Warfare’s Effect on the Medical Field in AmericaHippocrates is quoted as saying that “war is the only proper school for a surgeon”. America has had multiple technological advances from the many appalling wars it has endured. One of the many things in modern American society that has been affected by its many wars is the medical field. Warfare is extremely resource demanding, not only economically but also scientifically and medically. Just as problems are solved, new problems arise. From the Civil War to World War I, there have been many medical advances that have shaped the field today.While “advanced” may not be a word used to describe the medical field in the 1800s, modern hospital practices and treatment methods owe much to the legacy of the Civil War. The American Civil War was the bloodiest war in the history of the United States. Approximately 620,000 soldiers died during the war, and countless other soldiers were left disabled. Of the 620,000 soldiers who died during the war, 2/3 of these deaths were not the result of battle, but of disease.(1)There were over 75,000 cases of typhoid fever in the Union Army during the war. It was caused by exposure to fecally contaminated food and water. It killed 17% of affected soldiers in 1861 and 56% by 1865(2) . Typhoid fever was especially common in Washington, DC. Combating widespread diseases as well treating the wounded soldiers pushed Americans to rethink their theories on health and develop more efficient practices to care for the wounded and sick. At the beginning of the war, America’s medical knowledge and resources were struggling to combat the needs posed by the wounds, infections, and diseases that plagued both sides. Illnesses like dysentery, typhoid fever, pneumonia, and tuberculosis spread among the poorly sanitized war camps and hospitals. For doctors in the field during the Civil War, germ theory, antiseptic medical practices, advanced equipment, and organized hospitalization systems were basically unheard of. Medical training was just emerging out of a time where physicians advocated bloodletting and purging to remedy illnesses. Doctors were often encouraged to treat diseases like syphilis with mercury, an extremely destructive treatment to say the least. These aggressive “remedies” of this era of medicine were often worse than the problems they were trying to solve. The wounded suffered unsanitary conditions in the haphazard hospitalization systems that existed at the beginning of the Civil War. As battles drew to an end, the wounded were rushed to nearby cities, where doctors and nurses coped with the onslaught of wounded men in makeshift hospitals. These hospitals saw a great influx of wounded from both sides and the wounded and dying filled the available facilities to the brim. For example, the Fairfax Seminary opened its doors twenty years prior to the war with only fourteen students, but it housed an overwhelming 1,700 sick and wounded soldiers during the course of the war. In Walt Whitman’s Memoranda he describes the hospitals of the time as merely tents with the wounded lying on the ground(3). In addition to this, he is also quoted in saying that during his tour of these hospitals, he saw countless piles of amputated limbs with the dead piled up nearby.These extreme conditions helped speed up the progression of medicine, and helped bring an end the “middle ages” of American medicine. There were several proponents in the progression of medicine in the Civil War era. Major Jonathan Letterman saw the inefficiency with the current system to treat the wounded on the field and sought to remedy this weakness. While in his post as Major of the Army of the Potomac, he completely reorganized the medical system that was in place. Before his medical innovations, wounded men were often left to fend for themselves. Unless carried off the field by a comrade, a wounded soldier could lie for days suffering from exposure and thirst. Letterman started the first Ambulance Corps, which trained men to act as stretcher bearers and operate wagons to pick up the wounded to tend to their wounds. In addition to this, he also instituted the concept of triage for treatment of the wounded as well as an evacuation system for those injured on the battlefield. His system consisted of three parts: A Field Dressing Station located on the battlefield that was used to apply the initial dressings and tourniquets to wounds, A Field Hospital located close to the battlefield where emergency surgery could be performed, and a large hospital located far from the battlefield to provide additional care to soldiers with serious injuries. (4)In addition to Letterman’s efforts to improve the deplorable hospital conditions of Civil War, Surgeon General William A. Hammond started making changes at every level of the Army Medical Department. He established more stringent requirements for doctors and surgeons joining the service and set up examination boards to evaluate their qualifications. He initiated a hospital inspection system and designed new pavilion hospitals with strict specifications for layout, lighting, ventilation and patient space allotments. Furthermore, in 1863, Hammond wrote “Treatise on Hygiene, with Special Reference to the Military Service.” which laid out guidelines and regulations for the hygiene of military servicemen.(5) Clara Barton, well-known humanitarian and founder of the American Red Cross, brought professional efficiency to soldiers in the field, especially at the Battle of Antietam in September of 1862 when she delivered much-needed medical supplies and administered relief and care for the wounded.(6) The American Red Cross is still in service today and saves countless lives. (7) Disease and illness took a heavy toll on soldiers, but as these medical heroes show, every effort was made to prevent death caused by human error through the development of organized and more advanced medical practices. World War I was a miserable and bloody affair. In less than a year the American armed forces suffered more than 318,000 casualties, of which 120,000 were deaths. Almost 6,000 of these casualties were North Carolinians. (8)World War I was fought on a scale that had never been experienced before. At the Battle of Waterloo in 1815, the main infantry weapon was the muzzle-loading musket, which fired up to four shots a minute. At the Battle of the Somme, just over a century later, machine gunners could fire off 600 rounds a minute. High velocity rounds wreaked havoc in the body, twisting tissue and splintering bone. Fighting on farmland fertilised by manure meant that wounds quickly became infected; gangrene was widespread. This created serious problems that many American soldiers and doctors had not seen before. At first glance, the military medical system seemed unprepared for war. The entire Army was around 130,000 men, scattered in small units around the United States, and around the world. There was no previous experience of delivering care to large units. Preparing for conflicts of millions of men on a side, and casualties in the tens of thousands, had been unheard of for 60 years; but the system was ready to face these challenges. Following the public outcry over the large number of soldiers dying from disease in the Spanish American War of 1901, the Army Medical Corps had reorganized, establishing medical, dental, veterinary, and nursing corps, and the Army reserve corps for medical officers, to be mobilized in case of war. This last was the precursor of the Army Reserve system today. With the war looming, the National Defense Act of 1916 enacted further organizational changes(9). By 1917, the Medical Corps was, theoretically, prepared to field a number of hospitals. Unfortunately, these were neither staffed nor equipped to handle the massive number of wounded soldiers. A number of civilian organizations were available to take up this challenge. The Committee of Standardization was set up to coordinate medical supply and standardization, working quite successfully with industry to facilitate production of the vast amount of medical supplies needed.