British Military Medicine in the 18th Century

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Military and Medicine

To trace the footpath of military medicine from the fourteenth century to the eighteenth century is akin to detailing the medical advancements that has accompanied military conquests from the early civilizations to the present post modern society. The ancient medical knowledge and practices acted as the pedestal of modern civilian and military medicine. The Hippocratic theory espoused by Hippocrates remains the bedrock of medical advancements. Through military conflicts, conquests and trade, medical knowledge was transmitted from empire to empire. It is therefore prudent that to effectively discern, appreciate the progressivity and present the nature of military medicine as practiced by the British army in the eighteenth century, the bedrock of military medicine advancement must also be taken through a suave and logical analysis.

Military medicine refers to the application of medicine in a military setting specifically for the benefit of the military. It is but an outgrowth of civilian medicine in the civilian community adopted for the military community. The relationship between medicine and war has often been proclaimed as being beneficial. However, military medicine is a conservative and non innovative component of medicine. These are cases where medical advancements have originated from war. Leo Van Bergen states that “many steps in surgical advancement and anesthesiology during the 20^th century are a debt to military medicine… the impact of warfare… on medical research can be stimulating and demanding, leading sometimes to real achievements”

Ever since the beginning of wars and conflicts, the role of medicine in influencing not only the rate of change but also the outcome of conquest has never been ignored. There are cases where war served to advance medical knowledge. For instance, in the 16^th century the French Military surgeon, Ambroise Pare, discovered a new treatment for gunshot wounds. Casualties in war have always prompted doctors to use such opportunities and challenges as a pedestal for more advanced therapeutic alternatives. However, just as it can trigger a wave of new discoveries, war has been known to slow down medical progress. A notable example is the barbaric destruction of Rome by tribes of Northern Europe that led to the collapse of Roman empire and with it the medical knowledge that had been amassed for centuries. The resultant effect was medical progression in Europe during the subsequent era in the Dark Ages.

It is the logics and principles of the medieval medical practices that laid the groundwork that would shape modern medicine. From the fifteenth century efficient methods of disease intervention were continually perfected and passed from generation to generation. Today’s concepts that drive developments in diagnosis, anatomy, medical training, research and public health systems draw their roots from the middle ages.

In war medical doctors and physicians had the primary responsibility not only preventing and treating infections but also ensuring that recovery was quick to allow soldiers to return to fighting hence strengthening the work fighting force. Moreover the number of injured and the appalling front line conditions not only provided free human subjects for testing novel therapeutic interventions but also confirmed with certainty that if a soldier could be cured from any of the prevalent diseases in the camps without other treatment preconditions such as rest and time then such an intervention could even be more effective when applied in civilian medicine.

The development in military medicine has for so many decades been lain, neglected and maligned in favor of other medical disciplines. This is simply because military medicine is so adhered to war that it becomes almost difficult to study it in a predominantly peaceful period. However military medicine as a system of scientific knowledge and practice aimed at the improvement of the health of troops, prevention of prevalent diseases and treatment of injuries sustained during combat, has grown gradually into a system of medical institutions and personnel charged with the primary responsibility of health care for the armed forces with relation to peace time and wartime.

Military medicine has developed into an independent branch of knowledge and practice whose practice and institutional organization are determined by the political structure of a centralized state. Because the army is a permanent disposal of the state, so is military medicine that ensures that the fighting efficiency of the army is maintained through systematic medical service in peacetime and more importantly in wartime. It is for this reason that military medicine, a specialized organization in the military, conducts systematic health care of troops hence satisfying the conditions of an efficient combat troop.

The technology and the scale of war tactics and weaponry demanded the institution of military medicine. Massive military manpower meant massive human losses hence the need to restore the effectiveness of the injured or wounded soldiers. In 1945 Field-Marshal Bernard Montgomery issued a declaration that the importance of military medical services to the Allied victory had surpassed all calculation. In total war with manpower at a premium maximum benefit can only be derived from forces when there are good medical services. If all historical facts are sieved through critical analysis the invisibility of military medicine is directly correlated to some of the greatest military achievements of the British army.

