The ravages of scurvy among the crews of Vasco da Gama’s ships on the voyage to India in 1496 are thus described in the fifth Canto of the Lusiads, by the Portuguese poet Camoens. Scourges of this nature were the rule rather than the exception until relatively recent years. In the latter part of the 18th century a cure for scurvy was found—not a medicinal cure but a preventive cure. It was determined that a proper diet which included lemon juice not only cured scurvy but prevented its occurrence, and so scurvy rapidly passed into oblivion.
The Navy of today expects and takes for granted fundamental aspects of a healthy environment, such as a safe and potable water supply, wholesome food cleanly prepared in adequate quantity, and acceptable standards of housing accommodations. This has not always been the state of affairs aboard naval vessels. Only by glancing through the past annual reports of the Surgeons General to the Secretary of the Navy do some of the momentous achievements become apparent. Strong and repeated recommendations by the surgeons of the early Navy pleaded for improvement in environmental conditions. A typical problem was described in 1800 by Vice Admiral Lovell of the British Navy who complained that the bread of his ship “was full of maggots and weevils, the water so putrid, thick, and stinking, that often I held my nose with my hand while I drank it strained through my pocket handkerchief.”
Later, in 1824, Usher Parsons, M.D., stated that “Water is the best, and certainly the only natural drink of man. It has been considered by many as one of the causes of scurvy, when of bad quality. As the health and comfort, therefore, of the men at sea depend so much on its purity, particular attention should be paid to this beverage. . . . Where river water must be taken, although it may be drawn as near as possible to its source, yet certain precautions should be employed before it is used. These consist in throwing a handful of lime into each cask, or dissolving two ounces of alum to a hundred gallons, or passing through it a red-hot iron several times, or even throwing into it a little burnt biscuit.” Thus it is easy to see why the daily issue of grog was so important to the individual. In the earlier days of the Navy, grog was mixed in the proportion of one of rum to three of water and was called three-water- grog. The service did not take kindly to the stoppage of the time-honored issue when it was discontinued by General Order on September 1, 1862. Eventually distilled water was to take the place of distilled spirit.
That naval preventive medicine has been a long haul, all uphill, is supported by a recommendation of the surgeon attached to the USS Lancaster of the South Atlantic Squadron in 1873, when he made the following recommendation to the Surgeon General: “I would suggest that the Navy Department make a code of sanitary regulations, and make it obligatory upon commanding officers to observe them, for too often they consider any sanitary recommendations, however important, and however little it may interfere with the routine of the ship, as an unwarrantable interference, and disregard it. One of the most efficient means, in my opinion, to keep the men in good health within the tropics is frequent bathing. I am convinced that a number of men sent home from this ship invalided would have recovered on the station if there had been facilities for bathing.” This was later supported by recommendations by other surgeons that the men be compelled to bathe at least once every two weeks, with a change of clothing at least once every ten days.
The surgeon attached to the USS Franklin during the same year stated in his report: “The large sick-lists, which were the rule on this in common with all other newly recruited ships upon this station, and which almost totally disabled them for the first six weeks of their commission, were unmistakably the results, both of causes peculiar to the ships, and of others of external origin. Prominent among the first were foul bilges, unclean holds, defective fittings of ports, et cetera, for which the Navy yard officials were responsible, and, worse than all in its effects upon the health of the crew, there was on board this ship and others a most reprehensible system of discharging the noisome odors of the bilges through numerous large iron perforated plates, opening on both sides of the berth- deck, in the sick-bay, cells, store-rooms, and staterooms under each officer’s bunk, a fault of construction for which no pretext can possibly be suggested.”
In 1897, considerable impetus was added to the uphill struggle, as indicated by the following item from the Report of the Secretary of the Navy, 1896-1897: “The necessity for a comprehensive and uniform system of sanitary rules, to which attention was called in several previous reports, has been recognized, and a carefully considered circular of instructions, prepared by this Bureau (Medicine and Surgery), was issued by the Department (of the Navy) under date of April 8, 1897. The circular deals with the following important subjects: (a) ventilation, (b) water supply, (c) food, (d) clothing, (e) infected ports, (f) unhealthy ports and precautionary measures to be observed, (g) yellow fever, cholera, and smallpox, (h) infection on board ship, (i) disinfection, (j) precautions to be observed by landing parties in unhealthy localities.
