The French military medical system was still the most structurally advanced of all the armies of the period. Moreover, the revolutionary emphasis on equality provided a further impetus to provide good medical care for the soldier. The French armies were the first genuine citizen armies of the modern period, and while the sacrifice of the citizen’s life to the cause of the state was generally accepted as a cost of military service, the state recognized its obligation to provide for the citizen soldier’s medical treatment. As the eighteenth century came to an end and the specter of Napoleon loomed over Europe, the armies of the continent realized their military forces were no match for the French unless they resorted to national conscription and patriotic appeals to raise large armies. As part of their new bargain with formally excluded social elements, the continental armies began to explore ways to improve the medical care for their soldiers. In this sense, the spirit of the French Revolution spurred most of Europe’s armies to begin providing what would eventually become the modern system of military medical care.
PRUSSIA
The centralization of governmental power that marked most of the previous century in England and France occurred much later in Prussia, with the result that its centralized control of governmental functions lagged behind even that of the other continental powers. In the area of military medicine, this delay worked against establishing a government-sponsored military medical service in Prussia until late in the century. Even then the degree of its organizational sophistication remained low. For most of the eighteenth century, the Prussian military medical service and the degree of care and resources it provided to field medical units depended, as it had in the seventeenth-century England and France, primarily upon the army commander’s willingness to arrange it for a given campaign.
The first military hospital in Prussia, a “medical house” near the Spandau Gate in Berlin, was constructed in 1710, but it was only officially established as a regular military hospital fifteen years later.72 Meanwhile, in 1705, Prussia had a standing army of thirty-five regiments; however, only six of them had a normal complement of regimental surgeons and mates.73 In 1712, for the first time in the Prussian Army, supervision of company surgeons was transferred from officers of the line to the medical officers in the regiment. The status of Prussian barber-surgeons was so low that they ranked below the chaplains and only slightly above the drummers. Regimental surgeons still had to shave company officers, and senior officers could subject them to public whipping for the slightest offense.74 The barber-surgeons were forbidden to treat the wounded except under supervision of the regimental surgeons, who themselves usually had poor skills. Company surgeons were allowed to visit the sick and wounded and to report their condition to the regimental surgeons. Long after the distinction between surgeon and physician had begun to diminish in the other armies of the day, in Prussia the rigid separation lasted well into the nineteenth century, thereby preserving the regimental surgeons’ low status and training. The Prussian Army did not even have an officially commissioned surgeon general until 1716.
Frederick Wilhelm I appointed the first chief physician of the army in 1724. This officer was charged with presiding over all physicians and surgeons in the army and standardizing regulations governing medical competence. For the first time, both physicians and surgeons received the same training in the army.75 The army commonly withheld part of the company barber-surgeons’ pay to offset the cost of the regiment’s medical supplies. Jews were not admitted to military medical practice, and in Austria at the beginning of the Seven Years’ War, Protestant surgeons had to convert to Catholicism or leave the army.76 Some German states authorized surgeons to wear regular uniforms, and others forbade them to do so. The staffing of regimental hospitals with apothecaries was poor at best, and unlike in England at this time, nursing was not organized.
Frederick Wilhelm issued regulations requiring all military surgeons to be examined before the medical college as a test of competency, a regulation probably only rudimentarily enforced. Frederick made use of at least twelve French surgeons in his army, but little effort seems to have been made to have them train Prussian medical personnel. This lack of serious concern over military medical matters was evident in the infantry regulations of 1726 that still forbade medical attention to the wounded until the battle was over, a practice that other continental armies had long abandoned. The regulation read: “When the battle is over each regiment shall seek out its wounded and bring them to a definite place where they can be bandaged and cared for; no wounded may be recovered during the battle.”77 The same regulation noted that a military hospital was to be established in the nearest village or town to which the warring party’s sick and wounded could be sent. Each battalion was assigned a barber-surgeon and two attendants to provide medical care. The barber-surgeons were only supposed to attend the lightly wounded and to send others to the rear. Although general hospital personnel in the town hospital were presumably better trained, this was seldom the case. If the army moved on, a noncommissioned officer without medical training was assigned to remain with the sick and wounded. He was allotted a sum of money to help care for the patients and to purchase whatever medical help and supplies were available in the area. Although the field apothecary was also designated to remain behind and provide drugs, no one remained behind to tend the wounded. All other trained medical personnel moved forward with the army. When the sick and wounded required transport, the army used whatever wagons were available for it had no systematic provision for transport. In all these respects, the Prussian medical system in the first half of the century fell far short of the quality of medical care that soldiers in other armies received.
