MILITARY MEDICINE DURING THE EIGHTEENTH AND NINETEENTH CENTURIES

MD0501
Chapter 2


LESSON ASSIGNMENT
LESSON 2 Military Medicine During the Eighteenth and Nineteenth Centuries.
LESSON ASSIGNMENT Paragraphs 2-1 through 2-25.
LESSON OBJECTIVES After completing this lesson, you should be able to:
   2-1. Identify major military and medical events associated with the American Revolutionary War, including the people associated with the "Hospital."
   2-2. Identify major military and medical events associated with the French Revolution and the Napoleonic Wars, including the accomplishments of Larrey.
   2-3. Identify major military and medical events associated with the American Civil War, including the accomplishments of Letterman.
   2-4. Identify major military and medical events associated with the Spanish-American War, including the Dodge Commission.

SUGGESTION After studying the assignment, complete the exercises at the end of this lesson. These exercises will help you to achieve the lesson objectives.


LESSON 2

MILITARY MEDICINE DURING THE EIGHTEENTH AND NINETEENTH CENTURIES

Section I. AMERICAN REVOLUTIONARY WAR


2-1. BEGINNING OF THE AMERICAN REVOLUTION

After the defeat of the French forces during the French and Indian War (1754--1763), Great Britain needed to tax the colonies in North America to produce additional income. The king also removed some local governors and increased British troop strength. These actions angered the colonists who had become use to governing themselves with minimum interference from Great Britain. Soon colonial politicians like Samuel Adams began to gather support for independence.
   a. In 1770, a British patrol defended itself from a mob, resulting in the death of several civilians (the Boston Massacre).
   b. In September 1774, the First Continental Congress assembled in Philadelphia to protest British acts.
   c. In April 1775, a British force met armed resistance from the colonial militia at Lexington and Concord.
   d. Alarmed at the armed conflict, the Second Continental Congress assembled in Philadelphia and established a united Continental Army. In June 1775, George Washington was appointed to be commander of the colonial forces.
   e. Later in June 1775, British forces attacked colonial forces on Breed's Hill and Bunker Hill near the Boston harbor. Dr. Joseph Warren, a Major General in the colonial militia, was killed in the battle. Thus the first general officer killed in action was a physician.

2-2. THE "HOSPITAL"


Washington wrote to Congress on 20 July 1775:

"I have made inquiry with respect to the establishment of the hospital and find it in a very unsettled condition. There is no principal director, or any subordination among the surgeons. Of consequence, disputes and contentions have arisen and must continue until it is reduced to some system."



In July 1775, the Congress established a "Hospital" (actually a medical department) in Massachusetts with a Director-General (chief physician of the Hospital), four surgeons, an apothecary (pharmacist), and nurses (usually wives or widows of military personnel).


"Hospital" Salaries:
..........Director-General ----- $4.00 per day
..........Surgeons ------------- $1.66 per day
..........Apothecary ---------- $1.66 per day
..........Nurses --------------- $2.00 per month



   a. Congress did not specify the relationship between the new hospital system responsible to the central government (Congress) and the existing regimental systems responsible to the state governments. Staff and command responsibilities for medical matters were left fragmented between the state governments and Congress, between the regimental medical staff and the Hospital, and between military and civilians (physicians were not commissioned).
   b. Benjamin Church, a London-trained physician and member of the Massachusetts Legislature, was appointed by Congress as the first Director-General. One of his innovations was instituting examinations for surgeons that did not have a medical degree or certificate (a type of quality assurance).
   c. The Congress appropriated insufficient funds for the general hospital and no money for the regimental hospitals. It further confused matters by eventually creating other departments (theaters of operation), each with its own general hospital. Congress said nothing about the relationship between the chief physicians of these hospitals and the Hospital's Director-General. Matters became more confused when a regimental hospital deployed with its regiment. Patients who were too ill to deploy with the regiment were usually sent to the nearest general hospital without notification and without adequate provision being made for their care.

2-3. THE ATTACK ON CANADA

In 1775, the Continental forces attacked Montreal and Quebec. The attack against Montreal was successful. In November, the Continental forces surrounded Quebec, but the siege was eventually abandoned because of an outbreak of smallpox and harsh winter weather. The Continental army retreated to New York in 1776. A hospital was established in New York under Dr. Jonathan Potts to treat the soldiers returning from Canada. His work led to the only Congressional resolution praising a physician during the war.


Excerpt from the Congressional resolution:
"The unremitting attention showed by Doctor Potts and the officers of the hospital to the sick and wounded soldiers under their care is proof not only of their humanity, but also of their zeal in the preservation of the health and lives of the gallant asserters of their country's cause. ... "
Potts only response was to comment, "My only concern is to preserve the health of the soldier and to tenderly nurse the sick." Pots died four years later, worn out by his work and his total devotion to the troops.



2-4. THE MEDICAL COMMAND

   a. Director-General Church had difficulties with the regimental surgeons. Regimental surgeons, appointed by the colonel of the regiment, wanted to keep their patients in the regimental hospitals, usually field expedient buildings. Church wanted the patients sent to the general hospital and did not give the regimental hospitals the supplies they required.
Director-General Church was found to be in treasonable correspondence with the British in Boston. In October 1775, Church was court-martialed and found guilty.


General John Sullivan, in a letter to Congress, complained that Church's regulations would prevent soldiers from reenlisting:
"They would rather die... under the care of physicians they were acquainted with than be removed from their friends under the care of physicians they never saw."



   b. Later that month, John Morgan of Philadelphia succeeded Church as the second Director-General. He had helped found the medical school at Philadelphia. Morgan never solved the command problems. He was not a tactful person and was removed from his post in 1777. One of his supporters was Benjamin Rush, a physician who signed the Declaration of Independence and published a book on preventive medicine in the military. In his book, Rush stressed that physicians had to convince line officers to implement their medical advice for it to be effective.


Benjamin Rush wrote in 1778:

"Consider that the principle study of an officer in time of war should be to save the blood of his men. If it be criminal to sacrifice thousands by termidity in battle, why sacrifice twice the number in a hospital by negligence? An attention to the health of your soldiers is absolutely necessary to form a great military character."



   c. William Shippen, who also helped found the Philadelphia medical school, became the third Director-General. Shippen, however, did not do much better at running the Hospital than had Morgan. He was accused of corruption and court-martialed. Although acquitted, he eventually resigned in early 1781.
   d. The drug purchase and issue problems began to be addressed by Congress when it appointed Andrew Craigie to be the first Apothecary-General. He began to issue drug chests to both the regimental surgeons and the general hospitals. Regimental commanders complained that the chests were inadequate.
   e. John Cochran became the fourth Director-General. He had been a regimental surgeon in the French and Indian War and was the first Director-General not to have a formal medical degree from Europe. Cochran remained Director-General for the remainder of the war.

