Monday, December 5, 2011

Echoes of Navy Medicine's Past: Loblollies and Mess Decks

Part I: Loblollies and Messdecks (1775-1860)
By Jan K. Herman and Mr. Grog

Where there’s conflict there is always the need for medical care. The first shots of the American Revolution fired at Lexington and Concord on 19 April 1775 marked both the birth of a nation and the Continental Army. However, it was the British blockade of the American coast and the need to break that blockade that spawned the Continental Navy and Navy Medical Department.

In October 1775, the Continental Congress voted to fund the Continental Navy to augment the existing force of privateers and state vessels. The ships in this tiny fleet—Alfred, Andrew Doria, Cabot, Providence, Columbus, and Hornet—housed sick bays where Continental Navy physicians practiced their healing art. Surgeons and surgeons mates hired by the Continental Congress represented the early Navy Medical Department.

Drs. Joseph Harrison, Thomas Kerr, and Henry Tillinghast were some of these medical pioneers. Assisting them in the daily care of the sick and wounded were personnel called “loblolly boys,” enlisted boys and men named for the thick porridge or “loblolly” they rationed out to the sick. Loblollies also provided containers for amputated limbs, hot tar for cauterizing stumps, and sand for spreading on decks to absorb blood shed during combat and surgical procedures.

The Continental Navy did not long survive the Treaty of Paris in 1783. The United States was without a naval fleet until 1794 when Congress authorized the construction of six new vessels to defend its ever growing commercial interests. These warships, which became the nucleus of the new United States Navy, each had a surgeon, and, for the larger vessels of 36 guns, two additional surgeon’s mates.

The Department of the Navy came about on 30 April 1798 during the “Quasi-War” with France. A significant development during this period was the shore hospitalization of sick and disabled seamen. By an act of 1798, Navy sailors could now be admitted to civilian hospitals designated by directors appointed in ports of entry. These directors paid the incurred expenses from a Marine (later Navy) Hospital Fund maintained by monthly deductions of 20 cents from every merchant and Navy seaman, naval officer, and Marine. Subsequently, Navy hospitals were established in Syracuse, Sicily (1804) and New Orleans, Louisiana (1810) but neither hospital survived very long.

On 26 February 1811, Congress approved “An Act establishing Navy Hospitals.” The Act directed that money collected from naval personnel and the unexpended balance from the Marine Hospital Fund should be paid to the Secretaries of the Navy, Treasury, and Army. These were to act as the so-called “commissioners” of Navy hospitals. The commissioners were authorized to choose suitable sites for permanent hospitals and were then to construct buildings at these locations.

A decade went by before the first site was selected at Washington, DC, in 1821. This was followed by the acquisition of other sites—Chelsea, MA (1823); Brooklyn, NY (1824); Philadelphia, PA (1826); and Norfolk, VA (1827). In 1830, the Naval Hospital at Norfolk became the first of these facilities to admit patients, followed soon thereafter by the Philadelphia Naval Hospital located in the famed Naval Asylum. This multi-tasked institution, designed by noted architect William Strickland, also served as the home of a Navy school that would soon after morph in the U.S. Naval Academy in 1845.

What was health care in the early days of the U.S. Navy? Fortunately, the writings of some early Navy health practitioners provide some answers. While serving aboard USS United States, Surgeon Edward Cutbush, later dubbed the “Nestor of the Navy Medical Department,” reported that venereal diseases and diarrhea were quite common among the crew. He also reported their state of mental health. There were days, he said, in which sailors seemed “very low” and labored “under Nostalgia or a constant desire to return [home].” Surgeon’s Mate Benjamin Harris of USS Philadelphia reported that venereal diseases and influenza were common, and he treated the latter through “copious bleedings and other evacuations.” Harris stated that injuries from accidents during the warship’s Caribbean cruise were frequent in the early part of the voyage because of the crew’s inexperience. Scurvy also posed a problem for Harris and other Navy surgeons until 1812 when citrus fruits were issued to ships regularly at the urging of William P.C. Barton, Navy surgeon and future Chief of the Bureau of Medicine and Surgery.

