By Dr. Charles Van Way, III
Colonel, US Army Reserve, Medical Corps, Retired
Emeritus Professor of Surgery
University of Missouri – Kansas City School of Medicine
Director, UMKC Shock Trauma Research Center
War is an actual, intentional, and widespread armed conflict between political communities.Stanford Encyclopedia of Philosophy
Care of the injured soldier is as old as war. And war is as old as history. Perhaps older. People were fighting and hurting one another back into the old stone age, long before organized societies and armies. And others were caring for the injured. So one can make the argument that military medicine should go back a very long way. Yet, what we now call military medicine is really a product of the 19th and 20th centuries. It was in fact during the Napoleonic wars at the beginning of the 19th century that the organized practice of military medicine began, and it didn’t reach its modern form until the beginning of the 20th century.
What is this human activity that we call war? When did they invent it? How does it differ from simple fighting? As noted above, the definition of war includes nations, states, or their equivalent. In other words, civilization. No, not the computer game. The real thing. Primary civilizations appeared in four areas, widely separated in time and place. In chronologic order, from around 4000 BCE to around 1500 BCE, these were the Middle East, in Mesopotamia and Egypt; the Indus River valley, in present-day Pakistan and India; the Yangtze River valley in China; and the Americas, specifically meso-America and the Andes. All were agriculturally-based, and featured organized governments and armies supported by hereditary ruling and military castes. Without exception, all were warlike. Initially, it was thought that the meso-American civilization of the Maya were peaceful. The latest archeologic evidence is clear that they were not.
But when we say that armies of the ancient world were organized, that does not follow that they were organized as we would do so today. The treatment of casualties is very obviously an inherent part of military organization. But wound care and medicine itself varied widely from one culture to another. In ancient Egypt, for example, medicine was both sophisticated and highly specialized. The Smith Papyrus (1600 BCE) describes wound treatment, fracture splinting, and cauterization to control bleeding. Egyptian clinical practitioners were deployed to garrison posts. This can be seen as the beginning of a formal military medical service. Babylonian-Assyrian medicine (1000-600 BCE) had physician-priests for magic and ritual, but also had the “asu,” pragmatic practitioners who became the first full-time military physicians. On the other hand, the Persians, whose empire stretched from the Middle East to India around 500 BCE, had no military medical service, and very rudimentary wound treatment.
In the ancient world, Roman military medicine most closely approached what we have today. The Greeks had a long tradition of practical medicine, although handicapped with the “humoral” theory of disease. The Romans were still more practical. The Roman army had organized field sanitation, well-designed camps, and separate companies of what we would now call field engineers. They had a much better grasp of sanitation and supply than anyone else before, or for a long while after. Their camps were laid out in a way as to protect their water supply and to locate latrines downstream. Their permanent camps included separate hospitals. They had medical corpsmen, whom they called “immunes.” They practiced front-line treatment, beginning with soldiers treating one another, and they appeared to have a casualty collection system within each legion. They evacuated wounded legionnaires back down their well-organized support and logistics chains. They had more sophisticated wound treatment than anyone up to that time. Roman medicine reached a high point which was not to be equaled until the 18th Century.
It would be reasonable to argue that the Romans actually had something which we would call military medicine. Because of their improved sanitation, their armies suffered somewhat less from the epidemics which swept military camps, but only by comparison with their opponents. Two-thirds of their casualties were still due to disease. Their world-view included no such thing as bacteria or protozoa, and such things as immunizations were two millennia in their future. And, perhaps most important, their practices did not outlive their empire.
After the Romans came a period of regression, which has always been a bit difficult to characterize. It is probably best known for our purposes as the Early Middle Ages. The term “Dark Ages,” implying a regression into barbarism, has become politically incorrect. Besides, it isn’t really accurate. The people of the post-classical world often regarded themselves as quite civilized. In fact, they often regarded themselves to be Romans. The Eastern Roman Empire (Byzantine) so styled themselves until 1450, and the ruler of Russia was called “Caesar” (Czar) up into the 20th Century. But, I digress.
