As the twentieth century began, general and military medicine stood on the threshold of remarkable progress in their ability to save lives. The period witnessed the most important advances in disease prevention and surgical knowledge in human history. Medicine had become fully integrated into the larger web of general scientific exploration and discovery to where it finally stood as an equal partner in developing and sharing new scientific discoveries. This trend toward the integration of science and medicine, first begun by the Germans in the 1870s, has become the major characteristic of modern medicine in all developed societies. The walls between academic and scientific disciplines have largely crumbled, and the old prejudices between surgeon and physician have finally disappeared.
The advancement in medical knowledge and technique characteristic of postindustrial societies was already evident at the turn of the century and has resulted in the rapid application of these discoveries to military medicine. In turn, the press of war and the social organization of research increased the military medical establishment’s ability to make contributions to general and specialized medicine that would have probably taken years to occur in peaceful times. For example, military doctors achieved almost all the early advances in immunization and the prevention of communicable disease.1 The general mobilization of civilian medical resources for wartime use brought many new problems to the attention of the civilian medical establishment and at the same time provided its practitioners the opportunity and resources to address them through wartime service. Except for social rank, now no significant differences remain between military and civilian medical practitioners. Moreover, neither medical establishment is able to generate significant new knowledge without quickly attracting the attention of the other.
As the century began, however, military medicine differed only marginally from what it had been in 1870. The great achievements in military health care and the organizational sophistication needed to deliver that care to the wounded were far from certain; indeed, the belief in the inevitable progression of science to produce social betterment is a relatively new phenomenon, dating only from the close of World War II. The wars that occurred in the early part of the twentieth century—Spanish-American War, Boer War, and Russo-Japanese War—experienced the same familiar failures that had reduced military medicine’s effectiveness for a hundred years. Most of these failures can be attributed to the unwillingness of armies to take military medicine seriously as a means for salvaging manpower.
On the eve of World War I, the armies of Europe remained as unprepared to meet the challenge of saving lives on the battlefield as they had been for a hundred years previously. At the turn of the century, most medical service corps had officially existed for only a few years, none had sufficient manpower or supplies, military physicians lacked standing in their own armies, and surgeons continued to use techniques that most previous wars had demonstrated were ineffective. The rise of the industrial state and the integration of civilian populations into the armies serving as reserve forces, coupled with the increased destructive power of new weapons, convinced most governments that slaughter on the battlefield was an inevitable condition of modern warfare.2 Although the progress in military medicine seems obvious today, as the nations of the twentieth century lurched from one war to another—the Boer War, Russo-Japanese War, World Wars I and II, Korean War, and Vietnam War—that development was always in doubt when each war began. Any progress must have surely seemed less certain for the wounded and dying than we see it today.
The Boer insurrection in South Africa lasted from October 1899 to May 1902 and saw a Boer force of 87,000 mounted guerrillas confront a British Army of 450,000 men and 520,000 horses. In this war Mohandas Gandhi (1869–1948), then a young lawyer, served as a stretcher bearer, which the troops called “bodysnatchers,” and Arthur Conan Doyle (1859–1930), the creator of Sherlock Holmes, was knighted for his service as a civilian contract physician serving with the British medical corps in 1900.3 British casualties amounted to six thousand dead from enemy fire and another sixteen thousand dead from disease, mostly typhoid and dysentery. Four thousand Boer soldiers were killed, and twenty-six thousand Boer women and children died in British concentration camps of disease and starvation.4 As in so many previous wars, disease was the primary killer of the armies. Only twenty-two thousand British soldiers were treated for wounds, injuries, and accidents during the thirty-one-month-long war, but twenty times that number were admitted to hospitals for disease. Seventy-four thousand British troops suffered from typhoid and dysentery alone, and eight thousand died from the former.5 In the spring of 1900, the British Army halted at Bloemfontein, and during the single month of November, there were both five thousand disease cases and forty deaths a day in the hospital.
The British Army Medical Corps had officially existed for only a year before the war broke out, and it was critically short of personnel. Even so, it deemed the initial deployment of medical resources as adequate to support a force of two army corps and one cavalry division. Eight hundred and fifty medical officers were sent to staff seven “stationary hospitals” and three general hospitals located along the lines of rail communication.6 In addition, 40 warrant officers, 240 sergeants, and 2,000 enlisted men were assigned to the medical corps.7 Within a few months the military clearly saw that these assets were sorely inadequate and hired seven hundred civilian contract physicians and surgeons. As casualties mounted, the British medical corps continually augmented these numbers until, at war’s end, 8,500 personnel were assigned to the medical corps, including 151 staff and regimental medical units, 19 bearer companies, 28 field hospitals, 5 sanitary disease hospitals, 16 general hospitals, 3 hospital trains, 2 hospital ships, and 3 advance and 2 base depots for medical supplies.8 A total of twenty-one thousand hospital beds scattered over southern Africa were available, and eight hundred trained female nurses served these facilities.9 The centuries-old problem of medical unpreparedness evident at the start of the war required more than a year before adequate medical assets were in place.
British field hospitals were placed as far forward as possible, being consistent with the Germans’ doctrine of forward treatment that was proven in the Franco-Prussian War of 1870 and now adopted as standard practice in all armies. Stretcher bearers transported the wounded from the field to regimental aid posts, and from there, bearer companies moved casualties to the field hospitals. Although the wounded received attention at the regimental aid station, the service sent the severely wounded soldiers directly to the field hospitals, which were equipped with bell tents and performed much of the major and emergency surgery. A field hospital could accommodate a hundred casualties.10 Behind the field hospitals and located at intervals along arterial roads and primary rail lines were the stationary hospitals. These hospitals also had a hundred-bed capacity and were deployed forward as the army moved. Behind the stationary hospitals were the rear zone general hospitals, each of which had 520 beds.
A number of difficulties accompanied this structural arrangement. Although each brigade had a field hospital, there were no clearing points for triage and sorting casualties for evacuation to the rear. The gap between field and stationary hospitals proved as troublesome as it had been to the Americans in the Civil War. The Germans had improved on the American model used in the Franco-American War by creating mobile clearing stations at points between the field hospitals and the rear area hospitals. Surprisingly, the British had not adopted the idea. Near the end of the war, however, British medical units began to establish clearing stations at railheads for triage, stabilization, housing, and eventual evacuation by trains. In 1907, these new units were officially incorporated into the British medical service.11
One reason why the field hospitals assumed the load of emergency surgery was that transporting the wounded to rear medical stations was chaotic.12 The lines of communication were incredibly long, with the Boer theater of operations extending eleven hundred miles from north to south and six hundred miles east to west. Moreover, it was a war of mobility as small units ranged over wide areas, operating independently and often working without medical support. Transportation of any kind was scarce and vulnerable to attack, conditions that made it difficult for medical supplies and replacement personnel to reach the front regularly. Although designed for mobility, the field hospitals proved too cumbersome to move rapidly. Ambulance transport used two-wheeled Maltese carts and cape carts, four-wheeled wagons, and ox trek wagons, none of which was equipped with springs. They overturned easily on rough roads and provided such a rough ride that many of the wounded died en route. The troops refused to ride in them, as American troops had in the Civil War.
A lack of coordination between the litter bearer companies and the field hospitals made transporting the wounded even more difficult in the war’s early days. Although twenty-four hundred men were assigned stretcher bearer duty, their litter companies were attached to brigades and under military command of the division and not the hospital.13 After collecting the wounded and conveying them to the field hospitals, these companies returned to their line units and often marched off with the advancing brigade, leaving the field hospital deluged with casualties who needed evacuation to the rear but without the personnel or vehicles to accomplish this duty. The litter companies and the field hospitals eventually developed better coordination, but it was not until 1905 that the British finally combined the two into a single unit under the command of a medical officer in the medical corps chain of command.
The Boers had no formal medical support system when operating as guerrilla bands; yet they solved the problem of evacuating their wounded very well. The Boers went into battle in pairs, often with brothers or other relatives assigned as buddies. If one was wounded, the other was responsible for ensuring that the wounded man was saved from capture and transported on horseback to receive medical attention. Given the general scarcity of medical support usually available to insurgency units in these types of wars, the system worked as well as could be expected.
The Boer War presented a number of new challenges in the surgical treatment of the wounded; however, amputations, the scourge of all wounded since time immemorial, and high mortality rates were relatively rare. In the Crimean War, for example, 73 percent of those who underwent amputation died. Of those treated conservatively, 72 percent died. In the Civil War the rates were 53.8 percent and 49.9 percent, respectively. On the German side in the Franco-Prussian War, the rates were 65.6 percent and 28.7 percent, despite the wide use of Listerian methods of antisepsis, while on the French side, the amputation mortality rate was 90.6 percent.14 Almost no amputations were attempted for small-caliber gunshot wounds in the Boer War, even when they involved damage to the bone. Wounds caused by shrapnel or grenades generated the few amputations that were attempted. Whereas in the Crimean War no cases of knee joint wounds in which amputation was attempted survived, in the Boer War none died.15
This remarkable record was owed less to the quality of British medical practices than to other objective factors. Both sides in the Boer conflict used the new high-velocity rifles first adopted in 1888. The 7mm, thirteen-gram bullets were much lighter and smaller than the soft-lead bullets of earlier wars that often weighed between a half and a full ounce. The new bullets had protective metal jackets that considerably reduced the bullet’s tendency to deform upon impact and carry bits of clothing into the wound. Finally, improved powder propelled these projectiles at twenty-four hundred miles an hour, decreasing the probability that the bullet would lodge in the body rather than pass through it. These rifles made often small and clean wounds that only rarely produced extruding tissue. Further, their bullets were likely to nick a bone or pass completely through it rather than shatter it. These new rifles are often described as “humane” weapons in the military literature of the day, but these weapons had the unanticipated effect of introducing multiple wounds—a new problem to military medicine—when a bullet passed completely through its victim and wounded another soldier.
Another advantage was that sepsis was not a major problem in the Boer theater of operations. The area was only thinly inhabited, with few domestic animals to pollute the soil and no long tradition of farming with constant applications of manure to the soil. The soil itself was dry and sandy, rainfall was slight, and the hot, strong winds that blew over it prevented the growth of surface vegetation or any decaying vegetable and animal matter. These conditions reduced the probability of contaminating a wound, while the dryness and heat aided healing.
One consequence was that British doctors quickly adopted conservative techniques for treating gunshot wounds. They generally did not probe wounds, and their standard practice was to apply antiseptic dressings and immobilization, allowing the wound to heal by secondary intention. British soldiers also carried first aid dressings in pouches that contained gauze dressings impregnated with a solution of corrosive sublimate.16 After application, they covered the dressing with a waterproof jaconet. Experience demonstrated, however, that the waterproof covering prevented exposing the wound to the hot, dry climate, and keeping it moist only increased the chances of infection. The army eventually ordered the men not to apply these waterproof jaconets to their wounds.
British Army doctors were delighted that conservative wound management resulted in low rates of infection and high rates of successful healing. After the war, conservative treatment became the standard wound doctrine of the day. Unfortunately, British surgeons did not comprehend that their success was primarily because of the unique conditions of high-velocity wounds and that South Africa’s general climate was beneficial to healing. When the conservative approach was tried during the first years of World War I, it resulted in disaster. Unlike the Boer War, more than 60 percent of wounds in the First World War were caused not by high-velocity rifles but by shrapnel, which did far more damage. Moreover, the soil conditions of Flanders—damp, wet, and richly manured for centuries—were far more hostile to healing and produced high rates of wound infection. Because of their experience in the Boer War, the British also forgot about debriding wounds, which the Germans had first used extensively in 1870. Thousands of wounded soldiers died of infection as surgeons uselessly treated their wounds based on the lessons they had learned in the Boer war.
British physicians in the Boer War made frequent use of the new X-ray machine that Konrad Röntgen invented in 1895. American doctors had first utilized it in wartime during the Spanish-American War. Although more accurate than other “bullet detectors” of the day, the machine was cumbersome, so the army only installed them in rear area hospitals. The use of glass plates, which often broke in transit, instead of photographic film also posed a supply problem. Knowing the machine was available, doctors in field hospitals did not probe for the gunshot victim’s bullet, preferring instead to evacuate the casualty to a hospital equipped with the machine. Hundreds of casualties thus arrived in the rear with bullets still inside them and their surface wounds healed over. The ability of the X-ray to locate bullets without disturbing the wound further reinforced the medical service’s doctrine of conservative treatment.
More than in any other previous war, military surgeons in the Boer War paid close attention to the problem of surgical shock. For the first time, doctors extensively used the water bed, a system of tubes through which heated water was pumped to warm the patient and prevent shock. Although not used as extensively, they also administered transfusions of saline solution as a means of resuscitation and stabilization. Doctors did not do blood transfusions since they were regarded as dangerous and provoked systemic reactions. Scientists had not yet invented the technique of blood cross matching or discovered the anticoagulants necessary to ensure a proper flow of blood through the tubes connecting the donor with the patient.