2-5. THE BATTLE AGAINST SMALLPOX

Inoculation against smallpox was performed using live smallpox virus (Jenner had not yet developed his vaccination procedure using the cowpox virus). Inoculation could be dangerous. Since live viruses were used, the patient could contract smallpox and die. The patient could also infect others with smallpox.
   a. Inoculation had previously proven its effectiveness when it was used to control an outbreak of smallpox in Boston during the 1720s. At the beginning of the war, John Warren (brother to Joseph Warren) performed smallpox inoculations on new recruits when he served as a surgeon to a hospital in Boston.
   b. Director-General Morgan recommended to General Washington that troops be inoculated for smallpox. The Canadian campaign convinced Washington that inoculation was necessary and ordered that all Continental line troops be inoculated. This was the first time that an attempt had been made to inoculate an entire army. The results were successful. Inoculation reduced the death rate from smallpox from 160/1,000 to 3/1,000.


Washington wrote to Shippen from Valley Forge on 6 January 1777:
"Finding the smallpox to be spreading much and fearing that no precaution can prevent it from running through the whole of the Army, I have determined that the troops shall be inoculated. Should the disorder infect the Army in the natural way and rage with its usual virulence, we should have more to dread from it than from the sword of the enemy."



2-6. MILITARY MEDICINE DURING THE REVOLUTIONARY WAR

   a. Throughout the war, medical equipment, supplies, and drugs were in short supply. In addition, most regimental surgeons were not well trained, especially at the beginning of the war. Medical officers often set to work with only what they could carry in their pocket surgical kit and performed the only useful surgery they knew--amputation.
   b. Medical treatment facilities had to be moved as the Army was fighting and retreating. The field medical treatment facility was often in some local house to which the wounded were carried, dragged, or limped into on their own.
   c. Enlisted personnel were often assigned to help in the regimental hospitals. Rather than assigning personnel who could be trained to become efficient hospital personnel, commanders usually assigned enlisted personnel who were a burden to the unit and who were not suited for military life. (A hospital corps consisting of trained enlisted personnel would not be established until 1887.)
   d. The general hospitals became larger and better organized as the war went on. Dr. James Tilton, who eventually became Surgeon General during the War of 1812, believed that the large general hospital resulted in the spread of disease. He built smaller, well-ventilated hospitals ("Tilton's huts") which reduced the transmission of infection.
   e. Inspector General von Steuben published the first Army Regulations dealing with health care in 1778 and 1779. In them he stressed the duty of the regimental commander to preserve the health of his troops and the importance of cleanliness. He also gave the regimental surgeon authority to determine when a soldier had sufficiently recovered from his illness to resume his duties.


Excerpts from the first regulations published for an American force, written by von Steuben:

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

   "There is nothing which gains an officer the love of his soldier's more than his care of them under the distress of sickness: it is then that he has the power of exerting his humanity in providing them every comfortable necessary and making their situation as agreeable as possible."

   "When a soldier has been sick he must not be put on duty until he has recovered sufficient strength, of which the surgeon shall be the judge. The surgeons are to remain with their regiments, as well on a march as in camp, that in case of sudden accidents they may be at hand to apply the proper remedies." (Von Steuben, Regulation 5, 1778-1779)



   f. Cinchona bark (from which quinine was later obtained) was used with some success in treating malaria.
   g. No major advances in medicine or surgery came from the war, but smallpox control was a step forward. The war, which officially ended in September 1783 with the Treaty of Paris, still resulted in a considerable loss of life, mostly from disease.

Section II. NAPOLEONIC WARS

2-7. THE FRENCH REVOLUTION AND THE WAR OF THE FIRST COALITION


   a. Under the rule of King Louis XVI of France, there was much corruption in government, unjust taxation, oppression, and poverty. The French people were encouraged by the success of the American Revolution. Increasing public discontent in France exploded in 1789 in a successful attack on the Bastille, a notorious fortress used to hold political prisoners. During the next few years, there were royal attempts to placate the rebels, establish a constitutional monarchy, and ease taxes, but the efforts were not successful.
   b. The French turmoil was viewed as a threat to all of the monarchies in Europe. In 1792, Prussia, Austria, Great Britain, Spain, and Holland attacked France in the War of the First Coalition.
   c. In August 1792, mobs in Paris attacked the royal palace, arrested the King, and declared France to be a republic. Soon, however, radical elements took over the government and executed King Louis XVI, Queen Marie Antoinette, and many aristocrats and political leaders in what became known as the "Reign of Terror." French citizens were conscripted and sent to defend the new republic from the invading forces. The new troops were undisciplined, but ferocious fighters. Soon the invading Coalition armies were pushed back.

2-8. FRENCH MILITARY MEDICAL SERVICE

The war with Coalition forces resulted in a tremendous slaughter rate. Tactics of the time were massed musket and case shot with cannon rounds at close range followed by a bayonet charge.
   a. Much of the French military medical service had been destroyed during the revolution. The old regime had built a number of military hospitals on the northern frontier, but many were no longer usable. Those that were used were not sufficient for the large number of casualties that poured in, so nearby homes were used to billet the patients over the objections of the home owners.
   b. The medical command was divided between a physician-in-chief and a surgeon-in-chief. This split reflected the disciplinary split in civilian life. In the northern battles, the physician-in-chief was Jean Francois Coste and the surgeon-in-chief was Pierre Francois Percy. Both were career medical officers.


Percy had a fine grasp of the situation and the proper mind-set of a military surgeon:

"The art of healing men is a little like that of destroying them; timid actions gain nothing, and if victory often follows the audacity of brave soldiers, success also crowns the efforts of enterprising surgeons."



      (1) Physicians were still without a valid theory of disease, used polypharmacy prescriptions (many drugs in combination, often in excessive amounts), and used harmful procedures such as "bleed, purge, and sweat" to treat fevers.
      (2) No surgery was done on the battlefield; patients were simply hauled to the rear. Surgeons treated wounds by incising the wounds and fishing around with their fingers for the musket ball or fragment.
   c. As with other wars, it was disease, not wounds, that took the greatest toll on the military. Coste and his colleagues tried to follow the teaching of John Pringle and others on camp diseases and hospital sanitation, but without much success.

