Briefing Medical Students on Military Medical Life: Albany Medical College-Military Affinity Group’s Symposium on Life in the Military

Earlier this year we organized “AMC-MAG” with three Missions: – to provide for camaraderie among Albany Med alumni who’ve served in uniform; – to support AMC students currently enrolled or interested in enrolling in the Health Professionals Scholarship Program; – to inculcate a culture of philanthropy to the College. I believe that ours is the only such organization in an American medical school.

(Left to Right:) CAPT Tom Snyder ’69, AMC-MAG founder and Symposium organizer; MGen Kevin Kiley, AMC-MAG Faculty Advisor and Symposium participant; RADM Jim Sears ’63, AMC-MAG Honorary Chair (Image: Martha Hubbard)

On Saturday, 22 September, the Group mounted the first (of what we hope will become annual) Symposium on Life in the Military. Our first panel – “Medicine in the Military” – made up of alumni Colonel Dave Siegal ’57, Col Michael Zapor ’75, Major Andrew Plunkett ’03, Commander Ken Ortiz (who flew up to Albany from Norfolk on Navy TAD orders)

Commander Ken Ortiz, MC, USN, Navy Plastic Surgeon, briefs an Albany Med student on Medicine in the Military (Photo: Martha Hubbard)

 and faculty advisor MGen Kevin Kiley (AMC’s Chair of OB-GYN and former Army Surgeon General) gave our attendees a comprehensive view of various aspects of the practice of medicine in the armed services, from working in a large recruiting station performing physical exams on recruits to combat casualty care near the troops in Iraq and Afghanistan. Two of our participants, Col Zapor and Major Plunckett, joined us via Skype – an interesting and somewhat frustrating experience…

Our second panel – Family Life in the Military – featured Colonel Siegal’s wife, Bonnie, PhD, General Kiley’s wife Babs and Commander Ortiz. Noting her expertise gained from 26 change of station orders, Bonnie gave a detailed talk on military moves. Mrs Kiley gave an overview of military programs for support of families. Commander Ortiz gave

Colonel (retired) Dave and Bonnie (PhD) Siegal with invited Army Recruiter. The Siegals gave their experience as a medical practitioner and spouse manager of military moves – after 26 of them! (Photo: Martha Hubbard)

the view from a mid-career officer’s standpoint.

At the completion of our panels, we retired to the Hilton Garden Inn across New Scotland Avenue from the medical center for a leisurely lunch and conversation.

Luncheon for Symposium Attendees and Panelists: an Opportunity to Continue the Conversation About Medical Life in the Military (Image: Martha Hubbard)

Our first-time-ever effort was quite well received. Both students and panelists expressed the desire to see a similar event next year.

©2012 Thomas L Snyder

LST 464

According to the official history of the navy medical department in World War II(1), in early stages of the war in the Pacific, LSTs(2) carried one medical officer and equipment for emergency surgery. Experience quickly demonstrated that when these small ships took on casualties for evacuation to larger hospitals or hospital ships, the medical staffs were simply inadequate to provide necessary care for the 100 – 200 casualties typically taken aboard. And, given that the time it took to get casualties to definitive care under these conditions often exceeded 24 or even 48 hours, it became clear that facilities for major surgery closer to the area of combat were a necessity. While the small ships (not LSTs in this case) accompanying the landing forces at Arawe, New Britain in December 1943, for instance, carried surgical teams of 2 surgeons and 10 corpsmen, the care these teams could provide was not sufficient to the need.  Around this time, LSTs converted  specifically to accommodate casualty care and manned with surgical teams came into being, and they participated in the Cape Gloucester (at the northwest end of New Britain) invasion on 26 December 1943.

As operations continued in the Bismark / Solomon Sea areas, the need for a forward-deployed ship capable of providing definitive, specialized surgical casualty care became urgent. LST 464, the first and only LST converted into a hospital ship, served that need.

Work done in Sydney Australia fitted out its tank deck with an operating room, offices, laboratory, a radiology room, and an isolation ward. Its staff included a surgeon, internist, dermatologist, urologist, EENT specialist and supporting hospital corps officers and corpsmen. Additional surgeons were ordered aboard on an as-needed basis, and an anesthesiologist and psychiatrist were added later. Thus staffed, LST 464 supported early operations like Lae, Arawe and Cape Gloucester from advance bases at Cape Sudest, Morobe or Buna, where she received casualties from amphibious craft and transported them to Milne Bay, some 350 miles distant. After Humboldt Bay (now known as Yos Sudarso Bay, on the north central coast of Papua-New Guinea) was taken in April 1944, the ship moved there to serve as a base hospital to support construction battalions and other troops locally.

