The nineteenth century was the period in which the principle of empirical observation finally triumphed in medical matters over the influence of cosmological theorizing. As the century progressed, medical clinicians and researchers gradually worked out the methodological problems associated with discovery, innovation, and verification; abandoned old theories of disease; and established criteria of proof for new medical information. While the century was replete with new approaches and discoveries, the evolution and systematic application of new methodologies marked the century as the true beginning of modern scientific medicine. Table 7 presents a list of the most important medical advances and innovations relative to the wars that occurred in the nineteenth century.
The century was also marked by significant contributions that military physicians made to medical advances and the development of military medicine along modern lines. Military physicians applied to the battlefield various medical discoveries and techniques that the civilian medical establishment developed and greatly improved the organizational structures required to deliver effective medical care to the soldier in the field. Few armies began the period with anything approaching a systematic military medical service, but by the century’s end, all major combatants had set up independent military medical departments capable of dealing with mass casualties. The stimulus for these developments was, of course, the frequency of wars.
The wars of the nineteenth century were fought with increasing ferocity and lethality as a consequence of the technological advances in the killing power of weaponry. The French Revolution had created a new kind of army, an army of citizens, who, in exchange for the burden of conscription, expected better military medical care. The extremely high casualty rates caused by more lethal weapons forced political and military authorities to improve medical care as a way of conserving expensive manpower. Although few armies at the start of the period had learned these lessons, all major combatants had institutionalized their practices to establish adequate military medical services by the end of the century.
Table 7. Major Medical Advances of the Nineteenth Century and the First Half of the Twentieth Century
Few periods can compare with the nineteenth century in terms of the sheer frequency and destructiveness of warfare. The century began with the decade-long wars of the French Revolution only to witness, after a short respite, their continuation in the guise of the Napoleonic Wars. Across the Atlantic, the Americans fought the War of 1812 and the Mexican War of 1846–1848, both significant conflicts for the emerging United States. The Crimean War, which pitted the Russian Empire against a European alliance, caused so many casualties from weapons and disease that the public outcries of the combatants’ civilian populations forced significant military and medical reforms. The American Civil War, the world’s first truly modern war, shocked not only the United States but also caused European leaders to search for ways to increase the combat power and manpower assets of their own armies in anticipation of having to fight such wars themselves. France’s wars with Italy and Germany were bloodbaths, revealing the West’s complete inability to avoid horrific slaughter in its own backyard. In the end, the strategists and tacticians abandoned the search for solutions and resigned themselves to the fact that slaughter could not be avoided. Unwilling to abandon the structures and tactical principles, along with the accompanying privileges and social status, that had marked the military establishments of Europe for a century, the military thinkers of the late nineteenth century seem to have comforted themselves with more traditional doctrines of war fighting. When once again the major powers of Europe stumbled into conflict in the early twentieth century, these illusions evaporated overnight and left in their wake the most horrible slaughter ever wrought between contesting armies.
If war provided the stimulus for improved military medical care, the technological innovations of the Industrial Revolution provided the opportunity. The wars of the French Revolution and the Napoleonic era that followed interfered with the transfer of medical knowledge across national borders. The location of these wars and their long duration effectively forced medical research and discovery back within respective national borders. After 1815, wars of the period were fought on the periphery of Europe (Crimea) and outside Europe (the Mexican War, the Civil War) and were of short duration (France-Italy, Franco-Prussian War). The period following the Napoleonic Wars also saw great improvements in travel and communication. Medical discoveries and new treatment techniques were shared through printed books, newspapers, and medical and scientific journals, often transmitted telegraphically or through regular mail service that spanned the oceans in a few weeks. For the first time since the Roman Empire, the development of medicine could be viewed as a coherent whole rather than applying only to separate countries. A general commonality of medical knowledge and practice began that connected the efforts of researchers and practitioners across national boundaries. Only Russia—because of its geographic and, to some degree, cultural isolation—and Germany, because of its political fragmentation, remained apart from the stream of medical discovery and practice.
Neither medical nor military men could have anticipated the changes that occurred in warfare and military medicine during the nineteenth century. When the century began, the long-established tensions among the physician, surgeon, and barber-surgeon that had retarded the application of practical medicine to the soldier continued to strangle the medical profession. By the end of the century, except in Russia, the military barber-surgeon had disappeared, and surgery had finally established itself as an equal partner in the medical profession. A similar status was finally conferred upon military medical officers for the first time.
When the nineteenth century dawned, medical practitioners believed that the suppuration of wounds was a natural, inevitable, and beneficial part of the healing process, and they accepted the deaths of thousands of soldiers to wound infection as an unavoidable cost of war. By century’s end, however, discoveries in bacteriology made antiseptic and, later, aseptic surgery a common practice, and the death rate to wound infection dropped dramatically. Also at the beginning of the century, pain was the expected price of surgical application. Within fifty years, the introduction of anesthesia banished pain from the operating room and gave birth to the new science of anesthesiology. With pain alleviated, the necessity for surgical speed was reduced, opening up the possibility of more complex surgical procedures. Most military surgeons at the turn of the eighteenth century had not yet mastered ligature or the tourniquet; thus, amputation, the most common surgical procedure performed on the wounded, remained a traumatic and risky business. By the end of the nineteenth century, however, both ligature and tourniquet applications were normal practice, as was the use of the hemostat and surgical clip. Cautery was finally banished from the surgeon’s kit.
The greatest killer of soldiers at the beginning of the century was still disease, and it routinely carried off eight soldiers for each one felled by an enemy bullet. The advances of bacteriology, nutrition, and military and public sanitation, along with antiseptic surgery, finally made it possible for an army to kill more of the enemy with hostile fire than were killed by deadly infectious microbes. The Franco-Prussian War was the first war of any magnitude in which the number of soldiers lost to hostile fire was greater than to disease.
At the start of the nineteenth century, no army had established an independent military medical service under the control of medical officers for treating the sick and wounded. No nation could provide a trained medical staff, supply structure, transport, and medical personnel adequate to handle the usual casualty loads. By the end of the century, every major army had an independent, professionally trained, and sufficiently manned military medical service complete with an ambulance corps for reaching and evacuating the huge numbers of casualties that had never before been seen on the battlefield. If war finally reached modern proportions in all its respects in the nineteenth century, it is also fair to say that military medicine achieved a similar stature.
Effective and safe anesthesia was introduced to military medicine in the nineteenth century. The term “anesthesia” is generally credited to Oliver Wendell Holmes Sr. (1809–1894), to describe the effects of ether.1 Prior to the discovery of ether and chloroform as anesthetics, the most commonly used agent against pain was opium administered in liquid or powdered form. Other methods of rendering a patient unconscious or semiconscious for surgery were to reduce the blood supply to the brain either by compressing the carotid artery until the patient passed out or by bleeding the patient to a state of near total unconsciousness. Immediately prior to the introduction of ether anesthesia, some surgeons, including the famous English surgeon Sir Robert Liston (1794–1847), used hypnotic suggestion to induce sleep.2 All of these methods produced semiconscious states of only short duration, requiring the surgeon to complete the surgical procedure quickly.
The first gas recognized as having anesthetic properties was nitrous oxide, which Joseph Priestley (1733–1804) identified in 1772 as part of his experiments with oxygen. For several years the gas was thought to be deadly. In 1795, the chemist Humphry Davy (1778–1829) inhaled nitrous oxide and, noting its pleasant effects, named the mixture “laughing gas.” In 1800, Davy published a monograph in which he described the use of nitrous oxide to relieve the pain of an inflamed gum. More important, he suggested its use as a surgical anesthetic. Eighteen years later, Davy’s student, Michael Faraday, noticed the anesthetic effects of sulfuric ether and compared them to the effects of nitrous oxide. In 1842, Henry Hill Hickman, a member of the Royal College of Surgeons of London, performed the first operation with an anesthetic on animals.
None of these experiments evoked any serious interest. Although nitrous oxide and ether were well known by mid-century, the medical community still showed no systematic interest in using it for surgery, perhaps because of the widespread belief that pain was natural to illness. Medical students were aware of the anesthetic properties of both nitrous oxide and sulfuric ether, and they commonly used them at university parties to induce silly behavior. In January 1842, William E. Clarke, a student of chemistry, convinced Elijah Pope to extract a tooth from a patient anesthetized by ether. Two months later a Georgia dentist, Crawford Long, removed a tumor from the neck of a patient who was anesthetized by ether. After William T. G. Morton, a Boston dentist, extracted a tooth from a patient to whom he had administered ether in 1846, he published the results of his work in the Boston Journal. Morton was heretofore regarded as the discoverer of ether as a surgical anesthetic. In October 1846, Morton administered anesthesia while Dr. John Collins Warren removed a tumor from a patient’s jaw. The use of ether as a surgical anesthetic quickly spread to Paris and to London, where, in December 1846, Sir Liston performed a thigh amputation on an etherized patient and publicly proclaimed the new anesthetic a major medical innovation.
The U.S. Army was the first to formally issue ether for anesthetic purposes, having allotted supplies to the physicians and battle surgeons who accompanied Maj. Gen. Winfield Scott’s men in the 1847 landing at Veracruz during the Mexican War. That March or early April, Edward H. Barton, surgeon of the Third Dragoons, Cavalry Brigade, Twiggs’s Division, anesthetized a teamster of the U.S. Army’s logistics train to amputate his leg, which had been shattered by an accidental musket blast. The operation marks a military field surgeon’s first use of the ether anesthetic.3
Samuel Guthrie in the United States, Eugène Soubeiran in France, and Justus von Liebig in Germany almost simultaneously discovered chloroform in 1831.4 Chloroform was not used as an anesthetic, however, until 1847.5 Chloroform had a number of advantages over ether for military applications. The simple “rag and bottle method” of administering chloroform was easier to use since it did not require an inhaler. Smaller quantities were required to induce anesthesia, and chloroform could be more easily stored and transported in the battle surgeon’s pocket while in the field. Most important, unlike ether, chloroform was not explosive, an important consideration in a time when most operations were performed by candle or lantern light in close quarters. Given these advantages, it is difficult to explain why chloroform was so slow to catch on, especially among English military surgeons. From 1847 to the early days of the Crimean War in 1853, there was not a single documented instance of a British military surgeon using chloroform for anesthesia.6 John Snow (1813–1858) was the first physician to calculate specific doses for ether and chloroform as surgical anesthetics. He personally administered chloroform to Queen Victoria (1819–1901) during the births of the last two of her nine children, leading to the widespread acceptance of the use of anesthetics among English physicians. Although the French military had used it as early as the Paris revolt of 1848 and the Prussians likely used it in the Danish-Prussian War of 1848–1851, British military medical doctors did not begin to use chloroform until the first few months of the Crimean War. A British naval surgeon aboard the HMS Arethusa was the first to administer chloroform at sea in 1854.7
Anesthesia revolutionized military surgery, especially in the area of battlefield amputation. Without anesthesia, speed was the surgeon’s primary qualification. Sir Liston, the famous English surgeon, reportedly could amputate a leg in twenty-eight seconds. Even less skilled military surgeons could accomplish the task in less than a minute. Moreover, the doctrine of primary amputation advanced early in the century by Dominique-Jean Larrey, Baron Pierre-François Percy (1754–1825), and George James Guthrie (1785–1856) was gradually accepted as the century wore on, and under the influence of Sir Thomas Longmore (1816–1895) and George H. B. MacLeod in the Crimean War, it became established practice for military surgeons. Anesthesia made it possible to operate more slowly, to take the time to effect more complete hemostasis (stopping blood flow), and to prepare the stump for prosthesis. Although early in the century surgeons maintained that the pain associated with surgery was actually beneficial in that it kept the body’s systems fighting to survive, in fact the use of anesthesia greatly reduced the incidence of death by surgical shock.
The problem of hemostasis remained a serious obstacle to battlefield surgery, however. A common method of hemostasis during amputation was to put pressure on the femoral artery. Liston preferred this technique to the tourniquet. Ligature gained more acceptance as surgeons trained in battlefield surgery gradually learned how to accomplish it. At the beginning of the century, surgeons found that a ligatured artery formed a clot within the ligature. Military surgeons often left the ligatures long so that the suture could act as a drain outside the wound. A common practice until after the Civil War, this technique allowed the exposed suture to act as a wick along which infection could be transferred deep within the wound, provoking a secondary hemorrhage that was often fatal. Since the ligature material was not sterile, even a short ligature left in the wound provoked infection and secondary hemorrhage. Philip Physick (1768–1837), a Philadelphia surgeon, made some progress in this area. He experimented with ligatures made of buckskin and parchment to make them absorbable. Horatio Jameson (1778–1855) of Baltimore continued the work and, in 1824, introduced absorbable ligatures made of kid and chamois.8 The medical community, however, was slow to accept both advances. Until after the Civil War, most ligatures were still made of harnessmaker’s silk, horsehair, and catgut. Dr. Joseph Lister experimented with treating catgut with carbolic and tannic acid to make it sterile, but using these materials produced high rates of tetanus, anthrax, and gas gangrene in amputated limbs.9 Meanwhile, some advances in hemostasis were achieved. In 1829, Karl Ferdinand van Gräfe developed a lock to hold the hemostat closed, and more technical advances were made along the way until William Steward Halsted invented the modern hemostat in 1879.10 Spencer Wells contributed greatly to the introduction of bloodless surgery in 1872 when he used small arterial clips to close off blood flow temporarily during surgical procedures. In 1873, the German military surgeon Friedrich von Esmarch invented the Esmarch elastic bandage, which served as a battlefield tourniquet and promised the possibility, although unrealized, of bloodless surgery.
The large numbers of experienced surgeons on the battlefield over the course of the century generally improved the overall competence of surgical procedures and stimulated solutions to problems that they had commonly encountered. Thus, the French surgeon Charles Pravaz, searching for a way to administer drugs more efficiently, developed the hypodermic syringe in 1853. René Laennec, another military surgeon, carried out experiments with the stethoscope (published in 1819) and introduced this vital piece of diagnostic equipment for use on the battlefield.11 Wilhelm Röntgen’s discovery of the X-ray in 1895 became a revolutionary way of determining the position of projectiles buried deeply inside the body.12 Unknown military staff physicians in the Seminole War (1841) discovered that regular doses of quinine were a safe and effective preventive for malarial fever.13 In 1900, the U.S. Army Yellow Fever Commission, consisting of Walter Reed, James Carroll, and contract surgeons Jesse Lasaer and Aristide Agramonte, proved experimentally that yellow fever was transmitted by the bite of a mosquito. In 1898 American Army physician William Gorgas was assigned to eradicate Cuba of yellow fever, and his efforts later made the building of the Panama Canal possible.14 As important as these advances were, though, little progress in the field of military surgery and hygiene would have been possible without the discoveries in the field of bacteriology, which, for the first time, made it possible to prevent infection, the primary killer of wounded soldiers.
By 1830, improvements in the microscope began to open up the microbial world to medical investigation. Even so, by mid-century no one had made a systematic investigation into microbes as agents responsible for disease, although medical thought had already started to move in the direction of specificity of disease analysis. The most commonly held theory of disease causation at the time was that all sorts of foul matter, or miasmas, transmitted by air and water caused diseases. While medicine at least had abandoned the idea that evil spirits produced illness, conceptions of disease agents had not moved much beyond those of the Roman engineer Marcus Terentius Varro (177 BCE–27 BCE), who speculated that little animals too small to see invaded the body by respiration and breaks in the skin to cause diseases. It was the specific nature of these “little animals” that continued to elude scientific investigation.
Disease and infection continued to kill thousands of soldiers, especially those who succumbed to postoperative infection. In the early 1860s, Joseph Lister found that infection carried off 80 percent of the patients who underwent amputation of the femur and 50 percent who underwent amputation of the tibia in the Male Accident Ward at London Hospital.15 During the Crimean War, infection produced a mortality rate for thigh amputations of 62 percent, a scant improvement on the 70 percent mortality rate for similar operations during the Battle of Waterloo (1815).16 Until bacteriology was able to determine the specific cause of infection and disease, no serious attempt at preventing surgical infection was likely to succeed.
Between 1857 and 1863, French chemist Louis Pasteur (1822–1895) conducted a series of experiments on fermentation and putrefaction, successfully demonstrating that different microbe agents caused fermentation in different substances. Pasteur also proved that these agents were not spontaneously generated, a view that enjoyed wide currency at the time, but entered the substance from outside. Pasteur became the most forthright proponent of the germ theory of infection and, in 1878, presented a paper asserting that microorganisms were responsible for disease and infection. Because Pasteur’s results were hardly convincing, his new theory was not readily accepted.