2-9. EVACUATION PROCEDURES

Sick and lightly-wounded soldiers were simply left on the battlefield to hide until the battle was over. The more seriously-wounded soldiers were evacuated by fellow soldiers to a collection point outside the battle area where the wounded soldiers stayed until they were loaded into an ambulance wagon and carried to a military hospital, usually located about three miles behind the army.
   a. The evacuation process resulted in the loss of healthy manpower since it might require six to eight soldiers to carry one wounded soldier, his weapon, and his equipment from the battlefield. Wounded soldiers were carried on the arms of three or four soldiers; on an improvised litter made of guns, branches, or coats; or by farmer's carts pressed into service.
   b. Large, cumbersome wagons were the only ambulances the French army had. The ambulances were of limited use since there was only one ambulance for every 20,000 soldiers and the ambulances stayed far from the battle.
   c. Due to the cumbersome method of evacuation, it took 24 to 36 hours for the wounded soldiers to reach medical treatment. This resulted in many deaths. Many wounded stayed on the battlefield for three or four days after a battle until they could be collected and evacuated.
   d. Percy, the French surgeon-in-chief, addressed the problem by organizing litter bearers to work on the battlefield to bring in the wounded. It was another French surgeon, Dominique Jean Larrey, who actually developed a system of rapid evacuation.


Percy was driven to try to develop a system of rapid evacuation because of what he observed:

   "In retreat before the enemy there is no more frightful a spectacle than the evacuation of mutilated soldiers on big wagons; each jolt brings the most piercing cries. They have to suffer from rain, from suffocating heat or freezing cold and often do not have aid of food of any sort. Death would be a favor and we have often heard them begging it as a gift from heaven." 1792, Percy (in Vess)



2-10. LARREY'S CONTRIBUTIONS

   a. Evacuation. In 1792, Larrey joined the French Army and served in northern France. Larrey, recognizing the need for rapid evacuation and for treatment on the battlefield, came up with a solution. He designed two types of "flying ambulances" to rapidly evacuate wounded soldiers from the battlefield to the hospital. The ambulances also carried first aid items which were used to treat casualties on the battlefield.
      (1) One type of "flying ambulance" was a small two-wheeled carriage drawn by two horses. It could transport two litter casualties and had iron handles for securing the casualties to the floor.
      (2) The second type was a four-wheeled carriage drawn by four horses. It had body springs for a more comfortable ride and could transport four casualties laid in a horizontal position.


Larrey, recognizing the need for forward evacuation and for immediate treatment, came up with a solution:

   "This suggested to me the idea of constructing an ambulance in such a manner that it might afford a ready conveyance for the wounded during battle. My proposition was accepted and I was authorized to construct a carriage, which I called the 'flying ambulance.' I had made two kinds of carriages. The small, with two wheels, drawn by two horses... had a folding door. The floor was movable and on it was placed a hair mattress. The floor had four iron handles through which the sashes of the soldiers were passed. Two patients could lie full length in them; to the sides were attached several pockets to receive articles necessary for the care of the sick."

   "The second kind had four wheels, the body hung on springs, and was drawn by four horses. The left side of the body opens almost its whole length, by means of two sliding doors, so as to permit the wounded to be laid in a horizontal position. Four men might lay with their legs slightly contracted."



   b. Surgery. Delayed amputation was the rule based on civilian practice. Military surgeons, however, soon noted that wounded soldiers did not do well with delayed surgery. The casualties bled more and had more pain. The soldier's muscles became rigid, making the amputation more difficult. Gangrene, sepsis, and death were more common in patients who were evacuated to the rear with untreated wounds. Larrey noted that when a patient was in neurogenic shock, the bleeding was less, the muscles were relaxed, the limb was numb from bruised nerves, and the amputation pain was much less. He further noted that converting the injury to a clean, debrided, dressed surgical wound made evacuation more comfortable and made infection less likely.
      (1) Based upon his observations, Larrey established new surgical guidelines. Immediate amputation was indicated if:
         (a) The limb was shattered or the joints smashed.
         (b) Small bones, joints, and nerves were all broken up.
         (c) Too much muscle tissue or major arteries were missing, even if the bone or joint was sound.
      (2) Larrey stopped the use of salves and ointments, had wounds washed only with water, did inverted cone procedures so that the flaps fell together, and bandaged the stump with new adhesive bandages so the wound could drain.
      (3) Larrey's surgical skill became so great that he could amputate a leg in one minute and an arm in 17 seconds. However, he gave much of the credit in saving lives to his flying ambulances which allowed wounds to be dressed on the battlefield and the casualties to be quickly evacuated. Without them, many soldiers would have died of hemorrhage.

2-11. NAPOLEON AND LARREY

   a. In 1795, the Reign of Terror ended when a new government (with the help of a 26-year-old French army officer named Napoleon Bonaparte) was established. France had defeated the Coalition forces in the north. Only Great Britain and Austria continued to fight in Italy. Napoleon was given command of the French forces fighting the Austrians in Italy. Larrey was assigned to Napoleon's forces.
      (1) With Napoleon's support, Larrey perfected the organization of his flying ambulances and outlined their missions and priorities. Their primary mission was to rescue casualties on the battlefield, administer first aid, and transport the casualties to the first line of hospitals. Their second mission was to remove the dead for burial.
      (2) The priority for treatment was determined by the casualties' injuries, with the more seriously injured being treated and evacuated first without regard for rank or distinction. This was the beginning of modern triage (sorting).
   b. After Napoleon defeated the Austrians in 1797, the French government sent Napoleon to Egypt to open a land route to challenge the British in India. While in Egypt, Larrey adapted to desert warfare by replacing his horse-drawn ambulances with camels which carried medical supplies and pannier litters for patient transport. Napoleon defeated the Egyptian forces, but was trapped by the English fleet. In August 1799, Napoleon left the Army in Egypt and returned secretly to France. Napoleon invited Larrey to go with him, but Larrey chose to stay with the army and his patients. During the campaign, many of the French troops died of bubonic plague, smallpox, and dysentery.
   c. After Napoleon returned to France, he established a new government with himself as leader. A Second Coalition was soon formed by Great Britain, Austria, and Russia to fight France. Napoleon formed a new army, smashed the Second Coalition, and forced Austria, Russia, and Great Britain to sign a peace treaty. This permitted the army in Egypt, including Larrey, to return to France. When Larrey returned, he was appointed by Napoleon as surgeon to the elite Consular (later Imperial) Guard.
   d. Great Britain, Austria, and Russia, again concerned with the growing power of France, formed a Third Coalition and again declared war on France. In 1804 Napoleon crowned himself Emperor Napoleon I and defeated the Third Coalition.


Larrey wrote:

   "To prevent the evil consequences of leaving soldiers who are severely wounded without assistance, we placed the ambulances as near as possible to the line of battle, and establish headquarters to which all the wounded who require delicate operations are collected to be operated on by expert surgeons."



      (1) Larrey placed the ambulances as near the line of battle as possible to make the time between injury and treatment as short as possible. Surgeon's mates and corpsmen evacuated the wounded to the forward ambulances. Larrey's objective was to treat the wounds, including performing amputations if needed, within 24 hours after the injury occurred.
      (2) Larrey also established headquarters staffed by expert surgeons to treat soldiers requiring delicate operations.
   e. In the Russian Campaign of 1809, Larrey's medical results were impressive with a high rate of soldiers being returned to duty and a significant reduction in the death rate. As a reward for his work, Napoleon made Larrey a baron of the Empire.


