medicine

medicine. A striking feature of warfare up to 1939 is that, with the exception of the Russo-Japanese war of 1904–5, in which battle casualties were extremely heavy, more service personnel were lost to disease and accidental injury than to hostile fire. In this, the Second World War was little different from previous conflicts, with over two-thirds of admissions to hospital, in both Allied and Axis forces, resulting from sickness and injury not sustained in military action. Among British troops in North Africa, for instance, the average number of admissions from sickness was 564 per thousand and the number of battle casualties only 60 per thousand. In north-west Europe the sickness/casualty ratio among British troops was less marked, with an average of 151 admissions per thousand due to disease against 37 per thousand from hostile fire. The incidence of disease among British troops was highest in the South-East Asia Command, with an admission rate of 1,118 per thousand from disease (mainly malaria) and 45 per thousand from wounds. But in all theatres the incidence of most diseases and battle casualties was lower than it had been in the First World War, and for the first time in the history of warfare more service personnel died as a result of wounds sustained in battle than from sickness and disease.

Health, hygiene, and preventive medicine

Table 1 shows dramatic reductions in the incidence of many infectious diseases among British troops in the Second World War as compared with previous conflicts. Note in particular the much lower incidence of diseases such as enteric fever and dysentery. The introduction of preventive inoculation and, since the South African Wars (1899–1902), greater recognition of the importance of sanitary discipline meant that military commanders were by 1939 equipped with the means to keep such diseases under control.

Medicine, Table 1: Major infectious diseases in the British Army during wartime, mean monthly incidence per 1,000 strength

	1898–1901	1914–18	1944–5
Source: Crew, F. A. E., The Army Medical Services. Campaigns, Vol. IV, North Western Europe (London, 1962), p. 561.
Venereal disease	2.92	2.48	2.50
Jaundice	0.94	0.08	0.44
Diphtheria	0.01	0.11	0.69
Enteric fever	8.70	1.53	0.01
Dysentery	5.75	0.47	0.22
Pneumonia	0.38	0.42	0.17
Influenza	1.34	0.89	0.27
Scabies	–	–	3.46

Yet the lessons of the past were not always heeded by the major combatants, and the incidence of disease varied greatly in different armed forces and from one theatre to another. For example, the incidence of diphtheria among Allied troops increased greatly in 1944–5 as they came into contact with reservoirs of infection in the formerly German-occupied territories.

It is also necessary to consider separately the medical fate of servicemen captured by opposing forces. The fortunes of prisoners-of-war (POW) in Europe were mixed. Axis troops in Allied POW camps and English-speaking prisoners in German camps generally received some medical attention and an adequate diet, usually supplemented by parcels from voluntary organizations (see International Red Cross Committee). But prisoners of other nationalities, and especially Soviet troops, were often denied both by their German captors. It was among these prisoners that tuberculosis, which thrived in the damp and overcrowded conditions inside POW and forced labour camps, took its highest toll. Though conditions in German POW camps were often far from ideal from a medical point of view, levels of disease rarely reached those of camps run by the Japanese. In the Far East, undernourishment and malnourishment were common, and the incidence of deficiency diseases such as beri-beri reached staggering proportions. Cholera, dysentery, and malaria also claimed many victims among Allied prisoners in Japanese camps. More than 10,000 of the 12,600 deaths among British POW in the Second World War occurred in the Far East.

Much harder to gauge with accuracy is the medical impact of the Second World War on civilians, since medical records for many countries under Axis occupation are incomplete or unreliable. In the UK, where accurate records of the health of the civilian population were kept throughout the war, sickness and death rates (excluding air-raid casualties) did not exceed peacetime averages to any great extent. Food rationing maintained and, in some cases improved, standards of nutrition, while the Emergency Medical Service directed medical personnel and resources on a national basis according to need. In other European countries, where invasion and German occupation severely disrupted public health and medical services, the civilian population did not fare so well. Neglect of sanitation on the part of the German authorities left much of Europe prey to typhus, diphtheria, and other camp followers of war. It is estimated that cases of epidemic disease, except smallpox and influenza, in continental Europe doubled, and in some cases trebled, during the Second World War (see Table 2 as an example). Typhus, especially, was rampant in eastern Europe and on the Eastern Front, claiming some two million victims.