Following the Revolutionary War, the United States Navy fought against France, the Barbary Pirates, and Britain in the War of 1812. Throughout these conflicts, the duties of the Navy surgeon were quite defined. The surgeon visited sailors under his care at least twice a day, supervised surgeon’s mates, consulted with other surgeons in the squadron about difficult cases, daily informed the captain of his patients’ condition, and was expected to be prepared with his mates and assistants for battle. He kept a day-book, containing the names of his patients, their prescriptions and methods of treatment, when and how they became ill or injured, when they recovered or died, and when they were discharged to duty. From this document, he made two journals: a record of his “physical” practice and a journal of his “chirurgical” practice. At the end of each voyage he sent the two journals to the Navy Department. When ordering patients to hospitals, he was to send with them a record of their cases. The Navy surgeon was only authorized to send sailors to hospitals and sick quarters when they could not be adequately cared for aboard ship. He had charge of the requisition, inspection, storage, accounting, and dispensation of all medical supplies used aboard his ship. Upon receipt of defective or faulty supplies, the surgeon was to notify the captain. He also forwarded accounts of medical supplies received and consumed to the accountant of the Navy at the end of each cruise.

Although the early Navy medical community was small, many giants paved the way to today’s modern organization. Surgeon Edward Cutbush (1772-1843), a former doctor in the Pennsylvania militia, authored Observations on the Means of Preserving the Health of Soldiers and Sailors (1808). In this pioneering text, Dr. Cutbush proposed techniques for cleaning, disinfecting, ventilating, and drying ships. He advocated strict physical examinations of all recruits coming aboard to eliminate disease. Cutbush also urged sailors to wear their hair short, to shave regularly, and to wash themselves and their clothing.

Surgeon William Paul Crillon Barton (1786-1856), the son of the United States Seal’s designer and nephew of a well-known American botanist, proposed that Navy ships be better equipped for the care of the sick and wounded. He also suggested a system for organizing Marine hospitals and adopting better physical standards in recruiting. Barton emphasized that sick days compiled by the Navy were traced to the practice of accepting mentally and physically unfit sailors for duty. Dr. Barton experimented with lime juice and lemonade aboard ships years before the Navy recognized the importance of antiscorbutic treatment for the dreaded vitamin C deficiency. He was also one of the first to propose that female nurses “be included among Navy personnel.”

Surgeon Lewis Heermann (1779-1833), who served under LT Stephen Decatur in the war with the Tripolitan pirates, later established a naval hospital in New Orleans with his own funds. Andrew Jackson’s troops used this hospital after repelling the British invasion of New Orleans in 1815. The well traveled and educated physician’s organization of this short-lived hospital served as a model for future naval hospitals.

Surgeon Thomas Harris (1784-1861) founded in 1822 what is considered to be the first U.S. Navy medical school. Located in Philadelphia, school instructors taught newly commissioned Navy medical officers hygiene, military surgery, and naval customs.

It can be argued that the Navy Medical Department, or more accurately, the doctors who comprised the Navy medical community, were treated unequally compared to their compatriots in the rest of the U.S. Navy. For one, Navy physicians’ salaries were a great source of dissatisfaction. Drs. Barton, Cutbush, and Heermann protested against the paltry remunerations, stating that their pay should be at least equal to their counterparts in the U.S. Army, let alone the physicians in the British Navy.

Rank was another concern. Navy medical men were classified simply as surgeons or surgeon’s mates and did not have relative rank with naval officers. The Act of 24 May 1828 for the “Better Organization of the Medical Department of the Navy” marked the first time the status of personnel in the Navy Medical Department received serious attention. In this act, the title “assistant surgeon” replaced the designation surgeon’s mate. The act stated that all candidates for appointments as surgeon or assistant surgeon must first appear before and be approved by the Board of Naval Surgeons, that no person could be appointed as surgeon until he had served at least two years on board a public vessel of the U.S at sea, followed by an examination and approval for promotion by a Board of Naval Surgeons. After satisfying the requirements of the Examining Board, the assistant surgeon still would not receive an appointment as surgeon until surgeon vacancies occurred. During the waiting period, the successful candidate was known as “passed assistant surgeon,” a status that was not officially classified until 1898.

