Medicine in the eighteenth century centered around the effort to develop complete theoretical systems to explain disease and other medical phenomena. This approach was the logical consequence of the nascent empiricism that had emerged two centuries earlier during the Renaissance and had been given strong scientific impetus by the success of Newtonian inductionist approaches to understanding and explaining reality characteristic of the previous century. Medical investigators attempted to systematize medical knowledge along the lines of a single major force or cause that could be demonstrated to rest at the base of all medical phenomena. Medical investigation was attempting to do for medicine what Newton had done for physics and what Thomas Hobbes (1588–1679) had claimed to do for politics.
Searching for underlying unifying principles of medical knowledge, a kind of grand theory of synthesis, helped inform Herman Boerhaave (1668–1738). This great Dutch physician and teacher explained all pathological conditions in terms of chemical and physical qualities, such as acidity and alkalinity or tension and relaxation.1 William Cullen (1710–1790), a Scottish physician whose thinking had a major impact on American medicine at the time, believed that disease could be explained by either an excess or an insufficiency of nervous tension in the nerve pathways of the body and brain.2 Others argued for varying degrees of animism or excitation in the body’s organs. Few of these approaches produced anything of lasting medical value, for the complexity of medical phenomena repeatedly confronted these theoretical schemas with observations that could not be explained by their premises. Nonetheless, the search for the grand medical synthesis continued throughout the century.
The search for theoretical explanations did not hinder the development of an empirical approach to medical research. Indeed, it was precisely the establishment of the empirical method that forced medical theoreticians to continually reexamine their premises as observations time and again produced discoveries that could not be reconciled with theoretical approaches. The empiricism of the Renaissance combined with the rigorous thinking of Newtonian inductionism to produce a method of medical investigation that was soundly grounded in empirical observation. Unlike the scholastic approach to medicine that had characterized the search for knowledge during the Middle Ages, an approach that for centuries permitted empirical data to be rejected on the grounds that it did not satisfy the elegance of logic, the new method did not end in the mind. The willingness of eighteenth-century physicians to attempt to integrate new medical data into mental schemata prevented the development of a complete single-cause theory of medicine from gaining acceptance precisely because such theories did not square with empirical observation. The tyranny of scholastic logic finally came to an end and in its place arose the new methods of empirical observation and experiment. In this sense, the eighteenth century can be said to have laid the methodological groundwork for the progress in medical knowledge and clinical technique that was to follow in the next two centuries.
An individualistic approach to medical investigation had marked the previous century. Much of this trend continued in the eighteenth century and produced a number of important discoveries and surgical advances. The end of the religious and dynastic wars provided some breathing space within which the medical establishment continued its work. The period of peace, interrupted nonetheless by four major wars and three revolutions, also permitted some stability to permeate the social order of the day.3 As a result, the medical profession became institutionalized and medicine became a respected profession with practices passed from father to son. University education for physicians became commonplace. Dissection became a common method of medical study, as did clinical observation in teaching hospitals. Famous professors established a number of private medical schools and gathered students to their practices as a means of providing medical education. The most noteworthy of these students was Scottish-born John Hunter (1728–1793) in England and three generations of Monros in Scotland. Eventually, both schools became associated with universities, bestowing greater prestige on the study of medical pragmatics than ever before. For the first time in history, medicine was separated from superstition and ecclesiastical control, and the foundations of medicine as a science came into being.
In an equally important development, surgery finally became a legitimate discipline, respected even by the physician internists, and slowly began to develop its own teaching institutions. In 1731, the Académie Royale de Chirurgie (Royal Academy of Surgery) was established in Paris with Jean-Louis Petit as its first director. Later, the École Pratique de Chirurgie was established with François Chopart (1743–1795) and Pierre-Joseph Desault (1738–1795) as its first professors. The press of war placed a premium on training surgeons for the army, and for the first time military medical schools were established in Prussia, Russia, Austria, and France to meet the armies’ needs for surgical personnel. Greatly aiding these developments were significant improvements in surgical medicine as a consequence of the renewed empirical emphasis on anatomy and pathology. The greatest of the anatomist-pathologists was Giovanni Morgagni (1682–1771), who pioneered the science of postmortem investigation in an effort to link diseases to their specific anatomical effects. Morgagni was the first writer of a systematic treatise on morbid anatomy. The brilliant surgeons of the day, Hunter and Alexander Monro I (1697–1767), had begun their careers as anatomists, which helped them develop effective surgical techniques that gained wide acceptance. From this point forward, medical education began with studies of human anatomy, and for the first time in history, anatomical knowledge was generally accurate.
Surgery ceased to be merely a technical craft practiced by physicians of low status. Of course, the usual collection of barbers and quacks continued to exist, mostly in the armies, but gradually even their quality began to improve. The military’s need for surgical personnel led to regular examinations for candidates for surgeon’s mates and orderlies, and some countries provided medical training in special schools to even the lowest ranks of military surgical personnel. The millennia-old distinction between physician and surgeon, a distinction that had hindered medical progress for a thousand years, was gradually disappearing, with overall beneficial results for the civilian and the soldier alike.
Medical publishing was established on a large scale, and books and periodicals were readily available to the professional order as vehicles for expanding and spreading medical knowledge. Anatomical illustration reached great heights. The old copperplate method gave way to the steel plate and made producing anatomical illustrations in color possible for the first time.4 The advances in surgery also were evident in the proliferation of new surgical instruments designed for specific purposes. Pierre Dionis (1643–1718) published the Cours d’opérations de chirurgie in 1708 and presented complete sets of surgical instruments specific to particular operations. In 1782, Giovanni Alessandro Brambilla (1728–1800) assembled a folio of virtually all surgical equipment in his Instrumentarium Chirurgicum militare Austriacum.5 Near the end of the century, the numbers and types of surgical instruments had become so complex that the first catalogs for surgical instruments were published.
The eighteenth century can be characterized as the time when medicine first became a science complete with a new empirical approach that emphasized hard data. There emerged a new intellectual habit, first evident in the Renaissance, and a willingness to reject theoretical premises when they were shown to run contrary to clinical observation. The emphasis on anatomy gave physicians and surgeons more accurate medical knowledge, and the erosion of the social barriers between physician and surgeon finally permitted the latter to represent a legitimate branch of the medical discipline. Formalizing medical education permitted the transmission of accurate anatomy and new techniques to fresh generations of students in a more systematic and complete manner than ever before. Moreover, the stimulus of war forced the contemporary military establishments to pay greater attention to the soldier’s medical needs. More than in any century that preceded it, the eighteenth century witnessed the beginnings of truly modern medicine in both its civilian and military aspects.
In the eighteenth century, the state government recognized its function of providing medical care for its soldiers and provided and paid for it as a matter of course. At the beginning of the century, the pattern of military medical care remained essentially as it had been in the previous century. By mid-century, however, all major armies of the period had moved considerably toward establishing institutionalized systems of military medical care.
