Chapter 10
The Lessons of War: 1815 to 1818
The experiences of two wars and several expeditions against the Indians made it obvious not only that Army surgeons, like their colleagues everywhere in the late seventeenth and early eighteenth centuries, were unable to treat a large proportion of their patients successfully but also that the U.S. Army was unable to deliver the best medical care, as determined by the standards of the time, to its sick and wounded. After hostilities ended in 1815, a number of surgeons published journal articles about their professional experiences during the War of 1812, but since there was no central authority to coordinate their observations or to study their conclusions and since they had little understanding of the causes of disease and infection, the significance of their contributions was limited.
A number of the nation`s political leaders were also brought by the experiences of that war to urge the creation of a permanent, professional, and quickly expandable Army. Although their concepts failed to achieve wide acceptance in the years following the war and their efforts were to a significant degree frustrated, a permanent Medical Department was nevertheless established in 1818 when, as a result of the efforts of Secretary of War John Calhoun, legislation created a number of permanent staff departments for the Army. The disciplined, coordinated collection and study of data systematically gathered by the department from different areas of the country and over a long period of time now became possible; as a result, as the value of statistical studies received greater recognition, the department would be in a position to make important contributions to medical science. The existence of a permanent organization, furthermore, would also guarantee that a nucleus of experienced and disciplined military surgeons would be available at all times in the future to advise concerning the prevention of disease and to care for the Army`s sick and wounded.
INDECISION AND DECISION,
MARCH 1815 TO APRIL 1818
The confusion and suffering caused by the fact that the Medical Department was created after the War of 1812 had begun and therefore could not prepare for the care of large numbers of sick and wounded in the War of 1812 did not prevent the breakup of its central organization within a short time after the hostilities ended. The office of Physician and Surgeon General was eliminated by the legislation of 3 March 1815, which reduced the Army in size to 10,000 men, but the positions of Apothecary General and two assistants, considered still needed because of "principles of convenience and real economy,"1 were provisionally retained through an order of 17 May 1815. (See Appendix K.) The ratio of one surgeon and two mates per regiment was not altered, however, and a maximum of five hospital surgeons, fifteen hospital mates, and twelve post surgeons per division was also permitted. Many of the most experienced physicians were dropped, either temporarily or
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permanently, from the service, even in those instances when they had expressed a wish to be retained. By the end of the year, however, Secretary of the Army William H. Crawford was urging Congress to recognize the fact that the military should be given "in time of peace, the organization which it must have to render it efficient in a state of war." Even so, he did not suggest the creation of the post of surgeon general, but merely proposed that a permanent staff include an apothecary general, whom he would have stationed at Philadelphia.2
In April 1816, legislation was passed to clarify the organization of the medical support to be provided the Army and the positions of the Apothecary General and his two assistants were now made permanent. The Army was divided into a Northern Division with four geographical departments and a Southern Division with five. A ratio of four hospital surgeons and eight mates for each of the two divisions was established, and the position formerly known as garrison surgeon was officially redesignated post surgeon. Although there was now a small permanent staff to handle the supply of drugs and medicines, when John Calhoun became Secretary of War late in 1816, there was still no single superior over the entire department through whom the Apothecary General, Francis LeBaron, could work in estimating the overall needs of the Army`s surgeons.3
Apparently some critics of the medical care available to the men o the U.S. Army at this time blamed inadequacies in large measure upon "their regular and injudicious mode which government has pursued in the organization of a medical department." Calhoun, however, was a young man of both energy and ambition. He was convinced of the necessity of expanding the work of his predecessor in creating a peacetime staff organization which would be able to meet the challenge of war whenever it might come. By April 1818, the new Secretary of War was able to add to the permanent staff posts of the Army that of the Surgeon General of the Army Medical Department.4
