Between Flesh and Steel (28 page)

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.
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Prior to the Battle of Vitoria in 1813, McGrigor was able to return almost a full division of men to combat duty.
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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 line.
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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.
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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.

The Battle of Waterloo was fought on June 15, 1815. It lasted nine hours and ranged over five square miles of ground. Napoleon's army numbered 70,000 men and the allied armies under Wellington, 60,000. When the battle was over, Napoleon's force suffered 25,000 dead and 8,000 taken prisoner. The British and Hanoverian elements of Wellington's army had lost 10,700 men killed and another 7,000 wounded.
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The Prussians lost 7,000 soldiers killed and another 7,000 wounded.
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Within an area slightly larger than New York's Central Park, 56,700 casualties lay strewn across the blood-soaked ground.
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The French casualties continued to lie unattended for days, their medical service having been destroyed or disorganized in the battle. The British system was almost nonexistent, and as late as eleven days after the battle, British and French casualties were still awaiting treatment. The failure of the allied armies to prepare adequate general hospitals in Brussels and to provide transportation for the wounded meant that even when the wounded reached the rear hospitals, little medical treatment was available. Waterloo was a military medical disaster of enormous proportions.

Having dismantled their medical service a year earlier, the British were caught without any meaningful medical support at all. In theory, each battalion of six hundred men was authorized only one surgeon and two assistants. In reality, of the forty British battalions at Waterloo, only twenty-two had their full complement of medical personnel. One unit, the Twenty-Eighth Foot, suffered 50 percent casualties and had only one assistant surgeon to treat them.
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Few of these newly appointed surgical assistants, however, had any medical training. Without a corps of litter bearers, it was not uncommon for several men to help a wounded comrade to the medical tent and then refrain from returning to the battle. Wellington noted that 1,875 men were unaccounted for after the battle. They were later found to have helped their comrades to the medical tents and remained there until the battle ended.
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No provisions were made for wagons to serve as ambulances. Wellington had moved so fast to Waterloo that much of his wagon train, including the few medical assets available,
were still miles away when the battle began. What few carts and wagons that the medical service could scavenge were useless as the roads to Brussels were choked with the soldiers and wagons of Wellington's army as it withdrew. The general hospitals deep in the rear had only fifty-two surgeons and physicians to staff them. Under these conditions, the hospitals at Ostend, Brussels, Anvers, Ghent, and Bruges were useless.
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With its regimental hospitals designed to handle merely sixty casualties, the British medical service was quickly overwhelmed and collapsed. Only 273 medical officers were at Waterloo to serve the entire army, and at least a third of them had neither medical training nor combat experience.
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Thus the quality of medical care, especially surgery, left much to be desired. Amputations were frequent, with a mortality rate approaching 40 percent. The surgeon usually operated in the open, often on the ground, and without assistance. Even the general hospitals did not have operating rooms, and surgery was performed on makeshift tables. Unlike Larrey's system, the British had no triage system, and the wounded often waited their turn in line regardless of the severity of their injuries. The largely untrained personnel of the medical service had little experience with ligature and the other means of hemostasis, and their delay in reaching the wounded proved fatal in thousands of cases. Bleeding the patient was still a common practice, and one can only guess how many wounded soldiers lost their otherwise salvageable lives because of it.

The one bright spot was English surgeon George James Guthrie, who accompanied Wellington on all his campaigns and was called “the English Larrey.” Guthrie's experience with military surgery convinced him that Larrey was correct in his advocacy of primary amputation. In 1827, Guthrie published his
Treatise on Gunshot Wounds: Inflammation, Erysipelas, and Mortification, on Injuries of Nerves
, which established the doctrine of primary amputation in England and became the basic manual of British and U.S. military surgery until the Crimean War.
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McGrigor, who had been appointed director general of the Medical Department prior to Waterloo, held the post until the Crimean War. The medical disaster at Waterloo led him to attempt reform, but once again the government demobilized the army and drastically reduced funds for support its medical services. Curiously, Wellington did little to reverse this state of affairs. McGrigor tried to raise entrance standards for the medical service, purchased textbooks, began a medical library, and finally established an army medical school at Fort Pitt, England. Together with army doctor Henry Marshall (1775–1851), McGrigor attempted to institutionalize the
practice of regular medical reports on the health status of the army, but this reform came to fruition only after the Crimean War had proven yet another medical disaster for the British. With the French medical service destroyed after Napoleon's defeat and the British unwilling to learn from their experiences in the Peninsula and at Waterloo, the stage was set for yet another medical catastrophe when both countries once again stumbled into war.

