Waterloo
The Battle of Waterloo was fought on June 15, 1815. It lasted nine hours and ranged over five square miles of ground. Napoleon’s army numbered 70,000 men and the allied armies under Wellington, 60,000. When the battle was over, Napoleon’s force suffered 25,000 dead and 8,000 taken prisoner. The British and Hanoverian elements of Wellington’s army had lost 10,700 men killed and another 7,000 wounded.61 The Prussians lost 7,000 soldiers killed and another 7,000 wounded.62 Within an area slightly larger than New York’s Central Park, 56,700 casualties lay strewn across the blood-soaked ground.63 The French casualties continued to lie unattended for days, their medical service having been destroyed or disorganized in the battle. The British system was almost nonexistent, and as late as eleven days after the battle, British and French casualties were still awaiting treatment. The failure of the allied armies to prepare adequate general hospitals in Brussels and to provide transportation for the wounded meant that even when the wounded reached the rear hospitals, little medical treatment was available. Waterloo was a military medical disaster of enormous proportions.
Having dismantled their medical service a year earlier, the British were caught without any meaningful medical support at all. In theory, each battalion of six hundred men was authorized only one surgeon and two assistants. In reality, of the forty British battalions at Waterloo, only twenty-two had their full complement of medical personnel. One unit, the Twenty-Eighth Foot, suffered 50 percent casualties and had only one assistant surgeon to treat them.64 Few of these newly appointed surgical assistants, however, had any medical training. Without a corps of litter bearers, it was not uncommon for several men to help a wounded comrade to the medical tent and then refrain from returning to the battle. Wellington noted that 1,875 men were unaccounted for after the battle. They were later found to have helped their comrades to the medical tents and remained there until the battle ended.65 No provisions were made for wagons to serve as ambulances. Wellington had moved so fast to Waterloo that much of his wagon train, including the few medical assets available, were still miles away when the battle began. What few carts and wagons that the medical service could scavenge were useless as the roads to Brussels were choked with the soldiers and wagons of Wellington’s army as it withdrew. The general hospitals deep in the rear had only fifty-two surgeons and physicians to staff them. Under these conditions, the hospitals at Ostend, Brussels, Anvers, Ghent, and Bruges were useless.66 With its regimental hospitals designed to handle merely sixty casualties, the British medical service was quickly overwhelmed and collapsed. Only 273 medical officers were at Waterloo to serve the entire army, and at least a third of them had neither medical training nor combat experience.67
Thus the quality of medical care, especially surgery, left much to be desired. Amputations were frequent, with a mortality rate approaching 40 percent. The surgeon usually operated in the open, often on the ground, and without assistance. Even the general hospitals did not have operating rooms, and surgery was performed on makeshift tables. Unlike Larrey’s system, the British had no triage system, and the wounded often waited their turn in line regardless of the severity of their injuries. The largely untrained personnel of the medical service had little experience with ligature and the other means of hemostasis, and their delay in reaching the wounded proved fatal in thousands of cases. Bleeding the patient was still a common practice, and one can only guess how many wounded soldiers lost their otherwise salvageable lives because of it.
The one bright spot was English surgeon George James Guthrie, who accompanied Wellington on all his campaigns and was called “the English Larrey.” Guthrie’s experience with military surgery convinced him that Larrey was correct in his advocacy of primary amputation. In 1827, Guthrie published his Treatise on Gunshot Wounds: Inflammation, Erysipelas, and Mortification, on Injuries of Nerves, which established the doctrine of primary amputation in England and became the basic manual of British and U.S. military surgery until the Crimean War.68
McGrigor, who had been appointed director general of the Medical Department prior to Waterloo, held the post until the Crimean War. The medical disaster at Waterloo led him to attempt reform, but once again the government demobilized the army and drastically reduced funds for support its medical services. Curiously, Wellington did little to reverse this state of affairs. McGrigor tried to raise entrance standards for the medical service, purchased textbooks, began a medical library, and finally established an army medical school at Fort Pitt, England. Together with army doctor Henry Marshall (1775–1851), McGrigor attempted to institutionalize the practice of regular medical reports on the health status of the army, but this reform came to fruition only after the Crimean War had proven yet another medical disaster for the British. With the French medical service destroyed after Napoleon’s defeat and the British unwilling to learn from their experiences in the Peninsula and at Waterloo, the stage was set for yet another medical catastrophe when both countries once again stumbled into war.