(10) Its work was facilitated greatly by the expansion of the medical supply industry to supply France and Britain during the first three years of the war. Supply and hospitalization were not the only problems that needed to be solved however; medicine was still unrefined and inadequate to care for the countless number of bloodied and diseased soldiers. Military medicine had not changed much in the fifty years since the American Civil War. Battlefield doctors were slow to understand the link between exposure and the infections that set in quickly in dirty battlefield hospitals. As doctors became more aware of this link, they had to make sure that the wounded were brought to the operating table within twelve hours or the risk of infection was greatly increased. There was only salt water to rinse wounds, and there was no medication to stop infection once it had started. Thousands of men lost arms, legs, and even their lives. But advances in some medical techniques kept pace with the mass destruction of war. Innovations developed in the First World War had a massive impact on survival rates – such as the Thomas splint, named after pioneering Welsh surgeon Hugh Owen Thomas, which secured a broken leg. At the beginning of the war 80% of all soldiers with a broken femur died. By 1916, 80% of soldiers with this injury survived.Doctors had been attempting blood transfusions for well over 200 years before the start of World War I, but the process wasn’t popularized until the conflict. Its use during the war was made possible by a trio of well-timed discoveries earlier in the century—that not all blood is the same; that sodium citrate could be used to stop it from clotting; and that it could be refrigerated. The breakthroughs made transfusions safer and allowed blood to be stored. “This great stride forward in the technique of blood transfusion coincided so nearly with the beginning of the war that it seemed almost as if foreknowledge of the necessity for it in treating war wounds had stimulated research,” Geoffrey Keynes, a British surgeon and younger brother of economist John Maynard Keynes, wrote in “Blood Transfusion” in 1922. With transfusion still in its infancy, medical personnel on the Western Front were slow to recognize its value as a life-saving measure. Earlier attempts to introduce transfusion also proved difficult because of the stress of war conditions and were dangerous because of the lack of testing. It wasn’t until 1917, when British medics were joined by colleagues from the U.S., that knowledge of transfusion began to spread. Oswald Robertson, a British-born American officer, is credited by doctors writing at the time and historians with setting up the first blood depot.By 1918, blood transfusion was used extensively on the Western Front to treat injured soldiers, although there is no record of how many transfusions were performed during the war.Blood transfusion has since helped reduce the number of deaths in many wars and disasters.Today blood transfusions are very common, with five million Americans needing one every year, according to the U.S. Department of Health & Human Services.However, battlefield casualties paled in comparison to the massive onslaught of diseases. 51% of American deaths during WWI were caused by diseases(11). Trench fever was an unpleasant disease caused by body lice during World War One. The fever was easily passed between soldiers, causing them to suffer from high fever, headaches, aching muscles and sores on the skin. It was painful and took around twelve weeks to get better from. For many soldiers, it was an illness that struck them more than once. When medical officers first tried to treat trench fever, they used those medications that they had nearest to hand: those they carried in their standard issue drug boxes. One of these, quinine, was the first drug reportedly used to treat the condition. It seemed a sensible choice, as it was known to be effective against malaria, also a recurring fever. However, it had no effect on the natural course of the disease. Researchers were also unsuccessful in curing the disease by using a vaccine—injecting an emulsion of louse excreta, sterilized by heat or phenol. The response to trench fever was effective once the condition had been recognized as a specific, new disease. The medical profession was able to identify a vector, the louse, which was later proved to transmit the disease. It has been argued that this was one of the original contributions of the war period.The eradication of lice helped to reduce the prevalence of the disease. Not all battlefield diseases are physical, this is clearly demonstrated by Shell Shock. The term “shell shock” was coined by the soldiers themselves. Symptoms included fatigue, tremor, confusion, nightmares and impaired sight and hearing. It was often diagnosed when a soldier was unable to function and no obvious cause could be identified. Because many of the symptoms were physical, it bore little overt resemblance to the modern diagnosis of post-traumatic stress disorder. The pace and intensity of industrialized warfare had profound effects on the human mind and body that were not related to wounds or physical injury. Poorly understood at the time and for many years afterwards, the crying, fear, paralysis, or insanity of soldiers exposed to the stress and horror of the trenches was often held by medical professionals to be the result of physical damage to the brain by the shock of exploding shells. Military authorities often saw its symptoms as expressions of cowardice or lack of moral character. Its true cause, prolonged exposure to the stress of combat, would not be fully understood or effectively treated during the war.When faced with problems, the American people have always risen up to solve them, and the medical need of soldiers during wartimes are no exception. Before the Civil War, the medical field in America was in disarray. The extreme demand for medical care due to the casualties on both sides pushed American medicine out of this “middle age” and thrust it towards the refined field it is today. The Civil War shined light on the poor conditions of hospitals in America, and led to a vast improvement in healthcare. World War One opened the eyes of physicians in America to new practices, and better treatment of diseases. Innovations from these wars have continued on, and characterized the field as it is today.