Medicine, Table 2: Infectious diseases notified in France

	Median 1928–38	1939	1940	1941	1942	1943
Source: League of Nations, Bulletin of the Health Organisation, 10, 4 ( 1943/44), p. 608.
Typhoid fevers	5,868	4,373	4,304	7,934	10,612	13,761
Dysentery	73	67	651	250	80	23
Diphtheria	19,893	14,019	13,568	20,018	31,466	46,539
Scarlet fever	18,431	14,640	10,951	11,201	11,980	17,085
Cer.-sp. meningitis	461	328	2,321	1,143	585	406
Poliomyelitis	487	460	342	484	322	1,783
Typhus fever	0	–	3	3	230	4
Smallpox	6	5	5	8	63	5
notified cases	45,219	33,892	32,145	41,041	55,338	79,606
Percentage change
from 1928–38		−25	−28.9	−9.2	+22.4	+76.0

In many urban areas of occupied Western Europe food shortages led to an increase in deficiency diseases and a general lowering of body weights among children. In Poland, Yugoslavia, Greece, and the USSR, ruthless requisitioning of foodstuffs pushed the populations of those countries towards starvation. German occupation also saw the extension of the secret euthanasia programme begun in Germany in 1939 against the incurably ill and the ‘mentally deficient’.

Though often denied the civilian populations of occupied Europe, hygiene and preventive medicine usually occupied an important place in the minds of both Allied and Axis commanders. However, there were some important and surprising exceptions; not least the virtual absence of sanitary precautions in the German lines in the Western Desert campaigns. According to British observers, the German defences at the second battle of El Alamein were obvious from the amount of human faeces lying on the ground. This lack of sanitary discipline among the otherwise exemplary Afrika Korps cost it dearly in terms of sickness and its ability to combat the Allied offensive. Dysentery, hepatitis, malaria, and skin diseases were widespread among German troops in the Western Desert, and a German soldier was 2.6 times as likely to be incapacitated by disease as his British opponent. In the two months before the second battle of El Alamein, more than one in five Germans had been stricken by disease, and even élite units such as the 15th Panzer Division were well below strength. It seems likely that the greater awareness of hygiene in hot climates displayed by British combatant officers, as well as those in the medical corps, may be attributed to the British Army's long experience of conditions in Africa and India.

The medical lessons of colonialism also paid dividends for the Allies in the Far East, but in the early stages of the war tropical hygiene was difficult to maintain as the number of service personnel in South-East Asia and the Pacific underwent a vast and rapid expansion. American and Filipino troops defending Bataan were never issued with mosquito nets and the supply of anti-malaria drugs was insufficient to permit a prophylactic dosage. The consequences were catastrophic. In March 1942 the number of admissions to hospital from malaria rose from 500 to 1000 daily, leaving 75–80% of men in the front line infected with the disease. Medical officers of the British and Indian armies told a similar story. In Burma, annual sickness rates were as high as 1,850 per 1,000 men, malaria being responsible for at least 50% of cases.

Anti-malaria measures traditionally took the form of individual precautions such as mosquito repellants and the prophylactic use of drugs like quinine and mepacrine (atebrin), or more general measures such as drainage of mosquito breeding pools and the spraying of adult insects with insecticides. The high casualty rate suffered by the Allies in the first two years of war spurred research in all these directions. A systematic examination of the value of various anti-malarial drugs was undertaken at the Australian Army Medical Research Unit at Cairns, Queensland, and led to the development of a more effective drug (Paluride) though this did not come into general use until after the war.

The real value of the work at Cairns was that it highlighted the importance of anti-malaria discipline: of ensuring that anti-malaria drugs were taken on a regular basis. From 1943, as these findings came to light, anti-malaria discipline was tightened considerably in Allied units. General Slim, commanding the British Fourteenth Army in Burma, threatened to sack any regimental officer under his command who failed to see that his troops took their daily dose of mepacrine. Educational campaigns were also conducted to overcome widespread fears that taking anti-malarial drugs led to sexual impotence and other unpleasant side-effects.