This achievement was part of the nation states’ larger effort to improve the general quality and organization of their armies as the age of nationalism came to fruition. Armies encouraged voluntary enlistments, adopted limited periods of military service to replace the old practice of lifelong service, implemented regular medical examinations for recruits, issued standard uniforms, provided daily food rations that were paid for by the state treasury, and housed their soldiers in barracks instead of the usual inns, private houses, and barns. Military organizations generally became more structurally articulated as the century wore on, and permanent ranks, pay systems, and combat formations appeared. Armies were almost exclusively armed with firearms, and field artillery became more mobile. The first military medical schools were established, as were the first journals and periodicals devoted exclusively to military medical matters with articles written almost entirely by military physicians, surgeons, and medical officers. Advances in hospital administration were made, and some attempts were also made to prevent disease and generally improve and maintain the soldier’s health.
Armies became structurally organized into companies, battalions, and regiments with an increasingly professional corps of officers and noncommissioned officers to lead them. In their organizational realignment to increase control of the armies, the leadership put the troops in barracks and gave them regular rations. The old practice of billeting the troops with the citizenry or in rented inns had become increasingly unpopular, and the new system made controlling desertion easier.6 The British Army established its first barracks in Ireland in 1713. Barracks were introduced in Scotland two years later, and George I (1660–1727) constructed the first military barracks in England at Berwick-on-Tweed in 1723.7
The introduction of voluntary enlistments proved attractive mostly to the urban poor and surplus landless population that had manned armies for centuries. No longer driven by the cudgel or impressment, these social elements were attracted by the prospect of regular food and pay. The health of these recruits, however, proved to be as generally poor as it had historically been. In times of social disruption or difficult economic times, recruits flooded the recruitment stations, and large numbers of marginally healthy adults with poor sanitary habits entered military service. The huge losses to disease in the wars of the period led military officials to launch regular physical examinations for recruits. For the first quarter century, however, the unit or regimental commander conducted only cursory examinations of recruits. Beginning in 1726, the French Army instituted regular medical examinations. After 1763, each recruit regiment had a surgeon whose duty was to examine recruits for physical fitness and weed out those whose health failed during the training process. In France, an inspector general of recruiting was appointed in 1778 and charged with the task of overseeing the selection and health of new troops. Mandatory medical examinations were not instituted in the British Army until 1790. Prussia, meanwhile, had required regimental and battalion medical officers to conduct regular physical examinations of all soldiers since 1788.8
France was the first country to institute uniform clothing as early as the 1670s.9 English regulation military dress was mandated in 1751, following similar regulations by Frederick Wilhelm of Prussia (1688–1740) a few years earlier.10 As noted in chapter 3, the purpose of uniform clothing was to facilitate identifying friendly units on the smoky battlefield, but the leadership gave little thought to the effects of this clothing on the health and endurance of the soldier. Uniforms were most often made of cheap cotton that provided little warmth in cold climates and no protection from the rain. Tight stockings often restricted circulation and had no padding for the leather buckle shoes, which offered little defense against frostbite or trench foot. Adorning the uniform with tight buttons and belts often restricted the soldier’s breathing, and with high crowns, the heavy shakos and hats added to the soldiers’ load but did not prevent head wounds from enemy shell fragments and bullets. It would be at least another two centuries before anyone seriously considered designing a uniform for battlefield use while taking the health, comfort, and protective needs of the soldier into consideration.11
The standard military ration, meanwhile, did much to improve the soldier’s general health, and most soldiers ate better and more regularly in military messes than they had in civilian life.12 Rations were provided by a central commissary and at government expense as a matter of right.13 In France, the soldier’s daily allowance was twenty-four ounces of wheat bread, one pound of meat, and one pint of wine or two pints of beer. Frederick the Great provided his soldiers with two pounds of bread daily and two pounds of meat a week.14 Unfortunately, the promise of regular, good-quality food was more often broken than honored. All European armies relied on a supply system in which commissary officers contracted with provisioners, sutlers, and transporters for supplies. This arrangement led to common abuses of fraud and theft, and the pressure to keep expenditures down often reduced food for the troops to less than sufficient quantities or quality.
Before examining the improvements in military surgery, it is worth exploring the casualty burdens that the medical establishments of armies under fire encountered. By the eighteenth century, the armies were universally equipped with more accurate and deadly firearms, and the introduction of truly mobile artillery of increased ranges had the inevitable effect of greatly increasing casualties. Even in the early part of the century, these innovations had an enormous impact on casualty rates. For example, during the War of the Spanish Succession (1701–1714), the allied armies at the Battle of Blenheim in 1704 suffered 5,000 dead and 8,900 wounded. British forces alone endured 670 dead and 1,500 wounded, while the Bavarian armies suffered 12,000 dead and 14,000 wounded. Two years later at Ramillies, the French lost 2,000 dead and 5,000 wounded. It was not unusual during this period for armies to suffer similar casualty rates, with the usual effect of overwhelming the primitive field medical establishments of the day.
In this era, military medical surgery improved markedly and introduced a number of new techniques. Some of the old wound treatments—such as sympathetic powder and wound salve, mainstays of the previous century—disappeared, giving rise to the more extensive use of styptics to stop minor bleeding. Pressure sponges, alcohol, and turpentine came into widespread use for minor wounds. Military surgeons still cauterized arteries, but less frequently, as they widely began to use the new locked forceps as ligatures. They increasingly applied Petit’s screw tourniquet, which made thigh amputations possible and greatly reduced the risk associated with amputations above the knee. Military surgeons placed greater emphasis on preparing limbs for prosthesis, and flap and lateral incision amputations became common.
Although more surgeons questioned the need for the inevitable suppuration of wounds, many still provoked infection by inserting charpie and other foreign matter into wounds. While they continued to use the old oils and salve dressings for wounds, the new technique of applying dry bandages moistened only with water held much practical promise. That many of the old chemical and salve treatments endured is not surprising, since doctors often prepared and sold these potions themselves at considerable profit. The practice of enlarging and probing battle wounds continued unabated, but the new debridement treatment was gaining acceptance as an alternative procedure. Despite a literature that established clinical circumstances and guidelines for carrying out the procedure, the improvements in amputation surgery inevitably provoked a spate of unnecessary operations that continued for many years. Yet, without doubt, military surgery was improving at a rapid pace as military surgeons learned new and improved techniques of wound treatment.
John Hunter is generally credited with the first real improvements in understanding the nature of wound treatment. He began his career as an anatomist, only later becoming a surgeon. His training in linking anatomy to clinical signs of pathology served him well. He accepted a commission in the middle of the Seven Years’ War (1756–1763) with France and gained valuable surgical experience at the Battle of Belle Île (1761). Afterward he argued against the normal practice of enlarging gunshot wounds and against bloodletting, pushing instead for a conservative approach to treating gunshot wounds. In 1794, he published his Treatise of the Blood, Inflammation, and Gunshot Wounds, which is regarded as a major milestone in the surgical treatment of battle wounds.
