The history of military medicine and battlefield healthcare is the history of western civilization itself. The ideologies and philosophies that shaped the development of the modern west also directly influenced the evolution of military medical care. As the political structure of the western world moved from feudalism to absolutism to the modern nation-state, the importance of a strong, loyal, well-maintained army increased, as did the need for better military healthcare and adequately trained medical personnel. This need stemmed from two main reasons. First, the technology and planning of war continued to develop from about 1450 through the present. This improvement in weaponry and strategy led to a greater number of battle-induced casualties and injuries. Second, the ideas about the worth of humanity and the value of individuals began to change. As the western world came to believe that every life had value and was worth saving, the call for better care for even the lowliest soldiers increased. However, military medicine and battlefield healthcare were extremely slow to evolve until the 1860s. Unfortunately, by this time war technology improvements were such that the lethality of warfare had exploded to modern proportions (Gabriel 31). The real breakthroughs in military medicine came during the era following World War I. After this time, the true nature of total modern warfare was known, and battlefield healthcare had to constantly adapt to new challenges and situations. The evolution of military medicine and battlefield healthcare is one of the most significant achievements of western civilization.
During the Middle Ages, military structure and organization was the product of the totally decentralized nature of feudalism (Gabriel 1). Wars were fought between rival kings who formed their armies from the vassals who had pledged their liege to him. Since war was not fought between developed nation-states at this time, there was no centralized organization or production of weaponry, no standing armies, and no standard military training. The actual fighting of the war was disorganized in the extreme. There was typically no strategy and no rules. War was a virtual free-for-all of which the armed peasants bore the brunt (Gabriel 2). Any kind of medical care for the members of this kind of temporary army was essentially nonexistent. Because the army was not permanent, there was no need for even rudimentary general care, such as checking the person’s fitness for battle. There also was no need for any kind of battlefield care, since peasants were expendable to their lords. The mode of survival was pure luck. Battle casualties took many lives at this time, but rampant disease was the real killer of soldiers, a sad tradition of war that continued into the 19th century. However, the Middle Ages, a time of disorganization and decentralization, was followed by the Renaissance, a time when the old way of thinking was changed to make way for an era of learning.
The Renaissance, lasting from about the time of Constantinople’s destruction in 1453 to the beginning of the Thirty Years War in 1618, was a period of learning and a breakdown of previous belief systems (Gabriel 46). With the coming of the plague to Europe also came new ideas about the church’s role in society and about the lack of general medical knowledge. The church’s powerlessness to stop the plague, as well as the Reformation that followed, shook people’s faith in their oldest religious beliefs, including their belief in the healing power of faith. The epidemic nature of the plague demonstrated the severe lack of medical knowledge and exposed many of the illegitimate and incompetent members of the medical profession (Gabriel 46). The decreased power of the church and the tragedy of the plague, combined with the invention of the printing press, led directly to the beginning of systematic battlefield healthcare. Since common religious interests no longer unified the people of Europe, it became easy and common for political leaders to use religious controversy to rally support for their wars. The increase in religiously motivated wars led to a desire to increase medical knowledge through the rediscovery of many ancient texts on medicine and anatomy that had previously been forbidden by the all-powerful church. Due to the recent invention of the printing press, these ancient ideas, as well as the increasing number of new findings, could be rapidly spread throughout the medical communities of Europe. For all these reasons, the Renaissance saw the emergence of the military barber-surgeon as a new and important medical fixture in European armies.
At their inception, most military barber-surgeons were drawn from the enormous ranks of quack doctors who rendered their services to the uneducated poor (Gabriel 51). The specific purpose of these barber-surgeons was to follow behind the army during a battle giving medical care to soldiers, who then paid for the services from their own meager resources. At this time, surgery was separated from general medicine, and very few actual surgeons existed. For this reason, their services were reserved only for members of the upper class. Even though barber-surgeons had little training and often did more harm than good, they were the best option for the common soldier during this time when real medical care was reserved for officers (Gabriel 51). However, as these barber-surgeons gradually gained more knowledge and experience, they were better able to treat most wounds and began to develop treatments for injuries sustained from gunpowder weapons, which became commonplace during the 17th century.