After the Franco-Prussian War, Edwin Klebs (1834–1913) furnished convincing proof of the role of microorganisms in surgical sepsis. The most important evidence came with the publication of Robert Koch’s Investigations into the Etiology of Traumatic Infective Diseases (1879). Not only did Koch (1843–1910) establish through studies of the anthrax bacillus that microorganisms caused specific diseases, but equally important for future investigation, he established the methodology for testing the causative nature of disease-specific agents, one still in use today.17
The discovery that microorganisms were responsible for infectious diseases made the advent of antiseptic surgery and the prevention of postoperative infection possible. The idea of antisepsis had been around a long time, but medical practitioners focused on the use of disinfectants in hospital wards. Carl Wilhelm von Scheele had discovered the antiseptic properties of chlorine in 1774, and Bernard Courtois discovered iodine in 1811. Since 1820, chlorine and iodine solutions had been used as “deodorants” along with creosote and turpentine to clean hospital wards and equipment. At the time, a number of published articles suggested using chlorine and iodine solutions as hand rinses for surgeons, but the practice never attracted much attention.18 Carbolic acid, discovered in 1834, had been used to treat sewage in waste plants for some time, and it is likely that Joseph Lister’s experience with carbolic acid at the treatment plant in Carlisle, England, led him to use it in his experiments in antisepsis in the 1860s.
Lister was the son of an amateur microscopist and received early training in the use of the microscope. After completing his medical training, Lister was placed in charge of the Male Accident Ward at London Hospital as a professor of surgery. His own experience with amputation showed that the mortality rate in amputation cases ran between 45 and 50 percent from postoperative infection. Lister’s interest in microscopy led him to pay attention to Pasteur’s work long before its validity had been demonstrated. Believing Pasteur was correct in his assumptions, Lister began the search for a substance that would kill bacteria. In August 1865, Lister used bandages soaked in carbolic acid for dressing a compound fracture of the tibia. In May, he repeated the procedure on another compound fracture of the leg. Both patients recovered. Lister then developed a systematic procedure for keeping operative wounds wrapped in dressings soaked in carbolic acid. He had hit upon two major medical innovations—antisepsis, which involved destroying infective agents that had entered the wound, and asepsis, which prevented an infective agent from entering the wound. In March 1867, Lister published his results in the Lancet.
Although by 1869 the surgical mortality rate from infection had dropped from 45 percent to less than 1.5 percent in his accident ward, the reaction to Lister’s innovation remained mixed. To accept Lister’s method, one also had to accept Pasteur’s theories, and the latter were hardly demonstrated facts at this time. Resistance to Lister’s practices remained strong in France, England, and the United States, where, in 1882, the American Surgical Association officially rejected Lister’s doctrines and practice. Only in Germany was Lister regarded as a hero, and the German Army was the first to implement his antiseptic surgical procedures on a wide scale. This practice paid off handsomely during the Franco-Prussian War, when German military surgeons saved thousands of lives by using Lister’s technique.
The German medical establishment’s acceptance of Lister’s work provoked further investigations into bacteriology and antisepsis, such as the work of both Edwin Klebs and Robert Koch, who were also Germans. The Germans pioneered the use of steam sterilization of instruments, sterile operating gowns and masks, and rubber gloves.19 They were the first to abandon the crowded surgical amphitheaters for smaller disinfected operating rooms. While other countries gradually adopted these procedures, in no other country were they so widely, systematically, and rapidly adopted as in Germany.
These innovations only slowly seeped into the military medical services of other countries.20 For instance, the American Army made antiseptic surgery part of its official military medical practice in 1877.21 In 1899, the U.S. Army medical officers officially began using rubber gloves and then widely practiced antiseptic surgery in the Spanish-American War. By 1909, 60 percent of all operations in the American military featured rubber gloves, and by World War I, antiseptic surgery with rubber gloves and sterile surgical drapes was standard doctrine.22
The great strides in medical care that were made in the nineteenth century turned upon three major discoveries: anesthesia, bacteriology, and antiseptic surgery. These discoveries revolutionized medical care and opened the door for further research that produced remarkable advances in disease prevention and surgical procedures in the next century. Military medical men were among the first and most enthusiastic practitioners in adopting the new techniques to their task of caring for the sick and wounded, and most of the innovations of this period found their first large-scale use in the military medical environment. The task of treating the suffering and human wreckage of war has always forced the military medical mind into a more practical than theoretical bent and toward a propensity for utilizing what seems to work regardless of the larger theoretical issues involved. The increased degree of institutional development evident in the military medical institutions of the time positioned them perfectly to recognize and adopt new techniques much faster than the civilian medical establishments could. The nineteenth century, after all, was the period in which, by mid-century, every major army had developed a professional military medical service of some institutional stability and competence.
The armies of revolutionary France were huge for their time and presented a serious problem for their opponents’ well-disciplined linear armies. The use of “horde tactics” and frontal assaults produced horrendous casualties. After a poor start, the revolutionary armies succeeded in placing thousands of medical officers in the field. All civilian surgeons and physicians were placed under military conscription and control in August 1793, and in an attempt to abolish privilege, all medical schools were closed and medical practice was opened to anyone who could afford a license. Although the numbers of medical officers were sufficient, the quality of medical care provided to the soldier was often dismal. Inspector General Hercule Sieur of the French medical service called this period “the darkest period of French medicine.”23
When the Revolution suddenly swerved to the right with the fall of Maximilien Robespierre in 1794, the concern for all social welfare services, including military medicine, declined. Although the medical service had lost six hundred officers in the wars between 1794 and 1795, it remained the object of political scorn and interference. By 1795, the French military medical service had been placed under the political control of various ministries, which changed its organizational structure at whim. It no longer had a clear hierarchy of officers, a system of litter bearers, or a medical supply service, and medical personnel were subordinated to political administrators.24
To comprehend the opposition to an established, independent military medical service, it is important to remember that despite the slogans of the Revolution, within the military itself the spirit of privilege and caste was very much alive. The artillery arm had only recently attained equal status with the infantry and cavalry, and it strongly opposed extending similar status to the engineers and medical corps. By 1796, political authorities assumed control of the military hospitals, removed the mobilization and disposition of the ambulances from the authority of the chief surgeons, and appointed political officers from Paris to whom all medical officers in the field were subordinated. Medical service chiefs in hospitals were forbidden to interact with the administration of the hospitals themselves.25
The one positive effect of these “reforms” was to drive the best physicians and surgeons from the hospitals into the field to treat the wounded, thereby providing an excellent opportunity to develop a corps of experienced battle surgeons. Nonetheless, between 1800 and 1802 the number of military doctors attached to the armies fell by half, and the number of serving surgeons did not reach the original number again until 1809. By that time, however, the armies had doubled in size. In 1800, 210 physicians and 629 surgeons were in the army. By 1802, the number of physicians had fallen to 62 and the number of surgeons to 500.26 Napoleon compounded the disaster in 1803 by reducing the number of military hospitals in France to only thirty while simultaneously closing the military teaching hospitals that had been established during the Revolution.27 Napoleon also refused to make the commissions of military doctors permanent, and despite pleas from Larrey and Percy, he would not establish an independent military medical service.28
The results of these misguided policies made themselves felt in the enormous levels of French battle casualties suffered in the Napoleonic Wars. Of the 4.5 million soldiers who served in the revolutionary and Napoleonic armies, 2.5 million died in hospitals from wounds and disease.29 Another 150,000 were killed in action. During the Egyptian campaign (1798–1800), a force of 30,000 men suffered 4,758 dead in action and 4,157 to disease and infection. The army suffered almost 30,000 cases of ophthalmia, and the death rate from all diseases was 109 men per 1,000.30 When the sick and wounded were transported home, the mortality rate in transit reached 41 percent.31 The Russian campaign (1812) began with 533,000 men in Napoleon’s invasion force. By the time the army reached Moscow, disease had shrunk the force to 95,000, even though it had fought only two battles along the way. The retreat from Moscow was even more devastating, with thousands of men abandoned to die of disease and cold.32 Of the total force that began the invasion, only 40,000 lived to reach France. Of these men, fewer than 1,000 were able to return to duty.33 The death rate among military medical officers was equally appalling. At the start of the campaign, 876 medical officers of the Service de Santé (Health Service) attended the army. By the end, only 276 had survived, representing a loss of 551 officers, or 63 percent, to battle, cold, disease, or capture.34 To make matters worse, the quality of military surgeons had fallen so low in the Napoleonic armies that Baron Percy, the chief surgeon of the army, called them chirurgiens de pacotille, or “slop-shop surgeons.”35
There were exceptions to this general trend of poor quality, and Larrey, Napoleon’s medical director and chief surgeon, was first among them. Larrey took part in twenty-six campaigns, sixty battles, and four hundred engagements and was wounded three times. After Waterloo, the Prussians captured Larrey, but a Prussian surgeon recognized the famous military surgeon and saved him from execution. Marshal Gebhard von Blücher, whose son Larrey had treated before the war, ordered him released. Larrey’s memoirs, Memoires de Chirurgie Militaire et Campagnes (1812–1817), are the definitive source of information concerning military medicine in this period and make truly adventurous reading. At the Battle of Eylau (1807), Larrey operated for twenty-four hours without rest in weather so cold that his assistants could not hold the instruments. At Borodino (1812), by his own account, he performed no fewer than two hundred amputations in a twenty-four-hour period. His own experience with amputation led him to become an early advocate of the doctrine of primary amputation in contradiction to the then accepted advice of John Hunter. Larrey is recognized as the first military surgeon in Europe to advocate primary amputation. As a student of Desault’s, Larrey espoused and practiced debridement of necrotic tissue, and he realized the danger of closing traumatic wounds prematurely. Larrey stipulated basic clinical rules for determining when amputation was required, and these guidelines and the doctrine of primary amputation remained standard military medical practice until after the Russo-Turkish War, when a Russian military surgeon, K. K. Reyer, demonstrated that the majority of gunshot-induced fractures could be salvaged with the aid of antisepsis and early debridement.36 Larrey was also among the first surgeons to recognize the value of immobilization in healing, and he used the starch splint to reduce the pain that casualties suffered during transport.
Larrey had begun his military medical career in the armies of revolutionary France, where he was quick to recognize the poor quality of medical training and knowledge available to the hastily recruited medics of his day. To correct this problem, Larrey established ad hoc training classes in anatomy and surgery at each of his postings no matter the duration. In Egypt, he became aware of the dangers of disease contagion through his experience with infectious ophthalmia. His list of hygiene instructions to his surgeons was remarkable for its prescience. Larrey prescribed special surgical garments for doctors and nurses made of oiled cloth or rubberized taffeta. If these items were not available, he ordered that gowns should be made of tightly woven linen dipped regularly in vinegar water. He designed special wooden shoes coated with turpentine for use in medical wards. He directed that faces and hands were to be washed regularly in vinegar water, and when undertaking surgery, doctors had to wear linen surgical masks dipped in vinegar water. Larrey’s surgeons were required to change the patients’ dressings regularly and to minimize physical contact with the patient’s wound. Old bandages and bedding were to be burned immediately and instruments washed frequently and kept in an airy place. Before leaving the hospital, surgeons and physicians were required to change their outer clothing and underwear and wash their bodies with vinegar water.37 As contradictory as it seems, however, Larrey remained a believer in the necessary suppuration of wounds and recommended using charpie as a suppurative.38
Larrey may also have been the first to introduce a formal policy of combat triage among his battle surgeons. He ordered that the old practice of treating the officers and rankers first regardless of their degree of injury be replaced with preference for treatment going to the most severely wounded. His instructions to send the slightly wounded back to the second line were especially directed at officers “because officers have horses.”39
France’s most enduring contribution to the military medicine of the period was the innovation of an effective ambulance corps for evacuating casualties. This development was also a product of Larrey’s ingenuity. Under Louis XVI (1754–1793), the French were the first to introduce hospital wagons, and these wagons were still in service at the time of the revolutionary wars. They were very large, carried great amounts of equipment, and were staffed by 134 medical personnel, including thirty-one surgeons and thirty-one trained male nurses. The wagons’ colossal size required forty-nine horses to tow each one.40 Because of their size and slow speed, army regulations required that the wagons remain three miles behind the battle line. Even in the armies of revolutionary France medical personnel were forbidden to treat casualties until the battle had ended, but with the roads around the battlefield clogged, these hospital units normally reached the wounded twenty-four to thirty-six hours later. The huge wagons were often abandoned in retreat, leaving the wounded to their uncertain fate.41
The wagons were designed to bring medical treatment to the soldier, but the French Army had no means of evacuating casualties to aid stations or rear area hospitals. The problem of casualty evacuation led Percy, chief surgeon to Gen. Jean-Victor Moreau’s Army of the North, to introduce a lighter medical ambulance. Called by the German troops “Percy’s Wurst”—after the sausage—these new wagons packed sufficient medical supplies and instruments to treat twelve hundred casualties. The wagons had a complement of eight surgeons who sat atop the vehicle and eight surgical attendants who sat on the medical chests on the floor. Stretchers were stowed under the driver’s seat. Towed by six horses, these wagons were only slightly more mobile than the earlier collossi and were not integrated into an overall system of casualty evacuation.42 Moreover, while sitting atop the wagon, the medical personnel made easy targets for enemy riflemen. Percy’s most important innovation was the creation of a corps of litter bearers who could reach the wounded on the battlefield and move them to the medical wagons. These bearers (brancardiers) were first employed in the Spanish campaign (1808). Larrey then integrated the stretcher bearers into a modern system of evacuating and transporting casualties to clearing stations.
Larrey was a field surgeon with the Army of the Rhine in 1792 when he introduced his ambulance system. The idea was born from watching the newly mobile horse artillery—the artillerie volante, or “flying artillery”—moving horse-drawn guns, crews, and ammunition in independent mobile carts. Larrey designed and had built the prototypes of a new style of mobile field ambulance constructed on special springs to ease the wounded’s transport. Each wagon was covered and equipped with ventilation holes and mattresses that swung out on wheeled pallets to make loading and unloading easier. These ambulances came in both a light two-wheeled, two-horse variety and a heavier four-wheeled, four-horse design. The ambulances were to drive as close as forty feet to the battle line and deploy litter bearers to reach the wounded still under fire and transport them to the ambulance. Once aboard, the ambulances would move the casualties to nearby dressing stations. When the ambulances returned to the line for more casualties, they also would bring fresh medical supplies. Larrey was the first since Roman times to propose evacuating casualties from engaged battle formations in a military medical ambulance corps. His major innovation was to man these wagons with a corps of trained personnel assigned specifically to drive the ambulances, to carry the litters, and to remove these medical resources from the quartermaster’s control.
Larrey was also the first military medical officer to fully appreciate the value of concerted action between line and staff assets for the benefit of the wounded. To place the medical organization on a par with the military organization he had to redesign the division’s entire medical support system. The essence of his plan was to have a medical unit available for each military unit based around the division, and in 1793 he reorganized the medical units of the Army of the Rhine along genuinely modern lines. Larrey divided the medical responsibilities of the division into two sections. The first section comprised a commissary and other subordinate units in which twelve surgeons and twenty-five attendants were designated to provide medical and surgical services to the wounded. In another interesting innovation, probably adopted from the mounted artillery, he provided the surgeons and some attendants with mounts so they could move from behind the lines to where the casualties were heaviest. The second division was an ambulance corps of twelve light carriages and four heavier wagons doubling as medical supply transports. Each wagon had a man in charge, a driver, a horseshoer, and a bugler who also served as medical assets exclusively, and unit commanders could not commandeer them. One hundred and thirteen medical personnel staffed the division section. Subordinate units could be created ad hoc, each with a directing surgeon and fifteen assistant surgeons. Medical personnel staffed the aid stations close to the lines. After the ambulance corps brought casualties to these collecting points, those wounded requiring further treatment were sent along predesignated routes to the general hospitals farther to the rear. Everything in the modern casualty evacuation systems was included in Larrey’s organization, and he may be genuinely credited with creating the first modern casualty handling system in the West.
Larrey’s medical organization was tested at the Battle of Metz (1793) and was so successful that he was ordered to assemble the new ambulances and equip all fourteen armies of the Republic.43 Quartermaster general Jacques-Pierre Orillard de Villemanzy ordered a few prototypes to be built. Unfortunately, the idea came to the attention of the political authorities, who ordered a national contest to determine the best design. This committee’s interference delayed the ambulances’ introduction for more than two years.44 By the time a design was settled upon, political instability and the lack of a centralized medical organization resulted in the ambulances never being produced in sufficient quantity. It was not until Larrey served as chief surgeon under Napoleon that the new medical organization was finally tested.