Larrey wrote:

   "To prevent the evil consequences of leaving soldiers who are severely wounded without assistance, we placed the ambulances as near as possible to the line of battle, and establish headquarters to which all the wounded who require delicate operations are collected to be operated on by expert surgeons."



   f. When Russia again caused problems for France, Napoleon raised an army and invaded Russia. Larrey went with the army, treating wounds and directing junior surgeons. He was always at the battle's edge, once performing 200 amputations in 24 hours. The French troops captured Moscow but, the Russians burned Moscow and forced the French troops to retreat. The Russian winter of 1812-1813 was one of the worst in years. Starving and suffering from epidemic typhus, diarrhea, dysentery, and frostbite, the French army fought a rear guard action. The army was short of supplies and ammunition and was constantly harassed by Russian troops. Of the original 600,000 troops, over 500,000 were killed, died of illness or exposure, were captured, or deserted.
   g. The English and allied armies crossed from Spain into France in 1814 and captured Paris. Napoleon abdicated his throne and went into exile on the isle of Elba. King Louis XVIII was placed on the throne of France and began to have the same problems as the old monarchy.


Larrey wrote:

Note: Louis XVII, born in 1785, was the titular King of France in exile until his death in 1795.



   h. In March 1815, Napoleon returned to France and the army came over to him. The King fled and Napoleon once again ruled France. Napoleon marched to face the reassembled Coalition armies, but was defeated at the Battle of Waterloo. Napoleon escaped, but was later captured and exiled to the island of St. Helena where he died in 1821.


Larrey wrote:

In his will, Napoleon left Larrey 100,000 francs with this simple sentence:

"He was the most courageous and virtuous man that I have ever known."



      (1) After the defeat at Waterloo, Larrey was captured by Prussian troops. Larrey's life was saved by a Prussian surgeon who recognized him and by the Prussian commander (Larrey had saved the life of the commander's son during a previous battle).
      (2) Larrey returned to the military hospital to teach and write. Later he was appointed surgeon at the French veteran's hospital. He published books on surgery, took care of the veterans of the Guard, and completed his memoirs. Larrey died in 1842 at the age of 76, just after returning from an inspection tour of French military hospitals in northern Africa.


Larrey wrote:

Larrey summed up his career and his life,

   "To perform a task as difficult as that of a military surgeon, I am convinced One must sacrifice oneself, perhaps entirely, to others, must scorn fortune and must maintain an absolute integrity."



2-12. ADVANCES IN FOOD PRESERVATION


Armies had to spend much of their time in obtaining food to eat. Napoleon knew that if the army could carry sufficient food, it would be more efficient. Unfortunately, most fresh food would spoil during a campaign. Preservation methods such as drying and smoking helped, but Napoleon wanted a better method. In 1795, the French Government offered a prize for developing a method of food preservation.
   a. After years of work, Nicholas Appert, a French chef and candy maker, developed a method of preserving soups, fruits, vegetables, and other food products by the process we now know as canning. His method involved packing the food into reinforced glass containers, heating the food by placing the containers into boiling water for various lengths of time, and immediately sealing the containers. In 1810, Appert claimed the prize.
   b. Appert did not know why his process worked (Louis Pasture eventually discover that the heat killed the microorganisms which caused food to spoil), but he used the prize money to open the first commercial cannery. Later he developed the bouillon tablet and perfected an autoclave.

Section III. AMERICAN CIVIL WAR

2-13. AMERICAN MILITARY MEDICINE BETWEEN THE REVOLUTION AND THE CIVIL WAR

   a. After the Treaty of Paris which officially ended the American Revolution, the United States reduced its military forces, including the medical portion of the army. Congress appointed physicians to the Army and Navy forces with a commission or warrant, but it was not the same as a line officer's commission. Physicians did not hold military rank, did not have the privileges that officers received, and were not permitted to give orders; however, they were subject to military discipline, including courts-martial. Edward Cutbush, who served aboard the frigate United States as a surgeon, convinced the captain to authorize vaccination against smallpox using Edward Jenner's method in 1799. Physicians served with distinction in military conflicts with the Barbary States in the first decade of the nineteenth century.
   b. During the War of 1812 with Great Britain, there were problems with diseases, lack of hygiene in camps, inadequate supplies system, and lack of centralized control over military medical facilities. Navy and Army surgeons again proved their devotion to duty, such as Dr. Usher Parsons who served aboard the Lawrence during the Battle of Lake Erie.
   c. In 1818, Secretary of War John C. Calhoun established a permanent medical department headed by Joseph Lovell, the first physician to be given the title of Surgeon General of the Army. Lovell introduced several reforms, established a mandatory examination for all military physicians, oversaw extensive research in disease prevention and other medical issues, and instituted efficient medical administration.
   d. In 1822, post surgeon William Beaumont treated a civilian, Alexis St. Martin, for a gunshot wound of the abdomen. St. Martin recovered but Beaumont was unable to close a gastric fistula. With St. Martin's permission, Beaumont conducted experiments through the opening. Beaumont's work proved to be of great importance in the study of the human digestive system.
   e. When Lovell died in office in 1836, Thomas Lawson became Surgeon General. During the Second Seminole War in Florida, Seventy-five percent of the deaths in the war were the result of disease, usually malaria. The war resulted in the first large-scale trials of quinine obtained from cinchona bark. Results showed that quinine, when given in amounts far greater than previously considered to be safe, was effective in helping patients recover. This changed the treatment of malaria throughout the United States, saving many lives.
   f. At the beginning of the Mexican-American War in 1846, the frigate Raritan, was ordered to Mexico. The crew's diet had consisted largely of salted meat and biscuits with occasional vegetables for the past two years. The crew was in poor health and the surgeon, Jonathan Foltz, urged its commander to take on citrus fruit to help prevent scurvy. (Although the cause of scurvy was not known and the effects of citrus fruit was not understood, the British Royal Navy instituted mandatory citrus issue shortly after the beginning of the century.) The captain ignored the suggestion and about 40 percent of its crew had to be replaced due to scurvy. Land forces suffered from malaria and other diseases. Of the approximately 100,000 soldiers engaged in the war, about 1,500 were killed by the enemy, but over 10,000 died from disease.
   g. In 1847, Congress gave medical officers true commissions and real (not assimilated) rank.