The British record in preventing disease during the Boer War was outstandingly poor. Although the medical corps was now an officially established branch of the military, the army often regarded its sanitary officer as the most useless man in the service. Over the objections of the medical service, his post was officially abolished prior to the outbreak of the war.17 Sanitary regulations existed, but it was beyond the medical officer’s authority to enforce them. Field sanitation then depended upon the unit commander, who often ignored the issue. As one officer noted regarding sanitation, “Tommy doesn’t understand it, and his officers regard it as just a fad.”18 The troops frequently did not receive any training in personal hygiene. With little water to wash mess kits, the practice of washing them in sand or not at all became common. The men did not routinely clean the wooden water barrel carts and individual service water bottles, so they became breeding grounds for bacteria that caused intestinal diseases. The line commanders’ general refusal to require that water supplies be boiled resulted in 100,000 of their men being hospitalized for bowel infections before war’s end. The general sickness rate from all diseases during the war was 958 men per 1,000 per year.19
Typhoid was a major cause of disease for British troops. Of the mean annual deployed force of 208,000 men, 10 percent per annum were admitted to hospital with typhoid, with a 1.5 percent per annum death rate.20 Immunization for typhoid was known at the time but was new to medical practice. Dr. Almroth Wright (1861–1947), professor of pathology at the Army Medical School at Netley, England, developed a prototype antityphoid vaccine in 1896.21 The Plague Commission had granted permission to test the vaccine on Indian troops in 1898, and four thousand Indian soldiers were vaccinated with generally good results. During the Boer War, however, the War Office authorized typhoid vaccination only on a voluntary basis. Because of the often violent, though temporary, reaction to the injection, only 5 percent of the troops submitted to vaccination.22 The old canard, still heard among troops today, that certain kinds of injections affect virility probably did much to reduce the popularity of vaccination. The British medical service’s failure to pay adequate attention to sanitary measures resulted in fourteen thousand soldiers’ deaths from disease compared to only six thousand killed in action.23
By contrast, the American experience with typhoid was better. In the Spanish-American War, typhoid killed 1,580 men while only 243 died in action.24 American doctors were aware of the German and British experiments in typhoid vaccination, and medical officers were sent to the European laboratories to investigate their progress. Using the initial results as a base, an American Army doctor, Maj. Frederick F. Russell (1870–1960), modified the vaccine, and the first American attempt at vaccination for typhoid was tried in 1904. In 1909, the surgeon general ordered that the vaccine be tried on American troops. After administering twenty thousand vaccinations and observing the results, the American Army introduced compulsory vaccination for typhoid for all American recruits in 1911. Typhoid practically disappeared in the peacetime army.
The formal establishment of the medical corps in the British Army’s bureaucracy accorded it new influence with which to improve medical care for the soldier. To their great credit, the medical officers took the lessons of the Boer War seriously. Between 1901 and 1914, these officers brought about significant reform. The army medical school was transferred to London, where it could be in the center of medical advances developed in universities and teaching hospitals. They raised the general standards of training and practice for medical service officers. A school of sanitation was opened at Aldershot in 1906 to train regimental officers and noncommissioned officers for service in sanitary detachments that were now regularly assigned to each combat brigade. All troops were required to receive regular instruction in field sanitation and hygiene, and for the first time, to gain promotion, all officers had to pass regular examinations in sanitation. Immediately prior to World War I, Col. William Horrocks (1859–1941) of the Medical Corps had invented a sand filtration and chlorine process for decontaminating water for field use. His process was widely adopted, and portable water carts with the sterilizing apparatus were allotted to each field unit.
The British Army’s problem of casualty evacuation was addressed in 1906 when it combined the litter bearer companies with the field hospitals and placed them under the command of a medical officer. In addition, three field ambulances were allotted to each division, with one held in reserve. To fill the gap between the field hospitals and the stationary hospitals, the service introduced the clearing hospital, or the forerunner of the casualty clearing station. It served as the pivot around which the field medical service operated. It received casualties and sick personnel from the field ambulances; conducted triage, stabilization, and sorting; and then oversaw the wounded’s transport to the rear. To increase its mobility, it was located as far forward as possible and its load lightened. Although the idea was revolutionary, the failure to provide the casualty clearing hospital with its own transport to carry out its multiple missions proved a serious shortcoming when it first saw battle in World War I. Finally, the British Army created a Home Hospital Reserve with members of the Red Cross, reserve medical officers, and other ranks to expand the regular field medical force in time of war. Since most of these reforms had been implemented a few years prior to World War I, the British were relatively well prepared for what awaited them in Flanders’ fields.
The Russo-Japanese War of 1904–1905 had its roots in Japan’s emergence on the world stage as a major power in international politics. In 1871, scarcely forty years since Adm. Matthew Perry (1794–1858) opened Japan to Western influence, the entire structure of the Japanese state was reorganized along modern industrial lines. Shunting the old aristocracy aside, the new nationalist political order established a modern political, economic, and military infrastructure more appropriate to a great power. Desperately short of expertise in modern technology, the Japanese sent hundreds of military officers abroad to study war and industry. Most of its young army officers were trained in Germany, which had recently completed a successful war against France. Japan sent most of its naval officers to England, then the foremost naval power in the world, although some attended the U.S. Naval War College. Within a decade, Japan had created a modern ground army modeled after the German Army, including its general staff system, and equipped it with the latest weapons. By 1904, Japan was ready to challenge Russia for a place in Asia and the Far East and to signal its emergence as a world power.
When the war started in February 1904, the Russian Imperial Army had 1.1 million men in uniform compared to 180,000 for the Japanese. The Russian ready reserve totaled another 2.4 million men, while the Japanese could muster only 200,000 men in ready reserve and another 200,000 in second-echelon reserves. Many forget that the Russo-Japanese War featured major land actions that were larger than those fought at Gettysburg, Waterloo, and Borodino. The Battle of Liaoyang in August 1904 was second only to Battle of Sedan in terms of the numbers of men thrown into action. Six months later, at the siege of Mukden, the Russian forces numbered 275,000 infantrymen, 16,000 cavalry, and 1,219 pieces of artillery, or the largest field army that any nation had assembled in more than five hundred years.25 The Japanese threw 200,000 men against the Russian force. A Japanese field division comprised 11,400 infantry, 430 cavalry, 36 artillery guns, and 5,500 non-combatants, many of whom were in the medical corps.
This war saw the first large-scale use of the hand grenade and the introduction of the trench raid. While both sides carried the bayonet, only the Russians used it extensively in close combat.26 Of the 709,587 Russians who saw action, 146,000 were wounded and 4.2 percent of them died.27 The Japanese lost 43,892 killed in action and 145,527 wounded, of which 9,054 died, a wound mortality of 6.2 percent. This rate is comparable with a died-of-wounds rate of 6.1 percent for U.S. forces in World War I and 4.5 percent in World War II.28
From a medical perspective, the worst battle was the siege of Port Arthur (1904–1905). The Russians’ ability to cover the slopes with rifle and artillery fire made the Japanese recovery of their wounded almost impossible. The wounded on both sides crawled around for days without rescue or medical attention until they died. At night, Japanese litter bearers crept from the trenches to rescue their wounded, often only to meet Russian medical teams on the same mission. The Russians were suspicious of Japanese casualties’ feigning death and assigned armed men to their medical teams. They routinely shot Japanese wounded lying next to Russian casualties, and firefights broke out between the guards accompanying the rescue teams.29
The Russians’ habit of throwing food and personal waste outside their trenches, especially in the summer months of the siege, coupled with thousands of rotting corpses created serious health problems. The stench in the Russian trenches above Port Arthur was so strong that the men put up cloth strips soaked in camphor and carbolic acid in the trench dugouts to kill the odor. Japanese artillery often fell on Russian dressing stations and hospitals. When the seven-month siege finally ended in January 1905, the Japanese had suffered 57,780 men killed and wounded.30 As the Japanese medical officers moved into the city of Port Arthur, they found thousands of Russians suffering from scurvy and typhoid.31
The Russo-Japanese War was the first major war in history in which the number of men killed by bullets and wounds exceeded the number of soldiers who died from disease. The Japanese forces had 162,556 casualties from all diseases, of which 11,992 died. Official Russian sources put the number of Russian deaths from disease at 7,960, but the number is probably not reliable, given the generally poor quality of Russian medical care.32 While the Russian Imperial Army may indeed have lost more men to bullets than to disease, military physicians in the West studied the Japanese performance more, and the Japanese received great credit for their remarkable achievement in limiting disease casualties. Historically, in battle, an average of four to five soldiers had been lost to disease for each one lost to hostile fire. During the Russo-Japanese War, approximately 8 percent of the Japanese Army died from enemy fire and only 2 percent died from disease, thus reversing the historical pattern.33 The Japanese performance in military medicine became the envy of the world, and military medical officers from the Western nations flocked to Japan to learn how it was done.34
The modern phase of Japanese medicine began in 1870 when thirteen Japanese students were sent to Germany to study medicine. In 1877, Japan opened a medical school at the Imperial University and staffed it with German professors. As Japanese students returned from medical study abroad, they were integrated into the teaching faculty, and by 1900 the medical school’s faculty was almost entirely Japanese. For several more years, however, the language of medical instruction in Japan continued to be German.
The formative period of Japanese medical study abroad coincided with the findings of Louis Pasteur and Joseph Lister gaining prominence in Germany and German medical researchers, most notably Robert Koch, finally confirming the bacteriological nature of infectious disease. The Germans’ emphasis on germ theory and the prevention of disease strongly influenced the Japanese students, who taught it in Japanese medical schools upon their return to Japan. Thus, Nagano Sendai was placed in charge of a national program of disease prevention upon his return from Germany. Dr. Baron Kitasato Shibasaburō (1853–1931), who had been a student of Koch’s in Berlin, introduced the widespread use of bacteriological analysis to Japan and discovered the tetanus bacillus and its first antitoxin. Later, Dr. Masanao Goto established a series of national and military quarantines to prevent the introduction of disease by troops returning from overseas.35 From the beginning, Japanese military medicine had a strong emphasis on disease prevention that had no real counterpart in the West.
The real triumph of Japanese military medicine in the Russo-Japanese War came in the area of military hygiene and disease prevention. In Japan’s war with China in 1894, one of every nine Japanese soldiers suffered from some form of infectious disease. The Imperial Japanese Army in that war suffered 12,052 cases of dysentery, 7,667 cases of cholera (with a mortality rate of 61 percent), and 41,734 cases of malaria in a field army half the size of that employed in 1904. In addition, almost a third of the navy became sick with beriberi, a vitamin deficiency–related disease.36 With a small army of less than 200,000 men, a disease rate of these proportions almost crippled its combat power. The Japanese military medical establishment took steps to prevent a similar situation from occurring in the next war.
A key aspect of the Japanese preventive effort to control disease was ensuring that adequate means be available to achieve this goal. The National Sanitation Bureau undertook to produce sufficient drugs to tackle the problem of disease prevention and treatment. Under its auspices, the bureau oversaw the production and shipment to the army of 55,000 bottles of diphtheria antitoxin serum, 125 bottles of erysipelas antitoxin, 300 bottles of typhoid antitoxin, and 2,500 bottles of tetanus serum. It provided 450,000 capillaries for tetanus vaccination, each capable of vaccinating five persons.37
The success of the preventive medicine program is evident from the following data. During the Russo-Japanese War, the Japanese Army suffered 162,556 casualties from sickness, but only 10,565 suffered from infectious diseases, such as cholera, typhoid, and dysentery. Most of the sick suffered from noninfectious diseases, with 24 percent of the total sick suffering from beriberi. Of the infectious disease cases, only 4,557 died.38 In total, less than 1.2 percent of the entire field force of about 600,000 men died from disease. This result contrasted sharply with the usual 25 percent that had succumbed to diseases in various armies of the world over the previous two hundred years. In addition, 35 percent of the Japanese field force was never admitted to a military hospital during the entire course of the war, and 45 percent of the wounded were eventually returned to active duty.39 Japanese military medicine was extraordinarily successful in conserving Japanese military manpower.
The Japanese Army used the system of medical support and casualty evacuation that the Germans had copied from the U.S. Civil War system and then introduced in their war with France in 1870. The Germans had improved it by filling the gap between the field and base hospitals with a medical unit that functioned as a clearing station, and the Japanese also used this type of unit. Volunteer and Red Cross units in the Japanese armies functioned entirely under the army medical chain of command, while the Russians followed the Crimean War practice of allowing them independent status. The Japanese Red Cross never had independent status. It was created as a military auxiliary and was used exactly that way. The Japanese Red Cross had 1.25 million members located throughout the twelve Japanese military districts. During the war, it provided 3,852 nurses and staffed the army hospital ships. Eighty-two medical detachments were sent to the front, and the Red Cross provided thousands of litter bearers.
The Japanese casualty servicing structure placed the battalion aid and main dressing stations well to the front, either in the trenches or in a close-by ravine. The battalion collecting stations provided emergency first aid, while the dressing station somewhat more thoroughly examined the casualty and tried to stabilize his condition. Six regimental surgeons along with a number of attendants staffed each dressing station.
Behind the division-level dressing station was the field hospital, where temporary hospital treatment was provided. With a chief surgeon, eight assistant surgeons, and sixty enlisted men to act as nurses, the field hospital was the first point in the system where an operating table was available, and much emergency surgery was performed here. Behind the field hospitals were “stationary” hospitals, where more extensive care could be provided. These stationary hospitals, however, were expected to move with the army on short notice. When ordered to move, the usual practice was to divide the hospital contingent and leave behind the wounded to be cared for by the next echelon. The Japanese established base hospitals at key rail points to prepare casualties for evacuation to reserve hospitals in Japan.