At least twenty-two physicians who had served with the Army during the War of 1812 informed Tilton, who himself retired in the spring of 1815, that they wished to remain in the Army. It appears, however, that by January 1816, only seven of the twenty-two had actually been retained in any capacity whatever and that at least one of the seven was very unhappy with the position to which he had been assigned. One of those who was dropped from the Army commented to Tilton that "a just and honorable reward for public service is seldom bestowed on the humane and faithful physician and surgeon. "Although he remained in the Army, a second physician, Dr. J. H. Sackett who had served as a hospital surgeon`s mate during the war, joined those who complained of the Army`s attitude. Sackett had at first been dropped from the Army`s rolls in May 1815, but after being asked to remain the following month, was assigned the position of a mere garrison surgeon`s mate.5
Despite the fact that Dr. James Mann, in Tilton`s words, "the oldest surgeon on our register," was recommended for reappointment by both Tilton and LeBaron, among others, and wished to remain in the Army, he was not initially asked to do so. He appears, however, to have remained on duty at least through mid-April. He became quite bitter over what he regarded as the Army`s unfairness, since he had a family to support and had given up his private practice upon entering the Army. By the spring of 1816, however, he had apparently been reappointed and was serving as one of the four hospital surgeons in the Northern Division, along with Benjamin Waterhouse, Joseph Lovell, and Tobias Watkins.6
Even after hostilities ceased, large numbers of bills which Apothecary General Francis LeBaron had difficulty paying continued to come in to his office. Among the expenses
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he was required to handle were the costs of care for the men who were treated by private physicians after falling ill along the roadside when units of the Northern Army were on the march. Through the entire spring of 1815, LeBaron continued to press for the funds he needed to meet the department`s expenses, and during the summer the Secretary of War decided that one way of meeting some of these claims against the department would be to sell off all hospital supplies no longer needed.7
Early in 1816, LeBaron began to urge measures to eliminate waste and extravagance. Since surgeons were accumulating unnecessarily large quantities of supplies, specific regulations should be drawn up "for the economy of supplies in this Dept." LeBaron`s problems continued, however, and the spring of 1817 found him still concerned about the accountability of surgeons and others who handled supplies. He maintained that a one-quarter savings could result if surgeons were made responsible to the Apothecary General and the Apothecary General in turn to "some higher source. "He reported that he had been able, even so, to save some money by having old instruments repaired, but old medicines tended to deteriorate and those of his drugs which had been long in storage were losing in value with every passing day. They should, therefore, be sold at once.8
Another economy suggested by LeBaron in March 1815 was a consolidation of hospitals to reduce the cost of transporting supplies. The Apothecary General urged that the men then in facilities at Burlington, Brownville ,and Williamsville be sent to Greenbush, but he agreed with Waterhouse that an invalid hospital should be opened to serve the northern and western states. His suggestions, however, appear to have been to some degree ignored, since the hospital at Brownville was in operation as late as the fall of 1817 and that at Burlington was still open when the hospital surgeon who was in charge there in the winter and spring of 1815 left the Army that summer.9
LeBaron made a number of other suggestions for improving the efficiency of the department`s supply system, but it is not always possible today to ascertain to what extent his ideas were carried out. He appears to have succeeded to some degree in limiting the frequency of supply deliveries to any given area to once a year and hoped that, as a result, he would receive fewer of those small orders which could be easily lost. He requested that estimates of need be made up by March of each year, pointing out that timely returns could have saved $10,000 of the $36,000 to $37,000 which was spent on drugs in the twelve-month period ending in the summer of 1817.10
The path of distribution of supplies to the regimental surgeons lay through the quartermasters at such central points as Philadelphia, Boston, and New York. In early 1815, for example, the assistant apothecary general assigned to Richmond, Virginia, was receiving all of his medicines from the deputy commissary in that city. There was at least one request that a storage depot also be established at Baltimore, but LeBaron believed that taking this step would unnecessarily complicate the handling of supplies.11
LeBaron hoped to take advantage of water transportation wherever he could. With this in mind, he pointed out that New York City, where he wished to make his headquarters, was an ideal location. He apparently experienced difficulty in receiving permission to make the move and in the spring of 1816 was still urging that this step be taken. He pointed out to the Secretary of War that the rivers leading to the west from Philadelphia could be used for transport from a depot there and that New Orleans could serve as a center from which the deep South could be supplied. LeBaron`s work was complicated, however, not only by such occasional problems as the "uncommon scarcity of Water of the Mohawk" but also by the fact that he
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STATEMENT ON HOSPITAL SUPPLIESSENT FROM NEW YORK. (Courtesy of National Archives.)
