HEALTH AND MEDICAL CARE AT THE TIME OF THE AMERICAN REVOLUTION Ralph Edwards, Ed.D. Ralph Edwads, EdD., is Pmfessor of Health Education and Dean of Administmtwn and Planning;Kingsborough Community College, City Uniuersity of New York, Brooklyn, New York

By the beginning of the eighteenth century the population of the United States was about 300,000 whites (there being no record of the nonwhite population of the time) and during the colonial period it increased to about four million. With a larger proportion of educated medical men coming from abroad and settling in various parts of the country, it has been estimated that on the eve of the Revolution there were about 3,500 medical practitioners in the colonies. No more than 400 of these had received any formal training. Of the latter, only about half, or barely five percent of the total, held degrees of doctor of medicine. The few British physicians who migrated to America came in the main after 1730 and were Scots who fled from political and economic difficulties in their home land. The Anglican Church did not maintain the medieval tradition of caring for the sick poor, and no nursing orders existed which might have assumed this function. The English government failed to fill the health and welfare vacuum, leaving the maintenance of hospitals and medical education to voluntary initiative. Such initiative existed in London and large towns in Britain but was lacking in colonial villages in America. With the colonies having no medical schools, societies or hospitals, medial care was often based on folk medicine, including that borrowed from the Indians. Some concern about licensing practitioners was occasionally expressed in legislatures but no control was likely in the absence of formal education. Men and women engaged in medical practice for a fee. Most practitioners were trained only by apprenticeship and some of the best were practicing clergymen. Although the practitioners were called “doctors,” they resembled the surgeon-apothecaries of rural Britain who were engaged in surgery and drug dispensing as well as general practice. It is THE JOURNAL OF SCHOOL HEALTH

interesting that English surgeons had to be content with the title “mister” but the Americans, in the absence of an aristocracy, assumed the title of “doctor” as if they held university degrees. In colonial New England, doctors stemming from a church background did not charge very high fees. In the other colonies, doctors demanded and received substantial fees. Since cash was rare, nearly all transactions were on a barter basis. In Virginia, a doctor generally received 35 to 50 pounds of tobacco for a visit. In today’s terms, by making only one call a day, he could earn the equivalent of $8,000 to $9,OOO a year. Virginia doctors also charged dearly for their medicines, most of which they brewed themselves. Many early doctors, however, had a hard time collecting fees. Prior to the Revolution, the most outstanding medical event in the colonies was the first large scale approach to “preventive” medicine directed by the clergyman Cotton Mather and the physician Dr. Zabdiel Boylston in the Boston smallpox epidemic of 1721. By employing a concept of probability, they demonstrated that smallpox mortality dropped 1015 percent after inoculation with the diaease “virus” from the pustules of a person with a mild case. Boylston was not lacking courage having inoculated his own sons and slaves. He, himself, was immune to smallpox, having survived an attack in his early life, Boylston’s success reported in England, encouraged English physicians to evaluate the practice of inoculation. Jenner’s vaccination of 1799, although much safer and more effective, was, in principle, a modification of the earlier inoculation procedure. Despite the limited preventive efforts described, Americans, like other people, continued to view illness primarily as a misfortune to be met after it had occurred. Medical men were expected to restore health rather than preserve it. Europeans desiring some care, even for the destitute, in the interest of self-protection as well as of humanitarianism, paid for doctors. Colonial villages maintained this tradition and provided board and keep a t a neighbor’s home (later to become almhouses) for the 19

helpless and paid the fees of local practitioners to attend them. Since such service was a burden on local taxes, it usually was restricted to residents and sick transients were often hustled out of town posthaste. As villages grew into towns, it ceased to be practical to board people in private homes so the destitute of all types were collected into a single institution. Thus, Boston built it’s first almshouse in the 1680s and Philadelphia in the 17308. In the latter city, as an expanded infirmary for the almshouses, Quaker influence aided Dr. Thomas Bond (with the cooperation of Ben Franklin) in founding the first hospital in 1751 - Pennsylvania Hospital - the oldest such service institution in the modern sense. Initially, it was located in a private home on Market Street. In late 1756, a new brick building a t Eight & Pine was ready for occupancy. By this time, however, the hospital depended upon private funds and was governed by lay trustees, a practice in contrast to the Continental tendency to place such institutions under the control of Church or State. The hospital had a staff of six physicians who contributed part-time services, treated all noncontagious ills, maintained an insanity ward, and accommodated about 100 patients. During the colonial period, the apothecary was the highest paid member of the staff. I n addition to being the druggist, he sometimes served ae a house physician (since no physician lived in the hospital) and steward (chief executive officer). It is interesting that the f i t chief executive officer of the Pennsylvania Hospital was Elizabeth Gardner, a Quaker widow who was hired as matron to direct all salaried staff (except the apothecary). The creation of medical societies can be regarded as a positive action by physicians to share knowledge and act on issues of common interest. The first “medical society” seems to have been sponsored in 1735 by William Douglas, the only doctor in Boston possessing an M.D. degree. After the creation of other town groups by 1766,the first province-wide organization, the New Jersey medical society, was founded to deal with disputes of fees and licensing. It was a logical step for leaders in medical society to conclude they were qualified to conduct training programs for physicians. William B. Shippen, Jr. initiated a course of lectures in 1765 on midwifery. The 20 lectures, open to both sexes, were designed to train obstetrical physicians as well as midwives and are considered the first systematic teaching of medical subjects a t an academic level in the colonies. That same year, Dr. John Morgan founded the first American medical school (or first British 20