In many ways, the 17th century saw no appreciable improvements in military
medicine. Surgery was still kept separate from general medical practice,
making it impossible to create a corps of adequately trained military surgeons.
In addition, the study of anatomy, and indeed the study of medicine itself,
still relied almost completely on the works of ancients, such as Hippocrates
and Galen (Gabriel 80). The battlefield surgeons of the day faced two new
challenges. The first was the enormous number of gunshot wounds. The second
was the high rate of post-surgical infections. It was during this century
that the first useful firearms were introduced in mass quantities. During
the Renaissance, only 25 to 35 percent of infantries used firearms (Gabriel
82). However, at the start of the Thirty Years War in 1618, it is estimated
that an average of 65 percent of infantrymen were using firearms (Gabriel
82). For this reason, gunshot wounds became the major problem for military
The nature of gunshot wounds almost inevitably led to infections with which the surgeons were incapable of dealing. Therefore, surgeons relied more and more on amputation. The enormous increase in battlefield amputations during the 17th century was also the result of the inability of surgeons to deal with the increased number of shattered limbs caused by gunshot wounds (Gabriel 84). Due to a lack of knowledge about sanitation, proper surgical equipment, anesthesia, and the actual causes of infection, the most common outcome of these amputations was further infection. Compounding both these factors was a complete lack of general military hygiene. Diseases of epidemic proportions were still common in all military establishments, and no concerted effort was made to enforce any sort of rudimentary hygiene regulations. Hence, disease continued to be the major threat to armies, an even greater threat than the actual enemy. In spite of the odds stacked against it, military medicine underwent drastic changes during the 18th century.
The 18th century saw the birth of definitive, effective military medical
care regardless of rank. There were three main reasons for this change.
The first reason was the institutionalization of the medical profession.
For the first time, practicing medicine became a respected occupation,
and most doctors received university educations (Gabriel 99). The second
reason was that surgery became a legitimate medical practice and began
to foster its own training institutions. Even though military barber-surgeons
were still prevalent, their talent and proficiency increased as knowledge
of medicine and anatomy increased. The third reason was that the governments
of the 18th century accepted responsibility for military medical care.
By the 1850s, all major European armies had some sort of institutionalized
medical care for soldiers (Gabriel 101). In general, armies of this period
were attempting to organize themselves on all fronts, from the creation
of defined companies and battalions to the construction of designated military
barracks. This organization included creating a defined, effective system
of military medicine.
Many governments recognized the need for a professional military medical system of this sort because the armies were being overrun by large groups of moderately healthy, somewhat physically fit adults with poor hygiene habits (Gabriel 102). The large population of this type of soldier in the armies led to massive casualties from disease. Due to this sort of rampant disease, physical examinations for all men wishing to enter into military service became required, an important step in improving the quality of soldier enlisted, as well as the health of the overall army (Gabriel 102). Another change made to protect the soldier’s health was the improvement in the standard military ration consumed at this time (Gabriel 103). The standard military ration was redesigned in order to maximize the health of the common soldier, at the total expense of the government. During this time period, the first standardized uniforms were also issued. While this had the potential to be a key preventative measure, they did little to improve the health of the soldiers (Gabriel 102). Often made of cheap cloth, they were designed with fashion rather than practicality in mind. They afforded the soldier no protection from cold, rain, or frostbite, and often were tight enough to restrict proper circulation. The helmets merely added to the heavy load to be carried and offered no protection from bullets or shrapnel. In connection with the advances in preventative military healthcare, battlefield surgery improved during this time. New types of tourniquets improved the success of amputations and led to advances in preparing limbs for prosthesis (Gabriel 104). However, the need for cleanliness in the operating room had still not been recognized, except by a few observant physicians. Thus, many surgical patients were still lost to infection.