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could not be sure what forts were in use at any given time.12
The Apothecary General made an inspection trip in the late summer and early fall of 1816. It was planned to take him along the northern frontier, which was in an "unsettled state" as far as the Medical Department was concerned. He hoped to visit Brownville, Sackett`s Harbor, Niagara, and Detroit, and possibly Michilimackinac as well. When he learned that the men constructing a "military road" near Detroit would probably suffer a high rate of disease, LeBaron decided to take two wagonloads of items which they might need along with him when he left Albany. He seems to have set out upon this three-month voyage in the late summer of 1816,but in addition to being "sick most of the time," he was shipwrecked on Lake Ontario.13
Despite his efforts to improve the supply operations of the Medical Department, LeBaron`s position was made insecure by continuing criticism of the quality of the supplies he sent out. In February 1817, although the exact nature of the complaint was not spelled out in the Secretary of War`s letter to the Apothecary General, LeBaron was tersely informed that if there were further complaints on this score, "the government[will] . . . discontinue your services."14
Much of the work of Army surgeons in the period immediately after the end of the War of 1812 involved the sick and wounded still remaining in need of care or new patients from among the troops originally concentrated as a result of the war. In February 1815, for example, there were still "sundry considerable armies & cantonments" in the 9th Military District. As late as March there were also sick and wounded British prisoners in a hospital at Pittsfield, Massachusetts. Even in 1817, Army surgeons were still concerned with the veterans of the War of 1812. The certificate of an Army physician was required for some types of pensions, but apparently not all of the certificates issued were accurate. In at least one instance, a surgeon stated that a man had been wounded in action at a time when the individual had not yet joined the Army. The physicians involved, however, were not accused of fraud but rather of a lack of awareness which made them the easy victims of dishonest soldiers.15
Although there were still patients requiring care in the vicinity of Lake Champlain, Dr. Henry Huntt was on leave and Mann was attending the court-martial of Maj. Gen. James Wilkinson at Utica, leaving no hospital surgeon on duty in this area. By April, however, when Mann had returned to Plattsburg, the men were in excellent health, a fact he attributed to the "rigid discipline and judicious police" which prevailed among them. He also noted that the regimental units were well managed. Huntt was ordered to the general hospital at Burlington early in February 1815, but in June he was relieved of duty there and left the Army.16
By the end of June 1817, Dr. Joseph Lovell appears to have become, at least unofficially, the head of the Northern Division. He turned in a reporto f that date which was entitled "Remarks on the Sick Report of the Northern Division for the Year Ending June 30, 1817"17and later that fall was referred to as "Inspecting hospital Surgeon, at Head Quarters."18 As a result of his inspections he was able to report that the health of the men in the North was very good. More than 2,100 patients had been treated in the preceding twelve months, 838 of whom were suffering from fevers "and other important complaints,"193 from wounds, and 55 from venereal diseases.19
THE STATE OF THE ART
Two wars and a number of campaigns against the Indians offered the physicians who served with the American Army before the spring of 1818 opportunities they
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would not otherwise have had to observe diseases and their treatment and the effects of climate, weather, and geography upon health. Some of these surgeons attempted to record either formally or informally for the benefit of others what they had seen while in the Army and the conclusions they had reached, but the speedy disbanding of the Medical Department made the most effective use of their professional experiences during the war impossible.
Most of the observations of the military physicians of this period seem to have been directed at the practice of medicine rather than that of surgery. Concern continued to be shown for the prevention of disease, through improved hygiene and, in the case of smallpox, through the new process of vaccination. The prevalent types of treatment were also examined with a critical and discriminating eye.