Ancient Military Medicine in Europe

The ancient military physicians acknowledged that the battlefield would produce casualties with predictable forms of injuries like cuts from sharp swords, broken bones from blunt object injury, head injuries due to rocks hurled from the slings or deep wounds due to arrow penetrations. Because the occurrence of these injuries were over a limited duration, the military physicians had the opportunity to experiment various therapeutic options and there effect on treatment period and success.

This adoption of various substances on wounds and injuries was encouraged after these physicians had realized that shamans and priests who practiced civilian medicine were not helpful in the battlefield where soldiers were required to gain their strength and efficiency and return to the battlefield in the shortest time possible. Physicians applied honey and salt mixtures on wounds so as to aid in recovery. The physicians were always in a perpetual mode of experimentation and therefore they observed intervention that were beneficial and discarded those that failed to offer any considerable therapeutic advantage. Beneficial intervention were improved upon irrespective of the fact that these physicians did not generally understand the exact causative agent of the diseases they were treating.

Moreover, the fact that some of the mixtures they used had bactericidal and or bacteriostatic properties were not part of the medical knowledge at that time in history. Effectiveness was determined by the recovery rates. The develop associations that had a direct bearing to the health of the soldiers. They were able to connect the relationship of the situation of latrines and the sources of drinking water and connect these two circumstances to the outbreak of diarrheal diseases.

Intervention that aimed to limit such interactions of human stools and drinking water and food had positive resultant effects. Hence signaling the birth of preventive medicine, a predominant domain of a military physician. It is to be understood that the early military physicians did not limit their therapeutic interventions on soldiers only but that their campaigns also involved the animals that drew the army’s chariots or carried military supplies and other burdens. Animals that were slaughtered to provide meat were also examined to ensure that the human infection from infected meat was obliterated. In this regard, the military physicians were added two food related responsibilities. They acted as a military food inspector on one hand and a military veterinarian on the other.

Basic treatment of battlefield injuries constituted of cleaning the wound to rid it of any foreign object, controlling the bleeding in case of cuts or deep wounds caused by javelins or arrows. The third most important procedure involved prevention of secondary contamination.

Ancient warfare usually yielded limited injuries because the type of warfare practiced usually involved one soldier involved with another soldier on a face to face combat. The force generated at such a distance and in such a situation could only cause simple fractures but not crushing injury or multiple fractures. Moreover, when a soldier was injured, he was often slain on battlefield by his opponent. This implies that the casualties were only generated when enemy soldiers began fleeing leading to a disorganized rout. After soldiers had achieved victory, they would then trail the defeated army killing and striking down the fleeing soldiers; a tactic that ensured that maximum casualties were inflicted on the enemies while the victorious soldiers escaped with little danger.

Once victory was achieved, casualties were evacuated and treated. Soldiers with very serious injuries like penetrating abdominal wounds died regardless of the military physicians intervention. Cuts due to sharp clean blade strike had minimum contamination hence high chances of complete recovery. Simple fractures with a single or no break of the skin were successfully splinted. Multiple fractures were usually rare but if they occurred then they were treated by amputation.

The Spread of Medical Knowledge in Ancient civilizations and Middle Ages

The spread of medical knowledge across the world can be traced to wars and conflicts that ravaged one part of the world to the other. As one empire is felled, another takes its position of military prowess and the medical information is passed to the conqueror from the conquered. The historical background of medical knowledge and practice can be traced to a variety of cities in Egypt and Mesopotamia. Some ancient records drawn from these early civilizations point to the fact that physicians were occasionally assigned to carry out specified medical duties in army garrisons. These writings give a detailed descriptions of preparation and administration of medications used in treating different diseases. History of the Egyptian Army succinctly point out that the army was equipped with a military medicine component that served to treat common battle field injuries.

In India the Hindu society had developed a fairly advanced level of medicine as early as the fifth century B.C one of these advanced medical interventions involved the treatment of snake bites. Military surgeons were also very proficient in surgical extraction of missiles from the body, suturing patients and even amputation. In the codes of conduct of conducting warfare, the Hindu had agreements recognizing physicians and surgeons as non-combatants. This was to improve the efficiency of treating injured and even captured enemy soldiers.

