69. Garrison, Notes on the History, 139.
70. Ibid.
71. Ibid.
72. Ibid., 141.
73. Taylor, “Retrospect of Naval and Military Medicine,” 606.
74. Ibid.
75. It should not be assumed, however, that the physician and surgeon came to military service with the same educational background. The most that can be implied is that both received the same military medical training after entering military service.
76. Taylor, “Retrospect of Naval and Military Medicine,” 607.
77. Garrison, Notes on the History, 142.
78. Taylor, “Retrospect of Naval and Military Medicine,” 566.
79. The best English work on military medicine in Russia during this period is John T. Alexander’s “Medical Developments in Petrine Russia,” Canadian-American Slavic Studies 8, no. 2 (Summer 1974): 207.
80. Ibid.
81. Ibid.
82. Ibid., 210.
83. Ibid.
84. L. G. Eichner, “The Military Practice of Medicine during the Revolutionary War,” lecture presented at the Tredyffrin Easttown History Society, Pennsylvania, October 2003, 25.
85. Edwin P. Wolfe, “The Genesis of the Medical Department of the United States Army,” Bulletin of the New York Academy of Medicine 5 (September 1929): 823.
86. See Ibid., 613; and Taylor, “Retrospect of Naval and Military Medicine,” 627.
87. Wolfe, “Genesis of the Medical Department,” 613.
88. M. A. Reasoner, “The Development of the Medical Supply Service,” Military Surgeon 63, no. 1 (July 1928): 7.
89. Taylor, “Retrospect of Naval and Military Medicine,” 613.
90. David B. Davis, “Medicine in the Canadian Campaign of the Revolutionary War,” Bulletin of the History of Medicine 44, no. 5 (September–October 1970): 461.
91. Reasoner, “Medical Supply Service,” 7.
92. Ibid., 9.
93. William Shainline Middleton, “Medicine at Valley Forge,” Annals of Medical History 3, no. 6 (November 1941): 465.
94. Ibid.
95. Eichner, “Military Practice of Medicine,” 27, for a list of the specific medical conditions that caused death.
96. Howard Lewis Applegate, “Preventive Medicine in the American Revolutionary Army,” Military Medicine 126 (May 1961): 380.
97. Blair O. Rogers, “Surgery in the Revolutionary War: Contributions of John Jones, M.D. (1729–1791),” Plastic and Reconstructive Surgery 49 (January 1972): 3.
98. Davis, “Medicine in the Canadian Campaign,” 461.
99. Eichner, “Military Practice of Medicine,” 26.
100. Rogers, “Surgery in the Revolutionary War,” 9.
101. The name was changed from King’s College to Columbia University during the Revolutionary War.
102. Jones had been a military surgeon in the French and Indian War, an experience that prompted him to write his manual for wound treatment. The practical value of his manual, appearing as it did at the outbreak of the war, is obvious from the table of contents. Jones’s book contains chapters on inflammation, superficial wounds, general wounds, penetrating wounds, simple fractures, compound fractures, amputations, head injuries, concussions, skull fractures, gunshot wounds, and how to set up and manage a military field hospital.
103. Applegate, “Preventive Medicine,” 551.
104. Allen C. Wooden, “Dr. Jean François Coste and the French Army in the American Revolution,” Delaware Medical Journal 48, no. 7 (July 1976): 398. While Brown’s work was the first of its type written by an American in the colonies, Coste had authored a small military pharmacopoeia for the French troops’ use that had gained wide readership among American physicians.
5
THE NINETEENTH CENTURY
The Age of Amputation
The nineteenth century was the period in which the principle of empirical observation finally triumphed in medical matters over the influence of cosmological theorizing. As the century progressed, medical clinicians and researchers gradually worked out the methodological problems associated with discovery, innovation, and verification; abandoned old theories of disease; and established criteria of proof for new medical information. While the century was replete with new approaches and discoveries, the evolution and systematic application of new methodologies marked the century as the true beginning of modern scientific medicine. Table 7 presents a list of the most important medical advances and innovations relative to the wars that occurred in the nineteenth century.