THE CRIMEAN WAR
The Crimean War represented one of the great medical disasters of all time. Every major combatant entered the war with either an obsolete military medical system or, as in the Turkish Army’s case, no military medical system at all. A war in which only four major offensive ground engagements were fought, the Crimean conflict was characterized by continuous artillery bombardments and the terrible living conditions associated with long sieges and trench warfare that contributed to incredibly high rates of disease. The war saw the first use of the new conoidal bullet that Capt. Claude-Etienne Minié (1804–1879) developed. Along with the introduction of the rifled musket barrel that the Russian Army used extensively, this new ammunition increased the infantry’s range and killing power by a factor of seven.69 The new weapon produced battle wounds that were as much as thirty times larger than the size of the residual track of the penetrating projectile because the soft lead bullet broke apart upon impact. The improved rifle’s killing and wounding power was demonstrated in November 1854 at the Battle of Inkermann, where it caused 91 percent of the British casualties.70 While Russian and French forces used the new rifle, British forces remained armed with the Brown Bess smoothbore, muzzle-loading musket that fired round lead balls with a range of only 120 yards.
The medical statistics of the war were tragic. The French contingent numbered 309,268 men but only 500 medical officers. British forces comprised 97,864 troops with 448 medical officers, and the Sardinian contingent fielded 21,000 men with 88 surgeons. Despite the generally backward state of Russian military medicine at this time, the Russian Army deployed the largest military medical contingent with 1,608 medical officers and 3,759 feldshers for a force of 324,478 men. Turkish forces numbered 35,000 men but had no military medical support at all.71 The casualty rate from wounds and disease, when taken as a percentage of the forces deployed, was among the highest in history. For the Russians, of the 92,381 wounded, 14,671 men died; of the 332,097 sick, 37,454 succumbed to their illnesses; and 21,000 were killed in action.72 The French Army lost 8,250 men to hostile fire, 39,868 wounded, 4,354 died of wounds, 196,430 sick, and 59,815 dead from disease. The British suffered 2,255 killed in action, 18,183 wounded, 1,847 died of wounds, 144,390 sick, and 17,225 dead from disease.73 The Crimean War saw the highest battle losses per 1,000 men per annum (Russians) and the highest disease loss rate per 1,000 men per annum (French) than any previous war in recorded history.
Disease and infected wounds were the two largest causes of death among the armies. The germ theory of infection was still unknown, and the poor sanitary conditions in the few available military hospitals produced extremely high rates of wound infection and death. Among the British wounded in the Scutari hospital in Istanbul, for example, the mortality rate for amputees averaged nearly 30 percent.74 Of every 100 men admitted to military hospitals among the French forces, 42 percent died, or a hospital mortality rate equivalent to that of the Middle Ages.75 The disease rate per 1,000 men per annum was 253.5 for th
e French, 161.3 for the British, and 119.3 for the Russians. This proportion compares to a similar rate of 110 per 1,000 men in the Mexican War, 65 for the Civil War, and 16 in World War I.76
Florence Nightingale (1820–1910) and her trained nurses arrived in November 1854 after the Battle of Balaklava, and they introduced basic standards of hygiene and sanitation in the British military hospitals. Nightingale reported a hospital mortality rate at Scutari of 41 percent. As a result of her efforts, the rate dropped to 2 percent by the end of the war.77 She is often credited with starting the first female nursing corps in the Western armies. In fact, the credit for this innovation belongs properly to the Russians. The Russian grand duchess Elena Pavlovna (1807–1873) urged the czar to send trained female nurses to the Crimea so they could assist Nikolai Ivanovich Pirogov (1810–1881), Russia’s great surgeon general. A large nursing corps was deployed in Russian military hospitals almost a year before Nightingale and her nurses arrived in British military hospitals.78 That the Russian Army suffered fewer losses to disease and infection than the French did may be attributed, to some extent, to the former’s introduction of basic hygiene and sanitary conditions in its military hospitals earlier than the French did.
