Medicine, Military

Warfare and disease have always gone hand in hand. Disease affects armies, and armies spread disease. It seems probable that the first surgeons were military, treating the results of single combat or of tribal raids. The Roman army was the first for which there is much written and archaeological evidence of organized medical services. It was as much exposed to disease as any other, but because the troops were better fed and had better organized sanitary arrangements, strictly enforced, they suffered less than their opponents. Despite this, barely half the enlisted legionaries lived to complete their eighteen-year service. Rather fewer auxiliaries survived, but this was still a higher proportion than that for civilians.

The Romans felt that medical practice was suitable only for Greeks and slaves, so most, if not all, army doctors were Greek. Such tombstones, or altars, that have survived are of Greeks. In the legion, the doctor (medici) had under him orderlies (medici ordinarii) and dressers (capsarii) who seem to have been the equivalent of stretcher-bearers. They treated wounded in the battle lines, and evacuated them to safer areas. There is a scene on Trajan's column where an auxiliary is having his wounded thigh dressed.

Legionary fortresses were provided with a large hospital, containing many rooms, arranged round a courtyard and verandah. The larger auxiliary forts were also provided with smaller hospitals, of which several in Great Britain have been excavated. The best known of these is at Housesteads, on Hadrian's wall. Each hospital had a large room, occupying the full width of one end of the building, which seems to have been an operating theatre. The equipment of military surgeons has been found, and there are descriptions of the treatment of particular kinds of wounds. Split reeds were used to extract arrowheads, and a metal blade-like instrument was used for extracting larger missiles. Celsus (25 bc-ad 50), in De Re Medicina, describes a number of such operations, including limb amputations, carried out, of course, without anaesthesia. Herbal remedies were known and rather coarse antiseptics, such as pitch and turpentine, often accompanied by religious incantations, were widely used.

The first great figure of military surgery of whom much is known was Ambroise Paré, the greatest surgeon of the Renaissance. He served for almost 30 years in the armies of the French kings, with practice in Paris in the peaceful intervals. He left graphic descriptions of a vast array of wounds, with advice as to their treatment and the instruments to be used. Thomas Gale, a contemporary, published a treatise of gunshot wounds and their treatment in 1563, and William Clowes, who served in the Elizabethan navy, wrote on burns caused by gunpowder in 1591.

In the British army, organized military medicine began with the raising of a standing army in the 1660s. The army was organized on a regimental basis, and permanent commissions were given to regimental surgeons. They were not highly regarded, and career advancement for medical men was very uncertain. A surgeon and assistant surgeon formed part of each regiment, to run a small hospital and treat the sick. A few non-regimental doctors served on the administrative staff for general and field hospitals. Some distinguished medical men served in the forces. John Hunter (1728-93), the father of modern scientific surgery, served in both the army and the navy, and in 1790 was appointed surgeon general to the land forces, and inspector general of hospitals.

The Napoleonic wars produced many great medical figures. James Guthrie (1785-1856) joined the army at the age of 13, and became a Fellow of the Royal College of Surgeons at 16. He was bitterly opposed to the routine amputation of damaged limbs, and realized the necessity of rapid casualty evacuation. His textbook Commentaries on the Surgery of War 1808-1815 was a standard work for decades. Sir James McGrigor (1771-1858) was director general of the Army Medical Department from 1815 to 1851. He was a fine administrator, and quite early appreciated the dangers of cross-infection between wounds and infective fevers. He was even able to disagree with the Duke of Wellington and survive.

A worthy successor to the work of Ambroise Paré was Dominique Jean Larrey, who served in the French navy, the Republican army, and the Napoleonic army. He introduced ambulances volantes, light, two-wheeled, sprung vehicles, drawn by two horses, for the rapid evacuation of the wounded. He was a meticulous surgeon, who served in Egypt, Russia, Germany, and at Waterloo.