The medical service also operated twenty-seven hospital ships to transport casualties to the homeland.40 These ships were originally merchant ships that had been converted for medical use and outfitted with operating rooms, electric lights, plenty of light and ventilation, and bacteriology and chemistry laboratories. Female navy nurses cared for the wounded. Each hospital ship could accommodate about two hundred patients. The Japanese Navy established major naval hospitals in Sasebo, Kure, Tokosuka, and Maizuru. These hospitals were of pavilion design and had separate sections for patients suffering from wounds, contagious diseases, or psychiatric conditions.
Another innovation copied from the Germans was the provision of a sanitary detachment at the division level. Despite its name, the detachment’s primary function was to act as a clearing station. Staffed by nine surgeons and sixty enlisted nurses, it had two litter bearer companies of two hundred men who were equipped with their own stretchers.41 The unit’s litter-carrying capability was greatly enhanced by hiring or dragooning Chinese coolies for this task. This divisional unit operated on the battlefield at all levels, moving casualties from the battalion and dressing stations back to the division’s field hospitals. They were also capable of performing emergency surgery to stabilize the patient.
Japanese surgical practice followed the then current thinking on conservative treatment of wounds that had become popular through the British experience in the Boer War.42 Most of the wounded in the Russo-Japanese War also suffered injuries from the new high-velocity, lightweight jacketed bullets that had made their appearance a decade earlier. Shells and hand grenades injured only one-seventh of the wounded.43 Thus, the Japanese instructed their soldiers and medical personnel not to touch a wound unless it was absolutely necessary to do so. Soldiers received instructions in advanced first aid and how to apply sterile first aid pouches and bandages. Each company was assigned a number of “instructed men”—enlisted soldiers who were especially skilled in advanced first aid, bandaging, and stopping hemorrhage—to serve as combat medics. Their goal was to stop bleeding and keep the wound as sterile as possible. Within the medical chain itself, surgery was permitted on the battlefield only to the degree that it was absolutely necessary to stop hemorrhage. Otherwise, emphasis was on stabilizing and rapidly evacuating patients to rear hospital facilities, where surgery could be performed under antiseptic conditions. During the sixteen days of fighting around Mukden, the division hospital performed only five amputations.44 While each division hospital was equipped with an X-ray machine, personnel only rarely used it since they did not anticipate that the surgeons at the division level would need the information. Japanese medical doctrine reasoned that a soldier was at greater risk from infection than from the injury itself.
The Japanese medical corps was structured and utilized as an integral part of the military command apparatus. Its chief held the rank of lieutenant general and was a member of the general staff. Each field army also had a surgeon general who held the rank of major general. Unlike most armies of the West, Japanese medical officers held full command rank and status in their armies and were regarded as essential personnel to the fighting effort.45 In the field, the medical corps had its own parallel chain of command and had effective control of medical matters at all levels. Combat priorities might lead a line officer to override his medical officer’s recommendations, but he did so at great risk since the medical officer reported the incident up through his own independent chain of command, ensuring that the line officer’s decision would soon be brought to the attention of his commander.
The Japanese Army became the first army in history to require that the combat operations field order routinely include a plan for medical support.46 The fact that all officers, regardless of assignment, were required to take staff courses in hygiene and medical care and that field hygiene was a subject for examination in the naval and army academies also testifies to the importance that the army placed upon medical support. Further, the Japanese medical officers earned the line officers’ respect by bearing the burden of battle. At Mukden, for example, fourteen medical officers were killed or wounded.47
The emphasis placed on military hygiene and preventive medicine led the Japanese to staff their medical system with sufficient numbers of medical personnel at all levels. The Japanese never experienced a shortage of doctors or medical supplies at any level of command during the war. The ratio of doctors to patients was approximately 1 to 100, and the ratio of nurses to patients was 1 to 5. The Japanese had twelve major hospitals in Japan itself, each with five attached branches in the military districts. By war’s end, the rear area hospital system had 58,263 available beds.48 As the war progressed, Japan drew upon its supply of 45,000 physicians and surgeons for wartime duty, and almost 10 percent of the army’s manpower resources were assigned to the military medical system. The success of the Japanese system led most Western nations to adopt this 1 to 10 ratio as the basis for assigning medical personnel in their own armies, if only for planning purposes.49
The Japanese Army was the first to establish a successful medical supply service, originally designed around the German system. The Japanese soon introduced major innovations to their system, and chief among them was establishing the medical supply system as an independent section of the medical corps. Each level of the medical support structure had its own supply section, which was responsible for providing and moving medical supplies. Once in the theater of operations, these supplies moved through the medical supply system’s own dedicated transport. Rear area supplies moved in regular army ships and trains but in a planned, allocated space specifically for medical supplies. The Japanese utilized prepositioning of supply amounts based on tables of consumption calculated at various levels of combat activity, an innovation that Dr. Jonathan Letterman introduced during the Civil War. The provisioning of medical supplies was very efficient, and the Japanese Army did not report a single case of a medical unit finding itself short of necessary medical supplies.
The Japanese success in reducing death and illness due to disease was also attributable to their excellent field hygiene system. Their disastrous experience in the China incident of 1894 taught them that one of the most important roles of the medical officer was disease prevention, and the Japanese created an excellent military hygiene program for their armies.
The army had an official hygienic code that was promulgated among all ranks. Each line officer was responsible for continuously educating the men and enforcing hygiene practices in the field. Through their own chain of command, the medical officers immediately reported any line officers who failed to accomplish their duty. Every division hospital had a bacteriological unit whose job was to diagnose illness and to ensure that steps were taken to prevent the further outbreak of diseases. All units down to the battalion level were issued equipment for testing water supplies, and water testing was a command responsibility. The standard practice was to boil drinking water, and troops never ventured into the field without adequate supplies of boiled water. Division medical officers were assigned to lower units on patrols to test and mark wells, and a medical briefing was standard procedure prior to undertaking combat operations in unfamiliar areas. Foraging and scouting parties routinely brought along a medical officer to make assessments. Medical officers were also responsible for cleansing newly captured positions so their troops would not be exposed to diseases left by the enemy. The Japanese utilized the most advanced system for enforcing field hygiene measures that the world had ever seen to that time.
The Japanese solider had good personal hygiene habits. Daily bathing, a regular routine in peacetime, was practiced whenever possible, as was daily shaving and ensuring that the soldier kept his hair short. The men themselves regularly laundered their own uniforms, although fumigating ovens were provided at division level for cleansing the uniforms of disease patients. On average, the Japanese soldier was also younger than the Russian soldier and carried a lighter load in the field.50 The extensive use of coolies, forced or hired from local populations, and the greater availability of rail transport also kept the soldier’s load light. Used to a light diet of rice and vegetables, the Japanese soldier adjusted better to the hot weather than the Russian did; indeed, even Russian commanders were impressed by how little the Japanese succumbed to sunstroke and heat exhaustion.51
The Japanese Army also practiced excellent field discipline to reduce venereal disease and alcohol problems. No camp followers were permitted, and only a small coterie of licensed vendors was allowed near the army. The only place to obtain alcohol—a scourge of the Russian ranks, especially in hot weather—was in canteens located fifty miles behind the Japanese lines. The soldier was provided with cigarettes, handkerchiefs for personal cleanliness, toothbrushes, soap, rice paper fans with which to cool himself, and writing paper. He was also allowed to fish to supplement his diet with protein.
One of the most important factors reducing disease was the Japanese cultural practice of cremating their dead. At the start of the war, the Japanese prepared individual funeral pyres, but the shortage of wood on the Liao-tung Peninsula quickly led to the dead being cremated in groups of five or six. Individual cremation was reserved for high-ranking officers. Immediate cremation of the dead removed a potentially dangerous source of disease contagion.52
The emphasis on disease and infection control was also present in the hospitals that treated the wounded. Japanese surgeons preferred to operate without rubber gloves, but strong antiseptic control of all elements of the surgical process kept the wound infection and hospital death rates to a minimum.53 All hospitals had hand-washing basins scattered throughout the wards and corridors, and the doctors and nurses washed their hands in disinfectant before they entered a ward. The staff kept the wards spotlessly clean, and all human and medical waste was burned every day. Latrines were covered and disinfected every day, and mosquito netting was provided for each bed. These measures’ effectiveness in reducing infection and disease is evident from the record of Toyama Hospital, which treated 15,759 patients after the Battle of Mukden from April through June 1905: it lost only 41 patients in this period to infection and disease.54 At Daley Hospital, within the war zone itself, 222,000 casualties were treated during the war, and only 3,150 died, or a hospital death rate of 1.4 percent.55
One of the more interesting aspects of the Japanese military medical system during this period was the field evacuation system. For most of history, the seriously wounded found being transported to rear area hospitals on springless vehicles was the bane of their existence. The Japanese, however, did not use any vehicles to transport the wounded. Instead, thousands of litter bearers organized into bearer companies carried all the wounded in stretchers through each stage of the casualty servicing structure from the front line to rear area hospitals behind division level, or a distance of approximately five miles.56 No estimate is available indicating how many seriously wounded men reached medical treatment alive because of the gentle nature of this type of transport, but it must have been substantial.
The Japanese medical structure that made its debut in the Russo-Japanese War was the most sophisticated medical service that any army had used until that time in history. The Japanese willingness to examine the medical services of the West and to improve upon them proved a major resource for conserving the manpower of their small nation for war. For the first time in history, the emphasis on disease and infection prevention allowed the Japanese to bring the latest advances in bacteriology to bear on military operations and to achieve incredible results. For at least two hundred years prior to the Russo-Japanese War, armies lost 25 percent of their field forces to disease and infection. The Japanese, however, lost less than 2 percent of their force to these causes. Moreover, their various hygiene procedures were so effective that more than a third of the field army went through the entire war without ever reporting sick.
The Russian medical system in this war was unchanged in its essentials from what the Imperial Russian Army used in the Crimean War. As in Russian society, the status of physicians and surgeons in the military was far lower than in any army of the West. Contract physicians and feldshers, the latter of questionable medical training, provided most of the medical care. Russian doctors in military hospitals were not usually billeted with line officers and had to sleep on the floor between the patient’s beds. General Ezerski, the chief inspector of hospitals at Sha-Ho, was not a medical officer but a former police chief. The status of Russian medical officers was so low that doctors who did not wear their swords in the wards while attending patients were disciplined. Even the diagnosis of disease was biased by status pressure. Because the line officers considered an outbreak of dysentery as reflecting poorly on their commands, they often forced doctors to classify dysentery cases as influenza.57
The old practice of having line officers command medical units, abandoned in most Western armies after the Crimean and American Civil War, was still in effect in the Russian Army, as was the habit of relying on the quartermaster to supply transport for moving casualties. The Russian Army had no official ambulance corps and still depended on troops from the firing line to carry casualties back to the dressing stations, as it had in the Crimea. As Wellington had noted in the Peninsular War, when several soldiers carried a wounded comrade to the rear, their absence negatively affected combat power on the firing line. Using the same methods during this war left Russian combat power seriously depleted at critical points in numerous battles.58 Without ambulance vehicles assigned to the medical service to evacuate casualties, the army expected that soldiers would use empty supply wagons. They carried the wounded over the rough Manchurian roads and trails in small springless carts (dvukolks) that had been shipped to the army to move supplies. As in the American Civil War and the Boer War, the rough treatment the wounded suffered while being transported in these “avalanches,” as the troops sometimes called them, caused a considerable number to die.
In Port Arthur, some Russian hospitals were large, spacious buildings. Most, however, were makeshift affairs with little medical equipment. The medical staff in Port Arthur comprised 136 surgeons and apothecaries, 15 medical students, 17 army officers used as inspectors, 11 priests, 46 clerks, and 112 female “nurses,” who were actually girlfriends and family members of the officers.59
The condition of the Russian field hospitals was dreadful. Soap, mattresses, and bedpans were in critically short supply, and infection and dysentery were universal problems. A description of conditions in a Russian field hospital in Port Arthur noted that patients “lie side by side on the floor, on the bedboards, underneath them, just as they were placed when they came in. . . . Faces are shapeless, swollen and distorted, and upon the yellow skin are large blue bruises. Inside, in spite of the musty and sickening stench, the cold is intense. On all sides is filth, nothing but filth, and on it and among it crawl millions of greasy gray lice.”60 The traditional Russian fervor for religion, however, led the army to assign priests as medical assistants to every regiment. These priests were required to make regular visits to the sick and wounded in the hospitals. Although they were short of medical supplies, the physician who did not have an adequate supply of religious icons to give to the wounded and bolster their faith was subject to discipline by military authorities.61
The chronic shortages of boots, greatcoats, blankets, and food exacerbated the terrible conditions under which the Russian soldier had to fight. Nutrition was poor, and while scurvy was only a minor problem among the Japanese, it was endemic among the Russians. The problem of scurvy worsened when the corrupt medical corps officers took the best food for themselves and their families. When the siege of Port Arthur ended, Japanese medical officers found that 32,400 members of the Russian garrison were suffering from scurvy.62
Because of the chronic shortage of salt and poor field discipline, Russian forces also suffered a high number of sunstroke and heatstroke casualties. Only the black Chinese variety of salt was available, and the Russians couldn’t stomach it. Sugar, fresh fruits, and canned meats were unobtainable. The only item in great supply seems to have been vodka, which the troops and officers consumed in large quantities. The medical officers seem to have made no effort to ensure a supply of potable water for the garrison, and no water-testing apparatus was available. Japanese officers found that almost every well was infected with typhoid. The Russian Army did not have official hygiene regulations, formal field hygiene instructions for the men and officers, or sanitary officers or detachments posted with the troops. The Russian Army was a medical disaster waiting to happen, as it had been a half century earlier in the Crimean War.