The army of Frederick the Great made a number of improvements to this system. Still, the system itself was more the responsibility of the field commanders than of the national government. Frederick had a personal interest in medical matters, and his concern for his troops grew as much out of his genuine concern for their welfare as from the fact that the population of Prussia was small and every fighting man was a precious national resource. As a field commander, Frederick often personally selected locations for unit dressing stations when determining the battle plan. He ordered that these stations be appropriately fortified and protected from enemy fire and cannon shot.78 He introduced the old Roman practice of guarding safe water points and mixing a small amount of vinegar with water to make it more potable. He was personally solicitous of the medical care of his troops and ordered incompetent surgeons flogged. While the care of his own wounded had priority, Frederick issued orders that the enemy wounded should be cared for as time and supplies permitted.
As time went on, Frederick’s battle losses in his frequent wars forced him to take military medical care more seriously. Although he attempted several remedies to improve care, as the century ended Prussian military medicine remained considerably behind that of other armies. Frederick ordered the creation of permanent, fixed-site military hospitals at Breslau, Glogau, Stettin, Dresden, Torgau, and Wittenberg and introduced the use of forward field hospitals. Each regiment was provided with a barber-surgeon and four company barbers to provide first aid. While no dedicated personnel or transport were used to evacuate the wounded, Frederick dictated that regular detachments be assigned from the regiment’s manpower to accomplish this task. Efforts were made to draw these transport detachments from the regiments that had suffered the fewest losses in the day’s battle.
Prussia did not open its first military medical school, the Pépinière (later known as the Frederick Wilhelm Institute), until 1795. Austria had established the Josephinum, an academy for imperial army surgeons, ten years earlier.
RUSSIA
Russia’s long years of isolation from the European mainstream caused by its geography, religion, and foreign occupation left it far behind the continental powers in almost all aspects relating to military affairs, including military medicine. The condition of general medicine was also quite backward, and the number of traine
d medical personnel of any sort, in the army and society, were extremely few. Peter the Great, whose interest in medical affairs stemmed largely from his own suffering from various medical conditions, attempted to remedy this situation with numerous reforms.
The lack of native-trained physicians and surgeons forced Peter to rely on foreign doctors for his military forces. Although some were successfully recruited for short periods, the difficult living conditions, harsh terms of service, low pay, and the general suspicion that most Russians had for all foreigners made the program largely unsuccessful. In 1700 during the Great Northern War, Russia had fewer than sixty military surgical personnel in the army, and few of them had any formal medical schooling or training.79 In 1706, Peter reorganized the primitive military medical service, and each soldier was required to contribute a small sum from his pay to offset the cost of medical treatment. Regimental surgeons, usually ill-trained barber-surgeons, were appointed. The surgeon had to select a soldier from each company, at double pay, to shave the men and apply plasters. These soldiers also served in the line and were not full-time medical assistants.80 Peter’s “improvements” were actually old practices that the European armies had instituted a century earlier. Even the Russian surgeons’ mates, positions that hardly attracted the epitome of medical talent and training in the West, were far less skilled than those found in Western armies.
Forced to deal with a constant shortage of trained medical personnel for his armies, Peter founded the Gospitali with the express purpose of training military surgeons. The institution was placed under the direction of Nicolass Bidloo (1674–1735), the famous Dutch physician and surgeon, who arranged the curriculum along the lines of clinical empirical medicine characteristic of Dutch medical schools. From the outset, the institution had difficulty attracting the talented sons of the middle and upper classes, and for most of its history it drew its students from the lower classes. The school was under constant pressure to provide mates and surgeons for the armies; indeed, the director had to allow students to enter military service who had received only marginal training. In 1708, Peter ordered the college to provide twenty medical students for the army. Even by the low standards of Russian military medicine, the director agreed to send only six.81 The constant drain of half-trained medical students to serve as surgeons and mates almost forced the school to close. The school produced only ten graduates a year, and from 1712 to 1727 every member of every graduating class was sent into military service.
These difficulties aside, the number of trained medical personnel available to the army increased, albeit slowly. In 1713, the Apothecary Bureau reported that 262 medics of all types were assigned to military service. In 1720, the Baltic Fleet employed 102 medics, and seven years later, the number had increased to 165. The Russian Army’s medical branch was formally established in 1716, and medics were assigned to each regiment, apothecaries provided in the field, and field hospitals organized for the first time. In 1720, the navy was ordered to construct a similar medical system.82
The success of the Gospitali in providing military surgeons lent impetus to the construction of other medical facilities. The military itself began to construct military hospitals to care for its wounded and at the same time to serve as training facilities for medics. In 1715 the Petersburg Admiralty Hospital was founded. To provide military surgeons for the army, Russia built other hospitals at Reval (1717), Kronstadt (1717), Tavrov (1724), Astrakhan (1725), and Archangel (1733).83 Regardless of the effort, however, Russia continued to remain far behind the military medical facilities provided in other armies. It took more than a century, until the Russo-Japanese War of 1904–1905, before military medical care in czarist armies was on par with those found in armies of the West.
