There was not much money invested in medicine in the American colonies before the Revolution, and the practice of the art had not achieved either distinction or prestige. The lack of investment and low public regard may have discouraged Congress from giving much attention to problems of providing for the health of the soldiers. Whatever the reasons, it did not get around to establishing a hospital department until fully a month after it had created the army, late July 1775. Congressional neglect, however, did not preserve harmony in the department. Those commissioned by Congress to organize and run the service proved able to entangle themselves in controversy without external assistance—to the point of affecting adversely the care of sick and wounded soldiers.
In a sense Congress inherited its first director general and chief physician. He was Benjamin Church, and he ran the medical service of the New England army around Boston before Congress took over. Unfortunately he was also a traitor, having sold himself to General Gage several years before, apparently because he had grown fond of the fashionable and expensive life. No one in Congress knew of Church’s extracurricular activities in July when he was appointed, and no one learned until September. During the summer of 1775 Congress went about ignorant of medical organization, calling for regimental surgeons to work closely with line outfits and the general hospital to do something more.
Just exactly what the general hospital was to do was not altogether clear, and just exactly what the relation of the regimental surgeons was to it was no clearer. No clearer to outsiders, that is. Both the director general and the surgeons always maintained that they understood perfectly what Congress intended. They did not agree among themselves, however, on what their relation should be.
Before confusion grew into open disagreement, the army discovered Church’s treason and put him under arrest. That took place in September 1775, and in October Congress named John Morgan to succeed Church. Morgan did not reach Cambridge until the end of November.
Morgan did not take up his commission with many cards in his hand. Church had not done badly as director general, but he had not really done very much. In particular he had not begun to sort out the organizational lines soon to trap Morgan in struggles that distracted him from the main business—the health of soldiers. The regimental surgeons gave him his first taste of difficulty, and after he left the service in January 1777 they gave the same treatment to his successor William Shippen, who hung on until January 1781. John Cochran, the director who performed the best and who succeeded in asserting some control over the regiments, followed Shippen and served until the end of the war.
The regimental surgeons possessed a clear notion of how they should deal with the general hospital and its director—aloofly, except when they needed something. They wished to use the hospital as a supply house that would provide them with food, instruments, medicines, and bandages. They had a point; the troops preferred the regimental hospitals to the general hospital. The regiments’ facilities were always smaller, probably healthier, and nearer to comrades. And the regimental surgeon, who had usually been named by the colonel or the state assembly, was a known quantity.
The director general saw things differently. His situation may have been ambiguous, but Congress, from Morgan’s time on, had authorized him or his staff to inspect regimental hospitals and to transfer patients if conditions seemed to warrant such action. Washington had strengthened Morgan’s hand by giving him permission to determine the fitness of regimental surgeons and aides by examinations, which proved strenuous exercises. They so annoyed the surgeons of the regiments that when the army left Boston for New York, Morgan gave them up.
The strain between the regimental and general hospital surgeons did not really ease off until Cochran took charge. Morgan was relieved of his post by Congress at the beginning of 1777, and William Shippen, his successor, resigned early in 1781. Both men, and Samuel Stringer of the northern department, felt betrayed by Congress and the army. In fact, Shippen had connived shamelessly to get Morgan’s post, and Morgan, aided by Benjamin Rush, helped to force Shippen to resign. Shippen endured court-martial during his tenure and, though he was acquitted, his reputation was shattered.
These wars within the war contributed to years of shoddy medical services. Just how badly they undermined the health care of soldiers cannot be known, though the organizational weakness persisted until the end of the war. Had the institutional arrangements been first-rate by the standards of the day, the actual medical service provided soldiers would have left something to be desired, for America did not brim with physicians or medical knowledge. Recent estimates hold that there were some 3500 medical practitioners of various sorts in America when the war began. This figure probably includes quacks as well as reputable physicians and a great number of indifferently trained men who treated the sick and worked at other occupations as well. Probably fewer than four hundred had a medical degree.
