Between Flesh and Steel

by Richard A. Gabriel

  The Japanese Army was the first to establish a successful medical supply service, originally designed around the German system. The Japanese soon introduced major innovations to their system, and chief among them was establishing the medical supply system as an independent section of the medical corps. Each level of the medical support structure had its own supply section, which was responsible for providing and moving medical supplies. Once in the theater of operations, these supplies moved through the medical supply system’s own dedicated transport. Rear area supplies moved in regular army ships and trains but in a planned, allocated space specifically for medical supplies. The Japanese utilized prepositioning of supply amounts based on tables of consumption calculated at various levels of combat activity, an innovation that Dr. Jonathan Letterman introduced during the Civil War. The provisioning of medical supplies was very efficient, and the Japanese Army did not report a single case of a medical unit finding itself short of necessary medical supplies.

  The Japanese success in reducing death and illness due to disease was also attributable to their excellent field hygiene system. Their disastrous experience in the China incident of 1894 taught them that one of the most important roles of the medical officer was disease prevention, and the Japanese created an excellent military hygiene program for their armies.

  The army had an official hygienic code that was promulgated among all ranks. Each line officer was responsible for continuously educating the men and enforcing hygiene practices in the field. Through their own chain of command, the medical officers immediately reported any line officers who failed to accomplish their duty. Every division hospital had a bacteriological unit whose job was to diagnose illness and to ensure that steps were taken to prevent the further outbreak of diseases. All units down to the battalion level were issued equipment for testing water supplies, and water testing was a command responsibility. The standard practice was to boil drinking water, and troops never ventured into the field without adequate supplies of boiled water. Division medical officers were assigned to lower units on patrols to test and mark wells, and a medical briefing was standard procedure prior to undertaking combat operations in unfamiliar areas. Foraging and scouting parties routinely brought along a medical officer to make assessments. Medical officers were also responsible for cleansing newly captured positions so their troops would not be exposed to diseases left by the enemy. The Japanese utilized the most advanced system for enforcing field hygiene measures that the world had ever seen to that time.

  The Japanese solider had good personal hygiene habits. Daily bathing, a regular routine in peacetime, was practiced whenever possible, as was daily shaving and ensuring that the soldier kept his hair short. The men themselves regularly laundered their own uniforms, although fumigating ovens were provided at division level for cleansing the uniforms of disease patients. On average, the Japanese soldier was also younger than the Russian soldier and carried a lighter load in the field.50 The extensive use of coolies, forced or hired from local populations, and the greater availability of rail transport also kept the soldier’s load light. Used to a light diet of rice and vegetables, the Japanese soldier adjusted better to the hot weather than the Russian did; indeed, even Russian commanders were impressed by how little the Japanese succumbed to sunstroke and heat exhaustion.51

  The Japanese Army also practiced excellent field discipline to reduce venereal disease and alcohol problems. No camp followers were permitted, and only a small coterie of licensed vendors was allowed near the army. The only place to obtain alcohol—a scourge of the Russian ranks, especially in hot weather—was in canteens located fifty miles behind the Japanese lines. The soldier was provided with cigarettes, handkerchiefs for personal cleanliness, toothbrushes, soap, rice paper fans with which to cool himself, and writing paper. He was also allowed to fish to supplement his diet with protein.

  One of the most important factors reducing disease was the Japanese cultural practice of cremating their dead. At the start of the war, the Japanese prepared individual funeral pyres, but the shortage of wood on the Liao-tung Peninsula quickly led to the dead being cremated in groups of five or six. Individual cremation was reserved for high-ranking officers. Immediate cremation of the dead removed a potentially dangerous source of disease contagion.52

  The emphasis on disease and infection control was also present in the hospitals that treated the wounded. Japanese surgeons preferred to operate without rubber gloves, but strong antiseptic control of all elements of the surgical process kept the wound infection and hospital death rates to a minimum.53 All hospitals had hand-washing basins scattered throughout the wards and corridors, and the doctors and nurses washed their hands in disinfectant before they entered a ward. The staff kept the wards spotlessly clean, and all human and medical waste was burned every day. Latrines were covered and disinfected every day, and mosquito netting was provided for each bed. These measures’ effectiveness in reducing infection and disease is evident from the record of Toyama Hospital, which treated 15,759 patients after the Battle of Mukden from April through June 1905: it lost only 41 patients in this period to infection and disease.54 At Daley Hospital, within the war zone itself, 222,000 casualties were treated during the war, and only 3,150 died, or a hospital death rate of 1.4 percent.55

  One of the more interesting aspects of the Japanese military medical system during this period was the field evacuation system. For most of history, the seriously wounded found being transported to rear area hospitals on springless vehicles was the bane of their existence. The Japanese, however, did not use any vehicles to transport the wounded. Instead, thousands of litter bearers organized into bearer companies carried all the wounded in stretchers through each stage of the casualty servicing structure from the front line to rear area hospitals behind division level, or a distance of approximately five miles.56 No estimate is available indicating how many seriously wounded men reached medical treatment alive because of the gentle nature of this type of transport, but it must have been substantial.

