Early American Medicine

This summer my family and I explored Fort Ligonier, an eighteenth century British fort in Western Pennsylvania, and the Bushy Run Battlefield, a historic site of the Seven Years War (1756-1763). My children opined about what it must have been like to live in those days. As we looked at the hospital buildings, however, my daughter said “the thing that I would miss the most is 21st century medicine. “

She is not alone. Some people attend Renaissance Fairs and pretend to live in Medieval Europe. Others reenact the Civil War or other major conflicts. No one that I have ever spoken to, however, wants to give up modern medicine. Not that modern medicine is perfect. Too often it is impersonal, profit driven, complicated and expensive. However, compared to much of existed before, it is miraculous. We would do well to remember that, and be thankful for it.

Early American Treatments

Much of European and American medicine in the 17th and 18th centuries was based partly on the idea that health required the removal of toxins from the body, and partly on teachings of the Greek physician and philosopher Galen. Practicing during the Antonine Plague, Galen refined the Hippocratic theories about imbalance of humors (blood, black bile, yellow bile, and phlegm) causing disease. Because of the toxin theory, primary treatments of “heroic” physicians in the era focused on eliminating toxins. Patients would be bled with leeches or cutting veins open to remove blood toxins, blistered with rubbing and mustard plasters on the skin to eliminate skin toxins, and given ipecac (causing vomiting) or calomel (causing diarrhea) to purge the intestines. These treatments and other drugs often did more harm than good. Surgical interventions could be equally frightening; total dental extraction was a common treatment for arthritis until the early 20th century.

There were exceptions, as some drugs were effective. Quinine from cinchona bark treated malaria, digitalis from foxglove helped heart failure, colchicine helped gout, laudanum (opium) improved pain, and alcohol, which served as a solvent for most liquid medicines, made almost everything feel better.[1]

Nonetheless, with disease and death decimating every population, people were desperate for almost anything that they thought might help. The success of the Lewis and Clark Expedition was due in large part to the cooperation of the Native Americans they encountered. A big reason that these tribes helped the intrepid explorers was because Lewis and Clark tried to heal the Indians, as they would have called them. The two were as skilled as any physician of their day; one morning Clark saw four men, eight women and a child, giving liniment for painful joints and laudanum for hysteria.

More science was filtering into medicine. In the early 1800s Dr. Benjamin Dudley told his colleagues that their patients would do better if they boiled their surgical instruments. Dr. J Crawford wrote articles suggesting the mosquitos were the source of malaria and yellow fever.[2]

Native American Medicine

Indian healers or “medicine men” used a variety of local herbs to combat illness. Sweat lodges were used for lung disease, skin disorders, and rheumatism.[3] They emphasized fluids, nutrition and rest, and avoided some of the “heroic” treatments of the white man. Native Americans used willow bark, now known to contain salicylates similar to modern aspirin, to treat pain and fever. Medicine men were skilled at reducing broken bones. Further, medicine and religion were intertwined so their rituals often aided in the healing process. As a result of these practices, patients under of the care of Native American healers sometimes did better than those under European care.

Diphtheria became a greater problem as populations grew, and it would often kill by suffocation because an inflammatory membrane blocked the patient’s airway. A medicine man would force a sinew covered in sandburs and buffalo fat down the throat of a diphtheria patient. The melting fat would adhere to the inflammatory membrane and the healer would pull it out.[4]

Explorers, soldiers and pioneers typically lived on hard bread, salted beef, whiskey and coffee. Indians ate more leafy vegetables and the viscera (organs) of animals. These often contained high levels of vitamin C and so the natives were less likely to get scurvy.

Native Americans suffered terribly, however, from Old World infectious diseases. Lacking centuries of acquired immunity, whole Indian villages perished from smallpox, measles, and influenza. White mortality from smallpox was less than 30%, and mortality from measles and flu was far less. Alcohol was another scourge that afflicted Native Americans in their encounters with European settlers.

The Medical Marketplace in the 18th Century

The medical profession in the 21st century includes a bewildering variety of practitioners, from allopath (Doctor of Medicine, MD) and osteopath (Doctor of Osteopathy, DO) to physician’s assistants (PA), midwives, and nurse practitioners (NP). Modern medicine also has homeopaths, chiropractors, and others. Most of medicine, however, is highly regulated and practitioners need to meet high academic standards and undergo rigorous training for their credentials.