The century was also marked by significant contributions that military physicians made to medical advances and the development of military medicine along modern lines. Military physicians applied to the battlefield various medical discoveries and techniques that the civilian medical establishment developed and greatly improved the organizational structures required to deliver effective medical care to the soldier in the field. Few armies began the period with anything approaching a systematic military medical service, but by the century’s end, all major combatants had set up independent military medical departments capable of dealing with mass casualties. The stimulus for these developments was, of course, the frequency of wars.
The wars of the nineteenth century were fought with increasing ferocity and lethality as a consequence of the technological advances in the killing power of weaponry. The French Revolution had created a new kind of army, an army of citizens, who, in exchange for the burden of conscription, expected better military medical care. The extremely high casualty rates caused by more lethal weapons forced political and military authorities to improve medical care as a way of conserving expensive manpower. Although few armies at the start of the period had learned these lessons, all major combatants had institutionalized their practices to establish adequate military medical services by the end of the century.
Table 7. Major Medical Advances of the Nineteenth Century and the First Half of the Twentieth Century
Few periods can compare with the nineteenth century in terms of the sheer frequency and destructiveness of warfare. The century began with the decade-long wars of the French Revolution only to witness, after a short respite, their continuation in the guise of the Napoleonic Wars. Across the Atlantic, the Americans fought the War of 1812 and the Mexican War of 1846–1848, both significant conflicts for the emerging United States. The Crimean War, which pitted the Russian Empire against a European alliance, caused so many casualties from weapons and disease that the public outcries of the combatants’ civilian populations forced significant military and medical reforms. The American Civil War, the world’s first truly modern war, shocked not only the United States but also caused European leaders to search for ways to increase the combat power and manpower assets of their own armies in anticipation of having to fight such wars themselves. France’s wars with Italy and Germany were bloodbaths, revealing the West’s complete inability to avoid horrific slaughter in its own backyard. In the end, the strategists and tacticians abandoned the search for solutions and resigned themselves to the fact that slaughter could not be avoided. Unwilling to abandon the structures and tactical principles, along with the accompanying privileges and social status, that had marked the military establishments of Europe for a century, the military thinkers of the late nineteenth century seem to have comforted themselves with more traditional doctrines of war fighting. When once again the major powers of Europe stumbled into conflict in the early twentieth century, these illusions evaporated overnight and left in their wake the most horrible slaughter ever wrought between contesting armies.
If war provided the stimulus for improved military medical care, the technological innovations of the Industrial Revolution provided the opportunity. The wars of the French Revolution and the Napoleonic era that followed interfered with the transfer of medical knowledge across national borders. The location of these wars and their long duration effectively forced medical research and discovery back within respective national borders. After 1815, wars of the period were f
ought on the periphery of Europe (Crimea) and outside Europe (the Mexican War, the Civil War) and were of short duration (France-Italy, Franco-Prussian War). The period following the Napoleonic Wars also saw great improvements in travel and communication. Medical discoveries and new treatment techniques were shared through printed books, newspapers, and medical and scientific journals, often transmitted telegraphically or through regular mail service that spanned the oceans in a few weeks. For the first time since the Roman Empire, the development of medicine could be viewed as a coherent whole rather than applying only to separate countries. A general commonality of medical knowledge and practice began that connected the efforts of researchers and practitioners across national boundaries. Only Russia—because of its geographic and, to some degree, cultural isolation—and Germany, because of its political fragmentation, remained apart from the stream of medical discovery and practice.
Neither medical nor military men could have anticipated the changes that occurred in warfare and military medicine during the nineteenth century. When the century began, the long-established tensions among the physician, surgeon, and barber-surgeon that had retarded the application of practical medicine to the soldier continued to strangle the medical profession. By the end of the century, except in Russia, the military barber-surgeon had disappeared, and surgery had finally established itself as an equal partner in the medical profession. A similar status was finally conferred upon military medical officers for the first time.
