"Science sans experience N'apporte pas grande assurance." AMBROISE PARÉ.

SIR;

AVING been requested by you to prepare a statement which should exhibit the essential facts connected with the material organization of the American Ambulance, established m Paris during the siege of 1870-71, I have the honour of submitting to you herewith my Report.

Two sections of my subject---one relating to the history and functions of army hospitals, the other to the use of tents for hospital purposes---have received a much larger development than I had originally proposed. The importance of these special subjects in their relation to the American Ambulance seemed, however, to warrant an extended consideration. I have accordingly presented them in the Report, in separate parts, preliminary to Part III. which contains those facts which relate most immediately to the material organization of the Ambulance.

Very respectfully,

Your obedient servant,

EDWARD A. CRANE, M.D.

Paris, 15, Rue de la Paix,
August 26, 1872.

HE history of hospital establishments for the sick and wounded of armies is, unfortunately, a very short one. The most ancient records which have been preserved are almost uniformly silent as regards the care which may have been extended to the sick and wounded of armies; and it is even remarkable that the same silence should have been observed in the collection of Jewish sacred writings, which contains not only a narrative of the general political history of the Jews, but embraces as well a very extended and detailed account of the economical and social customs of that people.

Whatever care may have been given either to the sick or wounded soldier, in the early life of ancient states, was doubtless limited to such aid and assistance as relatives and companions were prompted by affection and pity to offer.

The first allusions to army surgeons represent them as having been either priests or soldiers.(1)

Æsculapius, according to Greek tradition, was the first man (although divine honours were rendered to him after death) who gave himself up wholly to the practice of the healing art. He accompanied Castor and Pollux on the Argonautic expedition, but seems to have been distinguished not less as a master of mystic rites and a dispenser of charms than as a physician and a surgeon. Still Aristæus, king of Arcadia, and Theseus, and even Jason, the leader of that expedition, are said to have been renowned for their skill in healing wounds.

The sons of Æsculapius, Machaon and Podalirius, who have been immortalized by Homer, were doughty chieftains "in arms, encircled with their native bands," to whose heroic martial feats a knowledge of the "sovereign balm, which Chiron gave and Æsculapius used," only lent an additional lustre. Homer's surgeons, whether Greek or Trojan, were all soldiers.

At a later period the Greek armies appear to have been followed by physicians and surgeons, whose only duty was to take care of the sick and wounded. It is doubtful, however, if they ever formed a recognized corps in the army, and their number must always have been small. Nearly all the allusions to army physicians and surgeons, in Greek writings, are in connection with their services to princes and generals. So Quintus Curtius introduces to us Critobulus, as "one of the most skilful men of his profession," and gives a very interesting description of the operation which he performed on Alexander for the extraction of an arrow; he also speaks of Philip, as "one of several famous physicians who followed the king when he left Macedonia."(2)

Xenophon, in the Cyropædia, insists upon the obligation which rests upon a commander to secure the services of good physicians. This obligation, he says, was recognized by Cyrus, who was even himself ready in case of need to assist his surgeons in their work.(3) Still, as we learn from Herodotus, long after Homer's time, it was the common practice among the Greeks, after general engagements, for the soldier to rely upon his fellow soldiers for surgical assistance.(4) Occasionally, if the number of the wounded was large, certain persons were detailed from the ranks to take charge of them.(5)

Xenophon has intimated, that during battles the wounded found a refuge, and received perhaps some sort of first treatment, in the quarter of the camp where the baggage was placed.(6) While according to Justinian, the Lacedemonians, occasionally at least, opened their houses to the wounded.(7)

Aside from a few facts like these, we know nothing of the measures taken by the ancient Greeks to succour the wounded.(8)

An equal obscurity obtains also, concerning the measures adopted by the Romans to provide for their sick and wounded. "It seems," says M. Peyrilhe, "as if the historians had concerted together to conceal from posterity everything relating to the healing art in the Greek and Roman armies. Could anything astonish one more than that so many judicious writers, who seem to have taken pleasure in reporting the minutest circumstances of the smallest wars, of the most inconsiderable revolutions, who describe with the greatest care the order of battles, retreats, encampments, the slightest change in military discipline, &c., should have said nothing in their writings concerning the care given to the sick, and, particularly, to the wounded of armies?"(9) A few passages, however, may be cited, to the effect that some care was at times bestowed upon both sick and wounded in Roman armies.

In one place Cæesar says, he broke up his camp, "no obstacle interposing, the wounded and sick having been taken care of" (sauciorum modo et ægrorum habita ratione).(10) And in another place he says, he "was obliged to go to Apollonia to leave his wounded" (ad saucios deponendos.)(11) But army surgeons are neither mentioned by him, nor by preceding Latin writers. Ælian (A. D. 70), is one of the first writers who intimate that surgeons were in the habit of following the Roman army; and he classes them with the sutlers and the train of menial followers.(12) Arrian (A.D. 110), also speaks of army surgeons, but only to class them as did his predecessor.(13) So Achilles Tatius, a Greek erotic writer of the third century, speaks of a camp or army physician;(14) and in short, several inscriptions have been discovered, containing the words, medicus cohortis, medicus legionis, &c.(15) These inscriptions have induced Salmasius, Guischardt, and others, to affirm that each cohort commonly had its physician.(16) But to say nothing of the probably apocryphal character of some of these inscriptions, they are without exception of a late date, and in the absence of any account of the functions which were connected with such titles, are almost meaningless. There is no evidence to show that the medicus was commonly anything but a slave in the service of his master, or a freed man, attracted to the camp in the hope of finding a better market for his ointments and balsams,(17) and to whom the privilege of attaching himself to a legion, a cohort, or a camp may have been accorded. It is certain that his duties were very limited, and that the little personal consideration shown him fairly measured the estimated value of his services.(18)

In the absence of organized surgical aid, it has been supposed that the Romans were in the habit of alleviating in a spontaneous and popular way, the sufferings of those, who in war might have become the victims of disease or wounds; and certain statements would seem to support this supposition.

Very early in the history of Rome, we are told that the Tuscans, having been defeated near that city, were received by the inhabitants "into their own houses," and that they there, "gave them food and dressed their wounds."(19)

A certain Fabius, seems to have gained an immense popularity by reason of his care for the wounded, whom he distributed among the patrician families, providing in his own family for the largest number, who were there taken care of, even better than elsewhere.(20)

Tacitus may have had in mind some such case as this, when he says that on the occasion of the falling of the amphitheatre of Fidena, a vast multitude having been wounded, "The Roman nobles opened their houses, medicine and surgeons came in from every quarter, and Rome took on the image of former times, when after great battles, the wounded were succoured with care and rewarded with bounties."(21)

So Alexander Severus, after a great battle, is said to have found quarters for his wounded in the neighbouring towns, in the houses of the rich. Indeed, several other instances might be cited, in which the Roman wounded are said to have been sent to the towns and cities in the neighbourhood of the battle-field.