2-14. BEGINNING OF THE CIVIL WAR

The American Civil War was the first modern war with the widespread use of railroads, telegraph, trench warfare, breech loading rifles, rifled cannons, and massive logistical support. It also introduced the modern military medical system.
   a. First Battle of Bull Run. The first major battle of the Civil War following the secession and formation of the Confederate States of America was fought on 21 July 1861 near Manassas, Virginia, at a stream called Bull Run. Both forces were unprepared for a major battle and neither side had a functional medical service.
   b. King. The medical director with the Union forces was William King. Establishment of regimental hospitals was not adequately planned and supplies were insufficient. Ambulances were too few and not properly organized. Combat soldiers left the line to evacuate their wounded friends. When the Union army fled back to Washington, most of the Union wounded were captured. Some of the wounded lay on the battlefield for several days before they were evacuated.

2-15. THE MEDICAL DEPARTMENT AT THE BEGINNING OF THE WAR

The Medical Department, like the Army itself, was not prepared for war.
   a. Finley. Thomas Lawson, who had been Surgeon General for 25 years, died in 1861. His successor was Clement Finley, who was over 65 years old himself. Finley was bound by office routine and regulations and lacked experience in large scale medical operations.
   b. Tripler. The medical disaster at Bull Run led to many changes, including the assignment of Charles Tripler as the new medical director of the Army of the Potomac. He concentrated on the organization of regimental hospitals, procuring ambulances and training ambulance attendants, vaccinating soldiers against smallpox, and improving sanitation. Lack of trained hospital personnel, however, complicated his problems.
   c. Sanitary Commission. The United States Sanitary Commission, a private organization modeled after the English Sanitary Commission of the Crimean War, was formed with Doctor Henry Bellows as its president. The Commission provided food, medicine, and comfort to the troops; established convalescent and expedient field hospitals for soldiers; and provided nurses.
   d. Evacuation. There was no system for planned evacuation. It was still improvised for the most part. The surgeons stayed with their regiments and did what they could with limited supplies. The wounded soldiers knew they faced a great likelihood of a hasty, painful field amputation (although ether and chloroform were in use). The survivors were sent to hastily created collecting points and field hospitals. After the Seven Days Battle (Peninsular Campaign of April-July 1862), the ambulance system broke down, civilian quartermaster drivers became disorganized, and the wounded stacked-up awaiting evacuation. The Sanitary Commission headquarters handled much of the evacuation of the wounded from The Seven Days Battle.
   e. Hammond. After much political infighting, William Alexander Hammond was appointed Surgeon General in April 1862. Hammond was 34 years old and had been an army doctor for 10 years. When he was promoted to Surgeon General, he went from lieutenant colonel to brigadier general. Hammond brought a hard-driving vigor and faced many problems that prevented a coherent medical response. The Quartermaster Corps built the hospitals and owned the ambulances, the Subsistence Corps had control of all rations, and procurement regulations made it difficult to purchase medical supplies. Hammond made many major reforms to the Medical Department. He also appointed Jonathan Letterman to be the new medical director for the Army of the Potomac.


Larrey wrote:

Orders from Surgeon General Hammond:

   "(1) Satisfy yourself that medical supplies are in proper quantity. The time has passed when the excuse 'no supplies' will be accepted.
   (2) You will require all medical officers to be faithful and attentive in the discharge of their duties.
   3) You will tell the Quartermaster your necessities in regard to transportation.
   (4) You will arrange for the safe, effectual, comfortable and speedy transportation of the sick and wounded.
   (5) You will hire such physicians, nurses, etc. as you require.
   (6) You are authorized to call directly upon medical purveyors (supply officers), who will furnish everything you may ask for, regardless of supply tables or forms.
   (7) And now I commit to you the health, the comfort and the lives of thousands of our fellow soldiers who are fighting for the maintenance of their liberties."

(Surgeon General Hammond, 23 June 1862)



2-16. LETTERMAN'S CONTRIBUTIONS

   Letterman took over his new job in June 1862 and acted vigorously and quickly. Using the authority Hammond had given him, he got the sick and wounded from the Peninsular Campaign back to Washington. The Union forces were defeated at the Second Battle of Bull Run in August 1862 and Union medical support was again deficient. Thousands of wounded Union soldiers were left on the battlefield. The ambulance system did not work. Six days after the battle was over, some of the wounded still remained on the battlefield awaiting medical care and evacuation. Letterman realized the desperate need for reform of the medical system.


Letterman had a clear view of army medicine:
   "The leading idea, which should be kept constantly in view is to strengthen the hand of the Commanding General by keeping his army in the most vigorous health, thus rendering it, in the highest degree, efficient for enduring fatigue and privation, and for fighting."
(Surgeon General Hammond, 23 June 1862)



   a. Ambulances. Letterman revised the ambulance system using some of the techniques developed by Larrey. He established an ambulance corps trained in the most easy and expeditious method of putting men in and out of the ambulances and in placing and carrying casualties on stretchers. He ordered that the ambulances be provided with attendants at all times and be able to move at any moment. He used the light two-horse, two-wheel ambulances for bringing men from the field and the four-horse, four-wheel ambulances for carrying those already removed from the front lines farther to the rear. Letterman made it explicit that the use of ambulances was restricted to patient evacuation and to carrying medical supplies.



In Letterman's words:

   "The subject of the ambulances became, after the health of the troops, a matter of importance. No system had anywhere been devised for their management They were under the control of the Quartermaster and, as a natural consequence, little care was exercised over them. They could not be depended upon for efficient service in time of action or upon a march, and were too often used as if they had been made for the convenience of commanding officers. The system I devised was based upon the idea that they should not be under the immediate control of medical officers, whose duties, especially on the day of battle, would prevent any proper supervision; but that other officers appointed for that special purpose should have direct charge of the horses, harnesses, ambulances, etc., and yet under such regulations as would enable medical officers at all times to procure them with facility when needed for their legitimate purpose."

Published in General Orders. Note the use of command authority.
   "The Ambulance Corps will be organized with an officer in charge. He will inspect the ambulance. He will institute a drill in his Corps, instructing the men in the most easy and expeditious method of putting men in and out of the ambulances; placing them and carrying them on stretchers. He will be careful that the ambulances at all times are provided with attendants, that they may be able to move at any moment, using the light 2-horse (2-wheel) ambulances for bringing men from the field, and the 4-horse (4-wheel) ambulances for carrying those already offended further to the rear. The ambulance will be parked in the brigade, to be used on the requisition of the regimental medical officers for transporting the sick and procuring medical supplies, and for nothing else."



