Between Flesh and Steel (21 page)

The mobile hospital system, while a great improvement in the formal structure of military medical care, did not usually work very well in practice. Dedicated transport and supplies surely helped, but these units still had to rely on the combat units' manpower for evacuating the wounded. It was not until the Napoleonic Wars that the army regularly provided to field hospitals the manpower assets to act as litter bearers and surgeons' helpers.
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The resources and management of the field hospitals fell not under military command but to civilian contractors, a practice that often led to fraud, abuse, and lack of provisions. The same contract system was used to provide resources to the general hospitals, frequently with the same results.

The Enlightenment in France led to an emphasis on scientific and statistical approaches to medical management in general. The emergent concern with the health of the general citizenry and the state's provision of health and medical care encouraged a similar movement in military medicine.
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In 1718, the first formal hospital regulations were issued for the military medical service in a document of sixty-two paragraphs. These regulations were so comprehensive that they served as the basis for all future French military medical regulations for the next century. They included detailed instructions for hospital personnel, the medical treatment of patients, hygiene regulations for medical attendants, administrative practices for controlling hospital supplies, and military hygiene regulations aimed at preventing disease among the soldiery. The monthly pay of surgeons and physicians was moderately increased, and annual courses in anatomy were prescribed for all military surgeons. Most innovative was the regulation that the cost of the military medical service was to be paid entirely from the king's purse, without taking deductions from the soldier's pay as reimbursement.

In 1775, a royal order authorized the opening of lecture rooms for instruction in military medicine at the hospitals in Metz, Lille, and Strasbourg. This decree marked France's first attempt to create an army medical school. In 1782, the
Journal de médecine militaire,
the first French periodical devoted exclusively to military medicine, was established in Paris. The French experience in the wars of this period revealed that the general military hospitals often failed to provide adequate medical care because of their distance from the fighting and the rampant corruption and
mismanagement that characterized their operation. To improve the medical care for the troops closer to the battlefield, the French military abolished general hospitals and created new regimental hospitals. In 1788, new regulations were issued assigning control of all military hospitals to a new military medical directorate composed of military physicians. A new sanitary council was established to oversee disease prevention and hygiene in the armies. The tide of the French Revolution (1789–1799), however, swept away these untested organizational improvements.

The French medical system was similar to the British system in that the wounded were evacuated to hospital clearing stations located near the battle lines. Here the regimental surgeon attended the soldier. Major surgery was sometimes performed in these regimental hospitals, but for the most part they treated only the lightly wounded and prepared the more serious cases for shipment to the rear hospitals. If the patient survived the twenty- to forty-mile trip to the general hospital, he would undergo surgery there.
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The French had no systematic method for evacuating the wounded from the front lines. Either a fellow soldier brought his wounded comrade to the medical tent or the wounded soldier made his way to the rear as best he could. The most seriously wounded moved from the regimental hospitals along the roads leading to the base of communications in the rear. Transport was sometimes provided for the medical units, but usually they used the empty food carts and supply wagons that had previously delivered supplies to the front. The wagon drivers were not military personnel but hired contractors who often treated the wounded cruelly, charged them a fee, robbed them, and even abandoned them on the side of the road if the highway became too crowded. Usually medical personnel did not attend the wounded in transit. When medical personnel were available, their numbers were invariably small. The horrors associated with moving the wounded provided an additional stimulus to reform the medical treatment system and to give the field medical detachments their own wagons and the necessary personnel to oversee the transportation of the wounded.

Even with reform, the system remained fragile in times of high casualties. Military medical texts of the period note that it was not unusual for an army to suffer eight thousand wounded in a single day.
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Under these conditions, it was neither practical nor possible to assign field medical units the necessary personnel or transport to move sufficient numbers of wounded on any regular basis. Much as in modern wars, the medical services of the eighteenth century frequently became overloaded and broke down, with much attendant human suffering.

For all its problems, however, the French military medical service on the eve of the Revolution was seen as the model for other countries, and Austria, Prussia, Denmark, and Sweden all reorganized their military hospital systems on the French model.
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The social disruption of the French Revolution, however, dashed the old system. In 1792, the new French Republic declared war on Austria. Motivated by the Revolution's sense of national patriotism, fourteen hundred physicians and surgeons applied for service with the new French national army.
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In August 1793, the National Convention placed all physicians, surgeons, and apothecaries at the service of the Ministry of War. By the end of the year, 2,570 medical officers of various types attended to the needs of the revolutionary armies.
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Within a few months, their number grew to more than 4,000, and by the end of the war in 1794, 8,000 medical personnel of various types had seen service with the armies.
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The war and social revolution had near catastrophic effects on the educational and organizational structure of the French medical establishment. In 1792, the National Assembly voted to abolish the eighteen medical faculties and fifteen medical schools in France, including the older schools in Paris, Strasbourg, and Montpelier and the Académie Royale de Chirurgie and the Société Royale de Médicine. In 1794, the state ordered the creation of medical schools for the express purpose of providing sufficient medical personnel to the armies. These schools trained only military medical personnel. After the disruption of the medical establishment, however, the quality of training in these schools fell drastically. Worse, the practice of medicine was thrown open to anyone of any status and education who could afford to pay for a license. Although the number of military medical assets available to the armies increased, the quality declined drastically. The French persisted with this system of military medical training until Napoleon ended it in 1804 and completely reorganized the military medical establishment.

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.

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.
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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.
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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.
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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.
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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.
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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.”
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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.
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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.