Napoleon’s attitude toward providing military medical care for his men was curiously ambivalent. On the one hand, he was personally solicitous of any wounded soldier, at times forcing his officers to walk while their horses carried the wounded. In Egypt, he gave up his own mount to the medical service and walked with the troops. On the other hand, Napoleon seems to have shared the traditional view of the officer corps and nobility of the ancien régime that soldiers drawn from the lower social orders simply did not count for much. After the Battle of Eylau, for instance, Napoleon walked the battlefield, noting that his casualties amounted to only “small change.” At the same time he was personally fond of Larrey because he had proven himself a true soldier by being wounded, so Napoleon gave him free rein to design a medical service for the Imperial Guard. But again, Napoleon’s attitude was contradictory. Throughout the wars, both Percy and Larrey pressed him to establish an independent medical service and make the commissions of physicians and surgeons permanent. Napoleon refused. And while the medical support for the Imperial Guard was the best in Europe, Napoleon never saw fit to extend this support to the rest of his army. Thus, during the Austrian campaign of 1809, while the casualties of the Imperial Guard were treated and evacuated immediately, the other French wounded were still left on the battlefield without medical attention three days after the battle ended.45
The medical service for the Imperial Guard consisted of a division d’ambulance for each corps, with one surgeon first class, two surgeons second class, and twelve surgeons third class supported by twelve hospital attendants (infirmiers). All of these people were mounted for increased mobility. Forty-four additional hospital attendants were available on foot and supported by selected officers and noncommissioned officers seconded from the line for medical duty. The transport train consisted of twelve ambulances, eight two-wheelers, four four-wheelers, and four heavy wagons of the Percy design outfitted as mobile casualty clearing stations. For the first time a primitive first aid kit of bandaging material was provided to designated officers and enlisted men in the medical units. The system apparently worked very well. At Aboukir (1799), none of the French wounded were on the ground for more than forty-five minutes. Later, at Austerlitz (1805), Napoleon’s bloodiest battle, the medical service reached and treated all casualties of the Imperial Guard and evacuated them to hospitals in less than twenty-four hours.46
The weak point of the Napoleonic military medical care system was the general hospitals. Napoleon reduced the number of military hospitals in France to fewer than thirty. Because the Grand Armée fought mostly on foreign soil and was always on the move, the available hospitals were mostly makeshift affairs in churches, houses, factories, and other accessible buildings. Because the best doctors served in the field to avoid the political interference and difficulty attendant from Paris, the general hospitals were either understaffed or staffed by incompetents. These makeshift hospitals became pesthouses, and “military hygiene in the modern sense was almost non-existent, and the sanitary status of the hospitals was almost the lowest in recorded history.”47 So many men died of illness and disease in these charnel houses that they became known throughout Europe as the “tombs of the Grand Armée.”48
Although French military medicine was poor, with the exception of that provided to the Imperial Guard, the ranks of the British-led alliance that opposed the Napoleonic armies during the Peninsular Campaign (1808–1814) received more terrible care. The British military medical system had not changed in a century. The Army Medical Board, consisting of a physician, a surgeon, and an inspector general, was charged with overseeing the few peacetime hospitals and providing for a surgeon and a surgeon’s mate in each regiment. The medical resources of the army on campaign remained under the control of the regimental officers of the line. The system for supplying doctors, medical materials, hospitals, transport, and nurses had to be re-created each time the army took the field. There were no intermediary hospitals between regiment and the general hospitals, and because the medical service had no organic resources, transport, or supply services, it still had to rely on the largesse of the field commander in any given campaign for these provisions. The commanders’ need to keep the army mobile and ready to move necessitated sending the wounded to the rear. Since the regimental surgeons were expected to move with the army, they had to abandon the wounded. From time to time, members of the regimental band were pressed into service as litter bearers.
The typical military surgeon in the British Army had little or no formal training; was inferior in status to the military physician, who had a university education; and thus occupied one of the lowest ranks in the military hierarchy. The high casualties that resulted from the engagements with the French in 1790–1791 increased the demands for greater numbers of military surgeons. While the French solved their manpower problem through impressment, the British simply lowered their already low standards to attract any young man with even the most rudimentary medical or pharmaceutical training to military service. George James Guthrie, the most famous British military surgeon of the day, noted that “surgeons were appointed without having served a single day in a regiment.”49 British regimental medical units often lacked a specified set of instruments, and still without an official sanitary code, the problem of field hygiene was left to the unit commander.
The medical experience of the British units at Walcheren, Holland, in 1809 was so horrible that it prompted reform of the medical system. In April, 39,214 men were shipped in 245 transports to the island of Walcheren to mount an attack against Napoleon’s naval base at Antwerp. Deployed in a disease-ridden swamp, 3,000 men were down with fever by August. By September, 14,800 were sick. A month later, only 4,000 men of the original force were fit for duty. When the army finally withdrew in February 1810, of the original force, 4,000 had died of disease, 11,000 were still in hospitals, 106 men had been killed by enemy action, and another 100 had died of wounds.50 The disaster resulted in the replacement of the Army Medical Board, whose members were replaced with experienced military surgeons and physicians. A new medical director, James McGrigor (1771–1858), was assigned to the staff of Maj. Gen. Arthur Wellesley, Duke of Wellington (1769–1852), in the Peninsular War.
Until the breakthroughs in bacteriology in the last quarter of the nineteenth century, disease often devastated armies and presented medical officers with insurmountable problems. Since the armies were large and remained in the field for long periods, the death rates from disease were higher in this era than ever before in history. The following data provide some insight into the problem. During Napoleon’s attempt to conquer Santo Domingo in 1802, a 20,000-man army under Gen. Charles-Victor-Emmanuel Leclerc lost 15,000 men to yellow fever.51 During the Peninsular campaign, the average British sick rate was 210 per 1,000 men annually,52 while the annual death rate from disease was 118 per 1,000 men.53 Of 61,511 men, the British lost 24,930 from disease and 8,889 to enemy fire.54 During the Mexican War, 100,000 American soldiers saw field service. Only 1,550 were killed or died of wounds, 10,900 were lost to disease, and another 12,280 were discharged from service for illness. At any given time, the sick rate for the army ran between 17 and 27 percent.55 Overall losses in the Crimean War were equally horrible. Although four thousand men died from wounds in the British Army, sixteen thousand perished from disease. On average, three of every ten men perished from disease each year of the war.56
When Wellington’s new chief medical officer arrived on the Peninsula in January 1812, McGrigor found that the common practice was to dump the wounded at makeshift collection points behind the lines where there were few hospitals to treat them. The army had made no provisions for medical supplies, and the hospital system was widely scattered, unregulated, and disorganized. Further, the large general hospitals, created ad hoc, could handle only three hundred casualties. McGrigor immediately overhauled the medical supply system and standardized the flow of medical supplies to the front. He also instituted regular procedures at the hospitals, appointing inspection teams to enforce hygiene measures to reduce disease. He introduced weekly medical inspections for the rank and file and a sanitary code for the regiments.
McGrigor knew that Wellington’s army was always short of manpower. He observed that once a wounded or sick soldier was sent to the rear hospitals, they had no provision for systematically returning him to his unit. McGrigor attacked the problem by requiring that standard medical report forms be submitted on a weekly basis. He moved the convalescing soldiers out of the hospitals to temporary collecting centers, where they were housed in prefabricated huts shipped from England. McGrigor was then able to establish a regularized system for returning recovered soldiers to their units.57 Prior to the Battle of Vitoria in 1813, McGrigor was able to return almost a full division of men to combat duty.58
Wellington’s tactics continually worked against McGrigor’s efforts to establish an efficient medical treatment system, however. Outnumbered, Wellington pursued a strategy of mobility, conducting deep, quick strikes into the enemy lines and retreating rapidly to prearranged defensive assembly areas. Wellington’s priority was to keep his army on the move. He continually rejected McGrigor’s attempts to requisition wagons and create an ambulance service, fearing it would clog his lines of communication and disrupt his artillery and logistics train. McGrigor adapted his medical system to these realities and created fully equipped mobile regimental hospitals to move with the army. Instead of evacuating the wounded to the rear, McGrigor attempted to bring the surgeons closer to the wounded at the battle line.59 By the end of the war, the system was working relatively well. At Toulouse in April 1814, 13 percent of the English force became casualties. Two deputy medical inspectors, ten staff surgeons, six apothecaries, and fifty-one assistant surgeons administered medical treatment to 1,359 wounded soldiers and 117 officers on the line.60
Unfortunately, the system of medical treatment developed during the Peninsular War was solely a product of the personal trust and working relationship that McGrigor and Wellington developed, and it represented no permanent change from the traditional pattern of establishing ad hoc military medical services. The army did not adopt any of McGrigor’s innovations on an institutional basis, and when the war was over, the army and McGrigor’s medical service were both demobilized. The trained corps of medical personnel was pensioned off at half pay. When the British met the French at Waterloo a year later, the British medical service already had fallen back into the old disorganized pattern that had characterized it for more than a century before the Peninsular War.
The Battle of Waterloo was fought on June 15, 1815. It lasted nine hours and ranged over five square miles of ground. Napoleon’s army numbered 70,000 men and the allied armies under Wellington, 60,000. When the battle was over, Napoleon’s force suffered 25,000 dead and 8,000 taken prisoner. The British and Hanoverian elements of Wellington’s army had lost 10,700 men killed and another 7,000 wounded.61 The Prussians lost 7,000 soldiers killed and another 7,000 wounded.62 Within an area slightly larger than New York’s Central Park, 56,700 casualties lay strewn across the blood-soaked ground.63 The French casualties continued to lie unattended for days, their medical service having been destroyed or disorganized in the battle. The British system was almost nonexistent, and as late as eleven days after the battle, British and French casualties were still awaiting treatment. The failure of the allied armies to prepare adequate general hospitals in Brussels and to provide transportation for the wounded meant that even when the wounded reached the rear hospitals, little medical treatment was available. Waterloo was a military medical disaster of enormous proportions.
Having dismantled their medical service a year earlier, the British were caught without any meaningful medical support at all. In theory, each battalion of six hundred men was authorized only one surgeon and two assistants. In reality, of the forty British battalions at Waterloo, only twenty-two had their full complement of medical personnel. One unit, the Twenty-Eighth Foot, suffered 50 percent casualties and had only one assistant surgeon to treat them.64 Few of these newly appointed surgical assistants, however, had any medical training. Without a corps of litter bearers, it was not uncommon for several men to help a wounded comrade to the medical tent and then refrain from returning to the battle. Wellington noted that 1,875 men were unaccounted for after the battle. They were later found to have helped their comrades to the medical tents and remained there until the battle ended.65 No provisions were made for wagons to serve as ambulances. Wellington had moved so fast to Waterloo that much of his wagon train, including the few medical assets available, were still miles away when the battle began. What few carts and wagons that the medical service could scavenge were useless as the roads to Brussels were choked with the soldiers and wagons of Wellington’s army as it withdrew. The general hospitals deep in the rear had only fifty-two surgeons and physicians to staff them. Under these conditions, the hospitals at Ostend, Brussels, Anvers, Ghent, and Bruges were useless.66 With its regimental hospitals designed to handle merely sixty casualties, the British medical service was quickly overwhelmed and collapsed. Only 273 medical officers were at Waterloo to serve the entire army, and at least a third of them had neither medical training nor combat experience.67
Thus the quality of medical care, especially surgery, left much to be desired. Amputations were frequent, with a mortality rate approaching 40 percent. The surgeon usually operated in the open, often on the ground, and without assistance. Even the general hospitals did not have operating rooms, and surgery was performed on makeshift tables. Unlike Larrey’s system, the British had no triage system, and the wounded often waited their turn in line regardless of the severity of their injuries. The largely untrained personnel of the medical service had little experience with ligature and the other means of hemostasis, and their delay in reaching the wounded proved fatal in thousands of cases. Bleeding the patient was still a common practice, and one can only guess how many wounded soldiers lost their otherwise salvageable lives because of it.
The one bright spot was English surgeon George James Guthrie, who accompanied Wellington on all his campaigns and was called “the English Larrey.” Guthrie’s experience with military surgery convinced him that Larrey was correct in his advocacy of primary amputation. In 1827, Guthrie published his Treatise on Gunshot Wounds: Inflammation, Erysipelas, and Mortification, on Injuries of Nerves, which established the doctrine of primary amputation in England and became the basic manual of British and U.S. military surgery until the Crimean War.68
McGrigor, who had been appointed director general of the Medical Department prior to Waterloo, held the post until the Crimean War. The medical disaster at Waterloo led him to attempt reform, but once again the government demobilized the army and drastically reduced funds for support its medical services. Curiously, Wellington did little to reverse this state of affairs. McGrigor tried to raise entrance standards for the medical service, purchased textbooks, began a medical library, and finally established an army medical school at Fort Pitt, England. Together with army doctor Henry Marshall (1775–1851), McGrigor attempted to institutionalize the practice of regular medical reports on the health status of the army, but this reform came to fruition only after the Crimean War had proven yet another medical disaster for the British. With the French medical service destroyed after Napoleon’s defeat and the British unwilling to learn from their experiences in the Peninsula and at Waterloo, the stage was set for yet another medical catastrophe when both countries once again stumbled into war.
The Crimean War represented one of the great medical disasters of all time. Every major combatant entered the war with either an obsolete military medical system or, as in the Turkish Army’s case, no military medical system at all. A war in which only four major offensive ground engagements were fought, the Crimean conflict was characterized by continuous artillery bombardments and the terrible living conditions associated with long sieges and trench warfare that contributed to incredibly high rates of disease. The war saw the first use of the new conoidal bullet that Capt. Claude-Etienne Minié (1804–1879) developed. Along with the introduction of the rifled musket barrel that the Russian Army used extensively, this new ammunition increased the infantry’s range and killing power by a factor of seven.69 The new weapon produced battle wounds that were as much as thirty times larger than the size of the residual track of the penetrating projectile because the soft lead bullet broke apart upon impact. The improved rifle’s killing and wounding power was demonstrated in November 1854 at the Battle of Inkermann, where it caused 91 percent of the British casualties.70 While Russian and French forces used the new rifle, British forces remained armed with the Brown Bess smoothbore, muzzle-loading musket that fired round lead balls with a range of only 120 yards.
The medical statistics of the war were tragic. The French contingent numbered 309,268 men but only 500 medical officers. British forces comprised 97,864 troops with 448 medical officers, and the Sardinian contingent fielded 21,000 men with 88 surgeons. Despite the generally backward state of Russian military medicine at this time, the Russian Army deployed the largest military medical contingent with 1,608 medical officers and 3,759 feldshers for a force of 324,478 men. Turkish forces numbered 35,000 men but had no military medical support at all.71 The casualty rate from wounds and disease, when taken as a percentage of the forces deployed, was among the highest in history. For the Russians, of the 92,381 wounded, 14,671 men died; of the 332,097 sick, 37,454 succumbed to their illnesses; and 21,000 were killed in action.72 The French Army lost 8,250 men to hostile fire, 39,868 wounded, 4,354 died of wounds, 196,430 sick, and 59,815 dead from disease. The British suffered 2,255 killed in action, 18,183 wounded, 1,847 died of wounds, 144,390 sick, and 17,225 dead from disease.73 The Crimean War saw the highest battle losses per 1,000 men per annum (Russians) and the highest disease loss rate per 1,000 men per annum (French) than any previous war in recorded history.
Disease and infected wounds were the two largest causes of death among the armies. The germ theory of infection was still unknown, and the poor sanitary conditions in the few available military hospitals produced extremely high rates of wound infection and death. Among the British wounded in the Scutari hospital in Istanbul, for example, the mortality rate for amputees averaged nearly 30 percent.74 Of every 100 men admitted to military hospitals among the French forces, 42 percent died, or a hospital mortality rate equivalent to that of the Middle Ages.75 The disease rate per 1,000 men per annum was 253.5 for the French, 161.3 for the British, and 119.3 for the Russians. This proportion compares to a similar rate of 110 per 1,000 men in the Mexican War, 65 for the Civil War, and 16 in World War I.76
Florence Nightingale (1820–1910) and her trained nurses arrived in November 1854 after the Battle of Balaklava, and they introduced basic standards of hygiene and sanitation in the British military hospitals. Nightingale reported a hospital mortality rate at Scutari of 41 percent. As a result of her efforts, the rate dropped to 2 percent by the end of the war.77 She is often credited with starting the first female nursing corps in the Western armies. In fact, the credit for this innovation belongs properly to the Russians. The Russian grand duchess Elena Pavlovna (1807–1873) urged the czar to send trained female nurses to the Crimea so they could assist Nikolai Ivanovich Pirogov (1810–1881), Russia’s great surgeon general. A large nursing corps was deployed in Russian military hospitals almost a year before Nightingale and her nurses arrived in British military hospitals.78 That the Russian Army suffered fewer losses to disease and infection than the French did may be attributed, to some extent, to the former’s introduction of basic hygiene and sanitary conditions in its military hospitals earlier than the French did.