During the Crimean war, the appalling conditions of the sick and wounded caused a public outcry. In that war 1, 761 British soldiers died of wounds and 16, 497 died of disease—almost ten times as many. The main causes of death were cholera, typhoid, and typhus, due principally to a total neglect of hygiene. Chaos reigned in the main hospital at Scutari, an old Turkish barracks, where, in the space of eight weeks, over 2, 000 men died of infections acquired in hospital. That remarkable woman Florence Nightingale took charge, and produced dramatic changes. She was autocratic and strong-willed, and needed to be, given the incompetence and obstruction of the medical and administrative staff. Surgery during the campaign remained fairly primitive, with wholesale limb amputations and a high rate of post-operative infections.

The American civil war took place on a vaster scale than the Crimean war, but the problems were much the same, although they were more efficiently tackled. Once again, disease was the major killer of soldiers. Of the approximate total of 618, 000 deaths on both sides, about 414, 000 were from disease and non-battle injuries, and 204, 000 from wounds. Although anaesthesia in the form of ether and chloroform was available for operations, because of the vast numbers of casualties, supplies sometimes ran out before all the wounded were treated. The Confederate forces were even worse off in this respect because their supply system was worse. Infectious diseases, by crippling armies, delayed some campaigns, and prevented others starting at all. The main killers were cholera, typhoid, dysentery, malaria, and tuberculosis, but there were also serious outbreaks of smallpox and measles, against which many troops had no immunity. In early battles, many wounded might lie out for two to three days, but by Gettysburg, at the end of each day the casualties had been cleared. Nearly all wounds became infected, the infection often being transmitted by the surgeons' unwashed hands and instruments. In the Union army, mortality from chest wounds was 62 per cent, and from abdominal wounds 87 per cent. An Ambulance Corps, to speed casualty evacuation, was formed in the Union army in 1862. As the war progressed, hospital arrangements became better, with many around Washington, and scattered throughout the Union states. Emulating Florence Nightingale, many women worked in hospitals, caring for the sick and wounded, and improving their lot considerably. Of the large number of POWs who died in camps, the vast majority died of dysenteric diseases, due to grossly deficient hygiene.

Following the Crimean war, an Army Hospital Corps was formed in the British army, but general medical care remained in the hands of regimental surgeons. The Army Nursing Service was formed in 1881, and the Royal Army Medical Corps (RAMC) was formed as a separate entity in 1898, in time for the medical chaos of South Africa. The Second Boer War once again proved the overwhelming importance of hygiene and sanitation in armies. In the British and empire forces there were 26, 750 battle casualties with 7, 994 deaths (29.8 per cent mortality) and 404, 126 non-battle casualties with 14, 448 deaths (3.5 per cent mortality). The much lower death rates showed the significant advances in medicine, but the spread of disease was largely preventable. Once again, the sickness and deaths were due to cholera, typhoid, and dysentery, as many Boer war memorials will testify. The British army was said to be fully prepared to fight the Crimean war again in 1899, but the medical services were even worse, being understaffed, inadequate, and unprepared. Large numbers of very well-paid civilian specialists had to be employed to treat the sick and wounded. At one stage, the sickness was 958 per 1, 000 troops. In the so-called concentration camps, organized by Kitchener, to hold Boer women and children, things were even worse. There were 20, 000 deaths among 117, 000 inmates, partly due to inefficiency, unpreparedness, and lack of supplies, and partly due to the Boers being unused to living in close communities.

WW I was expected by most combatant nations to be over in a few months. Few people had planned for the enormous number of men, or the enormous number of casualties, that would be involved. This applied particularly to the medical services, who were at first overwhelmed by the sheer number of battle casualties confronting them, and later, by the even larger number of sick soldiers. In all the worldwide theatres of war, disease admissions to hospital reached staggering proportions, considerably outnumbering wounds. During the German East Africa campaign for example, admissions to hospital reached 240 per cent of troops in the theatre, mainly from malaria and dysenteric illnesses, with wounds accounting for only 3 per cent of admissions. Areas like Macedonia and Mesopotamia were almost as bad. Even on the western front, among British and Dominion troops, battle casualties were only 39.5 per cent of admissions. Mortality rates fell to less than 1 per cent for disease, and less than 8 per cent for wounds, a great improvement on previous wars.

