselves, but from the rampant and devastating spread of infection that are all but guaranteed to accompany them.

Germ theory, the concept that microscopic entities (bacteria, viruses, parasites, fungi, etc.) cause infections, did not begin to take form until the mid-1800’s.  Before the discovery that infectious agents causing seemingly outdated diseases like tuberculosis and the Black Death, people were dying from what is now perceived as easily avoidable causes.  For example, dysentery (a severe form of intestinal distress) was a common cause of death before germ theory.  Today, this antiquated affliction is prevented by modernized waste disposal and water treatment.  Dysentery was one disease that ravaged the early American colonies as well as the battlefields of the Revolutionary War.  Another such disease was small pox.  Small pox was common in Europe, where many people acquired immunity through generations of exposure (this, however, did not stop the disease from killing a significant portion of Europeans and American colonists).  European settlers unknowingly carried it with them when travelling to America.  In turn, this microscopic stowaway devastated many Native American tribes who had no previous exposure to small pox.  To this end, the early colonists may have intentionally used this to their advantage by gifting the native peoples items that harbored the deadly virus.  

Although the native peoples of America were not equipped to fight small pox, they had their own unique  medicinal practices.  Specifically, the Cherokee tribe (known today as the Appalachian Cherokee Nation) was one group of Native Americans that lived in the Appalachian region during European colonization of America.  They primarily resided in the more southern part of Appalachia (what is now North and South Carolina, northern Georgia, and Tennessee), but were displaced during the Trail of Tears that resulted from westward expansion during the pre-Civil War era.  Still, a handful of Cherokee escaped to the more northern region of Appalachia to preserve their land and culture.  One benefit of living in Appalachia was the abundance of natural amenities that would often be used for healing by the Cherokee people.  Even more fascinating, many of these traditional forms of medicine have been proven by modern science to be effective.  For example, the Cherokee people used blue cohosh (a type of flower) root to treat rheumatic diseases as well as to induce labor in pregnant women.  Today, there is indeed scientific evidence that chemicals in this root can both block inflammatory signals (helping to diminish the severity of rheumatic disorders) and cause muscle contractions in the uterus.  The Cherokee people also used witch hazel for skin problems such as cuts, bites, and rashes.  This plant is still commonly used topically for skin disturbances, and is even a common ingredient in skin care products.  The Cherokee people were intelligent and resourceful, having harnessed the medicinal properties of the Appalachian flora without access to modern technology.

As westward expansion continued throughout the early nineteenth century, tensions between the northern and southern regions of the eastern united states built up.  In 1861, the Civil War officially broke out.  As the bloodiest war in American history, it ushered in a new age of battlefield medicine that had lasting impacts into the next century.  The Appalachian state of West Virgina owes its legacy to the war itself, becoming a state when the northwestern region of Virginia seceded from the rest of the state, and therefore the Confederacy.  Cue John Denver’s “Country Roads.”

Civil War battles that were fought in what is now West Virginia include the battles of Philippi, Cheat Mountain, and Harpers Ferry.  In 1862, an abandoned mansion in Harpers Ferry became the Clayton General Hospital.  Later that year, Confederate soldiers overtook the town, and the hospital would become the point of Union medical care on an active battlefield.  As stray bullets whizzed through medical tents set on the property’s lawn, nurses worked courageously to tend to injured soldiers.  Despite their dedication and diligence, many men would die of infected surgery wounds.  Because of the desperate situation of war, many military “surgeons” were not trained as such, and even those that were did not have any viable defenses against an infected wound.  Right before the Civil War, the English doctor Joeseph Lister showed that sterilization of surgical equipment and wounds saved a significant number of lives.  However, many American doctors denounced this “absurd” new view (aseptic techniques were even banned in one Massachusetts hospital), and would not admit otherwise until years later when Lister would come to America to defend his techniques.

Among the soldiers dying from wounds and infections were those dying from consumption, or tuberculosis.  Tuberculosis is an extremely contagious respiratory disease spread by aerosolized droplets harboring deadly bacteria known as Mycobacterium tuberculosis.  During the 1800s, the disease was known as Consumption due to the devastating way in which the disease seemingly deteriorated or consumed its victims slowly over time.  During the Civil War, the cause of tuberculosis was unknown, therefore, the disease could not be contained.  Close quarters and unhygienic living accommodations in both Northern and Southern camps only sparked the fiery spread of Consumption.  Interestingly, the spread among Civil War soldiers was not higher, as far as historians can tell, than the spread among civilians during this time period.  The disease was so outrageously contagious that people were dying from it all over the world at such high rates that the breakout of the Civil War did nothing to increase its already astronomical spread. 

One notable Appalachian epicenter of tuberculosis was the Hopemont Sanitarium in Terra Alta, WV.  Originally intended to house tuberculosis patients, the hospital was not opened until 1913, twenty-eight years after the end of the Civil War.  Still, the only “treatment” available was to quarantine the sick in an effort to contain the spread.  The first tuberculosis vaccine was not formulated until 1921, and the discovery of antibiotics was still three decades away.