In preparation for the invasion of Leyte, a blood bank (3) was established in LST 464. Its director was LT Ernest E Muirhead, MC, USNR, a physician experienced in blood bank operation. LT Muirhead had previously demonstrated the feasibility of such an operation when he prepared blood on another LST and carried it ashore to aid casualties in the Noemfoor Island landings of July 1944. The ship proved to be of particular value in the Leyte landings because she remained close-in, unlike the much actual hospital ships, which proved to be tempting targets for kamikaze pilots then being thrown into battle.  LST 464 remained in the Leyte gulf as a station hospital until March 1945, when she transited to Subic Bay in the Philippines, to serve the same role. At the end of the war, she was redesignated LST(H)-464. She served for a short time in Korea after the cessation of hostilities.

(1) NAVMED P-5031, The History of the Medical Department of the United States Navy in world War II – A narrative and Pictorial Volume (Volume 1), Washington, United States Printing Office, 1953. P 184, 187-188.

(2) LSTs (Landing Ship, Tank) fitted out for casualty care carried their usual armament and therefore did not enjoy the “protection” of the Geneva Conventions, which appear to have been largely ignored by the Japanese in any case. LST-464 was laid down in October 1942, launched in November, and commissioned in February 1943. After her conversion to a hospital ship function later that year, she was distinguished only by the six foot high white “464” painted on her hull amidships (http://en.wikipedia.org/wiki/LSTH, accessed 15 Sept 2012).

(3) Kendrick, Brigadier General Douglas R, “Blood Program in World War II”, Washington, Office of the Surgeon General, Department of the Army, 1964. Pp 594-595, 616-618, 620.

©2012 Thomas L Snyder

The Navy’s World War II Blood Program

Up until the beginning of World War II, the use of whole blood transfusion for combat casualties was very much a primitive, often ad hoc undertaking. Blood was usually collected on a direct “as needed” basis, a cumbersome procedure which quickly broke down under combat conditions. Two practical problems and one conceptual problem had to be solved before large scale use of blood for combat casualties would be instituted. The practical problems were those of  transfusion reactions – solved by the application of knowledge of blood grouping and the Rh “factor”; and storage or “banking” of blood solved by the used of anticoagulant-preservative solutions and refrigeration. The conceptual problem was the recognition that hemorrhage was actually the cause of shock in trauma, and that blood replacement rather than volume replacement was necessary for successful resuscitation of shock patients in preparation for surgery.

Early in the War, the U S blood program, organized mostly by the Army, in coordination with the American Red Cross, focused on the collection blood for its non-cellular fractions – plasma. It was a very successful program. For the month of June 1944, for example, the American Red Cross reported that its 33 major processing centers throughout the nation had collected more than half a million units of blood. Most of this blood was processed to produce dried plasma, which could be reconstituted in the field. This procedure reduced weight and volume (important when logistical space was limited and need for combat materiel was great), and avoided the problem of degradation of the fluids by heat and time. It wasn’t until late 1944 that Army medical officials accepted the notion that plasma alone was an inadequate medium for resuscitating shock patients, and that oxygen carrying capacity – red blood cells – was critical to survival in emergency surgery and for post-operative recovery. The Army began shipments of whole blood from the US to Europe in only in August 1944.

In the Pacific area, initial supplies of blood came from the Red Cross blood bank in New South Wales, Australia, where studies on blood storage had resulted in the use of  the preservation medium – dihydric sodium citrate-glucose solution (“ACD”*) – recommended by the British Medical Research Council – and the use of  heavily insulated wooden boxes fitted out to hold 10 1-liter bottles and 56 lbs of ice, suitable for transporting whole blood, at  4.5 – 8 degrees C, by air. This system was worked out and functioning for Australian troops as early as December 1942. By August 1943, U S forces in the southwest Pacific area were receiving blood from Australian sources, transported by air and sea.

In June 1944, Captain Lloyd R Newhouser, MC, USN, the director of the Navy’s blood program, was ordered to the Pacific to evaluate the need for, and means of supplying whole blood and blood products to the Pacific area. Early on, Captain Newhouser and his Army colleague Colonel Douglas B Kendrick, MC put their emphasis on procurement of blood locally, first in Australia, and then in Hawai’i. However, these sources were simply inadequate to the need. And with the high rate of malaria then prevalent among troops in the Southwest Pacific Area of Operations, surgeons became reluctant to use locally obtained blood. In October, Army Brig. Gen Fred Rankin (Chief Surgical Consultant to the Army Surgeon General) and Captain Newhouser agreed that the Navy should establish a processing laboratory in California. The Army would provide all necessary equipment. Red Cross collection centers in Los Angeles, San Francisco and Oakland initially provided blood for the Pacific airlift; as the need for blood increased, the Red Cross added centers in Portland, OR and San Diego to the supply chain. Chicago went on line for the Pacific in January 1945, and after the end of hostilities in Europe, whole blood for the Pacific began to flow from New York, Boston, Philadelphia, Washington and Brooklyn.

