William B. McAllister
Volume 35 (1993)
University of Virginia
The Period between 1850 and 1914 was the great era of the modernization of military medicine. Physicians in all armies faced an uphill battle to implement changes that they believed would benefit the army. In order to improve and maintain the health of the troops, medical men needed, first and foremost, freedom from institutional constraints that severely limited their ability to carry out their programs. Much of the story of military medicine in these years revolves around the efforts, ultimately successful, of military physicians and their supporters to create the conditions necessary for the implementation of their designs.
Military physicians in the French army wished and worked for this freedom no less than those in other armies but were singularly unsuccessful for a long period of time. Years after the other major armies of Europe had renovated their moribund medical services and given their doctors a modicum of independence, the French Service de santé still suffered under the fetters a debilitating military bureaucracy.
Why were the French so slow to take advantage of the increasingly apparent benefits of “modern medicine?” The answer lies in a combination of political, social, and institutional factors that were unique to 19th century France. Indeed, in the last three decades of the century, the manner in which the French sanitation service should function became a focal point of controversy in a much larger debate. Battles between proponents and opponents of army reform were part of a larger confrontation between those wanting to conserve the France of the past and those hoping to forge a France of the present and future.
In this supercharged atmosphere the fate of the Service de santé took on a symbolic importance that caused its disposition to be widely debated. The outcome of this debate was affected by many considerations that would appear at first glance to be extraneous to the relatively narrow issue of the functioning of the sanitation service. In order to comprehend the nature of the post-1870 debate, it is necessary to begin with an overview of pertinent aspects of the issue that predated the war.
THE STATE OF FRENCH MILITARY MEDICAL AFFAIRS BEFORE 1870
THE MOST important institution in the daily life of the Service de santé was the Intendance. The Intendance can best be described as a super-powerful quartermaster corps. In addition to the normal duties of supplying the army with all types of material, the Intendance was also partially or fully responsible for many other tasks. These other functions included arranging for the transportation needs of the army and supervising many of the ancillary personnel attached to other units, which in the case of the sanitation service included “Officers of Administration”, pharmacists, and nurse/orderlies. Additionally, the Intendance was given broad powers of financial control over branches of the army not designated independent corps, including the Service de santé. In the case of the sanitation service, the Intendance was authorized to approve or disapprove all spending requests made by physicians, pharmacists, and others, even if funds had been allocated in the budget for the items or services requested.
The amount of authority given to the Intendance was largely the result of an extreme emphasis on economy. Since the Intendance supplied the needs of the entire army and approved the expenditures of many of its branches, it was often more responsive to the requirements of the treasury than it was to those of the armed services. Additionally, once the Intendance had gained responsibility for some aspect of the army’s business, it was tenacious in defending its “turf” against any and all attempts at usurpation. The main battles between the Intendance and other branches of the army had to do with disagreements over the chain of command. In theory, command authority in the French army was divided into several reciprocal elements. Each was considered to be distinctly separate, yet dependent upon the others for the proper functioning of the army. Because of the nature of the responsibilities that devolved upon the “fluid” nature of the command structure created constant friction. The Intendance often ended up performing elements of several command functions. For example, with respect to military administration, the Intendance was expected to promulgate regulations, audit expenditures, and supervise the actions of its functionary personnel in the field. Officers in other branches resented the frequent intrusions into their affairs by penny-pinching (and often lower-ranking) intendants. In addition, because of its control over matters financial, the Intendance often contradicted directly or indirectly the wishes of other command authorities. As a result, the Intendance was extremely unpopular in numerous army circles. Some critics characterized the Intendance as wanting to be “in the army but not of the army” while others referred to it as the “scourge of the army”.2
“OFFICERS OF ADMINISTRATION” AND PHARMACISTS3
THE “OFFICERS of Administration” were functionaries of the Intendance in charge of specific areas of the military service including supply, financial affairs of the army, food, clothing and other equipment necessary for encampments, and the military hospital service. In the case of the section in charge of the military hospital service, the “Officers of Administration” commanded the clerks of the Intendance, and, more importantly, the hospital nurse/orderlies (infirmiers). The men comprising the units of nurse/orderlies were not, however, part of the Intendance, but rather were drawn from the ranks of the regular army. This led to confusing conflicts of authority.
In addition to these duties, the “Officers of Administration” were charged in war time with the direction of stretcher-bearers. There were no soldiers permanently designated as stretcher bearers in the French army, so that when war broke out the Service de santé was dependent on regular units to assign men to this task. It fell to the “Officers of Administration”, with no experience in medical matters, to organize and direct these untrained men.
Pharmacists were also considered part of the Service de Santé. Their main task was to concoct and dispense the medications prescribed by doctors. However, although orders for individual doses of medicine did not have to be approved by the local “Officer of Administration” or intendant, they did watch carefully to ensure that stores of drugs were not “unnecessarily” depleted. Since the Intendance alone had the authority to sanction expenditure for more medicines, they exerted a powerful influence over the pharmacists.
A QUESTION OF HONOR4
THE INTENDANCE in general and the “Officers of Administration” in particular, the nurse/orderlies, and the pharmacists all suffered from low levels of prestige. They carried the stigma of being non-combatant elements of the army and their tasks were considered by many to be servile. Animosity between these branches of the sanitation service only made the situation worse. The result of this state of affairs was the development of an overwrought sense of “honor.” Members of the Intendance, in particular, were extremely sensitive to any slight upon their character,and they routinely considered any criticism (constructive or otherwise) of their performance to be a blot upon their reputation. This sensitivity to any attempt to objectively review their effectiveness would make the Intendance a stubborn and formidable opponent of changes in the status quo.