Certainly, one of the most remarkable examples of voluntary effort in behalf of the wounded is one mentioned by Tacitus, who in speaking of Agrippina, says, "This noble-minded woman then assumed the duties of a general, and gratuitously gave to the soldiers who were in want or wounded, clothing and medicines." (22)

However interesting this statement may be, as perhaps the first record of "woman's work" among the sick and wounded in camp, it is scarcely less so, by reason of its containing the implied assertion, that to see the wounded were properly taken care of, was one of the duties of a General. That it was considered to be a duty of every commander to have some care of his sick, and to show them certain attentions, is unquestionable. Early in the history of Rome, Fabius Gruges is said to have been condemned, after having been beaten by the Samnites, not so much on account of his having lost three thousand men, as because he had neglected to give to the wounded the care they should have had; and Trajan has been praised, by Suidas and Pliny, because of his constant solicitude for the weary and the sick.(23) But so long as the duties of a general towards his soldiers, whatever they may have been presumed to be, were unprescribed, and he was unprovided by the state with the means of discharging those which he himself might consider as most important, it is very evident, that the claims of sick and wounded soldiers upon the state for care and succour were practically unrecognized.

The exhaustive researches of Percy and Willaume,(24) and other writers, have established, most unequivocally, the fact, that the ancient Greeks and Romans had neither civil nor military hospitals; and it appears to me as well, that even the allusions in classical writings to the opening of private houses for the reception of the wounded, are alike too infrequent and too vague to warrant the inference, that it was a common practice to call upon the people of the country where the battle might be fought to provide a shelter for the wounded. Doubtless such shelter was occasionally resorted to, but, in view of the fact that no mention is made by any ancient writer of a service, in the Greek and Roman armies, corresponding to that now represented by the sanitary service, it is most probable, that the seriously sick as well as the wounded were generally left to take care of themselves as best they could. That there was no field or ambulance service is almost certain, and Lucan's lines, in which he depicts the savageries of Marius, may be considered very justly as representing the common background of every battle-sketch---

Nobilitas cum plebe perit: lateque vagatur
Ensis: et a nullo est pectore ferrum.(25)

The infrequent reference to the presence of the sick in Greek and Roman armies has led to the supposition, that the sickness rates among soldiers, in ancient times, were generally much lower than those with which modern warfare has unfortunately made us familiar; and various reasons have been assigned for these supposed small sickness and death rates---men were more robust and vigorous, more capable of enduring hardships formerly, &c.---even the Platonic doctrine of eliminating the feeble and deformed, and the Greek practice of exposing such new-born children, have been said to "explain how, except in great calamities, so few sick are to be seen in the Greek armies."(26) Such explanations are, however, quite fanciful. There are many good reasons for believing, that the average power of endurance of modern men is greater than that possessed by the ancients; and for the same reasons, it is probable that the sickness rates in armies were even higher in ancient than in modern times. The existence of only a small amount of sickness might have been the cause of the silence referred to; but a much more probable cause was the indifference which formerly prevailed concerning most subjects not immediately connected with selfish and personal interests. If the actual sanitary condition of Greek and Roman armies was ever, in any respect, better than that common to modern armies, the only plausible general explanations which can now be offered are, that Greek and Roman armies were usually small---the soldiers may, therefore, have possibly been better selected---that the period of service was almost always short, and that in the event of any serious disability the soldier was probably immediately discharged.

With regard to the wounded it should be remembered, that of those put hors de combat, in ancient warfare, a much larger number were killed than is usual upon modern fields of battle. Men then met in battle hand to hand, and for the wounded there were few chances of escape. The soldier struck down was, if possible, at once dispatched by his antagonist. Flight also was often impossible, as Roman historians have told us, by reason of the very thickness of the fight; and the wounded, unable to getaway, frequently perished from loss of blood alone, or were trodden under foot in the general mêlée. With regard to those who were not killed outright on the field, it may be observed, that they were of two classes---those mortally wounded and those slightly wounded. With the use of firearms, the number of the severely wounded---an intermediate class---has been enormously increased. In ancient times, fractures of the bones were comparatively rare,---so rare that amputation(27) in the case of such fractures seems never to have been thought of; the wounds were for the most part only cuts and punctures, and when death followed it was usually from loss of blood. Where wounds were necessarily mortal, death was generally speedy, either from the direct loss of blood, or because some important visceral organ had been pierced. Where wounds were not mortal, most were really very slight, or, at least, were wounds which would be so considered at present. It will be understood, therefore, that where the relative number of wounded who escaped from the field was small, for the reasons stated, and where, of such wounded the mortally wounded died quickly from the nature of their wounds, and those not mortally wounded recovered speedily from the superficial cuts and punctures they might have received, the necessity for an ambulance service was by no means as apparent as in modern times.

During the period of the Byzantine Empire, some little attention was paid to the wounded on the field. We are told that there were among the troops, "trumpeters, and physicians, and surgeons," and that there "were persons who on the day of battle followed the army to pick up the wounded, and apply the first dressings; we call them now, Scriboni."(28)

But no information has reached us as to how these wounded were subsequently treated. No mention is made before the eleventh century, of hospitals, either temporary or permanent, established in the interests of the sick or wounded.(29) The Xenodochia,(30) said to have been created by the Emperor Julian, were established, principally, in the interest of travellers, and responded, in the absence of inns, and in the general poverty and want of hospitality among the people, to the caravansaries which have existed in the East since a time quite immemorial,(31) as may be inferred from a remark of Paula, a friend of St. Jerome, who caused several Xenodochia to be erected near Bethlehem, "in order," as she says, "that the devout idlers might fare better than the mother of God, who on her necessary journey thither could find no inn."(32)

So also, the celebrated hospital of St. John of Jerusalem, was established in the middle of the eleventh century, by certain pious merchants of Amalfi, because, when the pilgrims had passed the day in visiting the holy places, "it was not without great pain, and even peril, night having come, that they were able to find, a shelter in the city."(33)

The primary object of the establishment of most of the hospices in Europe, was rather to extend hospitalities to religious pilgrims, and perhaps, indigent wayfarers, than to provide an asylum for the sick. As it, was for the advantage of the clergy to increase the number of pilgrims, religious establishments were quite ready to add to the facilities of travelling. Indeed, certain Hospitaliers are said, not only to have covenanted to entertain strangers, but also to keep the roads in repair, construct bridges, &c.(34)

But in the course of time, many of these hospices became richly endowed, and seem to have so far widened the circle of their charities, as to have received the sick. Muratori quotes from a life of St. Lanfranc, Archbishop of Canterbury, a passage to the effect that, even as early as the year 1070, the archbishop caused a hospital to be built at Canterbury, so arranged that one part of it could be occupied by sick men, and the other by sick women.(35) And it was during the same century, that the first asylum for disabled and aged soldiers is said to have been established by Alexius Comnenus. But whatever may have been the original purpose of its founder, fatherless and motherless children constituted so large a majority of its beneficiaries, that the institution became known to the world as an orphanotropium, or orphan asylum.(36)

During the Crusades, in addition to the hospices, special hospitals for the sick and wounded returning from those expeditions, including even pesthouses, are reported to have been opened in several of the Mediterranean ports, as well as in other localities in Europe.(37)

But upon many important subjects connected with the internal economy of the hospices and hospitals of the middle ages, we have very little information. It was not until long after the creation of the great medical schools of Salerno, Bologna, Padua, Montpellier and Paris---until, in fact, the middle of the fifteenth century---that either physicians, surgeons, or apothecaries appear to have been in any way connected with them.(38) Most of these hospitals appear to have been simple dependencies of religious establishments, and frequently to have been maintained much less in the interest of the sick than as a part of the ecclesiastical machinery of the period, and as a source of revenue and profit to those connected with their administration.