The terrible conditions of combat and prolonged artillery bombardment produced a large number of psychiatric casualties and men with self-inflicted wounds. Line officers often made midnight raids on hospitals and evacuation trains, seeking to recover “malingering” soldiers who could be forced back into the line. The problem of psychiatric casualties reached alarming proportions. Curiously, the army was prepared to deal with this area of military medical concerns.
The Russian military had encountered significant numbers of psychiatric casualties in the Crimean War. A large number of British soldiers had also been driven insane by the tremendous firepower of indirect artillery barrages.63 Unlike the British, however, Russian military doctors remained interested in the phenomenon of battle shock after the war ended. Evidence of psychiatric casualties in the American Civil War and the Franco-Prussian War further stimulated their interest. In the Russo-Japanese War, the Russian Army became the first in modern history not only to determine that mental collapse was a consequence of the stress of war but also to regard it as medical condition. It was also the first army to try to treat psychiatric casualties, and in so doing, the Russians laid the foundations of modern military psychiatry.
Russian Army physicians diagnosed and treated approximately two thousand casualties during the war that they attributed directly to battle shock; however, the number of soldiers complaining of psychiatric symptoms was much larger. These numbers increased so much as the war progressed that field medical facilities were unable to handle the psychiatric casualty load. Many psychiatric casualties were evacuated to the rear through normal medical channels and turned over to the Russian Red Cross for institutionalized care. The number of cases reached such proportions that they eventually overwhelmed even these resources. The Russian experience with these myriad psychiatric casualties provided the first modern example of “evacuation syndrome.” When soldiers realized that “insane” soldiers were being relieved of combat duty, the number of psychiatric casualties increased dramatically, as soldiers unconsciously manifested psychiatric symptoms to escape the horrors of the front. Paradoxically, the Russian medical team’s willingness to recognize and deal with psychiatric casualties is what produced even more psychiatric casualties among the troops.
The Russian Army was the first to place psychiatrists near the front line. Most of these psychiatrists, however, came from civilian mental hospitals and had little training in treating psychiatric casualties in a military environment. Psychiatric dispensaries staffed with psychologists, neurologists, a psychiatrist or neurologist who specifically dealt with brain injuries, a physician’s assistant, and a complement of three feldshers were also established near the front lines. Western armies’ dispensaries did not attain this degree of organizational sophistication for managing psychiatric casualties until 1917. The Russians also set up a separate chain of medical evacuation for psychiatric cases. It was the first time an army attempted to handle psychiatric casualties through a special medical evacuation channel, an innovation that became standard practice in the later years of World War I.
The Russians made a major contribution to military psychiatry when they introduced the principle of proximity, or the forward treatment of psychiatric casualties. Experience had taught them that a number of psychiatric problems could be readily cured if treated rapidly within the battle zone. Experience in both world wars proved the Russians correct. Today the principle of forward treatment of psychiatric casualties remains the most basic principle of all military psychiatry.
The Russian Army was also the first to establish a central psychiatric hospital immediately behind the battle lines. Located in Harbin, Manchuria, this hospital recorded between forty-three and ninety psychiatric admissions a day. Only a few patients were quickly cured and returned to the front line. The rest remained in the hospital for fifteen days and were subjected to a variety of treatments. If recovery did not take place, a physician and a small staff of physician’s assistants accompanied the psychiatric patients as they were evacuated by train to Moscow, a trip that often took more than forty days on the single-track railroad. By the end of the war, the army was operating several special trains exclusively for psychiatric patients that were equipped with isolation compartments, restraint rooms, and barred windows.
Of the 265 officers admitted to the Harbin hospital for psychiatric reasons, only 54 recovered sufficiently to be sent back to the fighting. The rest were moved to Moscow. Of the 1,072 enlisted soldiers treated at Harbin, only 51 recovered and returned to duty, while 983 were evacuated. Russian psychiatrists made significant advances in clinically linking battle stress with a number of somatic symptoms, and they developed diagnostic categories that were quite modern. During the Russo-Japanese War, the Russians established most of the psychiatric diagnostic categories that the Western armies later used during World War I. Russian psychiatrists recorded cases of hysterical excitement, confused states, fugue, hysterical blindness, surdomutism, local paralysis, and neurasthenia. Since Russian psychiatry had its roots in German biological nosological psychiatry, Russian doctors tended to define these symptoms in physiological terms and attribute their causes to damage in the brain. In 1905, 55.6 percent of Russian battle stress casualties were diagnosed as stemming from traumatic damage to the brain, an approach that gave rise to a similar diagnostic methodology in the West with the “shell shock” issue of World War I.64
By World War I, the Russian Army was the most experienced army in the world in dealing with clinical problems of battle stress. It was the first to specify categories of psychiatric problems in a military environment, the first to institutionalize forward treatment, the first to develop a theory of what caused battle shock, and the first to handle the problems of evacuation syndrome and secondary gain. The West mostly ignored these lessons until World War I when the Western armies, confronted with their own huge manpower losses for psychiatric reasons, finally attempted to develop methodologies for managing the problem. While the Germans quickly adapted to the new reality, the French, English, and American armies managed barely to put a psychiatric casualty servicing structure in place by the end of the war.65
From the perspective of the development of military medicine, the Russo-Japanese War was one of the most important wars in history. Both Japan and Russia developed and introduced major medical innovations to treat battle casualties and disease that set new standards for the armies of the world. Improving greatly upon the American and German models, the Japanese were the first to introduce a thoroughly modern military medical system that integrated all the major elements of casualty care and disease prevention into a complete command structure. The Japanese Army was the first to require a medical plan as part of the combat operations order, the first to place the chief of medical services in the general staff structure, the first to provide full rank and status to medical corps officers in combat theaters of operations, and the first to create an effective, independent medical supply service with its own transport. These organizational changes constituted major modifications to the medical corps and revolutionized its capability to attend to its mission.
Building on the German Army’s initial efforts in 1870, the Japanese Army became the first modern army to thoroughly integrate modern science into the care and treatment of casualties. Its emphasis on disease and infection prevention by applying the lessons of bacteriology, vaccination, and antiseptic surgery resulted in an army losing fewer casualties to disease and infection than to enemy weaponry for the first time in two hundred years. The army’s hygienic practices and field discipline far surpassed anything that modern history had ever seen, and it resulted in a level of manpower conservation that remained unsurpassed until the Vietnam War.
Given the generally backward state of Russian medicine and the almost pre-modern condition of the Russian military administrative structure, that the Russians made such major advances in the treatment of psychiatric casualties is surprising. It is no exaggeration to say that the Russian Army established the modern foundations of military psychiatry both organizationally and clinically. The conceptual foundations of modern military psychiatry remain unchanged in their essentials since the Russian Army introduced them in 1905. The principles of proximity, immediacy, and expectancy, known in the modern discipline by the acronym PIE, still undergird all methods of battlefield treatment of psychiatric casualties. While the discipline has since expanded the range of diagnostic categories, the original categories of mental disorder found on the battlefield remain as sound today as they were when the Russians first identified them more than a century ago.
When taken together, then, the Russo-Japanese War was a period of major innovation in military medicine. It was a time when modern military somatic and psychiatric medicine made its debut.
The First World War was the most destructive conflict in history up to that time: the combatants mobilized 60 million men, killed 7 million of them, and wounded more than 19 million. Half a million soldiers underwent amputations. The introduction of smokeless powder propelled rifle and artillery projectiles at higher velocities and greater distances than ever before. Shrapnel and exploding artillery shot caused 70 percent of battle wounds and produced mutilations on an unprecedented scale.66
Military medicine witnessed a number of important medical advances in treating the wounded. For the first time diagnostic bacteriology conducted in mobile laboratories was available in frontline hospitals. Improvements to X-ray machines, making them lighter, allowed their use in forward surgical stations. Intravenous saline infusions in resuscitation became common, as did clinical thermometers, hemostatic forceps, hypodermic syringes, and better retractors and surgical lighting. The first field blood transfusion teams were introduced, and the casualty clearing station grew into the evacuation hospital and became a standard feature of the casualty evacuation system.
At the start of the war, the doctrine of conservative treatment and healing by secondary intention was widely used with disastrous results. The continued practice of limited debridement and secondary closure of severe shrapnel wounds that were contaminated by the richly manured soil of the battlefield led to high rates of amputation and infection, the latter almost always in the form of deadly gas gangrene. Wound mortality approached 28 percent in 1915, and the amputation rate ran as high as 40 percent for wounds of the extremities involving injuries to the bone.67 First attempts to control infection involved using various antiseptics directly on the wound. Experience taught that this procedure was ineffective and often harmed healthy tissue. Military surgeons gradually relearned old lessons and used debridement on all major wounds. In addition, they continually irrigated wounds with Eusol (Edinburgh University Solution of Lime) and, eventually, Carrel-Dakin solution—a diluted antiseptic of sodium hypochlorite and boric acid—to aid draining. Mobile bacteriology laboratories attached to the various hospitals took daily bacterial smears to determine the bacteria count before doctors closed wounds and saved many lives.
As these surgical procedures were gradually implemented, the rate of wound infection fell dramatically. In 1917, the Battles of Messines and Passchendaele (also known as the Third Battle of Ypres) produced more than twenty-five thousand wounded, of which only eighty-four contracted gas gangrene.68 By the end of the war, wound suppuration had become relatively rare. Signs in hospitals often included a statement by Alexis Carrel (1873–1944), the coinventor of the Carrel-Dakin solution: “Every wounded man who develops suppuration has the right to ask his surgeon to justify it.” By war’s end, overall wound mortality was 8 percent compared to 13.3 percent for the American Civil War and 20 percent in the Crimean War.69
Advances in wound surgery and reduced infection had the effect of decreasing the amputation rate, and as surgeons abandoned the traditional practice of prophylactic amputation for all compound fractures by 1917, the amputation rate dropped to less than 10 percent. Nonetheless, with half a million total amputations during the war, this area of surgery generated considerable interest and led to standardized surgical procedures, clinical definitions, prosthetic limb application, and the start of the science of rehabilitation. Sir Robert Jones (1857–1933), inspector of military orthopedics for the British Army, is credited with establishing seventeen rehabilitation centers of various types and introducing the first comprehensive approach to the rehabilitation of combat wounded attempted by an army.70 More than four hundred surgeons gained training in the new science of orthopedics during the war.71 Jones also advocated using the Thomas splint at all first aid posts when transporting men with compound femur fractures, reducing the mortality rate from this injury to less than 20 percent.72
Attempts to control shock in treating the wounded received major attention. Surgeons were aware that low blood pressure triggered shock, and they first tried intravenous saline replacements after the Battle of the Somme in 1916 but had disappointing results. In the same year, forward area surgeons tried to conduct blood transfusion by the direct method. Dr. J. Roussel is credited with making the first successful battlefield blood transfusion during the Franco-Prussian War. He drew upon the work of James Aveling, who invented a rubber bulb syringe to pump blood more quickly from the donor to the recipient. The French, Austrian, Belgian, and Russian armies adopted Roussel’s “transfuseur” apparatus at the turn of the century.73
Blood transfusions were not common before World War I, but sufficient numbers were performed for researchers to determine its major problems. The donor’s blood tended to clot before it could be infused into the recipient’s system. Various anticoagulants, such as sodium phosphate, were first used as early as 1869. Attempts were also made to remove the blood’s fibrin, but this process had the undesirable effect of removing other valuable components. The introduction of the Kimpton-Brown waxed tubes in 1917 to reduce clotting in the transfer apparatus helped only slightly.74 Antiseptic control of bacteria helped reduce the danger of infection, and in 1909 Karl Landsteiner (1868–1943), working from his discovery of blood groups, developed a classification of blood types to reduce the probability of reactions from transfusion.
By the start of World War I, Albert Hustin (1882–1967) had shown that sodium citrate was an effective anticoagulant; thus, for the first time, it became possible to store blood for future use. Coupled with type matching and waxed transfer tubes, these advances made blood transfusions practical. Although transfusion remained a major procedure that was as complex as the surgery itself, the British and American armies established the first transfusion resuscitation teams and assigned them to special shock centers. These teams could be moved quickly in anticipation of major casualties and often deployed forward to the field hospitals. The war ended before transfusion could be applied on a large scale, but the value of field transfusion units was clearly established. During the interwar period, practically every major medical service established these teams for use in the next war.
Trench warfare produced large numbers of facial wounds, and more than three thousand of the eight thousand Allied personnel who suffered facial wounds died.75 At the beginning of the war, no trained surgeons had specialized in treating maxillofacial injuries and no books on the subject of general plastic surgery were available.76 Military surgeons were so inexperienced in this area that they often transported their patients who had facial injuries in the supine position, one that blocked their airways and killed them. The British government’s initial effort to help those suffering from maxillofacial injuries was to contract civilian artists to create and paint realistic masks that the disfigured could use to hide their injuries.77 In time, however, the British established special hospitals to treat these casualties, and significant numbers of plastic surgeons were trained to staff them. The British started the first maxillofacial injury hospitals, but the Americans’ entry into the war in 1917 stimulated greater interest. By June 1917, the Americans had established four hospitals to handle maxillofacial injuries and are generally credited with introducing the team approach to reconstructive surgery that became standard in World War II.