THE MEDICAL OFFICERS OF THE SERVICE DE santé 5
IT WAS within this byzantine constellation of forces that the heart of the Service de santé, the medical officers, had to operate. In performing their daily tasks, the shadow of the Intendance loomed over all the parties doctors depended on to help them accomplish their duties. If a medical officer wanted a nurse- orderly to carry out some task, normal procedure required him to make a “request” of the “Officer of Administration” or intendant in charge. Pharmacists could normally be expected to fill prescriptions without difficulties, but soured relations between physician and pharmacist or physician and intendant might disrupt the process. The total amount of medicine available was, in the end, subject to the approval of the Intendance. Ordering even the most mundane supplies required the prior approval of the local representative of the Intendance. During maneuvers or on campaign, if, for example, a medical officer wanted to erect a field hospital in a certain location, he could only recommend this course of action to the commanding officer of the unit. If the commander agreed, he would then issue the necessary orders and deliver them to both the Intendance and his field commanders to execute, because the men required for field hospital operations were under a variety of different commands.
In addition to these problems, lack of prestige and low morale dogged the doctors at least as much as other members of the Service de santé. Because they were considered to be non- combatants, military physicians were not afforded many of the little courtesies usually afforded to officers, such as military salutes, bearing of arms, and the like. The notoriously low pay was little recompense for the years of study and the daily diet of indignities that medical officers had to endure. As a result, the ranks of the medical officer corps suffered from recurrent personnel shortages.6
THE 1848 REVOLUTION7
IN THE case of the Service de Santé, a further justification for strict supervision by the Intendance emerged from the events of 1848. On May 3, 1848, the new government declared autonomy for all branches of the army that had previously been sublimated to the Intendance. “Autonomy” allowed these branches to control their own spending, give orders to the troops under their command, and relegated the Intendance to a strictly subservient role of supply and bookkeeping. This move by the revolutionaries was firmly within the tradition of creating a politically reliable army, because the Intendance was widely (and correctly) believed to be an extremely conservative force within the armed services.
Medical students were in the forefront of this aspect of revolutionary activity. Whether this was because they were truly republican, or merely eager to remove themselves from the oppression of the Intendance is unclear. In any case, they agitated for the autonomy of the Service de santé, published a newspaper targeted at the service’s medical students and military physicians that called for reforms in the army, and treated the wounded during the bloody June Days.
Needless to say, activities of this nature did not endear the Service de santé to the authorities who gained control after the June Days, and especially to those who came to power in December of 1848. Consequently, a period of reaction followed. Between 1849- 1852 a series of new army regulations placed the sanitation service firmly under the authority of the Intendance again. This move was clearly designed to assure control over the potentially revolutionary (and possibly spendthrift) Service de santé by placing it under the watchful eye of the reactionary Intendance. As if to add insult to injury, pharmacists were recognized as a distinct group within the service, and given more autonomy of action than previously had been allowed.
The significance of the 1848 revolution lies in the symbolic impact of the supposed “revolutionary” propensities of the sanitation service. For those in favor of the political status quo, any talk of improving the lot of the Service de santé smacked of republicanism and chaos. However, because of the problems inherent in the system of military medicine as practiced in the French army, the difficulties of the Service de santé were often used as an example of the worst abuses of the Intendance by those in favor of general army reforms. For many conservatives this tainted all discussion of reform. Thus, by symbolic extension, the problems of the Service de santé had the potential to become a highly political issue, rather than one of merely how to most efficiently serve the medical needs of the army. Only in this way can much of the subsequent opposition to sensible reforms be explained.
THE FRANCO-PRUSSIAN WAR
As bad as the conditions under which the Service de santé had to operate may sound, they were not particularly unusual for the first half of the nineteenth century. The military medical services of the other major European armies were in roughly the same position. In the course of the 1850s and 1860s, however, the lessons learned from a combination of wars, mobilizations, and political realignments prompted Prussia, Britain, Austria, the United States, and many smaller states to make substantial changes in the operations of their sanitation services. Even though the French were directly involved in many of these same events, they made few substantive revisions in their system. As a result, by the summer of 1870 they had fallen behind all these competitors, and especially the Prussians, in their medical arrangements for the troops.
The amount of literature on the Franco-Prussian war is vast, and it is not necessary to deal with it in any detail here.8 A few statistical descriptions will suffice to make the central point: that Prussian performance was superior to the French efforts in all areas, including military medicine.
During the war the German forces were able to field 1 doctor for every 290 men. Although the French ratio was 1 to 580 on paper, in actuality they could only muster 1 military physician for each 740 men due to shortages of medical personnel.9 While the Prussians had allocated 1412 men per corps to perform the duties of the Sanitatsdienst, the French assigned only 126 on a permanent basis.10 At field hospitals, French doctors typically had to deal with caseloads of 400-500 men per medical officer.11 The confusion of lines of authority and the incompetence of the Intendance resulted in shortages of transportation, equipment, and supplies. The French Red Cross and other volunteer units, organized only on paper at the war’s beginning, hastily put together a number of ambulances and field hospitals staffed by well meaning, but unprepared doctors and amateur nurses.Having no direct communication or liaison with the army, these volunteer units proceeded to clog up the roads leading to the front, and, due to lack of accurate information, often appeared where least needed while other areas were overwhelmed with wounded. Unlike the detailed evacuation scheme employed by the Prussians,12 no advance preparations were made by the army to provide for hospitals in the rear, and most volunteer units headed directly to the front, because there was not as much appeal to merely attending to convalescent soldiers far from the “action” at the front. After the war, General Chenu estimated that 10,400 French soldiers would have lived if the French evacuation system had been better organized.13 Many sick and wounded Frenchmen survived only because they were captured in the quick German advance. Once behind enemy lines, they were saved by the superior arrangements of the Prussians.