Thus we are told that:---" The monks of St. Anthony have established a hospital which has neither foundation nor revenue, but which, from the abundant contributions which they have the secret of getting, brings unto them immense wealth. Bell in hand, and preceded by relics and the cross, they go about soliciting money, not only over all France, but through Germany and Spain as well. There is not a fair, not a city, not a bakery, not a mill, where they do not hold out their box, &c . . . . In their hospice they buy and sell. They are traders ; they are rich. Each one has his woman; they marry well their daughters; they keep a well-furnished table, but in all this, St. Anthony makes but a poor figure."(39)

Indeed, the final assumption by the crown of the direction of hospitals was occasioned by the scandals arising from the mismanagement of these institutions by the clergy.(40) Nevertheless, during the whole Capetian dynasty the kings of France exercised what was called le droit d'oblat, or the right of sending to monastic institutions officers and soldiers who, having been disabled by wounds, disease, or age, were unfit for further military service. These soldiers were called moines lays, and assisted the monks, so far as they were able, in the discharge of the menial services of the establishment to which they had been sent.(41) In fact, as late as the sixteenth century it seems to have been the common opinion, that it was the duty as well as the prerogative of the Church to provide alike for distressed bodies and souls; at least Seissel relates, that, in an abbey in Languedoc, there was a tradition that a certain abbot had been punished by Louis XII. for refusing to receive a convoy of sick soldiers sent to the abbey.(42) Indeed, after the time of Henry IV. it was a constant practice to billet the sick and disabled upon the convents, and it was only as late as 1629, that a royal ordonnance permitted a partial commutation of the "oblat," to the payment by the convents of 100 francs a year to each pensioner. But there is little reason for believing, that the convents were more exact in the payment of such forced assessments, than they had previously been willing to receive within their walls these unwelcome claimants to the rites of hospitality.

Without wishing to asperse in the slightest degree the humane sentiment of any time, I may observe, that there are many reasons for believing that the active and practical beneficence of the middle ages has been greatly exaggerated. Charities of every kind were monopolized as well as dispensed by members of ecclesiastical orders, and in the presence of the ignorance and selfishness prevailing everywhere, and the disorder which existed in every state, in every department of its administration, the most trivial and limited acts of public benevolence could scarcely fail to be noticed, while the smallest organized effort, in behalf of the suffering and needy, appeared all the more resplendent in contrast with the general abandonment and darkness of the times. The Church was also strongly interested in encouraging the idea of its vast, incessant, and altogether sufficient labours in every field open to the commonest human sympathies; and it is, therefore, that to the Church itself we are now principally indebted for the records of mediaeval benevolence, which have found a ready echo in the disposition universal and ever-existing, among sects, to discover in their own peculiar dogmas and doctrines the sources of those social developments or reforms, which are only expressions of the common conscience of the age.(43)

Concerning the measures adopted, during the middle ages, to secure immediate assistance for those wounded in battle, we are quite ignorant.

The Gallo-Roman armies were probably attended, as were the later Roman armies, by wound-dressers; but whether the Gothic armies, or even those of Charlemagne, were followed by such persons is by no means certain.(44) By the convention of Ratisbon (A. D. 742), every commander was to have with him two bishops, as well as a certain number of priests, chaplains, and confessors ---no mention is made either of physicians or surgeons. In William of Malmesbury's Chronicle of the First Crusade there is no allusion to the presence of either physicians or surgeons in the Christian armies. In Vinsauf's Chronicle of Richard the First's Crusade the wounded soldiers are said to have been carried to the "Standard," which was always kept near the centre of the army. The old chronicler also says: ---" The weak and sick would have been in danger of perishing if it had not been for the care of King Richard, who sent out messengers on all sides to collect them together and bring them to Ramula." These two references---one to the wounded, the other to a special effort on the part of Richard to aid his suffering army---are the only ones I find in this Chronicle which give the least intimation that the disabled were the subjects of care and attention. In the chronicles of the eighth Crusade, that of Edward I. and Saint Louis, physicians and surgeons---leeches---are occasionally spoke of, but the general provisions for the sick still appear to have been of the most indifferent character.(45)

It is certainly remarkable that, during the centuries Christendom was maintaining these immense expeditionary armies, the necessity of providing for the vast multitude of sick and disabled, which must have constantly encumbered the movements of such hosts, was never seriously considered. But there is no evidence that physicians and surgeons were appointed to attend upon them, or that hospitals of any kind were maintained in their immediate vicinity. Such medical and surgical assistance, as might at times be obtained by the common soldiers, was that charitably given by the medical attendants of princes, or that offered by itinerant leeches, or by the members of various religious orders, who were, in those times, the self-elected custodians and dispensers of human knowledge in nearly all its varieties. The priests, however, who assumed to practise the healing art, too frequently found it easier to appeal to the superstitious fancies of their patients, and to surround their practice with the mystic forms of pagan worship, than to investigate the causes of disease and discover remedies for the same. It was certainly unfortunate that the exercise of surgery, so necessary in the treatment of those disabled in war, should have been especially proscribed by the Church,(46) which thus practically for a long time impeded the work of a few faithful labourers in a wide field of usefulness.

It is a remarkable fact that the Arabs, notwithstanding the ardour with which they cultivated science, particularly medicine, when at the height of their political and military power, should have held the practice of surgery in disrepute.(47) To this fact, however, must be attributed the almost total silence of Arabic writers upon all questions connected with military medicine, as, perhaps, also to some extent the prejudices against surgery which subsequently existed in Europe.

Perhaps no more striking proof could be offered of the disrepute in which medicine, as well as surgery, was held in every Christian state, than is furnished by the fact, that for several centuries the Jews were the chief depositaries and disseminators of medical science.(48)

During the centuries which immediately followed the Crusades it is not altogether clear how the soldier who fell sick in camp was taken care of, as may be inferred from the following passage in Bardin. "After the establishment of permanent garrisons the communal authorities, perhaps, came to the relief of the sick soldiers; probably, the captains gave temporary furloughs to the sick ; probably, in besieged cities, chambers were prepared for the sick and wounded," &c.(49) As for the soldiers engaged in active campaigns, at this period, it is quite evident that they generally cured themselves as they could. When the communal militia were called out, they sometimes took with them their wives, that they might be taken care of by them in case of need. But as, until the sixteenth century, these troops were rarely paid, and were rarely called out for more than sixty days,(50) it is very probable that they were discharged from further service, and permitted to go home as soon as they were in any way unfitted for duty. This practice was certainly adopted in some instances. Thus Grose says:---"Immediately after a battle, such of meaner sort of soldiers, whose wounds seemed to require a considerable time to cure, were dismissed with a small pecuniary provision to carry them home," and he supports his statement by a reference to Barnes' "History of Edward III.," in which it is said the wounded were so disposed of, after the battle of Poictiers.(51)

In France, until the reign of Louis XIII. army surgeons were attached to the persons of those commanding troops, and not to the company or troop itself,(52) and if the soldier profited by the presence of a surgeon in the camp, it was because his services were voluntarily rendered. Such was the relation of Ambroise Paré to the Duke of Guise, at Metz; his presence, although welcomed with joy by the whole garrison, was an assurance of skill and personal devotion to but a few. The great mass of the wounded at this time were uncared for, and the only bed a wounded soldier was sure to find, to use the sad expression of the old Huguenot, De la Noue, was "the ditch into which he might have fallen."(53)

According to Fronsperger, who wrote about the middle of the sixteenth century, field surgeons and barbers had been employed for a considerable time prior to his writing, in the armies of Germany. He recommends the employment by each commander, of a chief surgeon, rather old than young, who should be able not only to work himself, but to teach his subordinates how to cure the diseases which arise when many men are crowded together. He should be present at the inspection of the troops, and see that his instruments as well as those of his subordinates were in good condition; should they have been injured, a corresponding deduction should be made from their pay. He should have charge of the medicines, and issue them to his assistants, as also, decide, in all contested cases, how much the soldiers should pay to the surgeon who claimed to have cured them.(54)

