What is military medicine? Today’s military medicine is an amalgam of trauma care, infectious disease treatment, preventive medicine, and public health. All of these are important. Trauma care includes not only the treatment of wounds, but also the rescue of injured soldiers, their evacuation, and the provision of a graded system of care from the front line to hospitals far in the read.
Equally important is infectious disease care and preventive medicine. Anyone who has been in military service can testify to the large number of immunizations they received. These have controlled the diseases that caused most of the casualties in previous centuries. Those that cannot be controlled by immunizations can be treated. Today’s antibiotics and other treatments are vital in military medicine. Unhappily, antibiotics were not available in World War I, and diseases such as pneumonia, dysentery, and tuberculosis continued to claim victims.
Public health, including environmental medicine, is recognized as a crucial part of military medicine. Disease agents such as mosquitoes can be controlled. Water supplies are routinely treated. Human waste is controlled and not allowed to spread disease. Environmental medicine is a large part of this. Wars are not usually fought in nice places. Even when they are, as in Flanders and northeastern France, those places quickly become adverse environments.
The First World War was fought largely in the trenches of the Western Front. That’s not the full story, but it was a dominant part of the war, and remains the public image. Trench conditions were miserable from a military standpoint, but 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.
Wounds were usually contaminated with the mud of the trenches. Tetanus immunization was available, and wounded soldiers were routinely given tetanus toxoid. Wound care was much better than during previous wars. It emphasized debridement of devitalized tissue and thorough cleaning with antiseptic solution (Dakin’s solution). Aseptic technique was (usually) used in operating rooms. General 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.
Even acknowledging all of the difficulties imposed by trench conditions, the casualty care system was still much better than in any previous war. Specialized military units, called ambulances were charged with picking soldiers from the battlefield and transporting them to aid stations, and then to field hospitals. For further evacuation, hospital trains 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.
The First World War claimed 9 million soldiers, and 7-10 million civilian lives. Civilian casualty 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 training camps in the United States. Did the war cause the flu epidemic? Perhaps so. Certainly, it created the conditions in which the epidemic began and spread. The question has been debated ever since. Whatever its cause, the flu epidemic killed more people than the war itself.
Precedents for American military medicine
Modern military medicine is a product of the 19th and 20th centuries. At the beginning of the 19th century, the organized practice of military medicine began. However, it didn’t reach its modern form until the beginning of the 20th century. American military medicine during World War I represents the coming of age of modern military medicine. But it built on the achievements of the previous century.
The epic Napoleonic wars, which began the 19th Century, were on a previously unheard-of scale. Armies of 100,000 or more raged throughout Europe. This forced 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, Napoleon's Surgeon
Dominique Jean Larrey, surgeon-in-chief of French armies from 1797 to 1815, contributed in many ways to modern military medicine. He established the criteria for “triage”, which is why we still use a French word to describe sorting casualties into urgent, emergent, and delayed treatment. He invented the “ambulance volante”, or flying ambulance. These were horse-drawn carriages, which could move quickly around the battlefield to provide evacuation. He staffed ambulance units with corpsmen and litter-bearers, placed aid stations just behind the battle, and formalized the use of field hospitals a few miles back from the battle. He is considered to be the first modern battlefield surgeon.
Civilian medicine made impressive advances over the course of the 19th Century, during the 100 years between the Napoleonic wars and the Great War. Perhaps first and foremost, medicine became an organized and respected profession. And not only doctors, but nurses, dentists, and veterinarians. The increasing status of medicine in civilian life carried over to the military. Medical professionals were not only better-established in the military services, they were heard at the highest levels.
The theories of disease and infection, and immunization, had its roots in the 18th century, but became firmly established through the 19th. These had great implications for military medicine. By the end of the century, immunizations for tetanus and typhoid fever were available, and there was effective prophylaxis for malaria. Typhus was known to be transmitted by body lice. These could be controlled by periodic delousing and other measures. Yellow fever was controlled by eliminating the mosquito vector. And the correct identification of bacteria as a cause for wound infection enabled effective treatment for wounds, and prevention of many, although not all, wound infections.
Surgery made great strides. The development of general anesthesia meant that longer and more sophisticated operations became practical. Operations were done with sterile technique, and then aseptic technique. Abdominal surgery became possible, and its development over the last half of the 19th century was rapid and dramatic. Equally, general anesthesia made possible more extensive treatment of wounds. Such measures as débridement of wounds (another French word) prevented infection and promoted healing. One of the great advocates of débridement was Alexis Carrell, a French-American surgeon who won the Nobel prize in surgery for that and other contributions. Local wound antisepsis with measures such as Dakin’s treatment was developed. These advances are discussed in more detail elsewhere (Wounds and Injuries), but taken in sum, they made military surgery far more effective.
Other aspects of medical therapy, were advancing rapidly. Intravenous fluids were available by the time of the great war. Early blood transfusion was available, but its use was uncommon. Blood banking was not developed until after the war. The existence of x-rays (“roentgen rays”) was established only in 1898, but their use in diagnostic medicine was firmly established by 1914-18. the Curie Institute in Paris, named for the chemist and physicist Marie Curie, was actively training doctors and technologists in the new field of radiology. Equipment was sufficiently portable to be carried to the battlefield. Medical laboratory studies became available, and incorporated into battlefield medicine.