THE BATTLE OVER REFORM 1871-1889
AFTER THE Franco-Prussian War (which contemporaries often referred to simply as “our disaster” or “the catastrophe”), a tremendous amount of time and energy was spent in France discussing what to do about army reform.14 Proposals concerning how best to counter the threat from Germany, the desirability of a truly citizen army, the nature and functioning of the General Staff, the accountability of the army to civilian authorities, and the reorganization of various branches of the armed services appeared from all quarters at a dizzying rate.15
Within the context of these larger debates, the role of the Intendance and the nature of its relationship with the Service de santé became major points of contention. Legislators, the government, representatives of sundry branches of the army, the press, civilian physicians, and interested citizens all argued vehemently and at length about the proper function of the Intendance and the Service de santé. The changes that would be engendered by the emancipation of the sanitation service from the Intendance would appear at first glance to be a relatively minor issue compared to the broader questions under discussion, but because of its political as well as actual significance, the fate of the Service de santé became symbolic. Advocates and opponents of reform would come to judge how successful they were by the status of the Service de santé.
THE PRO-REFORM CONSTITUENCY
OBVIOUSLY, those in the forefront of efforts to revise the system were the military physicians. The most senior members of this group, men such as Chenu and Hippolyte Larrey (son of the renowned Napoleonic-era military surgeon D. J. Larrey, and a well-known figure in his own right) had served in the Service de santé with distinction for many years and their views about this issue had been a matter of public record for quite some time. Though aging and at times willing to compromise more than some of their younger counterparts might have wished, they were still considered the preeminent spokesmen on military medical issues. They also had the advantage of access to the highest levels of the government and the legislature, ensuring representation for the Service de santé on the numerous committees, commissions, special commissions, and advisory bodies that wrestled with the issue of reform. A slightly less prominent, but still highly respected group of senior medical officers promoted change by testifying before the Senate and Chamber, discussing with anyone willing to listen, and agitating within the army. Those who fall within this category include Venant Antoine Leon Legouest, head of the Service de santé, Michel Levy, the director of the military medical school at Val-de-Grace from 1856 to 1872 who established a solid foundation for its operations, Louis Laveran, Levy’s successor, and Charles Emmanuel Sedillot, director of the Strasbourg-based army medical school from its inception in 1856 until shortly before its demise in 1870. The vast majority of military physicians worked diligently at their jobs and waited for these spokesmen to achieve a breakthrough on their behalf.16
Another group increasingly strident in their calls for reforms were civilian doctors. Their efforts to come to the aid of Service de santé were part of a large agenda intended to promote social progress through “science” and improve professional standards. Improving the health and sanitation of the populace was a key ingredient in their formula, and they wanted to transform the army into conduit of “progress” instead of an obstacle to it. Many doctors became directly involved in politics as a result, and in the early years of the Third Republic, the Chamber of Deputies was populated by numerous physician-legislators. These men could be counted on to support the cause of the sanitation service on the basic of principle. Additionally, the opinion of increasingly prestigious medical an~ scientific organizations with the same general outlook was an important boon to those in favor of reform.17
Non-medical legislators made up the third major constituency in favor of revisions. Their main motivation was the fear of another disaster like that of 1870. The level of commitment to the autonomy of the sanitation service varied from one to another, depending largely on their diagnosis was of what was wrong with the army. Generally, those in favor of more substantive reforms tended to be the most supportive of the cause of the Service de santé. For the most part this group held the “swing votes” which could defeat or enact legislation. On the whole, they tended to be in favor of some sort of change, but agreement on exactly what course to take was difficult to achieve. Most prominent among this group was Charles de Freycinet, a frequent contributor of reform plans and Minister a War in 1889 when the issue was finally decided.18
THE ANTI-REFORM CONSTITUENCY
HEADING UP the list of opponents of substantive change, as might be expected, were the personnel of the Intendance itself. Heavily criticized after the Franco-Prussian War for its role in the defeat, the Intendance found itself on the defensive. Its main goal, to preserve its independence and power as an integral part of the decision-making apparatus of the army was essentially a backward looking one. Consequently, its general strategy was one of obfuscation, including denial, appeals to patriotism, fear of rampant republicanism and making cosmetic changes when necessary to relieve extreme pressure for more fundamental reforms.19
Within the Service de santé itself, the Intendance had allies. The “Officers of Administration”, with a few exceptions, were more comfortable with the status quo than any of the proposed alternatives. Although a rather low-status and low-profile group, they did register their opinions when possible, usually when some committee or other was looking for testimony. The pharmacists, for the most part, also figured that their freedom of action and responsibility was maximized under the Intendance. Their quasi-medical position and prestige afforded them several opportunities to speak against the autonomy of the sanitation service.20
The other major constituency opposed to reforms were certain members of the legislature and the government. Usually of conservative bent, they feared the left-of-center political overtones of the reformers, were not particularly enamored with the increasing influence of “expert” and “scientific” advice, remembered well the “revolutionary” tendencies of the Service de santé in previous years,and believed that rather than a complete overhaul along the lines of the supposedly superior Prussian model, only some measure of fine tuning was necessary to fix the system. In a word, they feared the dissolution of la patrie in a flood of “solutions” that smacked of socialism, modernism, and Germanicization. The opponents of reform were usually represented by heads of the various services. In addition, post-1870 Ministers of War (until Freycinet) consistently sided with the interests of the Intendance.21
THE BATTLE FOR REFORM22
THE OPENING rounds of the battle occurred in the first three years after the end of the Franco-Prussian War. In late 1871, the editors of Le Temps, as a part of the larger discussion of army reforms, fired some of the opening shots. Their approach stressed pragmatism over dogmatic considerations, and probably fairly represented the middle-of-the-road position. Although they were opposed a priori to the current powerful position of the Intendance and placed much of the responsibility for the defeat upon it, the editors also took pains to state that there was plenty of blame to go around. Some changes in the military medical system were probably necessary, but they were not willing to endorse the full emancipation of the Service de santé. The most immediate task was to reopen a military medical school somewhere on French soil, since Strasbourg, site of the previous facility, was now part of Germany.23
Throughout 1872 and into 1873, the battle was fought out behind the doors of a “mixed commission” created by the government to concoct a more rational organization for the Service de santé.24 The committee, consisting of 2 generals, 1 colonel, 3 intendants, 2 pharmacists, 1 “Officer of Administration” and 4 medical officers was to draw up regulations that would be inserted into one section of an general army reform bill. The intendants and the “Officer of Administration” wanted to maintain the subordination of the doctors, and were supported by the pharmacists, who claimed that they needed continued independence from the physicians to exercise the proper amount of control over the dispensation of prescriptions. The medical officers pointed out the advantages of the Prussian system and the inconveniences of their own, and contended that their suggestions were actually good for both soldier and budget. After months of wrangling, the mixed committee reached a compromise that was not much different than the previous arrangement. The mixed commission submitted a document that even they admitted was lacking in logic and clarity. The “old guard” had won the first round.
