While military medical care had improved greatly over that of the previous century, by any objective standard it was still poor. This situation was not so much a consequence of poor medical knowledge but developed because no army succeeded in organizing a permanent medical care system that was adequately staffed with trained personnel, provided for the prompt removal of the wounded, ensured adequate medical supplies, and established hygienic hospitals. As in the previous century, command of the armies remained in the hands of temporary commanders of the nobility, and the extent to which any planned medical facilities actually were constructed and operated depended greatly upon the degree to which the respective field army’s commander was prepared to provide the necessary resources. Thus, whatever military medical facilities were available during the last war or campaign had to be totally reconstructed from scratch for the next war. The old lessons had to be relearned, with the inevitable result that the medical care provided to the soldier suffered accordingly.
NAVAL MEDICINE
The first literary evidence of medical support provided aboard ship is found in the Iliad, where Homer recounted his shipboard surgeon, Machaon, treating his soldiers’ wounds. In the Odyssey (700 BCE), Homer writes of Ulysses ordering the bodies of the slain to be covered with sulfur and burned, the first account of sulfur fumigation in history. In Roman times, naval surgeons were common fixtures in the medical service. The first evidence of a naval surgeon is taken from the tombstone of N. Londinius, who was the physician on the Cupid, a quinquereme of the Roman Navy. During the reign of Hadrian (76–138 CE), each Roman naval ship carried a medical officer, and the fleet strength of the naval medical service was approximately one physician for every two hundred men. This figure compares favorably to the ratio of six and a half naval physicians for every thousand U.S. naval personnel in World War II. Because the Roman Navy enjoyed the lowest prestige of all the empire’s military forces, the Romans sometimes had difficulty recruiting naval physicians. Next to the names of some naval physicians is the term duplicarius, indicating that they received double pay.35 The Romans used hospital ships for the transport and care of their sick and wounded. The evidence is inferential and based on the Greek and Roman practice of naming their ships to reflect the purpose for which they were used. There are records of a Roman vessel named Aesculapius (the god of medicine), which may have served as a hospital ship.36
During the Middle Ages it was common practice to have a physician aboard ship. The navies of this period with the most complete records available are the maritime republics of Genoa and Venice, and both had naval physicians aboard ship as a matter of course. During the Crusades (1095–1291), as ships ranged farther away from home port, navies established shore-based medical facilities to treat the sick and wounded. The medical officers of Genoa and Venice issued the first health certificates to naval crews and originated the practice of quarantining ships to protect against the spread of disease.37
Although physicians had served aboard ships since ancient times, naval medicine did not become an important branch of military medicine until the age of Christopher Columbus (1451–1506). Previously, most voyages were along the coast and of short duration, making it possible to provide adequate water and provisions to ensure the crew’s health. The proximity of port facilities, including land-based hospitals, made treating the sick and wounded a less pressing matter than it became when ships began venturing upon the open sea for months at a time. Only then did maintaining the health of the crew and treating battle wounds become a real necessity.
In the colonial era (1500–1750), the ship of the line became a new and important instrument in the equation of national power. States wishing to compete in the expanded geographic arena of international politics developed large naval forces to press their interests far from their national home bases. The navy became the main method of projecting power internationally. Accordingly, the navies of France, Spain, Italy, and England expanded greatly during this century, giving rise to a new branch of military medicine.
Medical conditions in the armies of the day were poor, and they were even worse in the navies of the world. The ships of this period were 150–220 feet long and 40 feet wide and displaced two hundred to seven hundred tons. The vessels required a large amount of muscle power to operate, and crew strength ranged from 800 to 950 men. Eight men manned each of the forty to seventy-five guns aboard a frigate. By comparison, a modern frigate is between 500 and 800 feet long with a beam of 70–100 feet and is manned with between 500 and 800 men. The overcrowded ships of the eighteenth century were nests of disease and infection.