The medical marketplace was no less varied, albeit far less regulated, in 18th and 19th century America. Allopaths practiced “heroic medicine” such as bleeding patients, blistering them, or giving the purges such as “thunderclappers” to clean their bowels. Under the theory that “like treats like” and “small doses cure”, homeopaths provided tiny doses of herbs and other chemicals in the hope of cure. Herbalists used larger doses of botanicals to heal. Inoculators specialized in giving inoculations and vaccines, and midwives delivered babies, especially in the West. Much of this specialization was a product of advertising. Indian healers advertised natural, Indian remedies. Bone setters and “cancer specialists” proclaimed their skills in local newspapers.[5]

There was notable overlap between the groups. For example, all used plant products to try to heal. Effective medicines at the time including colchicine (gout), digitalis (CHF), quinine (malaria), and laudinum (pain). Many drugs were dissolved in alcohol and made into elixirs, making the patients feel better if not actually doing them any good.

Medical care was expensive and not widely available on the frontier. When a doctor (of whatever type) arrived in town, the success or failure of his first case would mark him as competent or not. In the 19th century, both before and after the Civil War, towns sprang up at rivers, railroad junctions, mining locations, forts, and many other places. If a doctor was not successful in one area he could just move on to the next. Some physicians would “circuit ride” with ministers, providing medical services while the other provided spiritual services.

Physician training was through a medical college or apprenticeship, but some “physicians” simply bought their degrees through a “diploma mill”.

Medical Care in the Civil War

At the start of the war, medical providers, as well as everything else, were in short supply on both sides. They needed to rapidly expand their medical staffs and sometimes took on physicians with specious credentials. In time, however, the demands of combat casualty care weeded these men out. The medical departments, Union and Confederate, became highly professional. By this time, almost all physicians had stopped bleeding their patients.[6]

In a battle, the assistant surgeon would trail about 100 yards behind the forward line of troops, followed by personnel of the infirmary corps to evacuate the wounded. Triage developed similarly on both sides. Morning sick call was done by regimental surgeons. The minimally injured were returned to duty immediately while the moderately injured were treated immediately. Soldiers who were severely injured after a battle were given laudanum and were placed under a tree to die. The few who managed to rally, defying the expectations of the triage staff, would receive care after the other soldiers. Wounds that penetrated the abdominal cavity were almost always fatal. Chaplains were assigned to each field hospital, and they served to comfort the sick and dying and mediate disputes between Union and Confederates soldiers.

Chloroform was the primary means of anesthesia, sometimes augmented by whiskey. Since the Minie ball did far more tissue damage than a traditional spherical musket ball, wounds were more serious. Men hit in the torso usually died, but those with extremity wounds could survive. Amputations were common. Germ theory would not be widely known or accepted for at least another decade, and Joseph Lister’s revolutionary surgical sterilization with carbolic acid also lay in the future, so infections were common. For head injuries, trephination was done at site of skull fracture if possible, or over parietal bone when not. Overall, 90% of combat injuries were from the Minnie ball, 80% of the wounds were on the extremities, 70% of soldiers with amputation survived, and 46% of soldiers undergoing trephination survived. Enlisted and junior officers with amputations would be discharged. Higher ranking officers (those on horseback) could remain on active duty.

During the battle of Gettysburg, the Confederates had a field hospital at the Daniel Lady farm. After the battle there were 8000-9000 wounded confederates and 1300 wagons. A torrential storm hit on July 4, slowing the withdrawal but also slowing the Union pursuit. The Confederate wounded were in a wagon train 17 miles long under the command of General Boden. At Green Castle Union civilians attacked the wagon train. Later Union cavalry attacked and captured 100 wagons. Finally the retreating Confederates had to wait five days to cross the swollen Potomac River. Lesser wounded men walked 45 miles to a hospital in Winchester.

As deadly as combat was, disease and non-battle injuries killed more soldiers on both sides. During the Civil War, 53 of every thousand soldiers died from disease. This is 2-3 times as many as died from battle related injuries. Unfortunately medical treatment was poor. Diseases such as malaria could be successfully treated with quinine, but most infectious diseases could not. Having little to offer, physicians might use “blue mass”, a combination of mercury and flour that was made into pills and used for many diseases.