“The promulgation of this circular is a decided advance in efforts to promote the sanitary interests of the service, and doubtless will be attended by beneficial results.”
The period from 1881 to 1897 is considered by naval historians as the period of “the New Navy.” A new Navy was created through necessity, because the fourteen years preceding this period had seen a decline of the U. S. Navy to that of twelfth in naval strength. The new Navy encompassed changes in ship design to include such radical features as metal tanks for the storage of potable water, improved ventilation provided by forced draft, improved heating, electric lights, and facilities for cooking from a centralized galley by a specialized group of cooks and bakers.
From its modest beginning, naval preventive medicine progressed from the miasma and dank air theories of disease transmission into the realm of true preventive medicine: the scientific prevention of disease. With the discovery by Koch in 1876 that microorganisms caused disease, the true agents of diseases such as malaria and tuberculosis, with their preventive techniques, came under study in naval medicine. In 1900, Surgeons Stitt, Butler, and Leys received world-wide recognition as specialists in the field of tropical medicine, laying the groundwork of naval preventive medicine as we know it today. In 1902, Surgeon General Rixey established the U. S. Naval Medical School in Washington, D. C., in part of the spaces now occupied by the Bureau of Medicine and Surgery. (The school was moved to the National Naval Medical Center, Bethesda, Maryland, in 1942.)
Surgeon General Rixey also instituted the present policy of annual physical examinations for officers, and was strongly supported by President Theodore Roosevelt. One of the chief requirements was a horseback or bicycle ride of 150 miles in three days or a walk of fifty miles during the same period, to be followed by a physical examination. This requirement led to the expression of ingenuity in developing the requisite stamina. One writer tells about the physical program in Hong Kong that proved to be popular. Almost at the center of Hong Kong is a small mountain known as “the Peak.” A cable car ran to the top of the mountain, with a long, winding street from the top of the mountain to the bottom. The officers took their bicycles up the Peak on the cable car and coasted to the bottom on the paved road. After a glass of something cool and refreshing, they again rode the cable car up the Peak, and again coasted down the road. This was repeated until the required mileage had been accumulated—all downhill in this case.
Other major developments in controlling infectious diseases were: efforts to control syphilis by the salvarsan treatment “606” in 1910; antityphoid vaccination instituted in 1911, and made universal in 1913; vaccination and isolation of recruits within 24 hours of arrival at the training station (1909); and many other innovations. In the early days, as today, studies of preventive medicine encompassed a wide area, as is supported by comments by Surgeon General Braisted in the “Report of the Secretary of the Navy, 1917,” in which he stated that “a more startling and radical suggestion is that of providing on all the larger ships laundry facilities for handling the white clothes and undergarments of the entire crew.” Also proposed were white gloves for mess cooks, with hand washing facilities for the crew’s heads. In regard to maintaining the proper level of shipboard sanitation, attention was invited to the desirability of having a trained sanitarian as one of the members of each band of inspection and survey.
By 1917, naval preventive medicine had developed to such an extent that an additional division in the Bureau of Medicine and Surgery was created, to be known as the Division of Sanitation, with Passed Assistant Surgeon J. R. Phelps, USN, in charge. The essential functions of the division were to consider all matters pertaining to naval sanitation and hygiene—problems of excreta disposal, ventilation, potable water, clothing, etc. The path of preventive medicine was then broadened to include developments in submarine and aviation medicine.
Although World War I saw many improvements in naval preventive medicine, it was not until World War II that the greatest strides were made. Industrial hygiene units were set up in all Navy yards and industrial plants between 1941 and 1943. Clothing was developed for protection against flash burns; universal immunizations against smallpox, yellow fever, and tetanus were instituted; DDT and insect repellents were developed and adapted to naval use; use of penicillin for control of venereal diseases, local infections of wounds, pneumonia, and gas gangrene was adopted; apparatus was devised for the desalination of sea water; the anti-malarial program utilizing atabrine was developed, and many other important preventive medicine problems were solved.
