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Part 3

Table of Contents

PART III

The American Revolutionary War and
First Years of the Republic
(1775-1783; 1799)

ESTABLISHMENT OF THE
MEDICAL DEPARTMENT OF THE ARMY

At the beginning of the American Revolutionary War in the battles of Lexington and Concord on 19 April 1775, the Colony of Massachusetts had a relatively strong force of militia, but there was no organized army, no commander in chief, and no military medical department, or "Hospital," as the whole medical service came to be called. These deficiencies were soon remedied. On 14 June 1775, the Second Continental Congress voted to take over the forces assembled in Massachusetts as the Continental Army, and on 15 June appointed General George Washington as Commander-in-Chief. He arrived at Cambridge on 2 July and next day assumed command. Thereafter, one of his first communications to the Congress urged the immediate establishment of "the Hospital," provision for which had been omitted from the congressional military act. He wrote on 20 July:

I have made inquiry with respect to the Establishment of the Hospital, and find it in a very unsetled Condition. There is no Principal Director, nor any Subordination among the Surgeons; of consequence Disputes and Contentions have arisen and must continue until it is reduced to some System. I could wish that it was immediately taken into consideration as the Lives and Health of both Officers and Soldiers so much depend upon a due regulation of this Department. [Fitzpatrick 3: 350.]


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This letter, addressed to the President of the Congress, is symbolic of Washington's constant concern with provision of not only the best possible medical and surgical service for the troops, but also with measures for the preservation of their health. The Congress also had been aware of the need to establish a medical service for the army. On 18 July, 2 days before Washington's letter was written, the Congress appointed a committee to consider the method of establishing a hospital, and on 27 July 1775, voted for "the establishing of an hospital for an army consisting of 20,000 men," defined the staff and its duties, characterized the official positions which included "one Director General and Chief Physician," and specified the allowances of pay (37).

First American vade mecum of military hygiene, by John Jones (1775).-"At the commencement of the Revolutionary War," wrote Dr. John Shaw Billings (38) in 1876, "we had one medical book by an American author, three reprints, and about twenty pamphlets." The book referred to was a volume published (39) by John Jones, in 1775, shortly after the beginning of the Revolution (fig. 5).

Billings disparages the first part of this book which deals with the treatment of wounds and fractures, "as simply a compilation from Ranby, Pott, and others, and contains but one original observation." He does not mention the second part, the appendix on camp and military hospitals and "remarks on the means of preventing diseases in Camp or Garrison," for which, the author (John Jones) wrote, he was indebted to Sir John Pringle's "excellent observations on the diseases of Armies." John Jones had met Pringle in London, probably during his second visit abroad in the late 1760's. This book, by the Professor of Surgery at King's College Medical School in New York City, was the first medical book published in America. It was of great use to the young military surgeons of the Continental Army for whom it was "principally designed."

John Jones had served with colonial troops in a British Army in the French and Indian War from 1758 to 1763. During the Revolution, he served as surgeon's mate and


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FIGURE 5.- Facsimile of title page of the medical and surgical volume containing an appendix on the hygiene of camps and military hospitals, by John Jones (1729-1791), Professor of Surgery in King's College, New York. It contains a section, mostly derived from Pringle's "Observations," on the means for preserving health in an army. It was of great use to young military and naval surgeons of the Revolution. (Photograph, courtesy of the Library of Congress.)


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surgeon of the 10th Massachusetts Regiment of the Continental Line, from 1 September 1777 to 14 May 1781. Following an assignment to Philadelphia in an official capacity in July 1778, after the evacuation of the city by the British, he made his home there for the rest of his life. His frail state of health, due to asthma, limited his field service, but he was able to take an important part in the organization of the Medical Department of the Continental Army.

Van Swieten's manual on diseases incident to armies.-In 1776, 18 years after the appearance of the original German edition (18), two editions of an English translation of Baron van Swieten's "The Diseases Incident to Armies With the Method of Cure" were published in Philadelphia (40). This book was reprinted in Boston in 1777. To van Swieten's booklet were added surgical tracts and an essay on the prevention of scurvy. This publication made available additional information and advice derived from foreign experience in military hygiene. The second printing in 1776 was combined in a single binding with a reprint of John Jones's volume "Plain Concise Practical Remarks." The publication of these two volumes within a few months was indicative of the current interest in military preventive medicine.

In the preface to "Diseases Incident to Armies" (p. 7), van Swieten does not make any excessive claims, but does make a number of wise remarks. He commented:

It may not be amiss to premise some observations, by means of which, sickness may in some degree be prevented, and the health of the soldier preserved. We are sensible, that in time of war, it is not always possible to observe exactly all what we are going to say; but it cannot but be of use to know what is most advantageous, that it may be put in practice, at least when circumstances permit.

He gave advice, in the preface, under 11 specific "observations." Included among these were advice about diet: "The use of garden stuff and fruit prevents the scurvy, and even cures those already attacked with it"; about clothing, shoes, water, ventilation, selection of dry campsites, personal hygiene, exposure to the heat of the sun,


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and about avoidance of crowding: "Great care ought to be taken not to lodge many men in a small space;-and if it cannot be avoided, let the air be at least renewed as often as it can, whether those who lodge together are in health or sickness, for from hence arises the most dangerous, and even the contagious distempers."

Nostalgia, morale, and recreation.-Van Swieten, like Pringle and others, recognized the morale-building and health-aiding values of recreation-games, entertainment, amusements, and exercise. He wrote about this subject as follows:

First. The soldier fresh lifted, and torn at once from his family, no sooner loses sight of his village, but he becomes melancholy; and tho, a robust husbandman, finds himself scarce able to bear the fatigues and inconveniences of a military life. It were wished, that he could be used, little by little, to this new kind of life; but in the mean time nothing is better, than to procure him all kinds of amusement and diversions.

