Military hospitals, like their civilian counterparts, are institutions comprising organized medical and nursing staff. They provide a range of services, now including surgery and intensive care. Many military hospitals are mobile (field hospitals) or semi-permanent (general hospitals), with an emphasis on the treatment of mass, critical casualties, and include the provision of triage rather than an accident and emergency department. Often they exclude provision for maternity and childcare.
The origins of the modern hospital lie as far back as 400 bc when the temples of Greece were used as refuges for the ill, the injured, and the infirm. The Roman army had hospitals in its frontier forts and along major routes. They were well designed, some with an airy entrance hall which served as a casualty clearing station, and wards consisting of small cubicles arranged off a central corridor. The Byzantine army also had a sophisticated medical system, and even established hospitals for crippled soldiers or men with long-term medical conditions. In the West, monastic orders set up their own hospitals, hospices, and schools, and during the Crusades the Knights Hospitallers—the Sovereign Military Order of the Hospital of St John of Jerusalem, of Rhodes, and of Malta—had brothers who fought as well as cured, and built castles and hospitals across Outremer.
The structure of military hospitals evolved into recognizable form in the 17th century. Renaissance armies had provided surgeons and assistants for units in the field, and treated the wounded in temporary field hospitals (the first tier) from which they were often simply discharged to the care of their friends and relatives. However, permanent military hospitals (the second tier) were gradually established across Europe: by 1674 France had them in Arras, Dunkirk, Calais, and Perpignan, and newly designed fortresses routinely included hospital space. However, poor standards of cleanliness, medical ignorance, and the slovenly habits of some staff combined to make hospitals dangerous places. Disease, for centuries a far greater casualty-producer than steel or lead, swept through them. Even well-ordered medical arrangements, like those in the French army under Napoleon, collapsed under the sudden impact of major battle. At Borodino in 1812 many of the wounded were packed into improvised hospitals, like that in the monastery at Kolotskoi, of which a commissariat official wrote: ‘I had neither medical orderlies nor stretchers. Not only was the hospital full of corpses, but so were the streets and a number of the houses … On my own I took away 128, which were serving as pillows to the sick and were several days old.’ There was a growing recognition that hospitals were entitled to protection, and in 1747 Frederick ‘the Great’ urged his generals to have ‘a paternal care’ for their own wounded, and ‘do not be inhumane to those of the enemy’.
The third tier of hospitals—institutions concerned with the disabled and long-term sick—crystallized at much the same time. In 1603 the French introduced a system for the care of disabled soldiers, and this evolved, in 1676, into the Hotel des Invalides in Paris, which could house up to 3, 000 sick and disabled. Hospitals for disabled soldiers were built at Chelsea in England and Kilmainham in Ireland, with a hospital for sailors at Greenwich on the Thames.
The plight of British wounded in the hospital at Scutari during the Crimean war, tellingly reported on by William Howard Russell, encouraged the government to send out Florence Nightingale and her party of trained nurses. She is often credited with pioneering military nursing, but in fact the Russians already had their own military nurses and, under their surgeon-general, Nikolai Ivanovich Pirogov, had established a chain of evacuation linking battlefield dressing stations with hospitals in safe areas. Initial battlefield treatment was confined to inspection, prioritizing according to the nature of the wound, and transferring the casualty to hospital. Pirogov's concept of prioritization and ‘dispersion of casualties’, or ‘patch and dispatch’, remains at the core of modern military medicine.
Nevertheless, the dreadful example of the Crimea was important. It generated reforms in Britain, where it led to the establishment of a corps of hospital orderlies. It also inspired the US Sanitary Commission, which inspected Union hospitals, lobbied for improvements and offered direct assistance to the wounded and their families during the American civil war. The Commission's history concluded that ‘a certain inflexible military routine’ obstructed ‘that zeal and enthusiasm for the welfare of the soldier’ which characterized the people of a democratic state. The small size of the US regular army and its limited experience of large-scale operations meant that there were no general hospitals, and the largest post hospital, at Fort Leavenworth in Kansas, had only 41 beds. During the war, thanks largely to the efforts of Dr Jonathan Letterman, surgeon-general of the Army of the Potomac, front-line aid stations passed wounded back to mobile surgical field hospitals, whence they were evacuated by ambulance, train, or hospital ship to general hospitals. There were 204 general hospitals in 1865, with a total capacity of 136, 894 beds.
From the second half of the 19th century both hospital numbers and recovery rates rose. The introduction of anaesthetics and aseptic surgical practices helped increase survival, as did the development in 1890 of an anti-tetanus serum by a German medical officer, Emil von Behring. During the Franco-Prussian war the Germans, whose lead over their opponents in medical matters matched their wider tactical and strategic superiority, placed particular emphasis on prompt life-saving treatment followed by eventual evacuation by railway to general hospitals in Germany. The British copied the system, using a system of field hospitals, ‘stationary’ hospitals, and general hospitals in the Second Boer War. In WW I most combatants capitalized on the growing corpus of evidence to use an evacuation chain based—though national practices and terminology varied—on the regimental aid post, the advanced dressing station, the casualty clearing station (where surgery was routinely performed) to field hospital, and thence to the general hospital. The campaigns of WW II, sometimes fought at high tempo and in difficult terrain, encouraged the establishment of more easily transportable clearing stations, augmented by motorized surgical teams. Although the safety of hospitals was theoretically ensured by international agreement, they were bombed or shelled by accident from time to time and were occasionally subject to deliberate attack: there was a disgraceful example of this at Singapore in 1942 (see Malaya and Singapore campaigns).
Since 1945 the delay between the time of injury and the receipt of medical treatment has been reduced still further. Air transport for wounded was routinely used by the end of WW II, and to an even greater extent in the Korean war. The advent of the helicopter, with its ability to compress the chain of evacuation, helped get wounded in wars like Vietnam and the Falklands to a surgical facility more rapidly, often with the ‘golden hour’ after wounding. The improvements in military medicine from the mid-19th century were accompanied by the growth of uniformed, formally militarized medical and nursing corps and the building of military hospitals. This process may have begun to reverse. While there are now parts of the world in which military hospitals remain distinct from their civilian counterparts, and often enjoy better funding, there are signs that elsewhere the logic of air transport and rapid evacuation is encouraging governments to combine military and civilian general hospitals to reduce costs. Field hospitals will remain important, and increasing western concern for casualty limitation is likely to focus attention on their ability to receive wounded, often by helicopter, administer life-saving treatment, including surgery if required, and then stabilize the casualty for his journey, usually by air, to a general hospital at home.
— Peter MacDonald/Richard Holmes
