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Home : Quarterly Archives : Volume 41 |
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Tredyffrin Easttown Historical Society |
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Source: Winter 2004 Volume 41 Number 1, Pages 25–32 THE MILITARY PRACTICE OF MEDICINE
Background During the Colonial period there were only two medical schools in the colonies: the Medical Department of the College of Philadelphia, later the University of Pennsylvania, started in 1765, and the King's College, later Columbia University in New York City, started in 1768. By 1776 only 51 medical degrees had been conferred by these schools, yet there were 3000-4000 individual practitioners of medicine available within the colonies. Virtually anyone could just walk out and call themselves a doctor.
The civilian and military were inter-related. After the heavy casualties from the Battle of Bunker Hill, the Continental Congress established a “Hospital for the Army,” a term for the Medical Department, on July 27, 1775. It was to be headed by a Director General, plus a Chief Physician, both appointed by Congress. These two were to be assisted by four surgeons, 20 surgeon's mates, which we would today call physician's assistants or OR nurses, one apothecary, one nurse for every ten men, a clerk to keep accounts, and two storekeepers to serve a total of 20,000 men. In the same year Congress established the apothecary unit in the “hospital setting.” The apothecary is what we today call the pharmacy in a hospital. The medical establishment was inefficient, and often ineffective throughout the Revolutionary War. The Continental Congress never established a Table of Organization for the “Hospital.” There were overlapping jurisdictions, with a failure to establish lines of authority and responsibility. State regiments had separate medical services, and were appointed under the control of the individual states, similar to the National Guard providing service primarily to the state. For example, in 1775 New Jersey provided each of their battalions, consisting of several hundred men, with at least one surgeon and usually a surgeon's mate. Congress was too preoccupied with other matters to pay enough attention to the needs of the Medical Department. Rivalries among the top medical officers, congressional politics, and corruption within the services, interfered with the smooth operation of the Medical Department. Initially Congress had approved both state—civilian and professional—and army medical personnel, as a method of democratic checks and balances. The states, with their regimental surgeons, would continue as the home defense and offer support to the regular army. However, this led to disputes between the regular and state militia medical men. Among the top echelon, bitter disputes arose between the first Director General, Dr. John Morgan, and his arch-rival, the famous surgeon, Dr. William Shippen, who later replaced Morgan and who himself faced court martial. Some at the lower level were dishonest and actually sold medical discharges. Medical supplies were usually and often woefully inadequate, and shortages of food and clothing aggravated the problem. Often gross inadequacy prevailed, with a resultant complete absence of medical supplies at the front. Small amounts of supplies were smuggled from the West Indies, or captured from the British. The French also managed to send a few supplements. There were too few qualified personnel—surgeons and surgeon's mates— available. Washington, realizing the technical inadequacy of many of the medical personnel, attempted to require surgeons and surgeon's mates to take examinations, but Congress yielded to state rights pressure and no action was taken. Not until 1782 did Congress establish a screening board for military surgeons. Because of the inconsistent abilities of the individual regimental surgeons, Director General Morgan was forced to issue the following regulations on how to handle combat casualties:
After pressure from General Washington, Congress subordinated regimental hospitals to the Director General. Washington ordered the regimental surgeons to make their returns of casualties and supplies to the Director General. This order required the regiments to keep track of the medical materials used, and the names of the wounded. Prior to this, it was not uncommon for a commander to not know who was dead and wounded, and who had deserted.
General Hospitals were intensive care units established in public and private buildings, and run by Continental military. These could be single, or a series of buildings which included barns, homes, huts, colleges, and churches. They were located in relatively stable locations such as Providence and Newport in Rhode Island, Peekskill, Fishkill, and Albany in New York, Hackensack, Fort Lee, Elizabeth, Amboy, Brunswick, and Trenton in New Jersey, Bethlehem, Bristol, Reading, Lancaster, Manheim, and Philadelphia in Pennsylvania, and Alexandria and Williamsburg (The Governor's Palace) in Virginia. Flying Hospitals were mobile, being located in a hut or tent, with a few emergency beds and a surgeon's table. They were manned by Continental personnel. These were a precursor of the later M.A.S.H. units. Regimental Hospitals were specifically constructed and run by regimental surgeons for a large number of soldiers.