Although military medicine had made great strides in disease treatment, the richly manured soil of Flanders caused high rates of tetanus infection in the early years of the war. Advances in tetanus antitoxin vaccines produced a more effective vaccine that saw its first large-scale military use during the war. Tetanus had a mortality rate of 89–95 percent in the Civil War, and shortly before World War I when the first anti-tetanus vaccines were available, the mortality rate was still between 40 and 80 percent.78 In 1914, 32 percent of British wounded contracted tetanus. With the introduction of new vaccines and the practice of giving a wounded man a tetanus shot as soon as possible, the rate of tetanus infection dropped to 0.1 percent by war’s end.79 Even so, the mortality rate of those who contracted tetanus remained between 20 and 50 percent. Advances in tetanus antitoxins, the introduction of regular inoculations in the interwar period, and the widespread practice of debridement and secondary closure of wounds reduced tetanus deaths to almost zero by the end of the war. Among U.S. forces in World War II, of the 10.7 million men who served, only eleven known cases of tetanus were recorded.80
Advances in disease prevention and treatment were evident in World War I’s low rates of death to enteric fever, plague, smallpox, cholera, and typhus. New typhoid vaccines drastically reduced typhoid rates. In the Spanish-American War, 20 percent of the soldiers contracted typhoid, but typhoid afflicted only 0.04 percent of the American Army in World War I.81 While scientists had made some advances in the treatment of dysentery and malaria, these two diseases remained major problems. Trench foot (emersion foot) disabled thousands of soldiers on both sides, and trench fever, caused by parasites in the fecal matter of the louse, produced more than 200,000 casualties on the Allied side.82 Allied troops suffered 115,361 casualties to frostbite during the war. For the most part, however, establishing professional military medical services in the major armies paid big dividends as medical officers used their expertise in disease control and prevention. Except for the worldwide influenza epidemic of 1918, disease claimed far fewer men in World War I than had been the case in other wars.
The German Army was the most medically prepared of all the combatants of the First World War. The organizational model of its field medical care that had been unveiled in the Franco-Prussian war—complete with its first aid kits, forward surgery, casualty clearing stations and transport system, the integration of rear area hospitals into a complete system linked by rail, and the first large-scale introduction of Listerian methods of antiseptic and aseptic surgery—remained in place in 1914. The Germans’ penchant for planning—a product of that other German invention, the general staff—meant that sufficient medical personnel, supplies, rolling stock, and plans for moving the wounded had been put in place ten years before the war.83 Furthermore, Germany was the only nation that had established plans and facilities for rehabilitating the wounded and disabled.
After 1870, German medicine became totally integrated into the larger scientific community. Accordingly, German military medicine was able to muster the full range of scientific and technical expertise drawn from the intellectual resources of the entire nation. On the eve of the First World War most other nations had not fostered this degree of integration; however, by war’s end, the German pattern was characteristic of all the major combatants’ military medical establishments. Meanwhile, German casualties amounted to 1,531,048 killed in action, and of a total number of 19,461,265 men admitted to the hospital for all causes, 155,013 died from disease. The total mortality of the German Army was 1,686,061, or a wound mortality of approximately 8.6 percent.84
Of all the major combatants, the Russian Army, whose general health and social condition had begun to collapse even before the war, endured the worst medical situation. The available statistics of Russian losses indicate that their disease rate was the highest of all combatants. A total number of 5,069,000 are recorded as having been hospitalized for disease. Of these cases, 21,093 had contracted typhus, 97,522 typhoid, 75,429 remittent typhoid fever, 64,364 dysentery, 30,810 cholera, 2,708 smallpox, and 362,756 scurvy.85 A German medical team sent to Russia in July 1916 reported that every division set aside a hundred beds at the corps hospital to care for the victims of scurvy.86 The state of Russian preventive field medicine was terrible, and its troops suffered huge losses from diseases that had ceased to be serious medical problems in other armies. The official Russian figure of only 130,000 soldiers dead from disease, therefore, is probably not reliable.
Based on the only recognized statistical study, Russian forces lost 664,890 men killed in action with 18,378 dead from wounds within their units; that is, medical personnel never reached them for evacuation. An additional 300,000 soldiers died in hospital from their wounds. The Russians suffered a total of 3,748,000 men wounded, suggesting a mortality rate of approximately 8 percent.87 Another 1.4 million disabled men were discharged into a society wracked by revolution and lacking all facilities for rehabilitation.
The French medical service remained the only example of a major army whose medical officers were not part of an independent medical service and were under the command of line officers. Moreover, the general staff’s attitude regarding field hygiene had not changed since the last century. The men had little interest in hygiene and provided no training; responsibility for hygiene remained with unit commanders, unimpeded by the medical service. As a result the French Army suffered 50,000 cases of typhoid in the first three years of the war. When American units were assigned to former French training areas, they were horrified to find that almost all the water supplies were polluted by typhoid.88
Without an independent medical supply service, the French medical officers had to secure the quartermaster’s written permission for all supplies and vehicles. The chief surgeon of the army was relegated to the second line staff and separated from the general staff by thirty miles, indicating that the army had made no attempt to integrate a medical plan into the overall battle plan. Consequently, units often moved away from their hospitals and medical support without the hospitals being made aware of the redeployment.89
The French Army attempted to mobilize its civilian reserve physicians and surgeons for war only to discover that it possessed no complete list of their names and addresses. More than half of the medical personnel mobilized declined to serve as officers, resulting in a great waste of trained medical talent.90 The number of physicians and surgeons that the general staff had originally estimated as required for war turned out to be quite insufficient. Indeed, the army needed more than double the planned number of medical assets to handle the high casualty rates.
The organizational structure remained a shambles throughout the war. The chief surgeon had only a small staff to support an army operating over a thirty-five-mile front that was a hundred miles deep. At the beginning of the war, the chief surgeon did not have his own transport. The general staff first echelon had to approve any requests for personnel, equipment, reinforcements, and even the deployment of medical resources to field units first, making coordination with events on the battlefield an impossibility. The French began the war short of medical equipment. Its table of organization strength for medical assets, which had been drawn in 1910, remained unchanged. Only ten army corps had sufficient surgical material to supply their field ambulances, and the hospital trains were more like boxcars than trains suitable for casualties.91 Because these trains were not under the medical officers’ control, trains were not only underutilized but also faced incessant delays and overcrowding at assembly points.
Troops assigned to medical detachments still reported to their line officers and not to the medical officers. Detachments of wagon drivers and litter bearers were under the orders of the logistics and transport officers and not the chief surgeon of the hospital. No medical officer, including the director of the medical service, could order a change in the disposition of medical personnel without the army corps commander’s approval.92 The medical officer was even forbidden to send troops to the forward dressing stations to relieve them during an influx of heavy casualties. The service’s inability to move medical assets to the areas with the greatest casualties and lack of reliable manpower for the ambulance service produced delays in reaching and evacuating the wounded. Although the medical officers finally obtained some control over their own personnel by 1915, the problem of directing personnel assets persisted until the end of the war.
The quality of medical talent, including that of physicians and surgeons, was poor.93 Few of the medical students who had served their one year of military service before the war had attended their required training sessions. Reserve doctors often failed to attend as well. Once pressed into service on the battlefield, most found their skills inadequate to their responsibilities. It did not help that in hard-pressed sectors, line officers stripped the hospitals of their medical personnel, including physicians, and pressed them into service as combat soldiers. Of all the major combatants in World War I, with the possible exception of Russia, the French Army presented the poorest example of a military medical service.
In August 1914, the British Army had 100,000 men on the continent resisting the German advance toward Mons, Belgium. By 1918, more than 4 million British soldiers had seen action in the war. More than 700,000 of them were killed, were missing, or had died of their wounds; 2 million more were wounded—or a hundred times more men than in the Boer War—and 6 million men had been hospitalized at one time or another for disease or illness. At the Battle of the Somme in 1916, 316,000 men were admitted to the field ambulances, with 24,675 carted away in the first twenty-four hours of the battle. In France alone, the British Army Medical Corps attended 129,675 wounded and sick officers and 2,525,350 men of other ranks.94
At the outbreak of war, the regular army and reserve components of the British medical service had only 20,000 men. By 1918, 13,000 officers and 154,000 enlisted men had seen service in the medical corps. Medical assets deployed in the war included 235 field ambulances, 127 sanitary detachments, 78 casualty clearing stations, 48 motor ambulance convoys, 63 ambulance trains, 4 ambulance flotillas, 38 mobile hygiene and bacteriological laboratories, 15 mobile X-ray units, 6 mobile dental labs, 18 advanced depots of medical supplies, 17 base depots, 41 stationary hospitals, 80 general hospitals, and 77 hospital ships. In 1914, the British had only 18,000 hospital beds spread throughout the empire. By 1918, the number of hospital beds had expanded to 637,000, with more than half of them located in England.95
The static nature of trench warfare made moving the wounded easier. Although motor transport for casualties was introduced in 1911, the army staff vetoed using these vehicles for medical transport because it maintained the roads were already overburdened with more important supplies. Once again, the British attempted to use empty trucks and wagons of the supply train for double duty as casualty transport. The time required to load and unload the casualties disrupted combat supply timetables, so the army decided to equip the medical corps with its own wagons and motor transport operating on its own schedules. The sequence of evacuation ran from the stretcher bearers at the regiment and its medical officer, who, in turn, passed his casualties to the advanced dressing station and then to the main dressing station.
In its major innovation in the structure of medical care, the British placed their casualty clearing hospitals behind the main dressing station. This clearing unit was developed from the prototype that had been first attempted on a small scale during the Boer War. Originally it had been intended to serve as a drop point that would allow the field ambulances to “clear” themselves before returning to the front line, but the large number of World War I battle casualties changed their nature and function completely. Casualty clearing hospitals were located barely beyond the range of the most intense artillery, or about seven miles from the front. Six medical officers and eighty orderlies sorted and stabilized the casualties before passing them down the line.96 These stations could handle two hundred patients on stretchers, but they were not supplied with beds.97 The clearing station had only marginal surgical equipment available since the unit was not designed to undertake major operations. Each station was attached to a division and had its own horse and lorry transport that the division quartermaster supplied.
As the burden of casualties grew, the casualty clearing stations expanded so that they could receive, stabilize, ship, or post a thousand casualties a day.98 Their staffs increased to include medical surgical specialists, anesthesiologists, and special medical teams for serious surgery. They added two hundred beds per station, which became the main providers of field surgery in the forward area. In 1917 at the Third Battle of Ypres, for instance, surgeons performed 61,500 operations with anesthesia at the clearing stations.99
The litter bearers at regiment who served as the first line in the casualty evacuation system faced many obstacles. While the British planned to use two men to carry a stretcher, the explosive artillery disrupted the farmlands’ irrigation and stream patterns where battles were fought, and the extensive network of trenches soon produced a year-round sea of mud. Often moving a single litter required as many as seven men. Even in relatively safe rear areas, the medical service used a mix of no fewer than eighty-three types of special transport—including stretchers, motorized lorries, mules, and sledges—compounding the problem of medical evacuation.100 Medical units often designated combat soldiers to move their wounded comrades to the rear, but the British commander of the western front Gen. Douglas Haig (1861–1928) attempted to stop the practice because it drained combat power at the front. The average time elapsed from wounding to evacuation to a field hospital was five hours and then ten hours to the evacuation hospital. A number of factors slowed medical evacuation. Because of the sweeping machine gun and artillery fire, men wounded in the trenches could only be safely evacuated at night, often causing a delay of twelve hours. Men were told that if they were wounded in no-man’s-land to crawl to the open shell craters and wait there until darkness, when “scavenger teams” would search for them. Finally, the mud, generally poor road conditions, and harassment fire falling in the rear exposed ambulance convoys to destruction.101 Sometimes hand-carried litters transported the wounded the entire distance from the front to the field hospital.102
The American Expeditionary Force sent 2,039,329 men to combat duty in France, and of these men, about twenty-eight divisions, or 784,000 soldiers, engaged in battle. The total mortality of American soldiers in the western theater of operations was 75,658, of whom 34,249 were killed in action, 13,691 died of wounds, 23,937 died of disease, and 3,681 died of suicide, drowning, homicide, and other accidents.103 Among American medical officers in France, 46 were killed in action; 212 were wounded, of whom 22 died; 101 died of disease; 9 died from accidents; and 7 were missing.104
During World War I, the American Army expanded twelve-fold from its peacetime strength. In June 1917, the medical department of the army had 443 medical officers, 146 medical reserve officers, and 4,670 enlisted men assigned to it,105 but it had no real organization and mostly old equipment. By war’s end, the medical corps had grown to 30,591 officers—of whom 989 were regular officers and 29,062 temporary active duty officers—and 264,181 enlisted men, for a total strength of 294,772 men. In addition, 8,587 nurses served on active military duty.106 In France, the U.S. medical service provided 261,403 beds to service 193,448 patients—99,405 sick and 94,043 wounded. Stateside, 69,926 patients occupied another 121,883 available beds. The total beds, 383,286, were twice that available to the Union forces during the Civil War.107 By November 1918, the American medical service had evacuated 129,997 men via twenty-one hospital trains and had transported another 197,708 on hospital trains that the French made available.108 U.S. forces had sent some 6,875 motorized ambulances to France along with fifty medical barges operated on French inland waterways. Three hundred and thirty-three hospitals had been constructed by the U.S. government and military, with ninety-one of them located in the United States.109
The medical corps also provided other services, including administering psychiatric examinations to recruits. The high rates of psychiatric casualties had prompted field commanders to ask the medical corps to find some way of screening troops. The idea that some individuals were more prone to psychiatric collapse than others was adopted from the era’s emerging racial and eugenics theories, which held that particular behavioral proclivities were characteristic of certain “races.” This notion had already been established in criminology and psychiatric practice and had struck deep roots in Britain, Germany, and the United States. The medical corps administered 1,151,552 psychiatric examinations in an effort to screen the “unfit” from military service, but the screening had no effect at all on American rates of psychiatric casualties.110
The army medical corps also had the task of designing and producing gas masks. Until the task was turned over to the Chemical Warfare Service in June 1918, the medical corps produced 1,718,000 gas masks for soldiers, 154,000 masks for horses and mules, 502,000 breathing canisters, and 11,000 trench fans.111 The introduction of gas warfare in the middle of the war was at first thought to present the medical corps with new challenges in treating gas casualties. It was soon discovered, however, that the effects of wind, temperature, terrain, and better training in the use of protective masks made delivering effective gas attacks very difficult. The number of physical casualties from gas proved remarkably small, while the number of psychiatric casualties (hysterical reactions and self-inflicted smearing of mustard gas residue on one’s body) increased. In 1922 a British Army investigation concluded that most British “gas casualties” had in fact not been gassed at all or had inflicted the wounds upon themselves.
