Between Flesh and Steel

by Richard A. Gabriel

  An important advance of this period is attributed to the British Navy. Although notorious for the terrible medical conditions aboard its ships, the British Admiralty in 1798 authorized the discharge of patients from military service on the recommendation of military surgeons and physicians. For the first time, illness and disease in the military became a question of medical importance and not one of morale and discipline.49 More important, now a surgeon as well as a physician could authorize a medical discharge, clearly demonstrating that the old barrier between the two disciplines had finally eroded to the point where, at least in the military, the surgeon was achieving equal status and influence with the physician.

  The organization of the British military medical service was quite good, at least theoretically. During the Seven Years’ War, each regiment was assigned a surgeon and a mate; some regiments had two mates. In cantonment, the army usually requisitioned a building or house and converted it into a regimental hospital. In the large towns to the rear, general hospitals were constructed to treat the more serious cases. The surgeons and mates attended the wounded on the field and sent them to houses or tents located in nearby towns and villages. The marching or “flying” hospital with its own tents, transport, medical, and nursing personnel followed behind the army. These mobile hospitals could handle approximately two hundred casualties at a time. When the army moved on, these hospitals retained responsibility for the care of the sick and wounded until they could be sent to the general hospitals located along the lines of communication twelve to forty miles to the rear.50

  This organizational structure remained the basic model for British military medical care until mid-century, when the flying hospitals were discontinued. Changes in the general hospital allowed the army to abandon the mobile field hospital. In the past, the general hospital had been a permanent fixed-base structure, but by mid-century “the hospital” had really become only a hospital staff.51 The medical staff marched along with the army, setting up medical facilities wherever they were needed. The army’s goal was to place a cadre of trained medical personnel at the regimental hospital’s disposal and deliver better-quality care closer to the front. The plan’s shortcoming was that because the new hospitals no longer had the tents, transport, and supplies that had accompanied the flying hospital, they had to rely exclusively upon the field commanders for these items.52 An emphasis on mobility underpinned this change in the British military medical system, because the British forces were expected to deploy and fight far from their homeland. Continental armies, meanwhile, usually fought on their own territory, so they retained the idea of military hospitals as fixed and permanent buildings.

  The British closed their general hospitals at the end of the campaign season and reopened them when the war resumed. When a hospital closed, the sick and wounded were transferred farther to the rear at great cost in pain, suffering, and epidemic. While moving, the men suffered harsh conditions, and since most regimental surgeons and mates were required to remain with their units to tend the troops in regimental hospitals, few medical personnel accompanied the patients on the trip. Often a third of the casualties died from exposure, disease, or injury. In 1743, the British shuttered its hospitals in Germany after the campaign season and shipped their sick and wounded to a general hospital at Ghent. Of the three thousand sick and wounded who began the trip, half died on the way.53

  In winter quarters, the regimental surgeons and mates provided medical treatment. While the quality of these personnel was generally lower than that found in the rear hospitals, in fact soldiers retained in regimental hospitals often had a better chance of survival than if they had been evacuated. First, they were spared the hardships of the evacuation. Second, the regimental hospitals were usually makeshift buildings with better ventilation than the general hospitals had. Third, the patient load was considerably lower, reducing crowding and the risk of epidemic and infection. The last point is important, for hospital mortality from disease was a major killer of military casualties. Between 1715 and 1748, the mortality rate from disease in British military hospitals was 20 percent.54

  Medical care in rear hospitals was not good. The chief matron described the largest British military hospital at Albany in the American colonies from 1756 to 1760, for example, as “little better than a shed.”55 These hospitals were invariably too small to handle a significant flow of casualties, and the practice of placing two patients to a bed did little to prevent infection. The hospital staff included a director, who was often not a medical man; a physician and surgeon; a purveyor responsible for purchasing supplies; an apothecary for mixing drugs; a chief female matron to oversee the nursing staff; and a large number of cooks, orderlies, laborers, and chaplains. With the exception of the senior physician and surgeon, few of the other personnel were well qualified. The low salaries and poor living conditions worked to dissuade many competent physicians and surgeons from serving in the military. Turnover in the nursing staff, which soldiers’ wives often filled, was high. The purveyor’s responsibility to keep costs low often led to supply shortages and corruption, to the great detriment of the quality of medical care.