The Greek Empires medical practice was dominated by Hippocrates was stressed that medical practice could only be based on observable clinical signs and symptoms. One other key philosophy espoused by Hippocrates was that the body pressed the ability to heal itself. It is through the military conquests led by Alexander the Great that the culture and medical practices of the Greek spread throughout the world. Under the Supreme Command of Alexander the Great, Roman regions achieved the highest level of military medicine.

The formation of the Roman Empire under Octavian Ceaser heralded hiring of physicians to carry out treatment for the entire Roman army, not just the officers who had earlier been privy to this preferential treatment. Under the leadership of Ceaser, physicians were given honored positions in the military and they were also subject to certain benefits after their retirement. Manuals aimed at standardizing medical treatment in camps were developed and physical examinations during recruitments became the norm of the day. These physicians designed models of practices and behavior that ensured that sanitation, preventive health measures and daily bathing of troops were encouraged. To safeguard the troops against malaria, nets were provided to protect against mosquitoes. Regimented training ensured that troops adequately exercised daily and ate a diet that was nutritious.

Unlike earlier developments in military medicine, the Greeks demonstrated that bandages could be used to control bleeding. Special units where evacuated soldiers could be treated before they are forwarded to the military hospital came into use. It is the Roman regions that wholesomely advanced knowledge and treatment in military medicine. Before the Middle Ages, they had developed the tourniquet and litigation procedures to control bleeding hence allowing amputations to be performed more safely than before. By developing and using new surgical instruments extraction of penetrative missiles like arrowheads was improved. Strong wine applied on wounds reduced the potential risk of secondary infection while painkillers and sedatives preempted the development of advanced euthanasia currently in surgical use.

The collapse of the Roman empire, led to the consequent medical regression in Europe. Much of the ancient world regressed into a state of barbarism. If it were not for new political structures that arose, the Roman medical knowledge could not have been preserved. The Byzantine empire, the Islamic Empire and the Feudal Europe increased the flow of Greek and Roman medical knowledge into Europe. A key testament to the medical regression in Europe in the fourteenth century is the Black Death that nearly wiped out the European populace. Basic hygiene and cleanliness among individuals and the city itself was barely existed exacerbating the potential for disease outbreaks.

Military Medicine in the Renaissance Europe

Military medicine rebirth in Europe began in Spain. Towards the end of the fifteenth century, Spanish armed forces drove out the Muslims that had acquired a great wealth of medical knowledge by conquering other lands and by engaging in trade with the Byzantine Empire. After driving out the Islamic Moors the Spanish forces imitated the mobile hospital that had earlier on been used by the Islamic Moors. It is at this time that surgeons appeared in the French Armies.

The formation of nations in Europe, led to the formation of huge armies to offer defense to their territorial borders and also to enable them conquer new territories. The growth of new nations also stimulated a renaissance of learning. Ancient Greek and Roman texts that were preserved by the Byzantine and Arabic cultures were translated and eventually reintroduced into the European learning culture. Unfortunately some medical texts were translated faultily resulting in appropriate medical treatment of some injuries. For instance, wounds were reinfected with the belief that reinfection assisted in the healing process even though the Roman and Greek physicians knew that this was false.

The Introduction of Gunpowder and its Impacts on Military Medicine

During the fifteenth century, gunpowder was introduced into warfare and it became a very important military tool. Mobile siege guns were useful in the breeching of city walls. The sixteenth century came with muskets. Hand guns were also developed for individual soldiers. Additionally, antipersonnel cannons were developed and loaded with rocks, steel balls, nails, metal and glass pieces for use against enemies. All these military developments led to great human injury and death. The types of wounds that had earlier been predominant in ancient battles were replaced by more serious injuries. Simple features were replaced with compound fractures. The use of guns increased the distance between opposing infantries and so is the number of non fatal injuries.

