Between Flesh and Steel

by Richard A. Gabriel

  The British Army’s problem of casualty evacuation was addressed in 1906 when it combined the litter bearer companies with the field hospitals and placed them under the command of a medical officer. In addition, three field ambulances were allotted to each division, with one held in reserve. To fill the gap between the field hospitals and the stationary hospitals, the service introduced the clearing hospital, or the forerunner of the casualty clearing station. It served as the pivot around which the field medical service operated. It received casualties and sick personnel from the field ambulances; conducted triage, stabilization, and sorting; and then oversaw the wounded’s transport to the rear. To increase its mobility, it was located as far forward as possible and its load lightened. Although the idea was revolutionary, the failure to provide the casualty clearing hospital with its own transport to carry out its multiple missions proved a serious shortcoming when it first saw battle in World War I. Finally, the British Army created a Home Hospital Reserve with members of the Red Cross, reserve medical officers, and other ranks to expand the regular field medical force in time of war. Since most of these reforms had been implemented a few years prior to World War I, the British were relatively well prepared for what awaited them in Flanders’ fields.

  THE RUSSO-JAPANESE WAR

  The Russo-Japanese War of 1904–1905 had its roots in Japan’s emergence on the world stage as a major power in international politics. In 1871, scarcely forty years since Adm. Matthew Perry (1794–1858) opened Japan to Western influence, the entire structure of the Japanese state was reorganized along modern industrial lines. Shunting the old aristocracy aside, the new nationalist political order established a modern political, economic, and military infrastructure more appropriate to a great power. Desperately short of expertise in modern technology, the Japanese sent hundreds of military officers abroad to study war and industry. Most of its young army officers were trained in Germany, which had recently completed a successful war against France. Japan sent most of its naval officers to England, then the foremost naval power in the world, although some attended the U.S. Naval War College. Within a decade, Japan had created a modern ground army modeled after the German Army, including its general staff system, and equipped it with the latest weapons. By 1904, Japan was ready to challenge Russia for a place in Asia and the Far East and to signal its emergence as a world power.

  When the war started in February 1904, the Russian Imperial Army had 1.1 million men in uniform compared to 180,000 for the Japanese. The Russian ready reserve totaled another 2.4 million men, while the Japanese could muster only 200,000 men in ready reserve and another 200,000 in second-echelon reserves. Many forget that the Russo-Japanese War featured major land actions that were larger than those fought at Gettysburg, Waterloo, and Borodino. The Battle of Liaoyang in August 1904 was second only to Battle of Sedan in terms of the numbers of men thrown into action. Six months later, at the siege of Mukden, the Russian forces numbered 275,000 infantrymen, 16,000 cavalry, and 1,219 pieces of artillery, or the largest field army that any nation had assembled in more than five hundred years.25 The Japanese threw 200,000 men against the Russian force. A Japanese field division comprised 11,400 infantry, 430 cavalry, 36 artillery guns, and 5,500 non-combatants, many of whom were in the medical corps.

  This war saw the first large-scale use of the hand grenade and the introduction of the trench raid. While both sides carried the bayonet, only the Russians used it extensively in close combat.26 Of the 709,587 Russians who saw action, 146,000 were wounded and 4.2 percent of them died.27 The Japanese lost 43,892 killed in action and 145,527 wounded, of which 9,054 died, a wound mortality of 6.2 percent. This rate is comparable with a died-of-wounds rate of 6.1 percent for U.S. forces in World War I and 4.5 percent in World War II.28

  From a medical perspective, the worst battle was the siege of Port Arthur (1904–1905). The Russians’ ability to cover the slopes with rifle and artillery fire made the Japanese recovery of their wounded almost impossible. The wounded on both sides crawled around for days without rescue or medical attention until they died. At night, Japanese litter bearers crept from the trenches to rescue their wounded, often only to meet Russian medical teams on the same mission. The Russians were suspicious of Japanese casualties’ feigning death and assigned armed men to their medical teams. They routinely shot Japanese wounded lying next to Russian casualties, and firefights broke out between the guards accompanying the rescue teams.29

  The Russians’ habit of throwing food and personal waste outside their trenches, especially in the summer months of the siege, coupled with thousands of rotting corpses created serious health problems. The stench in the Russian trenches above Port Arthur was so strong that the men put up cloth strips soaked in camphor and carbolic acid in the trench dugouts to kill the odor. Japanese artillery often fell on Russian dressing stations and hospitals. When the seven-month siege finally ended in January 1905, the Japanese had suffered 57,780 men killed and wounded.30 As the Japanese medical officers moved into the city of Port Arthur, they found thousands of Russians suffering from scurvy and typhoid.31