The start of the Crimean War found the British medical structure essentially as it had been in 1815.79 Despite McGrigor’s best efforts to institutionalize his reforms, the medical service had been allowed to deteriorate after Waterloo. No fewer than seven independent governmental authorities had some responsibility for operating the British medical service. The two major authorities were the Army Medical Department, then headed by a senior physician with no military experience, and the Ordnance Department, presided over by an appointed nobleman. They did not include any purveyors to purchase supplies or any apothecaries in the system at all; indeed, these positions had gone unfilled since 1830.80 The medical service had only twenty-six clerks housed in a small London office to manage the entire medical department.81 The British military medical service had sunk to such a low position that the only medical regulations governing its operations consisted of a small pamphlet drawn up years before that outlined the rules for managing a thirty-bed hospital in peacetime. In addition, the army lacked any standard sanitary regulations.82 Less than a year before the outbreak of war, the British made minor reforms in the administrative system and placed authority for the military medical service under a single administrative office, but this move produced no significant change in medical capabilities.
Of the 225 medical officers serving in the British Army’s medical service at the beginning of the war, only 52 had medical degrees, while the rest had surgical diplomas.83 The quality of the military surgeons’ medical training was close to what it had been a half century earlier at Waterloo. Curiously, most British military physicians and surgeons were of Irish and Scottish descent.84 Doctors from these areas lacked civilian opportunities as a consequence of class discrimination, so many entered the military to gain position and experience. Although the number of military physicians eventually grew to approximately a thousand during the war, it was never sufficient to handle the extensive casualties. British authorities argued, however, that the ratio of 1 medical officer to 77 men under Lord Raglan (1788–1855) was better than the ratio in the Peninsular War when British forces had 1 medical officer for every 145 men. It was also noted that the French had only 276 medical officers compared to the British 406, even though the French Army was twice the size of Raglan’s force.85
The British ambulance corps was woefully inadequate. Although a few prototypes of the Larrey-type ambulance evacuation wagons had been produced, their number was far too small to provide adequate support. Moreover, these few vehicles arrived late behind the deploying army, and since the quartermaster did not give the corps horses, drivers, or carpenters to assemble the wagons, they had to leave the vehicles in Varna. Each regiment was issued eight stretchers but no litter corps to bear them. Any available men for stretcher duty had to be drawn from the line regiments, a situation that often led to mustering the regimental band members, the recovering sick and wounded, and whatever few men the regimental commander cared to spare. When the army proposed hiring local Turks and Bulgars as stretcher bearers, London denied the option as too expensive. As the casualty death rate mounted, however, the War Office ultimately provided for raising a Hospital Conveyance Corps to act as stretcher bearers. To keep costs down, the corps recruited from old pensioners and low-status personnel whose only virtue was their willingness to work for low wages. This small corps arrived in Varna in July during a cholera epidemic and was immediately incapacitated by the disease. Because the British failed to plan for medical support, they never succeeded in establishing a regularized system of ambulances or stretcher bearers during the war. Instead, the physicians had to go into the line and treat the wounded in the trenches where they fell.
To move the wounded and sick to hospitals, the British improvised and had the navy ferry casualties from the Crimea to the two major base hospitals three hundred miles away in Turkey. Conveying the casualties from the line to the ports remained a major difficulty throughout the war, and the poor means of overland transport caused many deaths. The navy had plenty of ships to accommodate the casualties once they arrived in port, but it had no organized system for loading them. As a consequence, the wounded and sick often lay in the rain for one or two days until placed aboard. Further, only a handful of ships were modified to house and care for casualties. Most often no trained medical personnel and few medical supplies were on board. Overcrowding also became a problem. One ship, the HMS Kangaroo, was equipped to carry 250 casualties but packed aboard more than 1,500 sick and wounded on a single trip.86 Loss rates among the sick and wounded of 20 percent were common, and soldiers arrived at the hospital days after being wounded still in their dirty, mud-covered uniforms and with their wounds untreated.87 Only in the last year of the war did the British medical service establish regularly scheduled steamships for ferrying the wounded from the front to the general hospitals in the rear.
The general hospitals, however, were little more than pestholes. The largest hospital, at Scutari, had no beds, so patients lay on the floor with the same clothing or blankets they had brought with them from the front. It did not have a kitchen to prepare food, and its two thousand patients were expected to make do with only twenty bedpans. The British did not even create a corps of hospital orderlies until the end of the war. It took the arrival of Nightingale and her nurses to improve the basic sanitary conditions of the British general hospitals. Their simple sanitary procedures, such as providing bedding, changing sheets, wearing hospital gowns, and regularly washing the physical plant, drastically reduced the rate of death from disease and infected wounds.
Dr. John Hall (1795–1865) oversaw the British medical system in the Crimea. His medical staff of fifty-six men included a director of hospitals, forty surgeons and assistant surgeons, a medical storekeeper, and fourteen noncommissioned officers. The regimental medical system, in place for more than a century, remained intact for all its faults. The regiment’s medical assets stayed in the hands of the field commander, however, and medical personnel had no authority to coordinate medical care between regiments. The regimental hospital, also a relic of earlier days, was equipped with only twelve beds with blankets and sheets, a medical chest, and a pannier of medical supplies for the horse carriage. The bell tents could only be closed from the outside, and the treatment of most casualties occurred on the ground.88 Most trained physicians served in the general hospitals, leaving the regiments with the least trained personnel to deal directly with the wounded. From the start, the number of casualties overwhelmed the regimental system, and it never recovered its ability to deal adequately with the wounded.
The poor organizational structure of the British military medical service in the Crimea was equaled by the generally poor medical treatment it offered. Dr. Hall had strong suspicions about chloroform and believed that the pain associated with surgery served to heighten the body’s ability to fight and survive amputation and infection. Although he did not prohibit it, Hall issued a warning on the use of chloroform that the younger surgeons took to mean that they ought not administer it regularly. The best trained and more experienced surgeons still widely used chloroform, but Hall’s directive kept the supply service from making chloroform a priority item to stock.89 Accordingly, chloroform was always in short supply, and the British missed an opportunity to standardize anesthesia’s use in battlefield surgery. Generally, the medical establishment also was strongly opposed to using chloroform. As late as 1857, the Crimean Medical and Surgical Society, an organization formed among surgeons who had seen service in the Crimea, warned against the general use of anesthesia.90
The medical horrors of the Crimean War provoked such a public outcry in the press and in Parliament that some reforms were attempted. Most, however, were not implemented in time to improve medical treatment during the war. In 1855, the medical service formed a corps of hospital orderlies consisting of nine companies of seventy-eight enlisted men to staff the general hospitals. After the war the corps became the Medical Staff Corps and a permanent part of the medical service.91 An inspector general’s postwar report led the British for the first time to establish a regular strength and resource table for medical assets. From then on, a medical corps of 280 men would be authorized for every division of 10,000 men. Unfortunately, the report did not address the formation of a stretcher or ambulance corps, and none was established on a permanent basis until the Second Boer War. In 1860, the first British military medical school to train military surgeons was established at Fort Pitt, and a system of regular medical reports was instituted throughout the army. In 1874, the regimental system, including its hospital system, was abolished to make way for new, larger fighting formations. The new hospital system, copied from the American experience in the Civil War, was organized around divisional units. In 1878, the army brought medical officer pay, privileges, and ranks into line with the rest of the service, but it still denied medical officers the privileges of command and needed the permission of their field commanders to gain control over medical resources. In 1890, the medical corps was placed on the same social and military level as the corps of engineers, and in 1898 its designation was changed to the Royal Army Medical Corps.92
The French medical corps was outdated, disorganized, and still suffered from the organizational and political effects of the army’s defeat at Waterloo. The political suspicions accompanying the Restoration compounded these problems, and the destabilization of the Revolution of 1848 and the rise of Napoleon III (1808–1873) followed. The turmoil of 1848 provoked widespread street fighting, and the French medical corps was pressed into service to treat the casualties with two significant results. First, French surgeons gained experience in using chloroform and standardized its use in the medical service. When the Crimean War broke out, the French administered chloroform as a matter of course and did so, they claimed, in thirty thousand operations during the war.93 Second, the political authorities recognized that the military medical service needed reform. In April 1848, the service began allowing its officers to exercise independent command of their own personnel and resources. The French were the first to take concrete steps to create an independent and autonomous military medical service. Unfortunately, when Minister of War Gen. Alphonse Henri d’Hautpoul (1789–1865) reversed these reforms a year later, the French medical service plunged into another period of disorganization.
General d’Hautpoul’s actions almost destroyed the service. He ordered that surgeons, physicians, and pharmacists be recruited exclusively from the graduates of civilian training institutions, so the French Army dismantled its military medical educational establishment. To prepare civilian medical personnel for military service, d’Hautpoul directed that they must take a one-year course in military medicine at the École d’Application de la Médicine Militaire at Val-de-Grâce. A year later, the French medical service equalized the status of physicians and surgeons by prescribing essentially the same refresher training for both, but it made no effort to assimilate these disciplines into the military’s ranks.94
The wars of Napoleon III all resulted in major medical disasters. Under d’Hautpoul’s medical system, the French entered the Crimean War with an acute shortage of medical officers, physicians, and surgeons. Before the war, the medical recruitment system had failed badly, and once the war broke out, it flunked completely. Few civilian medical personnel could be convinced of the value of military service, resulting in a precipitous decline in both numbers and quality. Between 1853 and 1855, of the eighty medical officer recruits required to fill out the ranks annually, the service attracted fewer than fifteen a year to take the examination. More damaging, of these, only four per year passed.95 During this period, the French Army in the Crimea expanded by ten battalions of infantry, enlarging the cavalry and artillery forces and creating an Imperial Guard. The French medical service never deployed sufficient medical personnel to serve this increased force. Moreover, of the 550 medical officers that served in the Crimea, eighty-three officers, or 15 percent, lost their lives.96
The medical disaster in the Crimea had even further negative consequences for the French medical service. The few remaining physicians after the war quickly left military service for calmer lives. Although the French created a new medical school at Strasbourg to train their replacements, it attracted few students. The service reduced the number of surgeons assigned to each division to four, but most regiments had only a single surgeon, who was usually an untrained assistant, or none at all. The ambulance system, never fully staffed, was allowed to decay to even smaller numbers. When war broke out with Italy in 1859, medical talent was in such short supply that in place of the required 150 physicians and 150 surgeons, the medical service had to make do with 200 untrained medical students to serve as assistant physicians in the regiments.97
The Battle of Solferino (1859) demonstrated that the French had learned nothing from their medical experience in the Crimea. The medical service was short of physicians, surgeons, nurses, dressings, ambulances, hospitals, surgical instruments, rations, anesthesia, and general transport. Henri Dunant, an eyewitness to the battle, found the slaughter and neglect of the wounded and sick so appalling that in 1862 he published Un Souvenir de Solferino (A Memory of Solferino), portraying the horror to the world. His work provoked a conference of the national Red Cross societies in Geneva in 1863 that led, in 1864, to the founding of the International Committee of the Red Cross and to fourteen nations signing the first Geneva Convention regulating the treatment of the wounded and conferring noncombatant and neutral status on the medical personnel of the national armies. The convention also adopted the red cross as the international symbol of the military medical services.
The Red Cross convention prompted France to create a Society for the Aid of Wounded Soldiers. When war broke out with Germany in 1870, the French medical service still was as ill prepared as it had been for the last war. French soldiers carried no first aid kits, and the medical service had no litter bearers, few ambulances, and no organized ambulance transport services attached to the regiments. Medical help to the soldier essentially stopped when he was dumped behind the regimental aid station, for no organized method existed to systematically move the wounded to interior hospitals. The medical supply storehouses were located too far to the rear to move supplies rapidly; however, within a few weeks, they ran out of medical supplies completely. The lack of a reserve pool from which to draw replacements compounded the shortage of physicians and surgeons. Because the French had also forbidden the use of inoculation, more than 200,000 soldiers contracted smallpox during the course of the war.98 The high death rates from wounds, infection, and disease prompted one commentator to refer to the period as “the most grievous in the history of French demography in the 19th century.”99
The French Society for the Aid to Wounded Soldiers obtained its first experience in providing ambulance and medical personnel to troops in battle with some considerable success. By the end of the war with Germany in 1870, however, many commonly recognized that the French medical service needed reform. In 1878, the International Congress of Military Medicine held in Paris passed a resolution calling for the creation of an autonomous medical service to guarantee better control over medical assets in wartime. A governmental commission was appointed to study the problem but adjourned a year later with no results. It required ten years’ worth of coverage in newspapers and journals to convince the French legislature finally to vote, in 1882, to create a semiautonomous military medical service. In 1889, the French became the last major Western power to adopt an autonomous military medical service for its armies. They created a new medical school to train military physicians, and they improved and organized recruitment. At last the medical personnel had control over their own resources, but they were still greatly restricted in their control and authority over the support resources needed to make the medical service perform adequately. This state of affairs continued until 1914 where, once again, the French entered another major war with a less than adequate medical service to treat its casualties.
If the medical care provided to the armies of France and England was poor, it was poorer still in the Russian Army. The Russian military medical corps entered the nineteenth century considerably behind the medical services of Europe because the medical profession in Russia was chronically underdeveloped. The country had only a few facilities for training physicians and surgeons, and their graduates were not attracted to a normal military career, which required twenty-five years of service. Consequently, the czarist armies relied heavily on barber-surgeons. Although the service made some efforts to train these feldshers, most of the medics assigned to military units were only marginally competent. In 1805, the Russian Army had only 74 feldshers assigned to the army and 388 to the navy.100 The official army title for them was tsiriulnik (barber), a title that reflected their low status.
At the outbreak of the Crimean War, however, Russia was able to produce sufficient numbers of barber-surgeons to fill out most field units. Indeed, as noted earlier, the Russian Army had the largest ratio of medical men to force, with 1,608 officers and more than 3,759 feldshers serving in the Crimean War.101 Despite these numbers and Russia’s internal lines of communication in the theater of operations, the quality of medical support provided to the Russian Army was dismal. What few hospitals existed were makeshift affairs and had high mortality rates from infection. Few provisions had been made for adequate beds and linen and none for an ambulance service. Transport was accomplished with whatever available wagons could be obtained on the spot, and the wounded were regularly transported while unprotected in foul weather. At the Battle of Sevastopol (1854–1855), the nearest aid station was sixteen miles away, and the trip in the open wagons took seven days.102
As mentioned previously, the most famous Russian surgeon to serve in the Crimea was Nikolai Pirogov. Well educated and having traveled extensively in Germany and the West, Pirogov had seen military duty in the Caucasus campaign in 1849 and was the first European military surgeon to use etherization in surgical procedures on battle casualties.103 Pirogov served two years in the Crimea as a battle surgeon, was an observer in the Franco-Prussian War and the Turko-Russian conflict, and developed renown as Russia’s greatest surgeon.104 He published two major works on military surgery, Introduction to General Military Surgery and Principles of General Military Field Surgery (1865), that are both regarded as classics. He was also a strong campaigner against large hospitals, which he viewed as cesspits of disease from overcrowding and poor sanitation. Instead, he recommended the use of pavilion hospitals along the model of those first used in the American Civil War.