Service aboard ship was dangerous business. Crews were jammed into three and four decks, where the air was fetid and ventilation nonexistent, causing even minor outbreaks of disease to spread to the entire crew. In 1753, Stephen Hales (1677–1761) devised a system of small hand-driven pumps to pump fresh air belowdecks. The British Navy was slow to adopt this idea, even though naval commanders recognized its positive effects on improving the sailors’ health. Lord Halifax noted, for example, that for every twelve men dying from disease on an unventilated ship only one died on the new ventilated ships.38
The method of ship construction also contributed greatly to the ill health of the sailor. Ships were built of green timber in the mistaken belief that unseasoned wood better resisted the sea rot caused by salt water. Shipbuilders soaked the wood in brine and pickling solutions to harden it against the corrosive effects of salt water and worms. These green timbers were a constant source of dampness below decks, and the habit of washing the decks daily with salt water added to the dampness. Naval ships were always dank, damp, dark, and cold, and these conditions produced high rates of rheumatism and consumption among naval crews.
Discipline in national navies was harsh. Flogging was a routine punishment for even minor offenses and produced open cuts on the sailor’s back that became seats for infection. Sailors in the British Navy were not provided with regulation uniforms until 1857.39 Until that time they provided their own clothing, which was often little more than a collection of rags that the men never washed or even changed during the entire voyage. These poor habits produced frequent outbreaks of disease and infection. The practice of impressment also added to the health risks at sea. Press gangs “shanghaied” all manner of urban poor from the city streets for forced military service.40 The health of these marginal elements of the population was almost universally poor and often broke completely under the rigors of sea duty. Changing crews at sea brought newly impressed sailors into contact with healthier crews. With the navy failing to require either medical examinations or quarantine periods for the impressed sailors, disease and infection were constantly being reintroduced to the fleet at sea.
The nature of naval combat often produced even more horrible wounds than those suffered by the ground soldier. Heavy iron cannon balls fired from ships shredded the wooden deckhouses, decks, railings, and masts, producing showers of wooden splinters moving at high speed. When they struck a sailor, they produced horrible wounds. Explosions from poorly cast cannons produced further injury. The necessity of storing powder on deck near the guns posed the threat of explosions and flash burns, presenting yet another hazard to the sailor.
Poor diet—usually little more than hard biscuits, salted meat, and pumpkins— and crowded conditions made scurvy the most common disease of the sailor. It was a great killer of naval forces. It was not uncommon for a ship to lose between a third and a quarter of its whole crew to the disease on a long voyage. James Lind (1716–1794), the famous Scottish naval physician, recorded that in a single voyage of three months’ duration, the Channel Fleet reported twenty-four hundred cases of scurvy.41 Lind noted in his work in 1754 that regularly issuing lime juice could greatly prevent scurvy, but not until 1796 did the British Navy finally include lime juice a part of the sailor’s rations.
Medical care aboard ship was almost universally poor. Because of its low social status, poor living conditions, and long vo
yages at sea, the navy attracted the lowest-quality surgeons, assistants, and physicians, and most had little training. Surgeons were required to purchase their own instruments, and many who could not afford them borrowed saws, knives, and sewing instruments from the ship’s sailmakers and carpenters to perform surgery. Shipboard surgery and medical treatment were performed in a small room deep below deck called “the cockpit” that was poorly ventilated and lit, and the ceiling was too low for a man to stand fully erect. No system existed for evacuating the wounded from their battle stations and transporting them to the surgery. Most often a sailor dragged himself or a friend helped him to the cockpit. This practice was dangerous, however, since a sailor helping a wounded friend could be flogged for deserting his battle station. The small complement of medical personnel had no system of triage and enforced no priority of treatment. The wounded simply lined up for medical attention. It was not uncommon for a slightly wounded sailor to be treated while the more severely wounded succumbed to shock and bleeding while waiting their turn.42
The French and Spanish navies made an effort to return their dead to home port. Not so the British. Indeed, a wounded man aboard ship who was unable to make his way to surgery was likely to be thrown overboard while still alive. Usually an officer or petty officer—not the medical officer who, in any case, was far below deck attending to the wounded—led this “selection process.”43 When Lord Horatio Nelson was fatally wounded at the Battle of Trafalgar (1805), he begged the ship’s captain not to have him thrown overboard. Capt. Thomas Hardy agreed, and when Nelson succumbed to his wounds, his body was sealed in a cask of brandy for transport back to Nelson’s father’s parsonage for burial. To this day the daily brandy ration issued to British sailors is called “Nelson’s blood.”