Suppositories could be made with hog fat to ensure that it would melt when in the rectum. Beeswax was used for making medications as well. Mercury, unfortunately, is a toxin and “blue mass” probably hurt more than it helped. Blue mass and other chemicals also found their way into pills. The druggist would combine the active ingredient with the pill base, such as flour. He would then roll a small amount of the mass on a pill rolling board, forming a long strand that he would then cut into individual pills. Once the mass had dried, the pill was ready to give to the patient.

Civil War medicine boasted some vivid personalities. Brigadier General William A. Hammond, an early Surgeon General of the Union Army, tried to prohibit the medical use of mercury compound such as blue mass and calomel. He immediately faced a storm of resistance, was court martialed, and was discharged. Jonathan Letterman was General George B. McClelland’s chief medical officer. He devised an ingenious medical evacuation and ambulance system at Antietam. Letterman hospital was opened in California only five months after Gettysburg. Dr. Hunter McGuire was the chief physician and surgeon of Confederacy. Sally Tompkins, a nurse, was the only woman commissioned in Confederate army. She was given the rank of captain.

Vaccinations

After Edward Jenner discovered a vaccine against smallpox in 1796, vaccines became an important part of medical practice. This is not to say that immunizations were immediately accepted, much to the contrary, but medicine finally had a powerful weapon against infectious disease. Missionaries took the smallpox vaccine to inoculate Native Americans as part of their ministry. When the Gros Ventres Indians on the Milk River in Montana contracted smallpox in 1869, the US Government provided sent in blankets, supplies and medicine.[7]

Sex-related issues

Babies were generally born at home under the care of female relatives and a local midwife. Complications were rare, but fetal and maternal mortality were much higher than today, especially on the frontier. Women were expected to deliver, put the baby to breast, and then get back to work. This may have been harsh for some, but such practice had the advantages of getting the mother up and avoiding both pneumonia and blood clots associated with bed rest.

Gonorrhea and syphilis were ubiquitous in the 19th century. Indian women, soldiers, explorers, miners and prostitutes traded venereal diseases among themselves incessantly and there was no effective treatment. Gonorrhea usually showed symptoms in men but not in women, who could easily become sterile from pelvic inflammatory disease. Syphilis caused symptoms in both sexes, and often led to heart disease, or neurosyphilis and insanity. Mercury compounds were used to treat chancres and other external manifestations of syphilis, but could not affect the course of the disease. No one knows whether Meriwether Lewis died of suicide or homicide when he perished in 1809, but many historians think that neurosyphilis played a role.

Unwanted pregnancies occurred as well. Abortion was practiced within both Native American and White communities, but delivering the child to other family members or to an orphanage was a common alternative.

Conclusion

People sometimes bemoan the weaknesses of modern medicine, failing to remember what came before. While we work to improve technology, as well as compassion, in present day healing, it is always useful to look back and see how far we have come. It is also useful to recognize the heroism as well as the frailties, and the acceptance as well as the bigotries, of those who have gone before us. We can only hope that our descendants do the same for us.

[1] Volney Stelle, Bleed, Blister and Purge, pp6-7

[2] Volney Stelle, Bleed, Blister and Purge, pp4-5

[3] Volney Steele, p19

[4] Volney Steele, p 20

[5] Steele, p5-6

[6] Volney Steele, p 8

[7] Steele, 39

Living History at Gettysburg on the Sesquicentennial

Some families enjoy history. Mine has reconnoitered the fields at Saratoga, examined the batteries at Fort McHenry, walked the decks of the USS Wisconsin, and explored the beaches at Normandy.  On Independence Day weekend my oldest son David, my oldest daughter Anna, and I enjoyed another famous battlefield, Gettysburg.

We arrived at the actual battlefield, run by the US National Park service, and discovered that they did not allow reenacting on the actual battlefield. The park ranger explained “men died on this ground, and we don’t want reenactors only pretending to die.” The second reason was that large units of reenactors, especially with cavalry and artillery, would tear up the fields. We discovered that the Gettysburg reenactment was at a farm a few miles north of the actual battlefield.