The main primary concern became the fear of infections. Almost all wounds had the potential of being infected due to secondary contamination from dirt, clothing and other materials forced into injury by the musket ball. Unsanitary conditions or surgical contaminations worsened the healing process. Fifteenth century warfare marked an era when soldiers who died from infection for outweighed death on the battlefield. Amputation of injured limbs with shattered bones often resulted in death due to shock or infection of the huge wounds caused by musket ball. Because warfare weaponry had underwent a revolution, military medicine also underwent a change in order to remain relevant in the military setting.

The Revival of the Hippocratic Theory in British Military Medicine

Hippocrates embodied the beginning of modern military medical practice. Though a process of critical reasoning and observation, Hippocrates began to lay the foundation of medical knowledge and practice that would span through ancient times to the present post-modern society. The theory of the four Humors is the philosophical benchmark of military medical practice and civilian practice even today. The theory according to Hippocrates consisted of liquids; the body-blood, phlegm, black bile and yellow bile. These four components were connected to the seasons of the year; blood with spring, phlegm with water black bile with autumn and yellow bile with summer. It was believed that imbalances in the four humors was predictive of disease: an imbalance in the body. Therefore if a person had fever, the prescription for treatment would be bleeding because fever meant too much blood in the body. The four humors became the basic diagnostic tool and doctors observed the patient for clinical symptoms which were recorded. It is Hippocrates who rejected the notion that diseases were caused or cured by gods, hence disengaging spirituality with pathological conditions. Moreover, he designed treatments aimed at restoring the balance of these four humors hence allowing patients to recover.

It became the primary responsibility of Claudius Galen, a Greek physician to push forward the Hippocratic theory. Galen is credited with the revival of methods that were favored by Hippocrates. He laid great emphasis on critical observation by engaging in thorough observation of a patient, noting down the symptoms before offering a prescription. He also accepted the Hippocratic view that the body had the ability to restore the imbalance caused by diseases. If a patient had fever, Galen prescribed something cold, if a man had cold, he treated him with heat hence espousing use of opposite in his clinical prescription. Those who felt weak for whatever form of infection of disease were given exercises to strengthen them and help them develop muscle. Patients with a weak chest were made to undertake singing exercises.

In anatomy Gales, improved surgical knowledge by dissecting apes and pigs and critically studying the structure of the bones and musculature. It is this deep quest of knowledge that led him to advice his patients to practice dissection by using apes and utilize every opportunity in studying the human anatomy. His interest in the physiology of the Nervous system made him experiment using spinal cords of pigs. The middle ages therefore provided the launch pad for the surgical and medical advancements.

Through conquests and civilization the highly advanced medical achievements transcended borders to the Roman Empire the Byzantine Empire, the Islamic empire and eventually to the European Empires. Greek surgical and medical interventions necessitated the paradigm shift from medicine being regarded as a spiritual component to medicine and medical practice being a rational practice.

Military Medicine in the Eighteenth Century

At the dawn of the century, the patterns that defined military medical care in the seventeenth century dominated military medical practice of the 18^th century. As progress in military prowess ensued towards mid century a drift towards the development of institutionalized systems of military medicine began to emerge. The provision of paid medical care to all military personnel became a prioritized function of the state. Basic needs such as food, shelter and clothing were also provided by the state so as to maintain the troops in good health.

The eighteenth century saw the establishment of foundations of scientific medicine. It is these foundations that made military medical progress possible. Moreover, despite adapting key practices espoused by the Hippocratic Humoural theory, they developed the contagionist theory to explain disease transmission because it offered an accurate model of disease classification. Schools that were steeped in Galelic and Hippocratic doctrines began adopting a more advanced rational system of medicine. However, emphasis was still laid on observation dissection and the compilation of accurate medical records and clinical experimentation. Dissemination of relevant medical knowledge and preventive medicine received greater emphasis than in the seventeenth centuries.

Following political organizational changes that developed the administration of military medicine as a definite component and function of the government, military medicine was drawn into the ensuing medical revolution. Consequently, regular medical examination of military personnel, a standard nutritional daily ration, regulation of hospitals in the army, regular and better pay for physicians and developments of military medicine periodicals became the standard models in military medicine.