  The Japanese medical structure that made its debut in the Russo-Japanese War was the most sophisticated medical service that any army had used until that time in history. The Japanese willingness to examine the medical services of the West and to improve upon them proved a major resource for conserving the manpower of their small nation for war. For the first time in history, the emphasis on disease and infection prevention allowed the Japanese to bring the latest advances in bacteriology to bear on military operations and to achieve incredible results. For at least two hundred years prior to the Russo-Japanese War, armies lost 25 percent of their field forces to disease and infection. The Japanese, however, lost less than 2 percent of their force to these causes. Moreover, their various hygiene procedures were so effective that more than a third of the field army went through the entire war without ever reporting sick.

  Russia

  The Russian medical system in this war was unchanged in its essentials from what the Imperial Russian Army used in the Crimean War. As in Russian society, the status of physicians and surgeons in the military was far lower than in any army of the West. Contract physicians and feldshers, the latter of questionable medical training, provided most of the medical care. Russian doctors in military hospitals were not usually billeted with line officers and had to sleep on the floor between the patient’s beds. General Ezerski, the chief inspector of hospitals at Sha-Ho, was not a medical officer but a former police chief. The status of Russian medical officers was so low that doctors who did not wear their swords in the wards while attending patients were disciplined. Even the diagnosis of disease was biased by status pressure. Because the line officers considered an outbreak of dysentery as reflecting poorly on their commands, they often forced doctors to classify dysentery cases as influenza.57

  The old practice of having line officers command medical units, abandoned in most Western armies after the Crimean and American Civil War, was still in effect in the Russian Army, as was the habit of rel
ying on the quartermaster to supply transport for moving casualties. The Russian Army had no official ambulance corps and still depended on troops from the firing line to carry casualties back to the dressing stations, as it had in the Crimea. As Wellington had noted in the Peninsular War, when several soldiers carried a wounded comrade to the rear, their absence negatively affected combat power on the firing line. Using the same methods during this war left Russian combat power seriously depleted at critical points in numerous battles.58 Without ambulance vehicles assigned to the medical service to evacuate casualties, the army expected that soldiers would use empty supply wagons. They carried the wounded over the rough Manchurian roads and trails in small springless carts (dvukolks) that had been shipped to the army to move supplies. As in the American Civil War and the Boer War, the rough treatment the wounded suffered while being transported in these “avalanches,” as the troops sometimes called them, caused a considerable number to die.

  In Port Arthur, some Russian hospitals were large, spacious buildings. Most, however, were makeshift affairs with little medical equipment. The medical staff in Port Arthur comprised 136 surgeons and apothecaries, 15 medical students, 17 army officers used as inspectors, 11 priests, 46 clerks, and 112 female “nurses,” who were actually girlfriends and family members of the officers.59

  The condition of the Russian field hospitals was dreadful. Soap, mattresses, and bedpans were in critically short supply, and infection and dysentery were universal problems. A description of conditions in a Russian field hospital in Port Arthur noted that patients “lie side by side on the floor, on the bedboards, underneath them, just as they were placed when they came in. . . . Faces are shapeless, swollen and distorted, and upon the yellow skin are large blue bruises. Inside, in spite of the musty and sickening stench, the cold is intense. On all sides is filth, nothing but filth, and on it and among it crawl millions of greasy gray lice.”60 The traditional Russian fervor for religion, however, led the army to assign priests as medical assistants to every regiment. These priests were required to make regular visits to the sick and wounded in the hospitals. Although they were short of medical supplies, the physician who did not have an adequate supply of religious icons to give to the wounded and bolster their faith was subject to discipline by military authorities.61

  The chronic shortages of boots, greatcoats, blankets, and food exacerbated the terrible conditions under which the Russian soldier had to fight. Nutrition was poor, and while scurvy was only a minor problem among the Japanese, it was endemic among the Russians. The problem of scurvy worsened when the corrupt medical corps officers took the best food for themselves and their families. When the siege of Port Arthur ended, Japanese medical officers found that 32,400 members of the Russian garrison were suffering from scurvy.62

  Because of the chronic shortage of salt and poor field discipline, Russian forces also suffered a high number of sunstroke and heatstroke casualties. Only the black Chinese variety of salt was available, and the Russians couldn’t stomach it. Sugar, fresh fruits, and canned meats were unobtainable. The only item in great supply seems to have been vodka, which the troops and officers consumed in large quantities. The medical officers seem to have made no effort to ensure a supply of potable water for the garrison, and no water-testing apparatus was available. Japanese officers found that almost every well was infected with typhoid. The Russian Army did not have official hygiene regulations, formal field hygiene instructions for the men and officers, or sanitary officers or detachments posted with the troops. The Russian Army was a medical disaster waiting to happen, as it had been a half century earlier in the Crimean War.

  The terrible conditions of combat and prolonged artillery bombardment produced a large number of psychiatric casualties and men with self-inflicted wounds. Line officers often made midnight raids on hospitals and evacuation trains, seeking to recover “malingering” soldiers who could be forced back into the line. The problem of psychiatric casualties reached alarming proportions. Curiously, the army was prepared to deal with this area of military medical concerns.