This kind of depression, or "homesickness," was called "nostalgia," a term first used by Johannes Hofer in 1688 (41).

Frequently during the Revolution, General Washington, other line officers, and military surgeons issued orders or recommendations on the subject of prevention of nostalgia among troops. These statements and subsequent actions forecast the policies and program of the Morale Division of the Adjutant General's Office and the Special Services Division of the Office of the Chief of Staff, in the War Department, in World War II, and their successors, including the Army Recreational Service.

Four great men in the Continental Army during the Revolution-two laymen and two physicians-stand out prominently for their constant striving in promulgating principles of hygiene and their efforts to obtain actions by officers and men to limit the occurrence and spread of disease, and to preserve the health of troops. These men were General George Washington, Maj. Gen. Baron von Steuben, Dr. Benjamin Rush, and Dr. James Tilton. They


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advanced the evolution of preventive medicine in the United States Army.

George Washington (1732-1799); care for health of troops.-The solicitude of the Commander-in-Chief for the health and welfare of his soldiers and his re-


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gard for medical officers and the Medical Department of the Army are documented by innumerable records. In the collected writings of George Washington (42), there are hundreds of references to military health precautions, cleanliness broadly conceived, sanitation, policing of camps, huts and quarters, food (diets, rations, and "the proper dressing" of provisions), clothing, hospitals and The Hospital, inoculation for smallpox, sulfur ointment for inunction for the itch (scabies), and a great variety of hygienic matters-all attesting to Washington's personal interest in doing everything he knew how to do to preserve the health of the troops. "The General has nothing more at heart, than the Health of the Troops," was written at the beginning of general orders issued from Headquarters in New York on 5 August 1776.

One of his first general orders issued at Headquarters, Cambridge, Massachusetts, 4 July 1775, addressed to line officers whom he held responsible for the health of their men, reads:

All officers are required and expected to pay diligent Attention to keep their Men neat and clean; to visit them often at their quarters, and inculcate upon them the necessity of cleanliness, as essential to their health and service. They are particularly to see, that they have Straw to lay on, if to be had, and to make it known if they are destitute of this article. They are also to take care that Necessarys [latrines] be provided in the camps and frequently filled up to prevent their being offensive and unhealthy. Proper Notice will be taken of such Officers and Men, as distinguish themselves by their attention to these necessary duties. [Fitzpatrick 3: 309-310.)

Mosaic sanitary code: cleanliness.-Throughout the Revolutionary War, general orders of this type were issued repeatedly. Many orders included exhortations, and threats of punishment of officers who did not persevere in the "constant and unremitted Execution thereof," and penalties (including being fired upon) for men who fouled the camp. Washington emphasized strongly the principle of cleanliness, broadly conceived to include both personal hygiene and environmental sanitation. Like Pringle, Brocklesby, Tilton, and others, Washington invoked the


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Mosaic sanitary code, as stated in the Fourth and Fifth Books of Moses in the King James Version of the Old Testament, Numbers 5: 1-4 and Deuteronomy 23: 12-14. This is shown in the facsimile reproduction (fig. 7) of the broadside of his general orders for the Army under the command of Brigadier General McDougall, issued at Head Quarters, Peeks-Kill [in October? 1777]. A copy of this broadside (43) is reprinted as appendix A, p. 189.

In this broadside, Washington refers to Moses as "the wisest General that ever lived, for he was inspired." He might also, with good reason, have referred to him as "the Founder of Preventive Medicine," as proclaimed by Wood and others (44).

At the end of the horrible winter of 1777-1778 at Valley Forge, Washington made one of his periodic inspections of the camp. According to a note in the Orderly Book of Brig. Gen. George Weedon on 13 March 1778 (as quoted by Middleton (45)), Washington found the camp filthy, with carcasses of dead horses and much offal in the streets, and "nastiness, is spread amongst ye Hutts, which will soon be reduc'd to a state of putrefaction and cause a Sickly Camp." Following this, on 13 March 1778, Washington issued general orders from Headquarters, Valley


FIGURE 7.- Facsimile of broadside "of Cleanliness," general orders issued by Washington at Head Quarters, Peeks-Kill [November 1777?]. Printed by Samuel Loudon, Fisk-kill, 1777. Only two copies of this broadside are known to exist. One is in the Houghton Library of Harvard University, Cambridge, Massachusetts. The other, from which this facsimile was made, is in the New York Historical Society. The text is more clearly reprinted in appendix A, p. 189. (References: Friedman, Lee M.: Washington and Mosaic Law. In Notes and Documents. Miscellanea. Publications of the American Jewish Historical Society 39 (Pt. 3): 318-320, March 1950; Guerra, F.: American Medical Bibliography 1639-1793. New York: Lathrop C. Harper Inc., 1962, No. A-615; and Vail, R. W. G.: A Patriotic Pair of Peripatetic Printers. The Up-State Imprints of John Holt and Samuel Loudon, 1776-1783. In Essays Honoring Lawrence G. Worth, Portland, Maine, 1951.) (Photograph, courtesy of the Armed Forces Institute of Pathology, photograph negative No. 66-8139.)


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Forge which have a plaintive tone combined with solicitude and sternness: "The Commander-in-Chief: Out of tender regard for ye lives & health of his brave Soldiery, and with surprise that so little attention is paid to his orders, He again in ye most positive terms, orders & commands * * * [clean up the camp and observe the manifold regulations regarding cleanliness]."

