It was not until about 8.30pm on the 18 June 1815 that the crash of gunfire and musketry, the neighing of horses, and the shouts and cries of thousands of men died down. This Sunday evening had ended Napoleon Bonaparte’s last desperate attempt to defeat the Allied powers (Britain, Prussia, the German states, and the Dutch/Belgians).
It had happened on the plains of what is now the Province of Brabant, in Belgium, just 11 miles south of Brussels. Around 55,000 dead, dying, and wounded men and thousands of injured horses lay across an area of little more than four square miles. The density of casualties per mile of front far exceeded that suffered by the British Army on the first day of the Somme in 1916.
It was the end of a 23-year-long war against Republican and Napoleonic France (1792-1815). This war had taxed Britain dearly, both financially and in human lives. The total bill was £1.6 billion, leaving a national debt of around £544 million. The human loss, at around 2.5-3% of the population, was proportionately higher than that of 1914-1918.
More servicemen died from disease, deprivation, and climate extremes than from battlefield injuries. And Waterloo turned out to be the second most sanguinary single-day battle during the entire conflict.
The development of military medicine
The first phase of the conflict (1793-1799) saw British forces fighting in either the extremely harsh winter climate of the Low Countries, or far away in the West Indies, where armies were decimated by disease and heat.
There were gross organisational failures and supply deficiencies in the Netherlands, and high rates of attrition due to yellow fever in the Caribbean. These two sites of conflict accounted for nearly half of all the war’s casualties.
In the second phase (1800-1808), some of even the few medical lessons learned earlier seem to have been forgotten, and it was not until the final phase, that of the Peninsular War (1808-1814) that the British Army and its Army Medical Department (AMD) achieved a degree of competence and reputation.
Up until 1811, the AMD was not in the best shape. In contrast, the Republican French Service de santé, formed in 1792, was a well-organised and efficient medical corps, under the leadership of well-motivated Republican surgeons like the Barons Dominique Larrey and Pierre-François Percy.
The training and organisation of French military surgeons was sound. The presence of units for front-line surgical care, called Ambulances volantes (‘flying ambulances’), gave much reassurance to French Republican soldiers. During the long campaigns of the Empire, however, difficulties with recruitment, increasing bureaucracy, and high casualty rates among medical staff reduced the efficiency of the service.
The Peninsular War
During the Peninsular War, significant improvements in the organisation and performance of the British forces and their Allies was eventually mirrored (by 1812-1814) in the quality of the AMD. Sir Arthur Wellesley, later the Duke of Wellington, worked closely with a Dr (later Sir) James McGrigor to ‘militarise’ and invigorate what had previously been a poorly trained, understaffed, and under-motivated department.
Changes included the use of smaller (sometimes portable) hospitals to avoid spread of contagion; improved departmental discipline; regular sick returns; and higher morale among medical staff, ensuring better outcomes, despite ignorance of nosology (the classification of diseases) and lack of effective pain relief and antisepsis.
Among surgical improvements were the conservation of limbs after injury, use of long splints for fractures, better understanding and timing of amputation and trepanation (creating better access in the skull after injury), and also safer control of bleeding following wounding and during surgery.
After a devastating retreat in Spain in 1812, McGrigor reckoned that the AMD restored to health around a division’s worth of fighting men (about 7,000), who then played their roles in the following year’s successful campaigns.
Surgeon George James Guthrie, an outstanding military surgeon, cared for around 1,420 surgical admissions after the sanguinary Battle of Toulouse in April 1814. While recognising that many wounded never reached care (and therefore went unrecorded), the in-hospital mortality among officers and men was remarkably impressive at just 11%.
The Waterloo campaign
The vast majority of Peninsular War surgeons and other medical staff were exhausted by six years of continuous campaigning, many going onto half pay, some retiring, a few dying of chronic disease. Thus the Waterloo campaign, only 14 months later, was bound to stretch the resources of the AMD.
Troops and medical men were rushed to Belgium from depots and garrisons in Ireland and Britain. Troopships destined for America were turned back to Europe. Napoleon moved fast, and Wellington did not initially know where he would strike. The redoubtable Sir James McGrigor was appointed Director-General of the AMD only four days before Waterloo.
Basic medical care was provided by regimental surgeons. The wounded would be carried off the field of battle by bandsmen or colleagues. Often casualties would then have to just fend for themselves.