  The Russian military had encountered significant numbers of psychiatric casualties in the Crimean War. A large number of British soldiers had also been driven insane by the tremendous firepower of indirect artillery barrages.63 Unlike the British, however, Russian military doctors remained interested in the phenomenon of battle shock after the war ended. Evidence of psychiatric casualties in the American Civil War and the Franco-Prussian War further stimulated their interest. In the Russo-Japanese War, the Russian Army became the first in modern history not only to determine that mental collapse was a consequence of the stress of war but also to regard it as medical condition. It was also the first army to try to treat psychiatric casualties, and in so doing, the Russians laid the foundations of modern military psychiatry.

  Russian Army physicians diagnosed and treated approximately two thousand casualties during the war that they attributed directly to battle shock; however, the number of soldiers complaining of psychiatric symptoms was much larger. These numbers increased so much as the war progressed that field medical facilities were unable to handle the psychiatric casualty load. Many psychiatric casualties were evacuated to the rear through normal medical channels and turned over to the Russian Red Cross for institutionalized care. The number of cases reached such proportions that they eventually overwhelmed even these resources. The Russian experience with these myriad psychiatric casualties provided the first modern example of “evacuation syndrome.” When soldiers realized that “insane” soldiers were being relieved of combat duty, the number of psychiatric casualties increased dramatically, as soldiers unconsciously manifested psychiatric symptoms to escape the horrors of the front. Paradoxically, the Russian medical team’s willingness to recognize and deal with psychiatric casualties is what produced even more psychiatric casualties among the troops.

  The Russian Army was the first to place psychiatrists near the front line. Most of these psychiatrists, however, came from civilian mental hospitals and had little training in treating psychiatric casualties in a military environment. Psychiatric dispensaries staffed with psychologists, neurologists, a psychiatrist or neurologist who specifically dealt with brain injuries, a physician’s assistant, and a complement of three feldshers were also established near the front lines. Western armies’ dispensaries did not attain this degree of organizational sophistication for managing psychiatric casualties until 1917. The Russians also set up a separate chain of medical evacuation for psychiatric cases. It was the first time an army attempted to handle psychiatric casualties through a special medical evacuation channel, an innovation that became standard practice in the later years of World War I.

  The Russians made a major contribution to military psychiatry when they introduced the principle of proximity, or the forward treatment of psychiatric casualties. Experience had taught them that a number of psychiatric problems could be readily cured if treated rapidly within the battle zone. Experience in both world wars proved the Russians correct. Today the principle of forward treatment of psychiatric casualties remains the most basic principle of all military psychiatry.

  The Russian Army was also the first to establish a central psychiatric hospital immediately behind the battle lines. Located in Harbin, Manchuria, this hospital recorded between forty-three and ninety psychiatric admissions a day. Only a few patients were quickly cured and returned to the front line. The rest remained in the hospital for fifteen days and were subjected to a variety of treatments. If recovery did not take place, a physician and a small staff of physician’s assistants accompanied the psychiatric patients as they were evacuated by train to Moscow, a trip that often took more than forty days on the single-track railroad. By the end of the war, the army was operating several special trains exclusively for psychiatric patients that were equipped with isolation compartments, restraint rooms, and barred windows.

  Of the 265 officers admitted to the Harbin hospital for psychiatric reasons, only 5
4 recovered sufficiently to be sent back to the fighting. The rest were moved to Moscow. Of the 1,072 enlisted soldiers treated at Harbin, only 51 recovered and returned to duty, while 983 were evacuated. Russian psychiatrists made significant advances in clinically linking battle stress with a number of somatic symptoms, and they developed diagnostic categories that were quite modern. During the Russo-Japanese War, the Russians established most of the psychiatric diagnostic categories that the Western armies later used during World War I. Russian psychiatrists recorded cases of hysterical excitement, confused states, fugue, hysterical blindness, surdomutism, local paralysis, and neurasthenia. Since Russian psychiatry had its roots in German biological nosological psychiatry, Russian doctors tended to define these symptoms in physiological terms and attribute their causes to damage in the brain. In 1905, 55.6 percent of Russian battle stress casualties were diagnosed as stemming from traumatic damage to the brain, an approach that gave rise to a similar diagnostic methodology in the West with the “shell shock” issue of World War I.64

  By World War I, the Russian Army was the most experienced army in the world in dealing with clinical problems of battle stress. It was the first to specify categories of psychiatric problems in a military environment, the first to institutionalize forward treatment, the first to develop a theory of what caused battle shock, and the first to handle the problems of evacuation syndrome and secondary gain. The West mostly ignored these lessons until World War I when the Western armies, confronted with their own huge manpower losses for psychiatric reasons, finally attempted to develop methodologies for managing the problem. While the Germans quickly adapted to the new reality, the French, English, and American armies managed barely to put a psychiatric casualty servicing structure in place by the end of the war.65