provincial school) in Philadelphia. The school was modeled after Edinburgh in that i t was associated with a college faculty rather than the English arrangement of providing such training within London hospitals. Two years later, a medical school was founded a t Kings College - now Columbia University. The post-revolutionary period produced Harvard Medical School established in 1782 as the first medical institution launched in the new nation. Harvard College, itself, was founded in 1654. When the Philadelphia school opened, it boasted a faculty of two professors: Morgan, professor of Theory and Practice of Physic, and Shippen, professor of Anatomy and Surgery. Students seeking admission to the school were found lacking in training regarded as fundamental. Consequently, in 1766, Dr. William Smith initiated a course of free lectures designed to give medical students an opportunity “of completing themselves in the languages and any parts of the mathematics a t their leisure hours.” Remedial education had begun. Adam Kuhn became the third professor with the chair of Materia Medica and Botony, and Benjamin Rush was appointed professor of Chemistry. By June 1767, the degree of bachelor of medicine was conferred on the first ten candidates. The M.B. degree could be advanced to an M.D. after an interval of three years and evidence of scholarship by examination or preparation of a thesis. By the turn of the century, this two-step process had been simplified under pressure to produce more physicians. The bachelor of medicine degree was abandoned and the M.D. conferred on completion of the course of study and training reduced from seven years to a minimum of four years consisting of two years of apprenticeship followed by two years of lectures. Meanwhile, Kings College, under the leadership of Samuel Bard began operation two years after Philadelphia and conferred its first M.D. degree on a 1769 baccalaureate in medicine. Robert Tucher thus became the first trained M.D. in the Colonies. The following year the M.D. was awarded to Samuel Kissam. Massachusetts lagged well behind Philadelphia and New York in providing formal medical education. John Warren’s series of anatomical lectures with dissections in 1780 was considered the first to be offered in the state and was designed to elevate the standards of doctors under his direction a t the military hospital in Boston. Warren became the leading New England surgeon, performing one of the first abdominal operations in America. In 1782 he was invited to submit a plan to Harvard JANUARY 1976 VOLUME X L V l NO. 1

College for a medical institution and became the founder of the Harvard Medical College. Formal medical education was a rigorous program and while it may have been appropriate in the European universities, it was too rich for the medical students in America. At any rate, by 1776, roughly ten years after their founding, the Colleges of Philadelphia and New York conferred a total of 51 M.D. degrees. The existence of native medical schools made the problem more acute of standardizing practice by licensing procedures. The local medical societies, and the first provincial society (New Jersey, 1761), all wished to distinguish between the physician and those with little or no training even by apprenticeship. Dr. Morgan wanted to organize a replica of the College of Physicians of London which would license for all colonies only men holding medical degrees. Physicians, in the London sense, would eschew surgery and drug selling but actually the American who held a medical degree not only enjoyed prestige but engaged in all types of practice just as did men who lacked formal training. While New York and New Jersey enacted legislation to provide examining boards and licensure, further legislation was postponed with the outbreak of the Revolution. During this era, it was assumed most candidates for a license would not be medical graduates. Hence, in order to introduce standards, regulations concerning apprenticeship as well as examinations were provided. It is difficult to say how effectively regulations were enforced or just what standards were maintained by the early examining boards. However, professional goals were at least given formal recognition and the procedures established were never forgotten thereafter. Early medical education labored under a lack of research and publications, which in part can be ascribed to the popular aversion to human dissection. Physicians had to steal corpses from graveyards for teaching apprentices the practice of surgery. Permission for autopsies could rarely be secured. There was also opposition to research in principle, even in medical circles. Would not investigations pursued perhaps out of sheer curiosity distract a man from his duty to his patients? The first work on surgery written by a n American in 1775 was John Jonses’ Plain Concise Remurks on the Treatment of Wounds and Fractures, designed for use by young military surgeons. Advice on hygiene was provided by Benjamin Rush in his Directions for Preserving Health of Soldiers, published in 1778 by the Board of War. It was in the field hospital setting that Rush first discovered the method of curing lockjaw with bark and wine. THE JOURNAL OF SCHOOL HEALTH

