C (4:49)

Thanks for having me.

B (4:50)

It amazes me constantly that men choose to fight wars in any age, but back in the days of musket and sword, things were getting very gnarly. Let's talk about the litany of injuries that were encountered, typically by army surgeons, and how they would have addressed them.

C (5:07)

Sure, probably more common then meeting a pointy thing. A sword or a bayonet was getting shot, and the musket balls of the day were large relative to modern bullets and much lower velocity, so they break your bones differently. You'll still end up with a broken bone if it tears through your flesh into a bone, but the cracking is a little different. There is often less damage to arteries, although their ability to treat things was so much lower than ours today that you are more likely to die from an infection or blood loss than you are today. They don't really have tourniquets, they don't have pressure bandages. They know who's not bleeding, but that's about it for frontline care.

B (5:56)

Who are the surgeons? Skilled technicians, surely, but not accorded any professional title. How did they Train. How did they become who they were?

C (6:03)

I wouldn't say they were really skilled because due to the risks of infection, most physicians actually don't perform surgery at this time. Cutting into somebody, the cut wouldn't kill them, but the subsequent infection that was almost guaranteed may well kill them. So most doctors have not performed any surgery in their career other than maybe lancing a boil to let some pus out of a little surface pocket. But major surgeries were extremely rare. They tried not to go into the trunk and the abdomen because infection there can't be solved with an amputation. If you have a bad infection in your leg or your arm, they can amputate above that to get rid of the infection. But the medical training is largely by apprenticeship. You would apprentice for three, maybe four years. If you hadn't gone to college, you would apprentice about twice as long. And so it was see one, do one. Congratulations, you're a doctor.

B (7:06)

Okay, but really backing up, I have to say. So is it the total lack of science, any kind of context, that a surgeon would be in a field hospital? And that's what we're talking about here, right? This doesn't happen elsewhere. This is. Whenever there's a battle, this is happening. They've seen it a lot, the older guys, I suppose. Do they not have any sense that infection is coming from somewhere? I mean, obviously it is, right? The gangrene, everything is happening because of this wound. And I've always wondered about this in a very basic way. Like, did they not do one and one is two here?

C (7:37)

They have a theory of miasmas, where some agent is moved somehow from person A or place A to person B. So if you live near a swamp, you are more likely to get sick. Is that because the swamp smells yucky? Maybe. They don't think of mosquitoes, they don't think of germs because the germs are microscopic and they don't have the tools to see that. There are some microscopes, but even your ordinary physician does not have one, probably has not used one. They don't know what's causing this. There are guys in the revolution who are, as you were hinting, saying, you know, if I've got a bunch of sick guys and a bunch of healthy guys sleeping next to them, the sick rate of the healthy guys goes up. The disease is spreading person to person. I don't know exactly how that's happening, but I know it's happening. You have some of this empirical observation, not direct line of dots to connect. And this plays through in some of the preventive medicine. So they know that if your latrines are near your kitchen and both of those are near your sleeping tents, more guys get sick. They. Yeah, there are so many factors that confound this. They don't have A, if X plus Y, then Z with, you know, 10% increase or 2% decrease. But they can very clearly understand that if you put your latrines near your kitchen, if you slaughter your animals, because a lot of the meat supply is coming in on the hoof. If you slaughter your animals near the latrines, you get more people sick. I don't know exactly why. I don't know exactly how many, but this is bad. Don't do this.

B (9:24)

The latrines of War, episode 600 of American history hit. The absence of anesthesia, obviously, is going on. I mean, let's put this in context. What we're talking. Talking about. Germ theory comes along in, like, 1850s and 60s, officially. I'm sure there's lots of discussion of it earlier than that in conferences and so forth. But really, we're about 75 years away from the great leap forward due to many different factors. But we're also far away from anesthesia. How is it until the 19th century, really, that there's any way to do this kind of surgery without that?

