I am presenting a Special Lecture on Global Crime and Public Health this semester, which is really the culmination of my work on international drug cartels, prohibition and harm reduction. In preparation for the lecture on harm reduction, at the end of the lecture on sex work and sexually transmitted infections (STIs) I thought I should give an overview of the “changing” attitudes towards public health and sex work and STIs in the medical literature. I remembered a few years ago reading an archived letter to the British Medical Journal (BMJ) in which a doctor advocates not treating syphilis because syphilis serves as a moral warning to society of the dangers of promiscuous sex (this was before Tuskegee, by which time we were so enlightened that only black people got no treatment). The BMJ now has all its issues since 1840 online, so I went trawling through back issues looking for admonitions against sleeping with “loose women” and ways of preventing said women from returning to their “vicious life,” and although I didn’t find that original letter I found a lot of other fun stuff. However, in the process I stumbled upon a doozy of a letter from a certain Surgeon-Lieutenant-General E.M.Wrench, MVO, FRCSEng (and if ever anyone deserved a medal this man did!) describing his experiences as a military surgeon in the Crimean War. It was published in 1908, so by that time he must have been quite old, but it presents a crystal clear image of his experiences in the war. Reading this I was both impressed by how primitive British war-making was in the mid-19th century, and reminded of why I really enjoy working with medical  doctors. Their sense of humour, their writing style, and their earthy view of the world is truly a rewarding combination to work alongside.

I’ve put in a few bold elements to indicate the bits I find truly disturbing, and a series of footnotes (of course) with cynical/salutary (take your pick) lessons for the modern NHS. But please don’t let them distract you from the horror that is a Doctor’s cynical report on life in the Crimean war. Incidentally, this report was entitled “Lessons from the past.”

The surgeon begins with discussion of the nature of his arrival, but we’ll skip that…

I will not, however, talk of these generalities, but describe my experience when in charge of a ward of what might be called the base hospital at Balaclava in November, 1854, shortly after the battle of Inkerman, some of the wounded from which were under my care, together with cases of cholera, scorbutic dysentery, and fever. It was situated in what had been the military school of St.Nicholas, which contained several rooms about 30 feet square. There were no bedsteads or proper bedding; the patients lay in their clothes on the floor, which from the rain blown through the damaged windows and the traffic to and from the open-air latrines was as muddy as a country lane. There were no nurses, no washing conveniences, either personal or for clothing. Two old soldiers, called orderlies, did their ignorant best to attend to the wants of the patients, but were chiefly occupied in rude cooking and burying the dead. There was no bread, of course no milk, and if I remember rightly, no tea, only the famous green coffee. There was certainly no beef tea – Liebig’s extract and similar substitutes had not been invented, and tinned meats were almost unknown. About midday a large iron witch’s-cauldron was carried into the middle of the ward; the patients crowded round to dip in their tin canteens, those bedridden dependent on the generosity of their comrades for a share of the contents of the pot – a mixture of lean mutton and fat salt pork[1], floating in the weakest of oily broth. Notwithstanding the shortcomings of the commissariat each surgeon had to make out a daily diet role, showing what each patient should have – full, half, or spoon diet – to satisfy the red tape system and prevent the purveyor being surcharged for the cost of the scanty food he was able to supply. We were practically without medicines. The supply landed at the capture of Balaclava was exhausted, and the reserve gone to the bottom of the Black Sea with the winter clothing and several surgeons in the Prince-steamer, so that in November, 1854, the base hospital was without opium, quinine, and ammonia. Sanitary science was in its infancy, and sanitary precautions were not capable of being carried out when the living were so hard pressed to live and dead men were for days floating about amongst the ships in the harbour.

You will not be surprised to hear that many of our patients died, but, probably owing to our unglazed windows, we were free from what was then aptly called ” hospital gangrene,” which carried off, I believe, every one of the thirty wounded Russians in the Town Hall not many yards away[2]. The stench of that building I shall never forget. You may ask why, with so many ships in the harbour, we were not able to obtain bedding and medical comforts. The reply is: The medical department was, in those days, powerless to incur expense[4], and the purveyors’ department was likewise in such a subordinate condition that they were afraid of responsibility. It was to Miss Nightingale’s bravery in setting all red tape at defiance that the success in reforming the great hospital at Scutari was due, and if there is one lesson more than another to be learnt from the breakdown of the medical department in the Crimea, it is that if the department is to be held responsible for the cure of the sick and wounded, it must have the power not only to administer pills and potions, but to secure at all costs the quite as – nay, more – important food, shelter, and equipment of the hospitals. The initial breakdown in the Crimea was the result of the military – monopolizing all the transports, and hence the landing of the army devoid of hospital equipment and the absence of hospital ships, so that the only apology for bedding in a ship full of sick and wounded, of which my brother-in-law, Mr. Swinhoe, had charge from Balaclava to Scutari, were the mats previously provided in the ship when conveying horses to the seat of war[6].