Shortly after the establishment of Hopemont Sanitarium came the passing of the Prohibition Act in 1920, which banned all sales and consumption of any beverage that consisted of more than 1.5% alcohol.  Unfortunately for those who enjoyed a drink (or an entire bottle), both brandy and whiskey were officially removed from the list of scientifically accepted medicines in 1916.  In 1917, the American Medical Association even voted in support of prohibition.  Previously, alcoholic beverages had been prescribed for a plethora of afflictions including chronic pain, pneumonia, and even diabetes.  When alcohol consumption became illegal, doctors and pharmacists ceased a golden opportunity to increase their profit margins.  Even under the Prohibition Act, it was completely legal for farmers to produce wine for their own pleasure as well as for religious ceremonies.  Stronger alcoholic beverages such as whiskey were also still being produced in smaller amounts for medicinal purposes regardless of their new status as pseudo-medicine.  Surprisingly, doctors could still legally prescribe whiskey for “medicinal purposes” using government-issued prescription cards.  Thus, many people in the medical profession made a pretty penny prescribing a stiff drink to their “sick” patients during the 1920’s and early ‘30’s. 

Around the time of the Prohibition Act, another huge public health effort was being made.  In large, the act of childbirth began to primarily take place in hospitals rather than in homes.  However, the use of midwives, or “granny women” for an at-home birth remained popular in Appalachia for the next couple of decades.  This is, in part, due to what we would think of today as “southern hospitality.”  Granny women continued to persist mostly in southern Appalachia because childbirth in the early twentieth century was seen as a gathering event for women—a setting in which midwives and experienced mothers could rally around the newest mom and offer their assistance.  On top of this, an at-home birth supervised by a professional midwife cost between three and five dollars, while a hospital would charge anywhere from two to six times as much.  Although this was most likely not known in Appalachia at the time, a Hungarian doctor named Ignaz Semmelweis had proved that a home birth with a midwife was actually way safer than a hospital birth just decades before.  Because germ theory was hardly past its own conception, doctors and surgeons would often go directly to assist with a birth straight from a morgue or dissecting table without so much as washing their hands, let alone putting on gloves or other protective equipment.  Because midwives were not in the practice of handling cadavers as well as aiding in childbirth, they were not carrying the same dangerous bacteria as doctors and therefore not transmitting deadly diseases to women giving birth. 

Within the past century, medicine in Appalachia has become increasingly more modern.  Unfortunately, access to innovative healthcare is highly limited due to a combination of factors including geography and socioeconomics.  However, residents of Appalachia have retained a sense of traditional medicine observed in various Native American cultures, such as the Cherokee people.  Any outdoor enthusiast or resident of the region knows that the Appalachian mountains are rich with plants that have a variety of medicinal properties.  For example, St. John’s Wort, an herb originally indigenous to Europe, is now commonly found in the Appalachian region.  This yellow flowery plant has been used traditionally to heal skin afflictions such as burns and other wounds.  Today, people still use its extract to treat a variety of conditions, the most common one being depression.  Although there are mixed results from scientific studies on the benefit of using St. John’s Wort to treat depression, its use still persists and has spread beyond Appalachia. 

Throughout its history, medical practices in the Appalachian region of the United States has developed in unique ways.  Driven by socioeconomic challenge, doctors over the years have had to fight to provide the best care for their patients with limited resources.  Appalachian health has been plagued by poverty in more ways than one.  In previous decades, the monopolies of coal companies in mining towns forced devastating health defects upon thousands.  Able-bodied men unfortunate enough to be caught in one of these towns had a choice between an early death from black lung, or an even earlier death—accompanied by their families—brought on by malnutrition and starvation.  Although coal mining towns are mostly a relic of the past, they left behind gigantic scars among the mountains.  The coal companies have lost their power, but the impoverished, blue-collar lifestyle persists.  There is now a wider variety of occupations in these places, but they pose their own risks.  Many blue-collar workers are severely injured and prescribed opioid painkillers.  The people of Appalachia are hearty, scrappy, and determined, but even these attributes cannot stand against the chemical rewiring of the brain exposed to opium-derived compounds.  All too often, these medicines take a hard-working family and destroy it in much worse ways than black lung ever could.  With the spread-out rural infrastructure that the mountainous landscape enforces, access to alternative therapies and intervention measures is very hindered.  Fortunately, there are many advocacy groups and intervention centers popping up throughout the region as the opioid crisis continues.  There are efforts made by universities, counseling services, and physicians to educate the public about alternative treatment plans for occupational injuries.  Some states have even legalized the use of cannabis, a non-addictive drug used to effectively manage pain in a wide range (including cancer and neurological diseases) of afflictions.  There is still a lot of work to be done to improve the quality of healthcare in Appalachia, but given the unmatched sense of community and the characteristic strong will of the Appalachian people, there is no reason why the collective health of this population cannot improve drastically in the years to come.