C (9:58)

We are about 75 years ahead of anesthesia. We are 50 years ahead of stethoscopes. There's no imaging technology other than cutting into the body to look for the musket ball and dirt and fabric that gets carried in. The main trick to surgery, you could give somebody some rum ahead of time. You could give them a piece of leather to bite down on so they don't grind their teeth and actually break their teeth from clenching their jaw so hard. The old story about biting a bullet is actually a myth. The lead is too hard. You wouldn't break your teeth if you really bit down that hard. But the trick to effective surgery is fast surgery. The fastest surgeons at the time could have a leg off in under 10 seconds.

B (10:44)

Wow. Really?

C (10:45)

That is. You know, if I have to have an amputation, I don't want it that fast. But that was what worked then. And they would then go in and tie off or cauterize, heat seal, basically the blood vessels. Yeah, the amputation worked, but they don't want you to bleed out after that.

B (11:00)

Yeah. I mean, we've seen the movies. I mean, it's this horrible show. The whole thing is butchery is what's going on.

C (11:06)

Movies don't give you the Smell either.

B (11:08)

Yes, exactly. Thankfully, these are aprons covered in blood. You talked about the injuries and surprising already, the cracking of bones, which I don't. I didn't think of. I think of a musket ball passing through soft flesh and residing in there because it wasn't going that fast, and then how they're going to get it out and all that kind of thing. Talk to me about the general treatment of these injuries, what they are and how they do it.

C (11:32)

They would know where the entrance wound was and if there is no exit wound, they would enlarge the entrance hole to go in and see where the ball ended up. Because if it hits something, it can change trajectory and move sideways. They had basically metal rods that they would stick in, as they called them, probes, and they probed with them to feel for the musket ball. They would then tweezer out the ball and ideally any clods of dirt, any pieces of fabric. They don't know what's causing infections, but they know foreign bodies are foreign and shouldn't be in the human body. And then they would reuse these same tools unwashed on the next patient. So they are removing some things that cause infection and then they are moving other things that cause infection around. So they don't have the science for this.

B (12:24)

So men are being shot, of course. They're also being butted, you know, in hand to hand combat. They're getting blunt force. The bayonets, as you mentioned, are stab wounds, which, yeah, I'm sure they're not as deep always as we think of them being, but they could go all the way through, I suppose. Tomahawks. In other ages, certain French and Indian war was a big deal. But also crush injuries. Right. Overturned wagons and so forth, collapsing horses, just breaking legs. All of this is the chaos of war, of course, but presenting special challenges to those surgeons in that time.

C (12:55)

Yes. And they would be using the same things for those injuries. And I'll ask you to think of an injury and a wound as a little different. A wound is military cause, whereas getting your leg run over by a wagon is an injury. They would have probably seen that in civilian life. Somebody would have had their foot stepped on by a horse. So broken bones. They would have seen all the diseases of civilian life, which are the same in the military environment because the diseases don't care whether you're wearing a uniform or wearing certain clothes. But it's the battlefield trauma that they really have not seen in civil life because they're not doing surgery.

B (13:35)

And increasingly, cannon fire Becomes a factor. Right? I mean, just from the burns alone.

C (13:40)

Cannon fire is something you really don't see in civilian life. It is relatively uncommon in the American Revolution. There are very few assaults on a fort. There's relatively few horses to haul cannon around on the battlefield. So there's a little less artillery than you see even in Napoleonic wars. But the causative agents, you know, the grapeshot would be about the size of a musket ball, so it would inflict similar wounds, Although quite likely two or three of them would hit you. So multiple trauma. If a cannonball hit you, it would tear off a limb right by itself. There are stories of people looking at a cannonball rolling across a field because it has slowed down enough, and they run out and try and stop it with their foot, kind of like a soccer ball, but it's still going fast enough that it just takes their foot off right at the ankle. And their buddies are looking at them like, oh, my gosh, I didn't think of that either. But now Fred is footless.