The Academy of Sciences took up the question in May of 1873, at the request of Ernest Courtot de Cissey, the Minister of War.25 The pharmacists, led by their chief, Antoine Baudouin Poggiale, realized that the autonomy of the sanitation service would amount to the subordination of the pharmacists to the doctors. They reacted violently to this prospect with an amazing variety of arguments: that the pharmacy service would be dishonored by a reduction of status- that this loss of status would result in even more acute shortages of personnel, that the change would threaten certain “sacred interests” of the army such as the acquisition and preparation of medicines, the chemical analysis of rations, the handling of toxic substances — all of which require specialized care, education and training; and that keeping their independence was the only way to protect the last bastion of pure scientific research in France against crass mercantile interests. The pharmacists rejected the assumption that physicians were somehow superior, and protested against their “pretensions of hegemony”, claiming that they held a vendetta against that convenient scapegoat for the faults of others, the Intendance. They also suggested that medical officers were unfit to command or supervise administrative tasks. Utilizing the sacrosanct language of the French Revolution, they insisted that each branch of the sanitation service be allowed its liberté and égalité under the aegis of the Intendance. They recommended that the most straight forward way to deal with the problems of the Service de santé involving pharmacists was to eliminate the existing “notorious” level of understaffing.
The physicians, led by Legouest and Larrey, countered these accusations by pointing out that the fundamental question at issue was how to best deliver services to the army. They had no desire to dominate the pharmacists, but if it was necessary to subordinate them in the interests of the sanitary needs of the army, so be it. The other major armies of Europe, the Germans in particular, had enacted similar regulations and suffered none of the dire consequences enumerated by the pharmacists. If military physicians in other countries could deal with the complexities of autonomy and deliver improved services into the bargain, why could they not in France?
The Academy of Sciences, with many more physicians than pharmacists in its ranks, saw the light and voted to support the principle of the autonomy of the Service de santé. The language of the report issued by the Academy condemned the status quo. However, an amendment calling specifically for the subordination of pharmacists was defeated. The final document left it up to the Ministry of War to decide what to do about the relationship between physicians and pharmacists.
Unfortunately for the doctors, they had won only a pyrrhic victory. While the debate raged at the Academy, the National Assembly had put the final touches on the Army Law of 1873. The wide diversity of opinions held by members of the Chamber and Senate precluded agreement on substantive changes, and the compromise solution they eventually passed left much of the basic organizational structure of the army intact. While the language concerning the role of the Intendance was somewhat vague and open to interpretation, the Service de santé was clearly intended to remain under its authority. It was left to the Ministry of War to promulgate specific regulations where the law was unclear.26
In the years immediately following the passage of the 1873 Army Law, those in favor of further reforms continued to keep up the pressure. On two occasions, in 1874 and 1876-77, it appeared as if the revisionists might win at least a partial victory by removing some of the restrictions placed on the Service de santé, but both times the National Assembly broke up before the legislation could come to a vote. The Ministry of War, never a bulwark of revisionist sentiment, displayed increasingly obstructionist behavior during this period. Whenever a bill was proposed that threatened the “honor” or independence of the army, it was met by a counter-proposal designed to diffuse pressure for substantive reforms.27
When the National Assembly reassembled in 1878, the pressure for reform was even greater than before. The disarray of the monarchist forces and growing opposition to the presidency of Marshall MacMahon encouraged Republicans and others favoring substantive changes in Army organization to bring matters to a head. Those in favor of reforms mounted an aggressive campaign designed to pierce the defenses of the Intendance while those opposed to change marshalled their reserves for a decisive battle.
An initial victory was scored by French military physicians when a congress on military medical services held in conjunction with the 1878 Paris Exposition came out with a strong endorsement of the principle of the autonomy of sanitation services from undue administrative control. Since autonomy had already been achieved by all the other major and many of the minor armies of Europe, this statement was clearly intended to impress upon the French their laggardness.28
The main battle was opened by a series of committee hearings in 1878-79. At these hearings, the principal spokesman for the Intendance was its head, General Vigo-Roussillon.29 He tended to concentrate less on the actual performance of the Intendance than on its heritage, expounding the history of the Intendance dating back to 1574. In order to enhance the pedigree of the Intendance, he recounted an impressive (and politically eclectic) list of great state servants of the past who had been its supporters, including such men as Sully, Louis XIII, XIV, and XV, Choiseul, Saint-Germain, Henry IV, and Napoleon.
