The Atlantic Monthly, Volume 08, No. 50, December, 1861

Such being the state of opinion and feeling in the profession, it naturally happened that British army-surgeons stuck to their Regimental Hospitals as long as they could, and, when compelled to cooperate in a General Hospital, made the institution as like as possible to a group of Regimental Hospitals,—resisting all effective organization, and baffling all the aims of the larger institution.

In busy times, no two Regimental Hospitals were alike in their management, because the scheme was not capable of expansion. The surgeon and his hospital-sergeant managed everything. The surgeon saw and treated the cases, and made out his lists of articles wanted. It was his proper business to keep the books,—to record the admissions, and make the returns, and keep the accounts, and post up all the documents: but professional men do not like this sort of work, when they want to be treating disease; and the books were too often turned over to the hospital-sergeant. His indispensable business was to superintend the wards, and the attendance on the patients, the giving them their medicines, etc., which most of us would think enough for one man: but he had besides to keep up the military discipline in the establishment,—to prepare the materials for the surgeon's duty at the desk,—to take charge of all the orders for the diet of all the patients, and see them fulfilled,—to keep the record of all the provisions ordered and used in every department,—and to take charge of the washing, the hospital stores, the furniture, the surgery, and the dispensary. In short, the hospital-sergeant had to be at once ward-master, steward, dispenser, sergeant, clerk, and purveyor; and, as no man can be a six-sided official, more or fewer of his duties were deputed to the orderly, or to anybody within call.

Nobody could dispute the superior economy and comfort of having a concentration of patients arranged in the wards according to their ailments, with a general kitchen, a general laundry, a dispensary and surgery, and a staff of officials, each with his own distinct business, instead of as many jacks-of-all-trades, each doing a little of everything. Yet the obstinacy of the fight made by the surgeons for the system of Regimental Hospitals was almost insuperable. There was no desire on any hand to abolish their hospitals, which must always be needed for slight, and also for immediately pressing cases. What was asked of them was to give way when epidemics, or a sudden influx of wounded, or protracted cases put a greater strain upon the system than it would bear.

The French, meantime, had three sorts of hospitals,—the Divisional ones coming between the Regimental and the General. Only the very slightest cases ever enter their Regimental Hospital; those which may last weeks are referred to the Divisional; and those which may last months, with prospect of recovery, to the General Hospital. The Sardinian plan was nearly the same. The Russians had Divisional Hospitals at various stations; and all cases were carried to them.

The Regimental Hospitals are wherever the regiments are. The advantage is, that aid can be immediately rendered,—not only in case of wounds, but of cholera, in which it is desirable to lay a patient down in the nearest bed to which he can be conveyed. The disadvantages are the hap-hazard quality of the site, the absence of quiet and seclusion, and the liability of being near the scene of conflict. These things cause the French to prefer the Divisional Hospital, which, while still within reach, is set farther back from the force, in a picked situation, and managed on a large scale and with nicer exactitude.

The General Hospital is understood to be at the base of operations: and this supposes, as a part of its organization, a system of transport, not only good of its kind, but adequate to any demands consequent on a great battle, or the spread of an epidemic in the camp. The nearer the hospital is to the active force, the better, of course; but there are conditions to be fulfilled first. It must be safe from the enemy. It must be placed in a permanent station. It must be on a good road, and within immediate reach of markets. It ought also to be on the way home, for the sake of the incurable or the incapacitated who must be sent home.

In the Regimental Hospital, the surgeon may be seen going from the man who has lost a finger to a fever patient,—and then to one who has ophthalmia,—passing on to a fellow raving in delirium tremens,—next to whom is a sufferer under bronchitis, who will not be allowed to go out of doors for weeks to come; and if half a dozen are brought in with cholera in the course of the day, the officials do not know which way to turn. It is possible that the surgeon may be found making starch over the kitchen fire, because there is nobody at hand who understands how to make starched bandages; or he may be at the desk, casting up columns of figures, or writing returns, when he is urgently wanted at the bedside. Such things can hardly happen now; but they have happened within ten years. The Russians, meantime, would be carrying all manner of patients to one of their hospital-stations,—each sufferer to the hospital of his own division. The French would leave the men with scratches and slight diarrhea and delirium tremens in the Regimental Hospital,—would send the fever and bronchitis and scorbutic patients to the Divisional,—and any gravely wounded, or rheumatic, or other very long cases to the General Hospital at the base of operations.

