History is replete with evidence that “the best-laid schemes o’ mice an’ men, gang aft a-gley.” Military tacticians or strategists cannot be successful if when their plans are to be put into operation an enemy takes charge who, unpredicted and unexpected, suddenly appears within the bodies of the persons who are to carry out those plans. Military and naval campaigns well worked out in advance have been lost or threatened with loss by the encroachments of famine and disease. Many a foe has been vanquished by disease or famine and many a superior force has failed of its objective because proper evaluation of the effect of these enemies from within was not taken into consideration by those who did the planning.
Of all the enemies that may attack a military force from within, with their inevitable accompaniment of doubt, discouragement, and loss of confidence in leaders, none have longer histories than famine and disease.
Famine
We need look no farther back than the Revolutionary War to see that among the many reasons why General Washington had to remain so long inactive at Valley Forge was lack of food. Not until the fertile valleys at his back produced and delivered sufficient food for his starving men was he able to build up his tattered forces to sufficient strength to take the field. Sherman’s march to the sea owed much of its effectiveness to the destruction of crops and burning of fertile fields so that food so sorely needed by horses and men was denied the Army of the South.
During the retreat of Napoleon from Russia across the frozen fields of middle Europe, starvation pulled down the bodies of his exhausted men. The under-sea campaign of the Germans was directed at the food supply of the English people. The propaganda against continuation of the war found a fertile soil in the German people when the allied blockade had starved those people to a state of physical weakness. Scurvy at sea has so weakened ships and fleets that preparation for naval campaigns has been delayed by weakness from within rather than by force from without. Beriberi and pellagra have made whole sections of people incapable of furnishing the expected quota of recruits for military campaigns. When we grouse because we are served pork instead of beefsteak, canned milk instead of cream, prunes instead of strawberries, how far we have come from the day at sea when there was gruel for breakfast, salt horse for dinner, hard-tack and lime juice for supper, with a little beer or a gill of grog to keep the dread specter of famine only just at bay. Food shortage, food deficiency, and famine no longer appear from within our ships to defeat our plans. The logistics of food supply are solved. Scurvy and famine will not defeat us before we meet the enemy nor need beriberi or pellagra attack us at sea or ashore.
Disease
Armies on the march or in camp, the crews of ships in harbors and at sea, have been decimated by disease. Stricken by dysentery, swept by epidemic diseases, routed by cholera and plague, weakened by malaria, stopped by yellow fever, eaten up by scurvy, laid low by beriberi, bored from within by syphilis, prevented from advance by influenza, paralyzed by typhus and typhoid, scattered by smallpox—these have been the traditional effects of disease upon campaigns by land and by sea. Great though the losses from battle casualties have been, greater by far has been the loss to military forces from disease, the enemy within.
Through all the years of combat, armies and navies have been accompanied by doctors. While the surgeons who worked during and after battle to relieve the sufferings of the wounded have perhaps obtained and held the limelight, those doctors who before the battle studied the effects of disease and who after a campaign reviewed the causes of defeat are the ones who have done the most to solve the problem of medical strategy and tactics against disease. Their solution of many of the problems of preventive medicine makes military planning more effective in operation now than it was in the past. Without effective preventive medicine, military planning is subjected to a great and formerly unpredictable hazard when put into operation.
It may be best to list here a few diseases and injuries which have had a definite effect upon battles and campaigns ashore and afloat, especially the effect of upsetting plans made by those responsible for those campaigns:
Disease and Injury
Due to food shortage, deficiency, or famine.— Scurvy; beriberi.
Due to water and food from ashore.—Typhoid; dysentery; cholera; Malta fever.
Due to insect life ashore or aboard.—Typhus (lice); malaria (mosquito); yellow fever (mosquito); plague (rat flea).
Due to infections received from others.—Smallpox; diphtheria; scarlet fever, measles, mumps, whooping cough; tuberculosis; syphilis; gonorrhea; influenza; cerebrospinal fever.
Due to other causes.—Food poisoning; heat cramps; caisson disease; respiratory and other diseases of poor ventilation.
We need look back but a few years in history to learn the war-time results of disease. In our own Civil War dysentery and its first cousin typhoid made our armies dwindle in effectiveness and prevented or delayed the completion of campaigns. The Spanish-American War cost us several times more lives from dysentery and typhoid fever than from battle casualties. In tropical Cuba our forces were weakened by malaria and yellow fever. On the western front during the World War typhoid fever caused an enormous number of casualties necessitating a serious drain upon the populace for replacements before the Allies adopted and enforced the use of anti-typhoid vaccine. Typhus fever almost routed the Russians on the eastern front and it greatly reduced the ability of the Balkan States to participate in the battle line.
Against the enemies from within, what has the medical profession accomplished? Has it done as well in medical logistics against disease as the commissariat has done in its logistics against famine?
Of all the diseases listed and said to have had a destructive effect upon military and naval plans and warfare, most are now either controlled or subject to control. No longer do smallpox, typhoid, typhus, cholera, scurvy, or beriberi take their toll of our naval or military personnel. Proper means of ventilation enable us to go to the depths of the sea in submarines. Studies of respiratory needs and other problems of aviation medicine have made it possible to help aviators breathe with safety in the rarefied atmosphere of the stratosphere. No longer need our engine-rooms after a speed run send men in agony to the doctor for relief. Our divers can go down and come up without being attacked by the dreaded “bends.” Yellow fever and plague have been pushed back 'to the edges of the civilized world. Cholera is controllable, scarlet fever and diphtheria susceptible to control, and preventives of malaria are known, cerebrospinal fever is robbed of its ability to produce panic by its presence on board. In our strategic and tactical maneuvers against the enemy, disease, we endeavor to keep pace with those whose plans are directed against the enemy from without.