The Crimean War represented one of the great medical disasters of all time. Every major combatant entered the war with either an obsolete military medical system or, as in the Turkish Army's case, no military medical system at all. A war in which only four major offensive ground engagements were fought, the Crimean conflict was characterized by continuous artillery bombardments and the terrible living conditions associated with long sieges and trench warfare that contributed to incredibly high rates of disease. The war saw the first use of the new conoidal bullet that Capt. Claude-Etienne Minié (1804–1879) developed. Along with the introduction of the rifled musket barrel that the Russian Army used extensively, this new ammunition increased the infantry's range and killing power by a factor of seven.
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The new weapon produced battle wounds that were as much as thirty times larger than the size of the residual track of the penetrating projectile because the soft lead bullet broke apart upon impact. The improved rifle's killing and wounding power was demonstrated in November 1854 at the Battle of Inkermann, where it caused 91 percent of the British casualties.
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While Russian and French forces used the new rifle, British forces remained armed with the Brown Bess smoothbore, muzzle-loading musket that fired round lead balls with a range of only 120 yards.

The medical statistics of the war were tragic. The French contingent numbered 309,268 men but only 500 medical officers. British forces comprised 97,864 troops with 448 medical officers, and the Sardinian contingent fielded 21,000 men with 88 surgeons. Despite the generally backward state of Russian military medicine at this time, the Russian Army deployed the largest military medical contingent with 1,608 medical officers and 3,759 feldshers for a force of 324,478 men. Turkish forces numbered 35,000 men but had no military medical support at all.
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The casualty rate from wounds and disease, when taken as a percentage of the forces deployed, was among the highest in history. For the Russians, of the 92,381 wounded, 14,671 men died; of the 332,097 sick, 37,454 succumbed to their illnesses; and 21,000 were
killed in action.
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The French Army lost 8,250 men to hostile fire, 39,868 wounded, 4,354 died of wounds, 196,430 sick, and 59,815 dead from disease. The British suffered 2,255 killed in action, 18,183 wounded, 1,847 died of wounds, 144,390 sick, and 17,225 dead from disease.
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The Crimean War saw the highest battle losses per 1,000 men per annum (Russians) and the highest disease loss rate per 1,000 men per annum (French) than any previous war in recorded history.

Disease and infected wounds were the two largest causes of death among the armies. The germ theory of infection was still unknown, and the poor sanitary conditions in the few available military hospitals produced extremely high rates of wound infection and death. Among the British wounded in the Scutari hospital in Istanbul, for example, the mortality rate for amputees averaged nearly 30 percent.
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Of every 100 men admitted to military hospitals among the French forces, 42 percent died, or a hospital mortality rate equivalent to that of the Middle Ages.
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The disease rate per 1,000 men per annum was 253.5 for the French, 161.3 for the British, and 119.3 for the Russians. This proportion compares to a similar rate of 110 per 1,000 men in the Mexican War, 65 for the Civil War, and 16 in World War I.
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Florence Nightingale (1820–1910) and her trained nurses arrived in November 1854 after the Battle of Balaklava, and they introduced basic standards of hygiene and sanitation in the British military hospitals. Nightingale reported a hospital mortality rate at Scutari of 41 percent. As a result of her efforts, the rate dropped to 2 percent by the end of the war.
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She is often credited with starting the first female nursing corps in the Western armies. In fact, the credit for this innovation belongs properly to the Russians. The Russian grand duchess Elena Pavlovna (1807–1873) urged the czar to send trained female nurses to the Crimea so they could assist Nikolai Ivanovich Pirogov (1810–1881), Russia's great surgeon general. A large nursing corps was deployed in Russian military hospitals almost a year before Nightingale and her nurses arrived in British military hospitals.
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That the Russian Army suffered fewer losses to disease and infection than the French did may be attributed, to some extent, to the former's introduction of basic hygiene and sanitary conditions in its military hospitals earlier than the French did.

The start of the Crimean War found the British medical structure essentially as it had been in 1815.
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Despite McGrigor's best efforts to institutionalize his reforms, the medical service had been allowed to deteriorate after Waterloo. No fewer than
seven independent governmental authorities had some responsibility for operating the British medical service. The two major authorities were the Army Medical Department, then headed by a senior physician with no military experience, and the Ordnance Department, presided over by an appointed nobleman. They did not include any purveyors to purchase supplies or any apothecaries in the system at all; indeed, these positions had gone unfilled since 1830.
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The medical service had only twenty-six clerks housed in a small London office to manage the entire medical department.
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The British military medical service had sunk to such a low position that the only medical regulations governing its operations consisted of a small pamphlet drawn up years before that outlined the rules for managing a thirty-bed hospital in peacetime. In addition, the army lacked any standard sanitary regulations.
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Less than a year before the outbreak of war, the British made minor reforms in the administrative system and placed authority for the military medical service under a single administrative office, but this move produced no significant change in medical capabilities.