Only two medical highlights emerged from the medical disaster of the Crimean War. First, the French surgeons’ widespread use of chloroform and the Russians’ use of ether convinced the rest of the world that anesthesia was an important and effective aid to field surgery. Although the British were slow to adopt its use, anesthesia became standard military medical procedure in the Union Army during the Civil War. A second important medical advance was the debut of plaster of Paris in splints. Antonius Mathijsen (1805–1878), a Dutchman, published his work on using plaster for bandaging broken bones in 1852. He may have called it plaster of Paris because in Paris in 1765 Antoine Laurent Lavoisier (1743–1794) had shown that a 95 percent solution of calcium sulfate with the right amount of water would crystalize and harden.105 Until plaster of Paris, physicians immobilized fractured limbs with a bandage stiffened with freshly made starch and cardboard, but the technique had little military use, since the starch took twenty-four hours to harden. While the evidence is less than clear, it seems likely that while in the Crimea, Pirogov was the first surgeon to use plaster of Paris splints in a military environment.106
Protected by its oceans, the United States remained little affected by the frequent wars in Europe. Accordingly, its military medical establishment had fewer opportunities to develop in response to actual field experience. The army was dismantled at the end of the American Revolution, and by 1802 the medical corps had only two surgeons and twenty-five mates. These few assets were assigned to garrisons and frontier posts and not the regiments. By 1808, the number of surgeons increased to seven and surgical assistants to forty. With the start of the War of 1812, the army found itself critically short of medical staff. Although additional medical personnel were obtained through the contract system, the number of medical officers was never sufficient to provide adequate medical care.107 The medical corps thus fell back on the old practices of the Revolution. Lacking an ambulance corps, the medical corps sent what few wagons it could obtain to search the battlefield and the woods to find the wounded. There were no hospitals. Temporary shelters called “Indian houses” were built after each battle, and the wounded were treated there.108 Requests to establish an ambulance corps were ignored, and with the cessation of hostilities the army once again dismantled its medical service.109
The medical system of 1812 suffered most from the army’s failure to provide a central authority responsible for creating and deploying medical assets. In 1818, Congress authorized the appointment of a surgeon general to head the medical corps, establishing for the first time an administrative organization for the medical department. Dr. Joseph Lovell (1788–1836), the first American surgeon general, served until 1836. At the start of the Mexican War in 1846, the American Army of 7,000 men included a medical corps consisting of a surgeon general and 71 medical officers. Congress increased the number of medical officers to 115 for the regular forces and 135 for the volunteers. The army had grown to about 100,000 men, proving even these increased medical assets inadequate.110 No provisions were made for an ambulance corps, although a few Larrey-type ambulances were used, and the old practice of begging available wagon transport from the quartermaster prevailed. Regimental hospitals used a few tents to provide primary medical care to the wounded; however, they were usually understaffed and inadequate to deal with the numbers of casualties. General hospitals were few and still created on an ad hoc basis. Both types of hospitals lacked stewards, nurses, cooks, adequate supplies, and trained physicians. Once again, the American Army suffered a medical disaster.
Of the 100,182 combatants committed to the Mexican campaign, 1,458 were killed in action and 10,790 died of disease. Statistically, the Mexican War was the deadliest from disease ever fought by an American force. Per 1,000 men per annum, mortality from disease averaged 110 men compared to a rate of 65 for the Civil War, 27 for the Spanish-American War, and 16 for World War I.111 The single positive medical contribution of the Mexican War was that an American military surgeon used ether anesthesia for the first time in combat. After the war, the American military medical service was once again reduced in strength, and no significant reforms were achieved.
Thirteen years later, no one was prepared for the magnitude of slaughter that accompanied the American Civil War. It was the first modern war insofar as the integration of the productive capacities of the Industrial Revolution with the military effort was complete. The magnitude of combat engagements was the largest in history to that time, and the exponential increase in the weapons’ killing capabilities, especially the improvements in the rifle, produced rates of casualties beyond the imagination of commanders and military medical personnel. In a five-year period, the combatants fought 2,196 engagements.112 A total of 620,000 men perished, 360,000 in the Union Army and 260,000 in the Confederate Army.113 Some 67,000 Union troops were killed outright, 43,000 died of wounds, and 130,000 were disfigured for life, often with missing limbs. In the Confederate forces, 94,000 men died of wounds.114 For the Union Army, the minié ball caused 94 percent of all wounds, artillery shell and canister led to nearly 6 percent, and the sabre and bayonet accounted for 922 wounds, of which only 56 were fatal.115 Thirty-five percent of the wounds were to the arms, 35.7 percent to the legs, and wounds to the trunk and head accounted for 18.4 percent and 10.7 percent, respectively.116
In a statistical sense, the Civil War was the most horrible war ever fought. The chance of a Civil War combatant not surviving the war was 1 in 4 compared to 1 in 126 for the Korean War. Of the Union dead, 3 of every 5 died of disease; in the Confederacy, 2 of every 3. Tables 8, 9, and 10 provide statistical summaries of the official casualty data for the Union Army.
Table 8. Special Causes of Death in the Union Army
Table 9. Wounds and Sickness in the Union Army
Wounds
Of the 246,712 cases of wounds reported in the Medical Records by weapons of war, 245,790 were shot wounds and 922 were sabre and bayonet.
Sickness
Of 5,825,480 admissions to sick report there were:
One reason for the staggering increase in the number and seriousness of the men’s wounds was the introduction of the new Springfield .58-caliber rifled-barreled firearm capable of propelling a minié ball at 950 feet per second to an accurate range of 600 yards. It used heavy, soft lead bullets that were unjacketed. The bullets flattened out upon impact, producing terrible wounds and carrying pieces of clothing into the wound itself. When the bullet nicked a bone, the weight and deformation of the projectile shattered the bone or severed it completely from the limb. Traumatic amputation or compound fracture was the most common result. Incredibly, the infantry continued to use the old tactic of massing forces to concentrate their firepower, which the old, inaccurate and limited-range musket necessitated, and made their formations vulnerable to long-range rifle fire. Moreover, the need to move the lines over greater frontages than ever before also increased the dispersal of the wounded to unprecedented levels, placing a greater premium on the ability to locate, treat, and evacuate the wounded. The Civil War medical officer faced problems of wound management that were unique for the time, and he was as unprepared to deal with them then as he had been in previous wars.
Table 10. Amputations in the Union Army (29,980 Reported Cases)
The improved kinetic power of the rifle bullet made amputation the most common battlefield operation during the Civil War. Of the 174,200 gunshot wounds to the arms and legs suffered by Union soldiers, 29,980 required amputation.117 Confederate soldiers suffered 25,000 primary amputations (meaning as soon as possible after wounding) and the Union Army 20,993.118 More limbs were lost in this war than in any other conflict fought by the United States, including World Wars I and II, Korea, Vietnam, Iraq, and Afghanistan. The old debate about primary versus secondary amputation reappeared. Within two years, experience had shown that the soldier’s chances of survival increased with primary amputation. The mortality rate for primary amputation was 26 percent compared to 52 percent for secondary amputation.119 Interestingly, however, 26,467 wounds of the extremities complicated by injury to the bone were treated “by expectation” (leaving the wound alone to heal itself) with a mortality rate of only 18 percent, which was much lower than the rate for either primary or secondary amputation.120
In the first year of the war, hemostasis was achieved mostly through the tourniquet and cautery, but both methods were dangerous to the patient. As the minimally trained surgeons gained more experience, however, they more commonly used ligature and pressure dressings to control bleeding. One of the war’s beneficial medical effects was that it gave thousands of surgeons experience in ligature, a training they could practice in civilian life. The common practice, however, was to leave the ends of the ligature long and extending outside the body. These loose ends proved to be excellent avenues for infection, producing septic conditions that led to secondary hemorrhage. The mortality rate for such secondary infections was 62 percent.121 The usual array of infections—tetanus, hospital gangrene, and various streptococcus infections—were ever present. In the early days, the mortality rate in some hospitals was as high as 60 percent. As surgeons gradually began using debridement and bromine solution applications, the mortality rate from wound infection fell to 3 percent near the end of the war.122
The Union blockade caused shortages of medical supplies that forced Confederate surgeons to develop alternatives that proved beneficial in fighting wound infection. Both sides cleansed wounds with sea sponges kept in buckets of water near the operating table. Used repeatedly after being squeezed in the dirty water, these sponges were major sources of disease transmission. A shortage of sponges in the South forced Confederate surgeons to use cotton rags instead. Since the rags were recycled, cleaned, boiled, and ironed, they served as relatively sterile wound dressings. The same was true of the bandages. With bandages in short supply, practitioners used raw cotton, but to manufacture the product, it was necessary to oven bake the cotton, producing a sterile bandage. While Northern surgeons used unsterile harness-maker’s silk for ligatures and sutures, silk was not available to the Southern surgeons, who used horsehair for the same purposes. To make the horsehair sufficiently pliable for surgical use, they had to boil it. By happy accident, the boiling process produced sterile sutures.123 Nonetheless, wound infection, especially in the general hospitals, remained a major problem. William W. Keen (1827–1932), who served as a surgeon in the Army of the Potomac, noted, “It was seven times safer to fight all through the three days of Gettysburg than to have an arm or leg cut off . . . and be treated in a city hospital.”124
Military surgeons of the Civil War used chloroform and ether anesthesia on an unprecedented scale. Military physicians used no fewer than eighty thousand applications of anesthesia. Official records show that anesthesia was used in 8,900 operations within general hospitals, of which 6,784 involved chloroform and 811 involved ether alone. In 1,305 cases, they used a combination of ether and chloroform. Remarkably, only thirty-seven deaths were attributed to anesthesia.125 They also made advances in immobilizing limbs, with plaster of Paris widely used for this purpose. Having studied in Europe, Dr. Gordon Buck (1807–1877) brought the technique to America, and the first application to immobilize a limb was accomplished in 1855. Dr. Nathan Little is generally credited with introducing the technique to the military medical community during the Civil War.126 In 1863, Union surgeon John Hodgen (1826–1882) introduced the famous Hodgen splint, which is still used today in fractures of the lower femur.
Drug application during the war was quite primitive because physicians of the period knew little about the specific effects of drugs. Except for calomel (mercurous chloride), which was so heavily prescribed that Surgeon General William Hammond (1828–1900) forbade its use as dangerous, most drugs did little harm if little good. The most indispensable and well-known drugs included morphine, opium, and quinine. Morphine was usually dusted directly on the wound and occasionally injected hypodermically. The hypodermic syringe appeared in the 1850s, but only 2,093 syringes were issued to the Union Army during the war. That their use had any medical significance is unlikely. Yet, Silas Weir Mitchell (1829–1914) noted that at the army hospital for nervous diseases, Turner’s Lane Hospital in Philadelphia, more than forty thousand doses of morphine were given hypodermically to patients in a single year.127 A significant addiction problem resulted from the Union Army’s wide use of opium pills and other addictive opium-based prescriptions. Records show that ten million opium pills were administered to patients during the war, along with 2,841,000 ounces of other opium-based preparations, such as laudanum, opium with ipecac, and paregoric. By contrast, only 29,828 ounces of morphine sulfate were administered.128 While not all addicts in the country were former soldiers, the United States had 200,000 drug addicts by 1900.129
A number of antiseptics were widely used, including potassium permanganate, sodium hypochlorite, bromine, iodine, turpentine, and creosote. Lister had not yet made his important discovery regarding antisepsis, and none of these preparations were used in wound treatment. They were, however, commonly used as deodorants in hospitals and did have the unintended effect of providing better sanitary conditions in the hospital wards.
As in all past wars, disease was the most common killer of Union and Confederate soldiers. Both armies were armies of volunteers, and in the early years of the war the armies performed little more than perfunctory medical examinations of their recruits. A normal day’s load for physicians examining recruits was between forty and fifty examinations a day. The quality of recruits, often motivated by patriotic fervor and the enlistment bounty, was less than desirable. In 1861, a Union Sanitary Commission report noted that three-quarters of the soldiers who had been discharged from the Union Army were so physically unfit that they should never have been allowed to enlist in the first place.130
Most recruits came from largely rural populations. Their isolated locations had prevented them from developing immunities to a wide range of childhood diseases. Once they were brought together in the close quarters required of military life, many fell ill.131 Their poor physical conditions and few immunities were compounded by generally poor nutrition from military rations and the general stress of military life. Scurvy was endemic, and outbreaks of cholera, typhus, typhoid, and dysentery took a generally heavy toll.132 Although tetanus mortality was high—89–95 percent— relatively few cases of tetanus arose because most battles did not occur in the richly manured soil of overworked farmland. Most cases of tetanus were contracted in field hospitals, when barns and stalls served as temporary surgical hospitals and aid stations.133 Disease killed approximately 225,000 men in the Union Army and 164,000 in the Confederate ranks. It is estimated that disease killed five times as many men as were slain by weapon fire.134
The Union Medical Department was totally unprepared for war. Its head, Surgeon General Thomas Lawson (1789–1861), was a sick and dying man who economized on expenditures by refusing to purchase medical books for the military. The small 26,000-man army was scattered along the frontier and had no military medical service to speak of. The regular army in 1860 had only thirty surgeons and eighty-three assistant surgeons, and twenty-four of them resigned to serve with the Confederacy.135 Medical supplies consisted of a few incomplete surgical kits and clinical thermometers. The country had no general hospitals, and the largest post hospital, located at Fort Leavenworth, Kansas, had only forty-one beds.136
There was no ambulance service. In the 1850s, Secretary of War Jefferson Davis (1808–1889) had ordered two military officers, one of whom was Capt. George B. McClellan (1826–1885), to prepare a study of the lessons to be learned from the Crimean War. McClellan’s report included a section on ambulance trains and medical supplies and recommended creating an army ambulance corps. A committee was appointed to accept designs for medical transport vehicles, but by 1860, the army had rejected all the designs and had not created an ambulance corps.137 For the war’s first two years, neither side had a systematic way to evacuate the wounded. After the disaster at the First Battle of Bull Run (July 1861), where vehicles had to be commandeered from the streets of Washington to move the wounded, individual field commanders improvised what little medical transport they could. Toward the end of the Peninsula campaign, an army corps of thirty thousand men had an ambulance transport system sufficient for only a hundred casualties. At the Battle of Wilson’s Creek (August 1861), the wounded could not be moved for six days owing to the lack of ambulances. In November 1861, Gen. Ulysses S. Grant (1822–1885) and his forces at Belmont, Missouri, had to abandon their wounded because they did not have ambulances.138 Ambulance transport in the Confederacy was even worse. In 1863, Confederate medical officers reportedly had only thirty-eight ambulances in the entire Army of the Mississippi. As the war continued, the situation worsened. In 1865, not a single ambulance could be found in the combat brigades of the armies of West Virginia and East Tennessee.139
Meanwhile, the appalling medical conditions of the Union Army provoked a public outcry, much as similar conditions had provoked public outrage among the British during the Crimean War. In 1861, Dr. Henry Bellows (1814–1882), a Unitarian minister from New York, led a committee that created the U.S. Sanitary Commission, which made recommendations to improve medical treatment. Its first suggestion was to fire Surgeon General Lawson and replace him with Dr. William Hammond. Upon assuming his position, Hammond appointed Dr. Jonathan Letterman (1824–1872) as surgeon general of the Army of the Potomac. Making several contributions to the Union’s medical service, Letterman quickly set about reorganizing the system and creating an ambulance corps.
Letterman’s ambulance corps was built around the Larrey model, and each army corps had its own dedicated medical transport assets. Each division, brigade, and regiment had its own medical officer responsible in a direct chain of command to the corps medical officer, who was responsible for coordination at all levels. The chief surgeon within each division controlled the ambulance corps, and he assigned all details regarding parking, roll call, stable call, veterinary services, and police duty to a line officer of the division. Each regiment received three ambulances and a complement of drivers and litter bearers, and each division had its own ambulance train of thirty vehicles. The ratio of ambulances to men averaged 1 to 150.140
Letterman established a trained corps of ambulance drivers and litter bearers and gave them a distinctive uniform and insignia. He specified that only medical personnel could remove the wounded from the battlefield, a regulation designed to reduce the manpower loss that normally resulted when soldiers left the line to transport their wounded comrades to the aid station. Ambulance wagons were removed from the quartermaster’s control and were to be used only for medical transport. Ambulances traveled in the front of the column to ensure they would be easily reached once the battle commenced. The first test of Letterman’s ambulance system came at the Battle of Antietam Creek (September 1862). Union forces suffered ten thousand wounded scattered over a six-mile area, but the system reached and evacuated most of them within thirty-six hours. Three months later at Fredericksburg (December 1862), the system worked so well that the wounded piled up at the aid stations faster than they could treated.141 Within twelve hours, all of the nearly ten thousand Union wounded had been located and cleared through the aid stations.
Letterman’s field ambulance system would not have worked as well as it did had it not been integrated into a larger network of casualty evacuation linking the field hospitals to the general hospitals in the rear. They also used the excellent Northern railway network to move casualties from collection points behind the battlefields to the general hospitals. The hospital cars varied in quality from first-class heated passenger coaches to unheated boxcars with little more than straw on the floors. By the end of the war, the Northern railways had transported 225,000 sick and wounded men from the battlefields to the general hospitals.142
The Union medical service also used coastal steamers and river steamboats to transport the sick and wounded. The Union contracted these hospital ships from civilians and initially gave the quartermaster corps control of them. Later in the war, the medical corps assumed control of these assets and used them exclusively for medical purposes. In 1862, the Union Army contracted for fifteen steamboats for use on the Mississippi and Ohio Rivers and seventeen ocean-going vessels for use along the Atlantic coast. In the last three years of the war, 150,000 casualties had been transported by boat to general hospitals.143 The first systematic use of the hospital ship was at the Battle of Fort Henry in February 1862 when the City of Memphis transported 7,000 casualties to hospitals along the Ohio River.144 The army purchased its first ship, the D. A. January, to serve as a hospital ship, and the crew saw its first action after the Battle of Shiloh in April 1862. The ship had a 450-bed hospital, bathrooms, laundry, baking and cooking facilities, and a full complement of surgeons and nurses. By the end of the war, the January had transported 23,738 patients on the Ohio, Missouri, and Illinois Rivers. The mortality rate among its wounded passengers was only 2.3 percent, better than most land-based hospitals of the day.145 The first naval nurses in America were the Catholic Sisters of Mercy, who served aboard the first U.S. Navy hospital ship, the USS Red Rover, and tended the wounded after the siege of Vicksburg.146 The ship also had African American women nurses aboard.