Surgery aboard ship often involved amputation. British naval surgeons heated their knives in scalding water in the belief that a hot knife caused less pain than a cold one. American medical officers imitated this practice, which had the unintended effect of providing some degree of antisepsis. The patient was given liquor or opium, if available, and a piece of leather to chew on while the cutting was accomplished. Because of the low degree of surgical training, the poor operating facilities, and the heat of battle, naval surgeons seemed not to have given much consideration to preparing the stump for prosthesis. The mortality rate was, of course, horrendous.
The care of the shipboard sick was equally primitive. Ships were not usually equipped with sick bays as such. The more customary arrangement was to leave the sick person to recover in his own hammock. Sometimes a small area belowdecks separated from the rest of the crew by canvas partitions was provided, but these primitive sick bays were located out of the way in the darkest, least-used, and unventilated areas of the ship. Also, although vaccination was now becoming commonplace in armies and other navies, the British Navy did not require vaccination against smallpox until 1858.44 Under these conditions, smallpox epidemics were commonplace aboard naval vessels.
Shipping large ground forces to colonial areas for military operations increased overcrowding; consequently, losses to disease aboard ship were often even higher than normal. To deal with this problem, the navy provided “hospital ships” to accommodate the sick. These vessels usually had no medical personnel aboard, and the ships’ physicians were forbidden to leave their own vessels to treat the sick. These hospital ships became little more than disease-ridden floating warehouses where the ill remained until they either recovered or died. A physician accompanying Lord Cathcart’s campaign in the West Indies in 1739 describes the conditions aboard one of these hospital ships anchored in Cartagena Harbor: “The men were pent up between the decks in small vessels where they had not room to sit upright; they wallowed in filth; myriads of maggots were hatched in the putrefaction of their sores, which had no other dressings than that of being washed in their own allowance of brandy.”45 The sailors threw the dead overboard, where they floated on the surface while sharks and birds of prey fed upon them in full view of the surviving patients.
These conditions did not escape the attention of physicians, and some undertook efforts to correct them. Among the more important naval medical reformers of the period were Lind, Thomas Trotter (1760–1832), and Gilbert Blane (1749–1834). Lind published three major naval medical treatises: A Treatise of the Scurvy (1754), An Essay on the Most Effectual Means of Preserving the Health of Seamen in the Royal Navy (1757), and An Essay on Diseases Incidental to Europeans in Hot Climates (1768). As noted earlier, Lind recommended lime juice be added to naval rations to prevent scurvy. He also argued for special tenders on which impressed recruits could be examined and quarantined before being allowed aboard ships of the line, and the navy adopted this reform in 1781. Further, Lind advocated for an improved diet, better uniforms and in sufficient number to permit regular changes, the use of quinine for malaria, and the regular issue of soap for bathing. Trotter became a strong advocate of vaccinating naval crews and recommended it be made compulsory. He also suggested ventilating the lower decks and using chemical disinfectants to clean the ships’ compartments. In his Medicina Nautica: An Essay on the Diseases of Seamen (1797), he recommended creating a naval health board to compel ships’ captains to implement basic sanitary measures, including more beds, more fresh air, and the liberal use of soap.