Benjamin Rush (1745-1813); preservation of health of soldiers.-Rush, at the beginning of his "Directions For Preserving the Health of Soldiers," published (46) first as a newspaper article in 1777 and next year, with revisions and additions, as a pamphlet (fig. 9), by Order of the Board of War, referred to the interest of the Congress in lessening sickness, "and, if possible, preventing it altogether." He wrote: "* * * I maintain that the mortality from sickness in camps is not necessarily connected with a soldier's life. * * *"

Having addressed these "Directions" to the officers of the Army of the United States, he pointed out that responsibility for the health of troops was a responsibility of command:

* * * the munificence of the Congress, and the skill of Physicians and Surgeons, will avail but little in preventing mortality from sickness among our soldiers, without the concurrence of the officers of the army. Your authority, Gentlemen [line officers], is absolutely necessary to enforce the most salutary plans and precepts for preserving the health of the soldiers.

In the statement quoted above, Rush emphasized a basic principle of operational preventive medicine, which is as sound today as it was then.

Later, in further development of his ideas as to the means of securing command concurrence and effective joint medicomilitary effort, he had the following to say about the relationship of chief medical officers to line commanders. On 26 July 1798, Rush wrote to Dr. James Craik, the newly appointed Physician General of the Army of the United States:

I admit with General Washington in a late letter [4 July 1798] to Mr. Adams [John Adams, 2d President of the United States]


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that the physician general of an army "should be one of the limbs of a commander in chief." He should reside in his family. No order for marching, encamping, eating, drinking, or even fighting (as far as it relates to the time of a battle) should be issued without his knowledge or concurrence. [Butterfield 2: 800.]

While this is a broad statement in favor of a high staff position for the chief medical officer of the army, it involves the whole series of staff relationships. It specifies both general and particular relationships recognized to be important. But far from being observed constantly in the


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FIGURE 9.- Facsimile of title page of "Directions for Preserving the Health of Soldiers: Recommended to the Consideration of the Officers of the Army of the United States." By Benjamin Rush, M.D. Published by Order of the Board of War. Lancaster: John Dunlap, 1778. This is a revision of the first version which was published in the Pennsylvania Packet or General Advertiser 6: No. 284, 1777 (Tuesday, April 22d). (Photograph, courtesy of the Library of Congress.)


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United States Army through the years, it was neglected or disapproved at various times, some of which were critical. It was a principle never so bitterly fought over as it was in World War II with respect to the relationships of The Surgeon General and the Medical Department of the Army to the War Department and the Army Service Forces (47). Cogent examples can be cited of the "need to know" by preventive medicine officers, and of the contributions they can make to campaigns when they are thoroughly informed of plans and operations, in advance.

Rush's "Directions" are divided into five sections and "a few hints"; * * * "the art of preserving the health of a soldier consists in attention to the following particulars":  I. Dress, II. Diet, III. Cleanliness, IV. Encampments, V. Exercise. In specifying what should be done under each heading, he adds only a few new items to the requirements and measures described by Pringle and others, which have been referred to in previous paragraphs in this volume. As a teetotaler, he strongly opposed the drinking of spirituous liquors, "which prevails so generally in our army," and being a miasmatist he inveighed against the rifle shirt which "besides accumulating putrid miasmata, it conceals filth, and prevents a due regard being paid to cleanliness." He urged commanders to take the utmost care to make their men avoid exposure to conditions of wetness and cold which might cause what is now called "cold injury, ground type." As pointed out by Whayne and DeBakey (48), James Thacher also reported on injuries from cold among troops at Valley Forge and in the raid on Staten Island.

The soldier's more than normal attitude of carelessness toward matters affecting his health is brought out by Rush in one of the "hints which appear to be worthy of the attention of the Gentlemen of the Army." He wrote: "Consider thirdly, that the discipline necessary to make an army victorious, requires that the principle of self-preservation should in some measure be suspended in a soldier. If he be taught that it is a crime to have a single thought about his life in the field, he will soon transfer


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the same indifference about his life to the camp or to his headquarters."

To adjust a soldier to this paradox was, and is, a duty of both line officers and preventive medicine officers. The procedures for doing this were, and are, educational-a phase of health education.

Rush's "Directions" continued to be used in the military medical service in the War of 1812 and even up to the time of the Civil War. A facsimile of the pamphlet copy, which had been owned by one of the latter surgeons, was published by Major De Forest in 1908 (49).

Benjamin Rush was a member of the Continental Congress, a signer of the Declaration of Independence, a combater of yellow fever, the founder of psychiatry in America, the greatest American physician of his time, an obstinate believer in miasmas and bloodletting * * * teacher, author, acerbic critic yet withal possessor of a talent for friendship. He wrote much and much has been written about him (50).

Dr. Rush entered the Continental Army Medical Service just before the battle of Trenton in December 1776. On 11 April 1777, he became surgeon and later physician of the Middle Department. Following his acrimonious attacks on Dr. William Shippen, Jr., who had been appointed Director General and Physician in Chief of the Army after the dismissal of John Morgan, and following Rush's criticism of Washington in the affair of the Conway Cabal, he resigned from the Army on 30 January 1778; but, from 1778 until the time of his death in 1813, Rush continued to be interested in the Medical Department of the Army of the United States.

In 1789 he published a volume summarizing and discussing the observations he had made upon the diseases which had occurred in the military hospitals and camps during the Revolution (51). This contained 23 brief specific statements, some of which present ideas and suggestions for military preventive medicine. By 1815, this volume had gone into its fourth edition.


