Between Flesh and Steel (18 page)

Habits of personal, medical, and surgical cleanliness were still dismal during this period, and the soldier faced a greater risk to his health while in the hospital than on the battlefield. It has been estimated that in the American Revolutionary War (1775–1783), the Continental soldier had ninety-eight chances out of a hundred of escaping death on the battlefield, but once he was hospitalized, his chances of survival after medical treatment and exposure to disease and infection fell to 75 percent.
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Some surgeons, however, did perceive a relationship between cleanliness and surgical infection. Claude Pouteau (1724–1775) a French surgeon, made cleanliness a requirement in his operating area and achieved the remarkable result of losing only 3 of the 120 lithotomies performed in his surgery to infection. John Pringle (1707–1782), the famous English physician and surgeon, first coined the term “antiseptic” in 1750 and in 1753 published the results of forty-three experiments performed over a three-year period that confirmed the antiseptic value of mineral acids.
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In 1737 Alexander Monro I claimed to have performed fourteen amputations at his Edinburgh surgery with no hospital mortality. By 1752, he had performed more than a hundred major amputations with a hospital mortality rate of only 8 percent. This achievement was all the more remarkable given that for the next century the mortality rate for hospital surgery was generally between 45 and 65 percent.
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Monro also had a fetish for cleanliness. Despite overwhelming evidence of the relation between
cleanliness and infection, however, the work of surgeons Pringle, Monro, and Edward Alanson (1747–1823) was largely ignored until the next century when Joseph Lister (1827–1912) introduced general antisepsis. One can only guess how many soldiers would have survived their wounds had they not been exposed to infection while recovering in the hospital.

While the eighteenth century saw numerous improvements in the establishment and organization of military hospitals, especially in the introduction of the mobile field hospitals that accompanied the armies on the march, they still offered the unsanitary and dismal-quality care as they had in the previous century. Hospital buildings were often little more than rapidly constructed huts in the field.
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While every army had a hospital medical organization to provide treatment and administration, they were rarely fully staffed. Moreover, there was a notorious lack of coordination between regimental, field, and general rear area hospitals, especially in the provision of medical supplies. Few armies had any organized and dedicated transport to move the wounded from the front to rear area hospitals, and it was not uncommon for a third of the patients to die en route. No army developed a satisfactory solution for extracting the wounded from the battle line, and troops usually made their way to the medical facilities as best they could. As in the previous century, some armies, notably Prussia's, actually forbade attempts to treat the wounded until the battle had ended. No one seems to have thought of copying the Romans' stationing of combat medics within the battle units themselves.

Disease continued to be the major threat to military manpower despite military physicians' many attempts at preventive medicine. Among Continental soldiers in the American Revolution, disease caused 90 percent of all deaths; among British regulars, the figure was 84 percent.
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Hughes Ravaton, the French physician, noted in 1768 that one of every hundred soldiers in the French Army would be unfit for duty because of illness at the beginning of a field campaign. Halfway through the campaign, another five or six would drop out of combat because of disease. By the campaign's end, ten to twelve more soldiers would be too ill to fight. By comparison, the death and injury rate from combat fire was approximately one per ten men.
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The range of diseases that afflicted the troops had changed little from the previous century. Respiratory illnesses were most often seen in cold weather and dysentery-like conditions in hot climates. Disease diagnosis had not yet become a science, and descriptions of disease from this period cannot be entirely trusted. The common “intermittent” and “remittent” fevers of the day were most probably malaria, a disease
widespread in Europe and the colonial dominions. Those conditions called “putrid,” “jail,” or “hospital fever” were probably typhus or typhoid. Dysentery and other stomach disorders were rampant, often as a consequence of poor field hygiene conditions. Venereal disease was almost epidemic. Pneumonia and pleurisy also presented a common threat. The records of the period also show that scabies was endemic. This infestation caused scratching, which produced serious infections requiring medical treatment. Although not fatal, scabies brought more patients to British Army hospitals during the Seven Years' War than did any other medical condition.
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Scabies continued to plague armies into modern times. In World War I, scabies or the pyrodermas produced by constant scratching caused 90 percent of the illness for which Allied troops sought hospitalization or field treatment.
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Smallpox was among the most debilitating and dangerous diseases that afflicted field armies, with numerous examples of entire campaigns being halted as a consequence of outbreaks. In 1775, Gen. Horatio Gates (1727–1806) had to break off the American Northern Army Command's campaign for five weeks because an outbreak of smallpox sent 5,500 of his 10,000 troops to the hospital.
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The disease afflicted the civilian population without mercy in multiple epidemics that marked the period.

The prevalence of smallpox in the civilian and military populations drove one of the more important medical advances of the century, inoculation. Credit for introducing smallpox inoculation is generally given to Edward Jenner (1749–1823), but in fact, inoculation against smallpox was already an established practice long before Jenner formalized the method. The practice of using cowpox inoculation to prevent smallpox disease was common in the Ottoman Empire before it was introduced into Europe. Lady Mary Wortley Montague, the wife of the British ambassador to Constantinople, knew of the practice as early as 1718 and had herself and her two children inoculated against the disease.
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In 1721, a smallpox epidemic broke out in Boston, and Dr. Zabdiel Boylston (1679–1766) used inoculation to prevent its further spread. He inoculated 247 persons with a loss rate of only 2 percent, compared to the usual 15 percent death rate.
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Jenner's contribution to inoculation seems to have been that he was the first person to conceive of inoculating whole populations against the disease, and he developed the popular support to carry out his idea. Jenner did not perform his first smallpox inoculation until 1796.