During the Battle of the Brandywine, the 600 American wounded were dispersed long distances to Philadelphia, Trenton, Princeton, Bethlehem, Ephrata, Lititz, and elsewhere. This was accomplished because of Washington's policy of sending casualties ahead of the retreating army, using the army as a shield to protect the wounded while they are being evacuated. One can only imagine the torturous journey for these wounded traveling these long distances in springless, open wagons, as well as by sleds, carts, wheelbarrows, and stretchers of muskets connected with coats or blankets. Many of the wounded died in transit.
The encampment of Washington and his troops in Valley Forge from December 19, 1777 to June 19, 1798 – a period of exactly six months – is recalled by most Americans as the time of the greatest suffering during the war. It may well have been so. In December 1777, 3000 were sick; by late January 1778 the number had reached 6000. At the end of the encampment in June 1778, of the 10,000 to 11,000 men that entered the encampment the prior December, 2500 to 3000, or one-fourth, had died of disease, exposure, and privation. Why such a catastrophe? Malnutrition, including scurvy, was a most widespread problem. The food was said to be bad, and infrequent. Even though food was available in the interior of Pennsylvania, there were few wagons or teams to haul it, and some of those were captured by British cavalry patrols. The biggest factors for the inadequacies included the agents of the various hospitals bidding against each other for medical supplies, the medical leaders feuding among themselves, and the sheer inefficiency and graft as mentioned by Congress. For example, Dr. Otto at the near-by Yellow Springs Hospital recorded that 1/2 to 2/3rds of the wagons transporting food for the wounded were regularly pilfered by teamsters. The weather during the encampment, despite the popular impression of persistent snow, actually accrued little accumulation. However, constant cold rain and sleet prevailed which directly contributed to such health issues as frost-bite, chilblains, pneumonia, pleurisy, rheumatic fever, and tuberculosis. There was meager knowledge of sanitation. Purification was attempted by wood smoke or sulfur from burnt cartridges. Washington ordered each soldier's hut to be sanitized in this way, and also by burnt tar, or vinegar sprinkled over the floor and furnishings. These steps were thought to thwart “crowd fevers.” Such measures, of course, were to be of no avail. The huts which housed the troops, replicas of which can be viewed today, had floors below ground level, and were cold and damp. The only fuel was green logs which produced a dense smoke. Vermin quickly filled these dwellings, as human excretion was frequently deposited from the incapacitated sick. Many died in their huts, and were so quickly buried that adequate records were generally not made of their deaths. A lot of men were buried at Valley Forge that no one really knew about or were accounted for. Today we would refer to these men as MIAs. Latrines were rarely used, despite stringent orders—even to shoot men on sight if caught relieving themselves in unauthorized parts of the encampment area. In addition, a large number of horse and beef cattle remains were left unburied about the encampment which served to pollute the few water sources. To compound the problem, disagreements among the medical staff existed with regards to the causes and prevention of camp diseases. This is understandable because the actual causes of these diseases were simply not known to science at that time. It is therefore no wonder that the soldiers were prime candidates for yellow fever, typhus, typhoid fever, smallpox, and even measles and whooping cough which were often fatal. Other conditions noted were scrofula, boils, and other skin infections which sometimes resulted in gangrene. Another skin condition know as “body itch,” probably caused by body lice, began in the fingers and spread diffusely, often developing into impetigo. Injuries such as broken bones and ax cuts occurred in the building of huts and fortifications, and the chopping of firewood. The General Hospitals previously mentioned were established in various types of commandeered buildings. However, at nearby Yellow Springs was the only building erected specifically as a field hospital. Its construction was completed early in 1778, and it had the following dimensions: 136 feet in length, 36 feet wide, with three stories and an attic. The first floor was stone and the rest wood. Samuel Kennedy and Bodo Otto served as chiefs, with Dr. Kennedy dying, probably from typhus, which he contracted while working at the hospital while receiving many of the sick from the encampment. Unfortunately, military hospitals often only compounded the problems of the sick and wounded. The famous Philadelphia physician, Dr. Benjamin Rush, stated: “Hospitals are the sinks of human life in the army. They robbed the United States of more citizens than the sword.” A soldier had a two percent probability of dying in combat, but when admitted to a crowded army hospital, the likelihood of death increased to 25 percent. Another source reported that six out of every seven soldier's deaths were due to camp illnesses. Another source cited nine deaths from