Pierre-Joseph Desault coined the term “débridement” and recommended not enlarging wounds as common practice. His new technique recommended cutting away only the necrotic tissue within the wound to remove a source of infection. Desault was the first to use the technique for traumatic wounds.15
For decades bullet wounds to the head had produced great risk of infection. Because doctors believed that blood that accumulated in the extradural or subdural spaces would eventually become pus, they allowed it to remain as a seat of infection. The military surgeon Percival Pott (1713–1788) was the first to argue against this practice, suggesting that this residual blood could be extracted by cranial draining. His contribution is often cited as a major advance in cranial surgery.16 For decades surgeons commonly operated on all head wounds with experimental trephination. Many of these operations were unnecessary and exposed the patient to great risk of infection. Near the end of the century, Sylvester O’Halloran (1728–1807), an Irish surgeon, demonstrated that experimental trephination was usually not needed. Within a decade, the practice generally came to an end. O’Halloran was also the first to improve the treatment of penetrating head wounds by regularly utilizing debridement.17
Habits of personal, medical, and surgical cleanliness were still dismal during this period, and the soldier faced a greater risk to his health while in the hospital than on the battlefield. It has been estimated that in the American Revolutionary War (1775–1783), the Continental soldier had ninety-eight chances out of a hundred of escaping death on the battlefield, but once he was hospitalized, his chances of survival after medical treatment and exposure to disease and infection fell to 75 percent.18 Some surgeons, however, did perceive a relationship between cleanliness and surgical infection. Claude Pouteau (1724–1775) a French surgeon, made cleanliness a requirement in his operating area and achieved the remarkable result of losing only 3 of the 120 lithotomies performed in his surgery to infection. John Pringle (1707–1782), the famous English physician and surgeon, first coined the term “antiseptic” in 1750 and in 1753 published the results of forty-three experiments performed over a three-year period that confirmed the antiseptic value of mineral acids.19 In 1737 Alexander Monro I claimed to have performed fourteen amputations at his Edinburgh surgery with no hospital mortality. By 1752, he had performed more than a hundred major amputations with a hospital mortality rate of only 8 percent. This achievement was all the more remarkable given that for the next century the mortality rate for hospital surgery was generally between 45 and 65 percent.20 Monro also had a fetish for cleanliness. Despite overwhelming evidence of the relation between cleanliness and infection, however, the work of surgeons Pringle, Monro, and Edward Alanson (1747–1823) was largely ignored until the next century when Joseph Lister (1827–1912) introduced general antisepsis. One can only guess how many soldiers would have survived their wounds had they not been exposed to infection while recovering in the hospital.
While the eighteenth century saw numerous improvements in the establishment and organization of military hospitals, especially in the introduction of the mobile field hospitals that accompanied the armies on the march, they still offered the unsanitary and dismal-quality care as they had in the previous century. Hospital buildings were often little more than rapidly constructed huts in the field.21 While every army had a hospital medical organization to provide treatment and administration, they were rarely fully staffed. Moreover, there was a notorious lack of coordination between regimental, field, and general rear area hospitals, especially in the provision of medical supplies. Few armies had any organized and dedicated transport to move the wounded from the front to rear area hospitals, and it was not uncommon for a third of the patients to die en route. No army developed a satisfactory solution for extracting the wounded from the battle line, and troops usually made their way to the medical facilities as best they could. As in the previous century, some armies, notably Prussia’s, actually forbade attempts to treat the wounded until the battle had ended. No one seems to have thought of copying the Romans’ stationing of combat medics within the battle units themselves.
Disease continued to be the major threat to military manpower despite military physicians’ many attempts at preventive medicine. Among Continental soldiers in the American Revolution, disease caused 90 percent of all deaths; among British regulars, the figure was 84 percent.22 Hughes Ravaton, the French physician, noted in 1768 that one of every hundred soldiers in the French Army would be unfit for duty because of illness at the beginning of a field campaign. Halfway through the campaign, another five or six would drop out of combat because of disease. By the campaign’s end, ten to twelve more soldiers would be too ill to fight. By comparison, the death and injury rate from combat fire was approximately one per ten men.23
The range of diseases that afflicted the troops had changed little from the previous century. Respiratory illnesses were most often seen in cold weather and dysentery-like conditions in hot climates. Disease diagnosis had not yet become a science, and descriptions of disease from this period cannot be entirely trusted. The common “intermittent” and “remittent” fevers of the day were most probably malaria, a disease widespread in Europe and the colonial dominions. Those conditions called “putrid,” “jail,” or “hospital fever” were probably typhus or typhoid. Dysentery and other stomach disorders were rampant, often as a consequence of poor field hygiene conditions. Venereal disease was almost epidemic. Pneumonia and pleurisy also presented a common threat. The records of the period also show that scabies was endemic. This infestation caused scratching, which produced serious infections requiring medical treatment. Although not fatal, scabies brought more patients to British Army hospitals during the Seven Years’ War than did any other medical condition.24 Scabies continued to plague armies into modern times. In World War I, scabies or the pyrodermas produced by constant scratching caused 90 percent of the illness for which Allied troops sought hospitalization or field treatment.25
Smallpox was among the most debilitating and dangerous diseases that afflicted field armies, with numerous examples of entire campaigns being halted as a consequence of outbreaks. In 1775, Gen. Horatio Gates (1727–1806) had to break off the American Northern Army Command’s campaign for five weeks because an outbreak of smallpox sent 5,500 of his 10,000 troops to the hospital.26 The disease afflicted the civilian population without mercy in multiple epidemics that marked the period.
The prevalence of smallpox in the civilian and military populations drove one of the more important medical advances of the century, inoculation. Credit for introducing smallpox inoculation is generally given to Edward Jenner (1749–1823), but in fact, inoculation against smallpox was already an established practice long before Jenner formalized the method. The practice of using cowpox inoculation to prevent smallpox disease was common in the Ottoman Empire before it was introduced into Europe. Lady Mary Wortley Montague, the wife of the British ambassador to Constantinople, knew of the practice as early as 1718 and had herself and her two children inoculated against the disease.27 In 1721, a smallpox epidemic broke out in Boston, and Dr. Zabdiel Boylston (1679–1766) used inoculation to prevent its further spread. He inoculated 247 persons with a loss rate of only 2 percent, compared to the usual 15 percent death rate.28 Jenner’s contribution to inoculation seems to have been that he was the first person to conceive of inoculating whole populations against the disease, and he developed the popular support to carry out his idea. Jenner did not perform his first smallpox inoculation until 1796.