Vaccination was not used within the Army with the enthusiasm which might have been expected, despite the fact that an early supporter of the procedure, Dr. Benjamin Waterhouse, joined the Army Medical Department during the War of 1812. Since, in addition, no deliberate effort was made to study the effectiveness of the procedure, a valuable scientific opportunity was lost. LeBaron, as Apothecary General, attempted in late April of 1813 to have all nonimmune troops vaccinated and urged that the material necessary be sent out at once so that all susceptible men could be immunized before the new campaign began. Although he sent out the "vaccine virus" to various commanding officers, LeBaron did not have the authority to order the troops to undergo the procedure. He made no reference to the existence of any smallpox within the Army, but pointed out that immunization was necessary because some of the localities through which the troops would have to pass were experiencing smallpox epidemics. He emphasized that no special preparation was deemed necessary before vaccination and that after the procedure had been completed, the men could continue with their normalroutines.20
Not long after he became head of the Medical Department in 1813, the Physician and Surgeon General appointed six young surgeon`s mates to forma vaccinating team to go out to immunize the Northern Army. Like LeBaron, however, Tilton made no mention of any smallpox epidemic within the ranks of the Army. Whether the mission he assigned was actually accomplished cannot be ascertained, but the next summer Maj. Gen. George Izard, alarmed by a single case of smallpox within his camp, sent "an express" to Albany to obtain "kine pox matter" and commented that his troops should have been vaccinated earlier.21
Although none of these documents refers to an epidemic of smallpox within the Army in the War of 1812, the fear that there might be one was evident. Since references to devastating smallpox epidemics were common in the documents of the Revolution, and since the disease was still dreaded, it is unlikely that similar epidemics in the War of 1812 would go unmentioned.
Discipline as a key to the prevention of disease was well recognized by the War of 1812 and was emphasized by the future Surgeon General, Joseph Lovell, who pointed out that one of the reasons for retaining a "military establishment" in peacetime was the fact that military experience was necessary to an understanding of regulations and their importance. The precautions recommended for the prevention of disease included not only the obvious sanitary measures but also the locating of camps in dry areas and the starting of fires early in the evening on the windward side of camp if circumstances made the pitching of camp in a damp area unavoidable.22
Proper clothing was considered to be very important. No new conclusions on the
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subject appear to have been reached during the War of 1812, however; faith was still placed in the wearing of woolen shirts, particularly north of Philadelphia, and Lovell recommended that the advice of Benjamin Franklin on that subject be followed: woolen shirts should be worn "until mid-summer" and put on again "the next day." Surgeons in the War of 1812 were apparently also familiar with the damage which cold and damp could cause to the feet. Lovell emphasized the importance of proper footgear, commenting that "the most important circumstance perhaps of all is to enable the soldier to keep his feet warm and dry by a liberal allowance of woolen socks and laced shoes, reaching at least to the ankle. "Lovell also believed, however, that letting the feet remain wet and cold for any length of time had "deleterious effects upon the constitution through the lungs and bowels.23 Tilton shared Lovell`s faith in flannel worn next to the skin, but he believed that wearing clothing which was too warm in the summer was also unwise. In hot weather the soldier should wear "pantelets & shoes, without stockings," but in every kind of weather, he should wear gaiters.24
Mann`s experiences, however, had not led him to great optimism concerning what preventive medicine could accomplish with the average soldier. The Army enlisted many men who were already "habitually intemperate, with constitutions broken down by inebriation and its consequent disease; whose bloated countenances exhibited false and insidious marks of health "and these "contribute to fill our hospitals." "It has been too much an object with officers on the recruiting service, to fill up their rolls with numbers." "The surgeons of the army," Mann lamented, "are made mere scapegoats, on whom are heaped a multitude of sins."25
Although hospital records surviving from the War of 1812 list fevers and digestive and respiratory ills as the most prevalent diseases, some patients suffered from "nothing" or even "rascality."26One Army surgeon, however, recommended a cure for this kind of ailment. Blistering, he said, was "a good test, in doubtful cases, whether a man was really sick. Rather than submit to the pain of blistering a second time, unless absolutely diseased, he would prefer going to duty . . . so that, whether a man was actually sick or only feignedly ill, blistering was an excellent remedy."27