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Among his observations, Rush noted that southern troops were more sickly than northern and eastern troops, and that native Americans were more sickly than native Europeans who served with the American Army. He attributed this susceptibility partly to the absence of exposure to disease previous to enlistment. His viewpoint was supported by the experience of others, as summarized succinctly by Col. William Smallwood (and quoted by Brown) in a letter to the Council of Safety of Maryland, October 1776 (52): "One good seasoned and well-trained soldier recovered to health, is worth a dozen new recruits * * *."

Most of the basic content of the "Directions" can be found in Pringle's "Observations on Diseases of the Army." Rush was familiar with this book, and had become acquainted with Sir John Pringle in London in 1768 through an introduction by Benjamin Franklin. On 21 April 1810, Rush began to review Pringle's books with the intention of publishing notes upon them. He finished these notes on 8 June and later in 1810 he brought out an American edition of Pringle's classic (53).

Rush was interested in getting this book into the hands of medical officers. On 4 June 1812, he wrote to William Eustis, Secretary of War, referring to the American edition of Pringle and asking:

* * * whether a copy of this work would not be an useful and important article in the furniture of every medical chest for the army of the United States. I am the more disposed to ask this question from my knowledge of the inability of many of the young surgeons to purchase it, and from my recollection of the sufferings of the soldiers of the American Revolution from the ignorance of their surgeons of the contents of that book. [Butterfield 2: 1140.]

In his reply dated 8 June 1812, Secretary Eustis stated that orders had been issued "to purchase a number of the late Edition of Dr. Pringle sufficient to be distributed to the medical Staff." [Butterfield 2: 1140, fn. 2.]

Baron von Steuben (1730-1794); order and discipline.-A product of the rigorous military school of Frederick the Great (1712-1786) and a veteran of battles of the Seven Years' War (1756-1763), von Steuben was a


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Prussian officer admirably qualified to train, drill, and discipline the raw soldiers of the Continental Army. In the grade of captain, he had been an aide to Frederick II, King of Prussia. Consequently, he had been a member of the staff of one of the ablest generals of history and a commander who possessed and practiced to an extraor-


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dinary degree a regard for the preservation of the health of his troops and for the care of the sick and wounded.

When, in Paris in 1777, St. Germain, then the French Minister of War, and Beaumarchais presented to Benjamin Franklin and Silas Deane von Steuben's suggestion that he offer his services to the Continental Congress, these two American Commissioners agreed he would be a valuable asset to the American Army. They realized, however, that as a mere captain he would have little chance of succeeding in the proposed work. Therefore, they introduced him as a lieutenant general of the Prussian service. It is recorded that Baron von Steuben, a man of imposing presence and engaging manners, ably played his part in the deception. In February 1778, he was received with high honors by the Congress at York, Pennsylvania. His offer to serve as a volunteer was accepted and he reported to Washington at Valley Forge on 23 February. Washington at once assigned him to the training of the troops. He was so successful in adapting Prussian military ideas to the American situation that by 5 May 1778 he was made Inspector-General, and Washington obtained for him the rank of major general in the Army of the United States.

During the winter of 1778-1779 at Valley Forge, he produced his "Regulations for the Order and Discipline of the Troops of the United States." These "Regulations," having been approved by His Excellency, General Washington, were adopted by Congress on 29 March 1779, and were published (54).

In its executive resolution, the Congress ordered that the regulations "be observed by all troops of the United States, and that all general and other officers cause the same to be executed with all possible exactness." Thereby the total text became an official directive and manual for the whole army. It is significant for the military remedial medicine and military hygiene of the time that these "Regulations," in addition to being a manual of arms and


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drill, contained numerous statements about the treatment of sick and wounded, and many stipulations of measures to be observed for the prevention of disease and for the preservation of the health of the troops. The instructions for all grades of officers specify what they "must" do to establish and maintain good sanitary conditions in camps and on marches. In these respects, the "Regulations" transformed the empirical, practical rules of military hygiene of van Swieten, Pringle, Brocklesby, Rush, and others into imperatives for health preservation-requirements by command of Congress.

Von Steuben's chapter XXIII: "Of the Treatment of the Sick" has been quoted often, as has his "Instructions." But little or no attention has been paid by historians or military writers to the many paragraphs and sentences that deal with principles and practices of military hygiene. A few typical examples are as follows:

Instructions for the Commandant of a Regiment. * * * 'The preservation of the soldiers health should be his first and greatest care; and as that depends in great measure on their cleanliness and manner of living, he must have a watchful eye over the officers of companies, that they pay the necessary attention to their men in those respects.'

The captains also 'must never suffer a man who has any infectious disorder to remain in the company, but send him immediately to the hospital, or other place provided for the reception of such patients, to prevent the spreading of the infection.' All officers and non-commissioned officers must share responsibility for the cleanliness of the men, their tents, and the camp as a whole. Numerous elements of cleanliness are specified.

In laying out a camp, the 'sinks' (latrines) must be located three hundred feet to the front and rear of the two tent lines. 'The quarter-master must be answerable* * * that the sinks are filled up, and new ones dug every four days, and oftener in warm weather.'

Implicitly indicating the policy that the preservation of the health of the troops was a responsibility of command, all of the sanitary orders in the "Regulations" are addressed to line officers. Surgeons are mentioned only in relation to the treatment of sickness.


