reached the hospitals of Scutari.19
The Russians, too, understood the need to treat the wounded as soon as possible, although conditions in their hospitals were far worse than anything that Florence Nightingale would find in Scutari. Indeed, it was a Russian, Nikolai Pirogov, who pioneered the system of field surgery that other nations came to only in the First World War. Although little known outside Russia, where he is considered a national hero, Pirogov’s contribution to battlefield medicine is as significant as anything achieved by Florence Nightingale during the Crimean War, if not more so.
Nikolai Pirogov
Born in Moscow in 1810, Pirogov began his medical studies at Moscow University at the age of just 14, and became a professor at the German University of Dorpat at the age of 25, before taking up the appointment of Professor of Surgery at the Academy of Military Medicine in St Petersburg. In 1847 he was with the Russian army in the Caucasus, where he pioneered the use of ether, becoming the first surgeon to employ anaesthesia in a field operation. Pirogov reported on the benefits of ether in several Russian-language publications between 1847 and 1852, though few doctors outside Russia were aware of his articles. Apart from the relief of pain and shock through anaesthesia, Pirogov emphasized that giving ether to the wounded on arrival at the hospital kept them calm and stopped them from collapsing so that the surgeon could make a better choice in selecting between those cases requiring urgent operation and those that could wait. It was this system of triage pioneered by Pirogov during the Crimean War that marked his greatest achievement.
Pirogov arrived in the Crimea in December 1854. He was outraged by the chaos and inhuman treatment of the sick and wounded. Thousands of injured soldiers had been evacuated to Perekop on open carts in freezing temperatures, many of them arriving frozen to death or with limbs so frostbitten that they had to be cut off. Others were abandoned in dirty barns or left by the roadside for lack of transport. There were chronic shortages of medical supplies, not least because of corruption. Doctors sold off medicines and gave their patients cheaper surrogates, exacting bribes for proper treatment. The hospitals struggled to cope with the enormous numbers of wounded. At the time of the allied landings, the Russians had hospital places for 2,000 soldiers in the Crimea, but after Alma they were overwhelmed by 6,000 wounded men, and twice that number after Inkerman.20
Conditions in the Sevastopol hospitals were truly appalling. Two weeks after the battle of the Alma, the surgeon from Chodasiewicz’s regiment visited the naval hospital:
He found the place full of wounded men who had never had their wounds dressed from the day of the Alma, except such dressings as they could make themselves by tearing up their own shirts. The moment he entered the room he was surrounded by a crowd of these miserable creatures, who had recognized him as a doctor, some of whom held out mutilated stumps of arms wrapped up in dirty rags, and crying out to him for assistance. The stench of the place was dreadful.
Most of the surgeons in these hospitals were poorly trained, more like ‘village craftsmen’ than doctors, in the estimation of one Russian officer. Practising a rough-and-ready surgery with dirty butcher’s knives, they had little understanding of the need for hygiene or the perils of infection. Pirogov discovered amputees who had been lying in their blood for weeks.21
As soon as he arrived in Sevastopol, Pirogov began to impose order on the hospitals, gradually implementing his system of triage. In his memoirs he recounts how he came to it. When he took charge of the main hospital in the Assembly of Nobles, the situation was chaotic. After a heavy bombardment, the wounded were brought in without any order, those who were dying mixed with those who needed urgent treatment and those with light wounds. At first, Pirogov dealt with the most seriously wounded as they came in, telling the nurses to transport them to the operating table directly; but even as he concentrated on one case, more and more seriously wounded men would arrive; he could not keep up. Too many people were dying needlessly before they could be treated, while he was operating on those patients too seriously wounded to be saved. ‘I came to see that this was senseless and decided to be more decisive and rational,’ he recalled. ‘Simple organization at the dressing station was far more important than medical activity in saving lives.’ His solution was a simple form of triage which he first put into practice during the bombardment of Sevastopol on 20 January. Brought into the Great Hall of the Assembly, the wounded were first sorted into groups to determine the order and priority of emergency treatment. There were three main groups: the seriously wounded who needed help and could be saved were operated on in a separate room as soon as possible; the lightly wounded were given a number and told to wait in the nearby barracks until the surgeons could treat them; and those who could not be saved were taken to a resting home, where they were cared for by medical attendants, nurses and priests until they died.22
In his sketch ‘Sevastopol in December’, Tolstoy takes his readers into the Great Hall:
No sooner have you opened the door than you are assailed without warning by the sight and smell of about forty or fifty amputees and critically wounded, some of them on camp beds, but most of them lying on the floor … Now, if you have strong nerves, go through the doorway on the left: that is the room in which wounds are bandaged and operations performed. There you will see surgeons with pale, gloomy physiognomies, their arms soaked in blood up to the elbows, deep in concentration over a bed on which a wounded man is lying under the influence of chloroform, open-eyed as in a delirium, and uttering meaningless words which are occasionally simple and affecting. The surgeons are going about the repugnant but beneficial task of amputation. You will see the sharp, curved knife enter the white, healthy body; you will see the wounded man suddenly regain consciousness with a terrible, harrowing shrieked cursing; you will see the apothecary assistant fling the severed arm into a corner; you will see another wounded man who is lying on a stretcher in the same room and watching the operation on his companion, writhing and groaning less with physical pain than with the psychological agony of apprehension; you will see fearsome sights that will shake you to the roots of your being; you will see war not as a beautiful, orderly, and gleaming formation, with music and beaten drums, streaming banners and generals on prancing horses, but war in its authentic expression – as blood, suffering and death.23
The use of anaesthetics enabled Pirogov and his team of surgeons to work extremely quickly, completing over a hundred amputations in a seven-hour day by operating simultaneously on three tables (critics said he ran a ‘factory system’). He developed a new type of foot amputation at the ankle, leaving part of the heel bone to give added support to the leg bone, and generally, in his amputations, cut much lower than most other doctors to minimize the trauma and loss of blood, which he understood posed the greatest threat. Above all, Pirogov was aware of the dangers of infection (which he thought came from contaminated vapours) and made a point of separating post-operative patients with clean wounds from those whose wounds were discharging pus and showing signs of developing gangrene. Through all these pioneering measures, Pirogov achieved much higher rates of survival than the British or the French – up to 65 per cent for amputations of the arm. For thigh amputations, the most dangerous and common in the armies of the Crimean War, Pirogov had survival rates of around 25 per cent, whereas only one in ten survived the operation in British and French hospitals.24
The British were much less enthusiastic about the use of anaesthetic than the Russians or the French. Shortly before the British army left Varna for the Crimea, the principal medical officer, Dr John Hall, issued a memorandum in which he cautioned the army’s surgeons ‘against the use of chloroform in the severe shock of serious gunshot wounds … for however barbarous it may appear, the smart of the knife is a powerful stimulant; and it is much better to hear a man bawl lustily than to see him sink silently into the grave’. British medical opinion was divided on the new science of anaesthesia. Some feared the use of chloroform would weaken the patient’s ability to rally, and others thought it was impractical to use it in battefield surgery because of the shortage of qualified doctors to administer it. Such attitudes were closely linked to ideas about withstanding pain that were perhaps peculiar to the British sense of manliness (keeping ‘a stiff upper lip’). The notion that the British soldier was immune to pain was commonplace. As one doctor wrote from the Crimea:
The pluck of the soldier no one has yet truly described. They laugh at pain, and will scarcely submit to die. It is perfectly marvellous, this triumph of mind over body. If a limb were torn off or crushed at home, you would have them brought in fainting, and in a state of dreadful collapse. Here they come with a dangling arm or a riddled elbow, and it’s ‘Now doctor, be quick, if you