The first army to try wholesale inoculation on its soldiers was the American Army. In 1775, noting General Gates's debacle while confronting smallpox, Gen. George Washington (1732–1799) obtained the approval of the Continental Congress
to inoculate recruits upon their entering into military service.
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The program was less than successful, however, and we do not know how many soldiers actually received inoculations. The British Army did not allow inoculation against smallpox until 1798, when the Sick and Wounded Board authorized the procedure at military hospitals for those who wanted it. As the century ended, there was still no mandatory inoculation for British troops.
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The successful immunization of military forces had to await the next century, when inoculation became more generally accepted. Holland and Prussia were the first countries to require inoculations of all their troops, while the French and English continued to lag behind. In the Franco-Prussian War of 1870–1871, unvaccinated French prisoners suffered 14,178 cases of smallpox, of which 1,963 died. The vaccinated German troops suffered only 4,835 cases of the disease, of which only 178 died, or a mortality rate of less than 4 percent.
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Recognizing the importance of military medical care in maintaining the fighting ability of their armies, some states established mechanisms for ensuring an adequate supply of surgeons and other field medical personnel. In the first quarter of the century, the French established schools for training surgeons and mates at a number of army and navy hospitals. The most important medico-military institution of the century was established when the French opened the Académie Royale de Chirurgie in Paris in 1731. That five of its seven directors and half of the forty members nominated by the king were prominent military surgeons who had served in battle attests to the academy's dedication to military medical matters. Further, army and naval surgeons wrote more than a third of the period's four volumes of medical papers.
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Saxony followed the French example and established an army medical school in 1748. Additional military medical schools were established in Austria in 1784 and in Berlin in 1795. In 1766, Richard de Hautesierck (1712–1789), inspector of hospitals, published the world's first medical journal devoted exclusively to military medicine.
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Gradually armies established regular field medical facilities. In 1745 at the Battle of Fontenoy, the British military medical service treated the wounded on the first line and collected them at ambulance stations. Surgeons performed capital operations at medical stations behind the lines and then transferred the more seriously wounded to hospitals prepared for them in nearby cities and towns. When these hospitals became overcrowded, the army made arrangements to ship the wounded farther to the rear. Although this model was becoming commonplace in all armies of the period, military medical facilities did not operate so efficiently as a matter of course. More commonly medical facilities were understaffed, were poorly supplied
and had little transport, and generally were overwhelmed by large numbers of casualties. Nonetheless, the structural articulation that the armies of the day were demonstrating in other areas was also evident in their attempts to provide better medical care for the soldier. It would take yet another century, but eventually the seeds of a full-time professional military medical service sown in the eighteenth century would come to fruition.

Before examining the development of the national military medical services, it is worth noting another development that did much to foster medical care in the armies of the period. Exempting the wounded from slaughter or imprisonment had begun in the seventeenth century, and the idea gained added support during the eighteenth century. In July 1743 at the completion of the Dettingen campaign, both sides signed an agreement that declared medical personnel serving in the armies would be considered noncombatants and not taken as prisoners of war. In addition, medical personnel would be given safe passage back to their own armies as soon as practical. Most important, both sides agreed to care for the enemy wounded and sick prisoners as they would their own and provide for their return upon recovery.
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While the Dettingen agreement was important for its humanity in dictating the treatment of the sick and wounded, it was also a significant spur to the further development of military medical facilities. While the old system of slaughtering the wounded reduced the casualty load for the medical facilities, the Dettingen agreement forced armies to increase their medical staffs to deal with the enemy wounded as well.

While military medical care had improved greatly over that of the previous century, by any objective standard it was still poor. This situation was not so much a consequence of poor medical knowledge but developed because no army succeeded in organizing a permanent medical care system that was adequately staffed with trained personnel, provided for the prompt removal of the wounded, ensured adequate medical supplies, and established hygienic hospitals. As in the previous century, command of the armies remained in the hands of temporary commanders of the nobility, and the extent to which any planned medical facilities actually were constructed and operated depended greatly upon the degree to which the respective field army's commander was prepared to provide the necessary resources. Thus, whatever military medical facilities were available during the last war or campaign had to be totally reconstructed from scratch for the next war. The old lessons had to be relearned, with the inevitable result that the medical care provided to the soldier suffered accordingly.

The first literary evidence of medical support provided aboard ship is found in the
Iliad
, where Homer recounted his shipboard surgeon, Machaon, treating his soldiers' wounds. In the
Odyssey
(700 BCE), Homer writes of Ulysses ordering the bodies of the slain to be covered with sulfur and burned, the first account of sulfur fumigation in history. In Roman times, naval surgeons were common fixtures in the medical service. The first evidence of a naval surgeon is taken from the tombstone of N. Londinius, who was the physician on the
Cupid
, a quinquereme of the Roman Navy. During the reign of Hadrian (76–138 CE), each Roman naval ship carried a medical officer, and the fleet strength of the naval medical service was approximately one physician for every two hundred men. This figure compares favorably to the ratio of six and a half naval physicians for every thousand U.S. naval personnel in World War II. Because the Roman Navy enjoyed the lowest prestige of all the empire's military forces, the Romans sometimes had difficulty recruiting naval physicians. Next to the names of some naval physicians is the term
duplicarius,
indicating that they received double pay.
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The Romans used hospital ships for the transport and care of their sick and wounded. The evidence is inferential and based on the Greek and Roman practice of naming their ships to reflect the purpose for which they were used. There are records of a Roman vessel named
Aesculapius
(the god of medicine), which may have served as a hospital ship.
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