Vigo-Roussillon was supported by the testimony of the head of the “Officers of Administration” of the military hospitals, Principal Administrator Antonini.30 Antonini expressed a variety of reservations on the prospect of autonomy for the sanitation service. Painting military physicians as a jealous, self-righteous and grasping lot, he feared that the subordination of the “Officers of Administration” to them would lead to rampant abuses. He cited many examples of unnecessary expenditures, administrative inability, and flagrant violations of regulations to reinforce his point. Claiming that the “Officers of Administration” represented “the law, the family, and also the state”, he contended that subordination to medical officers would diminish and dishonor the whole army and create conditions of chaos. As far as he was concerned, the only conflicts in the present system occurred when “Officers of Administration” attempted to enforce the regulations “to which everybody was supposed to submit” upon unruly doctors.
Principal Pharmacist Paul Jean Coulier felt much the same way about the military physicians.31 He described a pattern of disrespect for military pharmacists that he had seen exhibited by medical officers for many years. The autonomy of the sanitation service would only make the situation worse because there would be no supervision of the doctors, and they were likely to run roughshod over all their charges, including pharmacists. Preferring the present system because it recognized pharmacists and physicians as equal, he advised to leave things as they were.
Chief of the Service de santé Legouest testified in favor of autonoy, stating that the present system was irrational, inefficient and, ultimately, wasteful of men and money.32Decrying the interference of the Intendance in the hygiene of the army, he stated once again that the French were behind in their sanitary arrangements for the troops, especially when compared to the Germans. In addition to Legouest’s testimony, Larrey, a member of the committee, addressed many sharp questions and rejoinders to the opponents of autonomy, focusing on the failures of the present system.
One result of these hearings was that it became increasingly apparent that, although the anti-autonomy party was long on tradition and honor, they were short on results. The sanitary condition of the French army continued to lag behind that of other states, worst of all the Germans. Yet opponents of reform continued to advocate only minor changes in the system. When the majority of the commission recommended the subordination of the Intendance to the regular chain of command of the army and the autonomy of the sanitation service from the administrative control of the Intendance, the dissenters issued a minority report that proposed only superficial changes.33
As reform legislation moved from committee to the floor of the Chamber and Senate in 1880, the debate continued. The head of the committee and a dissenter from the majority report, General Francois Victor Adolphe de Chanal, rose to defend the honor of the Intendance.34 In his estimation the advantages of the present system included a high level of fiscal control, frequent inspections of procedure, and the surety of tradition. What the majority proposed was without precedent. M. Felix-Bernard Datas, a left-wing member of the Chamber and former Intendant also spoke in support of the status quo. In his experience, the officer corps of the army was often unwilling to follow established regulations and without a strong body of administrative control all accountability would be lost. After all, the treasury of the country needed to be protected as well as the populace. Supporters of the legislation, including non- physicians such as the conservative Bernard de Harcourt and Henri Camille Margaine retorted that autonomy for the sanitation service had been supported by a plethora of commissions and committees, and by deputies of all political stripes. The only way to truly protect France’s security and honor was to pass the legislation in question. Larrey stated that preventive measures to forestall the onset of disease were now the primary task of the Service de santé and that the present regulations severely hindered the doctors in their ability to improve the hygiene of the army.
At this point the Minister of War, General Jean-Joseph-Frederic-Albert Farre, rejected the legislation currently under consideration as unacceptable and proposed a new bill that did not subordinate the Intendance or provide for the autonomy of the Service de santé. This move necessitated the convening of a mixed commission to work out compromise language and all discussion of the previous legislation was suspended. Although there is no evidence in the public record as to why Farre took this course of action, he was no doubt, like his predecessors, trying to protect the army from the interference of civilians, republicans, and spendthrifts.35
This time the strategy backfired. Farre’s actions caused a public uproar.36 The objections raised by members of the National Assembly, the press, physicians, and the general public broke the back of the opposition. Although Farre’s proposal was not officially discarded until 1881, both the Chamber and Senate went to work on new bills designed to subordinate, once and for all, the Intendance to the command structure of the army.
The effort was ultimately successful, but those opposed to reform were not willing to give up without a struggle. Fighting a rearguard action, they forged a compromise of sorts that allowed them to save face. In the end, to gain the support necessary to definitively integrate the Intendance into the army, the complete autonomy of the Service de santé was sacrificed.37
The final document, after further obfuscative maneuverings by the Minister of Warand his allies, finally became law on 16 March 1882. The Intendance was relieved of its directive functions and the Service de santé was given its autonomy, albeit conditionally. All branches of the army were given the right to command the troops under their control. In the case of the sanitation service, medical officers were given the command of pharmacists, nurse/orderlies, members of attached ancillary services (such as the train), and the “Officers of Administration” of the military hospitals. Furthermore, commanders in the sanitation service were given the normal disciplinary powers accorded to army officers, and were granted the authority to give orders without the approval of their superiors in emergencies.