Stringent regulations soon made an impression on sickness rates, falling among British and Indian troops in Burma from 1,400 per 1,000 per annum in 1943, to 500 per 1,000 in 1945. But the importance of anti-malaria discipline was apparently not impressed upon officers of the Japanese forces. From March 1945 all Japanese troops captured by the British in Burma were questioned about the incidence of malaria in their ranks and about supplies of quinine. Interrogation revealed the relative neglect of precautions in Japanese lines and an incidence of malarial infection of 30–50%, equivalent to rates of infection among British and Indian troops two or three years earlier. The official historian of British Army medicine in the Burma campaign concluded that neglect of anti-malaria precautions by the Japanese was ‘one of the most important reasons’ for the Allied victory there ( F. A. E. Crew, The Army Medical Services: Campaigns, Vol. 5: Burma, London, 1966, p. 647).

In fact Japanese medical services seem not to have escaped the general Japanese disinterest in logistics, of which, in common with all armed services, they formed a part. According to Meirion and Suzy Harries (Soldiers of the Sun, London, 1991, p. 317), who quote a British expert as saying that Japanese professional knowledge of tropical diseases ‘was not of a very high grade’, the Japanese did not recognize scrub typhus for a long time. They called it Wewak fever and Hansa fever (see New Guinea campaign) and confused it with malaria. Nor did the Japanese medical services offer ‘prophylactic injections against tetanus, which left troops highly vulnerable to wounds received in the agricultural land that saw much fighting in Burma and the Philippines.’

Though the control of malaria in the Allied forces may be attributed largely to the vigilance of ordinary combatant officers, important developments also took place in the direction of mosquito eradication. In the three years before the war, the destruction of adult mosquitoes by insecticide had become recognized as one of the most effective anti-malaria measures. Pyrethrum was the active ingredient of most of these insecticides, but since it was extracted from flowers which grew mainly in Italy and Japan, it was necessary for the Allies to try to develop an alternative. The most important of the substances investigated by scientists in the UK and the USA was dichlorodiphenyl-trichlorothane, or DDT, first synthesized by a German chemist in 1874, though it was not until 1939 that its insecticidal properties were discovered. Subsequently, tests were carried out at the London School of Hygiene and Tropical Medicine, and at the Chemical Defence Research Experimental Station at Porton, to determine the extent of its application and its toxicity. The first full-scale use of DDT in a military context was in early 1944 against the body louse during the Naples typhus epidemic where it was credited with bringing the epidemic under control. From then on, DDT was used extensively for de-lousing by both Allied and Axis forces, though it often proved difficult to enforce in armies in retreat and disarray. Later the same year, field trials employing DDT against mosquitoes were carried out in India, and their success led to its extensive use by Commonwealth and US forces in the final stages of the war in the Far East. It was also employed in mosquito eradication by German forces, particularly in the malarious areas of the southern USSR.

The prevention of venereal disease (VD) was equally high on the list of most medical officers and military commanders: in previous conflicts it had been one of the single largest causes of incapacity among troops. By 1939 it was recognized that the success of VD prevention lay in the co-ordination of educational and other efforts between civilian and military agencies. However, the American experience of VD during the Second World War shows that the relationship between the civil and military sectors was often an uneasy one, despite their common aim.

In May 1940 the US Army and the US Public Health Service began an educational campaign to discourage promiscuity among troops by explaining to them the attendant risks of venereal infection. The other key aspect of their strategy was to discourage prostitution by placing red-light districts out of bounds to troops and in some cases closing down those brothels which had been traditionally tolerated by the military authorities. State and Federal laws were enforced and segregated areas of prostitution eliminated, but in many cases line officers refused to co-operate with central directives, and continued to allow their troops to attend nearby brothels. Their behaviour caused an outcry among civil public health agencies and religious groups, which urged the government to exert more control over the military. Although the issue became less prominent after 1942, some military authorities continued to tolerate prostitution under certain conditions.

Overseas, the US Army did even less to discourage prostitution, in fact—as in other Allied forces—prostitution usually received official sanction provided that women and brothels were registered and that prostitutes reported twice weekly for medical inspection. In most of the newly-liberated areas such as French North Africa and Italy, widespread poverty ensured that there was no shortage of women from all classes who were willing to earn their living as prostitutes. According to one observer in North Africa, ‘Every community of greater than hamlet size had several registered prostitutes, and the larger cities had hundreds’ ( T. H. Sternberg et al, ‘Venereal diseases’, in L. D. Heaton (ed.), United States Army Medical Department: Preventive Medicine in World War Two, Vol. 5: Communicable Diseases, Washington, DC, 1960, p. 206). Where registered prostitution was accepted, military authorities placed most emphasis on prophylaxis—often compulsory—which generally involved the application of antiseptic creams. Prophylaxis was seen by church groups and others in the USA as an implicit endorsement of promiscuity and prostitution, but military authorities had to balance health and morality against the morale of their troops. Few Allied commanders—with the notable exception of Montgomery, a bishop's son—were prepared to risk discontent and disciplinary problems among their troops for the sake of appeasing the religious lobby at home. The Japanese were more organized, and more ruthless, about controlling VD while maintaining the morale of their troops (see comfort women).