The eighteenth century medical practices has been referred to as the adolescence of modern medicine it marked a transitional period in history where external pressures of change drove the internal changes in the body of medical practice and knowledge. The thirst for substantive and relevant knowledge called for discoveries that redesigned or completely muffled Aristotelianism hence the revival of the Democriterian atomism. It is at this point that war became a predominant driving force for military medicine. Bombarded with startling suddenness, magnitude and variety of injuries and wounds sustained in the battle front coupled with the potential of loss of manpower and extreme suffering. Military medicine was forced to seek solutions to the sudden lost of military strength of the British Armies.

Initially, voluntary enlistments were encouraged for limited periods but the large number of marginally healthy adults introduced unhealthy and poor sanitary habits into the military service hence the advent of physical examinations in the recruitment process. In 1790, the British Army instituted mandatory medical examination. Additionally at the beginning of the eighteenth century entry qualifications to the practice of military medicine was highly recovered. However, towards the end of the century, entry levels were considerably lowered. During war, the entry level was even poorer with apprentices who had only completed a few months in apprenticeship being lowered into the army. Invariably specialized knowledge was acquired on the job.

Even though the medical history of key military campaigns were often neglected by historians in the compilation of military accounts, the developments in novel methods in warfare emphasized on battle and pressing operations regardless of climatic season. These developments necessitated drastic improvements in the institution and practice of military medicine.

In 1872 when war broke out very little technological or practical advancement had been made with reference to the seventeenth century.¹⁰ Medical practice in the armies remained largely compartmentalized with varying and sharp destructions and conflict between physicians’ apothecaries and surgeons reflected the medical practice in civilian life.

During peacetime, military hospitals were either maintained permanently in the garrisons or on the campaign fields. From historical records at least a single surgeon was attached to each army segment. The seventeenth century model where hospitals were set several miles to the rear was maintained and the primitive handling of wounded soldiers who had either dragged themselves to the hospital base or assisted by comrades was also maintained. For those who severely wounded to the extent that they could not find their way to the hospital base, they had to wait until action ceased. It is at this time that they were collected during which time peritonitis, sepsis and dehydration increased their chances of dying. At the military hospitals, surgeons worked under unclean conditions, severe pressure and with primitive surgical instruments decreased the chances of correct timing or dexterity of surgical operations. The extent of suffering and death toll was extremely high. Operative medical interventions were limited to amputation of limbs that had been shattered by bullets or cannon fire.

Throughout the history of naval and military conflict, debilitating and incapacitating disease; particularly diarrhea disease was a predominant contributing factor on naval and military campaigns. In Europe, during the Napoleonic wars that spanned between the year 1803 to 1815 it is estimated that eight times more people died of these diseases than the number of deaths caused by injuries sustained in battle. Earlier reports of crusades especially in the 11^th and the 13^th centuries, dysentery, fever and typhus were the great diseases that afflicted armies. Consequently in the 16^th century, diarrhea outbreaks were blamed on sudden diet changes. The 17^th century saw the bloody flux during the summer months blamed on food contamination by flies. Contrarily, the winter bloody flux was thought to be caused by cold, wetness exposure, lack of suitable food and even clothing.

Between war of Australian succession periods; 1741-1748 this was notable agreement among military physicians that the number of flies and insects, the causative agents of dysenteries were determined by seasons.

Towards the end of the 17^th century, the British appreciated that military success was largely dependent on disease prevention, well being and overall health care of the seamen or soldiers. It is because of this realization that Frederick William, the Great Elector of Brandenburg (1620-1688) carried out an improvement of the sanitary organization of his military force by increasing the pay and also the status of medical personnel. In 1758 Gerald Van Swieten, wrote a treatise detailing the nature of diseases met in the military camps. It is this book that greatly influenced military disease prevention policies.