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There is much good sense in these vigorous "Regulations," which were enforced in some measure. Such enforcement of them as was secured greatly improved discipline, for the benefit of both the fighting power and health of the troops. The sanitary requirements were advantageous. It is not a coincidence that from1779 to the end of the war, the military capability of the Army of the United States increased steadily until it was more than a match for the British Regulars, and that, on the whole, disease became less prevalent and mortality from sickness decreased. While it is true that inoculation for smallpox had a great deal to do with reduction of sickness after 1777, it is apparent also that these "Regulations" contributed both to vigor in arms and robustness in health.

James Tilton (1745-1822); rules for prevention of diseases.-The clearest and most forceful contemporary American treatise on the preservation of health of soldiers during the Revolution is Dr. James Tilton's (55) "Economical Observations on Military Hospitals; and the Prevention and Cure of Diseases Incident to an Army." It was based upon his experiences as a physician and surgeon in the Revolutionary Army in campaigns in the field and service in military hospitals during the years 1776 to 1782 (fig. 11). It was composed by an individual of Washingtonian proportions who was a man of great executive ability and an excellent sanitarian.

Tilton's emphasis upon the primary responsibility of command for military hygiene is stated at the beginning of his Part II, pages 27, and 28-29 passim, as follows.

It may seem strange at first view, that I should call upon commanding officers to take care of the health of the men under their command, or that I should expect they would pay any regard to sickness incident to an army. I hope, however, in the sequel to shew that upon them especially depend the health and comfort of the soldiers, and that the medical staff are only to be regarded as adjutants, in the recovery of the sick.

In a young and inexperienced army especially the officers are too apt to consider military duty as the only obligation upon them,


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FIGURE 11.- James Tilton (1745-1822), physician and Surgeon General of the United States Army (1813-1815). His "Economical Observations * * *," published in 1813, was largely a treatise on military preventive medicine, based upon his experiences on field service in campaigns from 1776 to 1782. In 1779-1780, be designed and built a hospital planned to "avoid infection." This was an early effort to construct isolation wards and to erect barriers against cross infection. (Photocopy of a composed portrait, courtesy of the Armed Forces Institute of Pathology, photograph negative No. WW-394.)

regardless of the condition of their men, when if they fall sick, are without further thought turned over to the care of the surgeons. The ignorance and irregularities of the men in a new scene of life, subject them to numberless diseases. The sick flow in a regular current to the hospitals; these are crowded so as to produce infection; and mortality ensues too affecting to describe. * * * Send as few as possible to the general hospital.


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Ways and means by which military officers have it in their power to prevent and alleviate ordinary sicknesses and distresses of an army are listed and discussed. These matters include:

1. Discipline, which is of the first consequence. "Without it, there can be neither health nor comfort in an army. * * * But more is comprehended under the word discipline than the mere exercise of arms."

2. Avoidance of excessive exposure to heat. "Military exercises ought to be performed in the morning, before the heat of the day, especially in warm weather."

3. Provision of supervised play, amusements, and short marches.

4. Cleanliness-essential. "Officers therefore, should be very solicitous to protect their men, as well as themselves, from the dreadful effects of filth and nastiness." The camp must be kept free from carrion, offal, dead horses, and excrement. Privies may be built over rivers, otherwise dig deep pits [latrines] and cover feces with dirt every day. Tilton calls attention to Brocklesby's quotation of a part of the Mosaic sanitary code as stated in Deuteronomy 23: 12-14, which Washington included also in his General Orders: Of Cleanliness, in 1777. (See fig. 7, p. 34, and appendix A, p. 189.)

5. Clothing and accounting of clothing (muster to prevent the men from selling their clothing to purchase liquor) are discussed from the hygienic and other points of view. In this connection, Tilton wrote: "When the Baron Steuben was appointed Inspector General, besides the muster of clothing, he introduced a number of salutary regulations, which contributed more to the health and comfort of the troops, than the utmost efforts of all the medical staff."

6. The immense importance of diet is reviewed. "The ordinary ration is sufficient if well managed." But it is advisable to supplement it with vegetables purchased locally. Soldiers should eat in messes. It is important to associate an old soldier with each mess. "An old soldier would make


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good and wholesome food of materials that a young recruit would spoil, in such a manner as hardly to be fit to eat."

7. Hardihood, necessary for efficiency and for withstanding accidents and stress, must be fostered. "A delicate soldier is very ridiculous indeed."

8. For good health and resistance to disease, special care of the skin must be required.

9. The mind of the soldier must be trained. "The influence of the mind upon the body is astonishing." Morale must be built up and maintained by cultivation of the soldier's self-esteem and his sense of honor and reputation.

Tilton's hospital.-Tilton was shocked by the unsanitary conditions that he saw in the military hospitals. He was appalled by the havoc and destruction, loss of life, and depletion of the Army by the sickness and mortality from diseases acquired in the crowded, filthy, stinking tents and buildings used for sheltering patients. In his opinion, "more men of the Army were lost by death and otherwise wasted, at general hospitals [in 1776-1779], than by all other contingencies that had affected the Army, not excepting the weapons of the enemy." As a source of information about proper management of hospitals, he refers to Dr. John Jones "and his useful treatise published at the commencement of the war." (See reference 39.)

Part III, addressed to the medical staff is almost entirely concerned with hospitals. "The cardinal point or principle to be observed in the direction of hospitals," he wrote, "is to avoid infection." Apparently, the word used in this connection meant foul air, or "poisonous atmosphere," miasmas.