   b. Command. Although the officers of the ambulance corps were usually Quarter-master officers and the enlisted soldiers were detailed from the line for duty as litter bearers, Letterman decided that they were to be under the direct control of the medical director. He further ordered that casualties were to be removed from the battlefield only by ambulance corps personnel who were to be identified by the special insignia they wore. The principles used by Letterman, with a few modifications, are the same as those in use today.
   c. Antietam. The Battle of Antietam, fought in September 1862 near Sharpsburg, Maryland, was the first test of Letterman's new ambulance evacuation and treatment policies. The Union forces won the battle, but it was the bloodiest day of the Civil War with 25,000 Union and Confederate casualties.
      (1) Initial collecting points were established for first aid and wound dressing. Regimental surgeons sent their patients by forward ambulance to forward surgical hospitals where hasty amputations were carried out using the Petit screw tourniquet. Amputations were performed to prevent death from infection due to the wounds. Most casualties with penetrating chest or penetrating abdominal wounds died. Almost all head-wound casualties with penetrating cranial traumas died.
      (2) Field expedient hospitals were set-up in barns and other buildings. Letterman preferred the use of tent hospitals to keep the sick and wounded with the army. Also, the infection rate was lower in the open air tent hospitals than in the general hospitals.
      (3) When the soldiers were ready for further evacuation, they were evacuated by rail. Letterman was the first to introduce the massive use of ambulance trains, later widely copied abroad. Patients were moved by rail to the general hospitals, facilities with hundreds of beds where civilian men and women came to nurse the sick and wounded.
      d. Fredericksburg. At the Battle of Fredericksburg in December 1862, Letterman's evacuation system worked excellently. Twenty-four hours after the battle, all of the 9,000 wounded had been brought in, treated, and hospitalized.
      e. Supply Reform. Under General Ambrose Burnside, Letterman reorganized medical supply procedures with automatic resupply from the rear based on a fixed table of allowances.


Letterman said:
   "I desired to reduce the waste which took place when a 3-months supply was issued to regiments; to have a small amount given to them at one time and to have it replenished without difficulty, to avoid a multiplicity of accounts and yet preserve a proper degree of responsibility, and to have a fixed amount of transportation for carrying these supplies and used for no other purpose."



   f. Standardization of Care. Letterman organized his surgeons, assigned them to treatment facilities by ability from initial dressing stations and collecting points to teams of the most experienced surgeons in the tent hospitals. He standardized surgical care using the principles of triage and echeloned surgical care on the battlefield. Letterman also established a corps of medical inspectors to help carry out his reforms.


Excerpt from Letterman's instructions to his corps of medical inspectors (a cross between a preventive medicine officer and an Inspector General):

   "The duties of medical officers are not confined to prescribing drugs, it is also their duty, and of the highest importance, to preserve the health of those who are well."



   g. Data. Letterman also established a standard system of reports and forms to track supplies and provide morbidity and mortality data. This project resulted in the classic, massive six-volume Medical and Surgical History of the War of the Rebellion.

2-17. NURSES IN MILITARY HOSPITALS

   a. Congress passed an act providing for paid female nurses in August 1861. Dorthea Dix, a Boston school teacher known for her efforts to improve the care of the mentally ill, was appointed superintendent of the women nurses. She screened applicants at the Surgeon General's office much like Florence Nightingale during the Crimean War.
   b. In contrast to earlier wars, Civil War nurses in the hospital service actually provided health care such as bathing wounded and sick soldiers, dressing wounds, and administering medications as ordered by the surgeons. One Civil War nurse was Clara Barton who later founded the American Red Cross. Walt Whitman, the poet, served as a male nurse in the hospital wards of Washington, D.C.
   c. Confederate women started similar relief societies and staffed hospitals with female nurses.

2-18. DISEASE

   The major problem to both armies was disease. More troops died from disease than died of wounds. Diarrhea and dysentery were common in the crowded, unsanitary camps. Too often camps were pitched in swamps and other sites with poor drainage and with overcrowded tents. Poor discipline and filthy camp sites helped to spread disease. Measles, mumps, pneumonia, and typhoid flourished in the overcrowded camps. Quinine, when available, was often administered in huge quantities as a remedy for just about every disease. In addition, large quantities of alcohol and opium-based medications were used.

2-19. LATTER STAGES OF THE WAR

   a. Hospital Ship. The battles to control the Mississippi River resulted in much naval action. Red Rover, a captured river steamer that was refitted as a hospital ship by the Sanitary Commission, became the first American hospital ship to operate in support of fleet actions in hostile waters.
   b. Hammond. Surgeon General Hammond received objections to Letterman's ambulance system in which line personnel reported to medical personnel. He had also upset physicians by eliminating calomel, a mercury compound used by many physicians, from the drug list since it was causing more harm than good. With support from Secretary of War Stanton, Hammond was court-martialed for failure to perform his duties and dismissed from the service. (Hammond was later exonerated after the war.)
      (1) Colonel Joseph K. Barnes, a capable administrator, replaced Hammond and saw many of Hammond's ideas through to completion.
      (2) During his service, Hammond organized the collection of pathological specimens from surgeons operating in the various theaters of the war. Hammond's research eventually became the foundation for the Armed Forces Institute of Pathology.
   c. Gettysburg. In 1863, Confederate forces under General Robert E. Lee were defeated by Union forces under General George G. Meade in a series of battles near Gettysburg, Pennsylvania. Although Letterman was at Gettysburg, General Meade made his corps commanders leave their ambulance and supply trains behind. Due to Meade's failure to use Letterman's system, some of the wounded were on the battlefield for days before they were brought in.
   d. Letterman. Letterman left the Army in 1864 due to illness. He returned to California where he wrote Medical Recollections of the Army of the Potomac, an important book on army field medical care. Letterman's evacuation system was used army-wide before the end of the war and was credited with saving the lives of many thousands of soldiers during the war.
   e. Appomattox. In April 1865, Lee surrendered to Grant at Appomattox Court House, Virginia. The war officially came to a conclusion soon after.

Section IV. SPANISH-AMERICAN WAR

2-20. ADVANCES IN MILITARY MEDICINE


   a. Research in pathology showed that diseases had specific causes which could be investigated using microbiology and physiological chemistry. Louis Pasteur provided evidence for the germ theory of disease which was empirically tested by Joseph Lister in the development of antiseptic surgery. Researchers such as the German Robert Koch did much to evolve germ theory into modern bacteriology. European scientists discovered the causative agents of an impressive list of diseases, among them amebic dysentery, typhoid fever, malaria, cholera, and tetanus, all of which were threats to military effectiveness.
   b. Weaponry advanced with the development of high-velocity, small-bore carbines. At first, bullets from these new weapons were thought to contain explosives. Kocher, Longmore, and Otis believed that the force of the bullet striking a bone shattered the bone and produced bone and bullet fragments which caused extensive tissue damage. In the Chilean deployment (1891), Edward Rose Stitt became the first American military physician to actually treat a patient who had been injured by the new weapons and verified their theory.
   c. American medical schools were still behind European schools in many areas. In 1893, Surgeon General George Sternberg formed the Army Medical School for graduate programs. In 1896, the War Department ordered that all enlisted men were to be trained to carry litters and administer first aid. Surgeons trained company officers in litter drill and emergency care of the wounded so they could in turn train their men. Military surgeons performed a wider range of operations than ever before, to include abdominal surgery.