THE AMERICAN COLONIES
The close relationship between England and the American colonies for more than a hundred years before the American Revolution exerted a considerable influence upon the development of military medicine during the American War of Independence. Most of the doctors with a formal medical education had been educated in England or Scotland, although some had received their medical training at Leyden in Holland. Only two medical schools existed in the colonies during the colonial period.84 Meanwhile, the garrisoning of English troops in the American colonies, the direction of state militias by British officers, and the numerous skirmishes that the Indians and the French fought with British and American forces for almost fifty years had the effect of introducing the American military forces to British military medical practices.
As early as 1676, the Massachusetts Bay Colony provided medical support for its militia when it appointed a surgeon at public expense to attend a force of five hundred troops. In addition, a special house was constructed to care for the sick and wounded.85 In 1762, a military hospital was built at state expense in Albany to care for the casualties of the French and Indian War (1754–1763). In imitation of the British practice of the time, a surgeon and one surgeon’s mate routinely attended militia companies. As in British units, American regimental colonels appointed their surgeons, who, in turn, selected the mates. Not surprising, many of the problems of competency and training associated with these British Army practices were also present in the colonial militia armies.
Massachusetts was the first colony to create the position of medical commissioner, whose charge was to purchase, store, and issue medical supplies to the armies. In May 1775, the colony rented buildings in Boston to billet and care for the troops, established separate hospitals to deal with smallpox cases among the soldiery, and made provisions for caring for the “insane of war.”86 In early June, a medical committee was appointed to devise means for providing the troops with medicine and supplies, and another committee was created to prepare plans and regulations for hospitals. These steps were taken before the outbreak of open hostilities. When war broke out with England, the Committees of Safety purchased medical chests and surgical instruments at public expense for the state regiments’ use and a complete set of medical instruments for each corps. At the Battle of Bunker Hill on June 17, 1775, however, the American casualties were so heavy that the planned medical system collapsed under the load.
It became evident early on that the quality of medical personnel available to the army posed a serious problem. Massachusetts took the lead in establishing a board of medical examiners to examine all candidates who applied for the positions of surgeon and surgeon’s mate. Although the regimental commander could submit the name of candidates, the board certified the military surgeons. For the most part, its examinations were thorough and difficult, although somewhat spotty in other states. Throughout the war, each colony remained responsible for providing medical personnel and supplies for its home regiments.
In July 1775, Congress authorized the establishment of a “hospital for the army,” a term for the medical department for a force of twenty thousand men. Following the British pattern, the hospital was really a medical staff whose task was to follow the army and set up ad hoc medical support behind the lines. The British pattern was followed in all important details, with the hospital comprising a director, one chief physician, four surgeons, one apothecary, twenty surgeon’s mates, one clerk, two storekeepers, one nurse for each ten sick, and one nurse matron.87 A total of three hospitals were created for the Northern, Middle, and Southern Departments (theaters of operation) of the armies. It developed two separate medical systems—one responsible to national authority and the other responsible to state authority—resulting in inevitable confusion, lack of supply, and poor coordination that hindered the provision of medical care to the field armies.
If the states did not provide sufficient medical supplies—and most often they either did not or could not—the regimental surgeon was largely on his own since there were no provisions to supply him regularly through national authorities. Medical tents were usually unobtainable, and when the army was garrisoned in a city, the regimental barracksmaster was responsible for finding a building suitable for use as a ho
spital. In winter encampments such as Valley Forge, makeshift log huts served as hospitals and housing. Beds and bedding were rarely provided to the hospitals, which were forced to rely on the regimental supply officer for these items. Each company was required to carry extra bed sacks to be filled with straw when the sick needed them, and the soldier provided his own blanket in the hospital. Without a dedicated supply train for the medical units, even these items were reserved for the wounded, but no provisions were made for the sick.
As in the English Army, there were no transport vehicles organic to the colonial medical service. It did not use any special ambulance vehicles, and what wagons were from time to time available were drawn from the regular army stores. The arrangements for evacuating the wounded were so poor that surgeons were instructed to find handbarrows to move the wounded to the hospitals. Any manpower that was made available for this task came from the largesse of the field commander. The manning levels for the medical service were low, with a single surgeon and five mates for every five thousand men. Further, the English blockade made it difficult to import medical supplies from abroad, the usual source for colonial physicians. An inventory of medical supplies on hand in February 1776 for an army of 16,877 men revealed only nine sets of amputating instruments, twenty pocket cases, two cases of lancets, twelve cases of crooked suture needles, two cases of surgical knives, twenty-four tourniquets, 859 bandages, and twelve pounds of surgical lint.88 Surgeons were instructed to use razors to perform operations in lieu of adequate surgical instruments. Six months later conditions had not improved. Four days before the Battle of Long Island (August 1776), the army’s total medical supplies on hand consisted of only five hundred bandages, twelve fracture boxes, and two scalpels.89
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