Between Flesh and Steel

by Richard A. Gabriel

  In the early days of the war, patriotic fervor prompted large numbers of citizens to enlist in the army. With no medical screening examinations for recruits, the American Army soon became a walking health disaster. Military medical officers attempted to establish field hygiene practices and encourage daily shaving and regular bathing to reduce the spread of disease. The American force was composed mostly of country boys and the urban poor, neither known for their cleanliness habits. Disease became the army’s constant companion throughout the war, and the overall death rate from disease was ten times higher than from enemy bullets.90 Disease was so common that it became increasingly difficult to recruit sufficient manpower as men now avoided military service out of fear of epidemic.

  The frequent incidence of disease in the revolutionary army is easily discernible from the following figures. In February 1776 the army of 16,877 men had 3,765 men, or 22.3 percent of total its strength, listed as unfit for duty due to illness.91 At Crown Point, New York, that December the nation’s largest military hospital listed 3,000 patients in that single hospital. In the first year of the war, more than 5,000 men, or 25 percent of the total force, were lost to death, illness, or desertion.92 In December 1777, 2,898 men of the 11,000-man force at Valley Forge were unfit for duty because of illness. By February 1778, 4,000 men were unfit because of illness and injuries from cold.93 The American Army was the first army to attempt widespread vaccination of its troops against smallpox, but the use of smallpox inoculation at Valley Forge sent 3,000 men to the hospital with reactionary cases of the disease. “Jail fever” (typhus), for example, was an ever-present danger in close quarters. In a three-month period, four hundred of the seven hundred prisoners died of jail fever and were buried in a common grave.94 The Valley Forge encampment of Washington’s army was a medical catastrophe. The encampment lasted from December 17, 1777, to June 19, 1778, or a period of six months. Some ten thousand soldiers had entered the encampment. By June, twenty-five hundred to three thousand had died of disease, exposure, or malnutrition.95

  The field hospitals in the Valley Forge cantonment were primitive, constructed largely of log huts. These “flying hospital huts” were twenty-five feet long and fifteen feet wide by nine feet high and covered with boards or shingles for roofs. Windows were placed on each side and a fireplace and chimney at one end. Two hospital huts were authorized for each brigade, but the space was never sufficient to handle the number of casualties and the sick from a single brigade. Hospitals were established in rear area villages and towns, but the local populace always raised considerable opposition to placing a hospital in their midst. The fear of epidemics, the requisitioning of buildings for military use, and the widespread fraud in purchasing supplies led the locals to treat the military suspiciously. Sometimes the number of casualties brought to a small town or village exceeded the number of residents.

  Of the thirty-five hundred colonial physicians and surgeons in America in 1775, only four hundred of them had medical degrees or formal medical education.96 In Virginia, only one in nine practicing physicians had received any formal medical training.97 These figures, however, do not provide an accurate portrait of the quality of medical personnel available to the military.98 Unlike in Europe, where strong guilds perpetuated the strict separation between surgeons and physicians, that practice never developed in America. American medicine was in the hands of the general practitioner who healed, operated, and mixed and prescribed his own medicines. His medical training was largely achieved less through formal education than through an apprentice system. General Washington realized that the states provided many physicians whose technical competence left much to be desired, and he pressed Congress to require surgeons and mates to take examinations before being assigned to military units. Congress yielded to pressure from the states, though, and didn’t take any action.99 Gradually the states enacted examination and licensing procedures, but Congress did not establish a screening board for military surgeons until 1782. Because of the apprentice system of medical training, however, the quality of military medical personnel was as good as, and in a number of ways even superior to, that available in European armies.100

  The pragmatic bent of American medical practice unhindered by the social distinctions between surgeon and physician was evident in the appointment of John Jones (1729–1791) as the first full professor of surgery at the Medical School at King’s College, New York.101 Jones wrote Plain, Concise Practical Remarks on the Treatment of Wounds and Fractures, the first surgical text published by an American in the United States in 1775. The book appeared in time for the war and became a basic training and field text for military surgeons.102

  The Revolutionary War provided a strong stimulus to developing military and general medicine in the colonies. The early problems of the military doctors’ competency forced states to adopt stringent examinations and licensing requirements that persisted after the war, generally raising the quality of medical practice. The war also gave physicians who heretofore were isolated in small rural communities an opportunity to interact with other physicians and to exchange ideas, treatments, techniques, and drug formulas. American doctors also came into contact with the medical staffs of their French allies and acquired skills on hospital administration for which the French were noted. Although expressly forbidden by both civil and military law, undoubtedly battlefield surgeons experimented on the bodies of the dead to improve their anatomical knowledge.103 Furthermore, because the severance of commercial ties with Britain removed the main source of medical equipment and drugs, the Americans were forced to develop their own substitutes.