Letterman’s field ambulance system proved so successful that in March 1862 Surgeon General Hammond recommended that all Union armies adopt it. The army high command dragged its feet for two years before Congress in March 1864 forced it to institute the system for all Union commands. It was only by the end of the war that the system was fully implemented. The United States had gradually developed a military medical system adequate enough to treat the casualties that a modern war produced only to see it demobilized with the rest of the army less than a year after the war ended. With the army returning to garrison and frontier duties, a mass casualty system was no longer needed.
Letterman also changed the structure of the field hospital system by turning the old regimental hospitals into frontline aid stations, or the equivalent of the modern battalion aid clearing point. Treatment of the wounded at these aid stations was limited to controlling bleeding, bandaging wounds, and administering opiates for pain. Limiting the functions of these aid stations enabled the medical personnel to hold the slightly wounded close to the front for their possible return to duty. Behind the aid stations, Letterman placed mobile surgical field hospitals. Controlled by division, the most competent medical personnel were assembled at these hospitals to perform major operations. These hospitals were the critical link, missing for most of military medical history, between the frontline aid stations and the rear area general hospitals. Behind these mobile field hospitals were the general hospitals, and the field ambulance corps, the railways, and hospital ships tied the whole system together. Letterman was also concerned about the manpower loss due to hasty and needless evacuation. To prevent it, all medical officers were ordered to hold the less severely injured at their respective hospitals. Letterman instituted systematic inspections of all patients to screen those held for possible return to duty before deciding what patients to evacuate.147
Letterman’s third major contribution to the Union medical service was the establishment of medical supply and equipment tables for medical units. Until this reform, the service obtained medical equipment and supplies from the quartermaster through the usual military supply system. Under the pressure of war, however, medical units rarely received what they needed. Letterman arranged supply tables equipping all units from corps through regiments with “basic loads” of medical provisions. Each unit was supposed to carry supplies for thirty days. A purveyor accompanied the army and was responsible for continually replenishing medical supplies. With each medical unit requiring specific amounts of supplies, the purveyor could now plan in advance to fill the requirements of each unit. For the first time, an army had developed a relatively modern medical supply service that worked well under field conditions.148
Most units in the Union Army were volunteer units that the states created. The state governors then commissioned the great number of surgeons and physicians that served in the war to provide medical support to state regiments. With few standardized licensing procedures for medical certification, it was not surprising that competency was a problem. Few of the physicians entering the state regiments had any surgical training. Indeed, the educational training of a physician or surgeon at this time entailed only one year of formal schooling and one year as an apprentice to a practicing doctor. Many of the “medical schools”—including Harvard University at the time—were little more than diploma mills.149 For reasons that remain unclear, all medical schools in the South, with the exception of the University of Virginia, were closed shortly after the outbreak of war, thus depriving the Confederate armies of a vital source of trained medical talent.150 As the war wore on, however, many of the marginally competent physicians and surgeons on both sides became excellent practitioners as a consequence of their battlefield experience.
About 13,000 physicians and surgeons served with the Union forces. Of these, Congress appointed about 250 regular army surgeons and assistant surgeons to serve as staff and administrators. Congress commissioned approximately 547 Surgeons of Volunteers, also called “brigade surgeons,” to assist the corps of regular army surgeons. Governors appointed some 3,882 regimental surgeons and assistants to provide medical support to state regiments. Most saw service in the regiments, aid stations, and mobile field hospitals. The army hired 5,532 contract civilian surgeons to staff the general hospitals in the major cities. These physicians and surgeons often divided their time between private practice and military service. An additional 100 doctors staffed the Veteran Reserve Corps to provide aid to the disabled, and 1,451 surgeons and assistants served with the 179,000 black troops in 166 regiments.151 One of the Union surgeons, Dr. Mary Edwards Walker (1832–1919), a graduate of Syracuse Medical College, served in the army as a nurse until finally appointed as an assistant surgeon. She became the first woman in American history to hold such a position.152 She was also the first to earn the Congressional Medal of Honor for her wartime service at Fredericksburg and Chickamauga, among other duties.
The general hospitals—designated as such because they treated the wounded regardless of what unit they were from—were located in the major cities along well-established water and rail routes. By 1862, a building program was undertaken in the North to provide hospital facilities for the rapidly growing lists of casualties. A year later, the Union Army had established 151 general hospitals with 58,715 beds. Two years later it had 204 such hospitals with a capacity of 136,894 beds.153 These hospitals ranged in size from small to 100-bed units, which the South commonly established next to railway crossings, and to the large Mower General Hospital in Philadelphia with 4,000 beds. The largest hospital on either side was the 8,000-bed Chimborazo Hospital in Richmond. With 150 single-story pavilions organized into five divisions, each with forty to fifty surgeons and assistant surgeons per division, it was the largest military hospital ever built in the Western world.154
The range of injuries that military medical practitioners confronted prompted the development of hospitals specializing in specific medical conditions. There were special hospitals for orthopedics and venereal diseases, and the famous Turner’s Lane Hospital in Philadelphia acquired a worldwide reputation for its expertise in nervous disorders. St. Elizabeth’s Hospital in Washington became the world’s first military hospital for combat psychiatric cases.155 It had long been recognized that large hospitals were conducive to infection and disease and that better ventilation and isolation reduced these problems. The pavilion-style hospital evolved as the best design for reducing infection and improving ventilation and isolation. These hospitals consisted of a series of long single-story buildings, each isolated from the next but connected by corridors. High ceilings with vents at the top and sufficient windows provided adequate ventilation. Normally connected to the central semicircular corridor, these sixty-patient building units were sometimes unconnected, providing excellent isolation for specific disease wards. The pavilion hospital design is generally credited to Dr. Samuel Moore (1813–1889), the Confederate surgeon general, who supposedly obtained the idea from British hospitals used in the Crimean War.156 More accurately the design is much older and generally reflects the arrangement that the Romans utilized.
Both armies in the Civil War used female nurses, a precedent that the Russians first set and the British soon followed in the Crimean War. The special place of women in Southern culture militated against allowing women to work in military hospitals; consequently, female nurses were not used on a large scale. In the North, however, 3,214 nurses served in military hospitals under the control of Dorothea Dix (1802–1887), who had been appointed as the Union Army’s superintendent of women nurses.157 An even larger female corps of cooks, cleaners, and general attendants—some of whom were African American—supported this nursing corps. Large numbers of Catholic Sisters of Mercy, Sisters of St. Joseph, and Sisters of the Holy Cross also served in this capacity. Dix did not trust Catholics but found that because the sisters were accustomed to discipline and obedience, they made excellent workers.158 Having gained valuable experience in treating the sick, all three of these religious orders remained in the hospital business after the war. Clara Barton (1821–1912), one of Dix’s regular nurses, went on to found the American Red Cross.
The prevalence of facial injuries encountered during the war stimulated the emergence of the new medical subdiscipline of plastic surgery. Civil War surgeons performed six reconstructions of the eyelid, five of the nose, three of the cheek, and fourteen of the lip, palate, and other parts of the mouth.159 Dr. Gordon Buck, while serving as a contract surgeon for the Union Army, performed the first total facial reconstruction in history.160 Another Civil War surgeon, Joseph J. Woodward (1833–1884), became the first person to link the new technology of the camera to the microscope and published the first microphotographs of disease bacteria in 1865. In 1870, while working for the newly formed Army Medical Museum, Woodward became the first person to take microphotographs, using artificial illumination.161 Woodward is also credited with the independent discovery of using aniline dyes to stain tissues for microscopic analysis.162
A comprehensive history of the Confederate medical service is yet to be written. The great Richmond fire of 1865 destroyed almost the entire archive of the Confederacy’s medical records. For the most part, however, the Confederate medical service was organized and operated almost as a copy of the Union system, although shortages of personnel and equipment nearly crippled it from time to time. The total number of medical officers in the Confederacy was 3,236—1,242 surgeons and 1,994 assistant surgeons. There were 107 officers in the naval medical corps, including 26 surgeons and 81 assistant surgeons.163 The Confederate general hospital system was every bit as good as what operated in the North. Chronically short of ambulance wagons in the first few years of the war, the South made greater and more efficient use of steamboats and rail to transport their wounded. Early in the war (1861), Surgeon General Moore established high qualifications for those wishing to enter the medical service and, in a truly revolutionary step, examined those physicians already in the service for competency, forcing significant numbers to resign.164 Shortages of quinine and chloroform plagued the South until the end, and Confederate disease losses might have been reduced had they embarked upon a smallpox vaccination program earlier in the war. The South recognized dentistry as a separate medical discipline and encouraged its growth. As secretary of war before hostilities broke out, Jefferson Davis had tried to convince the U.S. Army to establish a separate dental corps but failed. The South had a much more comprehensive dental care program than did the North, which contented itself with shipping to the artillery toothless soldiers who could no longer bite the end from their cartridge packets.165
Gen. Thomas J. “Stonewall” Jackson (1824–1863) introduced one of the more significant military medical contributions of the South when in 1862, he ordered all Union medical officers held by his command to be released and, henceforth, treated as noncombatants. By June of that year, both Robert E. Lee and McClellan agreed to a similar practice. Medical personnel were no longer subject to capture and, if taken, were supposed to be allowed to treat their wounded and immediately released. All medical personnel held in Union and Confederate prison camps were freed in 1862, and exchanges of captured medical personnel continued until the end of the war. Jackson’s actions had anticipated the Red Cross regulations dealing with medical personnel that the first Geneva Convention adopted a few years later.166
With the cessation of hostilities, the Union Army and its military medical service were demobilized. By the end of 1866, the Union Army had been reduced to a force of only 30,000 men.167 The army and its skeleton medical corps were scattered among 239 military posts stretching from Alaska to the Rio Grande. By 1869, the entire medical service comprised no more than 161 medical officers, and the frontier posts were forced to rely on civilian contract surgeons, which increased to 282.168 Although a young doctor could make more money in military service than he could in the first few years of his own practice, the shortage of military doctors remained a chronic problem. One reason was that the army maintained much higher entrance and training requirements than were generally found for civilian physicians.169
In 1862, Surgeon General Hammond ordered the establishment of the Army Medical Museum in Washington, D.C., to collect and study artifacts and information relevant to military medical care. In 1865 when John Shaw Billings (1836–1913) became director of the Library of the Surgeon General’s Office of the Army, he soon built it into the largest military medical library in the world, and the collection remains so today.170 After the war, Congress established a pension system for disabled soldiers that was far more generous and comprehensive than anything seen in Europe.171 The pension system was chosen over an asylum system of permanent care because it provided the disabled soldier with more freedom and mobility.
A number of significant advances in military medicine resulted from the Civil War. For the first time an accurate medical record system was established that made it possible to track casualty records for every soldier. One consequence was the U.S. government’s publication of the massive six-volume Medical and Surgical History of the War of the Rebellion (1870–1888), which remains the standard against which all such works are judged. The army also developed the first effective military medical system for mass casualties, complete with aid stations, field and general hospitals, ambulance and theater-level casualty transport, and the staff to coordinate it. It was the best military medical system ever deployed and remained a model for other countries for decades. The introduction of the pavilion hospital was so effective at reducing disease mortality that it became the standard design for military and civilian hospitals for the next seventy-five years. Wide use of anesthesia, primary amputation, the splint, and debridement of necrotic tissue were the first effective doctrines for wound management. Thousands of physicians learned these techniques through hard experience and carried them into their civilian practice, elevating the general level of medical care available to the nation. Effective sanitary measures, especially in hospitals, reduced disease and death. The advent of microphotography made the American military medical establishment receptive to the discoveries of Pasteur and Lister when they appeared a few years later. Nurses were used on a wide scale for the first time. The terrible slaughter of the Civil War ironically marked one of the most progressive periods in the development of military medicine until the twentieth century.
Fear and psychiatric debilitation are constant companions in war. Battle is one of the most threatening, stressful, and horrifying experiences that man is expected to endure. Even in relatively small engagements, the participants often suffer a wide range of psychiatric conditions that, if pressed by events, lead to mental collapse.172 Severe emotional response to battle is neither a rare nor an isolated event. One of the most outstanding medical developments of the Civil War was the emergence of the neurological profession in America and, along with it, the beginning of military psychiatry as a major subdiscipline of military medicine.173 Military psychiatry dates from the Civil War when neurologists made a systematic attempt to link damage to the brain to emotional behavior, but it did not become a separate discipline until the Russo-Japanese War of 1905.
Psychiatry was still in its infancy at the time of the Civil War, but neurologists recognized that soldiers could become debilitated from purely emotional forces. At that time, the discipline focused on the physiology of the brain and attempted to link disruptions of that physiology to behavioral disorders. Fewer than a dozen mental hospitals existed in the United States, but none served patients who developed mental disorders in war. Care of the mentally ill rested with the handful of superintendents of these mental asylums. The movement for humane treatment of the mentally ill that began in France fifty years before was only beginning to take root in the United States.174 The military itself had no psychiatrists and continued to take the traditional view that soldiers who broke in battle were cowards or had “weak” characters. By 1860, American military psychiatry had not come very far since the Revolution, and the discipline was considerably behind developments in Europe.175
Almost immediately after the outbreak of the Civil War, medical officers had to deal with the problem of psychiatric casualties. The War Department had rejected the offer by a group of superintendents of insane asylums to treat the problem on the battlefields, and treatment of psychiatric casualties fell to army physicians and surgeons. Their experience gained with psychiatric cases led to the birth of neurology in the United States and hardened further the tendency of medical practitioners of the day to regard soldiers’ mental problems as caused by damaged physiology of the brain. The Turner’s Lane Hospital in Philadelphia treated what were called “nervous diseases” during the war, but even the neurologists had to admit that a range of disorders that afflicted the soldiers had no sound physiological explanation. At the doctors’ urging, the Government Hospital for the Insane in Washington, D.C., admitted the psychiatric casualties to specific wings in 1863. The men preferred to call it St. Elizabeths Hospital, after the land on which it was built.
The most common psychiatric condition that military physicians had to confront was “nostalgia,” a cluster of symptoms resulting from emotional fatigue that made it impossible for the soldier to continue to fight. Nostalgia was marked by excessive physical fatigue, an inability to concentrate, an unwillingness to eat or drink that led at times to anorexia, feelings of isolation and frustration, and a general inability to function in a military environment. Swiss armies first reported the condition in 1569, and Swiss military physicians described it again in 1678.176 German physicians of the same period called the condition heimweh (homesickness), French military doctors termed the same symptoms mal du pays, and the Spanish, who noted their soldiers’ suffering an outbreak of nostalgia in Flanders during the Thirty Years’ War, called it estar roto (literally, to be broken).177 Even then military doctors recognized that the source of the symptoms was emotional and not physical, noting that “imagination alone can cause all this.”178 Nostalgia again was recognized and widely reported during the eighteenth century among the armies of France, Italy, Germany, and Austria. In one instance, a unit of Scottish Highland troops in 1799 succumbed to the condition almost to a man. To trigger the onset of symptoms, the report noted, the Highlanders only needed to hear the sound of the bagpipes. Nostalgia was reported among Napoleon’s troops at Waterloo, during the retreat from Moscow, and in the Egyptian campaign, where it became so serious among the officer corps that it threatened to cripple the army.179
During the Civil War, autopsies performed on nostalgia patients confirmed that besides producing emotional turbulence, nostalgia was capable of producing physiological symptoms of disease. Tragically, nostalgia itself was often fatal, especially if a wound or lack of nutrition weakened the soldier’s general resistance. When it did not kill, nostalgia often drove the soldier insane. In the first year of the Civil War, military physicians diagnosed 5,213 cases of nostalgia, or 2.34 cases per thousand.180 By the end of the war, almost 10,000 cases had been diagnosed among Union soldiers. In addition, physicians diagnosed a range of illnesses that are now known to stem from emotional turbulence and included “exhausted hearts,” paralysis, severe palpitations (called “soldier’s heart” at the time), war tremors, self-inflicted wounds, and various states of nostalgia.181 Military doctors diagnosed the more severe psychiatric conditions as “insanity”—today the condition is termed “psychosis”—and it accounted for 6 percent of all medical discharges granted by the Union Army.182 Physicians also identified a number of cases that they diagnosed as “feigned insanity,” a condition in which emotional turbulence produced severe symptoms for which a physiological cause could not be found. These conditions included lameness, blindness, deafness, local paralysis, and lower back pain.183 Today, military psychiatrists call these conditions “conversion reactions.” Psychiatric symptoms became so common among Union soldiers that field commanders pleaded with the War Department to provide some form of screening to eliminate recruits susceptible to psychiatric breakdown. In 1863, the Union Army instituted the world’s first military psychiatric screening program for recruits. It proved no more helpful than it would later in World War I, and the number of psychiatric cases continued to increase.