Two main problems plagued this embryonic military medical system. One was disease. At this time, disease was still the number one killer of soldiers, remaining a greater threat than even enemy fire. Mass inoculation of troops against certain diseases, especially smallpox, did improve the chances of survival (Gabriel 108). However, this was not effective for the prevention of all diseases. The second problem was a lack of coordination between front and rear area hospitals. The ambulance systems were rudimentary at best, nonexistent at worst. There was no provision made for actual combat medics, and in many armies, it was illegal to help the wounded until the battle was over (Gabriel 110). In most cases, it was left to the wounded to transport themselves to the nearest field hospital for care once the battle moved forward.
During the 18th century, military medical personnel and wounded soldiers were declared noncombatants by a mutual agreement of all the major European armies. The international agreement also contained provisions for the safe transportation of the wounded from the battlefield while the battle continued. This greatly decreased the number of casualties by forbidding the slaughter of the wounded and created a need for increased numbers of medical personnel to deal with the number of surviving wounded (Gabriel 110). Despite the momentous improvements in battlefield healthcare and the creation of organized military medical care in the previous century, the 19th century experienced even greater improvements in treatment of disease and success of surgical procedures.
Military medicine of the 19th century was characterized by the development of independent medical departments capable of handling mass casualties. The increased number of casualties was a direct result of the technological improvements in the lethality of weaponry, such as the invention of the machine gun. In addition to the changes in weaponry, the nature of the army had also changed. Prior to the French Revolution, armies had typically been comprised of the unskilled urban poor and unemployed rural farmers, led by second and third sons of the nobility. These types of soldiers and officers were more loyal to their steady pay than they were to the government and way of life they were defending. However, with the coming of the French Revolution and Napoleon, armies began to rely on conscripted citizens and an officer corps chosen on the basis of talent rather than social position. However, this new type of soldier demanded better medical care to compensate for the hardship of conscription (Gabriel 146). Moreover, the government was willing to accommodate these demands because of the increased lethality of ever-improving weapons, as a means to preserve their armed forces (Gabriel 145). By the end of the century, governments supported independent, fully trained, adequately staffed military medical corps, including completely functioning ambulance systems.
The greatest threat to soldiers at the beginning of the 19th century remained disease. It is estimated that during this time disease killed eight enlisted men for every one killed by an enemy bullet (Gabriel 147). However, by the end of the century, the casualties from disease had lost their magnitude and importance. For example, the Franco-Prussian War of 1870 was the first major, modern war where the enemy killed more soldiers than disease (Gabriel 147). This change in disease-related deaths was due to discoveries in the field of medicine. Deaths from wound infection were accepted as an inevitable consequence of war during the early 19th century. However, this belief changed as certain discoveries were made that improved the practice of medicine. These discoveries were anesthesia and antiseptics. The first compound to have recognized anesthetic properties was nitrous oxide, or laughing gas, discovered in 1772 (Gabriel 148). This paved the way for the discovery of other anesthetics, such as sulfuric ether and chloroform. The use of anesthesia was important for one main reason: it eliminated the pain felt by the patient during surgical procedures. Prior to this, patients were knocked unconscious by bleeding the wound or lulled into sleep through hypnosis before the surgery was performed (Gabriel 148). These were only temporary remedies that required the surgeon to complete the procedure as quickly as possible. However, the advent of anesthesia on the medical scene allowed surgeons more time to produce a better surgical result.
The discovery of antiseptics during the 19th century also greatly contributed to the ease of surgical procedure and the health of the patient. When Louis Pasteur presented his radical “germ theory” in 1878, the medical profession was revolutionized. The knowledge that microorganisms caused disease and infection, rather than putrid smells, created a wave of antiseptic discovery (Gabriel 152). With these antiseptics, it was possible for military surgeons to perform a greater number of successful surgeries and amputations with a lesser risk of post-surgical infection. The development of anesthesia and antiseptics in the 19th century was key to promoting the health of the patient-soldier and also to the evolution of military medicine. Even with these momentous changes in military medicine during the 19th century, it actually became the respected, modern institution it is today during the 20th century.