If there were a disease deserving of the name of "camp disease" in the War of 1812, Lovell believed it would have to be diarrhea and dysentery. The primary cause of this problem was, in his opinion, not bad food or water, but cold and damp weather. To treat diarrhea and dysentery, physician tried inducing perspiration by warm baths, warm drinks, warm coverings, and medicines believed to increase perspiration, such as Dover`s powder, a combination of opium and ipecac.28
Another goal of the physician treating dysentery was the emptying of the digestive tract by purges and emetics, an approach which was accepted with little or no question. There seems to have been some difference of opinion, however, on whether the purge should precede or follow the emetic. Waterhouse believed that ipecac should be administered before the purge, and that jalap, senna, aloes, rhubarb, and "perhaps calomel" should not be used for purging the sufferer from this disease because they increased "peristaltic motion." Epsom salts, manna, castor oil, and extract of butternut, on the other hand, were appropriate since they operated by "increasing the secretion of the glands of the intestines."Heustis, however, favored administering the purgative, preferably castor oil, before the dose of ipecac or tartar emetic. For severe and chronic dysentery he also recommended the raising of blisters just above the ankle and the administration of 1.5 to 2 grams
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of opium, to be combined in the case of heavy drinkers suffering from this disease with 2 to 3 grams of sugar of lead. Waterhouse used opium only when his "patient has been thoroughly evacuated," but admitted that the sufferer`s pain alone might make the use of opium necessary.29Mann, however, warned that the sudden checking of chronic diarrhea could bring on dropsy, which was best relieved by "drastic purges."30Waterhouse also recommended the use of "decoction of wild cherry" as an "astringent in the latter stage of dysentery."31
Neither Waterhouse nor Heustis seems to have believed in the unrestricted use of bleeding for dysentery and diarrhea. Heustis stated that only feverish patients should be bled, while Waterhouse recommended venesection only when the sufferer was young and had "a very hard and crowded pulse, "accompanied by "severe pains in his back and loins." Even in these instances, however, Waterhouse warned that patients should be bled but once.32
There was considerable agreement on the appropriate diet for the patient with diarrhea or dysentery. Heustis and Waterhouse agreed that meat in any form should be avoided, along with alcohol. Heustis encouraged the use of ripe fruit, especially mangoes, guavas, and pomegranates, for "scorbutic dysentery," while Waterhouse emphasized that the fruit must be truly ripe since green fruit would have a harmful effect. Heustis favored a milk and vegetable diet for these patients,33 and Mann added that "No article prescribed proved so beneficial as milk and its preparations. . . By milk alone, it was my persuasion, that many lives were saved, which, without it, would have been lost."34
Physicians in the early nineteenth century continued to question whether many of the fevers so prevalent among the Army`s patients were separate entities; nothing of significance had been learned about these diseases since the time of the Revolution. In 1817, for example, Heustis wrote: "Briefly, my opinion is, that the intermitting, remitting, yellow fever, and plague, are only gradations and modifications of the same disease. "In 1813, Dr. John Warren, who had served with the Hospital Department in the Revolution, speculated as to whether the disease known in the tropics as yellow fever was identical with typhus, although he was confident that the yellow fever which struck Boston in 1798 and 1802 was not typhus. Warren did distinguish between inflammatory fever and typhus, but he seems to have used the terms typhoid and typhus almost interchangeably.35A physician thus might describe a fever as being "a typhoid type" and characterized by a "total loss of appetite, great thirst, parched brown tongue, sordes on the teeth, increased heat of the skin."36
By 1817, studies arising from the interest in the possible effects of weather and climate, however, seem to have somewhat lessened the prevalent enthusiasm for the idea that the origin of fevers might be in "those changes in the air that are pointed out by the thermometer, barometer, or hygrometer." Waterhouse began to believe that the origin of these "wide spreading maladies, as well as endemics, or local disorders" lay in "some secret movement, or alterations in the earth, or on its surface." He noted that while "Epidemics seem to accompany or follow a blighted state of vegetation," they also seemed "to accompany an abundant harvest, but whether in the series of cause and effect, is not fully known." He then terminated his discussion with an abrupt "As to myself, I`m weary of conjecture!"37 Not long after the permanent organization of the department, Army surgeons would be required to begin contributing detailed and systematic reports to the study of the question Waterhouse and others had raised.