  The Russo-Japanese War was the first major war in history in which the number of men killed by bullets and wounds exceeded the number of soldiers who died from disease. The Japanese forces had 162,556 casualties from all diseases, of which 11,992 died. Official Russian sources put the number of Russian deaths from disease at 7,960, but the number is probably not reliable, given the generally poor quality of Russian medical care.32 While the Russian Imperial Army may indeed have lost more men to bullets than to disease, military physicians in the West studied the Japanese performance more, and the Japanese received great credit for their remarkable achievement in limiting disease casualties. Historically, in battle, an average of four to five soldiers had been lost to disease for each one lost to hostile fire. During the Russo-Japanese War, approximately 8 percent of the Japanese Army died from enemy fire and only 2 percent died from disease, thus reversing the historical pattern.33 The Japanese performance in military medicine became the envy of the world, and military medical officers from the Western nations flocked to Japan to learn how it was done.34

  Japan

  The modern phase of Japanese medicine began in 1870 when thirteen Japanese students were sent to Germany to study medicine. In 1877, Japan opened a medical school at the Imperial University and staffed it with German professors. As Japanese students returned from medical study abroad, they were integrated into the teaching faculty, and by 1900 the medical school’s faculty was almost entirely Japanese. For several more years, however, the language of medical instruction in Japan continued to be German.

  The formative period of Japanese medical study abroad coincided with the findings of Louis Pasteur and Joseph Lister gaining prominence in Germany and German medical researchers, most notably Robert Koch, finally confirming the bacteriological nature of infectious disease. The Germans’ emphasis on germ theory and the prevention of disease strongly influenced the Japanese students, who taught it in Japanese medical schools upon their return to Japan. Thus, Nagano Sendai was placed in charge of a national program of disease prevention upon his return from Germany. Dr. Baron Kitasato Shibasaburō (1853–1931), who had been a student of Koch’s in Berlin, introduced the widespread use of bacteriological analysis to Japan and discovered the tetanus bacillus and its first antitoxin. Later, Dr. Masanao Goto established a series of national and military quarantines to prevent the introduction of disease by troops returning from overseas.35 From the beginning, Japanese military medicine had a strong emphasis on disease prevention that had no real counterpart in the West.

  The real triumph of Japanese military medicine in the Russo-Japanese War came in the area of military hygiene and disease prevention. In Japan’s war with China in 1894, one of every nine Japanese soldiers suffered from some form of infectious disease. The Imperial Japanese Army in that war suffered 12,052 cases of dysentery, 7,667 cases of cholera (with a mortality rate of 61 percent), and 41,734
cases of malaria in a field army half the size of that employed in 1904. In addition, almost a third of the navy became sick with beriberi, a vitamin deficiency–related disease.36 With a small army of less than 200,000 men, a disease rate of these proportions almost crippled its combat power. The Japanese military medical establishment took steps to prevent a similar situation from occurring in the next war.

  A key aspect of the Japanese preventive effort to control disease was ensuring that adequate means be available to achieve this goal. The National Sanitation Bureau undertook to produce sufficient drugs to tackle the problem of disease prevention and treatment. Under its auspices, the bureau oversaw the production and shipment to the army of 55,000 bottles of diphtheria antitoxin serum, 125 bottles of erysipelas antitoxin, 300 bottles of typhoid antitoxin, and 2,500 bottles of tetanus serum. It provided 450,000 capillaries for tetanus vaccination, each capable of vaccinating five persons.37

  The success of the preventive medicine program is evident from the following data. During the Russo-Japanese War, the Japanese Army suffered 162,556 casualties from sickness, but only 10,565 suffered from infectious diseases, such as cholera, typhoid, and dysentery. Most of the sick suffered from noninfectious diseases, with 24 percent of the total sick suffering from beriberi. Of the infectious disease cases, only 4,557 died.38 In total, less than 1.2 percent of the entire field force of about 600,000 men died from disease. This result contrasted sharply with the usual 25 percent that had succumbed to diseases in various armies of the world over the previous two hundred years. In addition, 35 percent of the Japanese field force was never admitted to a military hospital during the entire course of the war, and 45 percent of the wounded were eventually returned to active duty.39 Japanese military medicine was extraordinarily successful in conserving Japanese military manpower.

  The Japanese Army used the system of medical support and casualty evacuation that the Germans had copied from the U.S. Civil War system and then introduced in their war with France in 1870. The Germans had improved it by filling the gap between the field and base hospitals with a medical unit that functioned as a clearing station, and the Japanese also used this type of unit. Volunteer and Red Cross units in the Japanese armies functioned entirely under the army medical chain of command, while the Russians followed the Crimean War practice of allowing them independent status. The Japanese Red Cross never had independent status. It was created as a military auxiliary and was used exactly that way. The Japanese Red Cross had 1.25 million members located throughout the twelve Japanese military districts. During the war, it provided 3,852 nurses and staffed the army hospital ships. Eighty-two medical detachments were sent to the front, and the Red Cross provided thousands of litter bearers.

  The Japanese casualty servicing structure placed the battalion aid and main dressing stations well to the front, either in the trenches or in a close-by ravine. The battalion collecting stations provided emergency first aid, while the dressing station somewhat more thoroughly examined the casualty and tried to stabilize his condition. Six regimental surgeons along with a number of attendants staffed each dressing station.