After some discussion of the construction of hospitals, Tilton describes the hospital which he "contrived," and utilized with success, at the encampment of the Army at Morristown, New Jersey, in the severe winter of 1779-1780. Laid out "upon the plan of an Indian hut," the one-story structure consisted of a central large section and


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two smaller wings on the ends at right angles to the central room. It was constructed of rough logs chinked with clay and had three doors on the south side. The three wards, equipped with bunks or beds, could accommodate a total of 28 patients, 8, 12, and 8, respectively. There were no doors or windows in the walls between the wards. In cold weather, "the fire was built in the midst of the ward, without any chimney, and the smoke circulating about, passed off thro' an opening about 4 inches wide in the ridge of the roof. The common surface of the earth served for the floor. The patients laid with their heads to the wall roundabout, and their feet were all turned to the fire. The smoke contributed to combat infection, without giving the least offense to the patient; for it always rose above their heads, before it spread abroad in the ward."

The ground plan and elevation are shown in figures 12 and 13. From these diagrams, it is evident that the structures provided a small, well-ventilated, uncrowded hospital in which groups of patients could be kept separate. With regard to the feature of isolation, Tilton wrote: "The importance of separating those ill of fevers, fluxes, etc., from the wounded and such as have only slight topical affections, will readily be perceived. Many a fine fellow have I seen brought into the hospital, for slight syphilitic affections and carried out dead of a hospital fever."

Tilton's hospital is especially interesting as an early example of a structure embodying concepts of preventive medicine.

Although much more might be written about those activities of Tilton which had a bearing upon military hygiene, only one type will be mentioned briefly here. These activities were of an administrative nature. From the first, upon his entrance into the Army in 1776, he had been aware of the inadequate oganization of the Medical Department. Although, during the next few years, he was little involved in the intrigues, jealousies, and quarrels which caused the bitter undoing of the first chief physi-


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FIGURE 12.- Tilton's hospital at Army Headquarters, Morristown, New Jersey, 1780. Front elevation showing log construction, position of doors, and smoke vents in the ridges of the roof. (Photocopy of a drawing by Tilton in his "Economical Observations * * *," p.51. Courtesy of the Library of Congress.)

FIGURE 13.- Tilton's hospital, floor plan. A represents the doors, B the fireplaces, C the bunks or bedsteads for patients. The middle, main ward, measured 31 1/2 x 19 1/2 feet in the clear, and was assigned to febrile patients. The smaller end wards measured 35 1/2 x 19 1/2 feet. They were occupied by wounded and other cases of "topical affection." (Photocopy from "Economical Observations * * *," p. 52. Courtesy of the Library of Congress.)


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cians-Drs. Benjamin Church, John Morgan, and William Shippen, Jr.-he was disturbed by the generally defective arrangements and mismanagement, and saw clearly their deleterious effects upon medicine and surgery, and upon provisions for the care of the health of the troops. He studied the situations at a number of camps and hospitals in 1778 and 1779, and formulated plans for improvements. As a result, he was highly influential in bringing about the passage of the Congressional Act of 1780 which reformed and reorganized the Medical Department of the Army. This activity was prophetic of his future service and career, to which allusion will be made later in this volume.

The Army inoculated against smallpox (1777).-Smallpox was generally prevalent in the Continental Army during the first 2 years (1775-1777) of the Revolutionary War. In 1776, hundreds died of it. The disease was a major factor in the failure of the Quebec campaign, and in the great suffering and mortality among troops which fell back to Crown Point and Ticonderoga in the winter and spring of 1775-1776. In violation of orders, many soldiers inoculated themselves, hoping to prevent an attack of smallpox, but inadvertently spread the disease at the same time. During the summer of 1776, in the Boston area, hundreds were inoculated at the command of military authorities (56).

In April 1776, the intelligent, well-informed Dr. John Morgan, Director General of the Hospitals and Physician in Chief to the American Army, recommended inoculation as universal as possible. His recommendation of the Dimsdale method was addressed not only to practitioners, but also particularly "to surgeons of the hospital, and those in the army under my direction." In doing so, he felt that he was (57) "performing one of the most important services a person in my station can well render to them, or to the country and people he is amongst."

The ravages of smallpox in the eastern and northern Armies in 1775-1776 materially reduced the number of


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available troops, and the fear of the disease discouraged recruiting. The threat to military operations moved the Commander-in-Chief and the Congress to take bold preventive action. On 6 January 1777, immediately after establishing his headquarters for the first time at Morristown, New Jersey, General Washington wrote to Dr. William Shippen, Jr., who had succeeded Morgan as Director General of the Hospitals and Physician in Chief to the Army, about his decision to attack smallpox, "the greatest enemy of the Continental Army."

To Doctor William Shippen, Junior.

Head Quarters, Morristown, January 6, 1777.

Dear Sir: Finding the small pox to be spreading much and fearing that no precaution can prevent it from running thro' the whole of our Army, I have determined that the Troops shall be inoculated. This Expedient may be attended with some inconveniences and some disadvantages, but yet I trust, in its consequences will have the most happy effects.

Necessity not only authorizes but seems to require the measure, for should the disorder infect the Army, in the natural way, and rage with its usual Virulence, we should have more to dread from it, than the Sword of the Enemy. Under these Circumstances, I have directed Doctr. Bond [Dr. Nathaniel Bond], to prepare immediately for inoculating this Quarter, keeping the matter as secret as possible, and request, that you will without delay inoculate all the Continental Troops that are in Philadelphia and those that shall come in, as fast as they arrive. You will spare no pains to carry them thro' the disorder with the utmost expedition, and to have them cleansed from the infection when recovered, that they may proceed to Camp, with as little injury as possible, to the Country thro' which they pass. If the business is immediately begun and favoured with common success, I would fain hope they will soon be fit for duty, and that in a short space of time we shall have an Army not subject to this, the greatest of all calamities that can befall it, when taken in the natural way.
                                                                                                        [Signed by Washington.]