When the nineteenth century dawned, medical practitioners believed that the suppuration of wounds was a natural, inevitable, and beneficial part of the healing process, and they accepted the deaths of thousands of soldiers to wound infection as an unavoidable cost of war. By century’s end, however, discoveries in bacteriology made antiseptic and, later, aseptic surgery a common practice, and the death rate to wound infection dropped dramatically. Also at the beginning of the century, pain was the expected price of surgical application. Within fifty years, the introduction of anesthesia banished pain from the operating room and gave birth to the new science of anesthesiology. With pain alleviated, the necessity for surgical speed was reduced, opening up the possibility of more complex surgical procedures. Most military surgeons at the turn of the eighteenth century had not yet mastered ligature or the tourniquet; thus, amputation, the most common surgical procedure performed on the wounded, remained a traumatic and risky business. By the end of the nineteenth century, however, both ligature and tourniquet applications were normal practice, as was the use of the hemostat and surgical clip. Cautery was finally banished from the surgeon’s kit.
The greatest killer of soldiers at the beginning of the century was still disease, and it routinely carried off eight soldiers for each one felled by an enemy bullet. The advances of bacteriology, nutrition, and military and public sanitation, along with antiseptic surgery, finally made it possible for an army to kill more of the enemy with hostile fire than were killed by deadly infectious microbes. The Franco-Prussian War was the first war of any magnitude in which the number of soldiers lost to hostile fire was greater than to disease.
At the start of the nineteenth century, no army had established an independent military medical service under the control of medical officers for treating the sick and wounded. No nation could provide a trained medical staff, supply structure, transport, and medical personnel adequate to handle the usual casualty loads. By the end of the century, every major army had an independent, professionally trained, and sufficiently manned military medical service complete with an ambulance corps for reaching and evacuating the huge numbers of casualties that had never before been seen on the battlefield. If war finally reached modern proportions in all its respects in the nineteenth century, it is also fair to say that military medicine achieved a similar stature.
ANESTHESIA
Effective and safe anesthesia was introduced to military medicine in the nineteenth century. The term “anesthesia” is generally credited to Oliver Wendell Holmes Sr. (1809–1894), to describe the effects of ether.1 Prior to the discovery of ether and chloroform as anesthetics, the most commonly used agent against pain was opium administered in liquid or powdered form. Other methods of rendering a patient unconscious or semiconscious for surgery were to reduce the blood supply to the brain either by compressing the carotid artery until the patient passed out or by bleeding the patient to a state of near total unconsciousness. Immediately prior to the introduction of ether anesthesia, some surgeons, including the famous English surgeon Sir Robert Liston (1794–1847), used hypnotic suggestion to induce sleep.2 All of these methods produced semiconscious states of only short duration, requiring the surgeon to complete the surgical procedure quickly.
The first gas recognized as having anesthetic properties was nitrous oxide, which Joseph Priestley (1733–1804) identified in 1772 as part of his experiments with oxygen. For several years the gas was thought to be deadly. In 1795, the chemist Humphry Davy (1778–1829) inhaled nitrous oxide and, noting its pleasant effects, named the mixture “laughing gas.” In 1800, Davy published a monograph in which he described the use of nitrous oxide to relieve the pain of an inflamed gum. More important, he suggested its use as a surgical anesthetic. Eighteen years later, Davy’s student, Michael Faraday, noticed the anesthetic effects of sulfuric ether and compared them to the effects of nitrous oxide. In 1842, Henry Hill Hickman, a member of the Royal College of Surgeons of London, performed the first operation with an anesthetic on animals.
