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
The Flying Ambulance
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 attenda
nts (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
British Medicine
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 li
ne.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.
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