B (14:39)

Add to that whole list that we've just done the standard illnesses of human beings in nature, you know, and having all the things that go on between people, it's quite an overwhelming amount of work. When does the Continental army get an official medical branch?

C (14:55)

That's a straightforward question with more than one answer. The Massachusetts and New England militia that have turned up outside Boston have surgeons as part of their regiments because they want medical support. When they go to war, they want medical support. This is part of the British military background. Since doctors get identified as a specialty in July of 1775. The Continental Congress says that's great, but we need more than just the doctors with the units, because if the unit needs to move from. Away from Boston because the British have moved, they would need to leave the sick and wounded behind or it's going to slow their march. So the medical department they set up, they call it N hospital. That's just the period term they use, is as much to let the rest of the army work smoothly and respond to military necessity as it is to take better care of the soldiers. They want to take better care of the soldiers. They don't necessarily have that just because medicine is as primitive wherever it's practiced, whether it's in a tent or in a barn or in a purpose built hospital.

B (16:09)

Okay, so it's really a logistical decision. And it's early on, surprisingly early. On July 27, I have 1775, which is, you know, not even Declaration of Independence time. Six weeks after the army was established is when that medical branch was instated, right?

C (16:24)

Yes. And people are thinking about that even earlier the day after he arrives in Cambridge, Massachusetts. George Washington says the smallpox isolation hospital is off limits. Do not go see your buddies or your family members if they are in the smallpox hospital. He's very worried about disease, especially smallpox, spreading back to the army.

B (16:45)

Yeah, exactly. I mean that's harkens back to what I was saying before. It's a miracle to me that people haven't figured this out at this point because plagues have been going on for centuries, of course, and the big ones making life absolutely miserable in the cities in the summers. It all happens pretty quickly in the next century. But this, they're still already working on it. Who are the authorities in charge? The name Dr. Benjamin Church comes to mind.

C (17:09)

Benjamin Church was a prominent physician in Boston who had been practicing there for I think a couple of decades. So established and prosperous because you don't prosper as a doctor unless you have a reputation in those days because your ability to cure people is no better than anybody else's. So you had to be respectable and a gentleman. Church is a member of the Sons of Liberty, but he's also interestingly in correspondence with the British governor and then the British general in Boston. So he's playing both sides of the street. He takes charge as the first surgeon general, we would now term it, of the Continental Army. But he's in contact with the British and giving them, we now know, information about what the patriots were thinking of doing. And when they find out that he is a double agent because they knew he was writing to family members still in Boston, but they didn't know that he was providing the British information. They give him the choice of going into exile. He says, yes, please don't try me and embarrass my whole family. And he goes off on a ship and the ship is lost at sea. So we don't know where he is, where he went down, but he disappeared in I think 1776. But the heads of the medical department are some of the elite doctors of the time. They're often university trained and have gone to Europe and gotten a second medical degree in Edinburgh or London or Paris and then come back to the US A couple of them have helped set up medical schools in Boston and Philadelphia. So the guys at the top are the best trained on paper. Again, this is not affecting their patients outcomes, but they are well trained, they are socially prestigious. Then there's a sort of a pyramid where the doctors at the hospitals are better trained again on paper. And the doctors with the infantry regiments, the artillery regiments, they are country doctors who have probably apprenticed are often locally known because these regiments, certainly the militia regiments, are raised in a particular place and would take the doctor from their town with them. He is one of the people. You also find doctors who are serving as officers because they are socially prominent and prestigious in the area. So they become an officer and some of them are patriotic and serve as private soldiers at least for a while and then will work for a while in a hospital and then go back to be civil life and come back. It's much more fluid than things are today.