The first major military medical development of the 20th century was improved treatment for surgical shock patients. With the advent of the water bed during the Boer War (1899-1902), fewer patients were lost to surgical shock than during previous times (Gabriel 224). The water bed was a system of tubes which carried warm water to improve a patient’s blood pressure and prevent shock (Gabriel 222). In the wake of this auspicious beginning, medical technology improved with a flood of new advances in the military medical system. The first improvements came in the form of improved sanitary and hygiene requirements for soldiers and a more complex ambulance system for the evacuation of casualties off the battlefield (Gabriel 222). The constant threat of disease began to be handled in a progressively preventative way, such as more practical uniforms and the creation of sanitary divisions (Gabriel 222). However, none of these earliest improvements could have prepared the military medical practice for the coming of World War I, World War II, and the Korean War.
World War I and World War II were the most destructive conflicts the world had ever seen. Seven million soldiers were killed in World War I alone (Gabriel 239). Military doctors in World War I were the first to be required to combat the deadly effects of gas and massive shrapnel injuries. Subsequently, field hospitals were moved even closer to the front line, in order to provide injured soldiers with the most rapid care possible. Despite all the medical advancements of the previous decades, nearly half a million amputations were performed during World War I (Gabriel 239). Consequently, the problems of improving prosthetic limbs and rehabilitation practices were major concerns for military medical personnel not directly involved in the fighting.
World War I also saw an increasing role of women in military medicine. This was mostly due to an increase in opportunities for women in the military medical field, especially regarding opportunities for women physicians. Military nursing began during the Crimean War when Florence Nightingale arrived in November 1854 (Small 22). Never satisfied with merely helping the wounded, she advocated military hospital reform until her death (Small 1). Her work paved the way for dramatic increases in opportunities for women during the 20th century. For example, in 1915 1000 women occupied the medical register, as opposed to only 477 in 1911 (Crofton 279). World War I witnessed the creation of the first female-run military hospital ever, the Scottish women’s hospital in Royaumont, France (Crofton 3). This hospital was staffed almost completely by women, from the orderlies to the doctors, evidence of the increasing acceptance of women in the realm of military medicine. The importance of women, especially as volunteer nurses, continued to increase through World War II and beyond. The best evidence of this is a British Ministry of Health recruitment poster from the World War II era that reads, “In every war in our history, Britain has looked to the women to care for the sick and wounded…The women of today have kept it [Florence Nightingale’s candle] burning brightly not only in France, Egypt and Greece but in…all the other battlefields of the Home Front (Starns 1).” Notwithstanding the modest improvements of the World War I era, the crisis of World War II fostered even greater advances in military medicine and battlefield healthcare.
The developments in military medicine during World War II can be narrowed down to three major ones. The first was the appearance of antibiotics in military medical practice. The discovery and use of sulfonamides and penicillin during the first half of the 20th century greatly increased a casualty’s chances of survival. In 1944, three billion units of penicillin were being produced annually, enough penicillin to treat every Allied casualty (Gabriel 254). The second improvement was the understanding of the causes of surgical shock and the common use of blood transfusions. Shock resulted from a severe drop in blood pressure during surgery (Gabriel 254). Once blood transfusions became commonplace, they were used in all matter of military areas, from field hospitals to in-flight medical facilities. For every hundred casualties during World War II, approximately 63 pints of blood were needed (Gabriel 254). Since blood transfusions became standard procedure, the loss of patients to shock decreased greatly. Preventative measures to combat venereal disease were the last major improvement in military medicine during World War II. The military’s decision to combat venereal disease stemmed from the extreme number of soldier candidates who were rejected because of a pre-existing venereal ailment (Fishbein 49). The numbers became so high that syphilis and gonorrhea cases were accepted and then treated in military medical facilities.