Such arrangements, however, are of no use, if the last be not so organized as to render it fit to supply what the others cannot give, and to answer purposes which the others cannot even propose.

When doctors and soldiers alike shuddered at the mention of the General Hospital as a necessary institution at or near the seat of war, they were thinking of what they had seen or heard of during the Peninsular Campaigns. There were such infirmaries wherever there was a line of march in Spain; and they seemed to be all alike. Hospital gangrene set in among the wounded, and fever among the sick, so that the soldiers said, "To send a poor fellow to the hospital is to send him to death." Yet there was nothing else to be done; for it was impossible to treat the seriously sick and wounded at the spot where they fell. During that war, nearly twice the number which composed the army passed through the hospitals every year; and of these there were known deaths to the amount of thirteen thousand five hundred; and thousands more were never the same men again. When the case was better understood,—as during the last year in the Crimea,—the mortality in the hospitals barely exceeded that of the Guards in their barracks at home! Recovery had become the rule, and death a remarkable event. General Hospitals had come to surpass all other means of curing patients, while fulfilling their own peculiar service to society through new generations.

What are the functions of General Hospitals, besides curing the sick and wounded? some readers may ask, who have never particularly attended to the subject.

The first business of such institutions is undoubtedly to restore as many as possible of the sufferers brought into them: and this includes the duty of bringing in the patients in the most favorable way, receiving them in an orderly and quiet manner, doctoring, nursing, feeding, clothing, and cleaning them, keeping their minds composed and cheerful, and their manners creditable, promoting their convalescence, and dismissing them in a state of comfort as to equipment. This is the first duty, in its many subdivisions. The next is to obviate, as far as possible, future disease in any army. The third grows out of this. It is to improve the science of the existing generation by a full use of the peculiar opportunities of observation afforded by the crop of sickness and wounds yielded by an army in action. To take these in their reverse order.

There must be much to learn from any great assemblage of sickness, under circumstances which can be fully ascertained, even at home,—and much more in a foreign climate. The medical body of every nation has very imperfect knowledge of classes and modifications of diseases; so that one of the strongest desires of the most learned physicians is for an improved classification and constantly improving nomenclature of diseases; and hospital-records afford the most direct way to this knowledge. Thus, while the phenomena are frittered away among Regimental or unorganized General Hospitals, a well-kept record in each well-organized hospital will do more than all other means to promote the scientific understanding of disease.

The statistics of disease in armies, the ascertainment of the numbers who sicken and who die of particular diseases, would save more lives in future generations than can be now appreciated; but what can the regimental surgeon do towards furnishing any trustworthy materials to such an inquiry? A dozen doctors, with each his smattering of patients, can learn and teach but little while they work apart: whereas a regular system of inquiry and record, in action where the sick are brought in in battalions, is the best possible agency. Not only are these objects lost when surgeons are allowed to make the great hospital a mere receptacle for a cluster of small and desultory hospitals, but the advantages of a broad study of diseases and their treatment are lost. Inestimable facts of treatment are learned by watching, at the same time and in the same place, a ward full of patients ill of the same disease. People of all countries know this by the special learning which their physicians obtain in large civil hospitals: and the same thing happens in military hospitals, with the additional advantage that the information and improved art tend to the special safety of the future soldiery, in whatever climate they may be called on to serve.