The early medieval armies were built around warlords and their bands of retainers. National armies, except for the Byzantine Empire, largely disappeared. Forces were made up from nobles and followers, tied to one another by a chain of reciprocal obligations and duties. We now call this the Feudal System. Whatever its name, it basically broke down armies into units the size of companies or smaller, with little central organization. All of the sophistication of the Romans regarding sanitation and camp organization was completely lost. Medical care was by whoever the lord happened to have in his retinue. The wounded were cared for by servants, camp followers, and other warriors. The lord might have a physician, but no more than one or two. In short, if a soldier was wounded, he was pretty much on his own. Most battles were between small armies, because anything over a few thousand men, could not be supplied, so the numbers of wounded were relatively small.
By the Late Middle Ages, organization had improved markedly. Armies of 10,000 to 15,000 men were routinely fielded. At the famous battle of Crécy, 1346, about 10,000 English beat 20,000 French, using the longbow, a weapon which dominated battle for the next 200 years. Over those years, gunpowder weapons evolved, and armies began once again to specialize. Cavalry and infantry were always present, but there began to be, besides archers, pikemen, engineers, artillerists, and finally musketeers. Medical organization did not advance at the same pace. Bandsmen, who typically weren’t much good at fighting, were designated to evacuate the injured. And again, camp followers, personal servants, and other members of the lord’s retinue were pressed into service. Local doctors and surgeons were conscripted into caring for the wounded. Indeed, this last persisted for a surprisingly long time, and was seen in our Civil War, as well as most other 19th Century wars.
The Early Modern Period was from about 1450 to 1700. (“Renaissance” has fallen into disuse, something like “Dark Ages.” Feel free to substitute if you wish.) This era was marked by the widespread use of gunpowder weapons and the rise of national armies. Paid soldiers, often with standardized weapons and uniforms, replaced the old feudal levy. The thing about the new weapons was, they used things up, like powder and shot. Someone had to make replacements, and then those had to be transported forward to the fighting line. Cannon and even early personal firearms had to be made in a rear area and then transported forward to make good losses and damage. Armies became too big to live off the land. Horses required fodder. So a system of what we now call logistics began to emerge. Of course, this would have been no mystery to the Romans. But around 1500, it was a major innovation. But for a number of reasons, a system of medical support failed to evolve in the armies of the day.
To be sure, medicine wasn’t very effective. And it was during this time that medicine re-discovered Greco-Roman medicine. Unfortunately, they latched on to the humoral theory of disease, and began to combine that with astrology. To compound a medicine, one needed to diagnose which humors were involved, then determine the house of the zodiac under which the patient was born, and then prepare the appropriate medication. If this seems odd, reflect that we have faithfully collected our patients’ date of birth down to the present day. At least today, we use it for identification purposes, so the effort isn’t entirely wasted.
The problem with all of this theory was that it wasn’t much use in treating a wound, or for that matter lancing a boil or removing a tumor. So these sorts of things fell to the less educated but more practical barber surgeons. These men (mostly) were the ones to accompany armies, and they were the ones who actually carried out wound treatment and care. The most famous barber-surgeon of this period was Ambrose Paré (1510–1590). From a family of barber-surgeons, he started as a battlefield surgeon, and eventually was in the royal service of five successive kings of France. He re-discovered the old Roman remedy of treating wounds with a compound which included turpentine, a harsh but effective wound antiseptic. He re-discovered (from Galen) the use of ligatures to tie off bleeding vessels, rather than using hot iron cautery or boiling oil, two of the “remedies” of the day. He even invented an early hemostat. He published, in 1545, The Method of Curing Wounds Caused by Arquebus and Firearms, a book cited by others for centuries.