Much of the Navy Medical Department’s activities during the war years was concerned with field sanitation and field medicine through its responsibilities to the U. S. Marine Corps. The implementation of the new techniques devised through initiative and research required constant vigilance of preventive medicine personnel from the most senior medical officer to the most junior corpsman. The statistics of effectives compared to non-effectives reveal just how thorough that vigilance was. In World War I, an annual rate of about seventeen men per thousand died from disease; in World War II, such deaths were reduced to approximately one per thousand. Through a continuous program of health education, supervision, and demonstration, the lessons of preventive medicine were impressed upon the individual. These lessons not only reduced the number of non- effectives, it provided a tremendous potential for improving the home community of these men who carried the knowledge of naval preventive medicine into their civilian future, because the field of naval preventive medicine is not peculiar to the Navy alone. The route of naval preventive medicine closely parallels that of civilian preventive medicine and public health. The principles learned under one situation apply just as readily to the other, since death or infectious disease is not respectful of military or civilian order.
The extremely effective and dynamic preventive medicine organization in action during World War II didn’t just grow—it exploded, practically overnight. As a major division in the Bureau of Medicine and Surgery with a staff of eight officers and fifty civilian employees, V-E Day found the same division with 42 officers, 150 Waves, and 200 civilians. In addition, it had under its control in the field 150 medical officers engaged in epidemiology and malaria control, 200 Hospital Corps officers engaged in epidemiology, sanitation, and malaria control, and 200 HS (Hospital Specialists) officers who were specialists in the sciences allied to the practice of medicine. Aiding the above officers were over 1,500 enlisted men trained in the various preventive medicine disciplines. During the war, the division organized, technically controlled, and equipped approximately 1-50 malaria control units, fifty epidemiology units, twenty rodent control units, and was set up to furnish sanitation units.
All this plus its dynamic projection in the other multitudinous facets, such as communicable disease control, tuberculosis and venereal disease control, vector and vector-borne diseases, environmental sanitation, occupational medicine and health engineering was no small accomplishment. To begin with, the number of trained personnel was not basically sufficient for rapid expansion. This necessitated procurement of professionally trained personnel from civilian life, expansion of existing naval schools, and creation of new schools and training programs to train and indoctrinate officer and enlisted personnel of the Medical Department for the gigantic tasks and difficult days ahead. That the nucleus of personnel in the Preventive Medicine Division at the beginning of the war was able to accomplish the tremendous task of expansion, numerically and professionally, speaks paeans for them and the few selected civilians who had given many years of faithful service and untiring efforts. This group may well be called the backbone of preventive medicine in the Navy as we know it today. It was only through their combined foresight and unity of effort that seemingly unscalable obstacles were surmounted.
During the initial attack phase of the war in the Pacific, lack of proper attention to the details of personal protective measures was a factor that seriously threatened the success of the Guadalcanal operation. Although the troops were properly indoctrinated, it was not appreciated by the commands that a man infected with malaria was a casualty as surely as though he had been wounded by enemy action. Their attention and energy were directed to the more immediate and urgent matters of killing the enemy and avoiding being killed. At this early stage, the commands had little regard for the practical value of antimosquito equipment and believed that this equipment was more of a hindrance than a help. Fortunately, the use of atabrine saved the military situation on Guadalcanal, although even the administration of atabrine was resisted. Thus medical personnel were obliged, in most instances, to stand at mess lines not only to dispense the medication, but also to look into the mouths of recipients to see that it was swallowed. The number of men who were infected with malaria on Guadalcanal will never be determined, but it is safe to assume that almost every man who served on the island during the period of August 7, 1942, to February 9, 1943, fell victim to the disease.
As a result of the lessons learned at Guadalcanal, ensuing operations and landings were protected by strict control over the preventive measures recommended by the malaria control officer, and led eventually to the establishment of the Malaria Control Unit, South Pacific, whose function was to provide equipment and trained personnel, and to supervise malaria control operations in the area.
One of the more spectacular achievements of the Malaria Control Unit during the New Georgia campaign was their convincing proof that infected native laborers were the major factor in epidemic malaria and that they were responsible for a far greater loss of man-hours among the troops than could be gained by their presence as laborers, because they proved to be a very significant reservoir of the disease.