The condition of the base hospital being such as I have described, that of the field hospital, seven miles away on an exposed plateau under canvas, was, if possible worse; hence it was the object of most regimental surgeons to send away their sick and wounded, as often as the French could lend their mule litters, for embarkation at Balaclava; though their chance of arriving alive at Scutari was not good, for 10 per cent during the winter were cast overboard as corpses during a voyage of 160 miles, none of the ships being fitted for the purpose, and some, as I have already described, intended for the conveyance of horses.

Much was said in days gone by of the advantages of the system of regimental surgeons, and as one who spent eight years in that capacity I can endorse it as very pleasant for the surgeon, and possibly, in those days of long service, of some advantage to the regiment, from the knowledge acquired of the history of the men, but in time of war no system could be worse. To give an example: During the month of June, 1855, my regiment, the 34th (now the Border[7]), in addition to their share of the fifty daily wounded[8] in the trenches suffered heavily at the assaults of the quarries on the 12th and 18th. On the latter date I marched down to the trenches with twelve officers, and back to camp with two, the other ten being killed or wounded. The men suffered nearly as heavily, and there being no division hospital we had to convert three regimental barrack huts into hospitals, and staff them with men from the ranks entirely ignorant of ambulance duties. Two of the three regimental assistant surgeons soon knocked up, and were temporarily invalided. The surgeon was very shaky; he died of delirium tremens shortly afterwards, and I had to work single handed. As a consequence some of the slightly wounded were not properly attended to for several days, the wounds became infected by maggots, and operations were performed under the greatest difficulties. I remember a case of amputation at the shoulder-joint, when I had to administer the chloroform, compress the subelavian and pick up the axillary artery, whilst the surgeon, with trembling hands, tied it; yet possibly in the same brigade there were several regimental surgeons almost unemployed.

Here I may allude to the dread of the use of chloroform (then recently invented) by the older surgeons, and to the famous memorandum issued by the Director-General condemning its too frequent use, and adding that the cries of the patient undergoing an operation were satisfactory to the surgeon as indicating the absence of syncope, and that pain was a stimulant that aided recovery. Surgery was then little advanced from classical times; antisepsis was unthought of, and the resection of a wounded joint so novel, that Fergusson invented the term “conservative surgery ” to describe it.

The duties, as well as the practice, of the regimental surgeon differed from those of the present day; one of his most unpleasant, was his enforced attendance alongside of the prisoner, at what was called “punishment parade,” when his duty was to watch the man being flogged lest he die under the lash of the cat-o’-nine-tails or faint from loss of blood, which usually flowed freely after the first few strokes. The parade over, the man was removed to the hospital for the surgeon to cure him and render him fit for duty as speedily as possible.

Wars always have been, and always will be, cruel. It is, however, the pride of our profession that, while sharing the fatigues and dangers of the campaign, our sole duty will be the protection of the soldiers from what, after all, is his most deadly enemy – disease[9] – and the alleviation of the sufferings of the wounded. The report of the Royal Commission on the Crimean War reported that the medical breakdown was the result of the system, and not of the surgeons – a lesson that I trust will not be forgotten by the nation. The medical department, unless made efficient and given proper authority[10] during peace, cannot be expected to do its duty satisfactorily during war.

Of course, in a Compromise and Conceit-style campaign, this would all be different, since there would be magical healing, the healer’s guild would have “a long, low-roofed white building” set up to receive the injured, and all would be peaceful sage candles and tender moments between red-headed chicks and their injured lovers. When, oh when will the NHS find faith healing?[11]

fn1: So, the hotel services in the NHS haven’t changed…

fn2: Hospital Acquired Infections were novel even then… and, the Daily Mail was right, it was all the foreigners’ fault[3]

fn3: You may laugh at this silly joke, but I have actually read newspapers in the UK trying to blame hospital infections on foreigners… more than once!

fn4: Whereas, under the current straitened conditions, the NHS is “quarantined” from cuts, and able to purchase such luxuries[5]

fn5: I have worked in an organisation subject to hiring freezes and budgetary constraints, so I understand exactly this man’s feelings

fn6: I think it’s worth noting that, while modern armies are well capable of providing hospital services, in certain recent wars their administrative organs certainly seemed to forget other aspects of planning for the post-invasion situation, with similar consequences (for the Iraqis, at least)

fn7: That’s right, the same regiment as George McDonald Fraser, of Flashman fame. Do they teach writing classes in that regiment, perchance?

fn8: It’s quite well-remarked (as we’ll see below) that compared to subsequent wars casualties in the Crimea were remarkably low, and in fact military engagements of the time were remarkable for their low casualty rates compared to modern wars between mechanized armies. The main killer in the Crimea was disease, which makes the war all the more tragically pointless.

fn9: In fact, the Crimean war had a role to play in the development of epidemiology, since the aforementioned “Miss Florence Nightingale” led a campaign to change conditions in military hospitals, and did so using some very cunning graphical devices, which presaged later methods for the comparison of disease. As I discovered in my trawling through the annals of Britain’s response to sexually transmitted infections, the military and their fighting fitness have played an important role in the development of modern public health practice, not just through direct intervention in their health problems, but through the peacetime health policy implemented in support of the health of soldiers.

fn10: And out of tragedy… a doctor demands more institutional authority!!! Who could have guessed it would end this way?

fn11: when some quack gets Prince Charles’s ear, obviously.