But eventually, medical science moved beyond the limits of the old theories. Great advances were made during the 18th century. Jean Louis Petit introduced the tourniquet, in 1718. Forceps were used to remove bullets. Pierre-Joseph Desault described the debridement of wounds. There were three textbooks of military medicine, John Pringle (1752), Richard Brockelsby (1756), and John Hunter (1794). Hunter’s views on the treatment of wounds dominated the next century, and many of his principles survive today. Perhaps most significantly, John Pringle, about 1740, described and identified the epidemic disease of typhus, one of the scourges of the battlefield.
Much of this came together in the epic wars which began the 19th Century, the Napoleonic Wars. Armies of 100,000 or more ranged throughout Europe, almost forcing the recognition of a need to care for the wounded, and to provide some organization to the medical system. This was done best in the French army. Dominique Jean Larrey, surgeon-in-chief of French armies from 1797 to 1815, contributed in many ways to modern military medicine. (See Figure 1.)
He established the criteria for “triage,” in case you were wondering why we use a French term for that. He invented the “ambulance volante,” or flying ambulance, which imitated Napoleon’s “flying artillery.” These were horse-drawn carriages, which could move quickly around the battlefield to provide evacuation. (See Figure 2.) He staffed ambulance units with corpsmen and litter-bearers, used initial care just behind the battle, and formalized the use of field hospitals a few miles back from the battle. He is considered the first modern battlefield surgeon.
In 1812, the French Emperor decided to invade Russia. Leaving Berlin with 600,000 men, he returned with 50,000. Of 800 physicians with the army, 300 made it back. Minard’s famous graphic is a milestone in its own way, shows the grim reality of the failed campaign. (See Figure 3.) What happened? Starvation, cold, exposure, typhus, diarrhea, and pneumonia. Poor logistics, corruption in the Army administration, poor attention to medical issues, and the Russian weather all contributed. Larrey ended the campaign as a hero for his efforts on behalf of the wounded and ill. But even he was unable to prevent the disaster. He could control the treatment of the wounded, and he did so. But he had no say in how the army was organized, nor how sanitation was carried out, nor over anything we would now term public health.
Napoleon’s invasion of Russia was perhaps the best documented military misadventure up to the 20th Century. Despite that Hitler’s Germany made the same series of mistakes in 1941 and thereafter. And as someone put it after that war, “At least Napoleon took Moscow. Hitler did not.”
By the beginning of the 19th century, then, Western European military medicine had equaled, and maybe surpassed in some ways, the military medicine of the Romans of the 3rd and 4th centuries. There was still a long distance to go. The place of physicians within the society of the day, and especially within the military caste, was relatively low. In an aristocracy, as most European countries were, physicians rank somewhere down in the social scale between merchants and shopkeepers. Barber-surgeons were still lower, and were regarded as skilled craftsmen. Put plainly, no military leader was going to listen to a physician tell him how to run a military camp, or take care of his troops. Indeed, Larrey became a French folk hero, in large part because he was willing to fight the higher command of the French army to see that soldiers under his care were well-treated. His efforts to care for the sick and wounded during the retreat from Moscow were things of legend.
While military medicine by the beginning of the 19th century looked much better than at any time in the previous millennia and a half, both trauma care and military public health were primitive by today’s standards. The development of what we now know as modern military medicine occurred over the course of the late 19th century, and into the 20th. While this evolution took place across Europe as well as in North America, we will concentrate upon the American experience. The European experience was essentially similar. Medical and trauma care made slow progress during the limited wars of the 19th century, but was greatly challenged by smaller wars in adverse environments. In the case of Europe, those would be the Crimean War and then the Boer War in South Africa. In our experience, this would be in the Caribbean and the Far East.
After the Napoleonic wars, which included our War of 1812, the United States had few major conflicts for 50 years. But then, we found ourselves in the bloodiest conflict of our history. The American Civil War was fought with mass armies, modern industrial technology, railroad transportation, and telegraphic communications.