Meanwhile, only a handful of physicians in the country—the superintendents of civilian mental asylums—had any experience in dealing with psychiatric patients, but none of these doctors saw military service during the war. Accordingly, military physicians were often at a loss when treating cases of insanity. With a long historical precedent in the armies of Europe, their particularly cruel solution in the first three years of the war was simply to muster out those soldiers diagnosed as suffering from severe psychiatric problems. Union and Confederate soldiers with psychiatric symptoms were escorted out of the main gates of their respective army camps and turned loose to fend for themselves. Others were put on trains with no supervision, the name of their hometown or state pinned to their tunics. Others were left to wander about the countryside until they died from exposure or starvation or were arrested for committing crimes. By 1863, the number of insane or shocked soldiers wandering around the country was so large that the public demanded an end to the military’s practice of expulsion. That same year, the military began sending psychiatric cases to the hospital for the insane in Washington.
As noted earlier, the Union Army had discharged nearly ten thousand soldiers suffering from nostalgia by the end of the war. The number suffering from “epilepsy” and forms of hysterical paralysis was probably twice as large, while those discharged for “general insanity” reached several thousand. Although the problem of psychiatric breakdown among soldiers reached major proportions by the war’s end, not a single article or book on the subject was published in the postwar years.184 The General Hospital for the Insane closed its military psychiatric facilities, and the government made no effort to involve the doctors who treated civilians with mental illness in helping the psychiatrically wounded. The veterans’ problems were conveniently forgotten, and except for the advances in neurology, battle shock and psychiatric debilitation were no longer of concern to the military. The failure to learn from this experience returned to haunt the American Army when it took the field again in World War I.
By the first quarter of the nineteenth century, surgery had attained the general status of a legitimate branch of medicine in the United States, France, and England. The old barber-surgeons’ guilds had largely disappeared. In Russia and Germany, this development did not occur until after mid-century; thus, in Russia, with some exceptions, surgery and military surgery remained largely in the hands of the feldshers. In Germany, surgery was still regarded as a low-status craft that barber-surgeons practiced in the military. The general status of medicine in the larger society was also low; however, surgery found a home in the universities, where it was practiced by medical researchers, academics, and scientists. The beneficial result of this situation was that as being researchers and academics first, surgeons in the universities tended to be more strongly grounded in the sciences, where the rigors of empirical proof and scientific investigations had long traditions. When the opportunity came to transfer these skills to military medicine, German surgeons were better prepared to assimilate and integrate new knowledge than were their counterparts in other countries.185
Until the 1830s, German medicine was mired in the Hegelian period of its development, and debates centered on the philosophy of science with little in the way of empirical emphasis. After 1848, German science and medicine began its transition toward systematic realism, with a strong emphasis upon data collection and observation. The old academic habits of rigorous method and proof moved German medicine rapidly in the direction of an exact science.186 As a consequence, German medicine was much more receptive to demonstrated evidence than were the medical professions in the rest of Europe. For instance, German physicians and surgeons were the first to accept Lister’s practice of antiseptic surgery. Once the idea of antisepsis caught on, the Germans’ thoroughness propelled them to be the first to introduce steam sterilization, to use surgical face masks and gowns, and to invent the sterile operating room.187 By 1870, German medicine had established itself among the foremost scientific medical establishments in the world. By the 1880s, the medical world had adopted German as its official scientific language because its linguistic precision lent itself perfectly to the new science.188
This well of scientific talent continued to reside in the universities and research institutions until after 1866 and the Austro-Prussian War, with the result that military medicine remained generally behind that of other countries. The political fragmentation of the German state also presented significant barriers to utilizing German medical talent in the armies, for the old länder (state) regimental system made it difficult to form a professional national army. With national unification under Otto von Bismarck (1815–1898), these political barriers disappeared. Moreover, the creation of a national army raised the status of any association with the military, making a military career attractive to physicians. The reserve system, designed to rapidly fill out the standing army, created expanded social opportunities for medical academics to obtain commissions in the reserve regiments. When these regiments were called to national service, as in the Franco-Prussian War, the best German physicians and surgeons in the country went along with them.189 Overnight, the German soldier became the recipient of the best military medical care in the world.
In the eighteenth century, military medical care had never been a matter of great concern for Frederick the Great. Between his death and the outbreak of the wars of the French Revolution, the German military medical system, along with much of the rest of the military establishment, had ossified.190 The press of the French wars, however, demonstrated the need for reform, and Johann Goercke (1750–1822), who served as surgeon general from 1797 to 1822, infused a new spirit into the German medical service.191 Goercke’s battlefield experience convinced him to improve the medical service, and he spent two years studying medicine in the leading centers of Europe before attempting reforms. In 1795, he founded the Pépinière in Berlin to train military medical officers and established a reporting system for evaluating the competency of medical personnel. To attract talent to military service, he convinced the king to establish a pension for military medical officers. The Pépinière graduated 1,359 medical officers for service in the army between 1795 and 1821, when it became the Frederick Wilhelm’s Institute.192 Goercke also obtained funds to create mobile field hospitals, but they did not become established until after the German defeat at Jena in 1806. By 1813, however, the German Army operated three general hospitals of twelve hundred beds each, one reserve hospital with three thousand beds, and nine mobile field hospitals of two hundred beds each. To support this system, thirty-eight military reserve hospitals were created in cities and towns.193 Although Goercke had introduced a small number of field ambulances as early as 1795, probably copying the French experience, by the time of Waterloo the army only had three ambulances left. The Prussian medical corps during the Napoleonic Wars had developed a well-trained litter bearer corps that was equipped with two-wheeled carts and distinctive badges and scarves for the personnel, but without a mobile ambulance system to transport casualties, the medical service still was rudimentary at best.194
Although some changes in the German medical service helped provide sufficient numbers of trained medical personnel to the army in wartime, the real stimulus for reform came with the experience of the Austro-Prussian War. For the first time the German Army used breech-loading rifles and artillery on a large scale. The Austrians, meanwhile, were equipped with the old smoothbore muzzle-loading cannon firing case shot, while their infantry carried the muzzle-loaded Lorenz rifles with .57-caliber rounds. The Prussian Army numbered 669,076 men, of which 2,286 were medical officers and 1,909 hospital assistants. Also seeing service were 3,420 apothecaries.195 Medical support was organized around the army corps, not the regiment. It is unclear how the Germans hit upon this idea, but they probably copied it from the Americans’ experience in the Civil War.196 Each army corps was provided with a medical train of three hundred men and an ambulance corps of one hundred men. The Prussians had twenty-seven corps hospitals, ten light field hospitals, and six general hospitals to treat casualties. Behind them were four reserve medical depots far to the rear. The system could accommodate forty-seven thousand casualties.197
Although the Prussian system was adequately staffed, its performance proved to be less than acceptable to the German high command. The Prussian Army inflicted more battle casualties upon the enemy than it suffered itself, but its sickness and disease death rates were higher. The army endured epidemics of cholera, typhus, and dysentery at higher rates than the Austrians did and averaged a manpower loss from illness of approximately 2.5 percent.198 Moreover, the death to wound ratio averaged between 11 and 12 percent, or much higher than expected, and the percentage of men with disease who were permanently invalided was also higher than expected.199 Shortly after the hostilities ceased, the German Army totally reorganized its medical service and created an independent military medical corps for the first time in German history.200
A few years later, the German medical corps performed so well in the Franco-Prussian War that it became the model that the British military medical system followed when it introduced reforms almost immediately after the war.201 The German hospital system remained almost structurally the same as it had been in 1866, but it had made great improvements in hygiene and sanitation. Most important was its first large-scale use of Listerian methods of antisepsis.202 The results were remarkable, and after the war Lister toured Germany as a hero, even while his innovations were still being debated in England and France.203 The Germans also made great improvements in their field ambulance system and assigned trained litter bearers to each regiment. A reserve litter company rushed stretcher bearers to those regiments that were particularly hard pressed. Special liaison teams whose task it was to manage the flow of vehicles from the field hospitals to the general hospitals coordinated the increased use of field ambulances.204 The medical service made extensive use of the American-style medical wagons that Dr. Letterman introduced in the Civil War, with their two tiers of ambulance beds, medical laboratory, and supplies of drugs and equipment.205
The smooth flow of wounded to the aid stations and collecting points behind the battle augmented the German medics’ ability to provide treatment to the wounded soldier more rapidly than any other army had previously accomplished. Each German soldier was provided with his own sterile first aid kit, which included an elastic Esmarch bandage,206 sterile lint, and other bandages. When medical personnel reached a soldier, the equipment they needed to stem bleeding and prevent shock was thus readily at hand. Utilizing special units of noncommissioned officers as corpsmen trained in the tourniquet’s use also reduced death from blood loss and shock. Among the Germans’ most interesting innovations were the medical cards that the soldiers wore around their necks. The field medics used these cards to record the soldiers’ injuries and condition. It provided the surgeon with a much-needed source of information that also saved time.207
As casualties flowed to the rear, the German Army’s railway corps provided a crucial link in evacuating casualties to general and reserve hospitals. Each army corps had its own medical railway unit to coordinate and oversee the wounded’s evacuation, with two hundred rail cars equipped with mattresses, straw, and nursing personnel who were organic to its organization. Those soldiers who were unable to travel were held at battalion aid or temporary barracks hospitals until their conditions stabilized. Railway medical personnel evacuated the most seriously wounded on a priority basis. Every hour or so, an average of fifty railway cars pulled out of German stations bound for rear area hospitals.208
The innovations of the German medical system greatly reduced the death rate. Using antiseptic surgery, curiously forbidden by the French, drastically reduced the surgical mortality rate from infection. Systematic vaccination, a procedure the French also chose not to employ, resulted in a smallpox casualty rate four times lower than what the French suffered.209 German Army doctors outnumbered their French counterparts almost 4 to 1, and the French ambulance corps was decidedly primitive by German standards. The French were still using hired labor to drive their field ambulances and saw the usual results. While the German system handled thousands of casualties smoothly, more often than not the French system was overwhelmed in the first few hours of battle. Even their rear area hospitals were inadequate to the task of handling the casualty load. The German system worked so well that for the first time in modern history, a war was fought where the number of casualties caused by hostile fire was greater than the number of soldiers lost to disease.
Perhaps no century in history saw more progress in the development of military medical care than the nineteenth century. The quality of care provided to a soldier during any period depended upon two factors—the quality of medical knowledge available to the military practitioners and the degree of organizational sophistication within an army to actually deliver medical care to the soldier lying injured on the battlefield. The nineteenth century witnessed the emergence of anesthesia, antiseptic surgery, and bacteriology as the three most important innovations in medical knowledge contributing to the improvement of military medicine. As rudimentary as these innovations were when compared to the degree to which they have developed in modern times, they were nevertheless revolutionary. Without them, many of the medical advances of the present day would not have been possible. In a sense, they were true conceptual revolutions that laid the basis for much of modern medicine.
Not a single major European army began the nineteenth century with an independent and well-developed medical system that could systematically deliver the medical knowledge of the day to the wounded soldier. By the end of the century, however, every army had such a system. Some, such as the Germans and Americans, gained extensive firsthand experience in handling mass casualties. Others either lacked this experience, as they fought only small colonial wars (British), or failed to learn from their experience with mass casualties (French and Russians). At the very least, however, although some armies failed to staff their medical services with adequate men and equipment during peacetime, the idea that any successful army required a medical service had set deep roots in all the armies of the world. Events might prove that existing arrangements for medical care were inadequate for a given war, but never again would a major power send an army into the field without providing some sort of medical care system.
The Franco-Prussian War of 1870 was the last major war of the century and produced the now commonly high casualty rates inflicted by modern weapons. Marking the last quarter century were small-scale colonial wars, often in medically hostile environments—for example, the Boer War and Spanish-American War—in which sickness and death by disease played greater havoc than injuries from weapons did. At the same time, medical advances in the etiology of disease contagion served as the starting point for a new approach in which it was more important to discover the mechanism of disease transmission than to discover the cause of the disease itself. Often after an initial period of terrible experience with disease epidemics among troops in the field, armies began to pay serious attention to preventing disease before an epidemic occurred. This approach led to great upgrades in military hygiene, beginning with improvements in the health and quality of the soldier himself. Advances in bacteriology, in turn, led to advances in immunology, and the list of diseases for which inoculations were available increased.
Military medicine had reached a point in its development at which it stood on the brink of a new frontier where the soldier could expect to survive most of the rigors of the battlefield unless his body was torn apart by flying metal. The focus on military sanitation, disease, and hygiene, coupled with the fading memories of mass casualties produced in previous wars, led to a reduction in the number and type of resources available to the peacetime armies. At the same time, few military thinkers truly appreciated the lethal possibilities inherent in the technological improvements that had occurred in weaponry since 1870. Not a single army in the world had changed its tactical thinking very much since the last major war. Because the colonial wars had been short and cheaply fought, the strategic doctrine of the day held that the next war, even if fought among the major powers in the European heartland, would also be short lived, with victory going to the side that could most rapidly mobilize and deploy its reserves. When the shots fired in the streets of Sarajevo echoed through the chancelleries of Europe, events proved just how wrong these strategic thinkers’ assumptions had been.
1. McGrew, Encyclopedia of Medical History, 14.
2. Hypnotism, popularized by Franz Joseph Mesmer, became known as mesmerism. Another earlier anesthetic technique that military surgeons used includes placing a metal helmet on the patient’s head and striking it with a wooden hammer to render the patient unconscious.
3. J. Antonio Aldrete, G. Manuel Marron, and A. J. Wright, “The First Administration of Anesthesia in Military Surgery: On Occasion of the Mexican-American War,” Anesthesiology 61, no. 5 (November 1984): 585.
4. Samuel Guthrie, an American, was the inventor of chloroform. He also invented the percussion cap that increased the rate of fire of Civil War muskets.
5. Although first used in obstetrics, chloroform was widely held to be dangerous because it reduced the pain that was “natural” to childbirth. It was further believed that chloroform induced sexual fantasies when administered to women. These objections came to an end when Queen Victoria was administered chloroform in childbirth in 1853.
6. John A. Shepard, “The Smart of the Knife: Early Anesthesia in the Services,” Journal of the Royal Army Medical Corps 131, no. 2 (June 1985): 109–12.
7. Ibid.
8. Aaron M. Schwartz, “The Historical Development of Methods of Hemostasis,” Surgery 44, no. 3 (September 1958): 608.
9. Ibid.
10. Ibid., 609.
11. Chamberlain, “History of Military Medicine,” 248.
12. Robert Wagner and Benjamin Slivko, “History of Nonpenetrating Chest Trauma and Its Treatment,” Minnesota Medical Journal 37, no. 4 (April 1988): 301.
13. Theodore E. Woodward, “The Public’s Debt to Military Medicine,” Military Medicine 146 (March 1981): 172.
14. Chamberlain, “History of Military Medicine,” 249.
15. Peter Aldea and William Shaw, “The Evolution of the Surgical Management of Severe Lower Extremity Trauma,” Clinics in Plastic Surgery 13, no. 4 (October 1986): 556.
16. Ibid.
17. McGrew, Encyclopedia of Medical History, 34; and Crissey and Parish, “Wound Healing,” 4.
18. Forrest, “Development of Wound Therapy,” 271.
19. Kirkup, “History and Evolution,” 284.
20. Wangensteen et al., “Some Highlights,” 108.
21. Lewis N. Cozen, “Military Orthopedic Surgery,” Clinical Orthopaedics and Related Research 200 (November 1985): 52.
22. Ibid.
23. Inspector General Hercule Sieur, “Tribulations of the Medical Corps of the French Army from Its Origin to Our Own Time,” Military Surgeon 64, no. 6 (June 1929): 843.
24. Ibid., 851.
25. Garrison, Notes on the History, 162.
26. A. G. Chevalier, “Hygienic Problems of the Napoleonic Armies,” Ciba Symposium 3 (1941–1942): 975.
27. Colin Jones, The Charitable Imperative: Hospitals and Nursing in Ancien Régime and Revolutionary France (London: Routledge, 1989), 228.