Improvements in the treatment of wounds and disease were astonishing for the time, under the pressure of warfare, with the prospects for a sick or wounded soldier improving steadily throughout the war. The hard-won experience of WW I surgeons and physicians proved a very sound basis for the continuing improvements which occurred in later wars. The medical advances made in this war were the greatest in any conflict, and vastly improved not only military but also civilian practice. The type of wound and the bodily area of wounding changed from previous conflicts. It was very much an artillery war and in the British army shells, mortars, and grenades accounted for 61 per cent of all wounds, with bayonet wounds accounting for only 0.3 per cent. Wounds of the limbs made up the greater part of the treated casualties, revealing the poor survival of chest and abdominal wounds. Patients with wounds to the head and neck survived better than had been expected, due to improved surgery, with an astonishing 82 per cent being subsequently fit for some form of duty.

A considerable amount of research, often under front-line conditions, went on into the problems of shock, fluid replacement, blood loss, and wound infections. There was close co-operation between the British, Dominion, French, and later American medical services on all these topics, and on others of common interests as well. Blood transfusion, which was rarely used pre-war, became routine later in the war. At first, blood had to be fresh, with direct transfusion from man to man, but by 1916-17 blood could be stored for several days, and stocks could be moved where needed. Blood groups were unknown, but a simple agglutination test was performed to check that blood was suitable for the recipient. Early in the war, blood transfusion could only be given in base hospitals, but by early 1918, a blood transfusion service existed, so that blood could be provided as far forward as the Advanced Dressing Station. Fluid replacement proved invaluable in the treatment of dehydration, due to cholera and dysenteric diseases, but intravenous fluid had to be made up fresh, and all equipment had to be boiled at every use. The problems of wound infections were attacked with great vigour and much bacteriological research was undertaken. By opening wounds, cleaning out and removing dead and damaged tissue, infection was controlled to some extent, but healing was delayed. A large, open wound could be observed and dressed more readily. The twin terrors of tetanus and gas gangrene, due to fighting over heavily manured ground, were diminished compared with many previous conflicts, and were rare away from the western front. Both of these diseases thrived in deep wounds, in the absence of oxygen. In the British army, and probably in all forces, infections from gas gangrene occurred in 10 per cent of all wounds in 1914-15, but had fallen to 1 per cent by 1918. Mortality was 22 per cent in 1918, the same figure as in British forces in North-West Europe in 1944-5, despite the use of antibiotics in the latter campaign.

One problem, which all forces had, was the comparatively primitive state of anaesthesia. Although dramatic changes had taken place in surgery in the previous 40-50 years, anaesthesia had not kept pace. General anaesthesia, using the agents then available, was hazardous for shocked casualties, so that more and more local anaesthesia, mainly Novocaine, was used in British units, even for chest and brain surgery. Other armies had different views, the Americans, for example, swearing by inhaled nitrous oxide. Most branches of surgery received tremendous impetus from the Great War, particularly surgery of the chest, brain, and plastic and reconstructive surgery. Dentists had first been attached to medical units, to treat jaw injuries, during the Second Boer War, and co-operation between dentists and plastic surgeons during WW I laid the groundwork for modern plastic surgery. The surgery of limb wounds made dramatic strides, with the amputation rate for upper and lower limbs falling to 3 per cent, which would have astonished Crimean or American civil war surgeons.

Casualty evacuation, which had been such a problem at the third battle of Ypres and the Nivelle offensive in 1917, had been improved by 1918, with a corresponding improvement in survival rates. The problem of psychiatric casualties, victims of what is now called combat stress, was gradually tackled on a systematic basis, so that by 1917-18 a well-developed hospital procedure was in place. Treatment and convalescent regimes meant that the vast majority of cases could be returned to duty, but not all to front-line service. Recurrence rates in some groups remained high. Of the 341, 025 soldiers discharged unfit from the British army by April 1918, only 6 per cent were for war neurosis, a lower figure than popularly supposed. After the war, large numbers of pensioners, no longer fit for service or full-time work, had to be provided for. The fact that disease was still more important than wounds was shown by the Ministry of Pension's figures for 1919-20, when pensions for disease were 63 per cent, wounds 35 per cent, and gas poisoning 2 per cent.