Unfortunately, its health care was barely up to the 18th century. Both armies had physicians, but there was only a rudimentary hospital and evacuation system. Both armies depended heavily upon civilian physicians and makeshift facilities to care for their injured soldiers. Even “army doctors” were contracted civilians. Public health was terrible. Many soldiers died of disease, often even before reaching the battlefield. Sanitation was abysmal. Epidemics of dysentery, pneumonia (“camp lung”), and typhus swept the camps. And yet, nothing was done after the war to change things.
The next war, the brief Spanish-American War (1898), was fought in the tropics, notably Cuba and the Philippines. Typhoid, yellow fever, and malaria were new to American troops, and killed far more than enemy action. There was little organization, few supplies, and poor use of resources. But the war was highly publicized in the newspapers of the day. After the war, there was a great public outcry about disease. The so-called “typhoid board,” often called the Reed commission, was set up during the war, and made a number of recommendations about sanitation, malaria control, and mosquito control. The Reed commission paved the way for the construction of the Panama Canal, overcoming the high rate of yellow fever among the workers in previous attempts to dig an Atlantic to Pacific canal. Walter Reed was an outstanding Army physician, one of the true heroes of the Army medical corps. (See Figure 4.)
He had immense influence during and after the war. He died in 1902, of appendicitis, but his work was carried on. The subsequent Dodge commission conducted a much more comprehensive review of the shortcomings of the Army medical services. These included poor preparation, poor sanitation in the camps, and failure to organize nursing services. As a result, there was a major re-organization of the Army’s medical support. So finally, during the first decade of the 20th century, the Army recognized the need for doctors, nurses, hospitals, corpsmen, and, in short, today’s medical services. Immediately prior to World War I, the Army was headed by a chief of staff who was a physician, Leonard Wood, MD. (See Figure 5.) He oversaw much of the transition of the Army medical service into a modern military medical system.
Why did it take so long, both here and in Europe? In all “civilized” countries, military medicine remained much worse than it should have been during the entire 19th century. There were three reasons. First, until the 20th century, most countries were run by aristocrats. Even in such ostensible democracies as England, they were the politicians, the generals, the senior military bureaucrats. Doctors were middle class, below the aristocracy. Simply put, nobody wanted to listen to them. This had been going on for centuries. Once, in the middle ages, physicians had a certain status as churchmen, but even that was incomplete. Barber-surgeons like Ambrose Paré were not only below the aristocracy, they were definitely lower class. Jean Larrey, a plebian, could succeed in only Revolutionary France. But such a man was looked down upon even in France, and would have been a second class citizen anywhere else in Europe. Second, public health itself was poorly understood. Cities down through the 19th century were, to put it bluntly, cesspools. Someone in the early 20th century commented that were it not for the automobile, city streets would have been three feet deep in horse manure. The countryside wasn’t much better, just less densely populated. Epidemics swept through Europe at regular intervals. Similar epidemics swept through military camps on a regular basis. Third, senior military officers were taught strategy and tactics. Logistics was a poor third. And the sort of logistics which concerns caring for and evacuating the wounded is not a pleasant topic, nor one which will win prestige for an ambitious officer. Much less public health. A famous comment made by a Civil War era general to a physician who wanted to clean up the camp was, “Don’t worry. All Army camps smell that way.” There was a sort of pessimistic complacency. Senior officers knew that if they could keep down losses from disease, they would have more men to fight. But they didn’t think anything could be done. Even if it could, they didn’t want to do it themselves.
The First World War was fought largely in the trenches of the Western Front. That’s not the full story, but it was and remains the public image. Trench conditions were miserable from a military standpoint. They were a disaster for public health. Sanitation was so bad that after a week or two in the trenches, troops had to be rotated back of the lines to be deloused, thoroughly cleaned, and provided with fresh clothing and equipment. Even so, disease was common, and wound contamination universal. Facilities were largely improvised, and soldiers were collected in the open to await care. All of this made wound care much more difficult. (See Figures 6 and and 7.)