The first army to try wholesale inoculation on its soldiers was the American Army. In 1775, noting General Gates’s debacle while confronting smallpox, Gen. George Washington (1732–1799) obtained the approval of the Continental Congress to inoculate recruits upon their entering into military service.29 The program was less than successful, however, and we do not know how many soldiers actually received inoculations. The British Army did not allow inoculation against smallpox until 1798, when the Sick and Wounded Board authorized the procedure at military hospitals for those who wanted it. As the century ended, there was still no mandatory inoculation for British troops.30 The successful immunization of military forces had to await the next century, when inoculation became more generally accepted. Holland and Prussia were the first countries to require inoculations of all their troops, while the French and English continued to lag behind. In the Franco-Prussian War of 1870–1871, unvaccinated French prisoners suffered 14,178 cases of smallpox, of which 1,963 died. The vaccinated German troops suffered only 4,835 cases of the disease, of which only 178 died, or a mortality rate of less than 4 percent.31
Recognizing the importance of military medical care in maintaining the fighting ability of their armies, some states established mechanisms for ensuring an adequate supply of surgeons and other field medical personnel. In the first quarter of the century, the French established schools for training surgeons and mates at a number of army and navy hospitals. The most important medico-military institution of the century was established when the French opened the Académie Royale de Chirurgie in Paris in 1731. That five of its seven directors and half of the forty members nominated by the king were prominent military surgeons who had served in battle attests to the academy’s dedication to military medical matters. Further, army and naval surgeons wrote more than a third of the period’s four volumes of medical papers.32 Saxony followed the French example and established an army medical school in 1748. Additional military medical schools were established in Austria in 1784 and in Berlin in 1795. In 1766, Richard de Hautesierck (1712–1789), inspector of hospitals, published the world’s first medical journal devoted exclusively to military medicine.33
Gradually armies established regular field medical facilities. In 1745 at the Battle of Fontenoy, the British military medical service treated the wounded on the first line and collected them at ambulance stations. Surgeons performed capital operations at medical stations behind the lines and then transferred the more seriously wounded to hospitals prepared for them in nearby cities and towns. When these hospitals became overcrowded, the army made arrangements to ship the wounded farther to the rear. Although this model was becoming commonplace in all armies of the period, military medical facilities did not operate so efficiently as a matter of course. More commonly medical facilities were understaffed, were poorly supplied and had little transport, and generally were overwhelmed by large numbers of casualties. Nonetheless, the structural articulation that the armies of the day were demonstrating in other areas was also evident in their attempts to provide better medical care for the soldier. It would take yet another century, but eventually the seeds of a full-time professional military medical service sown in the eighteenth century would come to fruition.
Before examining the development of the national military medical services, it is worth noting another development that did much to foster medical care in the armies of the period. Exempting the wounded from slaughter or imprisonment had begun in the seventeenth century, and the idea gained added support during the eighteenth century. In July 1743 at the completion of the Dettingen campaign, both sides signed an agreement that declared medical personnel serving in the armies would be considered noncombatants and not taken as prisoners of war. In addition, medical personnel would be given safe passage back to their own armies as soon as practical. Most important, both sides agreed to care for the enemy wounded and sick prisoners as they would their own and provide for their return upon recovery.34 While the Dettingen agreement was important for its humanity in dictating the treatment of the sick and wounded, it was also a significant spur to the further development of military medical facilities. While the old system of slaughtering the wounded reduced the casualty load for the medical facilities, the Dettingen agreement forced armies to increase their medical staffs to deal with the enemy wounded as well.
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.
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 voyages 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.
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 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.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.
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.
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 medical 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.
The French military medical system was still the most structurally advanced of all the armies of the period. Moreover, the revolutionary emphasis on equality provided a further impetus to provide good medical care for the soldier. The French armies were the first genuine citizen armies of the modern period, and while the sacrifice of the citizen’s life to the cause of the state was generally accepted as a cost of military service, the state recognized its obligation to provide for the citizen soldier’s medical treatment. As the eighteenth century came to an end and the specter of Napoleon loomed over Europe, the armies of the continent realized their military forces were no match for the French unless they resorted to national conscription and patriotic appeals to raise large armies. As part of their new bargain with formally excluded social elements, the continental armies began to explore ways to improve the medical care for their soldiers. In this sense, the spirit of the French Revolution spurred most of Europe’s armies to begin providing what would eventually become the modern system of military medical care.
The centralization of governmental power that marked most of the previous century in England and France occurred much later in Prussia, with the result that its centralized control of governmental functions lagged behind even that of the other continental powers. In the area of military medicine, this delay worked against establishing a government-sponsored military medical service in Prussia until late in the century. Even then the degree of its organizational sophistication remained low. For most of the eighteenth century, the Prussian military medical service and the degree of care and resources it provided to field medical units depended, as it had in the seventeenth-century England and France, primarily upon the army commander’s willingness to arrange it for a given campaign.
The first military hospital in Prussia, a “medical house” near the Spandau Gate in Berlin, was constructed in 1710, but it was only officially established as a regular military hospital fifteen years later.72 Meanwhile, in 1705, Prussia had a standing army of thirty-five regiments; however, only six of them had a normal complement of regimental surgeons and mates.73 In 1712, for the first time in the Prussian Army, supervision of company surgeons was transferred from officers of the line to the medical officers in the regiment. The status of Prussian barber-surgeons was so low that they ranked below the chaplains and only slightly above the drummers. Regimental surgeons still had to shave company officers, and senior officers could subject them to public whipping for the slightest offense.74 The barber-surgeons were forbidden to treat the wounded except under supervision of the regimental surgeons, who themselves usually had poor skills. Company surgeons were allowed to visit the sick and wounded and to report their condition to the regimental surgeons. Long after the distinction between surgeon and physician had begun to diminish in the other armies of the day, in Prussia the rigid separation lasted well into the nineteenth century, thereby preserving the regimental surgeons’ low status and training. The Prussian Army did not even have an officially commissioned surgeon general until 1716.
Frederick Wilhelm I appointed the first chief physician of the army in 1724. This officer was charged with presiding over all physicians and surgeons in the army and standardizing regulations governing medical competence. For the first time, both physicians and surgeons received the same training in the army.75 The army commonly withheld part of the company barber-surgeons’ pay to offset the cost of the regiment’s medical supplies. Jews were not admitted to military medical practice, and in Austria at the beginning of the Seven Years’ War, Protestant surgeons had to convert to Catholicism or leave the army.76 Some German states authorized surgeons to wear regular uniforms, and others forbade them to do so. The staffing of regimental hospitals with apothecaries was poor at best, and unlike in England at this time, nursing was not organized.
Frederick Wilhelm issued regulations requiring all military surgeons to be examined before the medical college as a test of competency, a regulation probably only rudimentarily enforced. Frederick made use of at least twelve French surgeons in his army, but little effort seems to have been made to have them train Prussian medical personnel. This lack of serious concern over military medical matters was evident in the infantry regulations of 1726 that still forbade medical attention to the wounded until the battle was over, a practice that other continental armies had long abandoned. The regulation read: “When the battle is over each regiment shall seek out its wounded and bring them to a definite place where they can be bandaged and cared for; no wounded may be recovered during the battle.”77 The same regulation noted that a military hospital was to be established in the nearest village or town to which the warring party’s sick and wounded could be sent. Each battalion was assigned a barber-surgeon and two attendants to provide medical care. The barber-surgeons were only supposed to attend the lightly wounded and to send others to the rear. Although general hospital personnel in the town hospital were presumably better trained, this was seldom the case. If the army moved on, a noncommissioned officer without medical training was assigned to remain with the sick and wounded. He was allotted a sum of money to help care for the patients and to purchase whatever medical help and supplies were available in the area. Although the field apothecary was also designated to remain behind and provide drugs, no one remained behind to tend the wounded. All other trained medical personnel moved forward with the army. When the sick and wounded required transport, the army used whatever wagons were available for it had no systematic provision for transport. In all these respects, the Prussian medical system in the first half of the century fell far short of the quality of medical care that soldiers in other armies received.