The same act created the title of “Surgeon of the Fleet” which authorized the president to designate and appoint to every fleet or squadron an “experienced and intelligent surgeon, then in the naval service.” The Fleet Surgeon was to serve in the flagship and be generally responsible for all medical matters within the fleet or squadron in which serving.

In the Act of 3 March 1835, Congress first considered surgeons and assistant surgeons as officers when these positions were finally subject to the same pay scale as Navy line officers. The General Order of August 1846 finally conferred relative rank to physicians serving in the Navy. “Commanding and executive officers, of whatever grade, when on duty, will take precedence over all medical officers. This order confers no authority to exercise military command, and no additional right to quarters.” By this General Order, surgeons of the fleet and surgeons with more than 12 years service were to have equivalent rank of commanders.

In addition to issues of rank and pay, Navy medicine also had organizational problems. On 31 August 1842, Congress passed a Navy appropriations bill that was a blueprint for efficiency. The legislation provided for five bureaus to replace the outdated Board of Navy Commissioners—Yards and Docks; Construction, Equipment, and Repair; Provisions and Clothing; Ordnance and Hydrography; and Medicine and Surgery. The president appointed a chief to head each bureau.

The Bureau of Medicine and Surgery (BUMED) became the central administrative headquarters for the Navy Medical Department, and those names became interchangeable. The General Order of 26 November 1842, which defined the duties of the new bureaus, charged BUMED with:

-All medicines and medical stores of every description, used in the treatment of the sick, the diseased and the wounded;
-All boxes, vials, and other vessels containing the same;
-All clothing, beds, and bedding for the sick;
-All surgical instruments of every kind;
-The management of hospitals, so far as the patients therein are concerned;
-All appliances of every sort, used in surgical and medical practice;
-All contracts, accounts, and returns, relating to these and such other subjects as shall hereafter be assigned to this bureau.

BUMED’s establishment contributed a great deal to the Medical Department’s development and efficiency. The availability and quality of medical supplies and equipment improved. The year 1853 saw the construction of the naval hospital at Annapolis, MD, and the establishment of the Naval laboratory in Brooklyn, NY. The lab, headed by Surgeon Benjamin F. Bache and Passed Assistant Surgeon Edward R. Squibb, experimented with the production of chloroform and ether anesthesia. Squibb’s major contribution was providing the Navy Medical Department with a reliable source of pure pharmaceuticals. In 1857, Dr. Squibb resigned from the Navy and founded the pharmaceutical house that bears his name.

What kind of medicine did Navy surgeons practice in the mid-nineteenth century and how was it different from the practice of their Army colleagues? The instruments of civilian manufacture were similar. A Navy physician’s surgical kit was almost identical to that of an Army physician, and, most likely, carried the same brand name. A surgical scalpel was a surgical scalpel, a tourniquet a tourniquet, the treatment of choice for a shattered limb was amputation. Indeed, many Army and Navy surgeons attended the same medical schools.

The difference was the environment in which the naval surgeon practiced. The maritime venue was decidedly different from the battlefield. Certainly the marine theater had its own unique hazards—handling of anchor gear, hoisting apparatus, dangers incident to storms or heavy weather at sea, falls from mast tops, spills down hatchways and ladders, being struck by a lead line, being caught between boats and gangways on ships and docks, entanglement in parting lines or cables when mooring or unmooring. The term loose cannon had an original and more deadly meaning. Sailors fell overboard and either drowned or died of hypothermia. Fire caused by spilled oil or kerosene lamps below decks was a constant and sometimes fatal hazard. Contagious respiratory diseases ran through close packed living spaces, leaving entire crews incapacitated.

By the eve of the Civil War, Navy medicine already had one foot firmly placed in the new age of steam. The new technology of ironclad ships and rifled guns would soon add a very new dimension to treating the sick and wounded.

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