Even acknowledging all of the difficulties imposed by trench conditions, the casualty care system was still much better than in any previous war. Special military units, called ambulances were charged with picking soldiers from the battlefield and transporting them to aid stations, and then to field hospitals. So-called casualty clearing stations were used to collect the wounded, and load them onto hospital trains. These were staffed with nurses and orderlies, and equipped to care for even difficult wounds. There were base hospitals and convalescent facilities both on the French coast and in England. As the American Army deployed to Europe in 1917–18, hospitals, doctors, nurses, and ambulances went with them.
Wounds were usually contaminated with the mud of the trenches. For this reason, wounded soldiers were routinely given tetanus toxoid. Wound care emphasized debridement of devitalized tissue and thorough cleaning with antiseptic solution (Dakin’s solution, to be precise). Aseptic technique was (usually) used in operating rooms, better anesthesia was available. Bowel injuries could be routinely repaired. Intravenous fluids were available, as were blood transfusions (sometimes). Radiography had only been invented some 16 years before, but was deployed on the battlefields by 1914. As an index of how much things had changed, mortality following amputation had been 25% in the American Civil War, and was 5% in World War I. Deaths from wounds dropped, but deaths from disease dropped even further. Far fewer soldiers died of disease as a percentage of total deaths than ever before. And this was despite the influenza epidemic of 1918–19, which claimed many victims at the end of the war.
An example of the greatly improved casualty care was the experience of Robert Graves, a young British officer who would later become one of the premier writers of the century. His open chest injury was so severe that he was triaged to “expectant,” and his death reported in the London papers. Yet he survived the injury itself, empyema, and the resulting broncho-pleural fistula. After he was evacuated to England, he placed a notice in the papers to the effect that reports of his death had been much exaggerated.
The First World War claimed nine million soldiers, and at least seven million civilian lives. Civilian estimates vary widely, and the true figure is probably unknowable. In 1918–20, over the course of the influenza epidemic (misnamed the Spanish flu), some 20 to 40 million people died. Half of all American soldier deaths from disease were due to influenza, many in the training camps in the United States itself. The extent to which the war caused the flu epidemic has been debated ever since. But the epidemic probably killed more people than the war.
Over the inter war years, and by World War II, many medical advances had been incorporated into military medicine. Blood and plasma transfusions, widespread use of intravenous fluids, antibiotics (but limited to penicillin and sulfonamides), endotracheal intubation, thoracic and vascular surgery, and the care of burn wounds. Plastic surgery had received a huge impetus from the World War I treatment of disfiguring wounds, and continued to advance before and during World War II. This war’s casualty lists were huge. There were some 20–25 million combatants killed, and 40–50 million civilians.
Both casualty care systems and public health continued to advance, but these were more a matter of degree than the much more dramatic improvements seen during World War I. (See Figure 8.) However, environments were equally challenging. Tropical environments were particularly difficult. It was a definitely mixed benefit that improved public health and sanitary measures enabled armies to operate in areas that were difficult even to live in. Tropical medicine began to assume a greater role in military medicine. And as always, at the point of the spear, casualties were high, resources limited, and medical support difficult. The many amphibious operations during the war were extremely challenging. Even when the operation was supported with hospital ships, initial care and evacuation offshore was difficult.
A major contribution of the 20th century was the widespread recognition and treatment of what we now call post-traumatic stress disorder, or PTSD. It has probably existed back into history. There are case reports from the Civil War, for example. During World War I, it was sometimes called “shell shock,” which probably included cases of actual brain damage. More often soldiers suffering from PTSD were diagnosed as “cowardice.” Soldiers were shot for it in the British, French, German, Austrian, and Russian armies. As the war dragged on, it became better recognized, but its treatment varied widely. The Russians tried to treat near the front lines, sending the soldiers back to their units as early as feasible. We adopted that practice, and in fact, armies today still treat psychiatric casualties this way. What may seem heartless, actually proved to be the most effective way to treat PTSD and to prevent long term sequelae. The recognition of PTSD as a psychiatric disease of war was not firmly established until World War II. They called it “combat fatigue.” But whatever they called it, they recognized it and treated it.