[Fitzpatrick 6: 473, 474. See also reference 45 (2), pp. 131-132, in the cited volume.]

On 18 January 1777, Shippen had these instructions revised to apply to inoculation of all recruits who had not had smallpox. On 10 February 1777 Washington informed the New York Legislature: "The Physicians are now mak-


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ing the proper preparations to innoculate all at the several Posts, in this Quarter, and Doctor Shippen will innoculate all the recruits, that have not had the disorder, as fast as they come in to Philadelphia." [Fitzpatrick 7: 129.]

On 12 February 1777, the Continental Congress, sitting in Baltimore, took action somewhat belatedly on the same subject. The Congress ordered that the Medical Committee write to General Washington and "consult him on the propriety of causing such of the troops in his army, as have not had the small-pox, to be inoculated, and recommend that measure to him, if it can be done consistent with public safety, and good of the service."

As General Washington had already instructed that "the troops shall be inoculated," the suggestion of the Congress was taken as a confirmation of the policy. On 23 April 1777, the Congress resolved that Dr. James Tilton be authorized to repair to Dumfries, Virginia, and take charge of the inoculation for smallpox of all Continental soldiers [recruits] coming from the South. Inoculation stations and infirmaries were set up and operated at Dumfries, Alexandria, and Fairfax.

In 1777, compulsory inoculation of recruits became a routine procedure. At that time the mortality from naturally acquired smallpox was about 16 per 100 cases; the mortality from inoculated smallpox was about 1 in 300 cases, 16 percent as compared with 0.33 percent. There was a risk of death in the procedure, but the judgment was to go ahead with it, the authorities believing, justifiably, that the savings far outweighed the possible losses.

Victories of a smallpox-free Army. - The results of inoculation were good. All who have studied this subject seriously (Blake, Duncan, Thursfield, and Hall, whose writings have been cited herein) agree that although after the introduction of inoculation the Army was not entirely free from smallpox, the disease never again caused losses like those suffered from it in the first 2 years of the war. In the writings referred to, there is the recurring type of statement: "After inoculation was introduced in the spring of 1777 Washington had a smallpox-free


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army." Inoculation for smallpox contributed substantially to the winning of the war. As Blake wrote (58): "In subsequent years [after 1777], however, most recruits to the American armies were inoculated at the time of induction, and throughout the rest of the War, smallpox, which otherwise might well have proved disastrous, was never a major problem. In this way the medical profession made its most important contribution to the winning of our national independence."

In a general evaluation, without specifically naming the Army, Dr. Benjamin Rush, addressing the students of the Philadelphia Medical School on 20 February 1781, said (59): "Gentlemen, It must afford no small pleasure to a benevolent mind in the midst of a war which daily makes so much havock with the human species, to reflect, that the small-pox which once proved equally fatal to thousands, has been checked in its career, and in a great degree subdued by the practice of Inoculation."

HEALTH OF THE CONTINENTAL ARMY
(1775-1781)

Unfortunately, during the preparation of this volume, the author had no opportunity to attempt an original, extensive study of the records of sick and wounded, and of mortality, among Continental troops during the 7 years of hostilities, 1775-1781, of the American Revolutionary War. Applegate (60) has rightly pointed out that such a study is greatly needed. If the data exist, they have never been compiled and analyzed. Certainly, complete data do not exist, as, according to Duncan (61): "No complete records of these casualties were kept for so much as one year. Then, too, sickness and mortality varied greatly in different years." Furthermore, as strength figures were not accurately reported, there is no valid base for the calculation of rates. Only partial Revolutionary annals, some estimates, and a few statements are available to serve as material for rough overall approximations, and in a number of instances, for vivid pictures of local situations.


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The first general estimate, which has been reiterated during almost a century and a half, was published in 1823 by Dr. James Thacher (62) who served in regiments and hospitals from Boston to Yorktown.

Without defining who or what "it" was, Thacher wrote: "It has been estimated, that the loss of lives in the various armies of the United States, during the war, is not less than seventy thousand." He admits that the number who died on prison ships could not be calculated, but states that it is confidently asserted that no less than 11,000 died on board the Jersey prison ship. Others, uncounted died at their homes, or by the wayside.

Duncan, using Thacher's figure for total deaths as 70,000, and dividing this by 7 (the years of hostilities from 1775 to 1781, inclusive), estimated a mortality of 10,000 deaths per year from all causes. From various reports, he estimated that 1,000 soldiers were killed in battle or died of wounds each year, making a total of 7,000 battle deaths in all. He concludes: "That ten men died of disease to every one whose life was taken by the enemy is a safe estimate."

With regard to strength figures, Duncan and others enumerate and discuss the many variables involved. While the exact number is not a matter of record, Duncan accepts the estimate of the total number of individuals actually engaged in the military service during the Revolutionary War at 250,000 Regulars and militia combined, as recorded by Heitman (63) from governmental reports made in 1787. The average yearly strength is still more a matter of doubt. After considering reports of enlistments, sample strength returns, etc., Duncan decided that it was reasonable to take the figure of 50,000 as the average annual strength of the Army. On this basis, using figures given above, he calculated a death rate of 200 per 1,000 per annum, or 20 percent. With the proportion of 10 dying of disease to 1 fatal battle casualty, the death rate from battle injuries amounted to 20 per 1,000 per annum, and 180 per 1,000 per annum for deaths from disease.


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From similar reports from British sources, Duncan calculated that the casualty (mortality) rates for the Continental Army troops were higher than they were among the British and German (Hessian) forces, as shown in the following tabulation.