However, the Intendance was allowed to retain a certain amount of control over the expenditures of the sanitation service. Although the budget was technically under the control of the medical of officers of the sanitation service, all monies were actually to be turned over to the Intendance and all expenses were to be approved by its functionaries. Additionally, the “Officers of Administration” of the military hospitals continued to be subordinated to the Intendance. This arrangement had the potential to lead to continuing conflicts over whose orders applied to the “Officers of Administration.” The rationale for keeping these “strings” on the sanitation service was that it needed to prove itself capable of handling administration effectively before all restrictions could be eliminated. Whether this was really a concern is questionable, but what is certain is that the only way to push the legislation through was to throw the Intendance a sop that would allow it to retire from the field gracefully.38
Somewhat surprisingly, given its past behavior, this is exactly what the Intendance did. Rather than continue to assert what prerogatives it still had left, the Intendance seems to have recognized the writing on the wall. Subsequent to March of 1882, there is little evidence in the Journal Officiel or Le Temps of the contentious relations between the Intendance and the Service de santé that had been common in previous years. Those concerned with military medicine now turned their attention to issues such as the health of the troops and hygienic conditions in the army, renovating the plans for the functioning of the medical services in time of war, and the proper role of the Red Cross and other volunteer societies in peace and in war.39 In addition to those issues, a most pressing concern was the continuing shortage of qualified medical personnel in the ranks of the Service de santé. Within a few years, it was clear that the influx of new military physicians that many hoped for after the promulgation of the 1882 law was not going to materialize. In response, supporters of a strong sanitation service advocated further revision.
The first item on the agenda of many reformers was the reopening of a medical school for the training of military physicians. Since 1871, when Strasbourg had become part of the German Reich, the system of military medical education in France had been incomplete. Standards for new students were lowered to attract more applications. Those accepted into the Service de santé were sent to civilian medical schools and/or military hospitals to receive their basic medical education before they passed on to the “finishing school” at Valde-Grâce. They were often pressed into active service before they had completed all the requirements for the M.D. A new medical school would allow for rationalization of the training regimen. More importantly, it would ensure a venue by which men of meager resources could, in exchange for serving the needs of the army, attain a medical degree at state expense. Since the majority of medical students had always been attracted through this opportunity, it was hoped that reopening the military medical school would alleviate much of the shortage of personnel. Secondly, reformers insisted that it was necessary to complete the emancipation of the sanitation service from the Intendance. Men of high quality would continue to pursue careers elsewhere as long as the Service de santé was a subservient branch of the army.40
There was no real opposition to these proposals once they began circulating in 1887 but, as is usual with parliamentary events, the pace of events was slow enough that they did not come to fruition until almost two years later. On 9 March 1889, the “School of the Military Sanitation Service” was officially opened in Lyon. Regulations concerning all aspects of its operation including admissions, personnel, the course of instruction, discipline, student subsidies, and administration were also promulgated at this time.41
On 1 July 1889 the Service de santé was given its unconditional release from the Intendance. The “Officers of Administration” of military hospitals were transferred to the jurisdiction of the sanitation service. All expenditures could be made without the prior authorization of the Intendance. The verification of receipt and proper disposal of purchases was to be confirmed by the administration of the sanitation service. The Intendance was reduced to the role of ordering supplies and auditing accounts for accuracy.42 Surprisingly little fanfare accompanied this event. By 1889 the old guard had surrendered the essential points several years earlier, the reformers had moved on to other projects, the military physicians themselves were hard at work consolidating their gains, and more immediate threats to the Republic, such as the Boulanger affair, captured the headlines.
With the advent of the 1889 reforms, the Service de santé acquired the fundamental attributes it needed to “catch up” with the sanitation services of its competitors. This process took quite awhile, but by 1914 the medical arrangements of the French would be on roughly the same level as that of the other major armies of Europe.
IN THE 1850s and 60s the French army had generally been quite successful on campaign, albeit at a terrible cost in men, and often accompanied by great wastage of material. The Franco-Prussian War, however, illustrated the price of not keeping abreast of the latest developments in matters military.
In the specific case of the sanitation service, successful examples of “how to do it right” were abundant, the most compelling one being right next door. Yet, the combination of forces that had to be overcome by French military physicians and their allies in order to achieve autonomy were formidable. They had to alter certain fundamental operating principles of the French army, overcome fear about the revolutionary propensities of the sanitation service, and defeat a hidebound traditionalism as personified by the Intendance.
Yet even after the disastrous defeat of 1870, it took eighteen years to fully implement substantive reforms. The reason for this tardiness can largely be explained by the many cultural factors that played an important role in the process. Issues such as the “liberty” and “equality” of a few hundred intendants and pharmacists, who was best suited to keep account books, and whether doctors were capable of handling routine administrative duties became contentious points in a debate that was ostensibly about how to best arrange for the defense of the country.
In reality, the battles about these and other relatively minor matters reflects a concern about issues that were both greater and smaller than that of national defense. On the one hand, a large measure of what went on can be described merely as overdrawn “turf battles” between warring bureaucracies within the French army. On the other hand, the symbolic importance attached to these issues reflects a very real concern about the fate of la patrie in the wake of the defeat of 1870. Would France have to become a carbon-copy of Germany in order to survive? If so, was this type survival desirable? Would the emerging professionalism of the era, as exemplified by military physicians, replace the more genteel expertise personified by the intendance? These questions permeated every discussion of army reform and help to explain why such an apparently secondary issue as the fate of the Service de santé generated so much heat.
In the end, the fate of the Service de santé was determined largely by such social considerations. This is the only way to explain the torpid manner in which the French dragged themselves into the era of modern military medicine. The story of the French sanitation service is a forceful reminder of the power of culture in determining the outcome of important issues. Even in the heyday of modernism, cold logic and statistical calculations did not always carry the day.
