Between Flesh and Steel

by Richard A. Gabriel

  France

  The French medical corps was outdated, disorganized, and still suffered from the organizational and political effects of the army’s defeat at Waterloo.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.

  Russia

  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 Wa
r.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

  THE MEXICAN WAR AND THE AMERICAN CIVIL WAR

  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 a
nd 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.