Between Flesh and Steel (20 page)

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.
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In 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.
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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.

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.
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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.
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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.
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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.
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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.
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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.
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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.”
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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.
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The army generally planned for a nurses-to-patients ratio of 1 to 10.
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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.”
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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.
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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.

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.
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At the same time, eighty-five military hospitals were ordered constructed or improved in the major fortified towns and cities of France.
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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.
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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.
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