Monthly Archives: October 2012

Baltimore in Late October – Visiting USS Constellation

Right now, I’m attending the 2012 Congress of the Naval Order of the United States, a venerable (founded in 1890) organization dedicated to the preservation and promotion of U S Naval history. The Congress venue is located in Baltimore’s Inner harbor area, an attractive collection of museums, hotels, eating establishments, shopping and historic ships open for touring.

Sick Bay aboard USS Constellation. Baltimore MD.

This afternoon, we had some time off from our program of talks (largely about the War of 1812), so I walked the USS Constellation.  As you might imagine, I was particularly interested in how the ship’s medical spaces were portrayed and displayed. Located in ship’s bow, a level below the gun deck (two decks below the weather deck), the surgeon’s pit was quite a bit more spacious than I would have imagined. I’m not sure the photo here gives a good perspective, but here it is. In the foreground you see a box-like bunk for a sick sailor (much more comfortable, one presumes, than the usual hammock), and in the distance you see a table where, presumably, the ship’s surgeon plied his trade. The recorded commentary for the sick bay told that the Assistant Surgeon, Clark – attached to the ship during the Civil War – could amputate an arm in less than a minute. This fact was presumably reassuring to the ship’s crew members! A glass front storage cabinet had on display a set of very sharp-looking amputation knives. I didn’t see any bone saws on display but presumably, if one of the surgeon’s went dull, he had only to call out to the next deck below – where the carpenter worked – for a sharp replacement. The commentary also pointed out that the quality of Civil War Naval surgeons was better than the Army’s because the Navy had a system of rigorous exams that candidate surgeons had to pass in order to receive their Naval commissions. I recall that the topics covered in these exams ranged from anatomy and physiology to obstetrics and gynecology to medical jurisprudence. And the pass rates for candidates graduating from the (now) Ivy League schools was not particularly high.

Surgeon’s Cabin: his cover on his desk, bunk behind.

“Officers’ Country”, where the ship’s commissioned officers lived and slept is located in the stern of the ship on the same level as the sick bay. Arrayed on either side of a spacious central gathering and eating space were the officers’ cabins – those of the line officers (the ship’s Executive Officer and lieutenants) to starboard, the staff officers (purser, surgeon, chaplain) to port. The ship’s dispensary, a small space located to starboard between Officers’ Country and sick bay was where the surgeon’s steward mixed and dispensed drugs. Much drug treatment was termed “heroic medicine” – purgatives to clear bad fluids and discharges from the body. A few truly effective medicines were available though: quinine for “fever” (especially, of course, fever of malarial origin) and mercurials, which, if used judiciously, might be useful in treating syphilis, if over-prescribed, could kill a man with mercury poisoning.

The derivation of the term the ship’s “head” (bathroom) in a sailing ship became quite clear on tour in Constellation: all crew members except the Captain (who enjoyed the pleasure of a private head – and a bathtub) had almost to climb the bowsprit at the very front of the ship to do their business. And this never occurred to me before: since the wind was coming from behind the ship, it would in fact blow the waste away, ahead of the ship. And, as the commentary noted, copious sea spray helped keep things pretty clean up forward.

One other observation: the smell below decks in Constellation reminded me of the smell in the aging caves in California wineries. I think it’s the smell of the oak used to make ships and wine barrels. And another thing: the decking timbers is least an inch and a half thick. They were pretty generous in their use of that oak, back in the day.

©2012 Thomas L Snyder

William Osler on Military Medicine (2)

In the first of this series, I noted that the beloved William Osler, teacher, writer, philosopher of medicine, had little to say about military medicine in his years at the University of Pennsylvania and Johns Hopkins.

William Osler, Regius Professor of Medicine, Oxford, 1906. http://digital.library.mcgill.ca/osler/fullrecord.php

This changed when Osler, a Canadian citizen, moved to Oxford as the Regius Professor of Medicine in 1905. Always a bibliophile, he began to avidly collect medical antiquities, and he may have dusted off his Latina and perhaps his Greek reading skills. As a result of his collecting and reading, he seems to have become more aware of the role of military doctors in the history of medicine. Among the antiquities, for instance, he cited Dioscorides, an army surgeon in Nero’s time as one of the first “scientific” students of pharmacology. (1)

In 1909, Osler reflected his study of more recent medical history when he mentioned the work of British Royal Navy scurvy pioneer James Lind, and malaria researcher Vandyke Carter of the British Indian Medical Service to highlight their individual contributions to the advancement of medical knowledge.(2)

Up to this point, Osler’s outlook emphasized the work of individuals in their quest to advance medical science. Gradually, however, he began to express appreciation for  the importance of military medical organizations, in what we would today call public health initiatives. Already, in a 1901 essay Medicine in the Nineteenth Century, he had cited the success of the German army in eliminating smallpox from its ranks by vaccination (3). In 1909, he noted the key role of a military organization in eliminating endemic tropical diseases thus:

It was a fortunate thing that the head of the American occupation of Cuba was General Leonard Wood, himself a well-trained physician, and deeply interested in problems of sanitation.  Backed by the military arm it took Dr Gorgas and his colleagues nine months to clear Havana, which had been for centuries a strong hold of [yellow fever].(4)

In 1914, with the outbreak of the Great War, Osler put on the uniform of an Honorary Colonel in the Oxfordshire Regiment, and by August, he was advocating for compulsory vaccination of British troops

Colonel Sir William Osler at Clivedon, site of a Canadian Military Hosptial, of Which He was Chief Physician. http://digital.library.mcgill.ca/osler/fullrecord.php

against typhoid fever. In a letter he prepared for The Times of London late in the month, he cited “the work of French army doctors and of British army surgeons, particularly in India” for “the remarkable reduction in the incidence of typhoid when vaccination is carried out”. In the same letter he wrote “[the] experience of the American Army is of special value, as the disease is so much more prevalent in the United States…” (5) In October, he again cited the success of armies (German, French, American) in virtually eliminating the disease by vaccination. (6)

I’ll conclude this consideration of Sir William Osler’s thoughts on military medicine in my next post.

(1) Cushing, Harvey, The Life of Sir William Olser, Oxford, Clarendon Press, 1925, vol ii, p 122, quotes an Osler letter in which he detailed his exploration of the Vienna Hofbibliothek, where he had a chance to see a fifth Century Dioscordian manuscript; he described this as “one of the great treasures of the library”.

(2) Osler, William, The Nation and the Tropicsan address at the London School of Tropical Medicine, quoted by Cushing, vol ii, pp 192-194, and published in the Lancet, 1909, vol 2, pp 1401-6.

(3) See Osler’s volume Aequinimitas, with Other Addresses to Medical Students, Nurses and Medical Practitioners, available in several printings and editions. The 1905 edition (Blakiston, Philadelphia) cites the elimination of smallpox in the German army by a program of  “efficient revaccination”, pp 251-252.

(4) The Nation and the Tropics, cited above.

(5) Letter to The Times is quoted by Cushing, vol ii, p. 427

(6) Osler, William, Bacilli and Bullets, an address to the Officers and Men in the Camps at Chum. I originally found this in the Osler Library in McGill University, in a volume “The Collected Essays of Sir William Osler” by John P McGovern and Charles G Roland, Editors, The Classics of Medicine Library, Birmingham (Alabama), 1985. This is now available on line: http://archive.org/stream/bacilliandbullet031212mbp#page/n9/mode/2up, accessed 19 October 2012.

©2012 Thomas L Snyder

William Osler on Military Medicine

William Osler, MD

William Osler – later, Sir William Osler – is seen by many in the profession as the father of modern medicine. Born (1849) and educated in Canada (University of Toronto and McGill), he matured at McGill (1874 – 1885) and the University of Pennsylvania (1885 – 1889), and reached the apogee of his career as one – along with William Henry Welch (pathology), William Halstead (surgery) and Howard Kelly (Gynecology) –  of the “Founding Four” professors of the Johns Hopkins Medical School (1889 –  1905). In his maturity, Osler, still a Canadian citizen, was invited to become the Regius Professor of Medicine at Oxford (1905 – ), a post he held until his death in 1919. Osler introduced bedside teaching at Johns Hopkins, an innovation at that time. He was accused of being a therapeutic nihilist, when in reality he simply did not use treatments that had no backing in science or in experience. His textbook of medicine, first published in 1892, was very influential; with updates, it continued in publication until 2001. Osler’s humanitarian and scientific ideals are held in very high regard within western medicine to this day. There are Osler Societies throughout the English-speaking world, and in Japan.

I first “met” William Osler while I was researching the history of my (Albany) medical school’s World War I  (Army) Base Hospital No 33. Albany Med stood this unit up after the onset of hostilities in Europe, as did many US medical schools and hospitals, under provisions of the National Defense Act of June 3, 1916. When the outfit set up shop in Portsmouth England in 1918, William Osler, then an honorary Colonel in the Oxfordshire Militia and consultant to many Canadian Army hospitals in England, was on hand at the hospital’s commissioning and personally raised the American flag over the facility.

By this time, with England embroiled in that devastating war, and Osler’s  thought was inevitably dominated by military medicine. But this was not always the case. In fact, according to Osler’s biographer the great physician Harvey Cushing, Osler “hated war”. (1) Certainly the lack of writings on military medicine in his early professional years bespeaks at least of disinterest in the matter.