Venereal disease in the military was not a phenomenon of World War II. Historically, cases of venereal disease have always skyrocketed during time of war. For example, it is estimated that 220 out of every thousand soldiers during the American Civil War had some form of venereal disease (Fishbein 159). However, the military’s new policy of education, the recommended use of prophylactics, and the activities of specially appointed venereal disease control officers decreased the number of venereal disease cases to approximately 160 out of every thousand soldiers (Fishbein 160-161). While the great military medical achievements of World War II dealt with preventative care and general medical improvements, the advances of the Korean War related specifically to field surgical hospitals.
By far the most important advancement in military medicine and battlefield healthcare in the 20th century occurred during the Korean War in the form of Mobile Army Surgical Hospital units. The premise of MASH units was rooted in the desire to provide the highest quality surgical care as close to the battlefront as possible. A MASH unit typically consisted of anywhere between 60 and 100 beds and was theoretically staffed by a team of specialized surgeons, nurses, general doctors, medical officers, and enlisted men (Gabriel 257). However, the MASH was not always as well staffed or as well equipped as the military would have wanted. In practice, MASH units often had 10-15 doctors total (including surgeons), approximately 20 nurses, and 120 or so enlisted men and unit personnel (Apel 98). This number of medical personnel was not enough to deal with the massive amounts of wounded delivered to the units everyday. Surgeons worked as long as casualties came. Dr. Otto Apel describes his first day as a surgeon in the MASH 8076th: “Seventy-two hours after I had arrived at MASH 8076, I had lost the sense of feeling in my feet. I do not think I had spoken to anyone…for at least twelve hours (Apel 36).” Dr. Apel performed 80 hours of non-stop surgery as his first assignment in the MASH. The significance of the MASH units was complimented by the development of two medical practices within the MASH itself. The first was arterial and venial repair for the treatment of vascular injuries (Apel 169-177). Pioneered in the MASH units, these techniques were quickly published and adapted by the civilian medical community. These treatments were developed in response to the severity of shrapnel wounds and contributed to a decrease in casualties from those wounds. The second advance had to do with a better treatment for surgical shock. Blood transfusions were still extremely important. Nevertheless, during this time, renal insufficiency, the failure of kidney function after grievous wounds or prolonged shock, was identified as a leading cause of post-surgical deaths (Gabriel 259). Consequently, special medical units were created specifically to deal with renal insufficiency and closely associated themselves with the MASH units.
The history of military medicine and battlefield healthcare does not end with the Korean War. Military medicine is a continually evolving science involving heavy cooperation with civilian medical personnel. Just as the prevalence of gunpowder weaponry proved so challenging to military surgeons during the 17th century, military doctors, surgeons, and nurses are constantly called on to develop ways to combat ever-evolving weapons systems, most importantly biological weapons. From the Middle Ages to the present, the history of military medicine and battlefield healthcare is a fascinating look at the history of warfare itself, as well as the changing attitudes towards the value of the soldier. The advances made in military medical establishments and field hospitals around the world are not merely good for the enlisted men, but good for humanity, as well. Thus, many procedures and preventative practices that aid all of mankind may, ironically, evolve out of a cycle of violence and death.
http://www.redcross.org/ Information about this essential extension of international military and relief medicine.
http://www.army.mil/cmh-pg/ Pictures of U.S. Army operations from World War II through the Gulf War, including photos of military medical personnel.
http://www.odedodea.edu/k-12/D-Day/GVPT_stuff/Nurse/Nurse.html Informative article on the U.S. Army Nurse Corps and their activities during World War II.
http://www.armymedicine.army.mil/armymed/default2.htm Information about current U.S. Army healthcare.
http://www.army.mod.uk/medical/royal_army_medical_corps/index.htm Information about current Royal Army Medical Corps healthcare (Great Britain).
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