It is apparent from the concluding statement that at the time when Fronsperger wrote, that of Charles V., if it was considered important that surgeons should be attached to the imperial armies, their general relation to those armies was still very much what it had been for centuries previously in France and other European states, where armies had been habitually followed "by a swarm of ignorant empirics and avaricious charlatans, attracted by the thirst of gain, and who sold at high prices the elixirs, balsams, and even charms of which they pretended to have the secret."(55)

With regard to the medical and surgical service in the English army, we are told in Rymer's "Foedera," that Henry V. of England when about to engage in a war with France, in 1415, employed as a field physician, Nicholas Comet. He was to take with him three mounted archers, and to accompany the king in person. Morstede, the chief army surgeon, was to take with him three archers and twelve surgeons. The nature of the services of these surgeons is nowhere recorded.(56) Their rank or grade, however, may be inferred from the fact, that the following year Morstede and Bredewardyn, having been engaged as surgeons, were at the same time commissioned to impress as many additional surgeons, as they thought necessary for the expedition; as also, from an allusion to the medici, in a military code published at Le Mans in 1416, which is as follows:---" Whether soldiers, shoemakers, tailors, barbers, physicians or washerwomen."(57)

The expedition to St. Quintin (1557) is the first in which many surgeons were employed by the English, the number being definitely stated ; fifty-seven surgeons are said to have accompanied the army then formed, which numbered about six thousand men. Thomas Gale served as a surgeon in this expedition. He subsequently became celebrated in his profession at London, and published various surgical writings, among which was a "Treatise on Gunshot Wounds." He also gives us much information concerning the state of military surgery in his time, information which detracts considerably from the apparent completeness of the surgical outfit of the expedition against St. Quintin. "When I was at the wars," says he, "there was a great rabblement there, that took upon them to be surgeons. Some were sow-gelders and horse-gelders, with tinkers and cobblers. This noble sect did such great cures, that they got themselves a perpetual name, for like as Thessalus's sect were called Thessalians, so was this rabblement for their notorious cures called dog-leeches ; for in two dressings they did commonly make their cures whole and sound for ever. But when the Duke of Norfolk, who was then general, understood how the people did die, and that of small wounds, he sent for me and certain other surgeons, commanding us to make search how these men came to their death; we according to our commandment made search through the camp, and found many of the same good fellows which took upon them the name of surgeons, not only the name, but the wages also. We asking them whether they were surgeons or no, they said they were. We demanded with whom they were brought up; and they with shameless face, would answer, either with one cunning man or another, who was dead. Then we demanded of them what chirurgery stuff they had to cure men withal; and they would show us a pot or a box, which they had in a budget, wherein was such trumpery, as they did use to grease horses' heels, and laid upon scabbed horses' backs ; and others that were cobblers and tinkers, they used shoemakers' wax, and the rust of old pans, and made therewithal a noble salve, as they did term it. But in the end this worthy rabblement was committed to the Marshalsea, and threatened by the Duke's Grace to be hanged for their worthy deeds, except they would declare the truth, what they were, and of what occupation, and in the end they did confess, as I have declared to you before."

Although Gale may have employed in his account more energetic denunciation than is usually consistent with a rigid observance of truth, it is very certain that the English army medical service was in his time most defective; defective not only because of the ignorance and incompetence of those who often succeeded in introducing themselves into the army as surgeons, but, because the Government itself understood but very imperfectly how immediately its own interests were concerned in the health of the army, and perhaps still less perfectly understood the obligations by which it was, at least tacitly, bound to offer some equivalent to those who had given away their health and strength in the service of the King. I find in Rymer's "Foedera," among the instructions sent to Sir Thomas Leighton, who was with the English army in Flanders in 1592, a passage which is not without interest in this connection. It is as follows:---" Item: where it appeareth, by all certificates sent from hence, that the one-half or more of the nomber that weare there in Paye, are sicke and ympotente and unable to serve, it shall be considered how many of them may likely be recovered in short tyme to be able to serve, and those to be retyened ; and for the others, whose infermites and sickness are such as there is no lykelyhood of their recovery in short tyme, order is to be given bothe to discharge the Queen of her paye and to return them to their own country."(58)

There is such a thorough heartlessness pervading this order, the object of which was to get rid of the inconvenience and expense of supporting sick servants who had lost their health by their devotion, that one is quite willing to attribute it to ignorance, to the moral darkness which still lingered behind the walls and in the closets of Government offices, during the freshness and early radiance of that morning of English national life. Bacon was then laying the foundation of every exact science, and Shakespeare was revealing the inexhaustible depths of human passion and sympathy, and Sydney, among these same troops, "sicke and ympotente and unable to serve," was leaving to mankind as a dying legacy the immortal example of an unselfishness, of an abnegation so complete as to inspire him to give to a wounded soldier near him the draught which had been brought to quench his own thirst as he lay pierced with mortal wounds. But the world was still ignorant, cold, and selfish, and a long dreary period lay between the seed-time and the opening harvest.

As I only propose to give an outline of the history of military medicine and surgery, and more particularly in its relation to the subject of hospitals, it is quite impossible for me to notice many facts of great importance, but which belong rather to the general history of medical science. But I may here remark that, although the medical service of European armies was for many centuries undertaken, as we have seen, principally by charlatans and ignorant pretenders, from the opening of the school of Salerno in the eleventh century, there never was a time in which there were not a few men who fairly represented medical and surgical science, whatever. may have been their attainments as measured by modern standards. Hugh of Lucca, Pitard, De Mondeville, and several surgeons of perhaps equal distinction, even followed the armies of the Crusaders. At the close of the thirteenth and at the beginning of the fourteenth century the study of surgery was introduced into the Universities of Paris and Montpellier, and for a time obtained a certain reputation through the names of Lanfranc and Guy de Chauliac. The study of medicine was still more actively cultivated subsequently, but whatever may have been the beneficent results of the increase and extended distribution of medical knowledge, it is only very recently that the soldier has been able to secure that share to which he is rightfully entitled.(59)

It should be remembered that until the time of Louis XIII. European armies were usually very small, as also that shelter and succour might occasionally be obtained by the poor and needy, as already stated, in the hospices established by charity, as well as in the numerous monasteries then existing in almost every part of Europe. Indeed, it was probably only with the establishment of large and permanent armies that the necessity for a medical department and for a well-organized and systematic disposition of the sick, began to be seriously felt.