Tickets were $40 per adult per day, with grandstand seats to watch the battle another $15. We went to the American Museum of the Civil War in Gettysburg, bought two day tickets for $60 per adult, and skipped the grandstands. On our second day a family who left early gave us their grandstand tickets, and so we got to experience this excellent view of the battle after all. Anna, David and I arrived a few minutes after the gates opened at 0830.

There were 13,000 reenactors, 200 cavalry (counted by my son), 135 cannon (registered) and tens of thousands of spectators. Activities tents hosted living historians describing their experiences as the character each played. In one talk, the living historian playing Confederate General James Longstreet was outstanding. Actor Patrick Falci described his experiences on the set of the movie Gettysburg. Other living historians in period attire, as well as yanks and rebels, wandered the Union and Confederate camps and the Living History Village to answer questions (and to enjoy themselves).

Vendors abounded in the Sutler Village portion of the Living History Village. They offered everything from books to sewing patterns, from arms to uniforms. Food sellers hawked sno-cones and drinks to beat the heat and more filling fare (such as hamburgers, hot dogs, and pulled pork) to fill the stomach. At the end of one battle, blue raspberry and cherry sno-cones helped cool us in the 91 degree heat. In the Authors and Artists tent, author Jeff Shaara and others were present for fans who wanted them to sign their copy of one of their works.

The Reenactors Missions for Jesus Christ (RMJC) described the spiritual needs of the soldiers on both sides and the invaluable and selfless efforts of chaplains to meet those needs. They gave free lemonade to any reenactor or veteran who asked. Four chaplains in the Civil War won the Medal of Honor. Other groups highlighted the contributions of nurses, the Christian Commission, the Sanitary Commission, and other civilians during Gettysburg.

The highlights were the battles. Reenactors staged 2-3 battles per day, including cavalry, infantry and artillery. Horsemen circled, thrust and wheeled away while they fired carbines and slashed with sabers. Foot soldiers advanced in line, charged and retreated amidst the din of the fight, the smoke of musket shots, and the falling of injured comrades. Artillery unlimbered, fired with clockwork precision, and limbered for movement again, wreathed in rings and clouds of dense smoke. It was an impressive sight.

We met some terrific people. Dennis and Susie with their three sons and two year old daughter traveled from Ohio. Their children would “rather go to this than to Disneyworld”, and Susie was bedazzled with antebellum fashion.  Lauren was a 21 year old novelist from Minnesota who reenacts in the Union camp with her father and sister. Marcy was visiting with her Army husband and three sons from Fort Bragg. All had no place that they would rather be. Ron, a lifelong friend from California who is a reenactor with the 71st Pennsylvania, wanted to be here as well but couldn’t afford it. I shot over 400 photographs for him.

Reading about Gettysburg in the American Civil War is fascinating, and watching movies provides a glimpse of how the battle may have been, but neither provides the experience of watching a reenactment. On a hot day in July 150 years ago, with the sweat of men and horses, the smell of manure and sulfur, the sounds of rifles and cannon and the sights of blood and steel, two armies fought and many men died at Gettysburg.  150 years later, those untimely born to participate in the battle can come as close as humanly possible to being there. To spectators, living historians, and reenactors, it is well worth doing.

The Dance of the Headquarters

In Iraq in late 2003 a draft recommendation came to the Task Force 1st Armored Division Headquarters from our higher headquarters, the Combined Joint Task Force Headquarters. It referenced tuberculosis in Iraq and proposed aggressive use of preventive measures against the disease, citing huge numbers of new cases per year. As the Task Force Preventive Medicine Officer and Deputy Division Surgeon, I was responsible to review all public health and other medical recommendations coming from outside. The math didn’t seem right and I went to the World Health Organization website to check the incidence and prevalence of tuberculosis in Iraq. Suddenly I realized that whoever had made the recommendation had badly overestimated the incidence of new tuberculosis cases. To our medical team it was just another example of trouble from our higher headquarters.

A few months later and still in Baghdad, our team visited the medical staff of one of our subordinate brigades. We asked questions of patients seen, quality of care, training plans, and changes in the rate of diseases we were seeing. Some of the leadership asked why we needed all of that information, and lamented that they were spending time generating reports that they could have spent taking care of patients. My team did our best to explain that these data were worthwhile and useful, but they seemed unconvinced. After all, we were from higher headquarters.