WW II showed further reductions in sickness rates and in mortality from wounds. There were several reasons for this. The availability and storage of blood was further improved, and ready sterilized and packaged intravenous fluids were supplied. There were, in addition, further improvements in casualty evacuation and a great improvement in anaesthesia. Advances in the diagnosis, prevention, and treatment of disease, particularly tropical disease, made a great difference. Antibiotics were available and their importance was very great, but this can be overemphasized except in the treatment of venereal diseases where it was outstandingly effective. Large numbers of men died, or were invalided, during WW I because of chest infections, particularly forms of pneumonia. Penicillin made a great difference to these in WW II. The results of treatment of abdominal wounds, which had been disappointing during WW I, improved, partly due to improved surgery and anaesthesia, but largely due to the control of infection. One problem which occurred after surgery, particularly of the upper abdomen, was the development of pneumonia due to breathing being restricted. The same thing had happened with chest wounds, not only in the affected lung, but also in the opposite one. Antibiotics made a great difference to this complication, with improvement in survival. Although the infection rate with tropical disease was bad, particularly malaria, for example during the Burma campaign, it was never quite the problem it had been in the German East Africa campaign in 1914-18. Casualty evacuation in Burma, New Guinea, and some of the Pacific Islands was as great a problem as it had been in Flanders, until air evacuation became a practical possibility.

One attempt to provide surgery as close to the action as possible was the Forward Surgical Unit (FSU), developed in Libya in 1941. A later development at the FSU was the provision of post-operative beds for supervision in the dangerous time after surgery. The developed FSU became standard practice later in the war, in all theatres. During the Normandy campaign the problem arose of how to evacuate wounded before there was sufficient room to set up hospitals ashore. This was solved temporarily by converting some LSTs (Landing Ship, Tank) to take about 300 patients. They proved adequate in calm weather, but rolled appallingly in rough seas. The problem was solved permanently when airstrips became available for air ambulance evacuation. Psychiatric casualties were expected in WW II, and during the campaign in Europe over 13, 000 cases were seen in the British forces, but adequate provision had been made beforehand.

The Korean war, and later wars, continued the progress made before. The widespread use of helicopters for rapid evacuation of casualties to specialized surgical units, revolutionized the outlook for the wounded. The first recorded helicopter casualty evacuation was in Burma in 1945, but the increasing availability of numbers of helicopters made them, by far, the best form of evacuation. Further improvements in anaesthesia and antibiotics also helped. The outlook for a casualty was much improved compared with 35 years earlier. Disease was not absent from Korea, as shown by American casualty statistics. They suffered in 1950-3 33, 629 killed or dead from wounds and 20, 617 non-battle deaths. There were also 10, 218 listed as missing or prisoners.

The Vietnam war confirmed the importance of air evacuation: 372, 947 Americans and Allied troops were carried to hospital by helicopter in 1965-9. The USAF evacuated, to facilities in South-East Asia or the USA, 406, 022 patients, including 168, 872 battle casualties in 1965-73. The type and causation of wounds suffered by US personnel differed somewhat from previous conflicts, with 16 per cent of wounds and 51 per cent of deaths caused by small arms, there being much less artillery used by their opponents. Seventeen per cent of wounds and 11 per cent of deaths were caused by various forms of booby trap, which came as a very unpleasant surprise. The lightweight, high-velocity, small-arm rounds caused significant entrance and even larger exit wounding, with massive tissue damage. On another front, penicillin-resistant venereal diseases announced the return of an old enemy.

The Falklands war and the Gulf war were largely continuations of previous wars, from the medical standpoint. The Gulf war was somewhat different, in that fear of Iraqi chemical and biological weapons caused many thousands of troops to be immunized, and given antidotes against every eventuality. This caused significant medical problems later.