Death rates per 1,000 per annum

Battle

Disease

Total

Colonials

20

180

200

British

18

100

118

German (Hessian)

18.75

62.5

81.25

All writers on this subject agree that there was much less sickness and mortality from disease among British troops than there was among American colonial troops. Among the several reasons for this, some are of general significance. The British Army was composed almost entirely of seasoned, regular troops, well-organized and disciplined, fully equipped and well-supplied, and having a relatively more efficient medical department. In contrast, the Continental Army was improvised from inexperienced militia, poorly organized, partially disciplined, often badly fed, frequently poorly clothed and equipped, and with a medical department not well-organized, torn with dissensions, indifferently administered, and inadequately staffed and equipped. The American soldiers came mostly from country districts where they had not had appreciable contact with communicable diseases. They were largely nonimmune and susceptible. Outbreaks of infectious diseases in some bodies of troops into which recruits entered were paradigms of modern experimental epidemiology.

The casualty (mortality) rates from disease among American troops, although not exact, are indicative of actual conditions. There was, indeed, much sickness and death from serious diseases, mainly infectious disease. Typhus fever (called putrid or hospital fever), smallpox (prior to inoculation of the Army), and dysentery (bloody flux) were the most severe. Measles, meningitis, and pneumonia occurred, but not conspicuously. Malaria was common, particularly in the South, but also in the region of


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Lake Champlain. Thousands of cases of typhus were contracted in the hospitals.

The most conspicuous differences in the amount of sickness and mortality among the soldiers of the Continental Army are to be found in the critical years 1776, and 1777-1778. Two military operations that were marked by severe disease occurred at Crown Point and Ticonderoga in the summer and fall of 1776, and at Valley Forge in the cruel conditions in the winter of 1777-1778. In June and July 1776, the emaciated, louse-infested (attacked by legions of lice, as one soldier expressed it), half-naked exhausted men, broken in spirit and discipline, crowded into the camps and hospitals at Crown Point and Ticonderoga at the end of the retreat from Quebec and Montreal, closing the disastrous Canada Expedition of 1775-1776. Smallpox, putrid fever (typhus), and dysentery (bloody flux) caused the loss of hundreds of men. Sanitation was almost entirely neglected. Some attempt had been made by the soldiers themselves to limit smallpox by inoculation, but as the practice spread the disease, it was forbidden. At Valley Forge in the winter of 1777-1778, sickness, suffering, and death from communicable diseases intensified the devastating effects of the ferociously cold weather upon soldiers who were short of clothes, shoes, blankets, fuel, and food, and existed in dismal, frigid, filthy huts. Contemporaneous and later writers, notably Middleton (64), have described the harrowing medical aspects of "the Gethsemane of the Revolution." In contrast, the campaign outstanding for healthiness, was the encampment and battle in the region of Saratoga, New York, in the summer and fall of 1777, which resulted in the defeat of British forces and the surrender of Burgoyne on 17 October of that year. The good health of the troops, and especially their freedom from smallpox (attributable to their having been inoculated), were important factors in the winning of the Battle of Saratoga, perhaps the most decisive battle of the Revolutionary War.


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SUMMARY AND CONCLUSIONS

The account of sickness and mortality from disease among the troops of the Continental Army during the American Revolutionary War is a gruesome story. There was, indeed, much sickness and a high death rate from diseases. From this, inferences might be drawn that efforts to devise and enforce a program of military hygiene, or what is now called military preventive medicine, either had not been made or were futile. Neither inference is correct. It is true that there was no organized preventive medicine service. However, efforts to prevent disease and to preserve the health of soldiers were centered in the command structure; not in the Medical Department. The combination of preventive activities along a number of lines can be said to have constituted an embryonic program of preventive medicine, although it was not so designated. Nearly all of the modern principles of military preventive medicine, except those which could not be developed before the bacteriological era, were formulated, announced, and sometimes made mandatory by order of the Commander-in-Chief, and even by Congress.

The failures were due largely to ignorance, lack of interest, carelessness, and lack of discipline. The results of the failures are known, approximately, but it is not known how much worse the conditions would have been if no effort had been made to observe these principles. Feeble accomplishments sapped the strength of good ideas, but in instances of good rule-of-thumb sanitation, the benefits were notable.

The preventive principles, which were expounded and observed in various degrees, may be listed in partial and condensed form as follows:

 1. Responsiblity of command for the preservation of the health of troops.
 2. Use of medical officers as advisers to line officers.
 3. Discipline, general and specific.
 4. Personal hygiene; cleanliness.
 5. Diet and nutrition.


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 6. Clothing and shoes.
 7. Avoidance insofar as possible of exposure to extreme degrees of heat, cold, and fatigue, and to prolonged wetness.
 8. Morale-building; recreational activities.
 9. Health education.
10. Immunization (active): inoculation for smallpox.
11. Environmental hygiene:
          a. Selection of campsites and shelters with regard to factors affecting health; ground water level, drainage, avoidance of marshes, attention to winds and ventilation.
          b. Avoidance of crowding; floor space.
          c. Sanitation of camps; cleanliness.
          d. Disposal of excreta and other wastes.
          e. Selection and protection of water supplies; purification of water.
12. Reduction of possible disease-transmitting human contacts; isolation of patients and quarantine.
13. Medical intelligence; rudimentary information about disease-prevalence in areas occupied or to be occupied by troops.

This list of principles has a modern cast. Although one can display the failures and contest the soundness of the basis of the formulations and practices of military hygiene in the Army of the United States in the Revolutionary War, it cannot be denied that military preventive medicine was on the march.