Montluc, when speaking, in 1575, of the wounded at the siege of Metz, says:---"l caused money to be distributed among them from the hospital which the admiral had erected." An ordonnance issued by Henry IV. at the time of the siege of Amiens, considers the subject of a military hospital, and shows how one might be supported by a tax on the sutlers and camp followers. At this siege (1597) Sully did establish a hospital, which soon became so favourably known as to induce people of quality to enter it for treatment. These two instances in which military, hospitals, or, rather, sedentary ambulances, were established are the most ancient which can be cited in Europe. It seems, however, that the good results obtained in the ambulance at Amiens, and which have been said to have gained for that siege the name of the "velvet siege,"(60) siège de velours, were soon forgotten, for we hear no more of military hospitals until the time of Richelieu, when temporary hospitals were erected in the rear of certain armies. But that these hospitals were by no means equal to the necessity which had suggested their establishment is shown by the following article, taken from the ordonnance authorizing these hospitals:

"If on the march certain soldiers should fall sick, so as to be unable to follow the flag, the captain, or whoever conducts the company, may give to them a passport, praying the mayors or sheriffs of the nearest city to receive them into their hospital, and to this city the mayors of the place, where they are, shall be obliged to see them conducted, and the mayors and the inhabitants of said city to receive and treat and medicament them carefully until their entire and perfect cure in the hospital, if there is one, and if not, at the expense of the city. And to this end the captains and governors shall aid on their part, and the bishops and curés shall be exhorted to commend them. And the said soldiers being cured and in a condition to return to duty, shall take a certificate from the magistrates of the place where they have been treated, upon which, and the above-mentioned passport of their captains, the cities upon the route prescribed by the magistrates, in order to join their companies, shall likewise be held to receive, lodge, and feed them in their hospitals, or elsewhere, that they may enable them by this charity to go from city to city until they reach the army or garrison." (61)

This statement is especially interesting, as it shows that permanent military hospitals did not then exist; that the droit d'oblat had ceased to be enforced as a means of securing a shelter for the sick, as also that the common practice of the time was to leave sick and disabled soldiers to the charity of the public, or as a charge upon the municipalities. And this condition of things prevailed in France until near the close of the reign of Louis XIV. That sovereign is said to have made use of temporary hospitals in the rear of his armies in 1672, and Voltaire gives a glowing account of the excellence of the hospitals at the siege of Lille, in 1707; but their exact relation to the army is not well known. Indeed, it is very singular that Chennevières, De Presle, Coste, and the several French authors who wrote particularly upon military hospitals during the middle and latter part of the eighteenth century, should have said so little, or written so confusedly, upon the organization of such hospitals during the period immediately preceding the time in which they wrote.

The hospital service was certainly not greatly improved during the reign of Louis XIV. There is no indication that permanent military hospitals were then established anywhere in France, or that the army was relieved of the care of its sick and disabled in any way other than that just described.

Nor is this fact particularly remarkable, since the functions of civil hospitals were at that time most imperfectly understood, and the limits of ecclesiastical, state, and municipal jurisdictions and responsibilities, had been by no means definitely established. As late as 1662 a royal edict was published, decreeing that:---" In' all cities and great boroughs there shall be hospitals to lodge, shelter, and nourish the poor invalid beggars, natives of these places, or who shall have been there a year; as also children, orphan, or born of mendicant parents, all of which poor shall be there instructed in Christian piety and in those crafts of which they may be capable." It will be seen that when this edict was published, the popular idea of the mission of a hospital was still that which had obtained during the middle ages, and which, in the eleventh century, had been represented by the orphanotropium of Alexius Comnenus.

The Hôtels Dieu and communal hospital establishments of France owed their foundation, however, principally to an edict of Louis XIV. issued in 1693, in accordance with which the goods and estates nominally belonging to pest-houses, but the revenues of which had been for a long time diverted to other purposes, were to be thenceforth employed according to their primitive destination; that is, as stipulated in the terms of the act, the revenues were to be applied to the maintenance of asylums for the support and care of the poor, and the relief of the sick poor of the localities in which the pesthouses had previously existed.(62) In a word, the Hôtels Dieu were nothing but great municipal pauper-houses, in which a medical service was maintained, and to which the state claimed the right of sending its disabled servants. Indeed, these establishments, as well as those more directly connected with monastic institutions, will always hold a much more prominent place in the general history of mendicity than in the history of asylums for the sick.(63)

The necessity of making a special and permanent provision for those disabled in war found its first serious expression in the project of a grand national asylum, which has since become celebrated in the military history of France.(64) And yet the Hôtel des Invalides, the foundation of which was laid in 1674, was established, in accordance with the terms of the royal edict, rather as a home for disabled officers and soldiers, than as a hospital properly so called.(65) It was only in 1707 that a surgeon-in-chief was appointed, and for many years after, the surgical organization of this asylum seems to have been sadly wanting in authority as well as efficiency. Nevertheless, the establishment may be considered as a hospital, and as one of the first of those institutions which, erected in the name of charity and humanity, have been intended rather to perpetuate the magnificence of their founders. The Hôtel des Invalides certainly offered better facilities for the treatment of disabled soldiers than had previously existed, and one can well understand how the courtiers of "Le Grand Monarque" should have said:---"The centuries the most distant shall see in it the substantial evidence of his liberality, of his magnificence, of his justice, and his piety." We are told that:---" All which is beautiful, grand, or majestic in architecture has been here employed, as well on the inside as on the outside. Gold, marble, exquisite paintings, nothing which sculpture or joinery-work, and all the other arts, could contribute to ornament an edifice, has been omitted;" and that the interior was arranged for the sick, as well as for those in health, with an "attention merveilleuse;" and, more than all the rest, that "on ne voit rien en tout cela qui sente la crasse des Hôpitaux."(66)

The history of the Hôtel des Invalides, in its immediate relation to our subject, is, however, chiefly important in view of the attempt there made, about the middle of the last century, to organize a course of anatomical and surgical instruction in the special interest of military surgery.(67)

The military hospitals which were established during the early part of the eighteenth century were for the most part merely sedentary establishments, created at the several bases held by active armies, and which disappeared with the special causes which had called them into existence. Their capacity was generally too limited to enable them to receive the number of sick inevitable in an army, and they were constantly dependent for supplementary aid upon the civil hospitals of the kingdom.(68) Although fairly well provided with physicians, surgeons, apothecaries, and the usual aids and subordinates, the physicians and surgeons seem never to have had that right of direction in the organization of the hospitals, which has always been an essential condition of efficiency. Scarcely had they escaped from the tutelage of the ecclesiastics of different degrees, who for ages had had the general control of such establishments, when they fell into the hands of the commissaires des guerres,(69) who, as the agents of the war department, have ever since successfully maintained their supremacy as well as their jurisdiction. Another evil which befell these establishments was occasioned by the system adopted by the French Government for their maintenance, a system practised at that time in several if not most of the states of Europe. The food, medicines, bedding,---everything, connected with the material organization and the daily maintenance of these hospitals, was furnished by contract; and more than this, the hospitals were as a common rule farmed out, the sick and wounded being provided with "everything necessary," at so much per head for each day. As the original contractors usually sold out their bargains to subcontractors, who in their turn sublet portions of the work to under-farmers, one can readily imagine the abuses, and even atrocities which would inevitably exist under such a system. Turpin de Crissé declares that he saw in the wars, between the years 1733 and 1741, vastly more soldiers perish in the hospitals from a want of proper care than lose their lives in combat.(70) Indeed, the parsimony of the administration and the avarice of contractors, in everything which concerned the organization and maintenance of military hospitals, were causes of unceasing complaint, and sources of scandal and disgrace to the government itself, during nearly the whole of the eighteenth century. This pernicious system was finally abandoned in the seventh year.

The importance of constructing permanent military hospitals was by no means generally recognized until about the middle of the eighteenth century. At this time it is said that there were eighty-five permanent military hospitals in France.(71) It will be understood, however, that these establishments were generally small. Coste, in 1790, recognized but four which could really be considered as of the "first order ;" these were at Lille, Metz, Strasbourg, and Toulon. Tenon, however, in 1788, speaks of that in Paris as being "distinguished by a spirit of order and good management," and as the hospital in Paris, where the sick were best distributed;(72) and Coste says of these establishments in general:---" They are national and characteristic, and worthy of all the admiration of foreigners, who cannot compare them with their own, without confessing the superiority of ours."(73) A number of these hospitals were reserved for the treatment of special diseases ; at Thionville there was a hospital for the subjects of scrofula; and special hospitals and sanitaria were established in the neighbourhood of certain mineral waters. Indeed, as early as 1730, a hospital, still maintained, was opened near the springs of Bourbonne-les-Bains.