  Although women had accompanied armies since ancient times and often been pressed into service as nurses, the British were the first to establish some regularity to the practice. By 1750, almost all nurses in the British Army were females, although some males served in that capacity as well. Most nurses were wives and widows of soldiers, but the British made efforts to plan for regular staffs of nurses in their hospitals. The position of chief matron was a regular and respected medical post and appeared in the table of organization for the medical service. A number of women made military nursing a career, and the leadership commonly assembled nursing staffs in England prior to a campaign and deployed them with the army in the field.56 The army generally planned for a nurses-to-patients ratio of 1 to 10.57

  Regimental medical services also left much to be desired. The quality of regimental surgeons and mates was the lowest in the army, and when a regiment occupied more than one cantonment, total responsibility for the men’s medical treatment fell upon the untrained surgeons’ mate. Few of the mates had any medical training prior to enlistment, and many joined the army to obtain that very training, hoping for some sort of medical career afterward. The surgeons’ mate was not a full-time position, so warrant officers of the line doubled as mates. When the army was engaged in battle, however, these warrant officers took their positions in the line, leaving the regimental medical staff without any help at all to treat casualties. Regimental surgeons commonly purchased their positions, and it was not unusual for a mate to secure his appointment by favoritism or by purchasing his surgeoncy and later be elevated to a staff position in the general hospital, all without any training whatsoever.

  A regiment’s usual casualty load ranged from five hundred to seven hundred men who needed some sort of medical treatment in the regimental hospitals. At the Battle of Albuera (1811), one surgeon described a situation in which he had three thousand wounded but only four wagons to transport them to the nearest general hospital seven miles away. Sir James Henry Craig (1748–1812), general of the British Army in Flanders in 1794, provided an apt description of the conditions that the soldier at the regimental level endured. Craig wrote, “Some kind of medical staff was improvised out of drunken apothecaries, broken down practitioners, and roughs of every description who were provided under some cheap contract . . . the charges of respectable members of the profession being deemed exorbitant. . . . The dreadful mismanagement of the hospital is beyond description.”58

  Military medical care also suffered as a consequence of the organizational relationship between the regimental and general hospitals. Senior medical personnel were quite aware of the poor quality of medical care found in regimental hospitals, and sometimes they pressured the field commander to forbid regimental surgeons from treating all but the most minor wounds. In particular, surgery was often prohibited. Regimental surgeons were encouraged to pass
the more serious cases or those requiring surgery to the general hospitals in the rear. Given the nature of emergency medical treatment on the line and the uncertainty of medical transport, these well-intentioned regulations usually resulted in an increased casualty mortality rate. Moreover, the general hospitals’ staffs, themselves of uncertain quality most of the time, were not adequate to handle high casualty loads, especially when a high proportion of them required surgery. Thus, for example, in 1742 in Flanders the general hospital had only one physician, one surgeon, one apothecary, and six surgeons’ mates to handle the entire casualty flow.

  The practice of closing hospitals at the end of each campaign season or disbanding them at the end of each war meant that almost the entire military medical system had to be reconstructed with new personnel whenever it was needed. Whatever expertise that had been acquired during the last war was inevitably lost. As a result, hospital staffs often performed dismally at the beginning of a campaign. As the war went on, however, these staffs improved as they gained experience. Mortality statistics from the War of the Austrian Succession (1740–1748) demonstrate this improvement. From the first large-scale landings of troops on the continent in 1742 until October 1743, 6,104 casualties were admitted to the general hospital, and 1,241 died, or a mortality rate of 20.3 percent. From 1744 until the end of the war in 1748, 24,612 casualties entered hospital, and 2,411 died, or a mortality rate of 9.8 percent.59 Upon the conclusion of the war, however, the experienced medical staffs of the military hospitals were released from service, taking their valued experience with them.

  FRANCE

  In terms of the structure of military medical care, the French system was the envy of other European armies. No monarch of the period did more to make military medical care of the soldier a formal state function than did Louis XIV. In 1708, the king issued an order that required physicians, surgeons, and hospitals to attend to the sick and wounded on the march. The order established a formal complement of two hundred physicians and surgeons for an army in the field. Moreover, special boards had to examine these medical personnel and ensure their competence. Louis also appointed 4 medical inspectors general to oversee the entire system, 50 advisory physicians to ensure quality medical practice in the military hospitals, 4 surgeons major to inspect military forts and camps, and 138 surgeons major to provide care for the armies in the field.60 At the same time, eighty-five military hospitals were ordered constructed or improved in the major fortified towns and cities of France.61

  A major reform was accomplished with the establishment of mobile field hospitals that followed the armies and augmented the care provided by the general hospitals. For the first time in any army of the period, these flying hospitals were not only staffed with adequate numbers of surgeons but also provided with their own independent source of supplies and transport, reducing the old problem of forcing medical units to beg the field commanders for them.62 While the French field hospital had been available for at least fifty years in one form or another, its lack of transport and supplies had always hindered its practical ability to aid the wounded. Without tents or wagons of their own, these early field hospitals often failed to reach the battlefield in time to do much good. It was not unusual for the soldier to lie on the field for a day or two, awaiting the medical units’ arrival.63

  The mobile hospital system, while a great improvement in the formal structure of military medical care, did not usually work very well in practice. Dedicated transport and supplies surely helped, but these units still had to rely on the combat units’ manpower for evacuating the wounded. It was not until the Napoleonic Wars that the army regularly provided to field hospitals the manpower assets to act as litter bearers and surgeons’ helpers.64 The resources and management of the field hospitals fell not under military command but to civilian contractors, a practice that often led to fraud, abuse, and lack of provisions. The same contract system was used to provide resources to the general hospitals, frequently with the same results.