  The quality of American medical thought and innovation during this period was evident in the publication of a number of American medical books. Jones’s book, already noted, became the definitive text in the field. Recommendations of Inoculation According to Baron Dimsdale’s Methods (1776) by John Morgan (1735–1789) influenced the American Army to adopt inoculation as a preventive for smallpox. Morgan became the first director general of the American military medical service. William Brown (1754–1808), an army doctor, wrote a Pharmacopoeia for Use of Army Hospitals (1778), the first book of its kind in the colonies.104 Benjamin Rush’s (1745–1813) Directions for Preserving the Health of the Soldier (1778) became the handbook for field hygiene, as did his other work, Regulations for the Order and Discipline of Troops of the US. Hospital administration and health care were the focus of James Tilton (1745–1822). He wrote about his experiences as a physician and surgeon in the war in Economical Observations on Military Hospitals and the Prevention of Disease Incident to an Army (1813). Ebenezer Beardsley (1746–1791) wrote an account of the cause, spread, and treatment of dysentery in colonial regiments. All of these works made significant contributions to the theory and practice of military medicine and reflected the pragmatism that continues to characterize American medicine to the present time.

  The care of veterans had long been a tradition in the American colonies. As early as 1636 the Plymouth colony passed a law providing for the support of the crippled soldier, and in 1644 the Virginia Assembly created a system of relief for the soldier maimed in battle. Immediately after the start of the Revolutionary War, Congress ordained that soldiers incapacitated by war should receive half pay, similar to the British practice of caring for their wounded veterans. In 1792, Congress passed a pension law for veterans.

  Congress always viewed its raising of a national army to fight the War of Independence as a temporary measure forced by difficult times, and when the war was over, the national army was demobilized. By 1783, the entire national armed force of the United States, renamed “The Legion,” consisted of fewer than a thousand men. With the army’s demobilization also came the dismantlement of the military medical service. Regimental surgeons and mates stationed with the troops in camp hospitals had provided the soldier’s medical care. The U.S. military continued to operate without a systematic military medical service until the War of 1812, when military necessity again forced the
country to devise ways to provide medical care for its soldiers.

  To recap, in the eighteenth century the centralized power of the nation state reached a level of organizational control that it had sought for three centuries. This centralization enabled the aggressive monarchs of the period to consolidate their power within their domestic realms and to expand it beyond their borders. Inevitably, the price of this expansion was war. With the improvements in military technology came a greater demand for large numbers of soldiers, a demand that could only be filled through voluntary enlistments. To encourage recruitment, the armies of the day had to improve the soldier’s living conditions. This effort also required developing better military medical care and establishing veterans’ programs. Consequently, the provision of organized military medical care became a recognized and regular function of government.

  Improvements in the general quality of medical education and training in civilian society enabled armies to enlist trained medical personnel to treat the soldiers. The advances in medical knowledge and technology inevitably, if slowly, found their way into the military medical organizations. Only the navies of the world, where medical care was as dismal as it had been during the Middle Ages, remained the exception to this general trend. The final liberation of surgery from the social and political tyranny of the physician establishment also elevated the quality of medical care for the soldier.

  As the nineteenth century dawned, armies had gained considerable experience in providing medical care to their troops in the field. In times of peace the medical service structures took the opportunity to improve their quality and, most important, to plan for providing medical care before the next actual fight. The stability of the organizational structure permitted the introduction of medical advances accomplished in the civilian sector much more quickly than before. Finally, the graduates of the first national medical schools of military medicine were reaching the peaks of their careers in the military bureaucracies, providing the armies with generally well-trained and experienced medical officers to manage the problem of medical care in wartime. The armies of the eighteenth century were poised on the edge of developing a modern military medical service in its degree of organizational articulation. Once the structure was in place, incorporating the medical innovations of the next century into the armies was relatively easy, thereby raising the quality of medical care available to the soldier to heretofore unachievable heights.

  NOTES

  1. Mary C. Gillett, The Army Medical Department, 1775–1818 (Washington, DC: Center of Military History, U.S. Army, 1981): 1.

  2. Ibid.

  3. Garrison, Introduction to the History, 397.

  4. Ibid., 335.

  5. Kirkup, “History and Evolution,” 284.

  6. H. A. L. Howell, “The Story of the Army Surgeon and the British Care of the Sick and Wounded in the British Army, from 1715 to 1748,” Journal of the Royal Army Medical Corps 22 (1914): 324.

  7. Ibid., 323.

  8. Heizmann, “Military Sanitation,” 295.

  9. Ibid., 296.

  10. Ibid.

  11. The first attempts to adopt clothing for purely military use were intended to afford the soldier greater concealment on the battlefield. The British Army abandoned the traditional red coat during the Second Afghan War and adopted khaki uniforms to better blend in with the light and sandy background of the country’s terrain. After the Franco-Prussian War, the Germans rid themselves of their brightly colored regimental uniforms and adopted the famous feldgrau, or “field gray”–colored, uniforms that are worn to this day.

  12. Starvation and poor economic conditions have driven military recruitment since time immemorial. The large contingents of Irish serving in the British armies since the Great Famine is an obvious example. A great number of soldiers in Gen. George Custer’s command were Irish immigrants. Much of the American frontier army was comprised of immigrants, free blacks, and other minorities (Mexicans and native Indians) as a consequence of the lack of opportunity for these groups in the larger society.