The army of Frederick the Great made a number of improvements to this system. Still, the system itself was more the responsibility of the field commanders than of the national government. Frederick had a personal interest in medical matters, and his concern for his troops grew as much out of his genuine concern for their welfare as from the fact that the population of Prussia was small and every fighting man was a precious national resource. As a field commander, Frederick often personally selected locations for unit dressing stations when determining the battle plan. He ordered that these stations be appropriately fortified and protected from enemy fire and cannon shot.78 He introduced the old Roman practice of guarding safe water points and mixing a small amount of vinegar with water to make it more potable. He was personally solicitous of the medical care of his troops and ordered incompetent surgeons flogged. While the care of his own wounded had priority, Frederick issued orders that the enemy wounded should be cared for as time and supplies permitted.
As time went on, Frederick’s battle losses in his frequent wars forced him to take military medical care more seriously. Although he attempted several remedies to improve care, as the century ended Prussian military medicine remained considerably behind that of other armies. Frederick ordered the creation of permanent, fixed-site military hospitals at Breslau, Glogau, Stettin, Dresden, Torgau, and Wittenberg and introduced the use of forward field hospitals. Each regiment was provided with a barber-surgeon and four company barbers to provide first aid. While no dedicated personnel or transport were used to evacuate the wounded, Frederick dictated that regular detachments be assigned from the regiment’s manpower to accomplish this task. Efforts were made to draw these transport detachments from the regiments that had suffered the fewest losses in the day’s battle.
Prussia did not open its first military medical school, the Pépinière (later known as the Frederick Wilhelm Institute), until 1795. Austria had established the Josephinum, an academy for imperial army surgeons, ten years earlier.
Russia’s long years of isolation from the European mainstream caused by its geography, religion, and foreign occupation left it far behind the continental powers in almost all aspects relating to military affairs, including military medicine. The condition of general medicine was also quite backward, and the number of trained medical personnel of any sort, in the army and society, were extremely few. Peter the Great, whose interest in medical affairs stemmed largely from his own suffering from various medical conditions, attempted to remedy this situation with numerous reforms.
The lack of native-trained physicians and surgeons forced Peter to rely on foreign doctors for his military forces. Although some were successfully recruited for short periods, the difficult living conditions, harsh terms of service, low pay, and the general suspicion that most Russians had for all foreigners made the program largely unsuccessful. In 1700 during the Great Northern War, Russia had fewer than sixty military surgical personnel in the army, and few of them had any formal medical schooling or training.79 In 1706, Peter reorganized the primitive military medical service, and each soldier was required to contribute a small sum from his pay to offset the cost of medical treatment. Regimental surgeons, usually ill-trained barber-surgeons, were appointed. The surgeon had to select a soldier from each company, at double pay, to shave the men and apply plasters. These soldiers also served in the line and were not full-time medical assistants.80 Peter’s “improvements” were actually old practices that the European armies had instituted a century earlier. Even the Russian surgeons’ mates, positions that hardly attracted the epitome of medical talent and training in the West, were far less skilled than those found in Western armies.
Forced to deal with a constant shortage of trained medical personnel for his armies, Peter founded the Gospitali with the express purpose of training military surgeons. The institution was placed under the direction of Nicolass Bidloo (1674–1735), the famous Dutch physician and surgeon, who arranged the curriculum along the lines of clinical empirical medicine characteristic of Dutch medical schools. From the outset, the institution had difficulty attracting the talented sons of the middle and upper classes, and for most of its history it drew its students from the lower classes. The school was under constant pressure to provide mates and surgeons for the armies; indeed, the director had to allow students to enter military service who had received only marginal training. In 1708, Peter ordered the college to provide twenty medical students for the army. Even by the low standards of Russian military medicine, the director agreed to send only six.81 The constant drain of half-trained medical students to serve as surgeons and mates almost forced the school to close. The school produced only ten graduates a year, and from 1712 to 1727 every member of every graduating class was sent into military service.
These difficulties aside, the number of trained medical personnel available to the army increased, albeit slowly. In 1713, the Apothecary Bureau reported that 262 medics of all types were assigned to military service. In 1720, the Baltic Fleet employed 102 medics, and seven years later, the number had increased to 165. The Russian Army’s medical branch was formally established in 1716, and medics were assigned to each regiment, apothecaries provided in the field, and field hospitals organized for the first time. In 1720, the navy was ordered to construct a similar medical system.82
The success of the Gospitali in providing military surgeons lent impetus to the construction of other medical facilities. The military itself began to construct military hospitals to care for its wounded and at the same time to serve as training facilities for medics. In 1715 the Petersburg Admiralty Hospital was founded. To provide military surgeons for the army, Russia built other hospitals at Reval (1717), Kronstadt (1717), Tavrov (1724), Astrakhan (1725), and Archangel (1733).83 Regardless of the effort, however, Russia continued to remain far behind the military medical facilities provided in other armies. It took more than a century, until the Russo-Japanese War of 1904–1905, before military medical care in czarist armies was on par with those found in armies of the West.
The close relationship between England and the American colonies for more than a hundred years before the American Revolution exerted a considerable influence upon the development of military medicine during the American War of Independence. Most of the doctors with a formal medical education had been educated in England or Scotland, although some had received their medical training at Leyden in Holland. Only two medical schools existed in the colonies during the colonial period.84 Meanwhile, the garrisoning of English troops in the American colonies, the direction of state militias by British officers, and the numerous skirmishes that the Indians and the French fought with British and American forces for almost fifty years had the effect of introducing the American military forces to British military medical practices.
As early as 1676, the Massachusetts Bay Colony provided medical support for its militia when it appointed a surgeon at public expense to attend a force of five hundred troops. In addition, a special house was constructed to care for the sick and wounded.85 In 1762, a military hospital was built at state expense in Albany to care for the casualties of the French and Indian War (1754–1763). In imitation of the British practice of the time, a surgeon and one surgeon’s mate routinely attended militia companies. As in British units, American regimental colonels appointed their surgeons, who, in turn, selected the mates. Not surprising, many of the problems of competency and training associated with these British Army practices were also present in the colonial militia armies.
Massachusetts was the first colony to create the position of medical commissioner, whose charge was to purchase, store, and issue medical supplies to the armies. In May 1775, the colony rented buildings in Boston to billet and care for the troops, established separate hospitals to deal with smallpox cases among the soldiery, and made provisions for caring for the “insane of war.”86 In early June, a medical committee was appointed to devise means for providing the troops with medicine and supplies, and another committee was created to prepare plans and regulations for hospitals. These steps were taken before the outbreak of open hostilities. When war broke out with England, the Committees of Safety purchased medical chests and surgical instruments at public expense for the state regiments’ use and a complete set of medical instruments for each corps. At the Battle of Bunker Hill on June 17, 1775, however, the American casualties were so heavy that the planned medical system collapsed under the load.