Although not himself a physician, the name of that scholar, scientist and patriot, Benjamin Franklin, adds almost as much luster to the medical history of Old Philadelphia as it does to American history. Franklin invented the flexible catheter, bifocal lenses, and healed nervous diseases by electricity known as Franklinism. His letters and investigations on lead poisoning, gout, deafness, sleep, heat of blood, optics, death rate, promotion of inoculation against smallpox and his effort to organize hospitals are examples of the breadth of his medical interests. Probably the most widely accepted theory of disease at the outbreak of the Revolution was advocated by Benjamin Rush. As a student of William Cullen, the Edinburgh scholar, Rush believed that disease was due tQ the constriction of body systems. Fever, particularly, was due to s p as ms in t h e v as cu l ar system a n d t h e recommended therapy was bleeding. All diseases were ascribed to capillary tension. The practice of bleeding usually by applying leeches was so common that “leech” came to mean physician. Rush and his contemporaries also treated epidemic diseases by “cleansing the stomach and bowels” through the use of two drugs - emetics which produced vomiting and cathartics or purgatives which acted as a powerful laxative. When the Second Continental Congress adopted the Declaration of Independence on July 4, 1776, the signers included four physicians and one former medical student. Since the colonies voted in geographic order, Dr. Josiah Bartlett of New Hampshire became the first to vote and sign the historic document followed by Drs. Benjamin Rush of Philadelphia, Matthew Thornton of Londonderry, New Hampshire, and Lyman Hall of Sunbury, Georgia, plus the one-time medical student Oliver Wolcott of Connecticut. Rush and Thornton were not members of the Congress when the Declaration was adopted. Of the group, Rush was to become the foremost American physician of his day pioneering in psychiatry, public health and medical education. Bartlett, upon his retirement from the study of medicine became Chief Justice of New Hampshire and later governor of the same state. Thornton took up the military as his business and served with distinction. He was later appointed to the New Hampshire Supreme Court. Lyman Hall, another of the giants who signed, being six feet four inches in height, was a zealous patriot who treated physical ills. Three weeks after the Declaration, Wolcott was in combat commanding a militia detachment in the battle of New York. He went on to become a major general in the Continental Armies and a governor of 21

his state. General’s rank was also won by fighting physicians who gave their lives in battle. Dr.Joseph Warren of Roxbury, Massachusetts, joined the prerevolutionary Committee of Public Safety and despite holding rank, served a s a volunteer and died a t Bunker Hill. In fact, he was buried with other dead in an unmarked grave and when the British left Boston, nine months after the battle, his body was positively identified by the two artificial teeth Revere had made for him. This may have been the first recorded instance of identifying a corpse by dental records. Of the more than four hundred casualties a t Bunker Hill, eleven were surgeons or surgeons’ mates. Since there was no advance plan for care of the casualties of Bunker Hill, the wounded were hastily bandaged and housed in deserted residences which became “regimental hospitals. ’’ One of the first undertakings of George Washington, after he became commander-in-chief, was the inspection of fortifications and hospitals. Afterward, he wrote the Continental Congress that an army medical department must be organized; consequently, on July 17, 1775, Congress provided for the appointment of a “director-general and chief surgeon,” four surgeons, one apothecary, 20 mates, one clerk, two storekeepers, one nurse to every ten sick, and occasional laborers. The Continental medical corps was torn by quarrels and scandal at the top but was redeemed by valiant service in the ranks. Throughout the war, the overriding medical problem was the Congress’s failure to provide the corps with the bare minimum of personnel, facilities, supplies or funds. Benjamin Church, the first director-general, was plagued by Congress’s failure to bring the regimental surgeons under the central medical department. The result was two services competing for limited supplies. During this controversy, Church was found guilty of carrying on criminal correspondence with the enemy to terminate hostilities. Sentenced to solitary confinement, he was released after one year for reasons of health and shipped to the West Indies. His ship was lost a t sea and he was never heard of again. Dr. John Morgan succeeded Church in October 1775, and soon after, Boston was evacuated by the British. During the year, Morgan traveled back and forth between Boston and Baltimore, laboring to supply regimental surgeons for whom Congress had not seen fit to provide supplies. Meanwhile, William Shippen was in Philadelphia ingratiating himself with Congress. Victimized by professional rivals and intolerable conditions, in a power play, Morgan was dismissed and Shippen was the next director22