Nevertheless, before the latter part of the eighteenth century, hospital establishments in France, whether military or civil, were in many respects badly conducted; within them there was a general insufficiency of food and clothing; but one bed, and that a narrow one, was allowed for two patients, and many of the commonest conditions of health as well as comfort were neglected.(74) Some of the causes of this state of things, I have already alluded to; but the principal cause, was the profound ignorance of the most elementary principles of hygiene on the part of the whole body of official administrators, who had been charged with the direction and control of these establishments. Notwithstanding the boasting of Coste, and other French writers, there are many good reasons for believing that if in Europe generally during the latter part of the eighteenth century, military hospitals were less numerous and splendid in their external appointments, such hospitals also suffered less frequently from overcrowding, and were quite as well maintained as those of France.

The period from 1750 to 1788 is that within which the system of permanent military hospitals received its largest development in France. In 1788 all the permanent hospitals, then numbering sixty-six, according to Coste, were suppressed, with the exception only of eight, which were preserved under the name of auxiliary hospitals. It was proposed to economize the funds of the state by the suppression of the fixed hospitals, and by an extension of the attributes of the surgeons-major attached to the troops, as well as of the functions and importance of the regimental hospital. Although a certain number of French medico-military writers have spoken of this change with regret, there is little reason to doubt that in 1788, the number of permanent . military hospitals in France, was much greater than it was for the interest of the administration to maintain, as also that the project of giving more importance to regimental and temporary field hospitals, was an attempt to improve the French army medical organization, precisely at those points, where it has always shown itself to be weakest.

The military hospitals were re-organized in France in 1793 by the National Convention, and the number of the permanent establishments was fixed by the Decree of the 4th Germinal at thirty. It is doubtful, however, if this number were really opened, as "in 1814 there were but eleven military hospitals in France which merited the name."(75) In 1828 the whole number, including those of instruction and d'Invalides, was thirty-four.

The necessity of establishing permanent military hospitals was very generally recognized about the same time all over Europe. Bardin says the English imitated the French in the construction of these hospitals; but this statement is not strictly correct, as the magnificent soldiers' hospital at Chelsea was founded in 1682, and the plans for the seamen's hospital at Greenwich, a construction still more imposing, were prepared by Sir Christopher Wren in 1695. Previously to the establishment of these hospitals, however, no permanent provision seems to have been made for those disabled in the English service. So late as 1664, we are informed by Mr. John Evelyn, who that year was appointed "a commissioner for the care of the sick and wounded in the Dutch war," that the custom was to billet the sick and wounded upon the civil hospitals, or quarter them in private houses; that no stores of medicines, provisions, or money were kept on hand; but that the sick were maintained from day to day as best they could be; and that the arrearage of the Government to the victuallers, and those who had furnished lodgings, medicines, &c., was occasionally such that their distress was scarcely less than that of the sick themselves. Evelyn says, that but about £34,000 was allowed for the taking care of the sick and wounded during this war---from 1664 to 1668----including the maintenance of all the prisoners. Writing on the 30th of September, 1665, to Sir Philip Warwick, he says:---" One fortnight has made me feele the uttmost of miseries that can befall a person in my station, and with my affections; to have 25,000 prisoners, and 1,500 sick and wounded to take care of, without one peny of mony, and above £2,000 indebted. Is there no exchange or pecuniary redemption to be proposed ? or is his Majestie resolved to maintain the armies of his enemyes in his own bosome ? whose idleness makes them sick, and their sickness redoubles the charge!" Elsewhere he complains bitterly of the suffering occasioned by this parsimony and want of foresight, not only to the prisoners, but to his own countrymen. "It is very hard there should not have been a sufficient fond consecrated & assign'd as a sacred stock for so important a service; since it has been a thing so frequently & earnestly press'd to their Lordships; and that this is not an affaire which can be menag'd, without p'sent moneyes to feed it; because we have to deale with a most miserable, indigent sort of people, who live but from hand to mouth, & whom we murther if we do not pay daily or weekely: I mean those who harbor our sick & wounded men, and sell bread to our prisoners of warr."(76)

Early the following year Evelyn laid before Charles II. a project for the establishment of an "infermerie" for the treatment of the sick and wounded. The king, "with great approbation recommended it to his R. Highnesse;" but nothing came of the project but approbation. To use Evelyn's own words:--- "I saw no mony, tho' a very moderate expense would have saved thousands to his Majesty, and ben much more commodious for the cure and quartering our sick and wounded, than the dispersing them into private houses, where many more chirurgeons and attendants were necessary, and the people tempted to debaucherie."(77)

The fact is, that the necessity of making a settled provision for the sick and wounded in the English service only became apparent, as elsewhere, after the army had been organized on a permanent footing, and this was very long after the establishment of standing armies in France, as well as in most of the European states. It is certain, however, that during the eighteenth century hospital establishments for the troops were organized in England, upon a basis substantially similar to that considered as necessary to secure the best results in civil hospitals. Indeed, since the establishment of permanent military hospitals wherever they may have been created, such hospitals have been constructed with the view of obtaining the hygienic conditions deemed essential in civil establishments. But it must be borne in mind that all these establishments, whether civil or military, have, until very recently, been constructed with little reference to those requirements which modern sanitary science has shown to be most indispensable.

Coste estimates that the establishment or building of the sixty-six military hospitals, which were maintained in France in 1790, involved an original outlay of money, as follows

1st class,

The buildings forming these hospitals(78) were most of them old convents, palaces, and private houses, transformed more or less extensively to meet the presumed requirements of the new service.(79) Most of the buildings, constructed especially for hospital purposes, were built in accordance with the plan known as the rectangle of Vauban, that is to say, two or more stories of wards were so erected as to enclose a quadrangular court. The military hospitals at Strasburg and Metz were examples of this sort of construction, which in its form is certainly one of the worst ever proposed. The space, moreover, within these buildings was generally exceedingly limited, but eighteen or twenty cubic metres of air being allowed each patient, with an interval of two and a-half feet between each bed. Overcrowding, and all the evil results of a defective ventilation, were inevitable in these establishments.

The hospital at Lille---of the first class---was, perhaps, one of the best examples of the hospital construction of the eighteenth century. In this hospital the principal buildings were so arranged as to form a cross, the four pavilions meeting in a central vestibule. Here was placed a large spiral staircase, which ascended to the roof. The well, which served as a sort of ventilating shaft, was covered by an open dome or lantern.