There has long been some general notion of the duty of army-surgeons to record what they saw in foreign campaigns; but no benefit has been reaped till of late. The works of French field-surgeons have long been justly celebrated; but I do not know that in the statistics and the nomenclature of disease they have done much more than others. The English surgeons carried or sent home in 1810 a mass of papers about the Walcheren fever, and afterwards of the diseases of the Peninsular force: but the Director General of the Medical Department considered such a bulk of records troublesome, and ordered them to be burnt! Such an act will never be perpetrated again; but directors will have a more manageable mass of documents to deal with henceforth. With a regular system of record, at a central station of observation, much more may be done with much less fatigue to all parties.

But how is it to be done? may well be asked. In the hurry and confusion of a war, and amidst the pressure of hundreds of new cases in a day, what can the surgeons of the hospital be expected to do for science, or even for the improvement of medical and surgical practice?—The answer is seen in the new arrangements in England, where a statistical branch has been established in the Army Medical Department. Of course, no one but the practising surgeon or physician can furnish the pathological facts in each individual case; but this is what every active and earnest practitioner does always and everywhere, when he sees reason for it. His note-book or hospital-journal provides that raw material which the statistical department is to arrange and utilize. The result will be that a flood of light will be cast on matters affecting the health and life of soldiers and other men, in regard to which we might have gone on groping for centuries among the confusion of regimental records, without getting what we wanted. As to the method of proceeding, I may have something to say farther on. Meantime, we must turn to the primary object of the institution of the Military Hospital,—the cure of the wounded and sick of the army.

In the case of active war, foreign or civil, the General Hospital is usually an extemporized establishment, the building a makeshift, and the arrangements such as the building will admit. In Spain, the British obtained any houses they could get; and the soldiers were sometimes crowded into half a dozen of them in one town. In the last war, the great buildings at Scutari were engaged three months before they were wanted for extensive use; so that there was plenty of time for making them clean, airy, warm, and commodious, and for storing them with all conveniences. This was not done; and the failure and its consequences afford a lesson by which every people engaged in war should profit. A mere outline of what was not done at Scutari may be an indication of what should be done with all convenient speed elsewhere.

There was a catgut manufactory close at hand, which filled the neighborhood with stench. Half a dozen dead dogs festered under the windows in the sun; and a dead horse lay in the aqueduct for six weeks. The drain-pipes within the building were obstructed and had burst, spreading their contents over the floors and walls. The sloping boarded divans in the wards, used for sleeping-places, were found, after the building became crowded, to be a cover for a vast accumulation of dead rats, old rags, and the dust of years. Like all large stone buildings in the East, it was intolerably cold in winter, with its stagnant air, its filthy damps, and its vaultings and chill floors. This wonderful building was very grandly reported of to England, for its size and capacity, its imposing character, and so forth; and the English congratulated themselves on the luck of the wounded in having such a hospital. Yet, in the next January, fourteen hundred and eighty were carried out dead.

It appears that nobody knew how to go to work. Everybody writes to somebody else to advise them to "observe"; and there are so many assurances that everybody means to "observe," that there seems to have been no leisure to effect anything. One thinks that this, that, or the other should be attended to; and another states that the matter is under consideration. It was some weeks before anybody got so far in definiteness as to propose whitewash. Somebody understood that somebody else was intending to have the corridors scoured; and representations were to be made to the Turkish authorities about getting the drain-pipes mended. The Turkish authorities wished to employ their own workmen in putting in the stoves; and on the 18th of December the responsible British officer hoped the stoves would be put up immediately, but could not be certain, as Turkish workmen were in question. This was a month after large companies of wounded and sick had been sent in from the seat of war. Even then, nothing had been done for ventilation, or, on any sufficient scale, for putting the poor sufferers comfortably to bed.

