It was Henry Middleton, President of the General Congress of Philadelphia, who once remarked, “Military men belong to a profession which may be useful, but is often dangerous.” As a masterpiece of understatement, that pretty well stands in a class by itself. For in the very nature of his calling the fighting-man is at far greater hazard of life and limb than the individual concerned with any other activity. It is truly enheartening, therefore, to have the assurance that the resources that must now be deployed to slay a single man in battle are about fifteen times as great as in the war of 1914-18, and a hundred times greater than at the time of the Boer War at the beginning of the century. That is the extraordinary but comforting paradox—that as the amount of assorted “iron-mongery” increases, so even more does the fighting-man’s chance of survival. (What it would be under the conditions of atomic warfare must, of course, remain a matter of speculation.)
This is a state of affairs that can be attributed to a higher standard of training, better battle-drill and discipline, to the tendency towards that wildly extravagant and ill-aimed expenditure of ammunition which has accompanied the introduction of automatic, quick-firing weapons, and, lastly, to an infinitely more knowledgeable and technically accomplished medical service than that which took the field even so recently as fifty years ago.
For many centuries the fighting-man, on sea and land, found a deadlier foe in disease than in the weapons wielded by the opponent with whom he actually strove in battle. The sick were far more numerous than the injured with the early tribal “hordes,” such as those led by Genghis Khan and Tamur- lane; and little provision was made for their care, admirably organized as these forces might be in every other particular. Pestilence was the predominant enemy; for the great epidemics of plague that swept the world in A.D. 80, A.D. 166, and A.D. 251—3 ravaged the nomadic warrior tribes as ruthlessly as they laid low the city-dwellers.
Where the great center of civilization was concerned, Pliny affirms that for the first six hundred years of its existence the Roman Empire somehow survived without the aid of any medical service whatsoever. And this despite the constant menace of the plague and the prevalence of a peculiarly malignant type of malaria. It was not until Greece became a Roman province in 146 B.C. that alien doctors and surgeons began to practice in the Eternal City. Once established, however, the military were amongst the first to avail themselves of their services; as were the naval authorities. The team of one surgeon and one medicus per major unit was supplemented by from six to eight deputati, or bearers, whose duty it was to seek out, remove, and tend the wounded. Provided with a horse equipped with a sidesaddle to transport the casualty, the deputati carried a water flask over the shoulder and were girded about the waist with a pouchful of bandages. The zeal of these bearers was further stimulated by the reward of a nomisma, or bezant (the equivalent, in contemporary spending value, of about $3.50), for every dangerously wounded warrior they contrived to escort safely from the field. Equivalent medical units were allotted to the quinqueremes, triremes, and lesser vessels that made up the Roman fleet.
But for all the ingenuity and resource of the Greek physicians and their Roman pupils, there was little they could do to counter a wave of pestilence, or even diminish the effects of the endemic malaria. So late as A.D. 410, Alaric the Goth’s capture of Rome followed a hold-up of two years, entirely attributable to the rampant sickness which had decimated the ranks of his followers.
Western Europe recovered but slowly from the great blight that had fallen on the world with the eclipse of Rome. Under the feudal organisation that eventually emerged, few arrangements were made for dealing with the sick and wounded en campaign. Truth to tell, until the arrival of the bow and the cloth-yard shaft, serious casualties among the heavily armoured knights were the exception rather than the rule. A live prisoner to be ransomed was far more valuable than a dead assailant whose only yield would be the armor in which he had fallen. As for the casualties suffered by the “rabble of foot,” these, while more numerous, evoked remarkably scant sympathy or attention. The total of the slain was recorded, and a certain number of barber-surgeons were available to minister to the wounded. For the most part, however, they were clumsy, ill-instructed practitioners whose attentions can have done little but add to their patients’ agony.
Scurvy1 made an early appearance during the Crusaders’ lengthy voyages from Western Europe to the Holy Land; plague was a pestilence that might strike at any moment, while dysentery was the common lot of the fighting-man in virtually all campaigns. It is questionable, for example, if England’s Black Prince would have stood to fight at Poitiers had not his half-starved bowmen been so debilitated by dysentery that further marching and counter-marching, to win a more favorable battle-position, was patently out of the question. Even as it was, the weakened archers staggered into action with the “points” that laced the hose to their trunks left conveniently unfastened. At the time there was but one medicus with the expeditionary force, and he was with the Prince’s personal retinue. By 1507, however, there was an allocation of fifty-seven surgeons to the force of between five and six thousand men ear-marked for the siege of St. Quentin. The normal distribution had become one chirurgeon to every hundred men; but it is clear that the medici were generally held in very poor esteem. In a contemporary list of persons subject to the jurisdiction of the Constable and the Marshal, they are entered after the barbers and just ahead of the washerwomen. Since many of them, even so late as the end of the 16th century, were apt to rely on such weird concoctions as the balm compounded of two whelps boiled alive and two pounds of earthworms purified in white wine, a certain want of faith in their ministrations is comprehensible. Up to the end of the 18th century, indeed, the physician enjoyed no greater standing than that of the colonel’s or ship-captain’s personal servant.