- For a succinct account of the history of the Intendancedating back to the 16th century, see Jean Milot, “L’evolution du Corps des intendants militaires” Revue du Nord 50 (1968) 198. Pierre Chalmin, L’Officier francaise de 1815 a 1870(Paris, 1957), 43-44; Richard Holmes, The Road to Sedan: the French Army, 1866-1870 (London, 1984), 77; John van Rensselaer Hoff, “Outlines of the Sanitary Organisation of some of the Great Armies of the World” Fourth Annual Proceedings of the Association of Military Surgeons of the United States (1894),428. For a helpful overview of how all the services interacted vis-a-vis the sanitation service, see Jean Charles Chenu, Statistique Medico-chirurgicale de la Campagne d ‘ltalie en 1859 et 1860, Service des Ambulances et de Hôpitaux (Paris, 1869),69-75, 109-116.
- Chalmin, L’Officier francaise,44-45.
- Ibid., 46; Pierre Jean Linon, Officiers d’administration du service de santé: Monographie d’un corps, d’une association(Paris, 1983), 19ff, 41-52, 57-58; 61-62; Holmes, Road to Sedan,77; Albert Fabre and Pierre Julliet, eds., Histoire de la medecine aux armées, tome II: De la Revolution Francaise au conflict mondial de 1914 (Paris, 1984), 206-207.
- Chalmin, L’Officier francaise,44- 48;Linon, Officiers d’administration du service de santé.57-61. 70.
- See: J. L. Poirier, Medecine et philosophie a la fin du XIXe siecle(Paris 1982)Jean-Baptiste-Eugine Rieux and J. Hassenforden, Centenaire de l’école d ‘application du service de santé militaire, 1850-1950. Histoire du Service de santé militaire et du Val-de-Grâce, (Paris, 1951),46-57; Robert Heller, “Officers de Santé: The second-class doctors of nineteenth-century France,” Medical History 22 (1978) 25-43 Chalmin L’Officier francaise,45-48; Jean de Blonay, 1870: Une revolution chirurgicale les origines et le development de la chirurgie civile et militaire moderne (Geneva,1975) 64-65; Linon, Officiers d’administration du service de santé, 41-70; Holmes, Road to Sedan, 77-78; Hoff, “Outlines of the Sanitary Organisations of some of the Great Armies of the World,” 428.
- Blonay, 1870: Une revolution chirurgicale,65, gives these figures of comparative remuneration for the Prussian and French medical services in the 1860s:
France Prussia (converted by Blonay to francs)
at start of career 2,050 fr. 250 fr.
at end of career, 8,500 fr. 1 250 fr.
with normal advancement.
Attrition among officers of the sanitation service at mid-century averaged over 5 l/2 percent per year. There were an average of 150-200 vacancies — 10 to 15 percent of the entire authorized strength — in the ranks of the physicians during the same years. These discrepancies were roughly double that of the army as a whole. Chenu Statistique medico- chirurgicale, 86.
- See Rieux and Hassenforden, Centenaire de l’école d’application du service de santé militaire,47-50; Hoff “Outlines of the Sanitary Organisation of some of the Great Armies of the World”, 428; Rene Izac, “La creation de l’école du service de santé militaire de Strasbourg d’Apres de documents inedits (1856)” Histoire des Sciences Medicales10 (1976) 202-218; Ch. Deporq, “L’école du service de santé militaire et la formation des officiers d’administration du service de santé,”Revue du Corps de Santé Militaire 15 (1959) 404-414; Fabre and Julliet, Histoire, 173-175, 181.
- Helpful for the focus of the analysis here has been: Thomas 1. Adriance The Last Gaiter Button: A Study of the Mobilization and Concentration of the French Army in the War of 1870 (London, 1987); Rieux and Hassenforden, Centenaire de l’école d ‘application du service de santé militaire,56-57; Holmes, Road to Sedan,Fabre and Julliet, Histoire,210-250; and Blonay, 1870: Une revolution chirurgicale .
- Ibid., 63. In fact, they actually did better by their animals. During the war, the French veterinary service fielded one veterinarian for every 250 horses — Fabre and Julliet, Histoire, 212.
- Blonay, 1870: Une revolution chirurgicale,66. This is somewhat misleading because in time of war the French provided the Service de santéwith stretcher bearers from the ranks of the regular army. Even then, however, the total number of men assigned to duty with the sanitation service was comparatively low, to say nothing of the qualitative gap that resulted from the lack of training.
- Holmes, Road to Sedan,78-79.
- For a brief account of Prussian/German military medical arrangements during this period, see William B. McAllister’s unpublished M.A. thesis ,Fighting the Good Fight: German Military Medicine, 1860-1914(University of Virginia, 1990).
- Blonay, 1870: Une revolution chirurgicale, 77.
While exact figures vary a great deal, and differences in “accounting” make figures not fully comparable, some reliable representative estimates record approximately:
Total mobilization 800,000 1,113,000
Mean Strength 534,000 788,000
Sick 339,000 475,000
Killed, Missing and Died
from Wounds and Disease 136,500 26,000
Cases of Smallpox 15,000 5,000
Deaths attributed to Smallpox 2,000 300
From Valentine. J. Swain, “The Franco Prussian War of 1870-71: Voluntary Aid for the Wounded and Sick,”British Medical Journal 3 (1970) 511-514; and Feilding H. Garrison, Notes on the History of Military Medicine (Washington, 1922), 177-79.
- See: Allan Mitchell, “`A Situation of Inferiority’: French Military Reorganization after the Defeat of 1870,” American Historical Review86 (1981) 49-67, and “The Freycinet Reforms and the French Army, 1888-1893,”Journal of Strategic Studies4 (1981) 19-28. See also Douglas Porch, The March to the Marne: the French Army 1871-1914 (New York,1981). Not only the army, but many other aspects of French society came under inspection in the years following the defeat. For related debates that have application to army reform and medical issues, see Allan Mitchell, Victors and Vanquished: The German Influence on Army and Church in France after 1870 (Chapel Hill, N.C., 1984), and Poirier, Medecine et philosophie a la fin du XlXe siêcle.