B (20:07)

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C (22:09)

Smallpox is a huge problem. It is a problem in the camps. For instance, camp at Valley Forge. It was a real problem for the expedition that tried to capture Montreal and Quebec and make Canada part of the United States. Probably the majority of troops on that campaign were sick with smallpox, at least for a while, and hundreds of them died. And that's in the winter of 75, 76 you mentioned 77. Washington has this data behind him. He knows that that expedition suffered catastrophically from disease. He knows that there is a smallpox outbreak in North America. So that if he moves his army around and they're unprotected from smallpox, they are likely to either spread smallpox to the civilian population, which is going to make the States unhappy and the civilians unhappy, or they're going to get smallpox from the civilian population. After a couple of years in command, he says it's now a 5149 proposition and I will order inoculation of troops. Vaccination is the modern term. It's actually introduced about 20 years after the Revolutionary War. And smallpox is the only disease they can do this for. But they know that smallpox spreads person to person. And if you take the scab or pus, literally pus from the smallpox patient, poke a hole in somebody who's currently healthy and smear that pus in them, they will get a mild case of the disease. So what they called wild smallpox had a death rate between 3% fatality and 30% fatality rate, whereas in a the inoculation death rate was 1% or less. So a lot of people wanted to be inoculated. Other people said no, that is still a risk and I don't want to take that risk. I will roll the dice that I, on my isolated farm in the backwoods, I'm not going to encounter that disease. So I'm just going to take my chances that way. And other people said no, it is contrary to God's will. We are messing with a God who is actively engaged on this earth.

B (24:21)

I'm sure they had anti vaxxers in those days for sure.

C (24:24)

It was illegal in some places. Yes, and this is interesting. Washington was very good at listening to the Continental Congress on this. He, as best I can tell, ignored local laws and in some cases state law about not inoculating.

B (24:40)

It strikes me that this sounds a lot worse for the Americans, for the Continental army than it does for the British. Were the British more systematically inoculating their troops? And in general they had to have had a much better system for care.

C (24:53)

British troops have come from a more densely populated country. They have come through cities to embark for North America. So they've gone through London or they've gone through Liverpool or Bristol. So they have been exposed to more diseases. If they're going to get sick. They've already gotten sick. The thing that they haven't experienced much is malaria, which is endemic in the American south, starts in the summer and continues into the fall with mosquitoes. You get malaria spreading. So the British suffer from malaria. The Americans suffer much more from smallpox. Because our population density is so low, many people have never been to a city of more than 5,000 people. And you're just not going to encounter the range of diseases we see that in the world up to the early 20th century is that people from rural areas get sick if they join the military, much higher rate than city slickers.

B (25:54)

I mean, add to that, you're saying we've got smallpox, we've got malaria, dysentery, typhus. I mean, the list in these days is amazing what an ordinary citizen encounters, never mind a soldier in the field. Add to this then, for the surgeon's point view, the infection of the wounds which are treated with such radical measures as bloodletting, blistering, purging. I mean, the names alone are gruesome. Never mind what this patient has to go through. How did they approach dealing with the wound itself and trying to control gangrene?

C (26:28)

If gangrene develops, they might well reoperate. But amputation was the best way to handle gangrene because you once it started, they didn't really have anything medically to treat it. So a lot of diseases were treated surgically by amputating above the infection. They don't understand that it's an infection, but they know that as it moves up closer to the heart, it's more and more likely to kill you.

B (26:55)

They did understand the danger of the latrines. They didn't understand why they were dangerous, but seemed to be more infection over there and disease as well. And so measures were taken for that. At some point, like with everything in the revolution, there was so much communication with Congress saying, please, we need more help. Was the Congress responsive to this as they understood the situation better?