The invention of gunpowder and its application to military purposes posed problems for which neither contemporary medicine nor surgery were sufficiently far advanced to cope with anything like adequacy. The method recommended for dealing with gun-shot wounds, for example, was to cauterize them with boiling oil; a procedure which demanded a good deal of robustness to survive. Gangrene and septicemia were two complications consequent on gun-shot wounds that found contemporary medical skill virtually resourceless; while the heavy, solid quality of the missile employed—of an ounce weight and more— occasioned fractures necessitating amputation; an operation the patient was exceedingly lucky to emerge from with any chance of recovery.
Under the long-operative provisions of King Richard Lionheart’s “Rules of Oleron” —the seafaring man’s first charter—any shipman taken sick while in harbor was to be sent ashore, and lodgings, candles, and a grommet—or ship’s boy—provided for him at the master’s expense; the grommet being detailed to remain with the patient to act as nurse and general attendant. Sickness or injuries incurred at sea were treated, if at all, by the master or some fellow-member of the crew boasting some slight acquaintance with the apothecary’s art. In general, although every medicus was exhorted to be “honest, sober, and of good council, skilful in the science, able to heal all kinds of sores, wounds, and griefs, to take a pellet out of the flesh and bone, and to slake the fire of same,” in most instances it was a case of “by guess and by God” and plain “muddling through.”
In times of emergency throughout the long and harassed reign of Queen Elizabeth I, conscription was resorted to as a means of swelling the ranks of the City Trained Bands and County Militia. The barber- surgeon, however, was exempt from compulsory service as a “private centinal” in the ranks, although he could be drafted in his technical capacity as a medical man. This led some of the unwilling to elude their personal obligation by providing a substitute—and not necessarily a qualified medico at that. For the most part, however, the barber-surgeon called up for service strove his utmost to do the best for his charges. Moreover, his search after greater skill and knowledge was untiring. This was reflected in the appearance of such works on the technique of surgery and its after-care as Thomas Gale’s Treatise of Wounds with Gonneshot, of A.D. 1563, and William Clowes’ Proved Practice for all Young Chirurgeons, published in 1591. Another textbook for the contemporary “sawbones” was the Viaticum, or Surgeon's Mate, compiled in 1628 by John Woodall, chief surgeon of the East India Company and Senior Member of the Worshipful Company of Barber-Surgeons. This marked an advance, if only on a limited scale, on the treatise On Wounds of the Head, published in the fourth century B.C., and hitherto regarded as entirely authoritative and reliable.
Neither was expense spared to furnish the fighting-man’s medical attendants with the instruments and medicaments then in current use. At the outbreak of the Civil War between King and Parliament in 1642, for example, the Barber-Surgeons’ Company received his Majesty’s command to furnish his forces with surgeon’s chests, valued at £27,2 and a number of “magazines,” or store chests, at £48, “with contents sufficient for two hundred and fifty men under charge.” At the same time sixteen Members of the Company “most expedient at healing gunshotte wounds” were recruited for service with the army, at a daily wage of 2/7d.
The Parliamentary Army, with its better lined purse and superior organisation, boasted a Surgeon-General, two Physicians-General, and an Apothecary-General on the Staff of each of its three army corps; an “establishment” subsequently adopted with the first Standing Army of the Restoration. Rates of remuneration ran from the 10/s a day of the Physicians-General to the daily wage of 4/s for the regimental medicos.
On occasion, however, private practitioners were called in to supplement the work of the regimental surgeons, when they appear to have been remunerated at piece rates. A medico of the name of George Bygrave, whose statement of account has survived, charged 10/s for curing “a sore bruised leg,” £1 for dealing with “a cut over the eye and a sore thrust in the arm,” and no less than 30/s for attending a certain John Bullock, “who had a very sore cut in the forepart of his head, which caused a piece of his skull, the breadth of a half-crown piece, to be taken forth.”
In the main, Parliamentary plans for the sick and wounded tended to promise more than they could perform. At no time was this more grimly demonstrated than after Robert Blake’s fierce encounter with Tromp’s Hollander fleet off Portland, in 1653. Portsmouth was so crowded with wounded landed from the ships that the overflow had to be transferred to other towns, some of them as much as forty miles away; a terrible journey over the vile roads of the period, jolting along in a lumbering, springless country cart. Surgeons were hurried down from London to the aid of the over-worked medicos already on the spot; while the good offices of the local townsfolk were stimulated by the example and tireless energy of the devoted Elizabeth Aiken— “Parliament Joan,” as she was called—who did not hesitate to empty her own slender purse when the Government’s grant-in-aid had been exhausted.