It became evident early on that the quality of medical personnel available to the army posed a serious problem. Massachusetts took the lead in establishing a board of medical examiners to examine all candidates who applied for the positions of surgeon and surgeon’s mate. Although the regimental commander could submit the name of candidates, the board certified the military surgeons. For the most part, its examinations were thorough and difficult, although somewhat spotty in other states. Throughout the war, each colony remained responsible for providing medical personnel and supplies for its home regiments.
In July 1775, Congress authorized the establishment of a “hospital for the army,” a term for the medical department for a force of twenty thousand men. Following the British pattern, the hospital was really a medical staff whose task was to follow the army and set up ad hoc medical support behind the lines. The British pattern was followed in all important details, with the hospital comprising a director, one chief physician, four surgeons, one apothecary, twenty surgeon’s mates, one clerk, two storekeepers, one nurse for each ten sick, and one nurse matron.87 A total of three hospitals were created for the Northern, Middle, and Southern Departments (theaters of operation) of the armies. It developed two separate medical systems—one responsible to national authority and the other responsible to state authority—resulting in inevitable confusion, lack of supply, and poor coordination that hindered the provision of medical care to the field armies.
If the states did not provide sufficient medical supplies—and most often they either did not or could not—the regimental surgeon was largely on his own since there were no provisions to supply him regularly through national authorities. Medical tents were usually unobtainable, and when the army was garrisoned in a city, the regimental barracksmaster was responsible for finding a building suitable for use as a hospital. In winter encampments such as Valley Forge, makeshift log huts served as hospitals and housing. Beds and bedding were rarely provided to the hospitals, which were forced to rely on the regimental supply officer for these items. Each company was required to carry extra bed sacks to be filled with straw when the sick needed them, and the soldier provided his own blanket in the hospital. Without a dedicated supply train for the medical units, even these items were reserved for the wounded, but no provisions were made for the sick.
As in the English Army, there were no transport vehicles organic to the colonial medical service. It did not use any special ambulance vehicles, and what wagons were from time to time available were drawn from the regular army stores. The arrangements for evacuating the wounded were so poor that surgeons were instructed to find handbarrows to move the wounded to the hospitals. Any manpower that was made available for this task came from the largesse of the field commander. The manning levels for the medical service were low, with a single surgeon and five mates for every five thousand men. Further, the English blockade made it difficult to import medical supplies from abroad, the usual source for colonial physicians. An inventory of medical supplies on hand in February 1776 for an army of 16,877 men revealed only nine sets of amputating instruments, twenty pocket cases, two cases of lancets, twelve cases of crooked suture needles, two cases of surgical knives, twenty-four tourniquets, 859 bandages, and twelve pounds of surgical lint.88 Surgeons were instructed to use razors to perform operations in lieu of adequate surgical instruments. Six months later conditions had not improved. Four days before the Battle of Long Island (August 1776), the army’s total medical supplies on hand consisted of only five hundred bandages, twelve fracture boxes, and two scalpels.89
In the early days of the war, patriotic fervor prompted large numbers of citizens to enlist in the army. With no medical screening examinations for recruits, the American Army soon became a walking health disaster. Military medical officers attempted to establish field hygiene practices and encourage daily shaving and regular bathing to reduce the spread of disease. The American force was composed mostly of country boys and the urban poor, neither known for their cleanliness habits. Disease became the army’s constant companion throughout the war, and the overall death rate from disease was ten times higher than from enemy bullets.90 Disease was so common that it became increasingly difficult to recruit sufficient manpower as men now avoided military service out of fear of epidemic.
The frequent incidence of disease in the revolutionary army is easily discernible from the following figures. In February 1776 the army of 16,877 men had 3,765 men, or 22.3 percent of total its strength, listed as unfit for duty due to illness.91 At Crown Point, New York, that December the nation’s largest military hospital listed 3,000 patients in that single hospital. In the first year of the war, more than 5,000 men, or 25 percent of the total force, were lost to death, illness, or desertion.92 In December 1777, 2,898 men of the 11,000-man force at Valley Forge were unfit for duty because of illness. By February 1778, 4,000 men were unfit because of illness and injuries from cold.93 The American Army was the first army to attempt widespread vaccination of its troops against smallpox, but the use of smallpox inoculation at Valley Forge sent 3,000 men to the hospital with reactionary cases of the disease. “Jail fever” (typhus), for example, was an ever-present danger in close quarters. In a three-month period, four hundred of the seven hundred prisoners died of jail fever and were buried in a common grave.94 The Valley Forge encampment of Washington’s army was a medical catastrophe. The encampment lasted from December 17, 1777, to June 19, 1778, or a period of six months. Some ten thousand soldiers had entered the encampment. By June, twenty-five hundred to three thousand had died of disease, exposure, or malnutrition.95
The field hospitals in the Valley Forge cantonment were primitive, constructed largely of log huts. These “flying hospital huts” were twenty-five feet long and fifteen feet wide by nine feet high and covered with boards or shingles for roofs. Windows were placed on each side and a fireplace and chimney at one end. Two hospital huts were authorized for each brigade, but the space was never sufficient to handle the number of casualties and the sick from a single brigade. Hospitals were established in rear area villages and towns, but the local populace always raised considerable opposition to placing a hospital in their midst. The fear of epidemics, the requisitioning of buildings for military use, and the widespread fraud in purchasing supplies led the locals to treat the military suspiciously. Sometimes the number of casualties brought to a small town or village exceeded the number of residents.
Of the thirty-five hundred colonial physicians and surgeons in America in 1775, only four hundred of them had medical degrees or formal medical education.96 In Virginia, only one in nine practicing physicians had received any formal medical training.97 These figures, however, do not provide an accurate portrait of the quality of medical personnel available to the military.98 Unlike in Europe, where strong guilds perpetuated the strict separation between surgeons and physicians, that practice never developed in America. American medicine was in the hands of the general practitioner who healed, operated, and mixed and prescribed his own medicines. His medical training was largely achieved less through formal education than through an apprentice system. General Washington realized that the states provided many physicians whose technical competence left much to be desired, and he pressed Congress to require surgeons and mates to take examinations before being assigned to military units. Congress yielded to pressure from the states, though, and didn’t take any action.99 Gradually the states enacted examination and licensing procedures, but Congress did not establish a screening board for military surgeons until 1782. Because of the apprentice system of medical training, however, the quality of military medical personnel was as good as, and in a number of ways even superior to, that available in European armies.100
The pragmatic bent of American medical practice unhindered by the social distinctions between surgeon and physician was evident in the appointment of John Jones (1729–1791) as the first full professor of surgery at the Medical School at King’s College, New York.101 Jones wrote Plain, Concise Practical Remarks on the Treatment of Wounds and Fractures, the first surgical text published by an American in the United States in 1775. The book appeared in time for the war and became a basic training and field text for military surgeons.102
The Revolutionary War provided a strong stimulus to developing military and general medicine in the colonies. The early problems of the military doctors’ competency forced states to adopt stringent examinations and licensing requirements that persisted after the war, generally raising the quality of medical practice. The war also gave physicians who heretofore were isolated in small rural communities an opportunity to interact with other physicians and to exchange ideas, treatments, techniques, and drug formulas. American doctors also came into contact with the medical staffs of their French allies and acquired skills on hospital administration for which the French were noted. Although expressly forbidden by both civil and military law, undoubtedly battlefield surgeons experimented on the bodies of the dead to improve their anatomical knowledge.103 Furthermore, because the severance of commercial ties with Britain removed the main source of medical equipment and drugs, the Americans were forced to develop their own substitutes.