The Navy’s processing center actually ended up in Oakland.

The first air shipment of blood left San Francisco on 16 November 1944. Between December 1944 and September 1945, 88,728 units of blood were shipped by air from the US to the Pacific. Shipments varied from none in a day to up to 12,000 pints shipped in one week, in May 1945. Blood flown from Oakland would be inspected and re-iced at Pearl Harbor after a 12 hour flight. It then went by air to Guam, from where it could be distributed to points of need throughout the western Pacific. While the actual flight time for blood was about 48 hours, when transport and flight stopovers are taken into consideration, most blood arriving at, say, Leyte, was up to five days old.

There is little doubt that the Navy’s blood air transport program saved thousands of lives. One Army field surgeon in the Pacific estimated that the mortality rate from abdominal wounds dropped 20% when whole blood, penicillin and oxygen therapy became available. Surgeons in the 119th Station Hospital noted that plasma was of little value for casualties received for care; their conclusion: “Blood is what is needed.” By the end of the war in the Pacific, the ratio of blood use was 1.5 units for every soldier or Marine in action. This from early in the war, when high U S medical officials denied the need for any red cells at all.

Next time: LST 464

 

* The Army blood program used a preservative called Alsevers Solution. While adequate for the purpose – refrigerated whole blood preserved with it could be safely used for up to 16 days after collection – it had the disadvantage of requiring 500 ml of solution for every 500 ml of whole blood. “Volume’ was an issue when considering valuable shipping space aboard aircraft carrying military supplies to Europe. The Navy’s choice of ACD, which preserved refrigerated whole blood for at least 21 days, had the additional advantage of much reduced volume of preservative (initially, 4:1 blood to preservative volume, later reduced to 6:1). From the beginning, the Navy used ACD for blood shipped to the Pacific.  The Army switched over to ACD for shipments of blood to Europe in April 1945.

Source for this Post: Kendrick, Brigadier General Douglas B, “Blood Program in World War II”, Office of the Surgeon General, Department of the Army. Washington, 1964

©2012 Thomas L Snyder

Benevolence Sunk!

This is the headline – emblazoned on a facsimile of a yellowed newspaper front page – that greeted me when I opened my home town newspaper, the Vallejo Times-Herald, yesterday morning.

USS Benevolence was  laid down on 26 July 1943 as a transport ship, SS Marine Lion, at Sun Shipbuilding and Drydock Company in Chester, PA. A year later, facing a surge in casualties in the Pacific Theater of Operations,the U S Navy designated her a hospital ship, AH-13. Todd Erie Basin Shipyard in Brooklyn completed her conversion to hospital functions, and she was commissioned on 12 May 1945. Benevolence transited the Panama Canal on 22 June, and after a brief stay in Hawai’i, made her way to the Eniwetok lagoon, where she provided care for war-wounded and sick Marines, sailors and soldiers until the end of hostilities. After a period of time at Yokosuka, where she gave care and comfort to liberated US POWs and civilian internees, she brought her first 1000 patients back to San Francisco in November. By 15 February 1946, she had completed her third “Magic Carpet” mission of bringing service personnel from Pearl Harbor back to  San Francisco.

USS Benevolence Anchored in Bikini Atoll for Atomic Tests, 1946 (Photo: NavSource Online: Service Ship Photo Archive, http://www.navsource.org/archives/09/12/1213.htm, accessed 26 August 2012)

From May to September 1946, Benevolence provided medical support for the Bikini atomic tests. After a 19 day rest in San Francisco, she deployed again, this time to serve as a station hospital off Tsingtao, China. After nearly six months, she returned to the US, this time to be decommissioned at Hunters Point Naval Shipyard in San Francisco. She was laid up in the Pacific Reserve Fleet until the outbreak of the Korean Conflict. She underwent refurbishment at the Mare Island Naval Ship Yard.

On her return from sea trials, with a small medical contingent and a large number of civilian technicians aboard, in heavy fog and zero visibility, Benevolence collided with the commercial ship SS Mary Luckenbach. The stricken hospital ship sunk within 25 minutes. Fortunately, all but 31 of her crew and passengers of more than 500 were able to get off the ship and into the frigid waters off San Francisco Bay. 18 people died or were lost. If she had had patients embarked, the tragedy could have been much worse.

USS Benevolence on her side off San Francisco Bay, 1950 (Photo: NavSource Online: Service Ship Photo Archive, http://www.navsource.org/archives/09/12/1213.htm, accessed 26 August 2012)

The ship lay in the shipping lane for 16 months while attempts were made to salvage her. When these were unsuccessful, salvage workers used three explosive charges to demolish her. She was stricken from Navy rolls on 20 December 1950.