Although ship-killing rather than mankilling had become the primary aim of naval battle-practice, casualties from cannon shot and small arms fire were still heavy. They were supplemented by the numerous injuries caused by flying splinters from the shattered woodwork. At the battle of Trafalgar, it will be recalled, Captain Thomas Master- man Hardy, walking at Nelson’s side on the quarter-deck, had the buckle torn from his shoe by a flying sliver of wood scooped out of the deck planking by an enemy musket ball. Furthermore, with ships’ diet lacking in sufficient anti-scorbutic elements, scurvy, like calenture, persisted as the inevitable accompaniment of any lengthy ocean-going voyage. Right back in Elizabethan days, Richard Hawkyns had affirmed that in twenty years’ seafaring he had seen no less than ten thousand men fall victim to this terrible scourge; and conditions showed virtually no improvement. In point of fact, contemporary medicine was endeavoring to tackle the problem from the wrong end, seeking rather a cure for the complaint than a means of preventing it. All sorts of remedies were tried, from “marmylade of carrots” and oil of vitriol to burying the sufferers in boxes of earth, stowed along the bulwarks; its being firmly believed that this process “provided the first of cures for scurvy.”
Where surgery was concerned, a great step forward had been achieved in 1674 by the French surgeon Morel’s invention of the tourniquet. But although by Marlborough’s day armies in the field were furnished with a reasonable quota of surgeons and physicians, and sutlers, camp followers and the lightly wounded could be pressed into service as stretcher bearers, the handling of casualties was based upon no real organisation. Moreover, the improvised field hospitals were overcrowded, insanitary, infection-spreading death traps, to which no man still in the possession of his senses would voluntarily resort.3 “Wise men took refuge in the virtues of cold water, and kept the surgeons at a safe distance,” according to the Honorable Sir John Fortescue in Volume I of his A History of the British Army. Since the conditions of service attracted few of the more accomplished practitioners, there was more than a little justification for the cynic’s dour comment, “Trust a doctor and he will kill you; mistrust him and he will insult you.”
This selfsame mistrust of the very men to whom the wounded should have looked for succour was just as strongly in evidence half a century and more after the Marlborough campaigns had been brought to a close; and was never made more sharply manifest than in the extraordinary case of the female Royal Marine, Hannah Snell. Struck down in the 1748 operations about Pondicherry, she successfuly eluded official ministrations and tended her own hurts—including a dangerous wound in the groin—-to such good purpose as eventually to report back fit for duty.
A similar lack of faith in their medical officers characterised the rank and file of the army that took the field under Frederick William of Prussia. Yet it was this monarch who had founded the Pépinière as a school of instruction specialising in military medicine and surgery.
With the British forces precariously sustained over three thousand miles of ocean, and with Congress so bedevilled by intrigue and mutual distrust as to have scant leisure to spare for the needs of the Army on which the fate of the neophyte Republic depended, it is small wonder that, on either side, arrangements for the care of the sick and wounded throughout the War of Independence left almost everything to be desired.
Since the Continental Army’s medical service had neither an existent organization nor long-established precedent upon which to build, improvisation was inevitably the keynote of its activities. And where human life is at stake improvisation is the father of more excuses than cures. Nowhere was this more tragically demonstrated than amidst the snow-laden poplars, white oaks, and chestnuts of Valley Forge. At the outset a reasonably healthy dietary was maintained, since “Mad Anthony” Wayne worked such miracles in rounding up carcass meat as to earn the honorable sobriquet of “Wayne the Drover.” But as the icy grip of winter tightened even “hog and hominy” failed. With no vegetables and a diet reduced to fire-cake and water, a little thin soup—“sickish enough to make a Hector spue,” as one veteran sourly commented—and an occasional loaf of rubbery rye bread that, when cut, was “tough enough to screech,” the standard of health fell off rapidly. The inevitable outcome was an outbreak of scurvy, dysentery, scabies, ulcerated stomachs, “bilious colics, a plague of boils, and putrid fevers,” which soon led to a sick list of 4,000 a month. The final blow came when an epidemic of small pox swept the camp—originally about 11,000 strong—leaving barely sufficient troops hale enough to mount the guard.
The hospitals improvised by Dr. Bodo Otto at Yellow Springs and Ephrata had speedily to be supplemented by additional sanatoria hastily prepared at Lititz, Trenton, Allentown, Trappa, Burlington, Princetown, and Reading; which in their turn soon became hopelessly overcrowded. Tetchy, opinionated Dr. Benjamin Rush and his successors had done all they could to deal with a situation which would have taxed even an experienced, full-fledged medical organization to the full. (Rush resigned his post as Surgeon-General on finding his advice consistently ignored.) But in the make-shift circumstances in which they found themselves it is little wonder that the endless tide of sick and suffering completely overwhelmed them. It says much for its tough fiber and native resilience that the Continental Army ever regained its pristine health and vigor.