Bibliography

• Grant, Michael, The Army of the Caesars (London, 1974).
• Guthrie, Douglas, A History of Medicine (London, 1945).
• McLaughlin, Redmond, The Royal Army Medical Corps (London, 1973)

— Geoffrey Noon

Medicine, Military, as a specialty, has focused on the surgical management of mass casualties; on the prevention and treatment of infectious diseases, especially tropical diseases; and, in the twentieth century, on the effects of operating military machines such as submarines and airplanes. As part of a military hierarchy, the organization of structured medical command and administrative systems has been important for interaction with the line and for function in combat.

Army Medicine

Medical support for an American army began on 27 July 1775 when the Continental Congress established a medical service for the army of Gen. George Washington during the siege of Boston. The organization followed the model of the British army. Military physicians wrote several texts on surgery, on preventive medicine, and on pharmacy during the Revolutionary War, the first American publications of their kind.

On 14 April 1818, Congress reorganized the staff departments of the army and established the present medical department. Medical officers gained military rank in 1847. A hospital corps, providing formal instruction for enlisted men as physicians' assistants, was formed in 1887; the present civilian programs for paramedical physician extenders have their philosophical base in this system. The army established the Nurse Corps in 1901, the Dental Corps in 1911, the Veterinary Corps in 1916, and the Sanitary Corps in 1917; the latter became the Medical Service Corps in 1947 when the Women's (since 1966, Army) Medical Specialist Corps enrolled dietitians and physical and occupational therapists. Corps functions had existed previously in the medical department, but organization into a corps not only formalized the position of the specialty in the military bureaucracy but also regularized the status of the individuals and provided for commissions, tenure, and pensions. Thus, because she was chief of her corps, it was possible for Col. Anna Mae Violet McCabe Hays of the Army Nurse Corps to become the first female general officer in American history in 1970. One consequence of formal organization, with command overview of health-care delivery, including the supporting infrastructure, was the development of a centrally managed health-care program outside the civilian fee-for-service system, which the Veterans Administration Hospital program later adapted to its needs.

The major military contributions of the surgical disciplines have been in mass casualty management, the evacuation of wounded, and in the treatment of battle wounds. Although the removal of the sick and wounded from the battlefield has always been a part of military operations, the development of an organized system did not come until 1862. Jonathan Letterman, the medical director of the Army of the Potomac, established the system that is now the practice of all armies: staged and echeloned medical care and forward treatment followed by evacuation of patients by medical elements in the rear. The next major advance was the use of airplanes for evacuating hospitalized patients in World War II, and of helicopters as forward tactical air ambulances in the Korean War. Later, having proved its worth in Vietnam, the helicopter was adopted by the civilian community for evacuating those injured in highway accidents. Army studies of wound ballistics, beginning in 1892, established the scientific rationale for wide debridement of wounds, and led to reduction in gas gangrene and wound infection, as well as to the development of individual body armor. Charles Drew, Douglas B. Kendrick, and others, developed systems for mass blood collection, distribution, and transfusion during World War II and introduced the civilian medical community to the concepts of massive blood transfusions for shock and trauma. An army burn research and treatment center, founded in 1947, was the first in the United States, and the use of Sulfamylon to prevent skin infection contributed greatly to the burn research program.

Communicable and infectious diseases have always been the major causes of morbidity among troops, and military medicine has made its greatest contributions in this area. In World War I, the application of infectious disease research to military sanitation produced a milestone in the history of war: lower mortality from disease than from battle wounds.

From 1818 to 1860, the army's medical department mostly concerned itself with patient care at the small army posts scattered over the southern and western frontiers. The department reported morbidity and mortality data in a uniform format, and published the collected reports, which included some civilian data, beginning in 1840; these national public-health statistics, the first of their kind, prompted the beginning of a national approach to public-health epidemiology. Because prevailing opinion believed disease etiology and occurrence were related to climate, post surgeons also included meteorological data with their reports. (The weather observations, separately published, were the only nationwide data of their kind, and the National Weather Service remained a medical department function until 1870.)