As a rule, however, the plan was simply to secure a large covered shelter, under which a multitude of persons might on an occasion be, crowded, so disposed that the general service of the establishment might be performed with as little inconvenience as possible. Says a writer of that time:---"In most European hospitals, four or five wards may be seen, more or less spacious, all communicating and mutually transmitting the unwholesome and epidemic vapours, which it was an object to isolate. These ancient plans, which religion seems to have consecrated to suffering humanity, have only been perpetuated because the service could in this way be the more easily performed. It is the fear of having to take a hundred steps more which developes this enormous complication of incurable diseases, devouring rocks, against which the profoundest observations that medicine can suggest are wrecked without the least success." (80)

The material organization of the civil hospitals, or Hôtels-Dieu, which had been used previously to the creation of military hospitals, and which were always relied upon by the military administration for supplementary aid, had been and then was even more defective. Limiting, however, my observations to points connected with their construction, I may observe first: their capacity to receive the sick was generally small as compared with the magnitude of the establishment, the ecclesiastical character of these foundations always predominating, even after a general direction over them had been assumed by the state. Previously to this, the various dormitories, refectories, chapels, sacristies, &c., usually occupied the greater part of the establishment. A church itself, on whose façade and walls had been lavished the moneys solicited for the poor, frequently formed the most prominent construction in the group of buildings; the church connected with the old Hotel-Dieu at Paris is said even to have "equalled in richness of ornamentation the most superb churches of the sixteenth century."(81) M.Viollet le Duc has observed, in speaking of the hospitals erected in the reign of Louis XIV. "It would be difficult to say that the hospitals of the seventeenth century are models worthy of imitation in their construction as regards salubrity, hygiene, or the respect which should be shown the sick poor ;" but, as is quite natural for a lover of art and the archæologies of architecture, he nevertheless discovers in the remains of the hospitals of the middle ages "a sentiment of charity, delicate as well as intelligent."(82) M. Viollet le Duc, in his admiration of certain national monuments, and the dispositions for the care of the sick and infirm therein exhibited, does not consider, when he makes this statement, the very limited capacity of these foundations. This capacity was limited, both relatively and absolutely ; relatively, because the need of public hospitals was then vastly greater than at present, not more on account of the general poverty of the lower classes than because of the enormous sickness rates which then weighed constantly upon the whole population ; and absolutely, because the infirmaries connected with conventual establishments were rarely capable of containing more than a small number of beds, while these beds were originally intended rather for the inmates of the establishment itself, or for sick and infirm members of the same or allied religious orders, than for the poor and destitute among the general population.(83) Says Husson :---" Aside from the ancient pest houses, where the separation of the sick was a forced consequence of contagion, and aside from a few other foundations of less importance, where charity assumed the character of private hospitality, we find in all the hospital constructions of the middle ages the same principle, absolute and exclusive, of large halls. Nearly everywhere the hospital was a great gallery, divided into two or three naves, built out from a cloister or a chapel. Sometimes, as at Lubec, the Hôtel-Dieu, unprovided with any of the general arrangements necessary for the treatment of the sick, was only composed of a church with three symmetrical naves that served as an entrance, and at the extremity of which was a large hall. Assuredly that was not a hospital, as we understand the word to-day, it was rather a charitable refuge, the ancient Xenodochium, which the church opened so widely to pilgrims, weary travellers, or the indigent without shelter."(84)

Secondly: these hospices and hospitals were usually constructed with very little reference either to light or ventilation. The very best of them had nearly all the objectionable qualities now generally attributed to churches, when used as hospitals. Often the hospitals were constructed exactly as churches, and served, in fact, at the same time as chapels and infirmaries ; such buildings still exist at Angers, Chartres, and Tonnerre. At Tonnerre the body of the building contains on each side twenty cells or alcoves, in each one of which was placed a bed ; galleries were established over the alcoves, which gave access to the windows, and permitted also a supervision of the interior of the cells, a disposition which was also subsequently adopted in the Hôtel-Dieu at Paris.

Although the special administration of permanent hospitals is not immediately connected with my subject, its relation to the care which the wounded have there received has always been most important. The direction of the permanent military hospitals in France has been uniformly entrusted to officers of the intendance or quarter-master's department, and one of these officers, called a comptable, has had the absolute direction of everything connected with the material organization and maintenance of each hospital, subject only to the general control of a central bureau.

In the management of the civil hospitals, it was only with the Revolution that the exercise of the right of administration was directly assumed by the state.(85) In 1801 M. Frochot, then Prefect of the Seine, in view of the disorganized condition of the hospitals in his Department, proposed to constitute an administration on the following basis, viz.: a central council of administration, conseil d'administration, to be constantly represented in each hospital by a surveillant (general director), and an économe (special director). The proposition was adopted, and it substantially represents the system upon which French civil hospitals are now generally conducted.

Thus it was only with the beginning of the present century that the distribution of the assistance to the sick, had been subjected to a central control, and the service and the administration of the hospitals, were directed in accordance with a plan which, whatever its faults, was at least uniform and regular.

The radical vice in the administration of French hospitals, whether military or civil, is that power is exercised within them without sufficient direct responsibility. The officier comptable, and the économe, do everything and are responsible for nothing, while the intendance, and the conseil d'administration do nothing, and are responsible for everything.(86) Nothing could be more simple, or perhaps methodic, than the division of administrative duties adopted, but the practical results are too frequently disastrous in the extreme. The worst of it is, that this system is not one peculiar to hospitals, but is one of the most distinctive and salient features of French bureaucracy in general. Whoever may have once made the vain attempt to discover the person responsible for the management of a French hotel, can readily understand the abuses likely to arise, when it is not always for the interest of those connected with an establishment, to see that nothing is wanting with regard to the food, shelter, and attendance of those to whom its doors are opened.

Closing here my general account of permanent military hospitals, I will now resume that part of the narration which relates to the immediate care of the sick and wounded in camp or on the battle-field, and which I had traced down to about the middle of the sixteenth century.

We have seen that, whenever surgeons were then mentioned as present in armies, they were quite uniformly represented as attached to the retinue of commanders. Indeed, there is no reason for believing that surgeons were ever engaged, in the French army, on any other recognized footing, before the reign of Louis XIII., when, for the first time in the royal ordonnances of France, "surgeons-major of camps and armies" are mentioned.(87)

Gustavus Adolphus (1611-32), is said to have first appointed four surgeons to each one of his regiments, which, numbering two or three thousand men, were subsequently reduced to twelve hundred, and afterwards to one thousand and eight men; and the credit has occasionally been given to him of having first established a regular military sanitary service. But it is by no means probable that this service in the Swedish army, at the beginning of the seventeenth century, was either more efficient or better equipped than the corresponding service in the armies of Germany, France, and England.

Ballingall says:(88)---"The appointment of regimental surgeons in the English army was, it is believed, coeval with their corps;" a statement not particularly satisfactory, as it is very uncertain when troops were first enrolled by regiments' in the English service.(89)

There is every reason to believe, however, that at the beginning of the seventeenth century the character of the surgeons employed in the English army had considerably improved upon that which fifty years before had stirred Gale to indignation. Grose(90) quotes from a manuscript in his possession, written by Ralph Smith during the reign of Queen Elizabeth (1558-1603), a description of the qualifications and duties of a military surgeon. The passage is as follows:---

"Surgeons shoulde be men of sobrietie, of good conscience, and skillfull in that science, able to heal all soares and woundes, specially to take oute a pellett of the same. All captains must have suche surgeons, and ought to see them to have all their oyles, balmes, salves, and instruments, and necessary stuffe to them belonginge, allowinge and sparinge carriadge for the same. That every souldier at the paye daye doe give unto the surgeon 2d. 'as in tymes past hathe beene accustomed' to the augmentation of his wages ; in consideration whereof, the surgeon oughte readilie to employ his industrie uppon the soare and wounded souldiers, not entermedlinge with any other cures to them noysome. Regarde that the surgeon bee truelye paid his wages, and all money due to hym for cures that bye the same hee maye bee able to provide all such stuffe as to him is needfull. Such surgeons muste weare their baldricke, whereby they may be knowen in the tyme of slaughter, it is their charter in the field."

