Organized military and naval forces in the West usually have provided some kind of medical care for their sick and wounded. Apart from the benefit of returning experienced personnel to duty, the morale factor has motivated this practice: abandonment of comrades does not enhance dedication to duty. Thus, it is not surprising that the oldest surgical text, the Smith papyrus of Egypt (from about 3000 b.c.) deals with the effects of wounds. Medical care of the sailor and soldier has usually been free of cost; in 1600 b.c. in Egypt, the law declared "on campaign, the sick are to be treated without cost to themselves."
Military medicine is commonly equated with treating the wounded. Certainly military historians have long accepted this definition and report "casualties" to mean the killed and (sometimes) the wounded. There is a long tradition for this view. The Hippocratic writings (400 b.c.) comment extensively on wound care, fractures, antiseptics, and bandages; the aphorism "He who would become a surgeon, let him join an army and follow it" urges the conclusion that war was the training ground for surgeons.
Battlefield medical care requires a structured system: the wounded must be moved from the place where they were hurt to a place of care. Data on such organization are scanty prior to the Roman army of the empire, in which physicians were assigned to the legions and enlisted soldiers (capsarri) were trained to dress wounds. Some evidence of transport of wounded and good evidence that military hospitals existed at the frontier posts has been found.
The general introduction of gunpowder weapons in the fourteenth century led to a change in wound care. Head, chest, and abdominal wounds remained overwhelmingly fatal; extremity wounds were contaminated by the material carried in by the musket ball, and amputation was thus the common major surgical procedure to prevent sepsis. This procedure was improved in the sixteenth century by Ambroise Paré, who added vessel ligature and the tourniquet to the operation. As armies became creatures of the organizing nation-states, the states paid for medical care. During the
Reconquest in Spain, Isabella paid for hospitals. Charles V introduced an early version of an evacuation and treatment system in about 1550. From the 1550s, the Spanish army deducted one-thirtieth of each man's wage for medical care and in return provided surgeons and a field hospital. From 1585 the Spanish army of Flanders operated the first permanent military hospital (330 beds) at Mechelen.
By the late seventeenth and early eighteenth centuries, armies had surgical care stations, variously staffed by barber surgeons or—later—by men with some formal training. Field hospitals were common, but evacuation was delayed until the fighting stopped. Navies began the regular employment of ship's surgeons. The wounded were removed from the gun decks during battle and taken below to designated spaces for care. The naval surgeons and their patients did not enjoy the army's luxury of being moved out of the battle zone if wounded. This remains true today.
During the Napoleonic Wars, Dominique Jean Larrey (arguably the most famous military surgeon) introduced the "flying ambulance"—either a vehicle or a unit, depending on the context. His great contribution was forward surgical care at the battle's edge, with trained litter-bearers employed as an evacuation system and an organization of about 40 doctors and 250 soldiers to support every 10,000 troops.
However, the laypersons' and military commanders' emphasis for centuries on surgery as "military medicine" ignored the real causes of mortality and morbidity in war. Military historians have made the same mistake. From the medieval period to the late nineteenth century, many more soldiers and sailors died of disease than were killed in battle. Although empirical observations as early as
Vegetius noted that camping near marshes and foul camp sites made soldiers sick, troop and ship commanders generally were unconcerned with preventive medicine measures. This attitude stemmed from several factors: class differences between officers and physicians, an inability to control the operational environment, lack of a sustainable theory of contagion, and the lack of predictability of illness in any given circumstance. In the
Crimean War, the British army became the model example of command indifference to medical care. In spite of this indifference,
Florence Nightingale's sanitary approach to nursing care saved hundreds of lives and after the war had a major impact on the British army.
Some commanders, such as
Marlborough and
Napoleon, saw tactical advantage in the illness of opponents; but, in general, although epidemic and endemic diseases were recognized as damaging to a campaign or a siege, they were viewed as uncontrollable events. Sometimes camp hygiene was enforced for aesthetic reasons and because of the belief that miasmas arising from rotting organic material poisoned the air and caused disease. Some military physicians, Sir John Pringle in England in 1752, for example, wrote useful instructional texts on troop hygiene specifically for officers. But the urgings of these physicians of the eighteenth and early nineteenth centuries were generally ignored, even when commanders faced horrendous losses from tropical diseases during military explorations in Africa and Asia.
The health of sailors began to improve in the early nineteenth century with the elimination of scurvy through prophylactic lime juice, following the work of James Lind in 1754. Personal hygiene measures—"receiving ships" for recruits, better nutrition, and enforced ship cleanliness—did reduce disease deaths in navies by the end of the nineteenth century.
The seminal contribution to the health of all commands came from the discoveries of Louis Pasteur, Robert Koch, and their colleagues as germ theory and understanding of specific causation of disease entered medicine in the last quarter of the nineteenth century. This eventually led to laboratory diagnosis of disease, proof of contagion and of contamination of water and food, and, hence, predictability of disease occurrence. The proof of insect transmission of malaria, yellow fever, and other tropical diseases at the turn of the century provided additional practical methods of disease control.