The casualty servicing structure of each regiment had a medical detachment of fifty-five officers and men. As this number proved inadequate, in times of heavy casualties the service commonly drew eight to twelve men from each combat company to assist the medical unit, usually as litter bearers. From the regimental aid post, the litter bearers from the ambulance company evacuated patients to the ambulance collecting stations, which were usually located at the most advanced points where motorized or horse-drawn ambulances could reach the casualties. The ambulance company headquarters was located about a mile from the fighting, and when a full ambulance passed through the headquarters’ control point, an empty one headed to the front to replace it on the line.
As with the British units, American field hospitals were located immediately outside the range of artillery fire. Each division had four field hospitals, two of which deployed for immediate use with the other two held in reserve in the event that the division began to move. Only emergency surgery, stabilization, and resuscitation— wounds redressed, splints applied, pain relieved, nourishment given, and shock treated—were done in these field hospitals, and the patient prepared for movement to the rear. Shell-shocked soldiers suffering light to moderate symptoms were held at the field hospital for a few days. If they recovered, they were sent back to their units. Those men with persistent symptoms were eventually evacuated to psychiatric hospitals in the rear.
The evacuation hospitals were located on railway lines twenty to twenty-five miles to the rear. These hospitals were well equipped with physicians, surgeons, and female nurses. After surgery, hospital trains and motorized ambulances transported casualties to general hospitals. When the war of movement recommenced, the force never had enough ambulances to move casualties to the evacuation hospitals. At times the distance between the field hospitals and the evacuation hospital was fifty miles or more over poor roads. During the Meuse-Argonne offensive (1918), U.S. ambulance drivers made twenty-four thousand trips to the evacuation hospitals, averaging twenty-eight miles each way.112 Each ambulance section had twelve ambulances, and two ambulance companies were assigned to each division. Even at the war’s end, the number of ambulances was never adequate.
The American force lost 58,075 men from disease over the course of the entire war.113 This figure is somewhat misleading, for the medical corps did a good job of controlling those diseases that had traditionally decimated armies of the past. There were, for example, only 1,055 cases of typhoid and paratyphoid with only 165 deaths. Diphtheria produced 4,860 cases but only 76 deaths. The 1,975 cases of dysentery resulted in 35 deaths; 950 cases of malaria, 2 deaths; 9,618 admissions for measles, 358 deaths; and 24 deaths from smallpox.114 The greatest killers were influenza, which produced 167,141 admissions with 6,072 deaths, and pneumonia, which resulted in 20,445 cases and 6,481 deaths.115 At the height of the influenza epidemic in November 1918, influenza patients occupied 193,016 hospital beds of the total 276,347 beds available.116 Meanwhile, the introduction of the Lyster bag— a double-lined, spigoted canvas water bag that purified water with the addition of calcium hypochlorite—did much to reduce water-borne disease.117
The high rates of manpower loss to psychiatric casualties forced the American Army to confront the problem. Dr. Thomas Salmon (1876–1927) visited France to learn how the French and British handled their psychiatric casualties. These two armies evacuated psychiatric casualties in the normal medical chain, a practice that resulted in large numbers of troops being lost to the war effort. Seeking to avoid this situation, Salmon designed a system based on the proximity of treatment, the screening of casualties for psychiatric symptoms, and an expectation of the patient’s return to combat. The American military began training doctors and support staff in military psychiatry and, by war’s end, had 693 military psychiatrists in its ranks with 263 stationed in France.118 Following the established Russian and German practice of forward treatment of psychiatric casualties, the Americans provided each division with a psychiatric section under the command of the division psychiatrist, and small psychiatric hospitals capable of handling thirty patients at a time were established near the front lines. Larger psychiatric hospitals were set up in the rear but still relatively close to the front. Approximately thirty-five men per thousand per year were admitted to these psychiatric facilities, with 40 percent returned to service.
The Spanish Civil War, which ended six months before World War II began, was a testing ground for new weapons and tactics that the Germans and Soviets supplied to the respective sides. It also became a testing ground for military medical advances. Gaston Ramon (1886–1963) introduced a new tetanus vaccine at the Pasteur Institute in 1931 that received its first large-scale field test in the Spanish Civil War. For the first time that the new sulfonamides—sulfa drugs, or a new group of antibacterial drugs working by bacteriostatic action—were used in war. Both sides generally adopted the German methods of antiseptic and aseptic surgery, leading to the widespread use of antibiotics and new antiseptics. The war saw the medical services widely utilize mobile surgical teams, which the Allies later perfected in World War II, and combat blood transfusion using stored blood for the first time.119 Overall these innovations in military medical care resulted in a drastic decline in the wound infection and amputation rates. Despite often primitive surgical conditions, only 342 of 42,000 wounded soldiers underwent amputations in the Spanish Civil War.120
During World War II, the British medical service treated 5 million patients, of whom 104,076 died of their wounds. Another 239,457 were wounded but survived.121 More than a thousand British medical units were mobilized for the war, including 148 field and general hospitals in the overseas theaters and 88 at home, 36 casualty clearing stations, 141 field ambulances, 49 ambulance trains, 34 hospital ships, 42 medical supply depots, 50 surgical field units, 36 blood transfusion teams, 64 field dressing stations, 27 convalescent centers, 122 field hygiene units and sanitary sections, 71 antimalarial control units, and an unknown number of mobile laboratories and other specialized units.122
The British went to war with a medical structure essentially unchanged since World War I, but the new mobile tactics and distances that it had to cover during casualty evacuation required more mobile medical facilities. To solve the problem, they adopted the American idea of equipping the entire medical structure with motorized transport. They reduced the size of the casualty clearing stations and made the field ambulance units lighter but gave them more vehicles, created field dressing stations and mobile surgical teams and equipped them with enough surgical supplies to conduct a hundred operations without replenishment. They also introduced mobile neurosurgical, maxillofacial, and field transfusion teams. The Blood Transfusion Service quickly became an integral part of forward surgical units.
The British experience at the start of the war demonstrated that a casualty had to be transported 133 miles from the forward aid station to the casualty clearing station and another 236 miles to the general hospital.123 This situation led to the creation of the advanced surgical center (ASC), which was located forward in the combat zone and designed to provide and rapid surgical care. Attached to a casualty clearing station or field dressing station, the unit was totally self-sufficient with complete facilities, personnel, and transport, including a field transfusion unit. The center could be quickly attached or detached from its parent unit and rushed to the point of greatest casualties. The advanced surgical centers dealt with all shock, penetrating abdominal wounds, chest wounds, amputations, femoral fractures, and major arterial injuries. They serviced approximately 15 percent of the total casualty load.124
New tactical units, such as airborne and commando outfits, required their own independent medical support, so the British developed special commando and airborne medical units. They trained twenty-five thousand special medical personnel for these sections, and the first air-droppable division medical component was used at Arnhem (1944).125 The long distances that the casualty transports traveled placed a premium upon limb immobilization. At the Battle of Tobruk (1942), the British used the Tobruk splint with great success. Essentially an adaptation of the Thomas splint of World War I, the Tobruk splint incorporated a plaster shell with a traction pulley anchored to the splint’s heel to allow constant traction on the fracture. Meanwhile, the first large-scale use of tanks and other armored fighting vehicles resulted in a high proportion of burn casualties. The early use of tannic acid for burn treatment proved ineffective and even damaging. Armored vehicle crews were later issued wound dressings made of sheets of gauze, which were impregnated with surgical jelly to which sulfanilamide had been added, and loose gloves made of waterproof silk that sealed at the wrist for hand burns. These efforts drastically reduced pain and infection from burns.126
World War II witnessed a number of major innovations in the soldier’s medical care. Among the most important were the new antibiotics. Sulfonamides had been first identified in 1908 but did not appear as practical antibacterials until shortly after World War I. The military initially utilized them because of their effectiveness against venereal disease. Their successful application in surgical treatment in the Spanish Civil War led to their widespread use in World War II.127 Alexander Fleming (1881–1955) discovered penicillin in 1928, and its gradual perfection by Howard W. Florey (1898–1968) and Ernst B. Chain (1906–1979) in the early 1940s led to the production of the most effective antibacterial wound agent that military physicians had ever used. The discovery in 1943 that large quantities of the drug could be made in cornstarch cultural mediums resulted in mass production and in the Allied armies’ widespread use of the drug in 1944. Until 1943, production was barely sufficient to treat a hundred cases. By 1944, penicillin production escalated to 3 billion units a year.128 By the Normandy invasion that June, the Allies had sufficient penicillin to treat all casualties.
Other significant medical advances in World War II were a better understanding of the causes of shock and the common use of blood transfusions. The first donor-originated, as opposed to cadaver-originated, blood bank was established at Chicago’s Cook County Hospital in 1937. In the late 1930s, the British made efforts to store whole blood but had only limited success. In 1943, an American team working under the auspices of the U.S. National Research Council developed an effective preservative, and within a few months large quantities of preserved blood were shipped to troops overseas.129 The team also developed a process for separating out fibrin and thrombin, valuable coagulants, and made them available to blood users in separate form. Early British experience with civilian casualties in the London air raids showed that the transfusion of blood was vital in preventing shock. It was not until the Battle of El Alamein in July 1942, however, that blood transfusions were attempted on combat casualties on a large scale.130 The armies responded by creating field transfusion units that were regularly attached to the casualty clearing stations and often sent forward to the dressing stations. On average, every hundred casualties required sixty-three pints of blood.131 Even larger quantities of plasma and blood products were needed.
Taken together, the short time from wounding to treatment, the standard practice of debriding and irrigating wounds, the bacteriological testing prior to wound closure, and the improved resuscitation due to available blood transfusions all worked to improve the casualty’s chances of survival. In the Allied armies, 21 percent of the wounded were operated on within six hours of being hit–“the golden period”—but the bulk of the wounded, 47 percent, were operated on within the following six hours. Thus, 68 percent of the wounded received surgical treatment within the first twelve hours of being wounded.132 Only 7 percent waited more than twenty-four hours for medical attention. The impact of such improved medical treatment in World War II was evident in the number of soldiers who reached medical treatment and later died of their wounds. Approximately 4.5 percent of the American wounded who reached treatment died of their wounds, down from 8 percent for American soldiers in World War I.133 In terms of comparison, 19.5 percent of the Russian wounded in the Crimea and 22.1 percent of the French wounded died. In the Civil War, 14.1 percent succumbed to wounds. In the Franco-Prussian War, which saw the advent of antiseptic surgery, 11.5 percent of the German wounded died.134 The death from disease rate of the American Army in World War II was less than 1 percent of what it had been for the Union Army in the Civil War. The only increase was in the amputation rate, which was 5.3 percent in World War II compared to 2.0 percent in World War I.135 This jump reflects the more rapid and efficient evacuation system, which preserved the lives of the wounded until they received medical attention. In World War I, these same wounded would have succumbed long before they reached medical attention.
With the exception of the Soviets, who used essentially the same casualty servicing structure they had in World War I, most Allied armies in World War II organized their medical facilities the same way; thus, spending much time on detailed individual descriptions is not necessary. Some attention, however, is due the German medical service. For the most part, it was organized around the American model as practiced from its inception in 1870. It differed largely in triage, or the sorting of casualties for specialized hospitalization. As would a company medic in the American Army, the German medical officer rendered first aid in a verwundetennest (battalion aid station) in the extreme forward area. The wounded were then evacuated by litter to the truppenverbandplatz (regimental aid station), where an officer corresponding to an American battle surgeon attended the casualty. After stabilization and resuscitation, all wounded were evacuated to a hauptverbandplatz (main dressing station) established about four miles to the rear of the combat line. The sanitäts kompanie (medical company) of the division operated the unit and performed both clearing and hospitalization functions. It was assigned two operating surgeons but could be reinforced by six or eight more in times of casualty stress. Significant surgical procedures and major operations were performed at this level.136
The next unit in the chain of medical evacuation was the feldlazarett (mobile field hospital), which was designed to care for two hundred patients. Staffed by two surgeons, it dealt largely with head and chest wounds. Each German Army group was assigned a kriegslazarett (general base hospital), whose function was to hospitalize all patients who could not be returned to duty in a short time. In periods of heavy casualties, all serious patients were transported directly to the kriegslazarett, while the forward surgical units concentrated on treating only those soldiers whose wounds would allow them to return to the fight. In each division there was an ersatz kompanie (replacement company) that served as a replacement depot and reconditioning unit for lightly wounded men awaiting return to their combat units.137 The entire structure was designed more to salvage manpower for continuing combat than anything else, and for the most part it did a credible job under very difficult combat circumstances.