I extracted the ship’s history  from Navy records, accessed 26 August 2012, http://www.history.navy.mil/danfs/b5/benevolence-i.htm
 
©2012 Thomas L Snyder

A Step Away From the Past and Into the Present and the Future – An Old Doc’s Look at Health Care Reform

My son James recently sent me a link to a New Yorker article on health care delivery with this question: “Is Kaiser [-Permanente] like the Cheesecake Factory?” He might also have asked, “Is military medicine like the Cheesecake Factory?”

Health Care Reform - Change and Hope

In “Big Med – Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?”, Boston surgeon and medical writer Atul Gawande tries to apply the lessons he learned, as a result of a meal at a Boston-area Cheesecake Factory, to health care delivery. While noting that the Cheesecake Factory chain has managed – very well – to control both cost and quality while assuring an excellent customer experience, Dr Gawande points out that medicine doesn’t do nearly as well.

According to Dr Gawande, even in the erudite halls of Boston’s vaunted teaching hospitals – presumably models of the best medical care America has to offer – physician approaches to patient care are individualistic – even idiosyncratic; this results in patient complication rates that vary by as much as threefold within the same hospital; and patient / family experiences have historically been almost invariably wretched. While these hospitals may be at the forefront of research and innovation in health care, they don’t seem to be doing a very good job of delivering quality “every day health care” to “every day patients”.

What are the lessons health care could learn from Cheesecake Factory?

The first is a consistent – and consistently good – product. In the restaurant business, consistency means “standardization”, a consistent way of doing the same thing over and over again. My first lesson in medical consistency came during residency: I trained in a Chicago hospital that catered both to “carriage trade” patients and people from a very poor “mile-square” area in the City. In caring for our patients, our attending physicians very early on cautioned us to use the same care procedures for both the very rich and the very poor, because the instant we tried to “customize” our care (either for the rich or for the poor), we risked introducing opportunities for  medical mistakes. Undoubtedly, in medicine just as in the cooking business, you need to apply the individual judgement of a well-trained and experienced professional to each case. But doctors are notoriously a restive group, very protective of their independence. How do you get a “herd of cats” to practice in a consistent manner, even while permitting those individual judgment calls that hone the standardized approach to each individual patient’s needs? Here, I believe, is the first place my Kaiser-Permanente and my military experience becomes instructive. In both Kaiser and the military, practitioners are salaried. Thus, they aren’t competing with each other for patients and for income. I believe this makes for an environment that encourages true collegiality and a sense of “we’re all in this together”. When you combine true collegiality with a strong culture of “best practices”, I think it becomes relatively easier to develop a department-consistent (or even a hospital-consistent) approach to any aspect of medical care delivery. Of course, this takes effective leadership – something both the military and the Kaiser-Permanente model have spent some resources in cultivating.

Another lesson from my experience not necessarily highlighted in Dr Gawande’s piece is the importance of “doctor-based” decision-making. My favorite example comes from northern California Kaiser-Permanente. I was the chief of urology at my Kaiser hospital. At one of our quarterly Chiefs meetings at the Oakland, California headquarters of The Permanente Medical Group, the 13 of us were pondering a question brought to us by the Chief of the 13 Chiefs of Medicine: what should “company policy” be regarding the use of PSA screening for prostate cancer? Then, as now, with the possible exception of one or two very well circumscribed situations, the data are not at all certain. And then, as likely we would now, we argued the pros and cons at some length. Finally, with no consensus forthcoming, we turned in frustration to the representative from “Higher Headquarters” and begged “What do you want us to do?”. The answer was “You are the content experts. When you decide a policy, that shall be the policy of Kaiser-Permanente.” (We’d probably be urged, today, to look for a “best practice” model to follow, subject to change, of course, as experience and research refined our understanding of the medical matter at hand.) What a reassuring message I could bring back to my colleagues, and to my patients! No “bureaucrat” is making health care decisions for you!

Back to the Cheesecake Factory, Professor Gawande takes notice of the extensive use of computers, with screens at face level throughout the kitchens. These provide the company recipes and serving suggestions, readily accessible throughout all 160 restaurants in the chain. Both the military and Kaiser-Permanente have adopted extensive computer operations throughout their systems. In fact, Kaiser was looking to introduce system-wide computerized health care records and data sharing as early as the late 1980s. Computerized systems permit a secure sharing of medical information – lab test results, radiology images and medical history information – at every hospital and clinic in the system. The value of this is immeasurable in the reduction of unnecessarily duplicated tests and exams, and the easy discussion of such things as Xray images between specialists within the system. When my wife was facing arthroscopic knee surgery recently, her orthopedist just pulled her MRI images up on the screen right there in the exam room and went over them with her and me in detail! With the computerization of health records comes a similar easy collaboration between primary care provider and a specialist or specialists who might be located – at least in the military – half way around the world. The Kaiser organization offers an electronic version of a patient’s health record – on a thumb drive – that he or she can take on vacation, at nominal cost.