When bacteriology became a science in the 1860s, military physicians were among the first to explore this new field. Joseph J. Woodward and Edward Curtis in 1864 introduced aniline dyes in the United States for staining in microscopy, and pioneered photomicroscopy of tissues and bacteria. George M. Sternberg of the U.S. Army published the first American bacteriology textbook in 1892; later, as surgeon general, he established and directed the two "Walter Reed boards" for the study of typhoid and yellow fever, in 1898 and 1900, respectively.

The history of Walter Reed's work on the transmission of yellow fever in 1900 is well known: he and his colleagues, using volunteer test subjects, took only a few months to disprove fomite infection, document mosquito transmission, and define the organism as nonbacterial. Less well known is the story of the "Typhoid Board" of 1898, which studied recruit camp epidemics, documented that contact mattered more than water in transmission, and suggested that a carrier state existed.

When Sternberg founded the Army Medical School in 1893—the first school of public health and preventive medicine in the United States—he began the trend of formal postgraduate education in the basic sciences for army medical officers. Renamed the Walter Reed Army Institute of Research, the organization became the largest tropical medicine research organization in the United States.

Tropical parasitic diseases occupied the attention of military physicians. Bailey K. Ashford, working in Puerto Rico after the Spanish-American War, isolated the American hookworm, Necator americanus, as the cause of anemia in Puerto Rican farm laborers. His program for detection, therapy, and prevention later became the model by which the Rockefeller Foundation attacked hookworm in the American South. Charles F. Craig wrote an early text on medical parasitology in 1911, developed serological tests for amebiasis, and described new intestinal parasites. Work at the Army Medical Research Board in the Philippines from 1900 to 1934 proved that dengue was a virus and that mosquitoes were the vector. The research also documented the usefulness of emetine in treating amebiasis; showed that Aedes mosquitoes were major vectors for equine encephalitis; and made critical contributions in new rabies and rinderpest vaccines, in the treatment of beriberi, and in zoonotic diseases.

Frederick F. Russell developed an American typhoid vaccine in 1909 at the Army Medical School. In 1911 the army immunized all its soldiers—the first time for an entire army—causing typhoid to disappear as a major cause of morbidity and mortality. Carl Rogers Darnall's introduction of anhydrous chlorine to purify drinking water in 1910 became the basis for present systems of municipal water purification. William C. Gorgas used the new findings on mosquito transmission to control yellow fever and Malaria, permitting the building of the Panama Canal. In 1933, the Army Medical Research Board in Panama conducted the first American studies on the efficacy of atabrine as a prophylactic drug against malaria; it became the standard drug of World War II until the chloroquine-primaquine combination tablet replaced it following definitive studies in Korea in 1960. In 1963, the army's medical department began to support the only large international research program for the development of new antimalarial drugs.

During World War II, the United States of America Typhus Commission, a joint military-civilian organization, did broad-scale work on the typhus fevers and was responsible for applying DDT to delouse populations and for field trials of vaccines. Similarly, military-civilian investigators of the Army Epidemiological Board investigated viral hepatitis, separated infectious and serum hepatitis as entities, and demonstrated the usefulness of gamma globulin for passive protection. After World War II, the concept of joint military-civilian teams persisted and led to such contributions as the use of chloramphenicol to treat typhoid fever and scrub typhus and the use of broad-spectrum antibiotics in the treatment of plague.

During and after the Korean War, members of the medical department studied communicable and infectious diseases, leading to the description of the ecology of the transmission cycle of Japanese B. encephalitis in 1955; the isolation of the Asian influenza virus in 1957; the isolation of the German measles virus in 1962, for later development of a vaccine by the National Institutes of Health; and the development of effective vaccines against adenovirus infection in recruit camps in 1967. Researchers also developed vaccines against meningococcal meningitis, while Central American countries used a vaccine against Venezuelan equine encephalitis during epizootics in 1969 and 1970.

