Military medicine, 175, 8: 118, 2010 118 military medicine

MILITARY MEDICINE, Vol. 175, August Supplement 2010 119
the epidemic constitution of the atmosphere. During their 
voyages, soldiers and sailors contracted new fevers and devel-
oped what are now defi ned as dietary defi ciency diseases. 
Efforts to prevent these diseases increased during the 18th 
century and, while empirical, some preventive modalities 
were evidenced based. 
Aboard the HMS Salisbury during the War of Austrian 
Succession, James Lind conducted the fi rst case-control study 
using oranges and lemons in the treatment of scurvy.
3
Although 
he proved the value of citrus fruit as a treatment and preven-
tive for the disease, it would take another 50 years before his 
fi ndings were implemented by the Royal Navy. Disease rates 
were also found to decline if sailors were made to change their 
clothes regularly and wear shoes aboard ship, sensible sugges-
tions that were implemented. 
Smallpox inoculation—rubbing smallpox scabs into a 
small incision hopefully to induce a mild case of the dis-
ease—was another evidence-based intervention, which 
gained acceptance in the 18th century. From midcentury the 
British Army in North America practiced voluntary inocula-
tion in the face of epidemics, but when smallpox threatened to 
destroy our army at Morristown in the winter of 1777, General 
Washington ordered that the entire army be inoculated. It was 
a bold move considering the dangers of inoculation, and to 
ensure this modality did not generate a smallpox outbreak, 
soldiers were segregated from nonimmunes and others who 
were sick. 
Segregating those with similar maladies was found to be 
benefi cial later in our war for independence by James Tilton. 
He designed smaller, well-ventilated hospitals and found less 
hospital transmission of camp fevers that we recognize today 
as typhus, streptococcal infections, and respiratory disease. 
The 18th century also saw a concerted effort on the part of 
medical offi cers to educate line commanders. John Pringle, 
MD, who fi rst defi ned jail, ship, and hospital fevers as all 
one disease, what we know today as epidemic typhus, wrote 
the fi rst English military medicine text in 1752. “My chief 
intention,” he stated, “was to collect materials for tracing the 
remoter causes of military distempers, in order that whatever 
depended upon those in command, and was consistent with 
the service, might be fairly stated so as to suggest… measures 
for preventing or palliating such causes in any future cam-
paign.”
4
Pringle’s text and the good relationship the medical 
establishment had with line offi cers had a positive effect on 
soldier health during the Seven Years’ War, in which small-
pox, scurvy, and dysentery were the main disease threats. 
This desire to educate line offi cers concerning soldier 
health continued in 1764 with the publication of Richard 
Brocklesby’s Oeconomical and Medical Observations
5
and 
Donald Monro’s An Account of the Diseases which were most 
Frequent in the British Hospitals in Germany with advice on 
military hospitals and soldier health. Monro’s book included 
specifi c instructions concerning clothing and diet in various 
climates, treating cold injury and avoiding heat injury on cam-
paign, and maintaining cleanliness aboard troopships.
6
Organizational, operational, and logistical requirements of 
the service, directed by line offi cers not physicians, determine 
who is recruited, the type and style of uniform, the soldier’s 
load, the rations eaten, and the health measures employed. 
The 18th century British soldier was recruited from the coun-
try yeomanry and the sweepings of jails. He was well fed for 
the era and trussed up in a tight fi tting wool uniform, which 
constricted his respirations and circulation, and altogether 
weighed close to 80 pounds.
7
His American counterpart was a volunteer who came to 
the war dressed as he was carrying his own fi rearms. General 
Washington, although he tried throughout the war, never had 
a uniformly clad army or one that was regularly or adequately 
fed by the government. However, he was devoted to preserv-
ing the health of his command. In early 1778 he selected a 
like-minded German offi cer, Baron Friedrich von Steuben, 
to train the provincial army then wintering at Valley Forge. 
Commissioned a major general, von Steuben did a superb 
job especially in training offi cers to attend to health issues. 
Later he produced the fi rst health regulations for an American 
army.
8
The following year Dr. Benjamin Rush published 
Directions for Preserving the Health of Soldiers . His text, like 
Brocklesby’s and Monro’s, was addressed to line offi cers and 
provided sound epidemiological observations. Increased trans-
mission of airborne diseases occurs in crowded tents. Young, 
immunologically naïve soldiers brought together from differ-
ent parts of the country had more illness than older, previously 
exposed soldiers. Southern troops had a greater incidence of 
malaria and other parasitic diseases than did their northern 
neighbors. Also Rush specifi cally noted the role and authority 
of the line offi cers in preventing disease and ensuring health 
with the advice and support of their medical offi cer.
9
Medical science began to positively impact army and sol-
dier fi tness in the 18th century. However, the line–medical 
offi cer relationship always suffered from a lack of concensus 
in, and predictability of, that science in the medical advice 
offered. Inoculating with smallpox might preclude an out-
break, but it might generate the epidemic one wished to avoid; 
changing camps frequently might reduce disease, but maybe 
not if carriers of typhoid, diphtheria, or meningitis were in the 
ranks; and citrus juice might prevent scurvy if the vitamin C 
had not been destroyed in preserving it. 
Some early 19th century medical offi cers, such as Army 
Surgeon General Joseph Lovell, systematically employed the 
current science to improve soldier fi tness. Surgeons main-
tained meteorological records, investigated the relationship 
of disease incidence to climate and weather, and provided 
recommendations on the health of forts and barracks on the 
basis of these descriptive epidemiologic studies. Lovell advo-
cated placing recruiting and disciplining practices within the 
domain of the medical offi cer.
10
His reports to the secretary of 
war concerning proper diet, exclusion of strong spirits, proper 
clothing and quarters, policing of camps, and his recommen-
dation for the senior surgeon of an army or district to function 
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