In spite of the many obstacles, preventive medicine did expand and was effective. Just how effective is pointed out by Captain Henry E. Eccles, USN, in his manual “Operational Naval Logistics, NAVPERS 10869,” in which he states: “In preventive medicine, again success was notable, but it did not come without many difficult periods. In the initial campaigns in the Pacific both malaria and dysentery took a heavy toll among forces ashore, and the high incidence of disease casualties was not checked until commanding officers learned to appreciate and to exercise their responsibilities. This illustrates an important principle: In the field of preventive medicine the medical officer can act only as an advisor and supervisor for the commanding officer, and the success of any program of preventive medicine is in direct proportion to the attention given it by the commanding officer.”
Naval preventive medicine provided another major contribution to the health of the Navy during the war years. Prior to this time there was no economically feasible method of taking chest x-rays on the scale considered essential by the Medical Department. Investigations started in 1939 at the Naval Medical School developed acceptable technique and equipment that led to the 35-mm. photofluorographic program that was put into universal use in 1945, and made possible the accomplished goal of 2,500,000 examinations a year. The goal is now expanded to include annual chest x-rays of all naval personnel, their dependents, and civilian employees of the U. S. Navy. This program has accomplished inestimable savings in effective military manpower and ultimate cost to the Federal Government in treatment, rehabilitation, and pensions.
Eventually, World War II was ended but the lessons in planning, organization, training, and practice of preventive medicine were not. The basic techniques were improved and rapidly implemented during the Korean hostilities. During the years 1946 to 1951, much activity and study were in progress leading to new developments, one of which was the armored vest first used in Korea in 1951. Experiences during the war years pointed out the need for a nucleus of professional personnel trained in the sciences allied to medicine. As a result, the Medical Service Corps was established in 1947, which combined the scientific personnel and the administrative personnel. Thus the many fine officers and men of the Hospital Corps with their specialties were augmented by other specialists recruited from civilian life, specialists in bacteriology, parasitology, entomology, public health, and other fields.
Although the termination of the Korean hostilities reduced the numerical strength of the preventive medicine personnel, it did not reduce the problems. Rather, developments in naval operations and equipment have served to increase the multifarious interests in the field, particularly in the area of occupational health. This program has developed from a remote and relatively specialized stepchild in 1940 to a full grown parent in the preventive medicine organization of today, with broad functions in the naval and civilian employee health program.
The prevailing concept in the Navy today is that preventive medicine is not alone a command responsibility, it is also a matter of individual concern, whether that individual be an apprentice seaman, chief petty officer, or an admiral, since the needs of the individual are the needs of the community and must be supported by organized community effort. This concept has been expanded through concerted and widespread efforts in the educational method of disseminating health information and techniques. The day of police tactics in enforcing preventive medicine regulations is rapidly fading. In its place have appeared courtesy, appeal to pride of the individual or group, patience, understanding, and utilization of all educational techniques, such as person-to-person contacts, formal and informal instruction, publicity media, and demonstration. In other words, the problems and corrective techniques are presented to the individual or group at the working level, with resort to police methods a last consideration.
That preventive medicine is rapidly reaching the stage where it becomes an individual responsibility as well as a command responsibility was emphasized by Admiral Arthur E. Radford, USN, when he addressed the 1956 Annual Convention of Military Surgeons. In effect, he stated in general terms the ultimate objective of the naval preventive medicine program, which is to educate each individual to become aware of and to assume his responsibilities to himself and to his associates in the development of a healthy, vigorous, and alert military community.
No discussion of naval preventive medicine would be complete without extending a fair share of the credits due for accomplishments to all Bureaus, offices, and all hands of the Navy Department, both military and civilian, who have made the tremendous progress of naval preventive medicine possible through their unlimited cooperation so cheerfully given. Naval preventive medicine, after all, is a community effort, sometimes guided and sometimes directed by the Medical Department. It never has been, and never will be, a “one-man show.” In this particular field, the Medical Department is somewhat analogous to the umpire in a baseball game who keeps the game progressing smoothly, arbitrates the rules and conflicts, and judges the play; the teams create the spirit and extend the effort and skill to make the game possible.