This statement is interesting; it shows that, as in the imperial armies of the time of Charles V., the English army surgeon in the sixteenth century received pay from the soldiers, as also money for cures, in addition to his salary ; that he was expected to provide at his own expense the medicines, &c., needful; that he wore in action a baldrick or shoulder-belt as an insigne of his office; and that "all captains must have suche surgeons." Clowes, a military surgeon who lived and wrote at the end of the sixteenth century, often speaks favourably of the attainments and character of his professional contemporaries, although he occasionally complains of "runnagate surgeons" as well as of the laxity which still permitted empirics to enter the service.(91) In 1620, for an army of thirty thousand men, which King James proposed to send, into the Palatinate, every regiment of foot, consisting of twelve companies of one hundred and fifty men each, had a "chief surgeon" and a "surgeon" for each company; yet no allowance or provision whatever appears in the estimate for medicines or for the establishment of hospitals, although there is a very minute detail given of nearly all the other necessary stores.(92) It is evident, therefore, whatever improvements may have been effected, that the field sanitary service at this time was still on a very indifferent footing; and there it remained, until about the middle of the eighteenth century, when, as we learn from Pringle, Munro, and Brocklesby, its important relations to the army had begun to be more generally recognized, and measures had correspondingly been taken to increase its efficiency.

As to the ambulance, or the temporary field hospital, it is difficult to say when it first came into use. It has generally been considered in France as a creation of Cardinal Richelieu, from a statement, made by the Cardinal in his "Testament Politique," commending the organization of hospitals which might follow the movements of the army, and asserting also, that in the campaign of 1639 this plan had been put in practice.(93) Chennevières is inclined to believe that ambulant hospitals were in use at an earlier period.(94) He, however, founds his opinion on the ordonnance of Henry IV., made in 1591 in the camp before Rouen, levying a tax on the wine and cider sold in camp, "to be expended in defraying the expenses necessarily occasioned in taking care of the wounded during the siege;" as also, upon the establishment created by Sully in the camp before Amiens six years later. But these provisions for the wounded were evidently quite exceptional, as we hear nothing more upon the subject for many years.

The first French official allusion to the establishment of temporary army hospitals is to be found in an article in the Ordonnance of January, 1629, which is as follows:---"Hospitals shall be maintained in the rear of armies for the relief of soldiers who are wounded or are sick." And it was by virtue of this article, that the same year a hospital was established at Cazal, the direction of which was, very naturally, according to still accepted traditions, confided to the Archbishop of Bordeaux, "with full power to choose the officers who are to serve there, as also, to establish the expenses which are to be incurred for food, the treatment of the sick and wounded, purchase of furniture, drugs, utensils, and everything which shall concern the maintenance of said hospital. His majesty also wishes, that the herein-named archbishop may give to the soldiers who shall have been, wounded, or who shall have been treated, certificates of their wounds, as evidence, when he shall accord to those maimed, in testimony of their services, places in religious establishments."'(95)The year following (1630) two hospitals, one for the sick and one for the wounded, were established at Pignerol, for the army of Italy. Nevertheless, that the relations of these establishments to the general administration of the army were very imperfectly understood, or at least defined, is shown by the fact, that whether he should or should not avail himself of their succour, were questions left entirely to the option of the soldier himself. Indeed, in 1638, a special establishment was made in favour of those soldiers who did not wish to go to the hospital, in virtue of which, in addition to the hospitals organized as at Pignerol, there were to be in each army:---

"Jesuits and cooks, who shall give broths and soups to all those sick who do not wish to go to the hospital, and moreover a surgeon and an apothecary, to take care of and treat with medicines those who shall need them.

"The grand army shall have six Jesuits; viz., four priests and two lay brothers; together with a cook and five aids, a surgeon and an apothecary. The said Jesuits shall have two two-wheeled carts, provisions, and six sheep every day.

"Each of the small armies shall have half of this attendance, viz., three Jesuits, a cook, three aids, an apothecary, a surgeon, a two-wheeled cart, and three sheep.

"The said Jesuits are particularly charged with the consciences of the sick, and to be near by on perilous occasions, for the purpose of giving absolutions, after obtaining from the soldiers "confessions of their sins and promises not to fall into them again."(96)

This is the first account which we have of the organization of a veritable ambulance, although this word did not enter into the French language until a century and a-half later. Its means must have been very limited ; its personnel was absurdly composed, but the account is none the less interesting for that reason. During the reign of Louis XIV. the field hospital service was conducted substantially in accordance with the provisions of the ordonnances cited, that is to say, the sick and wounded were treated in quarters, a few temporary hospitals being erected in the rear of active armies, as a means of partial relief, while it was the practice to evacuate the sick upon the Hôtels-Dieu or civil hospitals, or throw them as a charge upon the first municipalities who were able or willing to receive them. Nevertheless, in the opinion of the time, not only had the military sanitary service been greatly improved during this reign, but it had attained a degree of perfection, to improve upon which would have been nearly impossible. According to a military writer of this time:---

"Never was war carried on so conveniently as to-day in France. The care which has been taken by our monarch is inconceivable, and his prudence has so entirely anticipated everything, that one may say it has forgotten nothing which could be necessary. The hospital is of great service to the sick and wounded, who under the care of surgeons, physicians, apothecaries, and the ecclesiastics, organized under the supervision of a director, are as well off as if they were in the hospitals of the finest cities of the kingdom.

"The hospital constantly follows the army, until a proper and convenient place has been found for its establishment ; to it all the sick are brought ; and it is the practice to leave in the camp only a section of the hospital---un détachement de l'hôpital---to respond to pressing necessities. There is an abundant provision of every sort of remedies, instruments, and appliances for diseases and wounds. The service of the hospital is discharged by the Franciscans (Recolets), who also confess the wounded on the field."(97)

In one respect there was an improvement. The number of the physicians, surgeons, and apothecaries, and of the whole personnel of the field service, was greatly increased. According to the royal edict of January, 1708, there were to be "four medical inspectors-general of the land forces and the hospitals on the frontier, fifty consulting physicians-major for the hospitals, four consulting surgical inspectors of armies and hospitals, fifty surgeons-major for the hospitals, and eighty-eight surgeons-major for the eighty-eight regiments of our infantry;" and the cavalry and the other arms appear to have been equally well provided with medical attendants. The medical officers were also accorded, as we are informed, wages, appointments, privileges, immunities, exemptions, lodgings, rights, &c., &c. We are at least made acquainted in this edict with all the elements of an effective organization, and however loosely they may have been bound together, or chaotically they may have at times come in contact with certain parts of the machinery of the general administration, or indifferently they may have been provided with the means of treating either sick or wounded, they, doubtless through individual and personal efforts, often did good service. Says Audouin :---"Admitting ambulances to have only been established so late as the sixteenth century, and sedentary military hospitals in the seventeenth century, France still would have the priority over all other nations, for no one in those times, and not even after the example given by France, had military hospitals. Every people continued to treat the wounded and the sick in tents and quarters. The Austrians, the Prussians, the Danes, and the Swedes, imitated the French only towards the middle of the eighteenth century. The English had hospitals only a little earlier, but long after the French, and were still experimenting with their regimental hospitals. . . . . And it must be said, to the glory of French surgery, that if the hospital administration was more complete than abroad, the excellence of the surgical service contributed most powerfully to that difference."(98)