The quality of American medical thought and innovation during this period was evident in the publication of a number of American medical books. Jones’s book, already noted, became the definitive text in the field. Recommendations of Inoculation According to Baron Dimsdale’s Methods (1776) by John Morgan (1735–1789) influenced the American Army to adopt inoculation as a preventive for smallpox. Morgan became the first director general of the American military medical service. William Brown (1754–1808), an army doctor, wrote a Pharmacopoeia for Use of Army Hospitals (1778), the first book of its kind in the colonies.104 Benjamin Rush’s (1745–1813) Directions for Preserving the Health of the Soldier (1778) became the handbook for field hygiene, as did his other work, Regulations for the Order and Discipline of Troops of the US. Hospital administration and health care were the focus of James Tilton (1745–1822). He wrote about his experiences as a physician and surgeon in the war in Economical Observations on Military Hospitals and the Prevention of Disease Incident to an Army (1813). Ebenezer Beardsley (1746–1791) wrote an account of the cause, spread, and treatment of dysentery in colonial regiments. All of these works made significant contributions to the theory and practice of military medicine and reflected the pragmatism that continues to characterize American medicine to the present time.
The care of veterans had long been a tradition in the American colonies. As early as 1636 the Plymouth colony passed a law providing for the support of the crippled soldier, and in 1644 the Virginia Assembly created a system of relief for the soldier maimed in battle. Immediately after the start of the Revolutionary War, Congress ordained that soldiers incapacitated by war should receive half pay, similar to the British practice of caring for their wounded veterans. In 1792, Congress passed a pension law for veterans.
Congress always viewed its raising of a national army to fight the War of Independence as a temporary measure forced by difficult times, and when the war was over, the national army was demobilized. By 1783, the entire national armed force of the United States, renamed “The Legion,” consisted of fewer than a thousand men. With the army’s demobilization also came the dismantlement of the military medical service. Regimental surgeons and mates stationed with the troops in camp hospitals had provided the soldier’s medical care. The U.S. military continued to operate without a systematic military medical service until the War of 1812, when military necessity again forced the country to devise ways to provide medical care for its soldiers.
To recap, in the eighteenth century the centralized power of the nation state reached a level of organizational control that it had sought for three centuries. This centralization enabled the aggressive monarchs of the period to consolidate their power within their domestic realms and to expand it beyond their borders. Inevitably, the price of this expansion was war. With the improvements in military technology came a greater demand for large numbers of soldiers, a demand that could only be filled through voluntary enlistments. To encourage recruitment, the armies of the day had to improve the soldier’s living conditions. This effort also required developing better military medical care and establishing veterans’ programs. Consequently, the provision of organized military medical care became a recognized and regular function of government.
Improvements in the general quality of medical education and training in civilian society enabled armies to enlist trained medical personnel to treat the soldiers. The advances in medical knowledge and technology inevitably, if slowly, found their way into the military medical organizations. Only the navies of the world, where medical care was as dismal as it had been during the Middle Ages, remained the exception to this general trend. The final liberation of surgery from the social and political tyranny of the physician establishment also elevated the quality of medical care for the soldier.
As the nineteenth century dawned, armies had gained considerable experience in providing medical care to their troops in the field. In times of peace the medical service structures took the opportunity to improve their quality and, most important, to plan for providing medical care before the next actual fight. The stability of the organizational structure permitted the introduction of medical advances accomplished in the civilian sector much more quickly than before. Finally, the graduates of the first national medical schools of military medicine were reaching the peaks of their careers in the military bureaucracies, providing the armies with generally well-trained and experienced medical officers to manage the problem of medical care in wartime. The armies of the eighteenth century were poised on the edge of developing a modern military medical service in its degree of organizational articulation. Once the structure was in place, incorporating the medical innovations of the next century into the armies was relatively easy, thereby raising the quality of medical care available to the soldier to heretofore unachievable heights.
1. Mary C. Gillett, The Army Medical Department, 1775–1818 (Washington, DC: Center of Military History, U.S. Army, 1981): 1.
2. Ibid.
3. Garrison, Introduction to the History, 397.
4. Ibid., 335.
5. Kirkup, “History and Evolution,” 284.
6. H. A. L. Howell, “The Story of the Army Surgeon and the British Care of the Sick and Wounded in the British Army, from 1715 to 1748,” Journal of the Royal Army Medical Corps 22 (1914): 324.
7. Ibid., 323.
8. Heizmann, “Military Sanitation,” 295.
9. Ibid., 296.
10. Ibid.
11. The first attempts to adopt clothing for purely military use were intended to afford the soldier greater concealment on the battlefield. The British Army abandoned the traditional red coat during the Second Afghan War and adopted khaki uniforms to better blend in with the light and sandy background of the country’s terrain. After the Franco-Prussian War, the Germans rid themselves of their brightly colored regimental uniforms and adopted the famous feldgrau, or “field gray”–colored, uniforms that are worn to this day.
12. Starvation and poor economic conditions have driven military recruitment since time immemorial. The large contingents of Irish serving in the British armies since the Great Famine is an obvious example. A great number of soldiers in Gen. George Custer’s command were Irish immigrants. Much of the American frontier army was comprised of immigrants, free blacks, and other minorities (Mexicans and native Indians) as a consequence of the lack of opportunity for these groups in the larger society.
13. Officers, however, continued to pay for their rations and still do in most modern military establishments.
14. Heizmann, “Military Sanitation,” 296.
15. John Thorne Crissey and Lawrence Charles Parish, “Wound Healing: Development of the Basic Concepts,” Clinics in Dermatology 2, no. 3 (July–September 1984): 554.
16. West, “A Short History,” 147.
17. Gordon, “Penetrating Head Injuries,” 5–6.
18. Howard Lewis Applegate, “The Need for Further Study in the Medical History of the American Revolutionary Army,” Military Medicine (August 1961): 617.
19. Wangensteen et al., “Some Highlights,” 105.
20. Ibid., 106.
21. However, the disease and infection rates among soldiers in these primitively constructed hospitals were often much lower than in the larger hospitals. The poor construction left these makeshift hospitals subject to drafts, which provided ventilation and renewed the stale air within the wards. See Young, “Short History,” 488; and Howard Lewis Apple-gate, “Effect of the American Revolution on American Medicine,” Military Medicine (July 1961): 552–53.