The Cheesecake Factory has an active product development establishment that produces an updated menu about every six months. Each of the military services has the equivalent – a research arm which searches for innovations in preventive medicine and the special health requirements of people operating in challenging environments whether that be in submarines, in space, or in the mountains of Afghanistan. The Kaiser-Permanente Division of Research, based in Oakland, California, has published more than 4000 peer-reviewed medical articles in its 50 year history. In 2010, its budget of nearly $100,000 supported more than 50 researchers involved in more than 200 research projects largely but not exclusively oriented to the health of large populations.

Both the military and the Kaiser-Permanente systems of health care offer a feature Dr Gawande doesn’t mention – the regionalization of very specialized care. For example, in northern California, Kaiser-Permanente’s more than 3 million patients receive their cardiac surgery at specialty centers in San Francisco and Santa Clara. Neurosurgical care is centered in Redwood City and in Sacramento.  The military system has similar echelons of care, from clinics to primary care hospitals to specialty hospitals. This regionalization avoids unnecessary duplication of expensive specialty care and equipment, and, as a bonus, assures that super-specialty surgeons and physicians are constantly busy – one determinant of successful outcomes.

Then there is the matter of “size”. The Cheesecake Factory, with its 160 restaurants, experiences economies of scale in purchasing of everything from eggs to refrigerators. The Department of Defense medical establishment is huge – the largest in the country. If if were so oriented, its huge purchasing power could effect amazing savings of scale. One example of Kaiser-Permanente marketplace power comes from some years ago. As the story goes, one domestic insulin manufacturer bought out its competition and then announced a large increase in the price of insulin. Promptly the northern California Kaiser pharmacy operation, as a major purchaser of insulin,  reached out to a large Scandinavian insulin producer and offered to partner with them to bring product to market in the US. This effort was successful, and the price of insulin dropped promptly.

Health care reform, in my view, requires one more thing that was implicit in Dr Gawande’s New Yorker restaurant piece: competition. Even while it was struggling to grow in its early years, the Kaiser-Permanente organization realized that healthy competition is a necessity. From the early 1940s, the Kaiser mantra became something like “unless patients have choices in the care they receive, we will have no opportunity to show how good we really are”. When I was practicing Navy medicine as a General Medical Officer, lo, those many years ago, I remember resenting my patients going to the doctors “downtown”, on the civilian side, for their care. I knew we were giving every bit as good care as the “townies” did, but the knowledge that our patients had a choice kept us all on our toes to do the best we could, even in the”captive” care system that is military care.

There you have it: consistency of medical procedures while encouraging the application of sound judgement; salaried health care providers to eliminate destructive competition and encourage collegiality and unity of approach; doctors- or professionals-driven policy decision-making based on consensus best practices; extensive application of computer technology to record keeping, data sharing and promulgation of consistent practice; regionalization of super-specialized care; scale of economy based on large regional or national systems of organization; and vigorous competition among provider systems.

By way of background, I practiced medicine in all three practice settings: active duty military (Navy, for 3 years), fee for service in a small multispecialty group (5 years), and in the large northern California Kaiser-Permanente Health Care system (20 years). In addition, with 20 years in the Naval Reserve, I had contact and conversations with physicians from around the country who practiced in a variety of settings. These experiences all convince me that a salaried system of care providers virtually eliminates the extra and often unnecessary medical procedures engendered by the fee-for-service model where a physician is paid for each procedure carried out. Fee-for-service puts the emphasis, in my view, on health care providers (the more procedures, the higher the income), rather than their patients and what’s best for them. It’s much more natural for salaried providers to be driven by what’s best for their patients, since salaries are going to be paid whether procedures are performed or not.

©2012 Thomas L Snyder

Walking the Walk

This weekend is the annual Mare Faire on Mare Island, site of the first naval base on the U S Pacific Coast. Mare Island also was the home of the first Naval Hospital on the west coast. Opened informally – housed first in an unused granary – in 1864, the hospital closed in 1957. The Navy Schools Command operated the facilities until the Navy Base closed in 1997. Touro University took possession of the property in the early 2000s.

Mare Island Naval Hospital, 1871 (Image: National Archives)

;

The Mare Faire is my annual opportunity to tell the story of Naval Hospital Mare Island, California, to visitors from around the country. This weekend, both on Saturday and Sunday, I give a one hour PowerPoint® presentation, Mare Island’s Hospitals–Mare Fair 2012Aug11-12. Then, I lead a walking tour of the hospital property, which is today owned by Touro University California. with the exception of one building used for instructional spaces, and three for administration an faculty offices, the original hospital structures lie empty and unused. While university officials won’t allow us access to the interiors, we are permitted to walk the hallowed grounds where wounded and sick sailors and Marines walked for nearly 100 years.

So this weekend, I literally talked the historical talk and walked the historical walk.