England
The start of the Crimean War found the British medical structure essentially as it had been in 1815.79 Despite McGrigor’s best efforts to institutionalize his reforms, the medical service had been allowed to deteriorate after Waterloo. No fewer than seven independent governmental authorities had some responsibility for operating the British medical service. The two major authorities were the Army Medical Department, then headed by a senior physician with no military experience, and the Ordnance Department, presided over by an appointed nobleman. They did not include any purveyors to purchase supplies or any apothecaries in the system at all; indeed, these positions had gone unfilled since 1830.80 The medical service had only twenty-six clerks housed in a small London office to manage the entire medical department.81 The British military medical service had sunk to such a low position that the only medical regulations governing its operations consisted of a small pamphlet drawn up years before that outlined the rules for managing a thirty-bed hospital in peacetime. In addition, the army lacked any standard sanitary regulations.82 Less than a year before the outbreak of war, the British made minor reforms in the administrative system and placed authority for the military medical service under a single administrative office, but this move produced no significant change in medical capabilities.
Of the 225 medical officers serving in the British Army’s medical service at the beginning of the war, only 52 had medical degrees, while the rest had surgical diplomas.83 The quality of the military surgeons’ medical training was close to what it had been a half century earlier at Waterloo. Curiously, most British military physicians and surgeons were of Irish and Scottish descent.84 Doctors from these areas lacked civilian opportunities as a consequence of class discrimination, so many entered the military to gain position and experience. Although the number of military physicians eventually grew to approximately a thousand during the war, it was never sufficient to handle the extensive casualties. British authorities argued, however, that the ratio of 1 medical officer to 77 men under Lord Raglan (1788–1855) was better than the ratio in the Peninsular War when British forces had 1 medical officer for every 145 men. It was also noted that the French had only 276 medical officers compared to the British 406, even though the French Army was twice the size of Raglan’s force.85
The British ambulance corps was woefully inadequate. Although a few prototypes of the Larrey-type ambulance evacuation wagons had been produced, their number was far too small to provide adequate support. Moreover, these few vehicles arrived late behind the deploying army, and since the quartermaster did not give the corps horses, drivers, or carpenters to assemble the wagons, they had to leave the vehicles in Varna. Each regiment was issued eight stretchers but no litter corps to bear them. Any available men for stretcher duty had to be drawn from the line regiments, a situation that often led to mustering the regimental band members, the recovering sick and wounded, and whatever few men the regimental commander cared to spare. When the army proposed hiring local Turks and Bulgars as stretcher bearers, London denied the option as too expensive. As the casualty death rate mounted, however, the War Office ultimately provided for raising a Hospital Conveyance Corps to act as stretcher bearers. To keep costs down, the corps recruited from old pensioners and low-status personnel whose only virtue was their willingness to work for low wages. This small corps arrived in Varna in July during a cholera epidemic and was immediately incapacitated by the disease. Because the British failed to plan for medical support, they never succeeded in establishing a regularized system of ambulances or stretcher bearers during the war. Instead, the physicians had to go into the line and treat the wounded in the trenches where they fell.
To move the wounded and sick to hospitals, the British improvised and had the navy ferry casualties from the Crimea to the two major base hospitals three hundred miles away in Turkey. Conveying the casualties from the line to the ports remained a major difficulty throughout the war, and the poor means of overland transport caused many deaths. The navy had plenty of ships to accommodate the casualties once they arrived in port, but it had no organized system for loading them. As a consequence, the wounded and sick often lay in the rain for one or two days until placed aboard. Further, only a handful of ships were modified to house and care for casualties. Most often no trained medical personnel and few medical supplies were on board. Overcrowding also became a problem. One ship, the HMS Kangaroo, was equipped to carry 250 casualties but packed aboard more than 1,500 sick and wounded on a single trip.86 Loss rates among the sick and wounded of 20 percent were common, and soldiers arrived at the hospital days after being wounded still in their dirty, mud-covered uniforms and with their wounds untreated.87 Only in the last year of the war did the British medical service establish regularly scheduled steamships for ferrying the wounded from the front to the general hospitals in the rear.