22. Gillett, Army Medical Department, 3.
23. Ibid., 8.
24. Ibid., 6.
25. Grissinger, “Development of Military Medicine,” 317.
26. Abram S. Benenson, “Immunization and Military Medicine,” Clinical Infectious Diseases 6, no. 1 (January–February 1984): 2.
27. McGrew, Encyclopedia of Medical History, 155.
28. Benenson, “Immunization and Military Medicine,” 1.
29. Ibid.
30. Taylor, “Retrospect of Naval and Military Medicine,” 594.
31. Garrison, Notes on the History, 374.
32. Heizmann, “Military Sanitation,” 297.
33. Ibid.
34. Howell, “Story of the Army Surgeon,” 333.
35. For more on the military medicine of the Roman Navy, see Richard A. Gabriel, “The Roman Navy: Masters of the Mediterranean,” Military History, December 2007, 37–43.
36. Ibid.
37. The term “quarantine” comes from the Latin quarantine, which means forty. Tradition has it that the original period of quarantine for crews on commercial vessels was forty days, the same length of time that Christ was said to have spent being tempted in the desert.
38. Taylor, “Retrospect of Naval and Military Medicine,” 596.
39. Uniform clothing was not issued to the sailor as a health measure. The officers recognized that uniforms made sailors more easily identifiable on shore, an advantage in curtailing desertion.
40. The term “to shanghai,” meaning to impress a person forcefully into naval service, refers to the port of Shanghai, China. The idea is that once caught by the press gangs, the sailor’s next stop was Shanghai.
41. Taylor, “Retrospect of Naval and Military Medicine,” 596.
42. Lawson, “Amputations through the Ages,” 223.
43. Taylor, “Retrospect of Naval and Military Medicine,” 600.
44. Ibid., 601.
45. Howell, “Story of the Army Surgeon,” 327.
46. Taylor, “Retrospect of Naval and Military Medicine,” 603.
47. Howell, “Story of the Army Surgeon,” 321.
48. Chamberlain, “History of Military Medicine,” 240.
49. Nonetheless, armies persist in defining medical conditions as discipline and morale problems. Soviet frostbite casualties were so high during World War II that Joseph Stalin issued an order that any soldier careless enough to get frostbite would be shot. In Vietnam, American soldiers who contracted venereal disease were subject to punishment. Psychiatric conditions of the “silent” type often are still treated as discipline problems.
50. Howell, “Story of the Army Surgeon,” 332.
51. Paul E. Kopperman, “Medical Services in the British Army, 1742–1783,” Journal of the History of Medicine and Allied Sciences 34, no. 4 (October 1979): 428–29.
52. Howell, “Story of the Army Surgeon,” 332.
53. Ibid., 331.
54. Ibid.
55. Kopperman, “Medical Services,” 430.
56. Ibid., 437.
57. Ibid., 438, citing Robert Jackson, A System of Arrangement and Discipline for the Medical Department of the Armies (London: J. Murray, 1805), for these figures.
58. Taylor, “Retrospect of Naval and Military Medicine,” 596.
59. Kopperman, “Medical Services,” 454.
60. Garrison, Notes on the History, 138.
61. Edgar Erskine Hume, “The Days Gone By: Military Medicine in the Eighteenth Century,” Military Surgeon, October 1929, 563.
62. Ibid.
63. Chamberlain, “History of Military Medicine,” 240.
64. Ibid.
65. Louis S. Greenbaum, “Science, Medicine, and Religion: Three Views of Health Care in France on the Eve of the French Revolution,” Studies in Eighteenth-Century Culture 10 (1981): 373–91.
66. Heizmann, “Military Sanitation,” 299.
67. Hume, “Days Gone By,” 564.
68. Heizmann, “Military Sanitation,” 298.
69. Garrison, Notes on the History, 139.
70. Ibid.
71. Ibid.
72. Ibid., 141.
73. Taylor, “Retrospect of Naval and Military Medicine,” 606.
74. Ibid.
75. It should not be assumed, however, that the physician and surgeon came to military service with the same educational background. The most that can be implied is that both received the same military medical training after entering military service.
76. Taylor, “Retrospect of Naval and Military Medicine,” 607.
77. Garrison, Notes on the History, 142.
78. Taylor, “Retrospect of Naval and Military Medicine,” 566.
79. The best English work on military medicine in Russia during this period is John T. Alexander’s “Medical Developments in Petrine Russia,” Canadian-American Slavic Studies 8, no. 2 (Summer 1974): 207.
80. Ibid.
81. Ibid.
82. Ibid., 210.
83. Ibid.
84. L. G. Eichner, “The Military Practice of Medicine during the Revolutionary War,” lecture presented at the Tredyffrin Easttown History Society, Pennsylvania, October 2003, 25.
85. Edwin P. Wolfe, “The Genesis of the Medical Department of the United States Army,” Bulletin of the New York Academy of Medicine 5 (September 1929): 823.
86. See Ibid., 613; and Taylor, “Retrospect of Naval and Military Medicine,” 627.
87. Wolfe, “Genesis of the Medical Department,” 613.
88. M. A. Reasoner, “The Development of the Medical Supply Service,” Military Surgeon 63, no. 1 (July 1928): 7.
89. Taylor, “Retrospect of Naval and Military Medicine,” 613.
90. David B. Davis, “Medicine in the Canadian Campaign of the Revolutionary War,” Bulletin of the History of Medicine 44, no. 5 (September–October 1970): 461.
91. Reasoner, “Medical Supply Service,” 7.
92. Ibid., 9.
93. William Shainline Middleton, “Medicine at Valley Forge,” Annals of Medical History 3, no. 6 (November 1941): 465.
94. Ibid.
95. Eichner, “Military Practice of Medicine,” 27, for a list of the specific medical conditions that caused death.
96. Howard Lewis Applegate, “Preventive Medicine in the American Revolutionary Army,” Military Medicine 126 (May 1961): 380.
97. Blair O. Rogers, “Surgery in the Revolutionary War: Contributions of John Jones, M.D. (1729–1791),” Plastic and Reconstructive Surgery 49 (January 1972): 3.
98. Davis, “Medicine in the Canadian Campaign,” 461.
99. Eichner, “Military Practice of Medicine,” 26.
100. Rogers, “Surgery in the Revolutionary War,” 9.
101. The name was changed from King’s College to Columbia University during the Revolutionary War.
102. Jones had been a military surgeon in the French and Indian War, an experience that prompted him to write his manual for wound treatment. The practical value of his manual, appearing as it did at the outbreak of the war, is obvious from the table of contents. Jones’s book contains chapters on inflammation, superficial wounds, general wounds, penetrating wounds, simple fractures, compound fractures, amputations, head injuries, concussions, skull fractures, gunshot wounds, and how to set up and manage a military field hospital.
103. Applegate, “Preventive Medicine,” 551.
104. Allen C. Wooden, “Dr. Jean François Coste and the French Army in the American Revolution,” Delaware Medical Journal 48, no. 7 (July 1976): 398. While Brown’s work was the first of its type written by an American in the colonies, Coste had authored a small military pharmacopoeia for the French troops’ use that had gained wide readership among American physicians.