Although the physicians of the early nine-
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teenth century may not have been sure of the identity of typhus, at least one left a particularly vivid picture of the effects upon a patient of a disease to which he gave that name. Describing a case he had encountered in the vicinity of Niagara, Lovell wrote:
In the course of the 4th week, a small circumscribed spot of inflammation shewed itself in the face, generally, near the angle of the mouth. In a few days, the side of the face swelled; this tumour was very hard and pale, resembling the colour of a white swelling of the joints. It was not in the seat of the parotid gland but anterior to the branch of the lower jaw, and was attended with a most profuse and fetid salivation. . . . In a few days more, the red spot began to assume a vivid appearance, and symptoms of incipient mortification. In a short time the mouth was literally extended from ear to ear, exposing the backmost grinders on both sides.
Lovell ruled out the use of mercury as a cause of this horrible disfigurement, pointing out that "in the majority of these cases, not a particle of mercury had been used in any form."38
The treatment of whatever diseases might have been included in the term "typhus" varied. Lovell noted that militia doctors in the summer of 1814 treated it by blistering "the patient almost from the crown of his head to the soles of his feet; so that the chief difficulty was to remove the irritative fever induced by this empirical, slovenly practice." Some physicians also placed great reliance upon mercurialmedicines39 and still others upon the use of leeches and cupping, although they might believe that venesection itself was harmful and hadin some instances "destroyed patients."40
When treating fevers described as intermittents, Mann resorted to bleeding and also reported the use of medicines other than "bark" (by which, presumably, he meant cinchona bark), including aromatics, bitters, wine, snakeroot, and arsenic compounds; Lovell commented that he had been unsuccessful in the use of bark against a tertian form of intermittent. Mann also failed to relieve tertian intermittents with bark except when the patient was already convalescent, although he had used "an arsenical preparation" with this type of fever and it had "acted almost like a charm." Lovell, on the other hand, observed that intermittents which responded to arsenicals in 1813 had not done so in 1814.41 The question of the best drugs and dosages to use against malaria was to be taken up by the department and thoroughly studied with the aid of data collected from surgeons in the field after the permanent organization oft he department in 1818.
By mid-1817, however, intermittents were for some reason no longer being seen with any frequency in the North except in the new 5th Military Department and particularly Detroit. Lovell`s report of 30 June 1817 listed 164 cases of intermittent fevers in the North, of which 141 were in the 5th Military Department, 120 in Detroit itself. In the same report, Lovell listed 266 cases of inflammatory fevers, including colds and pleurisy, "which no ordinary care can prevent."42
Among other conditions mentioned in the records of this period was epilepsy, which Mann treated at Burlington with nitrate of silver. He concluded that "By this medicine alone, the morbid action, which constituted the disease, was entirely subdued."43 Mumps also appeared from time to time in the Army, and on one occasion Hanson Catlett maintained that it had been brought on by "exposure to severe cold weather, &storms of snow & rain, which we have had for some days past" at Fredericksburg, Virginia. Catlett maintained that mumps might prove fatal on this occasion unless the men were moved to drier quarters.44
On some occasions, Army surgeons used autopsies to further their understanding of
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the diseases they were encountering. Waterhouse recorded that postmortems on patients who died of dysentery showed him small ulcers all along the lining of the victim`s intestines. He concluded, as a result, that dysentery "is to the intestines what smallpox is to the skin."45Mann described many autopsies done in late 1812, in 1813, and in early1814 upon patients who died from the prevalent "pneumonia notha."46
By the end of the War of 1812, some surgeons who had cared for troops in that period were beginning to have reservations about a number of the remedies used. Opium, of course, was suspect because of its potential for causing "an interruption of the natural actions of the small intestines." Since it "corrects nothing, expels nothing; and only assuages and be numbs," opium was apparently not highly regarded.47 Sugar of lead, however, "was, at one time, a fashionable remedy among the surgeons of the army for chronic diarrhea." Surgeon Henry Huntt was familiar with a patient who used this remedy extensively for the better part of a year. Over that period the victim slowly developed constipation, loss of appetite, "profuse perspirations," an abscess on one leg, an ulcer on the other, and ever more violent pain. Before death brought release, he had become completely paralyzed. Although Mann noted that sugar of lead, like opium, could also lead to dropsy, Huntt placed the blame for its adverse effects not so much upon the medicine itself as upon its use in a fickle climate.48