  13. Officers, however, continued to pay for their rations and still do in most modern military establishments.

  14. Heizmann, “Military Sanitation,” 296.

  15. John Thorne Crissey and Lawrence Charles Parish, “Wound Healing: Development of the Basic Concepts,” Clinics in Dermatology 2, no. 3 (July–September 1984): 554.

  16. West, “A Short History,” 147.

  17. Gordon, “Penetrating Head Injuries,” 5–6.

  18. Howard Lewis Applegate, “The Need for Further Study in the Medical History of the American Revolutionary Army,” Military Medicine (August 1961): 617.

  19. Wangensteen et al., “Some Highlights,” 105.

  20. Ibid., 106.

  21. However, the disease and infection rates among soldiers in these primitively constructed hospitals were often much lower than in the larger hospitals. The poor construction left these makeshift hospitals subject to drafts, which provided ventilation and renewed the stale air within the wards. See Young, “Short History,” 488; and Howard Lewis Apple-gate, “Effect of the American Revolution on American Medicine,” Military Medicine (July 1961): 552–53.

  22. Gillett, Army Medical Department, 3.

  23. Ibid., 8.

  24. Ibid., 6.

  25. Grissinger, “Development of Military Medicine,” 317.

  26. Abram S. Benenson, “Immunization and Military Medicine,” Clinical Infectious Diseases 6, no. 1 (January–February 1984): 2.

  27. McGrew, Encyclopedia of Medical History, 155.

  28. Benenson, “Immunization and Military Medicine,” 1.

  29. Ibid.

  30. Taylor, “Retrospect of Naval and Military Medicine,” 594.

  31. Garrison, Notes on the History, 374.

  32. Heizmann, “Military Sanitation,” 297.

  33. Ibid.

  34. Howell, “Story of the Army Surgeon,” 333.

  35. For more on the military medicine of the Roman Navy, see Richard A. Gabriel, “The Roman Navy: Masters of the Mediterranean,” Military History, December 2007, 37–43.

  36. Ibid.

  37. The term “quarantine” comes from the Latin quarantine, which means forty. Tradition has it that the original period of quarantine for crews on commercial vessels was forty days, the same length of time that Christ was said to have spent being tempted in the desert.

  38. Taylor, “Retrospect of Naval and Military Medicine,” 596.

  39. Uniform clothing was not issued to the sailor as a health measure. The officers recognized that uniforms made sailors more easily identifiable on shore, an advantage in curtailing desertion.

  40. The term “to shanghai,” meaning to impress a person forcefully into naval service, refers to the port of Shanghai, China. The idea is that once caught by the press gangs, the sailor’s next stop was Shanghai.

  41. Taylor, “Retrospect of Naval and Military Medicine,” 596.

  42. Lawson, “Amputations through the Ages,” 223.

  43. Taylor, “Retrospect of Naval and Military Medicine,” 600.

  44. Ibid., 601.

  45. Howell, “Story of the Army Surgeon,” 327.

  46. Taylor, “Retrospect of Naval and Military Medicine,” 603.

  47. Howell, “Story of the Army Surgeon,” 321.

  48. Chamberlain, “History of Military Medicine,” 240.

  49. Nonetheless, armies persist in defining medical conditions as discipline and morale problems. Soviet frostbite casualties were so high during World War II that Joseph Stalin issued an order that any soldier careless enough to get frostbite would be shot. In Vietnam, American soldiers who contracted venereal disease were subject to punishment. Psychiatric conditions of the “silent” type often are still treated as discipline problems.

  50. Howell, “Story of the Army Surgeon,” 332.

  51. Paul E. Kopperman, “Medical Services in the British Army, 1742–1783,” Journal of the History of Medicine and Allied Sciences 34, no. 4 (Octobe
r 1979): 428–29.

  52. Howell, “Story of the Army Surgeon,” 332.

  53. Ibid., 331.

  54. Ibid.

  55. Kopperman, “Medical Services,” 430.

  56. Ibid., 437.

  57. Ibid., 438, citing Robert Jackson, A System of Arrangement and Discipline for the Medical Department of the Armies (London: J. Murray, 1805), for these figures.

  58. Taylor, “Retrospect of Naval and Military Medicine,” 596.

  59. Kopperman, “Medical Services,” 454.

  60. Garrison, Notes on the History, 138.

  61. Edgar Erskine Hume, “The Days Gone By: Military Medicine in the Eighteenth Century,” Military Surgeon, October 1929, 563.

  62. Ibid.

  63. Chamberlain, “History of Military Medicine,” 240.

  64. Ibid.

  65. Louis S. Greenbaum, “Science, Medicine, and Religion: Three Views of Health Care in France on the Eve of the French Revolution,” Studies in Eighteenth-Century Culture 10 (1981): 373–91.

  66. Heizmann, “Military Sanitation,” 299.

  67. Hume, “Days Gone By,” 564.

  68. Heizmann, “Military Sanitation,” 298.