28. After the battle of Marengo in 1800, France signed a treaty with Austria and England in 1802. Napoleon was regarded in France as a peacemaker, and the military hospitals were dismantled. Shortly after the demobilization of the hospitals began in 1803, the War of the Third Coalition broke out. Napoleon won so quickly at the battle of Austerlitz that the defects of the dismantled military medical system were not appreciated, and the dismantlement of the hospitals was allowed to continue.
29. Garrison, Notes on the History, 169.
30. A similar outbreak of ophthalmia among French troops in Syria six hundred years earlier had crippled the army and forced a retreat. Given the prevalence of hospitals dedicated to treating blind Crusaders during the Middle Ages, it seems reasonable that ophthalmia presented a serious disease threat to these armies.
31. Garrison, Notes on the History, 166.
32. For cold injury rates in all the wars from the Napoleonic Wars to World War I, see Charles Schechter and Irving A. Sarot, “Historical Accounts of Injuries Due to Cold,” Surgery 63, no. 3 (March 1968): 535.
33. Blaine Taylor, “Some Medical-Historical Aspects of the Later Napoleonic Wars, 1812–1815,” Maryland State Medical Journal, December 1978, 27.
34. Launcelotte Gubbins, “The Life and Work of Jean Dominique, First Baron Larrey,” Journal of the Royal Army Medical Corps 22 (1914): 188.
35. Sieur, “Tribulations of the Medical Corps,” 855.
36. Wangensteen et al., “Wound Management,” 224.
37. Chevalier, “Hygienic Problems,” 979.
38. Wangensteen et al., “Some Highlights,” 224.
39. Lyman A. Brewer, “Baron Dominique Jean Larrey (1766–1842): Father of Modern Military Surgery, Innovator, Humanist,” Journal of Thoracic and Cardiovascular Surgery 92, no. 6 (December 1986): 1097.
40. E. Robert Wiese, “Larrey: Napoleon’s Chief Surgeon,” Annals of Medical History 1 (July 1929): 444.
41. These wagons were called ourgons.
42. Wiese, “Larrey.”
43. Taylor, “Some Medical-Historical Aspects,” 27.
44. David M. Vess, “French Military Medicine during the Revolution,” PhD diss., University of Alabama, 1965, 118–19. This outstanding research work deserves to be published.
45. F. M. Richardson, “Wellington, Napoleon, and the Medical Services,” Journal of the Royal Army Medical Corps 131, no. 1 (1985): 9–10.
46. Wiese, “Larrey,” 44.
47. Garrison, Notes on the History, 164.
48. Chevalier, “Hygienic Problems,” 976.
49. Richard L. Blanco, “The Development of British Military Medicine, 1793–1814,” Military Affairs 38, no. 1 (February 1974): 5.
50. Robert M. Feibel, “What Happened at Walcheren: The Primary Medical Sources,” Bulletin of the History of Medicine 42 (1968): 64.
51. Taylor, “Retrospect of Naval and Military Medicine,” 622.
52. Garrison, Notes on the History, 167.
53. Taylor, “Retrospect of Naval and Military Medicine,” 622.
54. Garrison, Notes on the History, 167.
55. Taylor, “Retrospect of Naval and Military Medicine,” 622.
56. Ibid.
57. Blanco, “Development of British Military Medicine,” 9.
58. G. A. Kempthorne, “The Medical Department of Wellington’s Army,” Journal of the Royal Army Medical Corps, February–March 1930, 214.
59. Richard L. Blanco, Wellington’s Surgeon General: Sir James McGrigor (Durham, NC: Duke University Press, 1974), 117–19.
60. Kempthorne, “Medical Department,” 214.
61. J. M. Matheson, “Comments on the Medical Aspects of the Battle of Waterloo, 1815,” Medical History 10 (1966): 205.
62. Blanco, Wellington’s Surgeon General, 147.
63. A. Campbell Derby, “The Military Surgeon—Not Least in the Crusade,” Canadian Journal of Surgery 28, no. 2 (1985): 183.
64. M. K. H. Crumplin, “Surgery at Waterloo,” Journal of the Royal Society of Medicine 81, no. 1 (January 1988): 38. Also by the same author, see “Vascular Problems at the Battle of Waterloo,” European Journal of Vascular Surgery 137, no. 1 (April 1987): 137–42.
65. Crumplin, “Surgery at Waterloo,” 40.
66. Ibid.
67. Blanco, Wellington’s Surgeon General, 147.
68. Peter Alexander Young, “The Army Medical Staff: Its Past Services and Its Present Needs,” Edinburgh Medical Journal 4 (1898): 17.
69. Robert L. Reid, “The British Crimean Medical Disaster: Ineptness and Inevitability?,” Military Medicine 140 (June 1975): 424. Another important work based on original sources is Joseph O. Baylen and Alan Conway, eds., Soldier-Surgeon: The Crimean War Letters of Dr. Douglas A. Reid, 1855–1856 (Knoxville: University of Tennessee Press, 1968).
70. Reid, “The British Crimean Medical Disaster,” 424.
71. Garrison, Notes on the History, 171.
72. Ibid.
73. Ibid.
74. Reid, “The British Crimean Medical Disaster,” 424.
75. G. H. Rice, “The Evolution of Military Medical Services from 1854 to 1914,” Journal of the Royal Army Medical Corps 135, no. 3 (1989): 149.
76. Reid, “British Crimean Medical Disaster,” 422.
77. Owen Wangensteen and Sarah D. Wangensteen, “Letters from a Surgeon in the Crimean War,” Bulletin of the History of Medicine 43, no. 4 (July–August 1969): 376–79.
78. George Halperin, “Nikolai Ivanovich Pirogov: Surgeon, Anatomist, Educator,” Bulletin of the History of Medicine 30, no. 4 (July–August 1956): 351.
79. Rice, “Evolution of Military Medical Services,” 148.
80. G. A. Kempthorne, “The Medical Department in the Crimea,” Journal of the Royal Army Medical Corps 53, no. 55 (August 1929): 132.
81. John Sweetman, “The Crimean War and the Formation of the Medical Staff Corps,” Journal of the Society for Army Historical Research 53, no. 214 (1975): 113.
82. Kempthorne, “Medical Department in the Crimea,” 138.
83. Reid, “British Crimean Medical Disaster,” 422.
84. Nelson D. Lankford, “The Victorian Medical Profession and Military Practice: Army Doctors and National Origins,” Bulletin of the History of Medicine 54 (1980): 513–14.
85. Sweetman, “Crimean War,” 114.
86. Reid, “British Crimean Medical Disaster,” 423.
87. Kempthorne, “Medical Department in the Crimea,” 138.
88. W. A. Eakins, “Thomas Crawford: Regimental Medical Officer in the Crimea, 1855,” Ulster Medical Journal 51, no. 1 (1982): 47–48.
89. Shepard, “Smart of the Knife,” 112.
90. Ibid., 113. The fact that bleeding remained a common practice during the war did little to help speed the recovery of the wounded. Lord Raglan ordered twelve thousand leeches to be sent from Myrna for this purpose. They all arrived in tightly sealed jars, quite dead.
91. Sweetman, “Crimean War,” 118.
92. Chamberlain, “History of Military Medicine,” 240. See also P. S. London, “An Example to Us All: The Military Approach to the Care of the Injured,” Journal of the Royal Army Medical Corps 134 (1988): 83–85.
93. Ian Fraser, “The Doctor’s Debt to the Soldier,” Mitchiner Memorial Lecture, Royal Army Medical College, June 8, 1971, 63.
94. Sieur, “Tribulations of the Medical Corps,” 211.
95. Ibid., 212.
96. Ibid.
97. Ibid., 217.
98. Ibid., 219.
99. Ibid., 220.
100. Samuel Ramer, “Who Was the Russian Feldsher?,” Bulletin of the History of Medicine 50, no. 2 (1976): 213.
101. Garrison, Notes on the History, 171.
102. Halperin, “Nikolai Ivanovich Pirogov,” 351.
103. Ibid., 350.
104. Ibid., 354.
105. Fraser, “Doctor’s Debt to the Soldier,” 63.
106. Ibid.
107. Wolfe, “Genesis of the Medical Department,” 840.
108. Grissinger, “Development of Military Medicine,” 322.
109. Wolfe, “Genesis of the Medical Department,” 23.
110. Grissinger, “Development of Military Medicine,” 324–25.
111. Thomas R. Irey, “Soldiering, Suffering, and Dying in the Mexican War,” Journal of the West 11, no. 2 (1972): 285.
112. Stewart Brooks, Civil War Medicine (Springfield, IL: Charles C. Thomas, 1966), 74.
113. F. William Blaisdell, “Medical Advances during the Civil War,” Archives of Surgery 123, no. 9 (September 1988): 1045.
114. Ibid.
115. Brooks, Civil War Medicine, 74.
116. Ibid.
117. Ibid., 99.
118. Aldea and Shaw, “Evolution of Surgical Management,” 558.
119. Brooks, Civil War Medicine, 100.
120. Ibid.
121. Blaisdell, “Medical Advances,” 1049.
122. Ibid.
123. Willis G. Diffenbaugh, “Military Surgery in the Civil War,” Military Medicine 130 (1965): 491.
124. Aldea and Shaw, “Evolution of Surgical Management,” 558.
125. Brooks, Civil War Medicine, 95.
126. Robert F. Weir, “Remarks on the Gunshot Wounds of the Civil War,” New York State Journal of Medicine 82, no. 3 (1982): 392.
127. David T. Courtwright, “Opiate Addiction as a Consequence of the Civil War,” Civil War History 24, no. 2 (1978): 104–5.
128. Ibid., 106.
129. Ibid., 101.
130. Brooks, Civil War Medicine, 8.
131. Stanley B. Burns, “Early Medical Photography in America: Civil War Medical Photography,” New York State Journal of Medicine 80, no. 9 (August 1980): 1447.
132. McCord, “Scurvy as an Occupational Disease,” 590.
133. John F. Fulton, “Medicine, Warfare, and History,” Journal of the American Medical Association 153, no. 5 (October 1953): 180.
134. Brooks, Civil War Medicine, 106.
135. Taylor, “Retrospect of Naval and Military Medicine,” 615.
136. Brooks, Civil War Medicine, 41.
137. Miller J. Stewart, Moving the Wounded: Litters, Cacolets & Ambulance Wagons, U.S. Army, 1776–1876 (Johnstown, CO: Old Army Press, 1979), 26.
138. Ibid., 33.
139. Ibid., 36.
140. Taylor, “Retrospect of Naval and Military Medicine,” 617.
141. Stewart, Moving the Wounded, 182.
142. Brooks, Civil War Medicine, 37.
143. Estelle Brodman and Elizabeth B. Carrick, “American Military Medicine in the Mid-Nineteenth Century: The Experience of Alexander H. Hoff, M.D.,” Bulletin of the History of Medicine 64 (Spring 1990): 71.
144. Brooks, Civil War Medicine, 37.
145. Brodman and Carrick, “American Military Medicine,” 72.
146. Philip A. Kalisch and Beatrice J. Kalisch, “Untrained but Undaunted: The Women Nurses of the Blue and the Gray,” Nursing Forum 15, no. 1 (1976): 21–22.
147. Chamberlain, “History of Military Medicine,” 248.
148. Reasoner, “Medical Supply Service,” 17–18.
149. Burns, “Early Medical Photography,” 1447.
150. Brooks, Civil War Medicine, 24.
151. Burns, “Early Medical Photography,” 1450–57.
152. Brooks, Civil War Medicine, 28.
153. Blaisdell, “Medical Advances,” 1048.
154. Brooks, Civil War Medicine, 46.
155. Ibid.
156. Ibid., 47.
157. Kalisch and Kalisch, “Untrained but Undaunted,” 24–25.
158. Blaisdell, “Medical Advances,” 1046.
159. Richard B. Stark, “The History of Plastic Surgery in Wartime,” Clinics in Plastic Surgery 2, no. 4 (October 1975): 511.
160. Ibid.
161. Leonard D. Heaton and Joe M. Blumberg, “Lt. Colonel Joseph J. Woodward (1833–1884): U.S. Army Pathologist-Researcher-Photomicroscopist,” Military Medicine 131, no. 6 (June 1966): 534.
162. Burns, “Early Medical Photography,” 1463.
163. Ibid., 1464.
164. Frank R. Freeman, “Administration of the Medical Department of the Confederate States Army, 1861–1865,” Southern States Medical Journal 80, no. 5 (May 1987): 632.
165. Gordon E. Dammann, “Dental Care during the Civil War,” Illinois Dental Journal (January–February 1984): 14–15.
166. Burns, “Early Medical Photography,” 1464–65.
167. Peter D. Olch, “Medicine in the Indian-Fighting Army, 1866–1890,” Journal of the West 21, no. 3 (1982): 32.
168. Ibid.
169. Ibid., 34.
170. Grissinger, “Development of Military Medicine,” 338.
171. As noted in chapter 2, for example, the British did not have a comprehensive pension system even after the Crimean War.
172. For more on the general subject of military psychiatry, including its history and development, see the following from Richard A. Gabriel: No More Heroes; Soviet Military Psychiatry: The Theory and Practice of Coping with Battle Stress (Westport, CT: Greenwood Press, 1986); Military Psychiatry: A Comparative Perspective (Westport, CT: Greenwood Press, 1986); and The Painful Field: The Psychiatric Dimension of Modern War (Westport, CT: Greenwood Press, 1988).
173. Albert Deutsch, “Military Psychiatry: The Civil War,” in One Hundred Years of American Psychiatry, ed. J. K. Hall, G. Zilboorg, and H. A. Bunker (New York: Columbia University Press, 1944), 367.
174. Dorothea Dix was a major force in encouraging humane treatment for the insane in the United States.
175. Germany and Russia were the home of nosological biological psychiatry, and Russian neurologists serving in the Crimean War were the first to take systematic notice of psychiatric casualties. This interest was continued after the war and eventually resulted in the first military medical system for dealing with psychiatric casualties on the battlefield during the Russo-Japanese War of 1905.
176. Donald Lee Anderson and Godfrey Tryggve Anderson, “Nostalgia and Malingering in the Military during the Civil War,” Perspectives in Biology and Medicine 28, no. 1 (Autumn 1984): 156. See also George Rosen, “Nostalgia: A ‘Forgotten’ Psychological Disorder,” Psychological Medicine 5 (1975): 340–41.
177. Gabriel, No More Heroes, 57.
178. Rosen, “Nostalgia,” 342.
179. Gubbins, “Life and Work of Jean Dominique,” 188. Larrey treated the disorder by offering officers suffering from nostalgia bribes and better food if they would remain at their posts.
180. Deutsch, “Military Psychiatry,” 377.
181. Ibid., 370–72; and Weir, “Remarks on Gunshot Wounds,” 393, for the tendency to confuse psychiatric symptoms with malingering.
182. Ibid., 377.
183. Ibid., 372.
184. Ibid., 384.
185. McGrew, Encyclopedia of Medical History, 323.
186. Halperin, “Nikolai Ivanovich Pirogov,” 348.
187. Aldea and Shaw, “Evolution of the Surgical Management of Wounds,” 599.
188. Halperin, “Nikolai Ivanovich Pirogov,” 348.
189. Fraser, “Doctor’s Debt to the Soldier,” 65.
190. After the Prussian defeat at Jena in 1808, the army was reformed under the direction of Gerhard von Scharnhorst, who invented the prototype of the German general staff system that became the hallmark of German military efficiency for the next hundred years.
191. Garrison, Notes on the History, 168.
192. Ibid., 163.
193. Ibid., 169.
194. Stewart, Moving the Wounded, 18.
195. Fielding H. Garrison, “The Statistics of the Austro-Prussian War (‘7 Weeks’), 1866, as a Measure of Sanitary Efficiency in Campaign,” Military Surgeon 41 (1917): 711.
196. The German Army, along with others, sent observers to the respective sides in the Civil War. These observers prepared staff reports on various aspects of the war.
197. Garrison, “Statistics of the Austro-Prussian War,” 711–13.
198. Ibid., 713.
199. Ibid.
200. Sieur, “Tribulations of the Medical Corps,” 219.
201 Fraser, “Doctor’s Debt to the Soldier,” 65.
202. Lawson, “Amputations through the Ages,” 225.
203. McGrew, Encyclopedia of Medical History, 23.
204. Sieur, “Tribulations of the Medical Corps,” 219.
205. Valentine A. J. Swain, “The Franco-Prussian War, 1870–1871: Voluntary Aid for the Wounded and Sick,” British Medical Journal 29, no. 3 (August 1970): 514.
206. Chamberlain, “History of Military Medicine,” 246.
207. Swain, “Franco-Prussian War,” 512.
208. Ibid.
209. Henry E. Sigerist, “War and Medicine,” Journal of Laboratory and Clinical Medicine 28, no. 5 (February 1943): 535.