Between Flesh and Steel (34 page)

This well of scientific talent continued to reside in the universities and research institutions until after 1866 and the Austro-Prussian War, with the result that military medicine remained generally behind that of other countries. The political fragmentation of the German state also presented significant barriers to utilizing German medical talent in the armies, for the old
länder
(state) regimental system made it difficult to form a professional national army. With national unification under Otto von Bismarck (1815–1898), these political barriers disappeared. Moreover, the creation of a national army raised the status of any association with the military, making a military career attractive to physicians. The reserve system, designed to rapidly fill
out the standing army, created expanded social opportunities for medical academics to obtain commissions in the reserve regiments. When these regiments were called to national service, as in the Franco-Prussian War, the best German physicians and surgeons in the country went along with them.
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Overnight, the German soldier became the recipient of the best military medical care in the world.

In the eighteenth century, military medical care had never been a matter of great concern for Frederick the Great. Between his death and the outbreak of the wars of the French Revolution, the German military medical system, along with much of the rest of the military establishment, had ossified.
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The press of the French wars, however, demonstrated the need for reform, and Johann Goercke (1750–1822), who served as surgeon general from 1797 to 1822, infused a new spirit into the German medical service.
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Goercke's battlefield experience convinced him to improve the medical service, and he spent two years studying medicine in the leading centers of Europe before attempting reforms. In 1795, he founded the Pépinière in Berlin to train military medical officers and established a reporting system for evaluating the competency of medical personnel. To attract talent to military service, he convinced the king to establish a pension for military medical officers. The Pépinière graduated 1,359 medical officers for service in the army between 1795 and 1821, when it became the Frederick Wilhelm's Institute.
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Goercke also obtained funds to create mobile field hospitals, but they did not become established until after the German defeat at Jena in 1806. By 1813, however, the German Army operated three general hospitals of twelve hundred beds each, one reserve hospital with three thousand beds, and nine mobile field hospitals of two hundred beds each. To support this system, thirty-eight military reserve hospitals were created in cities and towns.
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Although Goercke had introduced a small number of field ambulances as early as 1795, probably copying the French experience, by the time of Waterloo the army only had three ambulances left. The Prussian medical corps during the Napoleonic Wars had developed a well-trained litter bearer corps that was equipped with two-wheeled carts and distinctive badges and scarves for the personnel, but without a mobile ambulance system to transport casualties, the medical service still was rudimentary at best.
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Although some changes in the German medical service helped provide sufficient numbers of trained medical personnel to the army in wartime, the real stimulus for reform came with the experience of the Austro-Prussian War. For the first time the German Army used breech-loading rifles and artillery on a large scale. The Austrians, meanwhile, were equipped with the old smoothbore muzzle-loading cannon
firing case shot, while their infantry carried the muzzle-loaded Lorenz rifles with .57-caliber rounds. The Prussian Army numbered 669,076 men, of which 2,286 were medical officers and 1,909 hospital assistants. Also seeing service were 3,420 apothecaries.
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Medical support was organized around the army corps, not the regiment. It is unclear how the Germans hit upon this idea, but they probably copied it from the Americans' experience in the Civil War.
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Each army corps was provided with a medical train of three hundred men and an ambulance corps of one hundred men. The Prussians had twenty-seven corps hospitals, ten light field hospitals, and six general hospitals to treat casualties. Behind them were four reserve medical depots far to the rear. The system could accommodate forty-seven thousand casualties.
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Although the Prussian system was adequately staffed, its performance proved to be less than acceptable to the German high command. The Prussian Army inflicted more battle casualties upon the enemy than it suffered itself, but its sickness and disease death rates were higher. The army endured epidemics of cholera, typhus, and dysentery at higher rates than the Austrians did and averaged a manpower loss from illness of approximately 2.5 percent.
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Moreover, the death to wound ratio averaged between 11 and 12 percent, or much higher than expected, and the percentage of men with disease who were permanently invalided was also higher than expected.
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Shortly after the hostilities ceased, the German Army totally reorganized its medical service and created an independent military medical corps for the first time in German history.
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A few years later, the German medical corps performed so well in the Franco-Prussian War that it became the model that the British military medical system followed when it introduced reforms almost immediately after the war.
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The German hospital system remained almost structurally the same as it had been in 1866, but it had made great improvements in hygiene and sanitation. Most important was its first large-scale use of Listerian methods of antisepsis.
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The results were remarkable, and after the war Lister toured Germany as a hero, even while his innovations were still being debated in England and France.
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The Germans also made great improvements in their field ambulance system and assigned trained litter bearers to each regiment. A reserve litter company rushed stretcher bearers to those regiments that were particularly hard pressed. Special liaison teams whose task it was to manage the flow of vehicles from the field hospitals to the general hospitals coordinated the increased use of field ambulances.
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The medical service made extensive use of the American-style medical wagons that Dr. Letterman introduced in the Civil War, with their two tiers of ambulance beds, medical laboratory, and supplies of drugs and equipment.
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The smooth flow of wounded to the aid stations and collecting points behind the battle augmented the German medics' ability to provide treatment to the wounded soldier more rapidly than any other army had previously accomplished. Each German soldier was provided with his own sterile first aid kit, which included an elastic Esmarch bandage,
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sterile lint, and other bandages. When medical personnel reached a soldier, the equipment they needed to stem bleeding and prevent shock was thus readily at hand. Utilizing special units of noncommissioned officers as corpsmen trained in the tourniquet's use also reduced death from blood loss and shock. Among the Germans' most interesting innovations were the medical cards that the soldiers wore around their necks. The field medics used these cards to record the soldiers' injuries and condition. It provided the surgeon with a much-needed source of information that also saved time.
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As casualties flowed to the rear, the German Army's railway corps provided a crucial link in evacuating casualties to general and reserve hospitals. Each army corps had its own medical railway unit to coordinate and oversee the wounded's evacuation, with two hundred rail cars equipped with mattresses, straw, and nursing personnel who were organic to its organization. Those soldiers who were unable to travel were held at battalion aid or temporary barracks hospitals until their conditions stabilized. Railway medical personnel evacuated the most seriously wounded on a priority basis. Every hour or so, an average of fifty railway cars pulled out of German stations bound for rear area hospitals.
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The innovations of the German medical system greatly reduced the death rate. Using antiseptic surgery, curiously forbidden by the French, drastically reduced the surgical mortality rate from infection. Systematic vaccination, a procedure the French also chose not to employ, resulted in a smallpox casualty rate four times lower than what the French suffered.
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German Army doctors outnumbered their French counterparts almost 4 to 1, and the French ambulance corps was decidedly primitive by German standards. The French were still using hired labor to drive their field ambulances and saw the usual results. While the German system handled thousands of casualties smoothly, more often than not the French system was overwhelmed in the first few hours of battle. Even their rear area hospitals were inadequate to the task of handling the casualty load. The German system worked so well that for the first time in modern history, a war was fought where the number of casualties caused by hostile fire was greater than the number of soldiers lost to disease.