The British, in possession of New York and, for a time, Philadelphia, had far better opportunity for organizing a satisfactory hospital service. The small advantage they took of it demonstrates only too clearly how trifling had been the advance made in the care of the soldier stricken by wounds or disease, since the days of Marlborough. Surgeons were still remunerated on the beggarly scale of 4/s a day, their Mates receiving 3/6d; while in times of stress any responsible noncommissioned officer, despite his entire lack of medical training, would be pressed into service to supplement the insufficient quota of “sawbones” assistants. Sergeant Lamb, of the 23rd Foot, records in his journal how he acted as “assistant surgeon” on many occasions during the course of the campaign. Anaesthetics being, of course, entirely unknown, the man to be operated upon would be half dazed by a swig of raw rum—or even tapped on the head with a mallet—held down on a carpenter’s bench or upended barn door, and given a leaden bullet on which to bite while the licenced butchery went grimly forward. Yet first class plastic surgery was already in operation, if only on a severely restricted scale. For so early as 1597 Gasper Taliacotius of Bosnia had successfully grafted supplementary noses cut from another, and less conspicuous, part of the body; and the principles of rhinoplasty had been established in Sicily at even an earlier date. Rhinoplasty had been practiced even earlier in India, where amputation of the nose was commonly decreed as a punishment for adultery and certain other offenses. But such esoteric techniques were far beyond the range of the ordinary naval or military surgeon, who did his gory best at pretty heavy cost in life and limb.
Even so, disease exacted a far heavier toll than bullets and cold steel. In the Seven Years’ War, for example, some 15,000 men were killed in action as against 134,000 who had died from various ailments; and the proportion remained much the same, on both sides, in the War of Independence. Even under conditions of peace, to be posted to one of the tropical stations, such as Jamaica, was virtually to be sentenced to death, so malignant were the fevers awaiting the newcomer. Service in India was almost as deadly; a memorial at Hyderabad recording that in seventeen years the 45th Foot lost 22 Officers, 70 Sergeants, 44 Corporals, 17 drummer boys, 995 privates, 103 European women and 187 children. Tropical disease appeared to have the medical fraternity completely baffled. The 18th century treatment for cholera, as recorded in the Memoirs of a Saddler-Serjeant, edited by Fortescue, was to half-roast the patient on a rack over a spirit stove—“to bring out the perspiration”—while such nursing as was authorized was mostly done by the rough, goodhearted but boozy and entirely uninstructed women “married on the strength.” The unhappy state of affairs prevailing with the land forces was more than matched afloat. Tobias Smollett, with no greater qualification than had been afforded by a period of instruction as an apothecary’s apprentice and a few months’ service afloat as a lob-lolly man, or sick-berth steward, obtained a Warrant as a full-blown Assistant Surgeon. In this capacity he accompanied Admiral Vernon’s fleet for the disastrous assault on Cartagena; and his letters, like his subsequent novel, Roderick Random, give an unforgetable picture of the squalor, ignorance, and sheer brutality prevailing in the contemporary Royal Navy when it came to dealing with the sick and injured. Of the type of boorish, ill-instructed surgeon to be found aboard His Majesty’s ships at this period, tough old Admiral John Jervis, Earl of St. Vincent, caustically remarked, “The moment they obtain a diploma they think themselves above the most ordinary and most useful part of their duty, . . . and make up their journals from Cullen and other medical authors, which gives them a reputation with the Board [of Admiralty] without the smallest title to it.” Ned Ward, in the scorching study of 18th century naval types he published under the title of The Wooden World, wrote of the Ship’s Surgeon, “As for his performance on arms and legs, he does it after a way, ’tis true; but, betwixt you and me, the slaughter-house on Tower Hill would scarce grant him there journeyman’s wages. The poorest patients,” he goes on, “are sure to fare best where he is, because he leaves them to Nature, the less dangerous doctor of the two.” The evidence of the poet Shelley’s friend, Trelawny of the Superbe, supports the contention that the insides of 18th and early 19th century battleships were painted red so that the blood would not show up too conspicuously.
It should be borne in mind, however, that men are conditioned by the age in which they live; that what would be regarded as unspeakable barbarities by the present generation found stoical acceptance by those bred in less exigent times. Neither is the picture of those far-off days unrelievedly sombre. For we have it on the word of no less an authority than John Masefield that in a “happy ship,” under a kindly and conscientious captain, “the sick and wounded were treated with comparative humanity.” They were indulged with hair mattresses, sheets of real linen, nightcaps, and special dishes of “sowens” and “flummery”; with a glass of port from “the owner’s” private store “to help build up the blood.” Moreover, a real effort was made to keep their sick quarters sweet and clean. Either a mixture of vinegar and brimstone was sprinkled on bucketsful of red embers, or a compound of sulphuric acid and powder of nitre was poured on heated sand; while in fair weather sails and canvas ventilators brought a welcome current of fresh air even into the most malodorous corner.
These measures were adopted far more often than is generally supposed; for not all captains were of the harsh, inconsiderate temper of Bligh of the Bounty or Pigot of the Hermione, who provoked the crew to a mutiny of such seriousness that it cost him his life.