The relationship between superior and subordinate headquarters has been troubled since war began. Lower commands believe that higher ones have no idea what they can do and what they are facing, and higher commands complain that lower ones neither know nor care about the strategic situation and how their unit contributes to the mission as a whole. Sometimes lower commands are right, as when Rommel and his Afrika Korps disobeyed orders from the Oberkommando der Wehrmacht (OKW), the German high command. The OKW ordered Rommel to hold Libya, but he attacked and nearly swept the British out of Africa in 1942. Sometimes higher commands are right, as when Jeb Stuart led his cavalry on a pointless ride to the east of Meade’s army, leaving Robert E. Lee and the Army of Northern Virginia without reconnaissance during the Gettysburg campaign in 1863.

Navy relations between lower and higher commands can be even frostier. Being alone on a ship hundreds of miles from the nearest friend, a captain and his crew have near complete autonomy, and near complete responsibility, for themselves and their mission. Even the admiral commanding the fleet has to ask permission to board a subordinate’s ship. A friend of mine once described the relationship by service, saying that Army units view higher headquarters with indifference, and Navy units view higher headquarters with indignation.

Against this backdrop, some on my staff have asked me to discuss the relationship between higher and lower headquarters. This paper intends to address this question.

Higher headquarters provide mission guidance, while lower headquarters direct units for mission accomplishment

Probably the single most important thing that higher headquarters do for their subordinates is to provide and clarify their mission – what they are supposed to do. The highest headquarters in the United States, the National Command Authority, sets the mission in its broadest terms in the National Security Strategy (NSS). The next level, the Department of Defense, interprets the NSS in military terms and so forms the National Military Strategy (NMS). Each service then produces subsidiary documents to interpret the NMS for their service. Subordinate commands, from geographic commands (i.e. European Command) to functional commands (i.e. Medical Command) do the same at their level and in their context. Eventually every rifle company, every frigate, every air squadron, and every hospital has a mission statement and strategy which describes how they will do their part to accomplish the NSS.

Each headquarters must not only identify its mission and strategy but must communicate it to headquarters above and below them. This task is vital and endless as the continual press of events makes it difficult for even the most dedicated unit to maintain its focus on the mission.

Higher headquarters provide resources, while lower headquarters direct the use of those resources to accomplish the mission.

It is impossible to accomplish tasks without resources, and higher headquarters are responsible to give lower ones whatever they need to fulfill their mission. This requires that they identify clearly what they want their subordinates to do and listen carefully when their subordinates describe what they need to do it. They must then provide their own analysis, discuss the results with the ones who will be executing the mission, and meet the need. Once the initial need is met, commands at all levels must keep watch over operations to ensure that resupply and refitting are done regularly and as needed. The mission is paramount.

No command ever felt like it had enough resources, and higher and lower commands have both made mistakes in this area as well. McClellan always overestimated the strength of Lee’s forces and chronically asked for reinforcements for the Army of the Potomac. As a result, he lost to a numerically inferior army in the Peninsular Campaign and failed to end the Civil War in 1862. On the other hand, the German Army Group South was tasked to provide food, fuel and ammunition to Von Paulus’ beleaguered and starving 6th Army at Stalingrad. What few aircraft got through the gauntlet of Soviet air and antiaircraft never had enough to sustain the troops. One shipment contained condoms instead of food or ammunition.

Higher headquarters provide information from equivalent and higher levels, and lower headquarters provide information from the front line.

Subordinate headquarters need to know more than just the mission. Most do not have intelligence shops and so rely on their higher headquarters to keep them abreast of what is going on around them. We may never know if Admiral Husband E Kimmel and General Walter C. Short could have anticipated the attack on Pearl Harbor had they been given all of the information that the US Government knew regarding an imminent Japanese attack. In 1999, Senator William V. Roth (R-DE) wrote that “they were denied vital intelligence that was available in Washington.” Whether this would have made a difference of not, the fact remains that one of the most important tasks of higher headquarters is to keep lower headquarters informed of all information they need to do their duty.
The converse is also true. During the German assault on Crete (20-31 May 1941), the British high command provided accurate and timely information to MG Bernard Freyberg’s Greek and British troops due to the decoded Enigma intercepts. However, commanders on the ground misunderstood and misused some of the information, allowing the Germans to capture the Maleme airfield, reinforce their position, and capture the island. In this case, poor communication between command elements played a decisive role.

