Medicine in Warfare in the Nineteenth Century
Medicine in Warfare in the Nineteenth Century
It is often said that war is the best medical school. The battlefields supplied young, often inexperienced surgeons with what seemed to be an unlimited number of cases. Military physicians were called on to deal with endless cases of camp fevers and dysenteries. Although some of the conditions encountered by military surgeons and physicians are peculiar to warfare, many of the lessons they learned and the training they obtained in military service were later applied to civilian life. Military medicine underwent many changes and reforms of techniques, organization, and personnel during the nineteenth century in response to experiences gained in the numerous wars fought in Europe and America.
Napoleon's favorite surgeon, Dominique-Jean Larrey (1766-1842), provides a good example of the advances achieved in military medicine and surgery. Baron Larrey, a French military surgeon, is primarily remembered for introducing the ambulances volantes in 1793. The moving ambulance made possible the rapid removal of the injured from the battlefield, while there was still hope of saving their lives. More importantly, however, Larrey was the founder a new era in military surgery. A strong, skillful, and daring surgeon, he was the first surgeon to amputate through the hip joint. He was also willing to cut into the pericardium (the membrane surrounding the heart) to remove fluid and pus from the pericardial cavity. Although the process known as débridement (the complete removal of dead or dying tissue and contaminants from a wound) had been recognized as early as the sixteenth century, it was generally ignored until Larrey's teacher Pierre Joseph Desault (1738-1795) realized its importance. During the Napoleonic Wars, Larrey insisted on rigorous attention to this procedure. Another method that Larrey used for cleaning wounds is known as maggot therapy. This technique was as effective as it was repulsive. Impressed by the cleanliness of wounds infested with maggots, Larrey realized that maggots improved wound healing by removing dead tissues. The intrepid Larrey traveled with Napoleon's army through Germany, Austria, Spain, and Russia. As a token of his respect and affection, Napoleon left his favorite surgeon 100,000 francs in his will.
Several simple, practical additions to the articles available to doctors were introduced by Johannes Freidrich August von Esmarch (1823-1908), a German military surgeon. In 1869 Esmarch devised the first "field dressing." Esmarch insisted that all soldiers should carry a first-aid kit and that each man should be taught how to use it. He also devised a rubber bandage (1873), now known as Esmarch's bandage, which is used to render a limb bloodless before amputation. The bandage is wrapped tightly around a limb to force the blood out so that operations can be carried out with relatively little loss of blood. During the Franco-Prussian War in 1870, Esmarch served as surgeon-general of the Prussian forces.
Another innovation that arose from nineteenth-century warfare was the recognition of the value of competent, trained, and well-organized female nurses. Florence Nightingale (1820-1910), who is mainly associated with the professionalization of nursing, was also deeply involved in the reform of military medicine. Nightingale demonstrated the value of good nursing during the Crimean War, fought in Turkey after England and France declared war on Russia in 1854 for its attack on Turkey. Medical preparations for the war were totally inadequate and the medical situation became a major scandal and disgrace in England. The conditions for sick and wounded soldiers were appalling because of the incompetence and indifference of the military and political authorities. The sick were left to suffer and die in filthy, inadequate hospitals. Epidemics of cholera, dysentery, and fever overwhelmed the doctors and orderlies who were supposed to care for the sick and wounded. Drugs, soap, anesthetics, drinking water, and decent food were almost nonexistent. The standard diet for the sick consisted of salt-pork or beef, hard biscuits, and bad coffee. The sick and wounded were evacuated to the notoriously filthy base hospital at Scutari. Amputations, without anesthetics, were performed in the middle of the wards that housed the sick and the dying. Many more men had died from disease than from battlefield injuries by the time Nightingale came to the Crimea with 38 nurses and important supplies for the patients and the hospital. These dedicated and hardworking women were not initially welcomed by the military authorities, but eventually Nightingale proved the value of good nursing. Her first priority was to clean up the hospital and bring order to hospital administration, including a routine of round-the-clock nursing care for the patients. She used her own money and funds collected in a public appeal, launched by the London Times, to establish kitchens and a laundry. When Nightingale arrived, the sanitary situation of the Scutari hospital building was abominable. Sewers were inadequate and filth flooded the wards and contaminated the water supply. Under Nightingale's direction, the mortality rate decreased from 42 percent to about 2 percent. Although nursing was an old profession, it was not until the Crimean War, through the work of Nightingale, that the military authorities actually realized the value of good nursing services.