Despite medical safeguards, the incidence of venereal disease rose alarmingly among Allied troops in certain theatres of the war. Troops in the Mediterranean and North African commands showed the highest rates of infection, with an average of 91 and 67 admissions to hospital per 1,000 US troops respectively in 1942–5, compared with 33 per 1,000 in the USA and 23 per 1,000 in the South-West Pacific. However, troops suffering from VD were likely to be returned to duty much faster than in previous wars, thanks to the development of more efficient treatment with sulphonamides and later with penicillin. Among RAF personnel, for example, the length of time before each venereal case was returned to duty fell from 31 days in 1939 to only 18 in 1945, compared with 61 days immediately after the First World War.

The medical sciences

It is ironic that the exigencies of warfare have often produced scientific and technical innovations of great benefit to humankind. There can be few better illustrations of this than the development of penicillin during the Second World War. Until the early 1940s bacterial infections resulting from injury and disease were generally treated with sulphonamide drugs, useful in the treatment of pneumonia, for instance, but largely ineffective when employed against streptococcal infections. The limitations of sulphonamides, and their often unpleasant side-effects, spurred research into the development of new drugs on the principle of antagonism between various species of microbe. In 1939, at the Sir William Dunn School of Pathology in Oxford, Professor Howard Florey began an investigation of the anti-bacterial properties of various substances, including Penicillium notatum, first observed by Alexander Fleming ten years before. In May 1940 encouraging results were obtained by Florey and his team in connection with penicillin and streptococcal infections and by 1941 enough evidence had been collected to warrant clinical trials. The tests confirmed that even the most severe bacterial infections could be controlled by penicillin and that it had no harmful side-effects.

However, penicillin could be produced in only minute proportions under laboratory conditions and just one case of severe sepsis might require the processing of up to 2,000 litres (440 gallons) of medium. It seemed that the only way to obtain sufficient quantities of the drug was to enlist the help of industry. But since industrial capacity in the UK was already stretched to its limit, enquiries were made via the Rockefeller Foundation to find a suitable manufacturer in the USA. By 1942 sufficient quantities had been produced by American firms to allow the use of penicillin in the field and in the following year the drug was being used extensively in the treatment of wound infections in North Africa.

The refinement of sulphonamide preparations and later of penicillin had a significant bearing on surgery during the Second World War. Due to the high mobility of armies in the North African desert, it was difficult to operate on wounded men until they had been evacuated to base. Chemotherapy and antibiotics, combined with drainage of the wound and its immobilization, kept the patient relatively comfortable and his wound free from infection until a hospital was reached. More complex surgical procedures such as closure of the wound and skin grafting could take place only when an army's advance was steady and when air superiority ensured constant supplies. For the Allies, these conditions did not occur until the end of the war.

As in former conflicts, surgical techniques themselves evolved to meet the changing demands of warfare. Among the more important developments in 1939–45 were the use of proximal colostomy in cases of injury to the large intestine and improvements in the treatment of burns, such as the saline bath associated with the British doctor A. H. McIndoe. McIndoe's technique, which was not entirely new, involved the immersion of severe limb burns in a bath of flowing saline solution, after which would be applied sulphonamide (later penicillin) powder or cream, and the burns covered with a bandage dressing which was floated off in a subsequent bath. Great strides were also made in anaesthesia—which had progressed relatively slowly in peacetime—with the introduction of ‘closed-circuit’ or ‘local’ anesthesia and of new anaesthetics, given intravenously and orally. Local anaesthesia revolutionized thoracic surgery in the combat zone and paved the way for the inception of cardiac surgery after the war.