The after-care of the injured and totally incapacitated was a responsibility the authorities, over a very long period, resolutely shirked. It was not until 1514 that the Guild and Fraternity that came to be known as Trinity House, erected a number of almshouses for the use of “decrepit shipmasters and mariners.” Seventy years later John Hawkyns and Francis Drake founded the benevolent fund known as the Chatham Chest. To this “mutual benefit” organization the serving A.B. subscribed 6d a month, the Ordinary Seaman 4d, and the grommet a modest 2d. Successive monarchs endowed the fund with the revenues from a number of properties, which were amplified by the fines imposed for certain breaches of maritime law. Greenwich Palace was turned over as a hospital for the exclusive use of the seafarer in 1692, ten years after Louis XIVth had founded the Hotel des Invalides for “those broken in the wars.” Greenwich was largely supported by the Sixpenny Chest, to which all serving mariners contributed their monthly “tanners”; the sum thus raised being supplemented by grants from the Royal Revenues.
It was not until 1770 that the idea of bringing medical aid right up to the casualty instead of condemning the sufferer to jolt over long distances in search of succour, was first given practical expression. In that year Pierre Francois, Baron de Percy, organized a mobile Surgical Corps for service with the French Army. It was a unit that worked in closest possible proximity to the battle-line, and even the bearers had a good working knowledge of first aid. Yet the first decade of the twenty years’ struggle between a French nation in arms and the other Continental Powers was marked, on both sides, by medical transport arrangements that left almost everything to chance. If public opinion was a trifle less prepared to accept such callousness and disregard, it was some time before the military outlook caught up with it. Napoleon had scant interest in any man who was not fit enough to march and fight. The Prussian Ober-Kriegs Kollegitim, which included a department especially designed to deal with the sick and wounded, had only been formed in 1787, and had scarcely got into its stride. In England, such was the maze of overlapping and mutually distrustful departments, civil and military, that were concerned with the activities of the Medical Board, that confusion, incompetence, and neglect became the hallmark by which it was known. One occasion saw supplies of rice, sago, and opium, desperately wanted in the Iberian Peninsula, despatched at great expense to Ceylon, whence they had just been imported. At the time of the ill-fated Walcheren expedition of 1809, it was discovered that three of the Surgeons appointed to accompany the enterprise had never even left the country. They were still cooling their heels—and drawing their pay—at the port of embarkation!
Among the medical officers who did go to Walcheren was a certain James McGrigor; and with the Peninsular campaign well under way he was speedily singled out by Wellington for the post of Principal Medical Officer. Keenly alive to the abuses that flourished in the ill-run, disorderly base hospitals near Lisbon, McGrigor persuaded the General Officer Commanding in great measure to supersede them by establishing regimental hospitals close up to the front. The base hospital at Belem was by far the worst; and its mob of undisciplined convalescents—known as the “Belem Rangers” —were a byword for disorderly conduct. It was a system whose value and economy the Scot had already put to the test in Egypt, and the success of the scheme in this new territory was immediate. For the regimental doctors, having at last achieved the status and powers of Commissioned Officers, were proud of their respective corps, deeply concerned for the welfare of their men, and only too anxious to keep the ranks up to strength. To this end they labored with tireless ardor not only to restore their patients’ health, but to send them back to the front as disciplined soldiers. Possessed of a remarkably shrewd eye for a malingerer, only those in genuine need of their services were accorded them; but when legitimately required they were given unreservedly and without stint.
When operations reached the thinly populated districts of the north of Spain, it seemed that McGrigor’s admirable organizations must break down for sheer want of suitable buildings. But the Scot was a man of resource, and, backed up stoutly by Wellington, he procured portable wooden structures from England, which could be fitted together in a couple of days. Thus the regimental hospitals remained well up with the troops till the campaign ended on the far side of the Pyrenees. Save for one terrible outbreak of typhus during the winter of 1810, which prostrated 70,000 of Wellington’s troops and left less than 23,000 fit for duty, McGrigor’s medical organization may fairly be said to have maintained a better standard of health than any previously known. And this despite a difficult climate, much rough bivouacking, and the temptation to excessive drinking offered by winegrowing countries wherein liquor was well within the reach even of the private soldier’s meager purse.
Where the contemporary sea-service was concerned, the recommendations of Dr. James Lind, Sir Gilbert Blane, and Dr. Blair, which made the issue of lime juice at the end of the sixth week of the voyage a sine qua non, had tackled the menace of scurvy the right way by concentrating rather on its prevention than on its cure. The outcome told its own highly satisfactory story; for whereas in 1760 one thousand, seven hundred and sixteen of Haslar Hospital’s two thousand, one hundred beds had been occupied by victims of scurvy, by 1806 there was not a single inmate suffering from this particular complaint.
Almost as prevalent and even more deadly than scurvy was “Yellow Jack,” the swift, virulent fever that struck at soldiers and sailors alike; although the cramped, insanitary conditions on shipboard conspired to render the mariners particularly susceptible to its onset.
Drake’s capture of Cartagena in 1586 was robbed of the full harvest of victory by the toll taken of the troops and sailors by the “seamen’s scourage.” “Yellow Jack,” as much as the irreconcilable differences between the naval and military commanders, accounted for Vernon’s disastrous failure before the same stronghold; a setback which “strewed the sea with English corpses”—including those of the Virginia and Massachusetts volunteers especially recruited for the enterprise by Lawrence Washington.