©2012 Thomas L Snyder

Navy Medicine in the War of 1812 – Action in the Year 1812, Part I

War of 1812 Propaganda Poster (Image: Ohio History Central. http://www.ohiohistorycentral.org/entry.php?rec=565)

The history community in the US and Canada (I don’t know about the UK) are ramping up for observations of the 200th anniversary of the War of 1812. Inasmuch as this war was in large part fought on water, it occurs to me that we should be looking, so far as we can, at the role navy medicine played in the conflict. For Part I of this discussion, I will depend largely on Professor Harry Langley’s 1995 book A History of Medicine in the Early U.S. Navy.

You’ll recall that British had raised the ire of Americans by their interference in our commerce with Napoleonic Europe, and, more importantly, by their impressment of American mariners into the Royal Navy. Initially, the US Congress retaliated with legislation – the Embargo and Non-Intercourse Acts of 1807 and 1809 – but these further decreased our overseas trade.  With New England merchants crying economic ruin, first the House (79-49 on June 4, 1812), then the Senate (19-13 on June 17) voted for war, and President Madison signed the Declaration on 18 June.

Commodore John Rodgers’s quickly assembled a squadron of four ships. Soon after they departed New York, on 25 June, they encountered HMS Belvidera, 36, northeast of New York. A brief but violent action followed, with USS President, 44,  pursuing. In the end, Belvidera ran north to Halifax, having sustained the loss of 2 killed and 22 wounded. President, the only American ship to engage, experienced 3 killed and 19 wounded. Langley says “…its surgeon and mates cared for the wounded.”(1)

Commodore Rodgers and his squadron proceeded to patrol within a day’s sail of the English Channel. Despite success in capturing British merchant ships – he had 80 – 100 prisoners aboard – the squadron had to return home to Boston earlier than planned because of a widespread outbreak of scurvy among his crews.(2) Langley says that his crews were hospitalized at the Boston Navy Yard, but this care must have been given in the Marine Hospital, because a Navy hospital in Boston was not constructed until 1836.(3)

USS Constitution meets HMS Guerriere (Image: U S Naval History and Heritage Command)

On August 19, USS Constitution won a celebrated victory over HMS Guerriere. Constitution suffered 7 killed and 7 wounded while her adversary lost 15 dead and 62 wounded. Surgeon Amos A Evans(4) and Surgeon’s Mate John D Armstrong attended the American injured; when the fighting was over, the two men transferred to Guerriere to assist her surgeon, who himself had been wounded, in the care of British sailors. Professor Langley gives us an interesting detail of Evans’s care of an amputee, one Richard Dunn. Two days after his surgery, when the patient complained of stump pain, Evans “wetted it with laudanum and gave the patient laudanum mixed with wine”.(5)

In October, November and December, ships in the American navy fought three more sea battles (I’ll write about lake battles later in this series) resulting in injuries cared for by naval surgeons. Stand by for future posts.

(1) Langley, Harold D., “A History of Medicine in the Early U.S. Navy”, Baltimore, Johns Hopkins Press, 1995, p 176.
(2) It is curious that scurvy should have been seen in large numbers at this late date, as the disease had been virtually eliminated from the Royal Navy by 1800, due to the common acceptance – by medical officers and commanders alike – of citrus juice as an effective antiscorbutic. The discussion of the conquest of scurvy in the Royal Navy by Lloyd and Coulter (Lloyd, Christopher, and Jack L S Coulter, “Medicine and the Navy, 1200-1900. Volume III–1714-1815″, Edinburgh and London, Livingstone, 1961, Chapter 18) is comprehensive.
(3) Langley tells that Congress appropriated $15,000 for a hospital in Boston to care for all sailors, both merchant mariners and navy sailors in 1802. The Boston Marine Hospital was constructed in 1803, and received its first patients in January 1804. The Marine Hospitals were operated by the Secretary of the Treasury; Navy officials came to believe this was an unsatisfactory arrangement because navy sailors had a propensity to desert from these places as they recovered from their illnesses or injuries. A Naval Hospital Fund, intended to pay for construction of hospitals specifically for the Navy, was passed in February 1811 and immediately funded with $50,000 transferred from the Marine Hospital Fund. The War of 1812 interrupted plans to build a Naval Hospital in Boston. It finally saw fruition in 1836. http://www.nps.gov/nr/travel/maritime/nav.htm accessed 4 August 2012.
(4) According to a brief University of Michigan biography, Evans studied medicine with a hometown practitioner “and attended lectures by Benjamin Rush in Philadephia”. He was admitted to the Navy in 1808, served in the naval hospital in New Orleans, in USS Constitution. While on shore duty, he earned his MD from Harvard in 1814. In 1815, he was promoted to be the navy’ s first Fleet Surgeon. He resigned from the navy in 1824. http://quod.lib.umich.edu/c/clementsmss/umich-wcl-M-262eva?view=text, accessed 3 August 2012.
(5) Langley, pp 177-178. Laudanum – tincture of opium – is a powerful narcotic pain medication. In his “Materia Medica and Therapeutics” (Philadelphia, F A Davis, 1891), John V Shoemaker, AB, MD, describes its beneficial application to wounds as “an antiseptic and to relieve pain”. http://books.google.com/books?id=SqBmb4sJKoIC&pg=PA783&lpg=PA783&dq=topical+laudanum&source=bl&ots=kL0jaQRZP4&sig=FknCNMtEPs3HcW-HAorPYvDeYTI&hl=en&sa=X&ei=2oUcUImjLMiuiALs3YGABA&sqi=2&ved=0CFAQ6AEwCA#v=onepage&q=topical%20laudanum&f=false accessed 3 August 2012.