Funding of British Military Medicine

During the 18^th Century a revolution occurred laying the foundations of modern day medicine and institutionalizing military medicine as an independent branch of medical knowledge and practice. This revolution could not be ignored by the political administration and hence the shift towards making military medicine an integral and definite composite function of the government. Consequently the government assumed the responsibility of ensuring that military personnel had access to regular medical examinations, that the military were adequately clothed in government barracks. Daily standard rations of food were provided to ensure that troops were of sound health. It is at this time that the government began building and regulating military hospitals as well as offering regular salaries to the physicians.

Because of a fresh thirst for knowledge(during and after the Renaissance), new medical literature was developed and military periodicals became regular reference and authoritative medical materials. Through the development and obsession with rational systems and routine medical practices as opposed to speculative thought, military medicine was endowed with the potential that would enable it control medical practice throughout the 18^th Century and even the early 19^th Century. Consequently then growth of nations made it mandatory for the government to fund military medicine because it was directly related to the armies’ health and hence the fighting strength. On the contrary, civilian medical practice was primarily funded through private sponsorships. In the Britain in the eighteenth century these hospitals were referred to as voluntary hospitals since they were fully dependent on voluntary contributions.

The Developments in Preventive Medicine

Attempts at instituting and adapting considerably successful disease prevention mechanisms can be comfortably traced to Sir. John Pringle (1707-1782) who is widely regarded as the father of modern military medicine in Britain (Ellis, Harold, 2007 p.6830). Sir John Pringle was a Scot and pupil of Boerhaave. Boerhaave had earlier on adopted a Hippocratic approach in his medicine and chemistry. He lay focus on critical and detailed observations as well as a patients well being. Pringle would undoubtedly follow into his footsteps( Coley). He became intimately acquainted with the British arm and rose to occupy military positions of great influence. At the outbreak of the Australian succession war, he was appointed by the Commander in Chief (The Earl of Stair) to be the physician in charge of the military hospital in Flanders. Also referred to as the father of military hygiene, he is the one credited for revolutionizing the prevention of the highly prevalent diseases at that time dysentery was characterized by frequent stools of blood stained mucus accompanied by tenesmus. The causative agent was believed to be foul air and Pringle’s treatment consisted of bleeding, purging and emetics. The use of bleeding as a curative method is a direct adherence to the Hippocratic theory of the four humors. These treatment methods were aimed at stopping the indiscriminate fouling of the surrounding grounds by troops while at the same time encouraging the practice of covering latrines with earth on a daily basis and ensuring that troops were moved from these fouled grounds should outbreak occur.

Through systematic observation and research, Sir Pringle applied his considerable medical practical experience under primitive warfare conditions, teaching good sanitation methods and ensuring that troops health was observed (Ellis, 2007, 683). In 1952 he put down his rules of hygiene, including recommendations for adequate latrines, good drainage systems and avoidance of marshes.¹¹ These were published in a monumental; Observations on the Diseases of the Army, in Camp and in Garrison. The book also recommended that to present typhus, the sick must be dispersed and adequate ventilation given. Additionally, warm clothing, good shoes and a blanket should be essential provisions for soldiers during the cold weather seasons. All these were reinforced with strict adherence to cleanliness.

In 1753, he communicated a memoir to the Royal society on typhus (jail fever). He demonstrated that jail fever was no different from hospital fever. This observation came long before the bacterial causative nature of hospital fever was discovered. Even though there was little or no curative medicine for sick soldiers, Pringle prescribed bleeding and sweating for inflammatory diseases. Dysentery was treated with emetics, inclusive of antimony and ipecacuanha. Fevers were managed by the Peruvian bark. Leeches were applied to swollen joints and interestingly during the convalescence of the patient, spirits were issued freely, a regulation whose intention was to bring the army in line with the navy.

For his tireless campaign on preventive medicine, he was awarded many honors and after being a fellow and council member for many years in 1772 he became the president of the Royal society and even better a physician to George III in 1774.