Larger hospitals and garrison and divisional services were staffed by Deputy Inspectors of Hospitals, the most senior rank of military doctor, staff surgeons (equivalent to today’s hospital consultants), assistant staff surgeons, orderlies, and a few nurses.
There were around 50 hospital staff in Brussels before Waterloo, some of whom had recently been on campaign elsewhere in the Low Countries. Other regimental doctors came over with their battalions, as did other hospital staff members (physicians, apothecaries, purveyors, and dispensers). Six hospitals were opened for casualties in Brussels, and others in Ghent and Antwerp.
At the time of Waterloo, there was no anaesthesia, no knowledge of or protection from bacterial infection, and hospital and daily care were still rudimentary.
Most battalions at Waterloo had a regimental medical officer and two assistants, the senior of whom would usually go into line and perform first aid – applying tourniquets, bandaging, splinting, suturing (stitching), giving water, and getting casualties out of the combat zone where feasible.
Many regimental surgeons and some assistant surgeons and staff surgeons collected at Mont-St-Jean Farm, about 400 metres behind Wellington’s line. This was the 1st Corps hospital, under the command of Dr John Gunning. Here wounds were redressed and cleaned, fractures were ‘reset’, and amputations and trepanning (skull surgery) performed.
Wellington had been wrong-footed by Bonaparte, who moved speedily up to Charleroi at the border, with five army corps and the Imperial Guard. Near here, the French army split into two.
On 16 June, an Allied holding action against Marshal Ney’s left-hand force took place at Quatre Bras. This resulted in around 4,000 casualties on each side.
At Ligny, to the east, however, a furious no-quarter action took place between the rest of the French army, commanded by Bonaparte and Marshal Grouchy, and the poorly positioned Prussian force. Around 18,000 Prussian and 11,000 French casualties resulted.
Bloodied and bruised, the Prussians retired to the north – not eastwards, as the French hoped and assumed. They thus moved parallel to Wellington’s force, which had also retired, falling back on a three-mile-long ridge a couple of miles south of the village of Waterloo. Marshal Grouchy, with 30,000 men, had been directed to follow the Prussians and prevent them joining Wellington; but he lost contact with his enemy and failed in his mission.
Morning and early afternoon
A torrential rainstorm all night prevented the waiting soldiers from heating any drink or food (salt beef and biscuit rations), or from getting much sleep. The overnight rain ceased around dawn, and some 160,000 men dried off and awaited the day’s events. The French ambulances (mobile field hospitals), with their stretcher bearers, rested behind their regiments, divisions, and corps.
After some delay, at around 11.30am, a diversionary attack on Chateau Hougoumont, a defended farm on Wellington’s right centre, began. It would rage all day, the position being stoutly held by German soldiers and the light companies of two British Guard regiments.
This group of buildings, along with La Haye Sainte farm in front of Wellington’s centre and the farm of Papelotte on the Allied left, served as defended outposts, with casualties treated on-site by junior surgeons. The contrasting losses – 5,000 French and only 850 Allied at Hougoument – reflect the stoic heroism of the French assaults.
Wellington’s ridge position was well chosen, since men could lie down behind the crest to shelter from enemy fire. At about 12.45pm, 62 pieces of artillery opened up on Wellington’s centre. The bombardment relented after around 45 minutes, leaving about 500 Allied casualties. Only men hit on limbs or receiving tangential strikes could survive a round-shot injury.
A 17,000-strong infantry assault by the French 1st Corps was then thwarted by a determined British heavy cavalry counter-attack. This resulted in severe casualties among the British horsemen, when they in turn were charged by fresh French lancers and cuirassiers.
Many men survived multiple lance wounds, since the 9ft weapon (not then used by the British) had to pierce a vital organ to threaten life. Of 48 wounds suffered by 22 troopers of the Scots Greys, 29 were lance injuries. General Sir William Ponsonby was lanced to death after being overrun by French cavalry.
Late afternoon and evening
The Prussian attack on Napoleon’s right flank began around 3pm, around the same time that two French cavalry corps assaulted the Allied line. Wave upon wave, about 12,000 horsemen in all, spent two hours attempting to break Wellington’s infantry squares, taking heavy casualties from musketry and canister. Inside the squares, junior surgeons dressed wounds and controlled bleeding.