Higher headquarters provide top cover, representing subordinate units at higher levels and shielding them from inappropriate tasks from outsiders.

Sir Douglas Haig (1861-1928) was the supreme commander of British forces in France during most of World War I. Millions of men had become casualties and the war had deadlocked in trench warfare since October of 1914. Despite the experience of the German and French at Verdun, who had suffered 700,000 dead, wounded and missing while gaining nothing in the battle of Verdun (February to December 1916), Haig planned and launched a major British offensive at the Somme in July. The British suffered 60,000 casualties on the first day, and over 600,000 by the time the battle ended in November 1916. Lieutenant Bernard Montgomery, who later became the senior British commander in World War II, wrote:

“The higher staffs were out of touch with the regimental officers and with the troops. The former lived in comfort, which became greater as the distance of their headquarters behind the lines increased. There was no harm in this provided there was touch and sympathy between the staff and the troops. This was often lacking. The frightful casualties appalled me. There is a story of Sir Douglas Haig’s Chief of Staff who was to return to England after the heavy fighting during the winter of 1917-18 on the Passchendaele front. Before leaving he said he would like to visit the Passchendaele Ridge and see the country. When he saw the mud and the ghastly conditions under which the soldiers had fought and died.” Apparently he was upset by what he saw and said: “Do you mean to tell me that the soldiers had to fight under such conditions? Why was I never told about this before?”

Haig was no different than most other European commanders at the time, and he ignored some of his subordinates when they told him before the bloodletting that the offensive was a bad idea. These commanders, who knew the obstacles far better than Haig did, tried to save their units from disaster, performing this function of higher headquarters, but were unable.

As a senior officer in the Joint Task Force National Capital Medicine (JTF Cap Med), I am routinely required to prioritize tasks that outside commands and other groups try to assign to our subordinate hospitals, the Walter Reed National Military Medical Center and the Fort Belvoir Community Hospital. Sometimes I am successful in diverting unnecessary tasks, or necessary tasks that should actually be done by others, away from these already overworked units. Other times I am not. Either way, it is our duty in the higher headquarters to enable our subordinates to do their mission, and that sometimes means deflecting distracters to that mission.

Higher headquarters provide expertise

The way to become a commander or a staff officer at a higher headquarters is to succeed at a lower one, since those who are unsuccessful are not given greater responsibility. Therefore people serving in higher headquarters units should, and usually do, have training, skills and experience to assist people in subordinate units to accomplish key tasks. Higher headquarters does not do the work of lower headquarters, but helps them do it themselves.

Higher headquarters coordinate efforts between lower level units

It was 16 June 1815, and Napoleon had just returned to France from exile in Elba and formed a new army to fight the invading Allies. He marched into Belgium and was faced with the English Army to the north and the Prussians marching to attack from the east. Napoleon had no chance of beating the combined Allied Armies, but he could win if he could destroy them one at a time. An allied Dutch-Belgian infantry division had occupied the strategic crossroads at the Belgian hamlet of Quatre-Bras, and Napoleon ordered Marshal Ney, a French wing commander, to take it. Another wing commander, Marshall Grouchy, was told to fight the Prussians in the east.

Over the course of the day, Marshall Ney wasted six precious hours and failed to take Quatre-Bras, and his I Corps commander D’Erlon marched his troops repeatedly between Quatre-Bras and the Prussians at Ligny in the east, failing to influence either engagement. Napoleon and Grouchy were more successful against Blucher at Ligny, but failed to win a decisive victory. The failure of French arms on 16 June, largely due to a failure of communication and coordination, ended in the French disaster and the destruction of their empire at Waterloo, only two days hence.

Whether fighting historic battles, coordinating training exercises or taking care of patients, higher headquarters coordinate the activities of their subordinate commands. Last summer Walter Reed National Military Medical Center needed surgeons, operative nurses and other surgical staff to help them care for the crush of combat casualties arriving from Afghanistan. Other military hospitals in the national capital region (NCR), coordinated by the JTF Cap Med contributed those professionals, and the wounded received the care that they needed.

Conclusion

It is often difficult for young officers and soldiers to know how to relate to headquarters, higher and lower. Misunderstandings abound, and it is easy for misunderstandings to develop into hostility. Mission failure is an all-too-common result.