Wartime medical research illustrates the trend, evident since the First World War, for scientists to become directly involved in the solution of military problems. The Second World War accelerated this process, with scientists anticipating as well as providing for the needs of the military. One area in which they made an important contribution in this regard was in the field of ‘Services Personnel Research’, which concerned the safety and efficiency of the armed forces. In the UK, working under the auspices of the Medical Research Council, scientists considered means of protecting service personnel against noise, blast, and the vagaries of climate, and nowhere was such research more important than in the field of aviation medicine. High-altitude flying was a miserable and often perilous experience. Bomber crews were regularly subjected to temperatures of 30–50°F below zero and flight surgeons estimated that half of all crewmen suffered from the effects of oxygen starvation. Oxygen masks tended to freeze above 6,100 m. (20,000 ft.) and lack of oxygen made men far more susceptible to the cold. Amputations due to frostbite were alarmingly common.

Research into these problems involved close collaboration between British and American scientists. The newly-opened RAF Physiological Laboratory at Cambridge, for example, conducted experiments regarding oxygen installations for high altitude bombers of the US Army Air Forces. This work led to the development of the ‘economiser-and-mask’ system, a constant-flow apparatus which wasted no oxygen during expiration. At the same time, American scientists developed electrically heated body suits and gloves for high-altitude flying, though their use was restricted and the suits themselves prone to failure. Some progress in aviation medicine were also made in the USSR, but, despite a number of exchange visits organized between Soviet scientists and their counterparts in the West, scientific interchange was limited and the flow of information largely travelled West to East. In Germany, the Forschungsführung der Luftwaffe and other aviation research institutions achieved results which matched those of Allied scientists, except in the development of high-altitude oxygen equipment.

Collaboration between Commonwealth and American scientists also proved successful in the investigation of the cause and spread of serum hepatitis which came to be distinguished from the ‘infective’ form of the disease. Research into jaundice was stimulated by several severe epidemics among Allied troops in Europe and during the early stages of the North African campaign. However, such investigations proved difficult because of the unusually long incubation period of the disease. Considering these obstacles, the successful conclusion of hepatitis research was considered at the time to be one of the outstanding medical achievements of the war. Scientists in the UK and USA came to the conclusion that hepatitis was caused by a virus transmitted by contact with contaminated syringes. However, a vaccine against serum hepatitis was not developed until 1969.

Two less well-known aspects of medical science during the Second World War are those related to atomic and chemical weapons research. The development of isotopic tracers during the war was a by-product of the preparation of radioactive and stable isotopes in connection with work on the atomic bomb. The outbreak of war in Europe also led to the intensification of research into the medical effects of chemical weapons. Though they were never employed in the Second World War, their use was both feared and contemplated by Allied and Axis governments. Researchers at the British Experimental Station at Portonassessed the offensive and defensive capabilities of a range of weapons including mustard gas, phosgene, and chlorine, as used in the First World War, and several new compounds were developed between 1939 and 1945. In order to gain an accurate impression of the effects of these weapons, researchers at Porton were authorized to use human guinea-pigs for some experiments. Volunteers drawn from the Porton research team and from the three armed forces were exposed to mustard gas and various other compounds designed to incapacitate troops.

By this time it was known that hot and sweaty skin was especially sensitive to the effects of vesicants such as mustard gas, and the entry into the war of Japan in December 1941 raised the alarming prospect of these weapons being used in tropical climates. Since it was difficult to simulate such conditions at Porton, two new experimental stations were established: one in Queensland, Australia, the other in southern India. Both made use of human volunteers, many of whom, as at Porton, suffered burns and other severe injuries as a result of their participation. It is a matter of continuing controversy whether or not some volunteers for these experiments were misled or inadequately informed of their probable effects.

We can speak with more certainty, however, about medical experiments carried out in the German concentration camps. In war crimes trials conducted after the war, it was a common defence among camp doctors to plead that any medical experiments were conducted with volunteers, yet the testimony of those subjected to these experiments, together with official documentation, shows that the overwhelming majority were carried out on inmates against their will, and in many cases with the willing compliance of camp doctors. These experiments frequently concerned matters of military efficiency such those carried out at Dachau simulating high altitude flying and those involving exposure to extreme cold. In the case of the former, inmates were forced into decompression chambers, where the pressure was steadily lowered until most died in agony. At other camps such as Ravensbrück and Buchenwald the emphasis was on the artificial inducement of, and experimental inoculation against, diseases such as typhus, which had claimed more than 10,000 German lives on the Eastern Front in the winter of 1941–2 (see German–Soviet war). Nazi doctors also found time to pursue research aimed at ‘proving’ Aryan racial superiority. At Auschwitz, the ambitious Josef Mengele embarked on a study to find evidence for the supposed ‘physical degeneracy’ of Jews, and there he conducted his infamous experiments on twins and the causes of dual births. Other doctors took advantage of ‘human guinea-pigs’ among the inmates to complete university doctorates in medicine and genetics.