Across the Atlantic, another physician Benjamin Rush published the “Directions for Preserving the Health of Soldiers” in 1773. The changes done to the design of vessels of the Royal Navy, produced overcrowding in the vessels. Additionally poor ventilation exacerbated by this overcrowding led to a consequent increase in diseases such as ‘fever, fluxes and scurvy. Increase in morbidity of the soldiers at sea led to the writing of the first book aimed at the prevention of sea diseases. John Woodwall who had earlier on been appointed as a surgeon General to the East India Company published the Surgeons Mate in 1617. Having made numerous voyages he used his observations to compile the surgical and medical book. Medical aspects of sea diseases was studied by William Cockburn. In 1696 he wrote his book the Nature and Disempers of Seafaring. James Lind, a Scot like Pringle detailed his observations of naval hygiene in a book he titled as ‘An Essay on the most Effectual means of preserving the Health of Seamen’ (1757). This was followed by the ‘Essay on Diseases incidental to Europeans in Hot Climates’ (1768). In 1785, Sir Gilbert Blane authored ‘Observations on the Diseases Incident to Seamen’. Whether this medical and surgical knowledge influenced disease prevention strategies on captain Cook voyages is still a controversial question.

Lind and Blane led notable reforms that spearheaded the improvements covering both the ventilation and hygiene of the soldiers’ living quarters. Dean clothing and reduction in overcrowding ensured the passage of typhus into ships was prevented and that the soldiers also received a more rational diet.

At the beginning of the eighteenth century, entry qualifications to the practice of military medicine was highly revered. However, towards the end of the eighteenth century and especially during wars, entry into the military medical service was considerably lowered. During the war, entry level was ever poorer with apprentices who had only completed a few months of apprenticeship being allowed into the army. Invariably specialized knowledge was acquired on the job.

Smith et al notes that the practice of military dermatology in the British Army was first brought to the fore by Pringle in his review of morbidity at the time of the Flanders campaign. Formalization of military statistics was done by Tulloch who led the initiation of an annual analysis of the morbidity rates in the British army during the nineteenth century. Military medicine had always been thought to be predominantly surgical treatment of wounds and injuries. Dermatological disease conditions were not factored into the general primary health care program among the military personnel in the earlier centuries despite considerable morbidity as a result of these diseases.

Pringle and Buchanan are credited for introducing the active practice of dermatology in military medicine. They noted that infestation among troops was universal and that treatment of inpatients with topical sulphur only served to worsen the pathological condition hence increasing morbidity.

Advancements in Empirical Medicine in the Eighteenth Century

The growth of empirical medicine can be traced from the British Navy. When Sir Gilbert Blane; a reputable physician, was appointed to the British fleet by Admiral Rodney in 1981 the development and treatment of scurvy (a common disease among seafarers) was enhanced. Through meticulous observation, Sir Gilbert Blane prepared and sent a memorandum concerning the rate of casualty in the fleet. The memorandum he sent to Admiral Rodney stipulated that in the previous year 1600 men died yet only a paltry 60 men had died from enemy invasion. While there were many debilitating diseases at that time, Sir Gilbert Blane attributed a majority of deaths to scurvy. He stated the following,

“…. Scurvy, one of the principal diseases with which seamen are afflicted, may be infallibly prevented or cured by vegetables and fruits particularly oranges, lemons or lime”.

According to the recommendations contained in the memorandum fresh fruits were presented to be the curative agent of scurvy. Sir Gilbert Blane returned to London accompanied by Admiral Rodney but he went back to the battlefield in West Indies to spend a further 2 years. Despite his unequivocal recommendations that fresh fruits were effective against scurvy, the Board of the Sick and Hurt Seamen refused to adopt his recommendations and the uncontrolled trials of remedies continued sometimes with success sometimes with little success. Bread, beer, molasses were all tried as a possible curative agent for scurvy. Later on sir Gilbert Blane returned to civilian life and authored the book ‘Observations on the Diseases of Seamen’ in which he presented convincing wealth of evidence that anti scorbutic activity of fruits and other foods in scurvy prevention and treatment.

Fortunately Sir Gilbert’s championing for adoption of fruits for the cure and prevention of scurvy received a major boost when he was appointed as a physician to the Household of the Prince of Wales. With this appointment came the social status and friendship attachments which enabled him to effectively express his news on scurv.