These things confirm the necessity of a regulated cooperation between the sanitary, the medical, and the military officers of an army. The sanitary officer should be secure of the services of engineers enough to render the hospital, as well as the camp, safely habitable. As soon as any building is taken possession of for a hospital, men and their tools should be at command for exploring the drains and making new ones,—for covering or filling up ditches,—for clearing and purifying the water-courses, and leading in more water, if needed,—for removing all nuisances for a sufficient distance round,—and for improving to the utmost the means of access to the house. There must be ventilating spaces in the roof, and in the upper part of all the wards and passages. Every vaulted space, or other receptacle of stagnant air, should have a current established through it. All decaying wood in the building should be removed, and any portion ingrained with dirt should be planed clean. A due water-supply should be carried up to every story, and provided for the bathrooms, the wash-houses, and the kitchen. Every edifice in America is likely to be already furnished with means of warmth; and the soldiers are probably in no danger of shivering over the uncertain promise of stoves on the 18th of December.

Next comes the consideration of store-place, which can be going forward while busy hands are cleaning every inch of ceiling, walls, floors, and windows within. There must be sheds and stables for the transport service; and a surgery and dispensary planned with a view to the utmost saving of time and trouble, so that medicines and utensils may be within reach and view, and the freest access allowed to applicants. The kitchens must have the best stoves and boilers, dressers and scales, and apparatus of every kind that is known to the time; for more lives depend on perfect food being administered with absolute punctuality than upon any medical treatment. There must be large and abundant and airy store-places for the provisions, and also for such stocks of linen and bedding as perhaps nobody ever dreamed of before the Crimean War.

The fatal notions of Regimental Hospital management caused infinite misery at Scutari. In entering the Regimental Hospital, the soldier carries his kit, or can step into his quarters for it: and the regulations, therefore, suppose him to be supplied with shirts and stockings, towel and soap, brushes and comb. This supposition was obstinately persevered in, at Scutari, till private charity had shamed the authorities into providing for the men's wants. When the wounded were brought from the Alma, embarked on crowded transports straight from the battle-field, how could they bring their kits? Miss Nightingale, and benevolent visitors from England, bought up at Constantinople, and obtained from home, vast supplies of body- and bed-linen, towels, basins, and water-cans; and till they did so, the poor patients lay on a single blanket or coarse canvas sheet, in their one shirt, perhaps soaked in blood and dirt. There were some stores in the hospital, though not enough; and endless difficulty was made about granting them, lest any man should have brought his kit, and thus have a double supply. Amidst the emergencies of active war, it seems to be an obvious provision that every General Hospital should have in store, with ample bedding, body-linen enough for as many patients as can occupy the beds,—the consideration being kept in view, that, where the sick and wounded are congregated, more frequent changes of linen are necessary than under any other circumstances.

The excellent and devoted managers of the hospitals of the Union army need no teaching as to the daily administration of the affairs of the wards. They will never have to do and dare the things that Miss Nightingale had to decide upon, because they have happily had the privilege of arranging their hospitals on their own principles. They will not know the exasperation of seeing sufferers crowded together on a wooden divan (with an under-stratum of dead rats and rotting rags) while there is an out-house full of bedsteads laid up in store under lock and key. Not being disposed to acquiesce in such a state of things, and failing in all attempts to get at the authority which had charge of the locked door, Miss Nightingale called to an orderly or two, and commanded them to break open the door. They stared; but she said she assumed the responsibility; and presently there were as many men in bed as there were bedsteads. Her doctrine and practice have always been,—instant and silent obedience to medical and disciplinary orders, without any qualification whatever; and by her example and teaching in this respect she at length overcame the jealousy and prejudices of authorities, medical and military: but in such a case as the actual presence of necessaries for the sick, sent out by Government or by private charity for their use, she claimed the benefit, and helped her patients to it, when there was no other obstruction in the way than forms and rules never meant to apply to the case.