general with the regimental surgeons under his jurisdiction. Shippen was immediately criticized by Benjamin Rush on his treatment of Morgan. Furthermore, Shippen was not helped by the lowered morale that followed the battle of Valley Forge in the winter of 1777-78,particularly by his inability to circulate among the staff and hospitals under his direction. Rush sent a letter to General Washington in which he detailed the abuses he had seen in the hospitals and offered suggestions to rectify them. Washington turned the letter over to Congress and they called both Shippen and Rush before an investigation committee. Shippen’s reputation was scarred during the hearings for his mismanagement and his use of hospital supplies. Congress, in the end, retained Shippen, however, and Rush resigned returning to practice and politics. In 1781,Shippen resigned “voluntarily” but unlike Church and Morgan, he went on to enjoy a long profession1 life. John Cochran succeeded Shippen in January 1781 and served through the remainder of the war, working with the meager resources provided by the Congress. In the field, individual physicians worked heroically and shared the hardships of the troops. The death rate in the army was a staggering 20 percent a year, nine-tenths of these from disease. The worst ravages were due to typhus spread by lice, dysentery, pneumonia and diverse fevers. I n September 1783, Congress authorized Washington to furlough the medical staff whose services were no longer needed. Nine months later the army was disbanded. The Medical Department of the Army was not fully revived until 1818. Physicians who served actively in the Revolution totaled some 1200,about a third of the profession in the Colonies. The proportions closely reflected a general division of sentiment estimated a t a third of the populace ardent for independence, a third opposed, and the rest a s neutral as circumstances would allow. At the conclusion of the war, medicine was still predominantly in a primitive state with no understanding of infection and anesthetics. Purging, bleeding, emetics and blisters were standard treatments. Smallpox, dysentery, jaundice, cholera and typhoid headed the list of diseases which exacted a higher death total than British bullets. The wounded, not infrequently, suffered cruelly from a lack of medicine, surgical instruments, bandages and adequate hospital facilities. The war, however, was a great leveler of American medicine. It brought together doctors from isolated communities on an unprecendented scale to treat traumatic injuries in undreamed numJANUARY 1976 VOLUME XLVl NO. 1

bers, to fight epidemic disease and to learn the rudiments of hygiene. The war provided practical medical education which raised the general level of medical care. The events of battle gave American physicians an opportunity to see and learn more in one day than they could have experienced in years of peace. While modest in scope, usually reflecting knowledge already held in European circles, the achievements were all of some benefit to the new republic and its infant medical and preventive health profession.

BIBLIOGRAPHY Commager HS, Morris RB: The Spirit of Seventy-Six:vol 1 & 2. Indianapolis, Bobbs-Merrill Co, 1958. Higginbotham D: The War of American Independence. New York, Macmillan Co, 1971.

Luter J, Craik J: The fist white house physician. Today’s Health 42(2):47-49, 67-70, 73, 1964. Marks G, Beam WK: The Story of Medicine in America. New York, Charles Scribner’s Son, 1973. Rothatein WG: American Physicians in the 19th Century. Baltimore, The Johns Hopkins University Preas, 1972. Skyrock RH:Medicine in America. Baltimore, The J o h Hopkins University Press, 1966. Williams WH: The early days of Anglo-America’s first hospital. J A M A 220(1):115-119, 1972. Winchester J: Doctors of the new United States. Today’s Health 44( 12):40-43, 1966. The author of this article is Ralph Edwards, EdD., Professor of Health Education and Dean of Administration and Planning, Kingsborough Community College, City UniuerSiy of New YO& Brooklyn, NY 11235.

CALL FOR RESEARCH PAPERS FOR 1975 ANNUAL MEETING The Research Council of the American School Health Association invites papers for consideration by a review committee for presentation at the 50th Annual Convention, October 7-10,1976, in New Orleans. The research must be relevant to some aspect of the school health program and must be now completed or expected to be completed before the date of the annual meeting. All applications must be received no later than May 1, 1976. Each must state the name of the authors, the author’s institutional affiliation, address, and the title of the paper as it is to be listed in the program. A minimum of two copies of a 5oo-word abstract should state the purpose of the investigation, establish its significance to health education, describe the procedures which were employed, and summarize the principal findings or conclusions. If audiovisual equipment is essential to the presentation, the type of equipment should be stipulated at this time. The paper must be presented by the investigator or co-investigator and must not have been previously presented or published elsewhere. It should be understood that if the paper is selected, THE JOURNAL OF SCHOOL HEALTH will have first option in considering its publication. All applicants will be notified of their paper’s acceptance or nonacceptance. Send abstracts and other necessary information by May 1, 1976, to the Research Council Program Chairman, Ann E. Nolte, Ph.D., Professor, Health Education, Horton 227C Illinois State University, Normal, Illinois 61761.

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Health and medical care at the time of the American Revolution.

HEALTH AND MEDICAL CARE AT THE TIME OF THE AMERICAN REVOLUTION Ralph Edwards, Ed.D. Ralph Edwads, EdD., is Pmfessor of Health Education and Dean of Ad...
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