Between Flesh and Steel (40 page)

The condition of the Russian field hospitals was dreadful. Soap, mattresses, and bedpans were in critically short supply, and infection and dysentery were universal problems. A description of conditions in a Russian field hospital in Port Arthur noted that patients “lie side by side on the floor, on the bedboards, underneath them, just as they were placed when they came in. . . . Faces are shapeless, swollen and distorted, and upon the yellow skin are large blue bruises. Inside, in spite of the musty and sickening stench, the cold is intense. On all sides is filth, nothing but filth, and
on it and among it crawl millions of greasy gray lice.”
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The traditional Russian fervor for religion, however, led the army to assign priests as medical assistants to every regiment. These priests were required to make regular visits to the sick and wounded in the hospitals. Although they were short of medical supplies, the physician who did not have an adequate supply of religious icons to give to the wounded and bolster their faith was subject to discipline by military authorities.
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The chronic shortages of boots, greatcoats, blankets, and food exacerbated the terrible conditions under which the Russian soldier had to fight. Nutrition was poor, and while scurvy was only a minor problem among the Japanese, it was endemic among the Russians. The problem of scurvy worsened when the corrupt medical corps officers took the best food for themselves and their families. When the siege of Port Arthur ended, Japanese medical officers found that 32,400 members of the Russian garrison were suffering from scurvy.
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Because of the chronic shortage of salt and poor field discipline, Russian forces also suffered a high number of sunstroke and heatstroke casualties. Only the black Chinese variety of salt was available, and the Russians couldn't stomach it. Sugar, fresh fruits, and canned meats were unobtainable. The only item in great supply seems to have been vodka, which the troops and officers consumed in large quantities. The medical officers seem to have made no effort to ensure a supply of potable water for the garrison, and no water-testing apparatus was available. Japanese officers found that almost every well was infected with typhoid. The Russian Army did not have official hygiene regulations, formal field hygiene instructions for the men and officers, or sanitary officers or detachments posted with the troops. The Russian Army was a medical disaster waiting to happen, as it had been a half century earlier in the Crimean War.

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

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

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

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

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

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

Of the 265 officers admitted to the Harbin hospital for psychiatric reasons, only 54 recovered sufficiently to be sent back to the fighting. The rest were moved to Moscow. Of the 1,072 enlisted soldiers treated at Harbin, only 51 recovered and returned to duty, while 983 were evacuated. Russian psychiatrists made significant advances in clinically linking battle stress with a number of somatic symptoms, and they developed diagnostic categories that were quite modern. During the Russo-Japanese War, the Russians established most of the psychiatric diagnostic categories that the Western armies later used during World War I. Russian psychiatrists recorded cases of hysterical excitement, confused states, fugue, hysterical blindness, surdomutism, local paralysis, and neurasthenia. Since Russian psychiatry had its roots in German biological nosological psychiatry, Russian doctors tended to define these symptoms in physiological terms and attribute their causes to damage in the brain. In 1905, 55.6 percent of Russian battle stress casualties were diagnosed as stemming from traumatic damage to the brain, an approach that gave rise to a similar diagnostic methodology in the West with the “shell shock” issue of World War I.
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By World War I, the Russian Army was the most experienced army in the world in dealing with clinical problems of battle stress. It was the first to specify categories of psychiatric problems in a military environment, the first to institutionalize forward treatment, the first to develop a theory of what caused battle shock, and the first to handle the problems of evacuation syndrome and secondary gain. The West mostly ignored these lessons until World War I when the Western armies, confronted with
their own huge manpower losses for psychiatric reasons, finally attempted to develop methodologies for managing the problem. While the Germans quickly adapted to the new reality, the French, English, and American armies managed barely to put a psychiatric casualty servicing structure in place by the end of the war.
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From the perspective of the development of military medicine, the Russo-Japanese War was one of the most important wars in history. Both Japan and Russia developed and introduced major medical innovations to treat battle casualties and disease that set new standards for the armies of the world. Improving greatly upon the American and German models, the Japanese were the first to introduce a thoroughly modern military medical system that integrated all the major elements of casualty care and disease prevention into a complete command structure. The Japanese Army was the first to require a medical plan as part of the combat operations order, the first to place the chief of medical services in the general staff structure, the first to provide full rank and status to medical corps officers in combat theaters of operations, and the first to create an effective, independent medical supply service with its own transport. These organizational changes constituted major modifications to the medical corps and revolutionized its capability to attend to its mission.

Building on the German Army's initial efforts in 1870, the Japanese Army became the first modern army to thoroughly integrate modern science into the care and treatment of casualties. Its emphasis on disease and infection prevention by applying the lessons of bacteriology, vaccination, and antiseptic surgery resulted in an army losing fewer casualties to disease and infection than to enemy weaponry for the first time in two hundred years. The army's hygienic practices and field discipline far surpassed anything that modern history had ever seen, and it resulted in a level of manpower conservation that remained unsurpassed until the Vietnam War.

Given the generally backward state of Russian medicine and the almost pre-modern condition of the Russian military administrative structure, that the Russians made such major advances in the treatment of psychiatric casualties is surprising. It is no exaggeration to say that the Russian Army established the modern foundations of military psychiatry both organizationally and clinically. The conceptual foundations of modern military psychiatry remain unchanged in their essentials since the Russian Army introduced them in 1905. The principles of proximity, immediacy, and expectancy, known in the modern discipline by the acronym PIE, still undergird all methods of battlefield treatment of psychiatric casualties. While the discipline has since expanded the range of diagnostic categories, the original categories of mental
disorder found on the battlefield remain as sound today as they were when the Russians first identified them more than a century ago.

When taken together, then, the Russo-Japanese War was a period of major innovation in military medicine. It was a time when modern military somatic and psychiatric medicine made its debut.

The First World War was the most destructive conflict in history up to that time: the combatants mobilized 60 million men, killed 7 million of them, and wounded more than 19 million. Half a million soldiers underwent amputations. The introduction of smokeless powder propelled rifle and artillery projectiles at higher velocities and greater distances than ever before. Shrapnel and exploding artillery shot caused 70 percent of battle wounds and produced mutilations on an unprecedented scale.
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Military medicine witnessed a number of important medical advances in treating the wounded. For the first time diagnostic bacteriology conducted in mobile laboratories was available in frontline hospitals. Improvements to X-ray machines, making them lighter, allowed their use in forward surgical stations. Intravenous saline infusions in resuscitation became common, as did clinical thermometers, hemostatic forceps, hypodermic syringes, and better retractors and surgical lighting. The first field blood transfusion teams were introduced, and the casualty clearing station grew into the evacuation hospital and became a standard feature of the casualty evacuation system.

At the start of the war, the doctrine of conservative treatment and healing by secondary intention was widely used with disastrous results. The continued practice of limited debridement and secondary closure of severe shrapnel wounds that were contaminated by the richly manured soil of the battlefield led to high rates of amputation and infection, the latter almost always in the form of deadly gas gangrene. Wound mortality approached 28 percent in 1915, and the amputation rate ran as high as 40 percent for wounds of the extremities involving injuries to the bone.
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First attempts to control infection involved using various antiseptics directly on the wound. Experience taught that this procedure was ineffective and often harmed healthy tissue. Military surgeons gradually relearned old lessons and used debridement on all major wounds. In addition, they continually irrigated wounds with Eusol (Edinburgh University Solution of Lime) and, eventually, Carrel-Dakin solution—a diluted antiseptic of sodium hypochlorite and boric acid—to aid draining. Mobile
bacteriology laboratories attached to the various hospitals took daily bacterial smears to determine the bacteria count before doctors closed wounds and saved many lives.