The American Civil War was also marked by the inadequacy of medical services. Surgeons and drugs were in short supply and antisepsis virtually unknown. Despite the American invention of anesthesia in the 1840s, surgeons generally amputated without anesthetic. Many thought that the heart could best stand the stress of surgery if it was performed while the patient was still in a state of "battle tension." Interestingly, a manual of military surgery written by J. J. Chisholm, a surgeon in the Confederate Army, recommended the use of curare for tetanus. The Crimean War had provided some lessons for improvements in hygiene and sanitation, such as the importance of adequate rations and nursing services. Nevertheless, for a war fought before the acceptance of the germ theory of disease, basic field hygiene and sanitation and post-surgical care remained major problems. As was usually the case, diseases such as dysentery, tetanus (lockjaw), and typhoid killed more soldiers than battle injuries.
The Union Army did, however, achieve significant organizational reforms and advances in the management of mass casualties before the end of the war. Surgeon-General William A Hammond, who was appointed in 1862, reformed the supply system, worked with the U.S. Sanitary Commission, and built large general hospitals. Jonathan Letterman, who served as medical director of the Army of the Potomac, built on the work of Baron Larrey and instituted his own innovative procedures and policies. Letterman advanced procedures for the use of ambulances to evacuate the wounded, required progressive surgical triage and treatment, centralized field medical logistics, instituted preventive medical inspections, established large mobile field hospitals in tents, simplified methods for the collection of medical data, and so forth. Indeed, the "Letterman system" became the foundation of modern medical systems in all armies.
In 1862 Hammond established the Army Medical Museum in Washington, D.C., to collect and study pathological specimens from military hospitals. Eventually the museum became the Armed Forces Institute of Pathology. Hammond ordered the writing of a comprehensive medical and surgical history of the War of the Rebellion. The completion of this monumental six-volume history took 18 years. At the time of its publication it was the most complete report of the medical data gathered during any war in history. Another contribution to medical history from this period was the creation of the Library of the Office of the Surgeon General (later the National Library of Medicine) by John Shaw Billings (1838-1913). Under Billings's direction this library became the largest collection of medical literature in the world. Billings also established the invaluable Index Catalogue of the Library of the Office of the Surgeon.
Another lasting innovation of the nineteenth century evolved from Henri Dunant's experience at the battle at Solferino in 1859, where the forces of Italy and France defeated Austria. Dunant (1828-1910), a wealthy Swiss banker, was shocked by the plight of the wounded, including at least 40,000 injured men who were left lying on the battlefield without aid or medical attention. Dunant's account of his experiences, A Memory of Solferino (1862), was widely read and very influential. Dunant called for the establishment of a voluntary aid organization to provide care for wounded soldiers. At the Geneva Convention of 1864 representatives from 16 countries drew up the system of rules for the care of the wounded and the protection of hospitals and medical personnel that eventually resulted in the formation of the Red Cross. In 1901 Dunant was awarded the Nobel Peace Prize.
LOIS N. MAGNER
Ashburn, Percy Moreau. A History of the Medical Department of the United States Army. Boston: Houghton Mifflin, 1929.
Bengston, Bradley P., and Julian E. Kuz. Photographic Atlas of Civil War Injuries: Photographs of Surgical Cases and Specimens of Orthopaedic Injuries and Treatments During the Civil War. Otis Historical Archives. Grand Rapids, MI: Medical Staff Press, 1996.
Chapman, Charles B. Order Out of Chaos: John Shaw Billings and America's Coming of Age. Boston: Boston Medical Library, 1994.
Dunant, Henry. A Memory of Solferino. Geneva: International Committee of the Red Cross, 1986.
Freemon, Frank R. Microbes and Minnie Balls: An Annotated Bibliography of Civil War Medicine. Rutherford, NJ: Fairleigh Dickinson University Press, 1993.
Hutchinson, John F. Champions of Charity: War and the Rise of the Red Cross. Boulder, CO: Westview Press, 1997.
Miles, Wyndam. A History of the National Library of Medicine, the Nation's Treasury of Medical Knowledge. Washington, DC: Government Printing Office, 1982.
Robertson, James, Jr., ed. The Medical and Surgical History of the Civil War. 15 vols. 1883. Reprint of Medical and Surgical History of the War of the Rebellion. Wilmington, NC: Broadfoot Publishing Co., 1992.