Casualty evacuation and treatment

Advances in medical science during the war did much to contribute to the recovery rates of sick and wounded service personnel. British casualties in north-western Europe were 25 times more likely to make a full recovery than their predecessors in the First World War, but this improvement was due as much to the more efficient organization of casualty services as it was to advances in medical science. The Allies learned much from defeats inflicted in the early stages of the war. An internal inquiry by the Royal Army Medical Corps in 1941 found its field units insufficiently mobile and not readily adapted to tactical changes on the battlefield. German casualty services were also found wanting during the invasion of the USSR in June 1941 (see BARBAROSSA). The severe Russian winter exposed all existing inadequacies and hindered the evacuation of sick and wounded by air and land. In this first winter of the war against Germany, the Soviets themselves suffered severe shortages of medical personnel and medical supplies.

In other combat theatres air transport was being used to better and better effect and, as the war progressed, the field medical units of the major combatants also became more mobile and more effective. In the Commonwealth armies, the process of on began with regimental stretcher bearers, who conveyed battle casualties to Regimental Aid Posts (RAP). These RAPs were usually makeshift structures such as a ruined cottage or a lean- to of bracken and branches. Next in line was the Casualty Clearing Post (CCP), equipped with a light ambulance and two trucks, around which the camp was constructed. Behind this lay the Advanced Dressing Station (ADS), a more permanent affair consisting of six or seven tents. The RAP and CCP were expected to respond almost immediately to an order to move, and the ADS at up to four hours' notice. After 1941, these units were assisted by several specialist formations such as the Field Dressing Station, which resuscitated casualties suffering from shock, and the Field Surgical Unit, a mobile team capable of being directed to any point on the battlefield.

Similar procedures for casualty treatment and evacuation were followed by all the major combatants. Every German infantry division had two medical companies, each of which provided one field hospital, two main dressing stations, and two casualty clearing stations to receive wounded from medical units in the field. In addition, all German medical companies were equipped with a motorized unit. Similarly, by the end of 1942, Soviet field medical units were accompanied by mobile specialist surgical and ophthalmic teams. In the US forces, special ‘Replacement Depots’ were created to receive, hold, and finally to assign service personnel from hospitals and convalescent centres to appropriate duties.

At the end of the war, Allied commanders were generally satisfied with the level of efficiency attained by their casualty services. At Iwo Jima, wounded US marines were quickly evacuated by air and sea, and, following the cessation of hostilities in Europe, Montgomery expressed his gratitude to the Allied medical personnel who had evacuated with the minimum of delay some 100,000 troops, greatly improving their chances of recovery.

Casualty evacuation and treatment at sea had also improved by the end of the war. In addition to sick bays on board fighting ships, several vessels were earmarked by the British and American governments immediately before the war for conversion into hospital ships. Hospital ships were of two kinds: those used by the navy as ‘floating general hospitals’ and those used to convey casualties from land theatres to hospitals in friendly ports. During 1939–45 a total of eleven hospital ships were in service with the Royal Navy, admitting a total of 93,142 patients. But the number of hospital ships was often insufficient, particularly in the later stages of the war in the Far East, giving rise to acrimonious disputes between the British Army and the Royal Navy over the allocation of these vessels. Following their entry into the war, American forces also felt the lack of hospital ships, but by the end of 1943 a number of large, specially-built, and well-equipped hospital vessels came into in service with the US Navy and altogether the US Army had 24 hospital ships (6 of them Liberty ships) and the US Navy 17.

Two features of casualty evacuation by sea are especially worthy of mention. One was the evacuation of the British Expeditionary Force from France in May 1940 when several hospital ships joined other vessels in picking up wounded troops from Dunkirk and other beaches under extremely hazardous conditions. Heavy shell-fire forced several hospital ships to return to England without completing their mission and two—Wakeful and Grafton—were sunk with the loss of many lives. The other was the use of specially-converted amphibians and landing craft during the Normandy landings in June 1944 (see OVERLORD) to carry wounded Allied personnel back to hospitals in the UK. Evacuation was somewhat slower than by ship—each crossing taking 26–30 hours—but a continuous shuttle service across the Channel meant that wounded men were evacuated from the beachhead without delay.