Given that the German medical service was superior in the wars of 1870 and 1914, it is interesting to compare its reputation then with its performance in World War II. The difficult circumstances under which it had to operate during the war years accounts for some decline. What is most interesting, however, is that the quality of German medical care seems to have slipped far lower than anyone had imagined prior to the country’s defeat in 1945. For example, an American military study after the war showed that the Germans apparently failed to incorporate developments in blood transfusion technology and had no regular blood banks to provide sufficient supplies of blood.138 The Germans had not discovered the secret of storing blood and still administered almost all blood transfusions from donor to recipient.139 More puzzling was the widespread belief among German doctors that blood should never be transfused in amounts greater than 1,000 cubic centimeters. If the soldier was not resuscitated by then, they neither made further attempts at resuscitation nor performed surgery.140 Most shocking was that German doctors seemed to have practiced poor hygiene when inspecting wounded patients, routinely lacking gloves and not washing their hands between patient examinations. German military doctors came to believe that suppuration of wounds was a natural condition and lacking penicillin and facing critical shortages of sulfonamides, the wound infection rate must have been high.141
One consequence of the Nazification of the German officer corps was the substitution of political criteria for medical criteria when determining military assignments, including assignments to the medical service. Especially at the higher ranks of the medical service, political criteria predominated. Within the ranks themselves, the high number of casualties seems to have forced the Germans to reduce the training requirements for medical personnel. Many “graduate wonders,” or poorly trained surgeons with little experience, found their way into the medical corps. For whatever reasons, one outcome of World War II was the decline of the German military medical service, a sad fate for a service that had been the envy of the military medical world for more than six decades.
In the Korean War the U.S. military lost 8,769 men killed in action, and another 77,788 wounded were admitted to medical facilities for treatment. An additional 14,575 men were slightly wounded and “carded for record only” before being returned to their units.142 Of the wounded, only 1,957 men died, for a wound mortality rate of only 2.5 percent.143 Excellent preventive medicine also reduced disease rates considerably. Acute respiratory infections accounted for a fifth of all disease admissions, followed by ill-defined general symptoms of illness and then various parasitic diseases. The psychiatric admissions rate of thirty-six per thousand slightly exceeded that of World War II.144 The success of sulfa and penicillin in preventing wound infection had become so common that young surgeons serving in the medical corps forgot the lessons of previous wars and, in the early days, failed to practice debridement and closed wounds prematurely. These oversights produced an initially high wound infection rate until the surgeons relearned the old lessons.145 A total of 89,974 surgical operations were performed, an average of 1.2 operations per wounded soldier.146
Four major innovations in military medical care were introduced during the Korean War. Among the most important was the introduction of the mobile army surgical hospital (MASH) units, an outgrowth of the mobile field surgical detachments first introduced in World War II. A typical MASH unit had from sixty to two hundred beds and was staffed with special teams of surgeons. The unit was not positioned within the normal vertical medical evacuation chain; instead, it was placed next to the regimental collecting station and the division clearing station. The idea was to provide high-level surgical care as close to the battlefront as possible. The most serious surgical cases were filtered out of the normal vertical chain of evacuation and moved laterally to the MASH unit for immediate emergency surgical care. After treatment, it moved casualties directly to the evacuation hospital for further treatment and evacuation disposition.147 With its complement of twenty-four medical officers and surgeons and forty-one nurses, MASH units sometimes served as many as twelve thousand surgical admissions a month.148
The army transported most of the wounded by vehicle. Curiously, U.S. forces ran short of proper ambulance vehicles throughout the conflict. The most common form of frontline casualty transport was the litter-jeep, which was capable of carrying four patients and was first used in World War II. Its virtues lay in its availability in sufficient numbers and its low profile, which made it a less inviting target on the roads. A major innovation was using the helicopter in medical evacuation for the first time, although the military’s critical shortage of these machines prevented the helicopter from playing a major role. The early helicopters were light and could carry no more than two casualties in external pods attached to the landing skids. In normal practice these machines transported the seriously wounded from the regimental and division clearing points to the MASH units. They also carried cases requiring more sophisticated treatment to the evacuation hospitals. In only a few instances did helicopters pick up casualties on the battlefield, a practice that became common during the Vietnam War. The medical evacuation system in Korea worked relatively well. Fifty-eight percent of the wounded received medical care within two hours of being wounded, and 85 percent were treated within the first six hours. The median time between wounding and treatment was only 1.5 hours.149 Fifty-five percent of the wounded were hospitalized within the same day of being wounded.150
A major medical advance arrived when battle surgeons could treat vascular injuries on a routine basis. Arterial repair was first tried in 1910, and the Russians reported their first large-scale series of attempted vascular repairs in the Balkan Wars of 1912–1913. In World War I, the Germans sought to undertake vascular repair in military hospitals, but the severity of the shrapnel wounds and the high infection rates halted progress in vascular surgery.151 The increased use of high-speed projectiles and shrapnel in World War II produced a sharp rise in the number of arterial wounds. Arterial wounds accounted for only 0.29 percent of the wounds during the Civil War and only 0.4 percent in World War I. The rate of these wounds doubled in World War II to 1.0 percent and doubled again during the Korean War to 2.4 percent.152
Small numbers of vascular surgeons served during World War II, when the standard treatment for injuries to the major arteries was ligation (tying the artery itself in a small knot). But this technique produced only marginal results, with 49 percent of the ligated patients contracting gangrene and requiring eventual amputation. Thirty-six percent of the patients upon whom arterial repair was attempted had to undergo eventual amputation. Taken together, 62.1 percent of cases of arterial injury to the lower extremities eventually needed amputation.153 When vascular surgeons first regularly operated in the frontline hospitals in Korea, they saw a dramatic drop in the amputation rate. In the early days of the war, the amputation rate from vascular injuries remained at the World War II rate of 62 percent. During the last eighteen months of the war, however, the amputation rate dropped to 17.7 percent and, finally, to 13 percent.154
Yet another advance in medical treatment was the great improvement in the management of shock. The ready availability of blood and transfusion helped greatly. Still, soldiers suffering from crushing injuries or prolonged shock often died of renal insufficiency while appearing to recover from their wounds. Doctors recognized this phenomenon during World War II, but no satisfactory treatment was available until the Korean War. A number of special medical units designed to treat acute renal insufficiency were placed near the MASH hospitals. The results of proper medical treatment were dramatic, and deaths due to renal failure declined by 50 percent.155
Between 1965 and 1970, 133,447 American wounded were admitted to medical facilities for treatment, of which 97,659 were admitted to a hospital.156 In Vietnam, small arms automatic weapons fire produced about a third of the injuries, while fragmentation missiles—often from booby traps—produced most of the rest.157 Burn injuries were frequent. Some resulted from explosions inside armored vehicles and bunkers, but more than half the burn injuries were accidental. Burn injuries were often accompanied by inhalation injuries, and wounds of this type produced 70 percent of the total burn fatalities.158
The official hospital wound mortality rate for the Vietnam War was 2.6 percent compared to 2.5 percent for Korea and 4.5 percent for World War II. These statistics are misleading, however, for they do not take into account how the excellent medical evacuation system successfully moved to hospitals seriously wounded men who would have died on the battlefield or at the battalion aid station in previous wars. A better way of understanding the medical care provided to the American soldier in Vietnam is to examine the “deaths as a percentage of hits ratio,” that is, the number of wounded men who survived. Viewed from this perspective, in World War II this ratio was 29.3 percent, in Korea 26.3 percent, and in Vietnam 19.0 percent. Stated another way, in World War II for every soldier who died, 3.1 survived their wounds. In Korea, the figure was 1 to 4.1 and in Vietnam 1 to 5.6.159
The nature of counterinsurgency warfare in Vietnam produced a war of small units widely scattered over inhospitable terrain, a situation that forced a rethinking of the casualty evacuation system. The classic pattern of ground evacuation of casualties while passing them through five echelons of medical care could not work rapidly enough to save the wounded in Vietnam, where distance and terrain slowed ground evacuation to a crawl. The helicopter permitted the greatest flexibility of movement in evacuating casualties, and the complete control of the air by U.S. forces made it possible for helicopters to land very close to where the casualty was wounded. Once the casualty was aboard a helicopter, the pilot could bypass the battalion and regimental aid stations and take the casualty directly to a hospital equipped for major surgery. Casualties were routinely transported directly to a field hospital, evacuation hospital, or even a hospital ship offshore.160 Hospital ships were used most often for surgical treatment of U.S. Marine casualties since the Marines came under the jurisdiction and control of the navy medical corps. Shipboard evacuation to hospital ships offshore for treatment of Marine casualties had been established during World War II when Marine units were used to assault Japanese positions on Pacific islands. Corpsmen at the battlefront first treated the wounded Marines, who were then transported to battalion aid stations on the beach. From there boats took them to medical facilities located on ships offshore.
At the peak of ground operations during the Tet Offensive in 1968, American troops received aeromedical support via 116 air ambulance detachments, each with five to seven UH-1E (“Huey”) helicopters capable of transporting six to nine patients at a time. Each division had aeromedical helicopters organic to its medical detachment.161 These medevac helicopters had trained medics aboard to provide in-flight advanced first aid to the casualty. The average medical evacuation flight from point of wounding to a hospital was only thirty-five minutes. The more seriously wounded usually reached a major surgical hospital within two hours of being wounded. Of the wounded who were still alive when they reached the hospital, 97.5 percent survived.162
The medical regulating officer controlled helicopter evacuation by designating assignments of medevac flights within his area of coverage. The call for a helicopter initially came from the combat unit’s medic. Helicopters already in flight were diverted depending upon the seriousness of the wound. In planned battle operations, helicopters hovered near the site of the action, ready to land at a moment’s notice. If no helicopter was in flight, machines of the aeromedical evacuation ambulances stood by on the ramp and upon receiving a call took to the air. Once on the landing zone (LZ), it took less than a minute to load the casualties and for the machine to become airborne again.
The medic aboard the helicopter contacted the radio controller, who had a direct “hot line” to the MRO. The MRO then designated the hospital destination depending upon the seriousness of the wound, the availability of expertise in a given hospital to treat the specific injury, and the time to transport the casualty to the hospital. Distance was always less important than time. If the helicopter commander questioned the decision to divert to a specific hospital, a physician was consulted by radio. The inbound helicopter then informed the receiving hospital of the number of patients aboard and their respective wounds; this information allowed the hospital to make any special necessary preparations. Usually within minutes of arrival, the patient was on the operating table.163
The medevac crews’ heroism in landing their machines on “hot LZs” is testified to by the fact that in a two-year period 39 crew members were killed and 210 wounded while flying medical evacuation missions. They flew 13,004 missions in 1965, and they increased to 76,910 in 1966, to 85,804 in 1967, and peaked in 1969 at 206,229.164 In addition to evacuating casualties, the medical helicopters also transported blood, supplies, and medical personnel throughout the medical evacuation system.
The Vietnam War saw the repair of vascular injuries become routine, and vascular surgeons were present at every major medical installation. The overall success rate of vascular surgery approached 75 percent by war’s end. During World War II, division-level medical facilities used almost no whole blood, relying instead on stored plasma as the primary agent to prevent shock. In Vietnam, 14 percent of all blood transfusions were done at division level, mostly with whole blood that could be stored safely in a new Styrofoam blood box.165 The forward units’ liberal use of whole blood was a major factor in reducing death by shock. Further, medical personnel found that the blood types stamped on the soldiers’ dog tags were incorrect in approximately10 percent of the cases, so blood typing became routine practice in surgical hospitals.166 To reduce blood transfusion reactions, a decision was made in 1965 to send only type O universal donor blood to the war zone. Between 1967 and 1969, 364,900 blood transfusions were accomplished with less than a thousand reactions of all kinds.167 For the first time in U.S. military history, military personnel, their dependents, and civilian employees at military installations donated free of charge every unit of whole blood used for casualties.168
The military introduced disease control programs early in the war, and these prevention programs did much to reduce troops lost to sickness. The major diseases affecting U.S. troops were malaria, viral hepatitis, diarrheal diseases, skin infections, fevers of undetermined origin, and venereal diseases. The average annual disease admission rate in Vietnam was 351 per 1,000 men compared with 611 per 1,000 in Korea and 844 per 1,000 in the Pacific theater in World War II.169 The encounter with a resistant strain of malaria resulted in a malaria rate of 26.7 percent, more than double the rate of 11.2 percent for Korea.170
1. An excellent overview of the major contributions of military physicians in the early twentieth century is found in William H. Crosby, “The Golden Age of the Army Medical Corps: A Perspective from 1901,” Military Medicine 148, no. 9 (September 1983): 707–11.
2. The racial theorists of this period argued that the slaughter of war was actually beneficial to the genetic health of the population because it weeded out “the unfit.”