  The Enlightenment in France led to an emphasis on scientific and statistical approaches to medical management in general. The emergent concern with the health of the general citizenry and the state’s provision of health and medical care encouraged a similar movement in military medicine.65 In 1718, the first formal hospital regulations were issued for the military medical service in a document of sixty-two paragraphs. These regulations were so comprehensive that they served as the basis for all future French military medical regulations for the next century. They included detailed instructions for hospital personnel, the medical treatment of patients, hygiene regulations for medical attendants, administrative practices for controlling hospital supplies, and military hygiene regulations aimed at preventing disease among the soldiery. The monthly pay of surgeons and physicians was moderately increased, and annual courses in anatomy were prescribed for all military surgeons. Most innovative was the regulation that the cost of the military medical service was to be paid entirely from the king’s purse, without taking deductions from the soldier’s pay as reimbursement.

  In 1775, a royal order authorized the opening of lecture rooms for instruction in military medicine at the hospitals in Metz, Lille, and Strasbourg. This decree marked France’s first attempt to create an army medical school. In 1782, the Journal de médecine militaire, the first French periodical devoted exclusively to military medicine, was established in Paris. The French experience in the wars of this period revealed that the general military hospitals often failed to provide adequate medical care because of their distance from the fighting and the rampant corruption and mismanagement that characterized their operation. To improve the medical care for the troops closer to the battlefield, the French military abolished general hospitals and created new regimental hospitals. In 1788, new regulations were issued assigning control of all military hospitals to a new military medical directorate composed of military physicians. A new sanitary council was established to oversee disease prevention and hygiene in the armies. The tide of the French Revolution (1789–1799), however, swept away these untested organizational improvements.

  The French medical system was similar to the British system in that the wounded were evacuated to hospital clearing stations located near the battle lines. Here the regimental surgeon attended the soldier. Major surgery was sometimes performed in these regimental hospitals, but for the most part they treated only the lightly wounded and prepared the more serious cases for shipment to the rear hospitals. If the patient survived the twenty- to forty-mile trip to the general hospital, he would undergo surgery there.66

  The French had no systematic method for evacuating the wounded from the front lines. Either a fellow soldier brought his wounded comrade to the medical tent or the wounded soldier made his way to the rear as best he could. The most seriously wounded moved from the regimental hospitals along the roads leading to the base of communications in the rear. Transport was sometimes provided for the medical units, but usually they used the empty food carts and supply wagons that had previously delivered supplies to the front. The wagon drivers were not military personnel but hired contractors who often treated the wounded cruelly, charged them a fee, robbed them, and even abandoned them on the side of the road if the highway became too crowded. Usually medical personnel did not attend the wounded in transit. When medical personnel were available, their numbers were invariably small. The horrors associated with moving the wounded provided an additional stimulus to reform the medical treatment system and to give the field medical detachments their own wagons and the necessary personnel to oversee the transportation of the wounded.

  Even with reform, the system remained fragile in times of high casualties. Military medical texts of the period note that it was not unusual for an army to suffer eight thousand wounded in a single day.67 Under these conditions, it was neither practical nor possible to assign field medical units the necessary personnel or transport to move sufficient numbers of wounded on any regular basis. Much as in modern wars, the me
dical services of the eighteenth century frequently became overloaded and broke down, with much attendant human suffering.

  For all its problems, however, the French military medical service on the eve of the Revolution was seen as the model for other countries, and Austria, Prussia, Denmark, and Sweden all reorganized their military hospital systems on the French model.68 The social disruption of the French Revolution, however, dashed the old system. In 1792, the new French Republic declared war on Austria. Motivated by the Revolution’s sense of national patriotism, fourteen hundred physicians and surgeons applied for service with the new French national army.69 In August 1793, the National Convention placed all physicians, surgeons, and apothecaries at the service of the Ministry of War. By the end of the year, 2,570 medical officers of various types attended to the needs of the revolutionary armies.70 Within a few months, their number grew to more than 4,000, and by the end of the war in 1794, 8,000 medical personnel of various types had seen service with the armies.71

  The war and social revolution had near catastrophic effects on the educational and organizational structure of the French medical establishment. In 1792, the National Assembly voted to abolish the eighteen medical faculties and fifteen medical schools in France, including the older schools in Paris, Strasbourg, and Montpelier and the Académie Royale de Chirurgie and the Société Royale de Médicine. In 1794, the state ordered the creation of medical schools for the express purpose of providing sufficient medical personnel to the armies. These schools trained only military medical personnel. After the disruption of the medical establishment, however, the quality of training in these schools fell drastically. Worse, the practice of medicine was thrown open to anyone of any status and education who could afford to pay for a license. Although the number of military medical assets available to the armies increased, the quality declined drastically. The French persisted with this system of military medical training until Napoleon ended it in 1804 and completely reorganized the military medical establishment.