Although generalizations about such a motley group cannot be reliable, it is unlikely that any theory of disease or therapy found wide acceptance among them. The physicians among them probably believed that sickness generally represented some variation from the normal patterns of the human system, an old idea which persisted through the eighteenth century. There were diseases identified as diseases, smallpox, syphilis, and tuberculosis, for example, but both theory and practice usually dealt with body conditions, such symptoms as fevers, fluxes, and dropsies. The assumption behind this practice was that a fever indicated that the state of the system was off, not that the body was afflicted by a disease. To be sure, some physicians had come to recognize that diseases were objectively real. While treating their patients, they had observed that a medicine might be effective against one set of symptoms but not another. From this experience they inferred that they faced two different diseases.
These physicians easily reconciled this inference with the ancient assumption that there was one basic cause of all disease. The most common theory held that the body’s humors were somehow awry, perhaps impure or out of balance, with one or more present in excessive or insufficient amounts. The treatment followed from the diagnosis, with bleeding, purging, and sweating all calculated to reduce excessive amounts, and diets and drugs intended to build up volume. Another basic cause of sickness, it was widely thought, might be a chemical imbalance, with body fluids showing an improper blend of acidity and alkalinity. The treatments in such cases often resembled those prescribed to restore humoral balance.
The ordinary soldier, of course, lived largely oblivious to theory, though he, his officers, and the regimental surgeons may have shared a good deal of common lore about health and medicine. Judging from the orders that came down from on high in every American camp, one belief they did not share was that cleanliness was next to godliness. Away from home, the American soldier did not mind the filth that piled up in crowded camps—or if he minded, refused nevertheless to follow rudimentary practices which would have kept them cleaner. Soldiers throughout the war apparently disdained use of the vaults, as latrine pits were called, preferring to void whenever taken by the urge. They also scattered food scraps, carrion, and garbage throughout the camps. They had to be forced to change the straw that served as bedding. And some had to be ordered to bathe. The British, professionals in this sort of thing as in all things pertaining to military life, kept clean camps and probably suffered less from disease.
Dysentery troubled the American army throughout the war. The filth the army created accounted for some of it and so did the low standards of cleanliness in cooking. Most of the time soldiers cooked for themselves, though there might be bakeries which served a brigade. Diets ran to fat meat and bread when they were available, but on the whole the army suffered more from a lack of food than an unbalanced diet.
Good officers did what they could to make camp life healthy. Washington set the standard with a flow of orders about sanitation, diet, bathing, all the concerns of a responsible commander who wanted to lead into battle men who were fit. At Valley Forge, for example, when the worst of winter had passed, he ordered renewed attention be paid to the cleanliness of troop quarters. Common opinion held that the air in each hut might be purified each day by burning the powder from a cartridge. A small amount of tar might be substituted if gunpowder were short. Tents were to be taken down daily and the ground around them scoured. Soldiers in Washington’s and Greene’s armies were encouraged to bathe—moderately. Immersion in water for too long a period might weaken the body, according to the folklore that made its way into regimental orders.
Good junior officers and noncommissioned officers could do much to protect the health of their charges. The memory of a Connecticut sergeant building a fire for his soldiers when they were cold and hungry stayed with one of his men for fifty years after the Revolution. No manual of leadership or of army medicine prescribed that sort of performance, but it undoubtedly contributed to the health of soldiers. Charles Willson Peale, serving as the captain of a Philadelphia militia company, found beef and potatoes for his company’s breakfast two days after the battle of Princeton. His men, so fatigued they could not look for food, had gone to bed without eating. Peale shook off his exhaustion and rambled from door to door at Somerset Court House until he had collected rations for his men. A few days later, Peale found that he had a sick Ensign, one Billy Haverstock, on his hands. Peale first got some sugar for Haverstock, a remedy that did not prove effective. Next he tried “a puke of Doctor Crochwin,” an emetic given to feverish patients. His final entry in his diary about the case described the use of an old standby, tartar emetic, a mixture of antimony and potassium nitrate, which he gave in a double dose. Haverstock apparently survived this treatment.