The navy implemented few of Lind’s and Trotter’s suggestions with any degree of regularity; however, Gilbert Blane, a scholar, used his political influence, reputation, and writings to provoke the navy to use many of their ideas. In 1785, Blane published his Observations on the Diseases of Seamen, which finally moved the naval authorities to exercise reforms. Blane succeeded in having the medical supplies of ships improved, soap issued on a regular basis, and the assignment of a regular space for use as sick bays. As a result, the British seaman’s health improved dramatically. In 1782, before these reforms, of the 100,000 sailors and marines in the British Navy, the proportion of sick sailors transferred to hospital to fit sailors was 1 to 3.3. Thirty-one years later, after many of Lind’s, Trotter’s, and Blane’s reforms were effectuated, of the 140,000 sailors and marines in the navy, the ratio of sick to fit personnel was only 1 to 10.75.46
The prevailing conditions, however, remained common until well into the nineteenth century when the permanently standing national naval medical services applied the national armies’ lessons pertaining to health and surgery to naval medicine. The introduction of the iron ship near the end of the century also altered the nature of the medical challenges aboard ship. Large enough to carry sufficient provisions and to distill its own drinking water, the modern naval ship’s conditions drastically reduced the health threats that sailors faced. But the nature of the ship’s construction created new problems for medical treatment while under battle stations. Replacing the old problem of flying wooden splinters was a new threat of airborne metal, fire, explosions, crushing injuries, and steam burns. Naval personnel closed their new ships’ watertight compartments when under fire, effectively making it impossible for the medical staff to reach the wounded and increasing the likelihood of wounds becoming infected. As in times past, the sailor had to depend on his mates sealed with him in his compartment to provide sufficient medical treatment to keep him alive until he could be transported to a naval surgeon. If a lull occurred in the battle, the men could remove some casualties to clearing points. Usually, however, the wounded sailor on the iron ships had to await the end of the battle before receiving treatment from medical personnel. Sometimes, as in the Battle of Tsushima Straight in 1904, the casualties had to wait until the ships disengaged and were safely out of harm’s way before they could be treated. Many of the Russian wounded lingered eight days before being attended to by the remaining members of the ship’s medical staff.
ENGLAND
The total medical staff of the British Army in 1718 was 173 medical officers, staff, regimental surgeons, garrison physicians, and surgeons’ mates for a field army of eighteen thousand men on campaign.47 I
n peacetime, few physicians or surgeons were regularly assigned to military postings. The few evident career medical personnel were some staff members and a few surgeons’ mates. In garrisons, officers and medical personnel were commonly granted extended leaves. In colonial garrisons, medical officers could be away for months, leaving these garrisons without any medical support. In 1751, English surgeons were permitted to wear the uniform of the troops to which they were attached. A law was passed in 1783 prohibiting the sale of surgeon positions in the army; however, the abuse continued for almost another century.48
Mention has already been made of John Hunter’s contributions to British military medicine and treatment of gunshot wounds. John Pringle, also made a number of significant contributions. In 1752, Pringle published what was perhaps the best work of the century on military hygiene, Observations on the Diseases of the Army, and set forth the principles of military hygiene with a special emphasis on the need to ventilate military hospitals. Pringle had noticed that soldiers treated in crude, drafty regimental hospitals often had far lower rates of wound infection than those treated in the large rear area hospitals. In addition, he suggested constructing barracks hospitals, identified hospital and jail fevers and proposed treatments for them, anticipated the practice of antisepsis, and used the term “influenza” for the disease that later came to be named such. Other major contributors to military hygiene were Richard Brocklesby (1722–1797), who wrote Economical and Medical Observations on Military Hospitals and Camp Diseases in 1764; Hughes Ravaton, a French surgeon, published Chirurgie d’armée in 1768; and Jean Colombier (1736–1789) published the Code de médecine militaire in 1772. All these works suggested great improvements to prevent and treat disease in the armies of the day. Unfortunately, the armies adopted few of the comprehensive approaches to military medical care on any scale until the next century.
Between Flesh and Steel Page 14