There are still many medical problems to be solved and some which although solved need further application of known measures of control.
Dysentery in mild but epidemic form still occasionally attacks and temporarily weakens the crews of our naval vessels. Food poisoning occasionally strikes us in sporadic outbreaks. Malaria still is an enemy well known to the marine forces. Influenza may again sweep the world in its tidal wave and again upset military plans as it did during the World War. Syphilis and gonorrhea continue to take their toll. Measles and a few other mild epidemic diseases appear now and again, men still occasionally fall overboard and drown, a few of poor mental fiber commit suicide, motor accidents ashore make inroads upon our efficiency, but by and large the naval surgeon and his profession are on the way, trying to keep step with their military brothers and ever alert to maintain the ground already won and to seek new methods of attack upon those diseases and injuries which still remain more or less threatening to military efficiency.
While it is true that the medical profession has done what it could to clear the military stage in civilized countries of most of these enemies, it must not be forgotten that the naval surgeon still has very definite contributions to make. It is his duty to define wherein his contributions are necessary and valuable to the naval establishment. Yes, he has the value of one interested in the alleviation of human suffering. He has a value as one who after battle may help in saving lives and in the repair of mutilated bodies, but his value to the naval service is best judged in terms of contributions made to preparation for war.
Naval strategy must include estimates from the medical department calculated to give the tactician a reliable dependence upon the physical endurance of personnel in battle. The medical department must help the naval strategist to have on board healthy seasoned crews. Medical examinations carefully and conscientiously made, vaccines given at the proper time, sufficiently long periods of recruit training ashore, lessen the hazard of the weakening effect of communicable disease among those who must live in the crowded compartments of ships at sea. Frequent inspections of the crew bring to light most of those who are potentially ill, with recommendations for transfer before they become a burden in battle. The special qualifications of gun pointers, aviation and submarine personnel, need accurate determination by medical study in order that physical deficiencies may not threaten the efficiency of the complicated mechanisms used against the enemy. Occasionally restrictions upon liberty and upon shore contact can be advised to reduce unnecessary or untimely exposure to respiratory and other communicable diseases. Food and water supplies must be continually guarded by medical knowledge and study. The effect of peace-time maneuvers with their watch and watch, darkened ship, and closed hatches, upon the comfort and morale of even seasoned healthy men must be studied. The naval strategist will not forget to retire to a proper place to replenish his fuel reserves so that power plants will respond to his call for speed or continued mileage, nor will he fail in planning for receipt of stores and ammunition. The medical department must advise him of the need for the replenishment of the vitality of his officers and men by proper periods of rest and relaxation. Men cannot remain too long at watch and watch, day after day, in a darkened ship, without a slackening in speed, a reduction in mental alertness and a lowering of morale. The ship or fleet which enters battle with a rested crew may win over one that has paid less attention to the human factors of mental and physical fatigue. Medical planning and study during peace-time maneuvers must be directed toward building up the factors of morale at the moment of battle. Medical plans will be of value if they contribute to that need. Medical thought must keep in line with naval strategy, the imaginative faculty of the medical department must be fed and stimulated by a continuing visualization of the objectives of those who plan battles at sea. By such contributions the naval surgeon can be of help to those responsible for the military safety of our country.
At the outset of war, during the period of mobilization, we must absorb those partially seasoned groups of men now in civil life who have been assembled for the day of need, the naval militia and the naval reserve. Fortunately these are already prepared by known and efficient vaccines to meet the inroads of typhoid and smallpox. These men have become somewhat used to seagoing. They will not be long in gaining their “sea legs” and adapting themselves to the conditions of the sea. However, even the influx of partly seasoned personnel and the inevitable shifts of personnel that will be necessary from ship to ship will increase sick lists and bring into each vessel an increased burden of ineffectives.
While in time of peace it may be economical to keep these sick on board, in time of war with battle imminent early evacuation of even the slightly ill is a prime necessity and evacuation means replacements. This situation demands an influx of recruits to training stations and urgent appeals to hurry the period of training. These new recruits who will be then needed as replacements bring in a certain amount of communicable diseases. No matter how effective their medical care may be, the number of sick among recruits will be larger than in peace times because of their more rapid flow and absorption into the service.
Ships will be required to carry newly recruited and other replacements to the fleet and to return sick casuals to the shore bases. Provision for this inflow and outflow of personnel must be made. Space must be reserved on ships of the train. Additional facilities for the care of the sick on those ships must be planned. Additional hospital ships must be provided to make evacuation rapid and economical. If battle casualties distant from shore bases occur, replacements of personnel and evacuation of the wounded and ill by ambulance ships become of vital importance.
With these thoughts in mind it is the duty of the medical department to estimate in terms of the expected numbers of invalided, to apprise those responsible for military needs of the space required to care for the sick and for replacement of the sick, to urge upon the Navy Department the need for ambulance ships and hospital ships and for adequacy of sick bays in ships of the train.
Proper evaluation and anticipation of these needs and a realization of their relation to the effectiveness of ships is the function of the medical department. Ability to estimate these needs and to impress the importance of such safety factors upon naval strategists in preparation for war will become the true standard by which to measure the value of the medical department to the naval service.