“Yellow Jack” made its sinister appearance in the American vessels blockading Yorktown, although the cause of independence was fortunate in the fact that the scourge failed to strike until after the surrender of the British forces under Cornwallis.
Even the inland metropolis of Philadelphia was not immune from the ravages of the deadly fever. For in 1793 the Congress was forced to flee the city—where it had been in session—leaving a shaken population to battle with an epidemic which eventually robbed it of one-eighth of its numbers.
The West Indians were always a festering hotbed of the ravening affliction; and in 1764 the garrison of St. Lucia lost 1,411 redcoats out of a muster roll totalling 1,500. Even so late as the mid-nineteenth century the newly-arrived officers would be met by a lugubrious individual, garbed in sombre black and carrying a seven-foot wand. Upon inquiry he was revealed as the local undertaker, who had taken the precaution to come down to the quayside privily to “measure up” the new arrival for the coffin of which, sooner or later, he would indubitably stand in need!
“Yellow Jack” intervened to scrawl his grim signature on the tally of events in the War between the States, both the Mississippi Squadron and the flotilla in the Gulf suffering such casualties as very nearly to put them out of business. Time and time again the ships’ crews were so reduced by the pestilence as to be unable to continue at sea.
Had it not been for “Yellow Jack” there well might have been no Louisiana Purchase, but, instead, the appearance on American soil of a French Army bent on conquest. For in San’ Domingo in 1802, a Gallic Force under General Charles Victor Emmanuel Leclerc—Napoleon’s brother-in-law and erstwhile Adjutant—was still fresh and invigorated by the recent victory over that sawdust dictator-of-a-day, Toussaint l’Overture. In the roads lay a squadron commanded by the enterprising Kerverseaux; all was ready for one of those brisk swoops for which the little Corsican’s soldiery were so admirably trained.
It was then that the fever struck—with sudden violence and a devastating effect only possible with the most pervasive of all tropical epidemics. As he witnessed his proud army swiftly and irretrievably disintegrate, Leclerc himself fell victim to the everpresent scourge; and with his death expired the last hope of Gallic conquest in the West.
It calls for little imagination to envisage what might have been the alternative, had “Yellow Jack” not proved the ally of the American people in one of the gravest hours of peril with which they have ever been confronted.
In later days the strategy of the Spanish- American War was at the mercy of a fever that had long been endemic to the scene of operations, for the death-rate in Havana was known to average 750 a year. With the landing of the troops the prophet’s grim forebodings were more than justified, for at the outset of the campaign deaths from the raging pestilence soon amounted to 200 a day. Yet it was the devoted work of the medicos in the Spanish-American conflict, together with that of their colleagues of the Panama zone, which eventually brought enlightenment as to the causes of the disease; the first step toward discovering those means for its prevention, which, in these days, ensure a degree of immunization that sets the pestilence confidently at defiance.
Not the least tragic thing about war is that its lessons are so swiftly and comprehensively forgotten. In that regrettable fact may be found the explanation for the deplorable lack of preparation characterizing the medical services at the outbreak of hostilities in the Crimea in 1854. It has also to be borne in mind that at this period, as the eminent surgeon and laryngologist, R. Scott Stevenson, has pointed out, “surgery was still in its infancy, not much advanced in essentials since the days of the Romans.” In the outcome, such crude hospital services as existed were completely swamped by the ever-flowing tide of the sick. For the influx of the victims of cholera, dysentery, typhoid, diarrhea, and scurvy—and later, frostbite—overflowed the four miles of beds in the hastily knocked-together General Hospital at Scutari, on the shores of the Bosphorus; where the sick and wounded were jumbled together higgledy-piggledy in the same wards, with the inevitable consequences.
When in response to public outcry Florence Nightingale was allowed to organize her own hospital, the mortality rate had risen to forty-two per cent. The festering old Selemiah Kishar barracks, turned into a temporary sanatorium, was a veritable sink of disease, iniquity, and corruption. For in its basement dwelt the horde of soldiers’ wives and prostitutes who had taken up unauthorized residence in such odd corners as they could find. Gin, arrack and other poisonous spirits circulated freely, if illegally; and women, children, and furtive convalescents huddled together in conditions of unbelievable squalor and depravity. “I have seen,” recorded one observer, “the bodies of the dead, stores for the living, munitions of war, sick men staggering from weakness, wounded men helpless on stretchers, and invalid orderlies” all jumbled together in this rat-infested warren, wallowing in their own filth.
With the numerically stronger French Expeditionary Force, Gallic losses were proportionately heavier. For despite the fact that their hospital arrangements were well organized and admirably run, their innate disregard of sanitary precautions rendered them peculiarly susceptible to disease, and to typhoid fever in particular. In all, disease accounted for the death of approximately 21,000 officers and men; over 4,000 of whom perished during the actual evacuation of the Crimea. Broadly speaking, the casualties from enemy action—killed and died of wounds—came to less than twenty- five per cent of those inactivated, for the Allies as a whole. By way of example, the day before the Balaclava fight there were 35,000 officers and men shown as on the rolls, but not more than 16,000 were fit for duty. The Light Brigade at the time of its famous charge barely mustered the strength of a regiment.