Immunization began early in the military.
George Washington ordered inoculation (with use of actual virus) for smallpox in 1777 in the
American Revolution, the first command-ordered immunization program. Although Edward Jenner's introduction of smallpox vaccination in 1798 was employed by some armies and navies, as late as 1870 the unvaccinated French army had thousands of smallpox cases in the
Franco-Prussian War, whereas the vaccinated Prussian force remained essentially free of the disease.
Surgical care of the wounded improved after 1847 when ether and then chloroform were introduced, but overall, better surgery had to await the "germ revolution" with Joseph Lister's introduction of antisepsis (1867) and its gradual acceptance and evolution into the aseptic surgery of today.
Management of medical support was perfected during the
American Civil War by Major Jonathan Letterman of the Union Army Medical Corps. He developed ambulance units, field hospitals, use of medical inspectors, echeloned surgical care, and supply and record-keeping systems that ensured a controlled flow of patients from point of wounding to initial and then definitive surgical care. His essential, final contribution was to persuade the senior line commanders to place all of his system under medical command and control. Letterman's overall scheme has been adopted by all Western armies and improved by aeromedical evacuation and better surgical technology—but the system does not differ in concept.
The 1864 Geneva Convention (see
Laws of War) and its subsequent modifications markedly changed and enhanced the status of medical personnel and their patients. The gradual provision of neutrality on battlefield and ocean, when offered by an enemy, simplified the evacuation and care of the wounded and sick. During the nineteenth century, the status of physicians was gradually transformed: formerly civilian participants, they became commissioned officers. Nurses, dentists, medical administrators, and veterinarians became officers during the twentieth century.
The first army to apply successfully all the technology of bacteriology, vector control, immunization, modern surgery, and echeloned care was the Japanese army in 1904-1905 in the
Russo-Japanese War. It was the first army to suffer more deaths from enemy action than from disease.
World War I brought all the new advances in civilian medicine to war: the x-ray, typhoid immunization, female nurse corps, automobile ambulances, blood transfusion, and major improvements in neurosurgery, wound care, and orthopedic and plastic surgery, for example. For the first time, psychiatry became a useful military medical discipline; it explained "shell shock" as a behavioral response rather than as cowardice or malingering. The airplane's entry as a weapon forced the development of the new physiological-clinical specialty of aviation medicine. Chemical warfare involved the medical disciplines in mask development and treatment of the chemically wounded. Mass weaponry produced mass casualties and the formal organization of triage as a medical procedure.
The interwar years saw the development of medical specialization, chemotherapeutic agents such as sulfa drugs and antibiotics, and marked improvements in specialized surgery.
World War II became a great clinical laboratory, testing massive use of blood transfusion, DDT, aeromedical evacuation, antimalarial drugs, and the management of burns. The special medical problems of submarine crews and the management of casualties during amphibious assault were gradually and successfully solved. Psychic collapse became known as "battle fatigue" or "combat exhaustion"—language understandable to the line, and thus acceptable as a medical condition. The end result of this massive investment in medical support was a 4 percent died-of-wounds rate (statistics from U.S. and British forces)—the lowest ever in major war. As dependable preventive, prophylactic, protective, and sanitary control measures became available, medical staffs urged them on the line commanders. Not all commanders were as receptive as
William Slim or
Douglas MacArthur. When commanders enforced hygiene, sanitation, the taking of prophylactic drugs, and so on, the disease rates fell. The troops of commanders who did not—such as
Erwin Rommel and
Omar Bradley —like the Japanese army, lost much of their fighting power because of disease, or in Bradley's case, to the cold of a European winter. Overall, World War II saw the death rates from disease fall markedly below the killed-in-action rates.
The more recent wars of the twentieth century have introduced technological changes that have benefited military medicine—the use of the helicopter for medical evacuation in Korea and Vietnam serves as an example. In spite of high-velocity and multifragment wounds, improvements such as faster evacuation, better ancillary support for surgery, and increased investment in military medicine have lowered the died-of-wounds rate to 2.5 percent. Much research has been devoted to the effects of radiation—happily, there has been no need to apply it. The hospital ship has become a true modern hospital afloat, and nursing and administrative specialists have assumed many of the tasks previously performed by physicians. Disease remains the greatest cause of morbidity, noneffectiveness, and temporary loss of manpower, in spite of increased use of immunizations, antibiotics, and control measures. It is necessary to continue teaching line commanders that they are responsible for the health of their command through their command of health.
Military medicine in the twentieth century in the West may be summarized as those aspects of medical practice and public health directed to diseases and injuries essentially restricted to combat. Line commanders have largely learned to understand and use the full capabilities of their medical support systems. Unfortunately, military historians still generally ignore the medical aspects of the campaigns and wars they report. Perhaps they will eventually accept the impact of medicine on war as at least as important as their discussions of weapons and tactics.
Robert J. T. Joy