disease for every one from battle wounds. The dead were buried in unmarked graves in grounds adjoining the hospitals. Not only were the sick and wounded troops vulnerable in the hospital setting, but so too were the physicians and nurses. This was particularly true in Ephrata and Bethlehem. In Bethlehem nine of eleven surgeons contacted typhus within a four-month period. In the House of the Single Brethren church building, where 700 casualties were crowded, it was recorded that four out of every five of the 200 soldiers who died succumbed to typhus. The condition of crowding was universal, and strongly contributed to both morbidity and mortality. The sick were laid in long lines upon straw. However, because of the scarcity of straw it was seldom aired or replaced. This, despite the order of General von Steuben, who was responsible for drilling the troops, to frequently air the bedding, and to burn all straw used by the dead or by patients infected with typhus. The covering of the straw depended upon whatever blankets the patient brought with him, and clothing was limited to whatever the soldier was wearing. Sheets were rare. To exacerbate the condition, a patient was forced to protect his possessions, as stealing was common. Attempts were made toward cleanliness, but they were usually limited to washing the face and limbs, and the combing of hair in an attempt to reduce the prevalence of lice. Unfortunately an unlimited supply of these creatures continued to be found in the straw and in the unwashed clothing of the patients. Toilets consisted of pails in the corners of rooms, which were occasionally emptied. Sometimes metal bedpans were available for the bedridden. However, because of overcrowding and poor conditions, the ill were often left in their own filth. Maggots frequently appeared in a patient's wounds, but it was soon recognized that they were able to remove necrotic, or dead, material. In fact, cultured maggots were used until quite recently for debriding, or ridding the wound of dead material by consuming it. I remember when I was an intern in the early 1950s, cultured maggots in necrotic wounds in a hospital setting. Tincture of myrrh, and turpentine, were used as cleaning agents for wounds. Unfortunately, wounds were often cleaned with plain water which was drained into a pail or basin and reused for all others with wounds on the ward. What better way to spread the infection! The nutritional aspect was dismal. Food shortages existed, of course, for the hospitalized as well as the other troops. But for the sick this food shortage was a greater problem as their specially needed supplies were in greater demand every-where. These were wine, rum, sugar, coffee, tea, milk, molasses, chocolate, mutton, veal, vegetables, rice, fish, and oil. Rum, wine, and whiskey were used as stimulants, and in large amounts as a narcotic in surgery. Molasses and sugar provided energy, and aided resistance to infection. Coffee, tea, and chocolate were also used as stimulants. The “invalids” were given a liquid diet because it was felt that solid foods used energy needed to fight disease. Soups and broths were prepared from Indian corn, barley, rice, fish, and oil. Bread was often crumbled into the soup or broth to form a mush for more substance. The need for salt was recognized, but unavailable. The means of feeding large numbers of patients with the soups, broths, and mush was unfortunately a significant aid to infection. It was the custom to feed the “invalids” from wooden bowls with the use of pewter or wooden spoons, but using one spoon to feed the entire ward.
The physician's often depleted medicine chest consisted of bottles of laudanum (tincture of opium) for relief of pain and diarrhea, crème of tartar—a cathartic, spirits of lavender (carminative) for digestion and to relieve gastric distress, and elixir paregoric for diarrhea, pain, cough, and nausea relief. Three types of medications were prepared:
Topical applications to wounds were sometimes sprinkled basilam powder or quinine, but usually whiskey. Cauterization—searing the blood vessels shut—was often employed, especially with bleeding. As mentioned, purgatives, emetics, blisters, and poultices—flannel compresses tied to the affected body part—were all used, as well as cupping—a way of drawing fluid out—and the use of leeches. Ironically, lest we express shock at this latter, leeches were still advertised by an apothecary near the Benjamin Franklin Bridge in Philadelphia until the early 1940s. I knew the man. Without question they would remove blood. Wounds might be packed with lint—scrappings from cotton or linen—and then bandaged and kept damp with water or vinegar. Surgery usually involved bullet wounds and amputations. Forceps and probes were used for the removal of bullets and splintering bone from wounds, with amputation often the next step. Until World War I, when steel-jacketed bullets were introduced, the projectiles fired from muskets and rifles were made from lead, and expanded upon impact, exiting the body like a tunnel going out. Large, jagged holes and bone shattering was the natural result, often causing irreparable damage to tissue and bone. Amputations were accomplished for the most part with large, curved knives, although later the use of saws was adopted from the British. 