With the minuscule Standing Army in existence at the outbreak of hostilities, medical arrangements throughout the War Between the States had very largely to be improvised. It followed that the opening of the campaign witnessed the traditional story, the usual display of ignorance, confusion, and neglect; with the sick—including many victims of smallpox—largely preponderant, as usual, over battle casualties.
The Army’s Surgeon-General, handsome, white-haired Clement A. Finley, was a man of admirable intentions and inexhaustible courtesy. But the task with which he found himself confronted was quite beyond his somewhat fossilized powers. The makeshift arrangements to which he was speedily driven bore the unmistakable hallmark of timidity in planning and reprehensible lack of foresight. In the absence of any Army General Hospital, the sick and wounded were bundled indiscriminately into hotels, warehouses, schools, and private houses, where they lay at the mercy of the green- sashed “contract surgeons,” many of whom were far from competent in their art.
It was not until the Unitarian minister, Dr. Henry Bellows, succeeded in forming the Sanitary Commission that order and efficiency began to get the better of muddle and incompetence. With the organizational genius of its general secretary, Frederick Law Olmstead, to “ride in the whirlwind and direct the storm,” the Commission soon had its own clean, well-run infirmaries, hospital ships properly equipped and staffed, suitable ambulance transport, and depots of medical stores at all nodal points. In remarkably short order, there was not a battlefield whereon the Sanitary Commission was not busy about its work of succor and relief.
Neither was Washington without its Florence Nightingale; although which of the three most prominent claimants to the title best qualified for it, it would be difficult to say. Perhaps the award was best merited by the shy, prim but indomitable Clara Barton. In her plain black print skirt and jacket, this forty-year-old ex-clerk from the Patent Office took her wagon of comforts and medical stores wherever the fight was fiercest; actually coming under fire and having a piece of her skirt shot away as she resolutely pressed forward across the swaying pontoon bridge at Fredericksburg. But if Clara Barton’s activities were the more spectacular, the solid, self-sacrificing work done in the hospitals by the life-long humanitarian, Dorothy L. Dix, and the big, bouncing, good-hearted Louisa M. Alcott, was of equally sterling value. The hour of crisis has never found the American woman wanting in the old courageous spirit of the frontier.
In early 1862 the bewildered—but still courteous—Finley was replaced as Surgeon- General by Dr. William Alexander Hammond; and one of his first acts was to appoint as the new medical superintendent of the Army of the Potomac a certain Jonathan Letterman. A small, slight, taciturn individual, Dr. Letterman subjected the service of the sick and wounded to thorough overhaul; and by the following summer his reforms had proved so effective that they were adopted throughout the whole of the armies of the Union. Yet in spite of increased skill and better organization, for every man slain in battle two died of disease.
The Confederate armies were handicapped, almost from the outset, by a want of resources which became progressively more acute. There was an abiding shortage of skilled medicos and trained nurses; and as the stranglehold of the Federal blockade tightened its grip, it became increasingly difficult to export the goods to pay for the desperately needed supplies that the blockade- runners and smugglers sought with desperate courage to import. As Mahan has aptly pointed out, “War is business, to which actual fighting is incidental”; and the Confederates were never in a position properly to run their “business.”
One outcome of the War between the States was that Letterman’s field medical organization became the model on which the Prussians patterned their own medical corps for the war of 1870-71; a conflict in which the disparity between battle casualties and the victims of disease was considerably less disproportionate. But disease was again well in the ascendant throughout the Boer War of 1899-1902, when there were fifteen casualties from enteric or some other clinical malady, to one in battle. A similar imbalance between those stricken down in action and those incapacitated by disease characterized the Spanish-American War of 1898, and particularly the effluent operations in the Philippines in the year following. During the second phase of the latter campaign, for example, General MacArthur’s move on the Pampanga River was inaugurated on April 2nd by a force of 6,000 of all ranks. By mid- May this total had been halved, the casualties being mostly attributable to endemic fevers and the exhaustion consequent on “bushwhacking” in country peculiarly unsuited to anything but guerrila warfare, conducted by partisans thoroughly acclimatized to local conditions.
In the Balkan War of 1912-13 disease and neglected wounds vied with each other to take the greater toll of the unfortunate Turkish fightingman. Under the corrupt and inefficient Sultanate, medical arrangements for the handling of the sick and injured were little more than a tragic farce. Barely twenty per cent of the wounded ever got back to the base hospitals; the remainder perished from exposure and neglect. Then cholera struck the survivors of the Turkish retreat from Lule Burgas; and with men who had been existing for ten days on raw mealie cobs and anything they could pick up in the bare countryside, the ravages of the epidemic were swift and deadly. It can have been of small consolation to these wretched victims of neglect to learn that their enemies had been smitten with almost equal violence with the triple scourges of cholera, dysentery, and enteric, as with the hunger typhus that was common to both sides.