None of these experiments evoked any serious interest. Although nitrous oxide and ether were well known by mid-century, the medical community still showed no systematic interest in using it for surgery, perhaps because of the widespread belief that pain was natural to illness. Medical students were aware of the anesthetic properties of both nitrous oxide and sulfuric ether, and they commonly used them at university parties to induce silly behavior. In January 1842, William E. Clarke, a student of chemistry, convinced Elijah Pope to extract a tooth from a patient anesthetized by ether. Two months later a Georgia dentist, Crawford Long, removed a tumor from the neck of a patient who was anesthetized by ether. After William T. G. Morton, a Boston dentist, extracted a tooth from a patient to whom he had administered ether in 1846, he published the results of his work in the Boston Journal. Morton was heretofore regarded as the discoverer of ether as a surgical anesthetic. In October 1846, Morton administered anesthesia while Dr. John Collins Warren removed a tumor from a patient’s jaw. The use of ether as a surgical anesthetic quickly spread to Paris and to London, where, in December 1846, Sir Liston performed a thigh amputation on an etherized patient and publicly proclaimed the new anesthetic a major medical innovation.
The U.S. Army was the first to formally issue ether for anesthetic purposes, having allotted supplies to the physicians and battle surgeons who accompanied Maj. Gen. Winfield Scott’s men in the 1847 landing at Veracruz during the Mexican War. That March or early April, Edward H. Barton, surgeon of the Third Dragoons, Cavalry Brigade, Twiggs’s Division, anesthetized a teamster of the U.S. Army’s logistics train to amputate his leg, which had been shattered by an accidental musket blast. The operation marks a military field surgeon’s first use of the ether anesthetic.3
Samuel Guthrie in the United States, Eugène Soubeiran in France, and Justus von Liebig in Germany almost simultaneously discovered chloroform in 1831.4 Chloroform was not used as an anesthetic, however, until 1847.5 Chloroform had a number of advantages over ether for military applications. The simple “rag and bottle method” of administering chloroform was easier to use since it did not require an inhaler. Smaller quantities were required to induce anesthesia, and chloroform could be more easily stored and transported in the battle surgeon’s pocket while in the field. Most important, unlike ether, chloroform was not explosive, an important consideration in a time when most operations were performed by candle or lantern light in close quarters. Given these advantages, it is difficult to explain why chloroform was so slow to ca
tch on, especially among English military surgeons. From 1847 to the early days of the Crimean War in 1853, there was not a single documented instance of a British military surgeon using chloroform for anesthesia.6 John Snow (1813–1858) was the first physician to calculate specific doses for ether and chloroform as surgical anesthetics. He personally administered chloroform to Queen Victoria (1819–1901) during the births of the last two of her nine children, leading to the widespread acceptance of the use of anesthetics among English physicians. Although the French military had used it as early as the Paris revolt of 1848 and the Prussians likely used it in the Danish-Prussian War of 1848–1851, British military medical doctors did not begin to use chloroform until the first few months of the Crimean War. A British naval surgeon aboard the HMS Arethusa was the first to administer chloroform at sea in 1854.7
AMPUTATION
Anesthesia revolutionized military surgery, especially in the area of battlefield amputation. Without anesthesia, speed was the surgeon’s primary qualification. Sir Liston, the famous English surgeon, reportedly could amputate a leg in twenty-eight seconds. Even less skilled military surgeons could accomplish the task in less than a minute. Moreover, the doctrine of primary amputation advanced early in the century by Dominique-Jean Larrey, Baron Pierre-François Percy (1754–1825), and George James Guthrie (1785–1856) was gradually accepted as the century wore on, and under the influence of Sir Thomas Longmore (1816–1895) and George H. B. MacLeod in the Crimean War, it became established practice for military surgeons. Anesthesia made it possible to operate more slowly, to take the time to effect more complete hemostasis (stopping blood flow), and to prepare the stump for prosthesis. Although early in the century surgeons maintained that the pain associated with surgery was actually beneficial in that it kept the body’s systems fighting to survive, in fact the use of anesthesia greatly reduced the incidence of death by surgical shock.
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