Surgeon General Sternberg once stated:
   "the principal reason for supporting an army in time of peace" was the maintenance of "an efficient organization... which will be ready for service in any emergency and serve as a nucleus for the larger army which will be required in case of war."



2-21. BEGINNING OF THE WAR

   a. Spain's heavy-handed colonial policies in Cuba resulted in armed insurrection that lasted for ten years. To force submission, Spanish troops stripped whole sections of the countryside agricultural products and killed workers. Disease and starvation resulted. American citizens, enraged by Spanish cruelty and inflamed by the "yellow journalism" of sensation-seeking newspapers, assisted the rebel forces with funds, supplies, and volunteers.
   b. In February 1898, the U.S. battleship Maine was destroyed by an explosion while anchored in Havana harbor with a loss of over 260 sailors. The 1898 investigation indicated that the Spanish government could have been responsible for the explosion. (In 1976, the Rickover board concluded that the explosion had resulted from a fire in the coal bunker which caused a detonation in the magazine.)    c. President William McKinley attempted to negotiate a peaceful settlement of the Cuban problem with Spain, but Spain refused to grant Cuba its independence. In April 1898, the United States and Spain went to war. Congress promised that the United States would not annex Cuba, but did not make this promise about other Spanish possessions.    d. The American military faced a Spanish army of over 175,000 regulars in Cuba, Puerto Rico, and the Philippines and another 150,000 in Spain. The greatest danger, however, proved to be disease within the United States.

2-22. MOBILIZATION

   a. The United States Army in 1898 was small and widely scattered. The regular Army was well-trained, but numbered only about 26,000 troops scattered across the country. The National Guard numbered about 100,000, but was deficient in training, discipline, and equipment. The plan for invading Cuba and Puerto Rico called for using Regular troops, National Guard troops, and Volunteer troops. Problems soon developed between the Regular and National Guard forces in commanding units and obtaining supplies.
   b. National Guard and Regular Army troops begin arriving at mobilization sites in New Orleans, Mobile, Tampa, and Chickamauga Park (Georgia) to prepare for the invasion of Cuba and Puerto Rico. Most National Guard troops were untrained, undisciplined groups of individuals, some still dressed in civilian clothes. Medical supplies and equipment were inadequate and were given low priority by the Quartermaster Corps who was responsible for shipment. Many regimental and division surgeons relied on relief agencies such as the Red Cross for resupply.
   c. Although standards of proper hygiene and sanitation were established by medical officers, the standards were not enforced by the line officers. Latrines were hard to dig and frequently overflowed due to heavy rains. Diseases such as typhoid fever, measles, and mumps developed rapidly at the mobilization sites within the United States. Surgeons compounded the problem by sometimes misdiagnosed typhoid fever as malaria.    d. A shortage of qualified nursing personnel resulted in infantrymen being detailed to perform ward duty, usually the worst soldiers. Their lack of basic personal hygiene helped spread disease throughout the camps. To overcome these inadequacies, professionally qualified female nurses were employed in military hospitals.
   e. Each volunteer regiment had its own hospital, usually lacking supplies and equipment. In May, Surgeon General Sternberg did away with such hospitals and replaced them with one 200-bed facility for each division. He also persuaded the Quartermaster Department to purchase and equip a hospital ship, the Relief.

2-23. MILITARY ACTIONS

   a. Philippines. The Navy's Asiatic Squadron under command of Commodore George Dewey sailed into Manila Harbor in the Philippines on 1 May. Within a few hours, Dewey destroyed the Spanish fleet. Dewey's victory increased the pressure to immediately invade Cuba.
   b. Invasion of Cuba. Toward the end of May, the Navy trapped the Spanish fleet in the Cuban harbor of Santiago. The Army was given the task of invading Cuba, but deployment was delayed due to lack of advance planning. Ships that could negotiate the Santiago coast were hard to find and many of the ships used were small, worn-out steamers. When the invasion force reached Cuba, there were not enough landing craft to off-load the ships. Horses and mules were thrown over the side and forced to swim to shore.
   c. End of the War. In early July, the city of Santiago was surrounded and the avenues of escape for the Spanish army were closed. The Spanish fleet was defeated when it tried to flee. Soon the Spanish forces in Santiago and throughout Cuba surrendered. The war, which is sometimes referred to as the "splendid little war," officially ended in December 1898. Possessions such as Puerto Rico, Guam, and the Philippines gave the United States responsibilities in the Caribbean and the Pacific.

2-24. MEDICAL FORCES IN CUBA

The American military actions met with surprising success. The American medical actions met with far less success.    a. Since medical requirements had been given low priority in the invasion, much of the needed medical supplies and equipment had been left behind. Fortunately, early contacts with Spanish forces were relatively bloodless.
   b. Letterman's system of evacuation was used as much as possible. Poor weather and inadequate roads hampered the use of wheeled vehicles and horse-drawn travoises were common in front line evacuation. Wagons were commandeered to evacuate patients.
   c. Aid stations and field hospitals had insufficient medical supplies on hand to adequately treat the wounded. Also, they were not prepared to provide medical treatment for the growing number of diseased patients that began to arrive. One of the primary diseases was yellow fever. The cause and transmittal vector of yellow fever were still unknown at this time.
   d. One new development that proved effective was the first aid packet that had been issued to all soldiers. The first aid packet contained antiseptic dressings and sterile bandages. Soldiers were able to dress wounds before they were treated by a physician, thus reducing chance of infection.
   e. Antiseptics prevented hospital gangrene and other hospital infections that caused so many deaths in previous wars. Amputations were rare.
   f. Although adequate supplies and food began to flow again after the surrender of Spanish forces, most of the American soldiers became ill with malaria, typhoid, or dysentery.
   g. Statistics showed that in the four months of combat operations, only 380 men were killed in action. Unfortunately, between 1 May 1898 and 30 April 1899, over 5,000 American soldiers died of disease, most without leaving the United States.