A vital component in the treatment of battle casualties in the Second World War was the development of more efficient forms of blood transfusion: many of the improvements in this field were a direct consequence of research conducted in the USA between 1939 and 1945. In December 1939, American scientists announced their discovery that unfiltered blood plasma was a useful substitute for whole blood in transfusion. It was impossible to dry whole blood without destroying the red cells, but plasma could be dried without damaging it and could therefore be stored and transported in all temperatures. The discovery of the rhesus factor in human blood by American scientists also had important implications for blood grouping and, ultimately, for the development of human genetics. But such developments were slow to reach the medical services of the Axis forces. Until 1943 the Germans relied upon a synthetic blood substitute called ‘Periston’, which most German medical officers interrogated by the Allies admitted was unsatisfactory. It was not until after the capture of dried blood serum from the British at Tobruk in June 1942 that natural blood substitutes were employed by German medical units.

Once a casualty had been removed from the battlefield, treatment took place in military hospitals or in military wings of civilian hospitals with a number of service personnel in attendance to maintain military discipline. In the UK, where it was expected that large numbers of civilian air-raid casualties would occur soon after the declaration of war, local authorities and the ministry of health were apprehensive about the requisitioning of hospitals for military use. The precedent of the Spanish Civil War suggested that estimates of high casualties among the civilian population were well founded, and the war cabinet accepted the ministry's suggestion that the army should relinquish its claim on 25 of the 29 general hospitals then under construction. But, though air-raid casualties were far from negligible, they did not occur in the numbers expected, reinforcing the argument of army commanders who had all along stressed the need for more hospital accommodation specifically for military use. Throughout the war, and afterwards, many remained critical of the inadequate hospital provision for military sick and wounded. The allocation of medical resources for civilian or military use was never adequately resolved, but in retrospect it seems unreasonable to have expected the government to have done anything other than plan for the worst of all eventualities. Few at the time disputed the civilian casualty ratio on which the ministry of health and the cabinet based their decision and, in the years leading up to the war, the prospect of a loss of civilian morale and social disorder as a result of air attack loomed large in the minds of all concerned.

While efficient planning enabled the UK to cope with its casualties of war, little could be done with regard to hospital provision in north-west Europe and other battle zones once conflict had begun. In western Germany, in 1945, hospitals were overflowing with sick and wounded from the Allied and German forces, as well as with civilians. On the Eastern Front the situation was even worse, though the expansion of hospital accommodation within the USSR during the war was an astonishing feat. At the beginning of 1941, hospital provisions for wounded Soviet troops were woefully inadequate: in five days, one 200-bed hospital near the front had to cope with more than 5,000 casualties. But by 1944 the Soviets had built more than 1,370 evacuation hospitals with some 664,595 beds, 75% more than in 1940.

Psychiatric medicine

Over one-third of medical discharges from the British and Commonwealth and American armed forces were the result, not of physical injury and sickness, but of psychiatric disorders, which also afflicted some deserters. More than half the psychiatric disorder cases were diagnosed as ‘anxiety neuroses’, stemming directly from combat stress (see Battle of the Pips for an example of this), or from a multiplicity of sources including separation from families and domestic problems. Other reasons given for psychiatric discharge, in descending order were ‘psychoses’, ‘mental deficiency’, and ‘psychopathic personality’. Though no major theoretical advances were made in military psychiatry during the Second World War, there were, in the Allied camp at least, significant developments in terms of the mechanism for dealing with psychiatric casualties and in the position of psychiatrists in relation to military administration as a whole.

As the Allied forces became more deeply embroiled in conflict, the value of psychiatrists in maintaining morale and in returning psychiatric casualties quickly to duty was increasingly recognized by officers in the field. During the Western Desert and the North African campaigns, individual army psychiatrists began to develop new methods of forward treatment for nervous exhaustion, and by 1944 these innovations had been incorporated into official procedures for dealing with psychiatric casualties in the Allied forces. Troops suffering from battle exhaustion were generally placed under sedation for 48 hours and removed to a therapeutic environment at a divisional centre. Thereafter, they underwent a period of rehabilitation in which military discipline was reimposed, before being returned to appropriate duties. In north-west Europe, official sources estimate that as many as 65% of British psychiatric casualties were returned to full combatant duty in less than a fortnight.