3. Rayne Kroger, Good-bye Dolly Gray (London: Cassell, 1960), 167.
4. Rice, “Evolution of the Military Medical Service,” 149.
5. Peter Lovegrove, Not Least in the Crusade: A Short History of the Royal Army Medical Corps (Aldershot, UK: Gale and Polden, 1951), 26.
6. Redmond McLaughlin, The Royal Army Medical Corps (London: Leo Cooper, 1972), 22.
7. Lovegrove, Not Least in the Crusade, 27.
8. Ibid.
9. McLaughlin, Royal Army Medical Corps, 22.
10. Edward H. Benton, “British Surgery in the South African War: The Work of Major Frederick Porter,” Medical History 21 (July 1977): 277.
11. Garrison, Notes on the History, 192.
12. Benton, “British Surgery,” 277.
13. Fraser, “Doctor’s Debt to the Soldier,” 66.
14. Theodore James, “Gunshot Wounds of the South African War,” South African Medical Journal 45 (October 1971): 1089.
15. Ibid., 1092.
16. Benton, “British Surgery,” 280.
17. Lovegrove, Not Least in the Crusade, 26.
18. Ibid., 23.
19. McLaughlin, Royal Army Medical Corps, 23.
20. W. Charles Cockburn, “The Early History of Typhoid Vaccination,” Journal of the Royal Army Medical Corps 101, no. 3 (July 1955): 174.
21. Stephen A. Pagaard, “Disease in the British Army in South Africa, 1899–1900,” Military Affairs (April 1986): 74.
22. Ibid.
23. McLaughlin, Royal Army Medical Corps, 24.
24. Benenson, “Immunization and Military Medicine,” 2.
25. Denis Warner and Peggy Warner, The Tide at Sunrise: A History of the Russo-Japanese War, 1904–1905 (New York: Charterhouse, 1974), x.
26. Gurdjian, “Treatment of Penetrating Wounds,” 164.
27. McGrew, Encyclopedia of Medical History, 104.
28. Gilbert W. Beebe, Battle Casualties: Incidence, Mortality, and Logistic Considerations (Springfield, IL: Charles C. Thomas, 1946), 77.
29. Warner and Warner, Tide at Sunrise, 351.
30. Ibid., 447–48.
31. McCord, “Scurvy as an Occupation Disease,” 591.
32. McGrew, Encyclopedia of Medical History, 104.
33. Louis L. Seaman, The Real Triumph of Japan, The Conquest of the Silent Foe (New York: D. Appleton, 1906), 103. Seaman’s report is that of an American military physician serving as an observer with the Japanese Army during the war. It represents the best and most complete work on the subject of Japanese military medicine during the Russo-Japanese War available in English. See also Jan K. Herman, “Dr. Rixey and the Medical Observations of the Russo-Japanese War,” The Grog: A Journal of Navy Medical History and Culture 4 (Winter 2011): 4–10.
34. The Japanese military preventive medicine programs were so effective that during the war the Japanese Army suffered only 362 cases of smallpox with 35 deaths from the disease in an army of almost three-quarters of a million men, even though smallpox was endemic to Japan at this time. See Grissinger, “Development of Military Medicine,” 347.
35. Seaman, Real Triumph of Japan, 223–25.
36. Ibid., 106–7. The surgeon general of the Japanese Navy believed that beriberi was caused by a nutritional deficiency and experimented with reducing the amount of rice in the sailor’s diet while increasing the amount of other foods. His observations proved correct, and two years before the war the Japanese Navy had all but eliminated beriberi in its ranks. The Japanese Army, however, refused to accept the navy’s success and stubbornly continued to feed its troops mostly on rice. The result was that 24 percent of the army’s total disease casualties during the war were caused by beriberi. See Alan Hawk, “The Great Disease Enemy: Kak’ke (Beriberi), and the Imperial Japanese Army,” Military Medicine 171, no. 4 (April 2006): 333–39.
37. Ibid., 336.
38. Ibid., 334.
39. Ibid.
40. For an interesting description of medical care in Japanese hospitals and hospital ships during this period, see Teresa Eden Richardson, In Japanese Hospitals during Wartime: Fifteen Months with the Red Cross Society of Japan, April 1904–July 1905 (London: William Blackwood and Sons, 1905), 259–62. This work is one of the few accounts of Japanese military medicine available in English and was written by a nurse who served in Japanese military hospitals. The basic information source for many works on the Japanese Army in the war is British War Office Staff Study, The Russo-Japanese War, 6 vols. (London: His Majesty’s Stationery Office, 1906–1908).
41. Seaman, Real Triumph of Japan, 123.
42. For an evaluation of British surgical doctrine as a consequence of the Boer War, see James, “Gunshot Wounds of the South African War,” 1089–1094.
43. In General Kuroki’s army at the battle of the Yalu River, 7,967 men were wounded: 6,753 by small arms fire, 1,073 by shellfire and hand grenades, and another 141 from bayonets. See Seaman, Real Triumph of Japan, 112.
44. Ibid., 125.
45. Garrison, Notes on the History, 193.
46. Ibid.
47. Seaman, Real Triumph of Japan, 125.
48. Ibid., 7.
49. Garrison, Notes on the History, 193.
50. Warner and Warner, Tide at Sunrise, 353.
51. Ibid., 365.
52. In collecting their dead for cremation, special medical teams cut the corpse’s Adam’s apple so that a small bone, the nodobotoke, or “little Buddha,” could be retrieved from the body and sent home to relatives. According to Japanese tradition, the shape of the bone determined the future fate of the dead. If the bone was shaped in the image of a small Buddha, it meant that the person’s next life would be one of happiness. If the bone was misshapen or shapeless, it indicated that the person’s next life would be one of pain. The relatives deposited these bones at the temple of Tennoji in Osaka, where they were placed in a vault. After years of collection, the bones were retrieved, ground, and mixed into a paste, and a statue of Buddha was sculptured from the material.
53. Richardson, In Japanese Hospitals, 48.
54. Seaman, Real Triumph of Japan, 32.
55. Ibid., 60.
56. Ibid., 261.
57. Warner and Warner, Tide at Sunrise, 387.
58. Garrison, Notes on the History, 193.
59. Seaman, Real Triumph of Japan, 177.
60. Warner and Warner, Tide at Sunrise, 421.
61. Ibid., 390.
62. McCord, “Scurvy as an Occupational Disease,” 591.
63. As a general rule, indirect fire is the greatest objective generator of psychiatric casualties. During the Crimean War, tremendous bombardments were common. It is likely that hundreds of psychiatric casualties resulted on all sides, but the lack of diagnostic tools to define psychiatric conditions meant that they were neither recorded nor treated outside the normal medical evacuation chain.
64. Gabriel, Soviet Military Psychiatry, 35–36. This work remains the only complete work on the history and development of Russian military psychiatry published in English.
65. This section on Russian military psychiatry is taken largely from Richard A. Gabriel’s works No More Heroes and The Painful Field.
66. Aldea and Shaw, “Evolution of the Surgical Management,” 561.
67. Ibid.
68. Anthony Bowlby, “The Hunterian Oration: On British Military Surgery in the Time of Hunter and the Great War,” Lancet 1 (February 22, 1919): 288.
69. Aldea and Shaw, “Evolution of the Surgical Management,” 561.
70. London, “An Example to Us All,” 86.
71. Aldea and Shaw, “Evolution of the Surgical Management,” 563.
72. Ibid.
73. McGrew, Encyclopedia of Medical History, 34.
74. Fraser, “Doctor’s Debt to the Soldier,” 71.
75. Aker et al., “Causes and Prevention,” 923.
76. Stark, “Plastic Surgery in Wartime,” 511.
77. Ibid.
78. Fulton, “Medicine, Warfare, and History,” 483.
79. Grissinger, “Development of Military Medicine,” 346.
80. Fulton, “Medicine, Warfare, and History,” 483.
81. Grissinger, “Development of Military Medicine,” 345.
82. Fraser, “Doctor’s Debt to the Soldier,” 72.
83. Garrison, Notes on the History, 196.
84. Ibid., 200.
85. Stanislas Kohn, The Cost of The War to Russia: The Vital Statistics of European Russia during the World War, 1914–1917 (New Haven, CT: Yale University Press, 1932), 137.
86. McCord, “Scurvy as an Occupational Disease,” 591.
87. Kohn, Cost of the War to Russia, 137.
88. P. M. Ashburn, A History of the Medical Department of the United States Army (New York: Houghton Mifflin, 1929), 334.
89. Sieur, “Tribulations of the Medical Corps,” 224.
90. Ibid., 226.
91. Ibid., 225.
92. Ibid., 226.
93. Ibid.
94. Lovegrove, Not Least in the Crusade, 36.
95. Ibid.
96. McLaughlin, Royal Army Medical Corps, 38.
97. Bowlby, “On British Military Surgery,” 289.
98. London, “An Example to Us All,” 85.
99. Bowlby, “On British Military Surgery,” 289.
100. McLaughlin, Royal Army Medical Corps, 54.
101. The field hospitals behind the lines at Ypres, for example, were struck by artillery fire with horrendous casualties. One of these hospitals was located in a place the soldiers called “Sanctuary Wood.” The Germans deployed long-range guns and, probably by accident, shelled the hospital, causing high casualties among the already wounded.
102. Ashburn, History of the Medical Department,” 347.
103. Garrison, Notes on the History, 200.
104. Ibid.
105. Ibid., 196.
106. Ashburn, History of the Medical Department, 215.
107. Garrison, Notes on the History, 197.
108. Ibid.
109. Ashburn, History of the Medical Department, 215.
110. The American rates of psychiatric casualties were no lower after psychiatric screening was introduced than they were before. Moreover, even though psychiatric testing was regularly used during the induction process in World War II, American psychiatric casualty rates during the war were actually higher than they had been in World War I.
111. Ashburn, History of the Medical Department, 306.
112. Ibid., 342.
113. Garrison, Notes on the History, 200.
114. Ashburn, History of the Medical Department, 325.
115. Ibid.
116. Ibid.
117. Rose C. Engelman and Robert J. T. Joy, Two Hundred Years of Military Medicine (Fort Dietrich, MD: Historical Section, U.S. Army Medical Department, 1975), 17.
118. Edward A. Strecker, “Military Psychiatry in World War I, 1917–1918,” in Hall et al., One Hundred Years of American Psychiatry, 386.
119. Fraser, “Doctor’s Debt to the Soldier,” 68–70.
120. Ibid., 70.
121. Lovegrove, Not Least in the Crusade, 56.
122. Ibid., 57–58.
123. McLaughlin, Royal Army Medical Corps, 67.
124. Derby, “The Military Surgeon,” 184.
125. McLaughlin, Royal Army Medical Corps, 64.
126. Ibid., 67.
127. McGrew, Encyclopedia of Medical History, 318.
128. Ibid., 249.
129. Fulton, “Medicine, Warfare, and History,” 484.
130. Aldea and Shaw, “Evolution of the Surgical Management,” 563.
131. McLaughlin, Royal Army Medical Corps, 87.
132. Beebe, Battle Casualties, 93.
133. Ibid., 22.
134. Ibid., 75.
135. Aldea and Shaw, “Evolution of the Surgical Management,” 563.
136. See Charles M. Wiltse, The U.S. Army in World War II (Washington, DC: Military History Section, Department of the Army, 1963), appendix C, 602, for a description of the German military medical service.
137. Ibid., 603.
138. Ibid., 606.
139. Ibid., 607.
140. Ibid.
141. Ibid.
142. Frank A. Reister, Battle Casualties and Medical Statistics: U.S. Army Experience in the Korean War (Washington, DC: Office of the Surgeon General, 1973), 3.
143. Ibid., 16.
144. Ibid., 8.
145. Fulton, “Medicine, Warfare, and History,” 484.
146. Reister, Battle Casualties and Medical Statistics, 83.
147. Albert E. Cowdrey, The Medic’s War (Washington, DC: Center for Military History, Department of the Army, 1987), 151. See also Warner F. Bowers, “Evacuating the Wounded from Korea,” Army Information Digest 5 (December 1950): 50.
148. Cowdrey, The Medic’s War, 150.
149. Reister, Battle Casualties and Medical Statistics, 79–80.
150. Ibid.
151. Aldea and Shaw, “Evolution of the Surgical Management,” 566.
152. Ibid., 565.
153. Ibid., 566.
154. Ibid.
155. Derby, “The Military Surgeon,” 184.
156. Spurgeon Neel, Medical Support of the U.S. Army in Vietnam, 1965–1970 (Washington, DC: Department of the Army, 1973), 50–51.
157. Aldea and Shaw, “Evolution of the Surgical Management,” 566.
158. Neel, Medical Support, 56.
159. Ibid., 50–51.
160. Leonard D. Heaton et al., “Military Surgical Practices of the U.S. Army in Vietnam,” Current Problems in Surgery 3, no. 1 (November 1966): 3–4.
161. Medical evacuation helicopters were often called “medevacs.” The term was derived from the radio call sign of one of the first evacuation helicopters used in the war. Its pilot, Maj. Charles L. Kelly, MSC, was killed on July 1, 1964, while trying to rescue casualties from a firefight.
162. Neel, Medical Support, 70.
163. Ibid., 74.
164. Ibid., 75.
165. Heaton et al., “Military Surgical Practices,” 8.
166. Ben Eiseman, “Combat Casualty Management in Vietnam,” Journal of Trauma 7, no. 1 (January 1967): 58.
167. Neel, Medical Support, 122.
168. Ibid., 127.
169. Ibid., 32.
170. Ibid.