La Haye Sainte finally fell, and Wellington’s position was severely threatened. Casualties poured into Mont-St-Jean Farm, which eventually held around 7,000 wounded men.
Dusk approached, and more Prussians arrived on Wellington’s left. The last dice were thrown when Napoleon committed nine battalions of his Imperial Guard, at least 4,000 experienced soldiers, advancing en échelon, in dense columns of attack, adding to the pressure on Wellington’s centre right.
The line was stabilised by Dutch infantry and artillery (it was at this time that William, Prince of Orange, received his shoulder injury), and then this final French assault was hurled back by a volley from Maitland’s Guards brigade and by Adam’s brigade of the 2nd Division.
‘A damned nice thing, but a near-run thing,’ as Wellington later said. Prussian cavalry were given the task of mercilessly hacking down and lancing the exhausted French as they fled the field. Then the grim work of the medical men ramped up. The four-day campaign had given them around 63,000 casualties to care for.
Many had to struggle to a nearby aid-post or hospital. The rest waited (and many died) for comrades to collect them, taking most to the farm buildings of Mont-St-Jean. Wounded Frenchmen were anxious to avoid capture and imprisonment on the notorious British prison hulks. But priority, anyway, was given to the British and Allied wounded. About 40 spring-wagons were hired from Brussels to bring in the casualties from the battle.
The effects of shot
Most wounds were inflicted on limbs (around 75%), and two-thirds were caused by small-arms fire from low-energy, smooth-bore, muzzle-loading fusils, carbines, and pistols. After 50 metres or so, the lead missiles lost kinetic energy, since they were heavy and round. Also, loading and powder quality were often substandard. Thus many injuries were caused by ‘spent’ balls. Discs of bacterially contaminated clothing were also frequently driven into the depths of these wounds by the missiles.
To repair the damage, the surgeon first explored the wounds, using his finger. This preceded removal of debris, using probes, bullet scoops, or forceps.
One young officer of the 1/95th Rifles, George Simmons, had a musket ball traverse his right chest from the rear at diaphragmatic level and then scuff the liver. He was bled a dozen pints with the thumb lancet over a week – a common and useless practice of the times. He was then ‘leeched’ with 25 animals and left for dead.
Two weeks after injury, a large sub-phrenic abscess (an abscess around the liver) discharged into Simmons’s bed. Profoundly weak and anaemic, Simmons survived.
Wounds from heavy iron cannon-shot – between 3lbs and 24lbs in weight – were usually fatal if received centrally or on the head and neck. Many limbs were avulsed (torn off) by round-shot.
Tangential strikes by large balls could cause severe internal disruption. Quartermaster Sir William Howe de Lancey was hit a glancing blow on his right loin by a round-shot. He took a week to die. At post-mortem, it was found that eight ribs had been avulsed from his spine, and he had suffered muscle, lung, and renal injuries. His new wife Magdalene nursed him until he died. Few contemporary surgeons believed in ‘the wind of the ball’ as a potential cause of injury.
Dressings and amputations
Most gaping wounds were left open and dressed with moist lint, or in the case of burns, non-adherent oily or waxed dressings. Rolled linen bandages (‘rollers’) were applied to limb and trunk wounds. Although débridement (thorough wound-cleansing) as we know it today was rarely employed, surgeons often removed some dead tissue or foreign material.
Débridement literally means ‘unbridling’ – that is, releasing tension in the wound – which was occasionally practised for severely swollen soft-tissue wound infections.
Other wounds, such as those caused by sabres, lances, or, rarely, bayonets, were closed with linen or silk sutures or adhesive tapes. The French occasionally applied hot cautery irons to such penetrating injuries, but the cautery was not in general use.
Roughly 2,000 amputations were carried out during or after the four battles (Ligny, Quatre Bras, Wavre, and Waterloo), with perhaps 500 Allied limb removals on the day of Waterloo.
Sitting upright and restrained by assistants, the unfortunate victims had a screw tourniquet applied to the damaged limb, and the soft tissues were pulled up and cut around in a series of sweeps of a large knife, followed by bone division. The arteries were then tied off and the wound was dressed. The whole operation took about 15-20 minutes. No alcohol or painkillers were administered before surgery.