In the Axis forces there was no comparable system of treatment for battle exhaustion and other psychiatric disorders, though the German Army had a high incidence of psychiatric illness on the Eastern Front. In his book Hitler's Army (Oxford, 1991, p. 22) O. Bartov notes that during the Soviet counter-offensive in front of Moscow in December 1941 ‘Symptoms of mental attrition caused by fatigue, hunger, exposure, and anxiety’ became increasingly prevalent and that there were ‘numerous cases of physical and psychological breakdown caused by the wretched living conditions.’ The German High Command responded to this crisis after 1942 simply by tightening military discipline as the majority of German military psychiatrists had long insisted that stress breakdowns were military rather than medical problems, resulting from deficiencies in leadership and morale. Treatment generally amounted to indoctrination of the sick or, in extreme cases, electric shock therapy, and the military authorities reacted to all breaches of discipline, regardless of whether these resulted from psychiatric breakdown, with undiscriminating severity. By mid- 1944, 107,000 German soldiers had been tried for absence without leave, and a further 49,000 for disobedience. More than 7,000 were executed for desertion and subversion as against only 48 in the First World War. Suicides among German troops also increased markedly at the end of the Second World War, some 10,000 occurring among those undergoing treatment for battle neuroses.

The other important development in military psychiatry in the Allied camp was the introduction of psychological and intelligence testing. Acute manpower shortages in 1941, especially in the skilled trades, led Allied military authorities to consider a more efficient basis for the allocation of service personnel. Some means had also to be devised for detecting and disposing of the many ‘undesirable’ persons admitted to the armed forces through conscription. Intelligence, aptitude, and ‘character’ testing provided a rationale for such procedures and opened an avenue to academic psychologists hitherto marginalized by the military and academic establishments. Increasingly, military psychiatry came under the influence of men who saw themselves as social engineers. Whole regiments, such as the British Pioneer Corps, were formed to provide employment for men not considered suitable by virtue of ‘low intelligence’ or ‘inappropriate personality’ for the combatant or technical branches of the army. These tests continued to form the basis for personnel selection in the British Commonwealth and American armed forces after the war. In a slightly modified form, they were later introduced for candidates for the British civil service.

Post-war planning

Throughout the Second World War, Allied leaders gave much thought to the problem of reconstruction when victory was achieved. Planning for health administration and medical relief following the liberation of occupied countries began as early as 1941, when, at an inter-Allied conference in London, it was accepted in principle that these tasks should be the joint responsibility of the Allied nations. As a result, an Allied Post-War Requirements Committee was set up to estimate the immediate post-war needs of various countries under Axis occupation and its work paved the way for the formation of UNRRA in November 1943. In conjunction with Allied military authorities, civil governments, and voluntary organizations, UNRRA was empowered to co-ordinate and administer the provision of clothing, shelter, health services, and other forms of aid. The Health Division of UNRRA became one of its most important branches, and regional organizations were formed in Europe and the Far East.

In practice, however, the responsibility for health administration fell most heavily on the Civil Affairs Administrations of the liberating armies (see Allied Control Commissions and Allied Military Government of Occupied Territories). In the final years of the war, training centres were established by the Allied armies to school both service and civilian personnel in various aspects of public administration and to familiarize them with the social and economic conditions of occupied countries. However, it is unlikely that this training would have prepared relief workers for the scale of the problem they actually encountered in the liberated countries. In Germany, the British Army alone had responsibility for some 700 camps containing more than 750,000 displaced persons (see refugees). Typhoid, diphtheria, poliomyelitis, and other diseases were rife among the dispossessed, and de-lousing and other typhus control measures were instituted in all camps under Allied command. However, it was some time before the medical advances which had so markedly improved the lot of servicemen in the Second World War began to touch the lives of those who had been left destitute by five years of conflict and occupation.

Mark Harrison

Bibliography

Copp, T., and and McAndrew, W. , Battle Exhaustion: Soldiers and Psychiatrists in the Canadian Army, 1939–1945 (Montreal, 1990).
Green, F. H. K., and Covell, G. (eds.), Medical Research: Medical History of the Second World War (London, 1953).
Heaton, L. D. (ed.), United States Army Medical Department, 10 Vols. (Washington, DC, 1955–63).