The need for care in the use of mercurial compounds was now also recognized by at least some Army surgeons, since misuse could lead to the "destruction of not only the muscles, but the bones of the face." Mann recorded "Four cases, under these formidable effects of mercurial ptyalism "who were admitted to the Lewiston general hospital. Of these, three died with their jaws and faces dreadfully mutilated. The fourth recovered, but with the loss of the inferior maxilla on one side and the teeth on the other. "He lived a most wretched life . . . incapable of taking food, except through a small aperture in place of his mouth." Mann doubted, furthermore, that calomel administered during a campaign ever completely cured syphilis. He suggested that it should be used only after the troops had entered winter camp, since, if carelessly used in the field, it was "frequently injurious to the bowels." It should never be given to patients "when exposed to cold and moisture," since if the skin could not be kept warm, "either the bowels or the glands of the mouth suffered."49
Reservations concerning such time-honored remedies as the antimonials and venesection were also now being expressed. Mann urged that the former not be used when the men were being sheltered from changeable weather intents, and Waterhouse pointed out that although "If a thick muscular part is inflamed, we can, at once, remove that inflammation, by taking off its tension, by bleedings," "if the mucous membrane, lining any internal cavity, more especially of the intestine, be inflamed, we cannot take off its tension by bleeding, without hazarding life."50
The Army`s physicians of the early nineteenth century did not often comment on their experiences in the field of surgery. Apparently little surgery was performed outside the areas of major military activity; in the 3d Military District during the entire war only two amputations and one operation for the correction of hydrocele were recorded. When surgery, such as the setting of broken bones, became necessary at posts where there was no surgeon, the procedure might well be done by someone without any training whatever. Mann was very much concerned about the quality of the surgery which Army surgeons were performing and urged that his colleagues pay particularly close attention to the work of the famous
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French military surgeon, Dominique Larrey.51
One surgeon, W. E. Horner, in the 9th Military District where most of the action of the War of 1812 took place, wrote a series of articles on the surgical cases he had encountered and the conclusions he had drawn from them. He noticed, for example, that buckshot wounds rarely proved dangerous unless a vital organ was hit and that bullet injuries which hit neither bones nor the "great cavities" also did not usually pose a great problem. He believed that the large size of English musket balls made amputation necessary when one of the "large cylindrical bones "was hit.52
Major amputations posed a number of further problems. The onset of hot weather greatly decreased the patient`s chances for survival; mortification quickly set in, muscles retracted to an unusual degree, and many patients died. There was still considerable debate over the advisability of postponing amputations. Horner believed that if a patient did not have to be moved, it might be wise not to inflict the shock of amputation upon a man still suffering from the shock resulting from his wounding. Indeed, if a limb had been torn off, something could be said, he maintained, in favor of letting nature take care of the situation, since "by her law if a bone protrudes beyond the limit of its covering by muscles and skin, she in a few weeks, reduces its length to the proper mark by the process ofexfoliation."53
Horner was familiar, however, with Larrey`s preference for immediate amputation and credited the French surgeon as well as his English colleagues with the preference Americans showed in favor of early operation, even when they were familiar with instances during the War of 1812 when the survival rate among those whose amputations were temporarily postponed was higher than that among those whose surgery was performed at the first possible moment.54
Among those undergoing amputation who were discussed by Horner was one patient who greatly puzzled him. This soldier underwent the excruciating procedure with complete serenity, "smoking tranquilly during the whole operation; his ease not seeming to be an affectation," while his leg was removed.55
Several physicians with experience gained in the War of 1812 criticized the plan developed for a military hospital by Tilton during the Revolution.(See Chapter 5.) Surgeon William Barton was vigorously opposed to Tilton`s design and, in a "treatise on various types of military hospitals, "ridiculed Tilton`s notion that earth floors and a center fireplace without a chimney would reduce the spread of disease. He maintained that wooden floors were entirely safe if kept clean and thickly covered with sand and added that he did "not think any plan was ever conceived, so fraught with mischief as this; and which certainly does not reflect either credit upon the inventor`s ingenuity or discernment." Barton was apparently unaware of the existence of Tilton-type huts at Brownville, New York, where the surgeon in charge was quite pleased with the design, and at least one other site, for he claimed that "not withstanding the elevated rank of Dr. Tilton during the war, his plan was never adopted by a single surgeon."56There is no evidence, however, that Tilton ever attempted during the War of 1812 to have such a hut constructed.