What the jealousy was appeared through very small incidents. A leading medical officer declared, in giving evidence, that the reason why the patients' meals were sometimes served late and cold, or half-cooked, was, that Miss Nightingale and her nurses were forever in the way in the general kitchen, keeping the cooks from the fire: whereas the fact was, that neither Miss Nightingale nor any nurse had ever entered the general kitchen, on any occasion whatever. Their way was to have a kitchen of their own. The very idea of that kitchen was savory in the wards; for out of it came, always at the right moment, arrowroot, hot and of the pleasantest consistence,—rice puddings, neither hard on the one hand nor clammy on the other,—cool lemonade for the feverish, cans full of hot tea for the weary, and good coffee for the faint. When the sinking sufferer was lying with closed eyes, too feeble to make moan or sign, the hospital spoon was put between his lips, with the mouthful of strong broth or hot wine which rallied him till the watchful nurse came round again. The meat from that kitchen was tenderer than any other; the beef-tea was more savory. One thing that came out of it was a lesson on the saving of good cookery. The mere circumstance of the boiling water being really boiling there made a difference of two ounces of rice in every four puddings, and of more than half the arrowroot used. The same quantity of arrowroot which made a pint, thin and poor, in the general kitchen, made two pints, thick and good, in Miss Nightingale's.

Then there was the difference in readiness and punctuality. Owing to cumbrous forms and awkward rules, the orderlies charged with the business were running round almost all day about the food for their wards; and the patients were disgusted with it at last. There were endless orders and details, whenever the monotonous regular diet was departed from; whereas the establishment of several regular diets, according to the classifications in the wards, would have simplified matters exceedingly. When everything for dysentery patients, or for fever patients, or for certain classes of wounded was called "extra diet," there were special forms to be gone through, and orders and contradictions given, which threw everything into confusion, under the name of discipline. The authority of the ward would allow some extra,—butter, for instance; and then a higher authority, seeing the butter, and not knowing how it came there, would throw it out of the window, as "spoiling the men." Between getting the orders, and getting the meat and extras, and the mutual crowding of the messengers, some of the dinners were not put on the fire till an hour or two after the fainting patient should have had his meal: and then, of course, he could not take it. The cold mutton-chop with its opaque fat, the beef with its caked gravy, the arrowroot stiff and glazed, all untouched, might be seen by the bedsides in the afternoons, while the patients were lying back, sinking for want of support. Probably the dinners had been brought up on a tray, cooling all the way up-stairs and along the corridors; and when brought in, there was the cutting up, in full view of the intended eaters,—sometimes on the orderly's own bed, when the tables were occupied. Under such a system, what must it have been to see the quick and quiet nurses enter, as the clock struck, with their hot-water tins, hot morsels ready-cut, hot plates, bright knife and fork and spoon,—and all ready for instant eating! This was a strong lesson to those who would learn; and in a short time there was a great change for the better. The patients who were able to sit at table were encouraged to rise, and dress, and dine in cheerful company, and at the proper hour. It was discovered, that, if an alternation was provided of soups, puddings, fish, poultry, and vegetables, with the regular beef dinner, the great mass of trouble about extras was swept away at once; for these varieties met every case in hospital except the small number which required slops and cordials, or something very unusual. By this clearance, time was saved to such an extent that punctuality became possible, and the refusal of food almost ceased.

All these details point to the essential badness of the system of requisitions. In the old days, when war was altogether a mass of formalities,—and in peace times, when soldiers and their guardians had not enough to do, and it was made an object and employment to save the national property by hedging round all expenditure of that property with difficulties, the system of requisitions might suit the period and the parties. Amidst the rapid action and sharp emergencies of war it is out of place. It was found intolerable that nothing whatever could be had,—not a dose of medicine, nor a candle, nor a sheet, nor a spoon or dish, nor a bit of soap,—without a series of permits, and applications, and orders, and vouchers, which frittered away the precious hours, depressed the sick, worried their nurses, and wasted more of money's worth in official time, paper, and expensive cross-purposes than could possibly have been saved by all the ostentatious vigilance of the method. The deck-loads of vegetables at Balaklava, thrown overboard because they were rotten before they were drawn, were not the only stores wasted for want of being asked for. When the Scutari hospitals had become healthy and comfortable, there was a thorough opening-out of all the stores which had before been made inaccessible by forms. No more bedsteads, no more lime-juice, no more rice, no more beer, no more precious medicines were then locked away, out of the reach or the knowledge of those who were dying, or seeing others die, for want of them.