Had a physician treated Haverstock, he might still have recovered. Physicians followed just about the same lore as laymen, though they may have been more inventive in their uses of medicines. What made most of them so dangerous was their fondness for bleeding patients. When they did not bleed them, they often resorted to purging and sweating, techniques not certain to cure dysentery, malaria, typhus, typhoid, pneumonia, and smallpox, the diseases which afflicted American troops in their camps.
When surgeons were available they took care of the wounded. Bleeding the wounded sometimes served as treatment and not always with fatal results. Dr. James Thacher, who was taken into the medical department of the army as a surgeon’s mate, reported that one of his senior colleagues, a Dr. Eustis, once treated a “dangerous wound” of the shoulder and lungs by bleeding. While dilating the wound, Dr. Eustis “recommended repeated and liberal bloodletting, observing that in order to cure a wound through the lungs, you must bleed your patient to death.” Thacher reported that the wounded man recovered; the principal reason, Thacher believed, was the treatment he received.
Perhaps the best guide for surgeons, Plain, Concise, Practical Remarks on the Treatment of Wounds and Fractures by Dr. John Jones, advocated rather different procedures. Jones was a professor of surgery in King’s College, New York; he had received his medical degree from the University of Rheims in 1751 and shortly after served in the French and Indian War. The first concern in the case of a wound inflicted by a musket, he wrote, should be to extract the ball and, second, to stop the hemorrhaging. Jones’s manual divided wounds into categories; each sort required its own treatment. But in treating all kinds, Jones urged that care be used to clean the wound and to dress it carefully. He had a sense of the limits of surgery, noting, for example, the danger of amputation when the wounded man was reduced to a “low and weak state.”
Whatever the effects of Jones’s prescriptions, the treatment of wounds remained a most problematic enterprise. Soldiers who survived serious wounds doubtlessly did so through a mixture of luck and their own strong constitutions. Most surgeons tried to give their best to their patients. In the Continental army, chronically short of medicine, bandages, nurses, and food, the “best” often could not prevent death.
No disability from either wounds or illness caused more concern than smallpox. In fact smallpox frightened everyone in the eighteenth century. Battles left men wounded, sometimes disabled for life, and of course sometimes dead. Battles were frightful events, but in the Continental Army some soldiers probably feared smallpox even more.
A wound could be dressed and bandaged up; there was agreement about that. There was no such agreement about what to do about smallpox, which found quarantine and isolation of the afflicted competing with inoculation, itself a treatment that produced the disease. No one knew this better than General Washington.
Washington contracted smallpox in 1751 in Barbados while accompanying his brother Lawrence, who had traveled to the island in search of relief, if not a cure, for an ailment that was destroying his lungs. Lawrence Washington had what the eighteenth century called consumption; the modern name is tuberculosis. He died in 1752. George Washington of course survived his affliction, but he never forgot his own experience with smallpox and may have been especially sensitive to its rigors when he took command of the army in 1775 outside Boston. Smallpox lurked nearby in the city and in many of the surrounding towns. Some 13,000 civilians lived in Boston—several thousand had fled by early 1775, when the war broke out, and, cooped up by the siege, those remaining proved vulnerable to the spread of the disease.
Smallpox was an old and familiar visitor to the American colonies. New Englanders had attempted early in the eighteenth century to meet it head-on using a procedure called inoculation or variolation. In 1721, Cotton Mather, the great Puritan divine, persuaded Zabdiel Boylston, a medical practitioner in Boston, to inoculate those willing to undergo the operation. There was an epidemic in the town and the attempt to halt it with a method untried before in America kicked up an enormous storm. The reasons are not hard to understand. Inoculation entailed making an incision on the body, usually the arm but occasionally the hand, and inserting infected matter, pus, extracted from a pustule on a sufferer from the disease. The inoculated contracted the disease a few days afterward, but surprisingly, in a form less severe than usually experienced when the infection was transmitted naturally. The tumult over inoculation in 1721 was understandable, though Cotton Mather considered the bomb thrown through his window an extreme expression of discontent.