Mann`s experiences in the War of 1812 led to criticism of the Tilton plan which was milder than that of his outspoken colleague. He agreed that it was desirable that a hospital, particularly a temporary one, be only one story high, making proper sanitation easier and eliminating possible disturbance from footsteps overhead, but he disagreed with his superior on many other aspects of hospital design. Wood floors were warmer than those of earth, he, noted, and in hot
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weather tents were better than huts. The smoke which filled Tilton-style units aggravated coughs and chest problems, and unless the required lumber were standing in the immediate vicinity, obtaining logs needed for the Tilton units could be very expensive.57
As Mann envisioned it, a military hospital should have windows on the east and west and, "On the west, a closed passage should extend the length of the hospital 12 feet wide, into which the doors of the several wards open." This passage would shield the western windows from the summer heat. Within the building, each separate ward should be thirty feet by twenty-four feet in size and thus large enough to hold twenty patients, with ceilings at least eleven feet high. Since ventilation without drafts was of great importance, hospital windows should be double-sashed. Each ward would require the attention of two nurses, unless more were required to handle the cooking. Wards for patients with contagious diseases should contain fewer patients than other wards, surgical patients should be kept separate from those with fevers, and men with either venereal disease or scabies should be kept away from all others. There should also be a separate room where patients about to be admitted could be washed with tepid water and dressed in clean linen.58
Mann pointed out that while the medical staff of each army on the move should be prepared to set up a field hospital and to provide transportation to this facility for its patients, each permanent hospital should have its own separate staff. In the temporary hospital, instead of the customary bunks, Mann suggested the use of "canvas bed-bottoms, constructed with loops on the side, through which pass poles for their support. The bed-bottoms are supported by stakes drove into the earth with a fork on the top to support the poles, to which the bottoms are attached. These beds may be put up in a few minutes."59
Mann urged also the keeping of systematic hospital records concerning patients and prescriptions, but he pointed out that, except for the Burlington hospital in the winter of 1813-14, this was not generally done. Lovell, in his report of June 1817, went even further than Mann and urged that hospital surgeons and mates also keep careful records of weather and local climate;60 he would later, as head of the department, require this of them.
In his Medical Sketches which appeared in 1816, Mann discussed not only the problems of the individual military hospital but also those of the Army Medical Department as a whole. Since his opinions were generally well received by his colleagues, it is likely that they agreed with the emphasis he placed upon the need for preparing for the medical care o the nation`s soldiers before the outbreak of war and also with his plea for increased stature for the Army`s surgeons.61
Throughout the period from 1775 to 1818, the inability to plan a head on a long-range basis to meet the needs of the Army`s sick and wounded had forced the Medical Department to function in an inefficient and, too often, ineffectual manner, handicapped by a lack of supplies and housing and by surgeons who were to varying degrees unresponsive to discipline. In addition, innumerable opportunities to evaluate the effectiveness of various forms of treatment on a wholesale basis and thus to advance the state of the art of medicine were lost because of the lack of a permanent organization to plan and conduct such studies.
The lessons so painfully learned in two wars and a host of Indian skirmishes finally became too obvious to ignore. As the new nation expanded with great rapidity and Army units took up their duties increasingly far from Washington, an ever greater need
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arose to attract into the Army and train physicians qualified and willing to work in isolated areas on a permanent basis. To attract and supervise such a staff and to plan and coordinate not only the care of military patient but also the highly valuable studies Army surgeons would in the future conduct, a permanent central organization was necessary. The establishment of the Army Medical Department on a permanent basis in April 1818 was, therefore, a vital step toward making the best care possible available to all the sick and wounded of the United States Army.