Perhaps no century in history saw more progress in the development of military medical care than the nineteenth century. The quality of care provided to a soldier during any period depended upon two factors—the quality of medical knowledge available to the military practitioners and the degree of organizational sophistication within an army to actually deliver medical care to the soldier lying injured on the battlefield. The nineteenth century witnessed the emergence of anesthesia, antiseptic surgery, and bacteriology as the three most important innovations in medical knowledge contributing to the improvement of military medicine. As rudimentary as these innovations were when compared to the degree to which they have developed in modern times, they were nevertheless revolutionary. Without them, many of the medical advances of the present day would not have been possible. In a sense, they were true conceptual revolutions that laid the basis for much of modern medicine.

Not a single major European army began the nineteenth century with an independent and well-developed medical system that could systematically deliver the medical knowledge of the day to the wounded soldier. By the end of the century, however, every army had such a system. Some, such as the Germans and Americans, gained extensive firsthand experience in handling mass casualties. Others either lacked this experience, as they fought only small colonial wars (British), or failed to learn from their experience with mass casualties (French and Russians). At the very least, however, although some armies failed to staff their medical services with adequate men and equipment during peacetime, the idea that any successful army required a medical service had set deep roots in all the armies of the world. Events might prove that existing arrangements for medical care were inadequate for a given war, but never again would a major power send an army into the field without providing some sort of medical care system.

The Franco-Prussian War of 1870 was the last major war of the century and produced the now commonly high casualty rates inflicted by modern weapons. Marking the last quarter century were small-scale colonial wars, often in medically hostile environments—for example, the Boer War and Spanish-American War—in which sickness and death by disease played greater havoc than injuries from weapons did. At the same time, medical advances in the etiology of disease contagion served as the starting point for a new approach in which it was more important to discover the mechanism of disease transmission than to discover the cause of the disease itself. Often after an initial period of terrible experience with disease epidemics among troops in the field, armies began to pay serious attention to preventing disease before an
epidemic occurred. This approach led to great upgrades in military hygiene, beginning with improvements in the health and quality of the soldier himself. Advances in bacteriology, in turn, led to advances in immunology, and the list of diseases for which inoculations were available increased.

Military medicine had reached a point in its development at which it stood on the brink of a new frontier where the soldier could expect to survive most of the rigors of the battlefield unless his body was torn apart by flying metal. The focus on military sanitation, disease, and hygiene, coupled with the fading memories of mass casualties produced in previous wars, led to a reduction in the number and type of resources available to the peacetime armies. At the same time, few military thinkers truly appreciated the lethal possibilities inherent in the technological improvements that had occurred in weaponry since 1870. Not a single army in the world had changed its tactical thinking very much since the last major war. Because the colonial wars had been short and cheaply fought, the strategic doctrine of the day held that the next war, even if fought among the major powers in the European heartland, would also be short lived, with victory going to the side that could most rapidly mobilize and deploy its reserves. When the shots fired in the streets of Sarajevo echoed through the chancelleries of Europe, events proved just how wrong these strategic thinkers' assumptions had been.

1
. McGrew,
Encyclopedia of Medical History
, 14.

2
. Hypnotism, popularized by Franz Joseph Mesmer, became known as mesmerism. Another earlier anesthetic technique that military surgeons used includes placing a metal helmet on the patient's head and striking it with a wooden hammer to render the patient unconscious.

3
. J. Antonio Aldrete, G. Manuel Marron, and A. J. Wright, “The First Administration of Anesthesia in Military Surgery: On Occasion of the Mexican-American War,”
Anesthesiology
61, no. 5 (November 1984): 585.

4
. Samuel Guthrie, an American, was the inventor of chloroform. He also invented the percussion cap that increased the rate of fire of Civil War muskets.