©2012 Thomas L Snyder

U S Naval Receiving Hospital San Francisco California, December 1944 – December 1945

One of the joys of being the Executive Director of the Society for the History of Navy Medicine is that, on occasion, a person will find me on the internet and offer to share something about a relative who served in the Navy, typically, in World War II.

Such was the case when I received an email from the daughter of Ken Crawford, PhM2, USNR. Ms Crawford made mention that she held her dad’s “Anniversary Booklet” for the United States Naval Receiving Hospital, San Francisco, and asked where she might donate it. I  referred Ms Crawford to the archivist at the Navy’s Bureau of Medicine and Surgery, in Falls Church, VA. But first, I asked if I might have an opportunity to see the booklet for my own research purposes. The little treasure arrived in my mail today.

U. S. Naval Receiving Hospital (Fleet Hospital No 113), San Francisco, California, 1944-1945 (From the hospital Anniversary Booklet

According to the Booklet, the hospital was originally assembled at the Medical Supply Depot in Brooklyn, and later expanded “in echelons” at the Naval Supply Depot in Mechanicsburg, Pennsylvania. Shipped to California  in September, 1944, the hospital’s 61 “task force-type” buildings found their home in Crocker Amazon Park, at Geneva Ave and Moscow Street in San Francisco.  Commissioned on 9 December 1944, the hospital staff included 11 medical officers, 4 dental officers, 50 nurse corps officers, 11 hospital corps officers, 10 pharmacists, 2 chaplains, 2 supply officers and a Marine Corps officer and more than 600 enlisted people including (more than 500) pharmacists’ mates, storekeepers,  seamen, Marines, and 43 cooks. The number of patients this seemingly ample staff served is not noted in the Anniversary Booklet. The hospital’s missions were to receive overseas casualties, provide hospital services for nearby naval activities and “to act as a training center for newly indoctrinated medical officers and hospital corpsmen”.

As Robert C Fenning, LT (jg), Chaplain Corps, USNR wrote in the booklet, “To the returning casualty Fleet Hospital 113 was a pause for adjustment. On home soil again, he could offer thanks…” The hospital offered a full agenda of entertainments and activities including stage shows, celebrity visits (Walter Winchell, Jack Dempsey, Helen Hayes and Eddie Foy, Jr. are specifically mentioned), dances and sports activities.

“Receiving Examiner” for December 6, 1945

With the war over and patients eager to go home, the hospital was scheduled for decommissioning on 15 December 1945, just a year and a week after its commissioning. According to the ParkScan website, the Navy vacated the site in 1946, and the structures turned over to the San Francisco Housing Authority for use as veterans’ housing during the post-war housing shortage. The park returned to recreational usage in 1957.

©2012 Thomas L Snyder

 

 

 

 

 

 

Former Navy Surgeon General Named New AMSUS Executive Director

The Society for the History of Navy Medicine has a relationship with AMSUS in that he have mounted a panel at the organization’s annual meeting and plan to do so in future. Given that, the announcement here should be of interest. I received it in this morning’s email traffic.

The AMSUS Board of Managers is delighted to announce the selection of retired Vice Admiral Michael Cowan to serve as AMSUS Executive Director. Doctor Cowan will follow retired Major General George Anderson in this key leadership role. Doctor Anderson has served as Executive Director since 2005 and will complete his time at the helm in November, 2012.

AMSUS is the Society of Federal Health Professionals. The society was organized in 1891 and chartered by Congress in 1903 to advance the knowledge of healthcare within the federal agencies and to increase the effectiveness of its members. It is dedicated to all aspects of federal medicine – professional, scientific, educational and administrative. Presently our nearly 8,000 members represent all healthcare disciplines and serve in the Active and Reserve Components of all of the uniformed services as well as the Department of Defense and the Department of Veterans Affairs.

AMSUS will host its 118th Annual Meeting in Phoenix this fall, and Admiral Cowan will become Executive Director following that convention. He will continue to serve on the AMSUS Board of Managers and as the AMSUS Awards Committee Chair until he assumes his new role.