However Sir Blane’s assertion about scurvy preceded the 1753 book ‘A Treatise of the Scurvy’ authored by James Lind. At the core of the book Lind records a number of his clinical trials and observations about the potential curative agents for scurvy. According to Lind, oranges and lemons were conclusive curative agents for scurvy. The results of his findings were presented to the Admiralty but these findings were not implemented in the military until sometime after forty years. In 1795, lemon juice was issued to sailors. In the Salisbury experiments, Lind delved deeper into the symptomatic nature creating an impressive phenomenon and fascination among physicians.

In 1795, Lind died leaving his works that were important but which received little recognition mainly to his low influential and social status. Blane recognized the importance of his work together with other works that had been published before and presented these works to important influential committees thereby saving so many lives. Scurvy was more dangerous and caused more deaths than even storms, shipwreck, other diseases or combat all combined. Ever since the ancient times, scurvy had puzzled both the philosophers and physicians. The foundation of medical knowledge the Hippocratic theory failed to offer conclusive solutions to the condition. New theories were sought, new remedies proposed. Dozens of factual presentations about the causes of scurvy were varied. Some argued that scurvy was caused by laziness, copper poisoning, excess of black bile, foul vapors, inherited predisposition, divine disfavor or blocked perspiration. Common cures were at worst bizarre. Cures included bleeding, purging with salted water, eating sulphuric acid, smearing mercury into sores or even eating vinegar. There were also some instances where the workload was increased for those soldiers afflicted soldiers in the belief that the disease was caused due to indolence. This presented situation where the commonly used curative interventions became as deadly as the disease condition. One interesting fact is that it is during this time that Lind offered lemons and oranges to scorbutic soldiers. The impracticality, the perishability and the cost of ensuring that soldiers had plenty of fruit led to the dismissal of Linds’ recommendations. Soldiers continued to die from the disease because the causative agents could not be conclusively identified. Moreover, supply of these fruits at ports was not guaranteed because of the prevalent hostility that accompanied the British soldiers around the world.

Towards the end of the eighteenth century, particularly the West Indies war in 1792-1815, the profound effect of pressure on medicine triggered another wave of advancement in pathological conditions including autopsies. The pathological characteristics of diseases and conditions received more advanced terminologies. The terms abscesses, ulcers, inflammation, tumors and hemorrhage were added to medical terminologies. Additionally a novel concept of disease came into the offing as army physicians abandoned the speculative and metaphysical theories that had dominated medical practice to localized surgical pathology approach to medicine.

Conclusion

War and medicine are enduring aspects of human existence. Ever since time immemorial, military medicine has been practiced as a necessary act of alleviating suffering of soldiers through treatment and management of injuries sustained in the battlefield. From the ancient times to the eighteenth century and into the post modern 21^st Century, war has not only acted as a stimulus for medical advancement but as a pedestal for the institutionalization of military medicine as a unique and independent branch of medical practice that supports the existence of the military force. Military medicine not only aids the physical component of military workforce but also the psychological and social facets that must be met for the political objectives of maintaining a sturdy and reliable military workforce.

The progressive developments in empirical and preventive medicine benchmarked by the ancient Hippocratic, speculative and metaphysical theories and later day Democriterian atomism and technologically advanced diagnosis and treatment were driven to a certain extents by wars and conquests. Therefore at the heart of medical revolutions, military has often been credited for stimulating medical advancement. It is during the eighteenth century that the foundations of modern day scientific medicine. At the same time theories that had existed for centuries without question were tried and tested against new developments from the renaissance period. The contagionist theory was espoused to offer a more advanced and reliable understanding on the transmission of diseases. However it is at the same period in history that the admiralties refused and rejected unequivocal medical interventions that would have saved seriously reduced mortality at sea. Changing theoretical knowledge transformed medical practice from days of religious rituals and magical incarnations. The renaissance promoted medical practices such as bleeding, purging and trepanning. After the renaissance medical knowledge and practice evolved to antibiotics , preventive medicine and advanced diagnostic techniques in the post modern world. Preventive medicine and empirical medicine have now evolved and assumed a central component of military medicine in addition to acting as a pedestal for future medical advancements.

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