C (27:17)

The Congress passes a number of laws to try and reorganize the medical department, and that is not particularly successful. There is a shortage of practitioners. So there's maybe 3,500 people who claimed to be a doctor in the colonies, not all of whom will serve in the war, most of whom will serve for at least some time in the war. But you don't have nurses, you don't have veterinarians. You don't have any of the people that we expect now to augment the doctor. The Congress says, hey, you can have this amount of money to buy medical supplies, which is fine, except that you have the inflation that eats away at all continental money. And there's just a real shortage of medical supplies to buy with any kind of money. We imported medical supplies. We imported medical equipment, which in those days meant surgical kits, basically from Europe. And the British blockade cut those off, so prices went up. This is, you know, basic economics. They are going out and trying to find bushes and leaves and roots that they can use as medicine. But there are surgeons who appeal to the people for lint and bed sheets and strawberries to take care of the wounded. With whatever success, they get straw and sheets easier. But taking things apart to make lint for bandages, that's a lot more time consuming.

B (28:47)

We haven't even talked about how the doctors are affected, of course, by being around so much infection and disease. They must catch all sorts of things and have a very high death rate.

C (28:57)

The numbers are imprecise. All numbers are imprecise for this time. But yes, as best we can tell, the doctors died at a higher rate than combat arms officers. So the infantry and the artillery and cavalry, because they're just not fighting that much, your chances of dying were, as you said, 10 to 1 from disease over battle. The doctors are around those diseases day in and day out, and they prove their patriotism, even though they're not considered officers and eligible for uniforms from the quartermaster and such until late in the war. But they are doing their best for their fellow Americans.

B (29:35)

Sanders, as an army historian, I mean, so much of the Continental Army's experience in war was about learning how to even have an army. Never mind then, you know, all the accoutrement, all the systems that have to go into supplying that thing. I mean, Washington, of course, is famously more skilled at that than anyone else. By the time we get to the end of the war, how much of a system is medical practice then going to be developed? Or does it just die off like the army does? I mean, that's kind of how it works in the United States for a long time.

C (30:08)

They haven't learned really anything during the war about better treatment of a disease. They have learned a bit about better prevention of disease. Again, keeping your latrines away from your kitchens and your tents. They have no more science behind this. And then when the army is pretty much abolished in 1783, there is a doctor kept on staff to treat the. I think it was 80 soldiers who formed the. The whole of the US defense establishment in 1784 or so. But they're with only one guy. There's no need for an organizational structure, and they absolutely abolished that until there's a need for it in the War of 1812.

B (30:56)

It's one of the biggest takeaways I've had from posting this series. How such a fact of life was that the military was not supposed to be. The federal military was not supposed to be a big presence in our life. So all the things that went into supporting it certainly all went away with it every time a war stopped. And then we had to find our way back to those systems when it was necessary, which I guess accounts for a lot of the chaos that we think of in the Civil War as they're still trying to figure this thing out.

C (31:22)

Absolutely. They know essentially how to treat a patient that's the same in civilian life as in the military. But the civilian doctor would be there to see the patient from day one until recovery, whereas the military had one doctor would handle him early and then move the patient somewhere to the rear. And somebody has to be in charge of that. And there has to be another facility for them to be treated partway to the rear. And if they get better, then they go forward. But if they don't get better, then they go again further to the rear. So the organizational structure is different, civilian and military. Now we kind of have a system where you're in maybe in an ICU and then you step down to a medical surgical bed and then you go off to a rehabilitation center. So now we kind of have that idea in civilian medicine, but that largely comes out of the military.

B (32:16)

Well, Dr. Sanders Marvel is the senior historian at the Army Medical Department center of History and Heritage. It's quite a title there. He's been working on army medical topics for almost 20 years. How can people find out more about what you do and the history that we're talking about?

C (32:30)

Well, the Army Medical Department center of History and Heritage and yes, that is a long name. We do have a website to save people the typing trouble. It is Achh. Army Mil. Well, there you go.

B (32:42)

Not only do we have a better medical practice, we also have a website. Fantastic. Thank you very much, Sanders. Nice to meet you. Appreciate you being on the show.

C (32:50)

Hey, happy to do it.

B (32:57)

Thanks for listening to this episode of American History Hit. As you've made it this far, why not like and follow us wherever you get your podcasts? American History Hit. A podcast from History Hit.

A (33:15)

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