As the result of many years of unremitting research and experiment, the first German War saw the ratio of sickness to battle casualties fall from fifteen-to-one to two-to-one. The incident of the deadly typhoid fever declined even more—from 275 per thousand to a mere five per thousand, a truly remarkable diminution. Malaria persisted, however, as one of the prime sources of wastage; and there was a punishing outbreak of dysentery in Mesopotamia which went far to account for the lack of progress that marked the outset of the campaign. Where gun-shot wounds were concerned, the improvements made in anaesthetics since their introduction back in the 18th century, together with the progress achieved in the practice of Lister’s principles of antiseptic surgery, added enormously to the casualty’s chances of recovery. Nothing was thought of patching up one young officer shot through that particular region of the heart which can be penetrated without vital damage being done; and he lived on, hale and hearty, to do most valuable work in the more recent conflict. The writer can vouch for this, as the officer in question was a personal friend.
In the twenty years between the two major wars neither surgery nor medicine stood still. It was realized that any world conflict which involved hastily mustered “national” armies more than ever unconditioned to Service life, would inevitably give rise to problems normally unencountered with forces exclusively composed of long- service personnel. And so it proved; for whereas ulceration of the stomach accounted for the discharge of no more than 709 recruits in the first eighteen months of the earlier war, between the September of 1939 and the end of 1941 the British Services lost no less than 23,574 of their personnel from this same cause. On the other hand, the toll exacted by those maladies peculiar to active service—malaria, dysentery, yellow fever, typhoid, and other definitely tropical diseases—was astonishingly diminished. Research in parasitology and microbiology had produced a synthesis of drugs especially designed to perform some specific task. The synthetic Mepacrin and Paludrin proved far superior to the “Jesuit bark” (quinine) as suppressive agents for malaria; while sulfa- guanidine reduced the mortality from dysentery from 5.30 to 0.05. Even the death rate from cerebro-spinal fever was brought down from 72 to 20 per cent. Conversely, the psychiatrics formed from one third to one half of all those demanding medical attention—a lurid reflection on the appalling lack of fibre begotten of our hectic, neurotic, nerve- jangled twentieth-century civilization.
On the surgical side, the swift removal of the wounded by air ambulance or helicopter, or, where amphibious operations were in question, by LST’s and other landing craft, delivered the seriously wounded to the surgical teams awaiting them with the minimum of delay. This speed-up in the treatment of the injured, together with the use of blood plasma, penicillin, and the like, so tremendously enhanced the chances of recovery that 12j is recorded as the percentage of the wounded requiring exceptional and continued surgical treatment. This is indeed a very long remove from the state of affairs prevailing even a hundred years ago.
The fighting-man is not only entitled to a worthwhile cause and a well-founded plan, but to the confident knowledge that succor for his hurts will be speedily available and thoroughly competent. It can scarcely be in question that psychologically the first need is to render as immediate aid to the wounded as is humanly possible. And this, during a period of battle-fighting, even at the risk of categorizing a certain proportion of the medical service as potentially “expendable.” “Help given quickly is of double value”; and if a man under fire is confident that, in the event of his falling, his hurts will be accorded almost immediate attention, his morale will be correspondingly reinforced, and he will go forward in good heart.
Once stricken down, a man’s most urgent desire is to get away from it all—to the sanctuary of hospital ship or remote field ambulance. For the moment he has fought his fight; and he should be given the speediest attention and thereafter removed from the scene of action as swiftly as possible—if only that he may live to fight again another day.
Few men going into action consciously recall the old soldier’s grim dictum, “Somewhere there’s a bullet with your name engraved on it.” In the main, dread of extinction is far less acute than the fear of mutilation—the thought of a wound that will cause facial disfigurement or sexual impotence. But the greatest fear of all is the dread of being overlooked and abandoned. There is no more terrifying loneliness in this world than that of the stricken man left behind as the flurry of the fight moves forward; with the thirst that is unquenchable tearing at his throat, a prayer on his lips, . . . and hope fast fading in his heart. His is the agony that can only be assuaged by skilled aid, that comes swiftly to his succor. “Hope is brightest when it dawns from fears.”
1. In a mild form scurvy was endemic to all the populations of Western Europe. This was owing to the fact that, with no root crops, only a tithe of the cattle could be carried through the winter. A heavy killing of carcass meat in the autumn yielded the salted and pickled viands for consumption throughout the winter and spring. This dietary, not being balanced by anti-scorbutics in the way of vegetables or fresh fruit, led to an annual “Spring scurvy,” from which everyone suffered to a greater or lesser degree.
2. To obtain some idea of the contemporary spending value of money, in all instances multiply by five.
3. Losses were heavy in the Marlborough campaigns. At the assault on the Schellenburg the Allies’ armies had six Lieutenant-Generals killed and five wounded; the 1,500 British casualties including four Major-Generals and 28 Brigadiers or Lieutenant-Colonels.