Prior to retiring from the Navy Admiral Cowan served as the 34th Naval Surgeon General and Chief of the Navy Bureau of Medicine and Surgery. Since retirement from the Navy he has been a professional services and information technology consulting executive for Oracle, Inc., BearingPoint, Inc., and currently at Deloitte Consulting LLP.

BG Michael J Kussman, MC, USA (Ret.)

Chair, AMSUS Board of Managers

Rum In the Navy

Two weeks ago, I related the urban legend of how Lieutenant – later Rear Admiral – Lucius Johnson, Medical Corps, U. S. Navy, introduced the rum-based daiquiri to Washington DC society in the late 19th century. I want now to briefly review the history of rum in the Navy.

“Rum had always been the naval drink, since beer and water did not keep at sea…” wrote Lloyd and Christopher in their definitive history of British naval medicine, “and gin was largely confined to the land, or to the wardroom.” When Admiral Sir Edward Vernon arrived in the West Indies in 1740, he was taken with the “swinish vice of drunkenness” he saw there. After consultation with his surgeons, Vernon hit upon the notion of diluting the rum ration with water as a way of reducing its intoxicating effect. The formula Vernon (referred to as “Old Grog” for the Grogram water-proof cloak he habitually wore) specified in the order he issued to his ships’ commanders was a quart of water added to the sailors’ half-pint daily rum ration. Thus was the famed navy grog invented.(1)

While Admiral Vernon’s innovation was widely adopted, Naval surgeons fretted and Admirals thundered about the “crime of drunkenness” throughout the 18th century. While floggings and other punishments were instituted in attempts to quell the widespread problem, another reforming Admiral, Lord Keith wrote in 1812, “…it will be impossible to prevent [it] so long as the present excessive quantity of spirits is issued in the Royal Navy; for men seem to have no other idea of the use of spirits than as they afford them the means of running into excess and indulging in intoxication”(2) According to Lloyd and Christopher, it was only with the changing mores incident to the Victorian era that abuse of spirits decreased. Cocoa became the more popular “pick-me-up” in the Royal Navy.

Despite the Revolution, our Navy adopted many customs of the Royal Navy, including the rum ration. As one naval history source(3) puts it, “[i]n the early days of the U.S. Navy rum was a part of daily life and the grog ration was a half-pint a day. During the days of Constellation there was a saying that showed the importance the men placed on their daily ration of grog. This saying was: “Blow up the magazines; throw the bread over the side and sink the salt horse – but handle them spirits gentle like.”

Late 19th Century Navy Copper Measures. Smallest is 1/2 Gill. U S Navy daily ration was 2 gills (Photo: http://www.thepirateslair.com/4-us-navy-copper-measures-1.html)

By the 1820s, the nation began to develop a predominating opinion toward temperance. The House of Representatives reflected this emerging sentiment by adopting a petition to encourage the Secretary of the navy to assess the effects of alcohol upon the service.  John Branch (served as Secretary of the Navy 1829-1831 tasked Surgeons Heerman, Barton and Harris the task of evaluating whether the grog ration was a “naval necessity”. Presumably reflecting informed medical opinion of the day, all three believed the grog rations “was unnecessary and harmful to morals and health”, and “subversive to discipline”. These experts recommended to the House of Representatives that sailors be encouraged to commute their spirit ration by being paid a generous sum of money as a means voluntarily reducing alcohol consumption.(4) Branch’s successor Levi Woodbury instituted this reform in 1831, setting the commutation rate at 6 cents per day.

In succeeding decades, despite multiple pressures for reform, the grog ration was not officially ended until 1862, by an Act of Congress passed 14 July. Personal stores of alcohol, the officers’ wine mess and alcohol retained for medicinal purposes and under control of the Surgeon were still permitted. It was not until 1 July 1914 that Secretary of the Navy Josephus Daniels’s General Order 99 prohibited “the use or introduction for drinking purposes of alcoholic liquors on board any naval vessel, or within any navy yard or station”. Medicinal alcohol is still retained. Your author, in destroyer service during the Vietnam conflict, had occasion to break out the medicinal brandy to reward a crew for rescuing a man overboard in hazardous conditions.

1. Lloyd, Christopher, and Jack L S Coulter, “Medicine and the Navy: 1200 – 1900 Vol III”, London, E & S Livingstone, 1961, p 88ff.
2. Quoted in Lloyd and Coulter, above, p.90
3. http://www.history.navy.mil/faqs/faq78-1.htm#anchor94512, paragraph “Grog”, accessed 23 July 2012.
4. Langley, Harold D., “A History of Medicine in the Early U. S. Navy”, Baltimore, The Johns Hopkins Press, 1995. pp 294-295.
 
©2012 Thomas L Snyder
Follow

Get every new post delivered to your Inbox.

Join 262 other followers