The general hospitals, however, were little more than pestholes. The largest hospital, at Scutari, had no beds, so patients lay on the floor with the same clothing or blankets they had brought with them from the front. It did not have a kitchen to prepare food, and its two thousand patients were expected to make do with only twenty bedpans. The British did not even create a corps of hospital orderlies until the end of the war. It took the arrival of Nightingale and her nurses to improve the basic sanitary conditions of the British general hospitals. Their simple sanitary procedures, such as providing bedding, changing sheets, wearing hospital gowns, and regularly washing the physical plant, drastically reduced the rate of death from disease and infected wounds.
Dr. John Hall (1795–1865) oversaw the British medical system in the Crimea. His medical staff of fifty-six men included a director of hospitals, forty surgeons and assistant surgeons, a medical storekeeper, and fourteen noncommissioned officers. The regimental medical system, in place for more than a century, remained intact for all its faults. The regiment’s medical assets stayed in the hands of the field commander, however, and medical personnel had no authority to coordinate medical care between regiments. The regimental hospital, also a relic of earlier days, was equipped with only twelve beds with blankets and sheets, a medical chest, and a pannier of medical supplies for the horse carriage. The bell tents could only be closed from the outside, and the treatment of most casualties occurred on the ground.88 Most trained physicians served in the general hospitals, leaving the regiments with the least trained personnel to deal directly with the wounded. From the start, the number of casualties overwhelmed the regimental system, and it never recovered its ability to deal adequately with the wounded.
The poor organizational structure of the British military medical service in the Crimea was equaled by the generally poor medical treatment it offered. Dr. Hall had strong suspicions about chloroform and believed that the pain
associated with surgery served to heighten the body’s ability to fight and survive amputation and infection. Although he did not prohibit it, Hall issued a warning on the use of chloroform that the younger surgeons took to mean that they ought not administer it regularly. The best trained and more experienced surgeons still widely used chloroform, but Hall’s directive kept the supply service from making chloroform a priority item to stock.89 Accordingly, chloroform was always in short supply, and the British missed an opportunity to standardize anesthesia’s use in battlefield surgery. Generally, the medical establishment also was strongly opposed to using chloroform. As late as 1857, the Crimean Medical and Surgical Society, an organization formed among surgeons who had seen service in the Crimea, warned against the general use of anesthesia.90
The medical horrors of the Crimean War provoked such a public outcry in the press and in Parliament that some reforms were attempted. Most, however, were not implemented in time to improve medical treatment during the war. In 1855, the medical service formed a corps of hospital orderlies consisting of nine companies of seventy-eight enlisted men to staff the general hospitals. After the war the corps became the Medical Staff Corps and a permanent part of the medical service.91 An inspector general’s postwar report led the British for the first time to establish a regular strength and resource table for medical assets. From then on, a medical corps of 280 men would be authorized for every division of 10,000 men. Unfortunately, the report did not address the formation of a stretcher or ambulance corps, and none was established on a permanent basis until the Second Boer War. In 1860, the first British military medical school to train military surgeons was established at Fort Pitt, and a system of regular medical reports was instituted throughout the army. In 1874, the regimental system, including its hospital system, was abolished to make way for new, larger fighting formations. The new hospital system, copied from the American experience in the Civil War, was organized around divisional units. In 1878, the army brought medical officer pay, privileges, and ranks into line with the rest of the service, but it still denied medical officers the privileges of command and needed the permission of their field commanders to gain control over medical resources. In 1890, the medical corps was placed on the same social and military level as the corps of engineers, and in 1898 its designation was changed to the Royal Army Medical Corps.92
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