However, during his years at Penn, he developed friendships with several Army medical leaders, among them the eminent bacteriologist and epidemiologist George M Sternberg. When he became Army Surgeon General, Sternberg established the Army Medical School, and it was he who induced Osler to speak to the first graduating class of the school on “The Army Surgeon”. (2)

In his talk to the five members of the Class of 1894, Osler offered the thought that the isolation experienced by Army Surgeons stationed in remote forts could lead, in a man of independent nature, to a healthy self-reliance, and he named such medical luminaries as Jenner and Koch as men who did their pioneering medical research in isolated settings.  Addressing a strength of military organization, he noted the remarkable success that several armies had enjoyed in public health efforts to prevent diseases like smallpox (through systematic revaccination) and typhoid fever through careful attention to field sanitation.  He closed by emphasizing that these new graduates would have great opportunities to advance medical knowledge; all they had to do was to seize them. This was all pretty academic stuff, and Osler made no mention whatever of the matter of combat casualty care.

Two years later, in a talk  “On the Study of the Fevers of the South”, given at the AMA in Atlanta, Osler pondered war and pestilence. He gave the nod to pestilence:

Humanity has but three great enemies: fever, famine and war; of theses by far the greatest, by far the most terrible, is fever. Gad, the seer of David, estimated aright the relative intensity of these afflictions when he made three days’ pestilence the equivalent of three month’s flight before the enemy, and of three (or seven) years of famine. As far back as history will carry us, in ancient Greece, in ancient Rome, throughout the Middle Ages, down to our own day, the noisome pestilence, in whatsoever form it assumed, has been dreaded justly as the greatest of evils.

 Osler did appreciate recent advances in medicine to reduce the impact of “fever” – cinchona for treatment of (malarial) fever,  vaccination for prevention of diseases, and asepsis in surgery – he celebrated only the work of civilian medical workers in these successes.(3)

Despite the good news in medicine that Osler highlighted at the AMA, he did not report, and may have been unaware that a shift in the cause of soldier deaths was already under way. Nevertheless, the American Civil War bore out his conviction about the impact of pestilence – nearly twice as many men had died of non-combat causes, “pestilence” mostly, than had died of their wounds in that most horrific of armed conflicts. Just five years later, however, in the Franco-Prussian War, the numbers were reversed: about 28,000 Germans died of their wounds while around 12,000 succumbed to infectious diseases. (4) The data for French soldier deaths are more evenly distributed, but the trend was established: as scientific principles of disease prevention became applied, the impact of pestilence upon mortality in armies fairly rapidly declined. We do not know if Osler was aware of this change at the time.

It was only when he moved to England to take up the Regius Professorship of Medicine at Oxford, that military medicine began to enter the great physician’s thinking anew.

Next Post: The Evolving Thought on Military Medicine of Osler as Regius Professor of Medicine at Oxford

(1) Cushing, Harvey, The Life of Sir William Osler, Vol 1 (of 2), Oxford, Clarendon Press, 1925, p 631. Cushing wrote this in his commentary about Osler’s life in Baltimore, during his Johns Hopkins years. Cushing’s magisterial biography is available in many editions, including a one-volume book, published in 1940 and 1946. It is also available in a print-on-demand paperback edition, all from http://www.abebooks.com.

(2) Published in a collection entitled Aequanimitas with other Addresses to Medical Students, Nurses and Practitioners of Medicine. H.K.Lewis, London, 1904. The speech is available on-line at http://mcgovern.library.tmc.edu/data/www/html/people/osler/PA1/P25000.htm

(3) Osler, William, The Study of the Fevers of the South, JAMA, Vol XXVI, No. 21, May 23, 1894, pp 999-1004.

(4) The online source Statistics of Wars, Oppressions and Atrocities of the Nineteenth Century (the 1800s), http://necrometrics.com/wars19c.htm, accessed 14 October 2012, cites several authors with general agreement among them.

©2012 Thomas L Snyder

More on the Navy’s History and Heritage Command

My younger son is in town for a visit before he ships out to Maputo, Mozambique for a two year tour at our embassy there, so I won’t be writing this week.

However, you might find a podcast interview with the new Director of the Naval History and Heritage Command, done by the redoubtable “CDR Salamander” to be of interest. The link delivers you to the CDR Salamander blog page; then just follow the prompts to the podcast under “Talking History”.

CDR Sala-mander’s Logo

Next week, I’ll start posting a short series on Sir William Osler’s thoughts on military medicine. Born and trained in Canada, Osler came to the US to teach at Penn late in the 19th century. He found fame as one of the “Founding Four” of the Johns Hopkins University School of Medicine. Beloved by many in the profession as the father of modern western medicine, Osler was a prodigious writer on medicine in  its scientific, philosophical and historical dimensions. I researched this topic for a paper I gave at the American Osler Society a couple of years ago. I’ll put up a distilled version of that paper.

Sir William Osler