Trepanning with a cylindrical saw was done for undepressed skull fractures, to provide relief of a concussion, clots and pus, to relieve fluid pressure, allowing the dissolution of inflammation from the brain lining, called the dura mater, or to prevent future “mischief” from delayed hemorrhage. Anesthesia was provided with a quantity of alcohol or a tobacco juice concoction. All too often, however, the patient was forced to simply “bite the bullet”—a lead musket ball to grind their teeth down on to stifle a scream of pain—while attendants literally held down the patient (victim) to restrain him. This latter practice continued all too often well into the 19th century. Suturing was performed with a linen thread, or sinew, with the use of a curved needle similar to that used by a sailmaker, which served as the forerunner of today's needles. Other surgery consisted of tooth pulling using a cork-screw and a hooked metal key.
As happens in every war, advancements are spun off. This occurred with hospital care. It was originally the policy that as soon as a patient was mobile, he was generally to be returned to full duty. This policy not only served as a hindrance to the patient's complete recovery, but also to the smooth functioning within the patient's military unit. In September 1776 the State of Connecticut, becoming aware of their troops returning to their units still ill and wounded, introduced small hospitals in every town. These were known as convalescent hospitals, and their use actually enabled many soldiers to return more quickly to full duty. The disastrous effect of hospitalization during the Valley Forge encampment led a prominent New Jersey physician, James Tilton, to devise the use of small general hospitals in Moorestown, New Jersey during the winter of 1778-79. Tilton's concept, based upon the “wigwam,” had three small log cabins, each with a dirt floor, constructed in a U configuration. A fire was tended in the midst of each cabin—or ward—with a 4-inch square opening made in the ridge of the roof. The air and smoke within each cabin would thereby circulate before passing through the roof opening, thus providing better ventilation than in other designs. Sleeping men were positioned with feet turned closest to the fire for warmth. In warm weather Tilton advocated a relocation from the cabins into long tents to decrease the potential for contagion and disease.
As the war progressed, the American army began to recognize the benefits of hygiene and sanitation. This was the major medical advance of the Revolutionary period. Three publications were instrumental in promoting these benefits: • Military Hygiene in 1776, by Dr. John Jones, • Diseases Incident to the Armies Within the Method of Cure – 1776, by Baron von Sweeten, and most especially, • To the Officers in the Army of the United American States: Direction for Preserving the Health of Soldiers, by Dr. Benjamin Rush. Much of the following is excerpted from Dr. Rush's book:
Out of the many medical mistakes made during the Revolution, the following positive effects resulted:
However, significant and adequate advancements in the practice of surgery and anesthesia were still many years in the future—long beyond the Civil War.
Beck, James B. Medicine in the American Colonies. Horn & Wallace, 1966. Brinton, Robert. Notes Regarding The Yellow Springs Hospital in the Revolutionary War. Burkhart, Larry L. The Good Fight: Medicine in Colonial Pennsylvania – 1681 to 1765. University Microfilms, 1982. Cowen, David L. Medicine in Revolutionary New Jersey. New Jersey Historical Society Commission, 1975. Moorestown Memorial Hospital. Medicine and Surgery During the American Revolution. O'Connor, Robin. “American Hospital: The First 200 Years.” Hospitals, Journal of the American Hospital Association, January 1, 1976. Wilbur, C. Keith, Revolutionary Medicine: 1700-1800. Globe Pequot Press, 1980. Dr. Eichner received the M.D. degree from Thomas Jefferson Medical College in 1954, and recently retired after 42 years of practice in Internal Medicine. He served for two years as a physician in the United States Marine Corps, and has lived in Easttown Township for over forty years. He is a past president of the Tredyffrin Easttown History Club.
Presented at the October 2003 meeting of the Tredyffrin Easttown History Club. |
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