Other discoveries and contributions made by medical department members have been important to general medicine. In 1833, William Beaumont published his classic work on the physiology of digestion from his ten-year study of the gastric fistula of Alexis Saint Martin. In that decade, the surgeon general established a collection of medical books, which grew over time—and especially after the Civil War—to become the Army Medical Library; in 1956 it became the National Library of Medicine under the aegis of the Department of Health, Education, and Welfare.

The career of John Shaw Billings typifies military involvement in the mainstream of American medicine. In 1870 Billings's investigation and recommendations changed the Marine Hospital System to its present U.S. Public Health Service structure. He designed Johns Hopkins Hospital and was responsible for the selection of William H. Welch and William Osler as faculty for its medical school. As librarian of the Army Medical Library, he developed the Index-Catalogue and, with Dr. Robert Fletcher, developed and published the Index-Medicus. He recommended the use of electrically sorted punch cards for medical record-keeping, and oversaw Herman Hollerith's testing of such a system at the surgeon general's office. In retirement, Billings organized and built the New York Public Library and became its first director.

The Civil War period saw the founding of the Army Medical Museum, renamed the Armed Forces Institute of Pathology in 1949, from which, in the next thirty years, came the Medical and Surgical History of the War of the Rebellion, the first detailed account of the medical and surgical findings of the impact of war on an army. This era also saw the beginning of formal research in pathology in the United States.

Navy Medicine

Congressional appropriations on 2 November 1775 provided for surgeons on naval ships, but the navy did not establish its Bureau of Medicine and Surgery until 1842 and did not authorize flag rank for the surgeon general until 1898. The navy established its Nurse Corps in 1903 and its Dental Corps in 1912.

Edward R. Squibb, who later founded the pharmaceutical firm of the same name, founded a naval laboratory for the production of pure drugs in 1853. The Naval Medical School was established in 1902. The navy introduced annual physical examinations for officers in 1903, laying the foundation for programs of multiphasic health screening.

Edward R. Stitt, later surgeon general, wrote the first modern American text on tropical medicine in 1914. In 1958, navy physicians developed methods for fluid replacement in the treatment of Cholera, which became standard procedures, especially during epidemics. Toxicological research on trace-element effects in the closed environment of submarines produced some of the earliest data now useful for civilian pollution studies.

Aviation Medicine

Aviation medicine began in Europe as a medical problem of the army, and in 1917, with the entry of the United States into World War I, the army established a research laboratory and the School for Flight Surgeons. Louis H. Bauer, the first commandant of the school, wrote the first American textbook of aviation medicine in 1926 and became the first director of civil aviation medicine for the Department of Commerce. In 1936, Harry E. Armstrong, later surgeon general of the U.S. Air Force, built the first centrifuge to study the effects of acceleration on humans.

The Air Force established a separate medical department in 1949. In 1950, the School of Aerospace Medicine began biological research on the effects of space flight, and air force officers conducted the great majority of the medical work in the National Aeronautics and Space Administration. John Paul Stapp's studies in 1954 on abrupt deceleration founded the present field in crash injury. Air force studies of anthropometry, human factors, designs of instruments, displays, and basic work in vibration effects and noise-level tolerance have had widespread application to design.

Bibliography

Ashburn, Percy M. A History of the Medical Department of the United States Army. Boston: Houghton Mifflin, 1929.

Bayne-Jones, Stanhope. The Evolution of Preventive Medicine in the United States Army, 1607–1939. Washington, D.C.: Office of the Surgeon General, 1968.

Hume, Edgar Erskine. Victories of Army Medicine: Scientific Accomplishments of the Medical Department of the United States Army. Philadelphia: Lippincott, 1943.

Peyton, Green. Fifty Years of Aerospace Medicine: Its Evolution since the Founding of the United States Air Force School of Aerospace Medicine in January 1918. Brooks Air Force Base: U.S. Air Force School of Aerospace Medicine, 1968.

Roddis, Louis. A Short History of Nautical Medicine. New York and London: P. B. Hoeber, 1941.

Tobey, James A. The Medical Department of the Army: Its History, Activities and Organization. Baltimore: Johns Hopkins Press, 1927; New York: AMS Press, 1974.