The most notorious amputation after the battle was that performed on Paget, Lord Uxbridge, after a serious knee injury. Wellington’s personal physician Dr John Hume (who was well rehearsed in surgery) performed a flap amputation (as opposed to a guillotine operation) after seeking a second opinion on his illustrious patient, who commanded the British cavalry and was brother-in-law to the Duke.
At one point, the saw jammed as the bone became angled on the saw. Dr Hume cursed, and Uxbridge enquired what had happened. Apart from this interjection, he bore his procedure quietly, and his pulse had remained steady throughout surgery, but Uxbridge did have a senior officer check on the amputated limb, to see that the operation had been justified!
Trepanning was an uncommon procedure, and by the time of Waterloo was employed in a more rational manner than previously. With the patient’s head shaved, the scalp was cut in a cruciate manner and the periosteum (the membrane covering the bone) scraped away.
Then the centring pin on the trephine was extended (to prevent ‘skiting’ of the saw on the bone) and, by rotating the small circular saw manually, a bony disc was cut out. This procedure was to gain better cranial access, elevate impacted down-driven bone fragments, and release compressing blood.
Lieutenant Purefoy Lockwood of the 2/30th Regiment had a musket ball driven into his frontal bone and, after removal of part of the ball and some bone fragments, was later trepanned to remove more bone and the remainder of the lead ball. He had a silver plate made with the words ‘Bomb Proof’ engraved on it – to cover his unsightly forehead defect!
Sir Charles Bell and Professor John Thomson visited the Waterloo casualties, and produced colourful verbal and pictoral accounts of their experiences at the Brussels and Antwerp hospitals. Thomson was the first of two Regius Professors in military surgery in Edinburgh. This attempt at formal medical military instruction in Scotland was in contrast to the lack of training in England. The Waterloo battlefield proved to be the principal training-ground for the aspiring military surgeon.
George James Guthrie, a formidable Peninsular War surgeon with a fine reputation, went to Waterloo two weeks after the battle and performed a disarticulation at the hip joint (removing the leg at the hip) on a French prisoner-of-war, a certain François de Gay, who survived. As far as we know, seven of these massive surgical procedures were performed unsuccessfully by the great Dominique Larrey. Guthrie went on to teach military surgery vigorously and gratis for years following Waterloo.
The inpatient mortality at Waterloo was around 9% – a seemingly very good result, until we realise how few serious casualties ever reached hospital.
In April 1816, ten months after the battle, of 6,831 admitted casualties, 5,068 (74%) were able to rejoin their unit, 506 were discharged from service, 854 were still inpatients, 236 survived amputation, and 167 joined veteran battalions.
Many casualties became in- or out-pensioners at the Royal Hospital Chelsea or at Kilmainham in Ireland. Prosthetic limbs were issued from these hospitals, but often a local artisan would construct an artificial part for an amputee.
There was a new Waterloo medal and two years added pension allowance for all combatants. Prize money, collected by public subscription and levies on the French Government, was issued – £61,000 for the Duke of Wellington, £90 7s 4d for a surgeon, and £2 11s 4d for a private soldier, drummer, or corporal. Pensions for the injured were awarded by the Royal College of Surgeons of London.
Many medical lessons gleaned from this long war were forgotten in the two generations of soldiering that followed. Parsimony, complacency, and gross mismanagement were to blight the British Army in the years 1815 to 1854, setting the stage for the medical disaster of the Crimea. .
Mont-St-Jean Farm stands about 400 yards behind where the Allied line formed up at Waterloo. It then served as the principal (1st Corps) field hospital, under the direction of Deputy-Inspector John Gunning. Here regimental and staff surgeons cared for about 7,000 casualties. There was a central water supply, and barns where the wounded were dressed and received surgery.
Thanks to local businessman, brewer, and entrepreneur Anthony Martin, the farm complex has been elegantly restored to its former glory, with a restaurant, shop, microbrewery, and permanent medical museum. The latter, situated in the main farm building, consists of medical data, medical memorabilia, illustrations, and surgical instruments.
This unusual addition to the battlefield site reminds the visitor of the darker side of Waterloo, and has added a new dimension to the bicentenary heritage trail.
Mick Crumplin is a retired surgeon, curator, and archivist at the Royal College of Surgeons, and author of The Bloody Fields of Waterloo.