the military practice of medicine during the revolutionary war

THE MILITARY PRACTICE OF MEDICINE DURING THE
REVOLUTIONARY WAR
L. G. Eichner, M.D.
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.
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 Medical Department of the
American Army
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 archrival, the famous surgeon, Dr. William
Shippen, who later replaced Morgan and
who himself faced court martial. Some at
The civilian and military were interrelated. 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.
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Reduce, or set, fractured bones
to realign them,
Apply dressings to wounds. If
the dressings are too tight,
bloodflow is decreased and will
increase inflammation
and
"excite" a fever. If the dressings
are too loose, fresh bleeding
may recur or set bones may
displace. If you move someone
and the bones are not set tightly
enough, the bones will slip out
of alignment,
• Regimental surgeons and mates
are ordered to the general hospital
if it becomes overcrowded with
new casualties. Medical staff are
to be removed from the front and
brought back to the receiving
facilities as those facilities become
overcrowded with casualties,
• Before each battle, check with the
regimental officers for men to
carry off the wounded. A supply of
wheelbarrows, other convenient
biers, or whatever transport is
available, is to be secured in order
to carry off the wounded.
These orders have a familiar personal
ring to recent, fast-moving military units.
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 personnelsurgeons 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:
• Dress the wound by a hill 30005000 yards to the rear of the battlefield. This was intended to remove
patients and caregivers beyond the
range of artillery and musket fire,
• Regimental surgeons are to be stationed with their militia men when
in a fort or on a defense line,
• Give emergency care only. In the
heat of battle, amputation or any
capital operation is best avoided.
Emergency duties to be carried out
directly on the battlefield include:
Stop bleeding with lint and
compresses,
ligatures,
or
tourniquets,
Remove foreign bodies from the
wound,
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.
Types of Hospitals
General Hospitals were intensive care
units established in public and private
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Medical Review of the Valley Forge
Encampment
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.
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?
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.
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 nearby Yellow Springs Hospital recorded that
1/2 to 2/3rds of the wagons transporting
food for the wounded were regularly pilfered by teamsters.
Regimental Hospitals were specifically
constructed and run by regimental surgeons for a large number of soldiers.
Medical Review of the Battle of the
Brandywine
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 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 frostbite, chilblains, pneumonia, pleurisy,
rheumatic fever, and tuberculosis.
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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.
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.
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.
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.
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.
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
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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.
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.
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 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.
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 everywhere. 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.
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.
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 wood-
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.
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en bowls with the use of pewter or wooden spoons, but using one spoon to feed
the entire ward.
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.
Physicians Equipment and Hospital
Procedures
The physician's often depleted medicine
chest consisted of bottles of laudanum
(tincture of opium) for relief of pain and
diarrhea, creme 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:
• Liquids mixed in copper kettles over
a fire, given hot to the patient usually as purges and emetics,
• Dry, prepared with a mortar and
pestle, and,
• Pills rolled by the physician—and,
until quite recently, still done.
Topical applications to wounds were
sometimes sprinkled basilam powder or
quinine, but usually whiskey. Cauterization—searing the blood vessels s h u t was often employed, especially with
bleeding.
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.
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.
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 (vic-
Wounds might be packed with lint—scrapings from cotton or linen—and then
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cated a relocation from the cabins into
long tents to decrease the potential for
contagion and disease.
tim) 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 corkscrew and a hooked metal key.
Preventive Care
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.
Hospital Advancements
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.
Much of the following is excerpted from
Dr. Rush's book:
• Skin - the hands and face should be
washed once daily, and the entire
body 2-3 times weekly,
• Shaving - stubble is to be removed
at least three times per week. The
soldier had to pay the barber for
this task,
• Hair - hair is to be thinned and
worn short at the neck, with daily
combing and dressing,
• Clothing - linen hunting shirts absorbed perspiration well, and therefore should be changed frequently,
• Shoes - should be of thick, strong
leather and all seams waterproofed
by waxing. Nevertheless, Indian
moccasins were considered by the
troops to be warmer than common
leather shoes because the moccasins
would breath,
• Tenting - tents should be placed on
dry spots, well aired and shaded.
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 advo-
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•
Areas near marshes and bodies of
water should be avoided,
• Heat - avoid the sun,
• Air - fire, wood smoke, burning sulfur, and exploding gunpowder were
felt to preserve and restore the purity of the air,
• Bedding - straw should be
frequently changed. Blankets are to
be aired in the sun. Bedding is to be
raised off the ground,
• Privies - There is to be no elimination about the camps, except in
privies. If flux or diarrhea occurs,
deeper pits are to be dug with a
thick layer of earth to cover waste.
Privies are to be placed either in
front or to the rear of the camp,
depending on the wind's direction,
• Victuals - chiefly vegetables and
fresh fruit were advocated. Bread is
to be well baked and of pure flour.
Cooking vessels are to be carefully
washed after using, a necessity
proven in military organizations
since then,
• Water - drinking water must be
pure. River water near the banks is
to be avoided. Water purity is to be
checked with a few drops of alum
tartune. If the tested water is pure,
only a small cloud will appear in the
water. When impurity is suspected,
six ounces of vinegar are to be
added to three quarts of water.
•
A policy for battlefield treatment of
the wounded, and their evacuation,
was recognized, and,
Initial efforts to structure a military
medical department were made.
However, significant and adequate
advancements in the practice of surgery
and anesthesia were still many years in
the future—long beyond the Civil War.
Bibliography
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.
Conclusions
Out of the many medical mistakes made
during the Revolution, the following
positive effects resulted:
• Beginning principles of sanitation
and hygiene were recognized,
• Steps in disease control were initiated,
• The importance of smallpox
vaccination was established,
Presented at the October 2003 meeting of
the Tredyffrin Easttown History Club.
Transcribed by Roger D. Thorne.
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