Both the Korean and Vietnam wars proved to be severe challenges to the medical system, the former for cold weather operations, and the latter for tropical and jungle warfare. The medical services gradually adapted to these challenges. By the time of the Vietnam war, for example, operations could be done in contained, air-conditioned operating theaters that were containerized so as to be moved close to the battlefield. Helicopter evacuation supplemented ground ambulances, and air transport replaced hospital trains. The system of progressive levels of casualty care has turned into doctrine, and remains the guiding principle for casualty care.
Operation during the 40 years since Vietnam have produced far fewer casualties, yet have challenged the military medical services in different ways. Small unit operations at greater and greater distances have increased reliance on medical corpsmen, who are now trained to at least the level of civilian Emergency Medical Technicians, and often higher. Casualty care and evacuation in a hostile civilian environment, always a problem in warfare, has been made more complex by opponents who refuse to respect the non-combatant status of medical facilities and personnel.
What can we say about military medicine today? Most of us focus on combat casualty care, as has been discussed over the past few paragraphs. And indeed, this is the primary focus of the system. We put huge resources into this, as well we should. The death rate for soldiers who survive long enough to reach medical care today is only a few percent. Overall casualty rates have decreased steadily since the middle ages, even though today’s weapons are far more powerful than those our ancestors fired off at one another.
Yet it is just as important to look at military medicine as a system of disease treatment and prevention. Deaths from disease have dropped far more than deaths from battle. In the Civil War twice as many soldiers died of disease as from battle. In World War I, for the U.S. Army, the numbers were about equal. In World War II, only half as many, and in Vietnam, only one-fifth. These great improvements have come from the disciplines of what we now term “deployment medicine.” We have learned, often painfully, that these are as important to the overall health of the military forces as the system of casualty care. Perhaps, from a purely military standpoint, even more so. A soldier ill from disease is removed from the combat strength as surely as one who is wounded. Yet, the illness is usually preventable. Deployment medicine is, in the Army’s unique jargon, a “force multiplier.”
As we watch combat operations on the nightly news, most of us look at these environments with horror and disgust. Everything looks destroyed, broken down. That’s true. In the first place, wars are not usually fought in vacation spots. Even when fighting occurs in pleasant places, they quickly become unpleasant places. Differences in climate aside, one war zone looks much like another. To maintain the health of armed forces, deployment medicine must address many issues. Adverse environments, with heat, dust, sand, wind, and/ or cold. Insect-borne diseases such as malaria, yellow fever, and typhus. Food and waterborne diseases, such as cholera and dysentery. Epidemics, such as meningitis and hepatitis. Skin diseases. Parasitic diseases. And above all, the inevitable social breakdown, with civilian suffering, refugees, and the inevitable victimization of the weak by the strong.
There are five basic constraints which deployment medicine must overcome. Resources are always scarce. The environment is always adverse. Populations are usually hostile, if not deadly. Disease is always present, lurking in the corner. And finally, change itself is constant.
War is inhumane, and terrible. Yet, war has always been with us. The 20th century has been a century of war. Future generations will no doubt call it, “The Awful Twentieth Century.” But one of our greatest medical accomplishments of the last 100 years, among a host of other accomplishments, is the system of military medicine. Today’s military medicine combines combat casualty care with public health. As William Tecumseh Sherman put it, “War is all hell.” But we can take pride that we have done and are doing as much as humanly possible to reduce the horrors, and to save those who have been broken on the modern battlefield.
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Originally published by The Journal of the Missouri State Medical Association 113:4 (July-August 2016, 260-263) and 113:5 (September-October 2016, 336-340), republished by the U.S. National Library of Medicine to the public domain.