Between Flesh and Steel

by Richard A. Gabriel

  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 WAR

  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 buddie
s. 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, s
till 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.