The years following Boston’s first experience with inoculation saw the practice slowly take hold. But it was frequently condemned, barred by law in cities and towns throughout the colonies. Americans learned more about the disease and about treating it in these years before the Revolution. To stop the incursion of smallpox from reaching epidemic proportions, communities resorted to quarantine, and some attempted a modified form of inoculation. Medical wisdom gradually came to the conclusion that inoculees should prepare themselves before allowing the infection to be inserted; preparation included a special diet (of doubtful value) and isolation from those free of the disease. That infected matter taken from a person who had smallpox contracted through inoculation produced illness less severe than that contracted from someone who had taken the disease naturally was recognized by mid-century. Still the use of inoculation remained controversial even when coupled with isolation and quarantine. It also sometimes proved dangerous. There is no evidence that Washington knew of Boston’s history with inoculation, but he must have heard of some parts of it.
Faced with smallpox in Boston in 1775, Washington pondered his choices, knowing that he would have to decide soon whether to use inoculation or depend upon isolation and quarantine. Most soldiers in Washington’s army had never had the disease, and he feared that if he ordered inoculation he would weaken his army temporarily to the extent of destroying its ability to maintain the siege. The inoculated were sometimes so sick as to be unable to fight. Done carefully and in stages, and without the enemy’s knowledge, inoculation would reduce the risk. Still the danger remained that one inoculee released from quarantine too early could disable troops bivouacked in tight lines around the city. In the end Washington decided against inoculation. He would quarantine troops who caught the disease naturally and civilians already infected who escaped Boston and entered his lines. Washington’s prudence paid off; most of his soldiers avoided the infection.
By January 1777, with his army at Morris Town, New Jersey, he had reason to make a different decision. Smallpox had struck his troops heavily, and other American forces as well, and he feared that it might render his army useless. He knew that inoculation would arouse opposition of the sort he had heard earlier. One example of such opposition had come to him in August of 1776, when he was told that the Governor of Connecticut, Jonathan Trumbull, had described inoculation as “pernicious” and predicted that “ ‘if it is not timely restrained it appears to me it must prove fatal to all our operations and may ruin the country.’ ”61 Washington saw ruin of another kind: an army overwhelmed by the disease. The orders therefore went out to begin immediately to inoculate soldiers who had not had the disease. He did not act recklessly but organized the process with care, making certain that the sick were isolated and that the newly inoculated were kept in quarantine.
Since recruits to his army usually came through Philadelphia, where the disease was common, the possibility was strong that they would arrive in Morris Town carrying the infection. Washington therefore issued a second set of orders instructing William Shippen, the director general and chief physician of the army, then in Philadelphia, to inoculate all recruits before sending them on to Morris Town. Soldiers who might be carriers of the disease were to be kept out of the city until they had received a change of clothes—new clothes “if possible,” and if none were available, the old clothes were to be “well washed, aired and smoaked.”
Once under way in 1777, inoculating the troops continued well into the next year when the army was in camp at Valley Forge. The medical committee of the Continental Congress gave its approval—an important action because Benjamin Rush, a medical doctor trained in Britain, chaired the group. Soon inoculations were being given wherever sizable numbers of troops were located. In many cases these soldiers were headed for the main encampment. In the year 1777, thousands were inoculated in at least three camps in Virginia, one in Maryland, two in New York, and one in Connecticut.
Unhappily, though Washington’s policy worked and almost all of those inoculated survived, a similar effort had to be undertaken again after the army settled in at Valley Forge. Washington estimated that some three or four thousand men needed protection against smallpox. The veterans had undergone the procedure, but more recently recruited troops had not, a fact that should not have occasioned surprise since the turnover rate in the army was disturbingly high. Life at Valley Forge was difficult even without inoculations, but smallpox was a serious threat in these winter quarters. By this time the army’s leadership felt confident of the efficacy of inoculation, and little time was lost before the medical branch swung into action. The troops survived the rigors of inoculation as they had every other sort at Valley Forge, and in the spring when their general ordered them into action against a British army then pulling up stakes and setting out for New York, they were ready.
Looked at from a later perspective, it is hard not to conclude that the attack on smallpox through inoculation saved the army from disintegration. The procedure seems harsh, and was, but in its absence, smallpox took many lives. With it, the army survived in fairly good shape and maintained a combat strength that would not have been possible without General Washington’s medical policy.