2-25. RESULTS OF THE WAR

The Spanish-American War had great effect upon military medicine. The alarming rate of death from disease during mobilization caused a reevaluation of the military medical situation.
   a. Because of the high rate of typhoid fever incurred at the mobilization camps, The Surgeon General, in an unprecedented move, established the Typhoid Board to investigate the cause of the epidemic and make recommendations. This board, headed by Major Walter Reed with Major Victor Vaughan and Edwin Shakespeare, began in Aug 1898. Theirs was the first of many in a series of medical boards that would be appointed in the decades to come to investigate the diseases that threaten the army. The Board found that more than 90 percent of the volunteer regiments developed typhoid fever within eight weeks after going into camp. The board members inspected all the major camp sites with regard to sanitation, tent placement, and conditions in general hospitals. They interviewed medical officers, verified camp records, and traced each soldier through every hospital, both military and civilian, that cared for him. The Board found poor sanitation practices in the ranks. It also found that medical officers failed to recognize typhoid fever. Many did not have the experience or knowledge to accurately diagnose the disease. Additionally, it was found that in some cases the disease was misdiagnosed as typho-malarial fever to avoid an admission of the existence of typhoid fever. The experience with the Seventh Army Corps, encamped in Florida, was illustrative of the diagnostic situation. Corps surgeons would not admit that there was an epidemic of typhoid fever among the troops. The diagnosis was important to the Army surgeons professionally because typhoid was a preventable disease and, if the camps had typhoid epidemics, the implication was that the medical officers were not doing their jobs.
   b. In February 1899, President McKinley formed the Dodge Commission. The commission recommended improvements such as stockpiling medical supplies, giving medical personnel control over the transportation of medical supplies, having more trained doctors and a reserve of trained nurses, reducing "red tape" that hampered the medical forces, federal examinations of all medical officers, better field training for National Guard troops, and the enlargement and reorganization of the Quartermaster and Medical bureaus.


President McKinley, commenting on the establishment of the Dodge Commission, expressed the view that:
"The people of the country are entitled to know whether or not the citizens who so promptly responded to the call of duty have been neglected or maltreated by the Government to which they so willingly gave their services. If there have been wrongs committed, the wrongdoers must not escape conviction and punishment."



   c. In 1899, Ronald Ross of the Indian Medical Service proved that the mosquito transmitted malaria to humans. This discovery would have a great impact on future military medicine.


EXERCISES: LESSON 2


INSTRUCTIONS.
The following exercises are to be completed by writing the lettered response that best answers the question or best completes the incomplete statement or by writing the answer on paper that you provide. After you have completed all the exercises, turn to "Solutions to Exercises" at the end of the lesson and check your answers.



1. Patients in a regimental hospital who were too ill to deploy when the regiment left the garrison would be transferred to:

   a. A civilian hospital.
   b. A general hospital.
   c. Another regimental hospital which was not being deployed.

2. Which of the following performed smallpox inoculations on new recruits in Boston during the beginning of the war?

   a. Jonathan Potts
   b. Benjamin Rush.
   c. John Warren.
   d. Joseph Warren.

3. Which of the following served as the third chief physician of the Hospital? Hint: He resigned after being acquitted at a court-martial.)
   a. Benjamin Church.
   b. John Cochran.
   c. John Morgan.
   d. William Shippen.

4. The attack on Quebec by Continental soldiers was defeated in part due to an outbreak of:

   a. Malaria.
   b. Smallpox.
   c. Syphilis.
   d. Typhus.

5. The first major use of vaccination against smallpox in the American military using Edward Jenner's procedure occurred:

   a. During the American Revolution in 1779.
   b. During the Whiskey Rebellion in 1794.
   c. During the Mediterranean operations in 1799.
   d. During the War of 1812.
   e. Immediately after the Spanish-American War of 1898.

6. Congress passed legislation giving medical officers in the army true commissions and real rank as op-posed to assimilated rank in:

   a. 1785.
   b. 1798.
   c. 1814.
   d. 1847.

7. What medical information was obtained during the Second Seminole War in Florida?

   a. Large doses of quinine were needed to treat malaria.
   b. The doses of quinine used by the military to treat malaria were too large, but quinine was effective if used in small amounts.
   c. Quinine proved to be more effective against diarrhea than against malaria.

8. Who developed the "flying ambulances" used by the French military in the early nineteenth century?

9. Which of the following statements is/are true concerning Larrey?

   a. He favored delayed amputation rather than immediate amputation if the joint was smashed.
   b. He stopped the use of salves and ointments in cleaning wounds.
   c. He established treatment priorities based upon the casualty's rank.
   d. Responses "a" and "b" above are true.
   e. Responses "a," "b," and "c" above are true.

10. Which of the following describes a major contribution by Nicholas Appert?

   a. He developed a method of preserving food by canning using glass jars.
   b. He developed a vaccine for smallpox.
   c. He developed an improved method of evacuation used during the French invasion of Russia.
   d. He developed the first practical French military uniform.

11. In the Mexican-American War (1846-1848), scurvy became a significant problem for the American Navy blockade off the coast of Mexico. Although the cause of scurvy was not understood, the British Navy had known for about a century that scurvy could be treated using:

   a. Cinchona bark.
   b. Citrus fruits.
   c. Heavily salted meat.
   d. Penicillin.

12. Which one of the following was NOT a principle of the Letterman evacuation system?

   a. The command and control of the entire medical operation was performed by the tactical commander in the field.
   b. The most qualified and carefully certified surgeons were assigned to medical treatment facilities in the division rear rather than to forward medical treatment facilities.
   c. The transportation of patients was performed in vehicles dedicated to that purpose with trained personnel assigned to them.
   d. Regimental surgeons provided only essential care before sending the patients to surgical hospitals farther to the rear.

13. During the Chilean deployment (1891), Edward Stitt became the first American military physician to study:

   a. Wounds caused by high-velocity, small-bore carbines.
   b. Wounds caused by low-velocity, large-bore carbines.
   c. The relationship between water consumption and cold injuries.
   d. The relationship between water consumption and heat injuries.

14. A hospital corps consisting of trained enlisted personnel was established in:

   a. 1775.
   b. 1812.
   c. 1862.
   d. 1887.

15. Which of the following statements is/are true concerning casualties during the American Civil War?
   a. Head wounds with penetrating cranial trauma were usually fatal.
   b. Penetrating chest wounds caused by a minie ball were usually fatal.
   c. Penetrating abdominal wounds caused by a minie ball were usually fatal.
   d. All of the above are true.

16. During the Spanish-American War, Surgeon General Sternberg persuaded the Quartermaster Department to purchase and equip a hospital ship called the:

   a. Lawrence.
   b. Maine.
   c. Relief.
   d. Red Rover.


SOLUTIONS TO EXERCISES: LESSON 2.



   1. b (para 2-2c)

   2. c (para 2-5a)

   3. d (para 2-4c)

   4. b (para 2-3)

   5. c (para 2-13a)

   6. d (para 2-13g)

   7. a (para 2-13e)

   8. Dominique Jean Larrey (paras 2-9d, 2-10a)

   9. b (paras 2-10b(1), (2), 2-11a(2))

   10. a (para 2-12)

   11. b (para 2-13f)

   12. a (paras 2-16b, a, c(1))

   13. a (para 2-20b)

   14. d (2-6c(1))

   15. d (2-16c(1))

   16. c (para 2-22e)