- As early as September 1871, Le Tempswas already able to list fourteen different reorganization plans that had been published in book or pamphlet form; see 1 Sept.,34; see also 31 July, 3(c). For Le Temps,whenever desirable, a lower-case letter indicating the column in which the article begins is given in parentheses after the page number.
- Fabre and Julliet, Histoire,173- 75, 179, 254.
- For the extent of the involvement of doctors in parliament see Jack D. Ellis, The physician-legislators of France (Cambridge, 1990);see also Fabre and Julliet, Histoire, 254-258.
- Fabre and Julliet, Histoire,258- 259.
- See Milot, “L’evolution du Corps des intendants militaires,” especially 401-402; Fabre and Julliet, Histoire, 153.
- For the opinions of an apparently small group of “Officers of Administration” who were in favor of submission to the sanitation service, see the Journal Officiel,(1880) 1478; Fabre and Julliet, Histoire,253-254, and Linon, Officiers d’administration du service de santé, 76-79.
- Fabre and Julliet, Histoire,253.
- For overviews of the 1871-1889 period from secondary sources, see Fabre and Julliet,Histoire, 251- 253,259-261 and Linon, Officers d’administration du service de santé, 72-75.
- Le Temps,22 Sept. 1871, 1; 10 Nov. 1871, 1-2; 15 Nov. 1871, 2(c). For other opening rounds in the debate see, for example, the occasional publication of comparative health statistics in Le Temps, 9 Nov.1872,3(d),and in the Journal Officiel, (1871) 5010-11, and (1892) 6039-40.
24 For a succinct account of the deliberations of this committee see Le Temps, 3 Aug”>”>.
“>.1873,1-2; 4 Aug. 1873.
- For the text of the 1873 law, see the Journal Officiel,(1873) 5281-3.
- See Le Temps,19 Oct.1875, 1-2; 30 Oct.1875,1-2; 5 Nov.1875 1-2,29 Nov.1875 2(a); 3 Apr.1876,1; 19 May 1876,1(c); 7 June 1876,1(e); 8 Aug. 1876,1(d)- 19 Aug 1876,1-2; 8 Nov.1876,1-2; 13 Nov.1876,1(e); 23 Nov.1876 1-2,31 Jan 1877,1(a) 10 Feb.1877,1(d). In addition, see the Journal Officiel,(1874) 5737-38, (1876) 2146-48, 2226-31, 2361-64, 2411, 6955-64, 8019, 8302-10, 9026-27, 9050-52.
- See Le Temps,14 Aug. 1878, 2(e); 21 Aug. 1878, 1(c).
- For the series of hearings held during 1878-79, see the Journal Officiel,(1880) 1266-77,1311-25,1361-74, 1405-12,1451-61,1475-95,1510-14. For Vigo-Roussillon see ibid., 1324-25, 1405, 1486-95, 1507-10.
- Ibid., (1880) 1478-80.
- Ibid., (1880) 1480-86.
- Ibid., (1880) 1475-78.
- See, for example, editorials in Le Temps,14 Mar.1879,1(e),4 July 1879,1(c), and 25 Mar. 1880, 1(d). See Journal Officiel,(1880) 1846-49; (1881) 1596-97.
- This running debate can be followed most easily in Le Temps,7 June 1880,3ff, 9 June 1880, 1(b), and 3(d); and 10 June 1880, 1(b).
- See Journal Officiel, (1880) 8377-78.
- For the overwhelmingly negative reaction to Farre’s maneuver see Le Temps16 June 1880,1(c), and 3(b); 19 June 1880, 1(a); 20 June 1880,1(b); 23 June 1880, 1(c) 24 June 1880, 1(c); 27 June 1880, 4(f); 10 July 1880, 1(d).
- For the painfully slow process of hammering out a new project de loi,see Journal Officiel, (1881) 1203-18,1590-94; (1882) 177-80,351-55. For the continuing pressure for and resistance to reforms, see ibid.,(1881) 121-22, 785; and Le Temps, 24 Feb.1881 1(b); 30 Sept. 1881, 2(e); 10 Nov. 1881, 2(e); 1882: 13 Feb. 1882, 1(d).
- For the actual text of the new law and the explanations of its provisions, see Journal Officiel, (1882) 1625-29, 2850-51.
- See ibid., (1883) 228, 297-99; and Le Temps, 25 Dec. 1884, 2(a); 23 Nov. 1886, 2(d); 9 Jan.1887,3(b); 28 Jan.1887,2(e); 3 June 1887,1(c); 9 Sept.1887,1(d); 31 Mar. 1888, 2(d); 18 June 1889, 2(c).
- For the beginnings of discussion about this issue, see the numerous references to it on page 22-23 of the “Table Alphabetique” of the 1884 Journal Officiel.
- See Le Temps, 22 Mar.1887,4(c); 27 Sept.1887, 2(e); 3 Mar.1889, 2(d); 5 Mar. 1889, 2(c); 11 Mar. 1889, 2(b); 11 May 1889, 2(c);Journal Officiel, (1888) 5490-95; Fabre and Julliet, Histoire, 261-69.
- See Journal Officiel, (1887) 814,443; (1889) 698-700,1213-14,1218-19,3138-39, 7735; Le Temps,27 Sept.1887, 2(e); 4 June l889, 2(d); Linon, Officiers d’administration du service de santé, 87; Fabre and Julliet, Histoire, 260-261.