  Behind the division-level dressing station was the field hospital, where temporary hospital treatment was provided. With a chief surgeon, eight assistant surgeons, and sixty enlisted men to act as nurses, the field hospital was the first point in the system where an operating table was available, and much emergency surgery was performed here. Behind the field hospitals were “stationary” hospitals, where more extensive care could be provided. These stationary hospitals, however, were expected to move with the army on short notice. When ordered to move, the usual practice was to divide the hospital contingent and leave behind the wounded to be cared for by the next echelon. The Japanese established base hospitals at key rail points to prepare casualties for evacuation to reserve hospitals in Japan.

  The medical service also operated twenty-seven hospital ships to transport casualties to the homeland.40 These ships were originally merchant ships that had been converted for medical use and outfitted with operating rooms, electric lights, plenty of light and ventilation, and bacteriology and chemistry laboratories. Female navy nurses cared for the wounded. Each hospital ship could accommodate about two hundred patients. The Japanese Navy established major naval hospitals in Sasebo, Kure, Tokosuka, and Maizuru. These hospitals were of pavilion design and had separate sections for patients suffering from wounds, contagious diseases, or psychiatric conditions.

  Another innovation copied from the Germans was the provision of a sanitary detachment at the division level. Despite its name, the detachment’s primary function was to act as a clearing station. Staffed by nine surgeons and sixty enlisted nurses, it had two litter bearer companies of two hundred men who were equipped with their own stretchers.41 The unit’s litter-carrying capability was greatly enhanced by hiring or dragooning Chinese coolies for this task. This divisional unit operated on the battlefield at all levels, moving casualties from the battalion and dressing stations back to the division’s field hospitals. They were also capable of performing emergency surgery to stabilize the patient.

  Japanese surgical practice followed the then current thinking on conservative treatment of wounds that had become popular through the British experience in the Boer War.42 Most of the wounded in the Russo-Japanese War also suffered injuries from the new high-velocity, lightweight jacketed bullets that had made their appearance a decade earlier. Shells and hand grenades injured only one-seventh of the wounded.43 Thus, the Japanese instructed their soldiers and medical personnel not to touch a wound unless it was absolutely necessary to do so. Soldiers received instructions in advanced first aid and how to apply sterile first aid pouches and bandages. Each company was assigned a number of “instructed men”—enlisted soldiers who were especially skilled in advanced first aid, bandaging, and stopping hemorrhage—to serve as combat medics. Their goal was to stop bleeding and keep the wound as sterile as possible. Within the medical chain itself, surgery was permitted on the battlefield only to the degree that it was absolutely necessary to stop hemorrhage. Otherwise, emphasis was on stabilizing and rapidly evacuating patients to rear hospital facilities, where surgery could be performed under antiseptic conditions. During the sixteen days of fighting around Mukden, the division hospital performed only five amputations.44 While each division hospital was equipped with an X-ray machine, personnel only rarely used it since they did not anticipate that the surgeons at the division level would need the information. Japanese medical doctrine reasoned that a soldier was at greater risk from infection than from the injury itself.

  The Japanese medical corps was structured and utilized as an integral part of the military command apparatus. Its chief held the rank of lieutenant general and was a member of the general staff. Each field army also had a surgeon general who held the rank of major general. Unlike most armies of the West, Japanese medical officers held full command rank and status in their armies and were regarded as essential personnel to the fighting effort.45 In the field, the medical corps had its own parallel chain of command and had effective control of medical matters at all levels. Combat priorities might lead a line officer to override his medical officer’s recommendations, but he did so at great risk since the medical officer reported the incident up through his own independent chain of command, ensuring that the line officer’s decision would soon be brought to the attention of his commander.

  The Japanese Army became the first army in history to require that the combat operations field order routinely include a plan for medical support.46 The fact that all officers, regardless of assignment, were required to take staff courses in hygiene and medical care and that field hygiene was a subject for examination in the naval and army academies also testifies to the importance that the army placed upon medical support. Further, the Japanese medical officers earned the line officers’ respect by bearing the burden of battle. At Mukden, for example, fourteen medical officers were killed or wounded.47

  The
emphasis placed on military hygiene and preventive medicine led the Japanese to staff their medical system with sufficient numbers of medical personnel at all levels. The Japanese never experienced a shortage of doctors or medical supplies at any level of command during the war. The ratio of doctors to patients was approximately 1 to 100, and the ratio of nurses to patients was 1 to 5. The Japanese had twelve major hospitals in Japan itself, each with five attached branches in the military districts. By war’s end, the rear area hospital system had 58,263 available beds.48 As the war progressed, Japan drew upon its supply of 45,000 physicians and surgeons for wartime duty, and almost 10 percent of the army’s manpower resources were assigned to the military medical system. The success of the Japanese system led most Western nations to adopt this 1 to 10 ratio as the basis for assigning medical personnel in their own armies, if only for planning purposes.49